Next Valentine’s Day, as your dearly beloved runs into the local drugstore for that last-minute Valentine’s Day card and box of chocolates, he will also have the chance to pick up an at home sperm count test called SpermCheck. I used to joke that we take all the “fun” out of conception in the IVF lab. More true than funny, explaining why I don’t make a living as a comic. Soon, you’ll be able to do a non-fun semen analysis at home too. (Actually, if you really want this test, you can already buy it on-line.)

Recently, Walgreens announced that starting in April 2012, they will start to sell SpermCheck  in 7,800 Walgreen stores. How does SpermCheck work?  It is an antigen based test, like a pregnancy test,  where you look for a binding between an antigen and its antibody on a pretreated strip. The reaction between the antigen on the sperm and the pretreated strip causes a color change. For SpermCheck, the man mixes a pre-determined volume of his semen with liquid supplied in the test kit. The mixing releases a sperm protein from the sperm called SP-10. If he has at least 20 million sperm per milliliter, there is enough reaction between the free SP-10 and the test strip to form a reddish line on the test strip. (I have to wonder how bright this reddish color is because they have a disclaimer that “Poor vision and/or improper lighting may affect interpretation of the results.” So,  don’t perform this test by candle light.)  Twenty million sperm per milliliter is the cutoff for minimal normal sperm concentration. Detailed instructions for using the kit can be found here.

I have mixed feelings about this at-home sperm count test. On one hand,  any man who takes the initiative in getting his part of the reproduction effort tested is really stepping up as a partner in the procreative effort and that is a very good thing. I am saddened when I see couples in the clinic where the woman is being prodded, examined, injected and annoyed on a daily basis for diagnosis and then treatment; meanwhile,  her man balks at ejaculating in a cup. I have to wonder,  if he can’t man up for the simplest part of the effort, will he help with the heavy lifting of taking care of a newborn and then all the not so fun stages of childhood? Where’s the commitment?

So kudos for initiative, but I still have some concerns about these at home tests. They can not replace a full semen analysis in a laboratory.

If the result is good and your man’s test result shows that he has at least 20 million sperm per ml, that doesn’t rule out male infertility. Why? Because the test looks for an antigen on the sperm surface that doesn’t distinguish between live or dead sperm, swimming or non-motile sperm, just reports how many sperm cells are present. So it is possible to have 20 million dead, non-moving or very sluggishly moving sperm.

Another limitation of the test is that unlike a regular semen analysis in the lab, you don’t get any feedback about what the sperm look like. If the sperm have a high percentage of abnormal forms, you wouldn’t know it from this test.

Sperm tests, performed at home or in the lab, can give misleading results if the sample is not fully liquefied before testing. Sperm is initially gluey and thick. With time, usually within 30 minutes,  it thins and it is possible to thoroughly  mix the sample so that sperm are present in the same concentration in every part of the sample so you don’t have a sampling error. Sometimes, sperm is so thick, it does not liquefy on its own even after an hour or more. In the lab setting, we can add a proteolytic enzyme (chymotrypsin) to liquefy the specimen and perform an accurate test. You can’t do this at home.

This limited at home test is not cheap- $40. If your insurance pays for semen analysis at a fertility lab, you’ll get a more thorough test for free. A regular semen analysis will usually also report on other aspects of the semen sample, such as percent of motile sperm, how well the sperm swims (percent progressive forms), presence of agglutinated sperm (suggesting antibodies), presence of RBCs (suggesting blood in the sperm tract), presence of white blood cells (suggesting infection, if high)  and the pH of the sample (which has urological implications if pH is too acidic or too basic). The assessment of percent normal forms (the morphology test) is typically performed as a separate test from the routine semen analysis but not always. If you have to pay for the semen analysis out of pocket, it will typically cost somewhere between $80-150 at the clinic. Be sure to ask what any tests cost in advance and also check with your insurance company to see if the test is covered.

Patients seem to be reluctant to ask what health care will cost and whether insurance will pay for it. Your clinic should be able to answer these questions for you. All clinics have someone responsible for the finances of the clinic and this person routinely checks insurance coverage on patients so that the clinic can charge the self-pay portion and bill the rest to insurance, if applicable. Don’t be afraid to ask.

Because  the at home test is inconclusive- even for positive results- you’ll end up needing a regular semen analysis anyway so it might just make more sense to just do the test in the clinic and save the $40 for a nice dinner out. Happy Valentine’s Day.

Unexplained infertility is a frustrating diagnosis. The usual diagnostic work up has no “AHA!!”  moment and clear treatment plan. In spite of no obvious problems, there’s still no pregnancy month after month. Scientist Dr Megan Lloyd and her team announced the discovery of an antibody against the glycoprotein zona pellucida 3 (ZP3) which induces sterility in mice. Interestingly, antibodies to the same protein have been found in women but this study shows that targeted ovarian antibodies may be sufficient to cause sterility.

What is the zona pellucida and why is it important to the egg? The zona pellucida or ZP is a porous glycoprotein coat that surrounds the egg. A glycoprotein is simply a protein molecule with carbohydrate groups (the glyco part) hanging off the protein. These sugar-protein hybrid molecules often have specific jobs and being receptors for cell-cell interaction is one possible  job for these molecules. When the egg forms within the ovarian follicle, the follicle  lays down a matrix of glycoprotein molecules  around the egg. In the human, there are four varieties of glycoprotein molecules (ZP1, ZP2,ZP3 and ZP4) that create the finished zona pellucida. All the ZP proteins are synthesized by the egg as it lies in the ovarian follicle, growing and maturing over months prior to ovulation. Different roles have been identified for some of  these proteins.

ZP1 is synthesized by the oocyte and surrounds the oocyte. ZP1 crosslinks ZP2 and ZP3.

ZP2 provides a critical gate-keeper function at fertilization. Sperm bind to ZP2 which is a receptor molecule that induces the acrosome reaction in bound sperm. The acrosome reaction is an important step in fertilization. During the acrosome reaction the sperm sheds the acrosomal membrane, a sac of enzymes located at the tip of the sperm head, releasing sperm enzymes which help the sperm digest a path through the zona to get to the egg inside. Once the acrosome reaction has occurred,  in addition to providing digestive enzymes, the sperm head now has newly exposed proteins that can bind to the ZP2 molecule. One of these exposed sperm proteins is called (drum roll) the zona pellucida binding protein which gives sperm the ability to bind to zona proteins. After fertilization occurs and the sperm membrane and egg membranes interact, the ZP2 protein is removed via an enzymatic reaction initiated by the egg (the zona reaction) which slams the door shut on any other sperm that are trying to fertilize the egg, preventing polyspermy. Polyspermy, like it sounds, is an abnormal event in which many many sperm enter the egg which does not result in normal fertilization but typically results in egg death.

ZP3 is necessary molecule for the initial steps of laying down the zona matrix. At fertilization, it plays a role in species-specific recognition and binding of sperm.

ZP4 has several jobs including participating in the creation of the initial zona matrix , helping during the induction of the acrosome reaction and inhibiting the binding of excess sperm after fertilization.

A nice summary of molecular events at fertilization can be found here.

Obviously these zona proteins are essential for normal fertilization, so anything that can bind to these zona receptors and block the sperm interaction could prevent normal fertilization. Antibodies against zona proteins produced by vaccination in several species appear to be able to cause sterility by binding to zona proteins, blocking sperm access to the egg. Vaccines against zona proteins in both domestic and wildlife species have been shown to be effective  for population control.

Most recently, a study by researchers at UWA’s school of Biomedical, Biomolecular and Chemical Sciences found another mechanism by which antibodies could cause infertility. Specifically, researchers were able to deplete follicles in the mouse ovary using a vaccine against ZP3. This study shows that antibodies can be used to cause ovarian damage, not just prevent fertilization by interfering with egg-sperm binding.  ZP3 antibodies have been found in the blood of some women suffering for infertility so this may explain some cases of infertility that were previously unexplained.

In fact, ovarian autoimmune disease has previously been identified as a possible underlying cause for both premature ovarian failure and subsequent infertility. Interestingly, more than 40 years ago, an article published by WJ Irvine and others suggested that the high incidence of premature ovarian failure in women with Addison’s disease (an autoimmune disease) may suggest a form of ovarian autoimmune disease. The antibodies that Irvine was seeing in  slices of ovarian tissue was generally against “endocrine producing cells” in the ovary and were likely targeting multiple unidentified proteins inside the ovary. The zona proteins were likely one of the antibody targets detected in this early study.

Tests to look for antibodies against zona proteins are commercially available, but  I suspect they are not as widely used as the more established sperm antibody tests. Sperm antibody tests  look for antibodies to sperm in either the female’s serum or male’s semen.  Urologists may order testing of semen for antibodies to sperm (not uncommon after testicular trauma or vasectomy) which can cause problems with agglutination in which live sperm clump together in non-functional masses, also contributing to male infertility.

If antibodies against either sperm or egg proteins are detected, intracytoplasmic sperm injection (ICSI) may be indicated, because sperm injection neatly bypasses all sperm-egg binding issues that could inhibit fertilization.

(Note that I have no financial interest in any of these diagnostic tests.)

The American Society for Reproductive Medicine has a Ethics Committee which issues recommendations regarding various ART medical practices. Most recently, they published “Disclosure of medical errors involving gametes and embryos”  If this link doesn’t work, you can download a PDF copy for yourself directly from www.asrm.org.

In this article, the Ethics Committee generally advocates for medical disclosure but describes two types of errors that may be managed differently. They make a distinction between errors that cause obvious harm to the patient such as mix-ups of wrong gametes cultured together or wrong embryos transferred and those that result in a loss in the “number or quality of gametes or embryos”. Specifically,

“A difference of opinion exists as to whether mistakes involving the number or quality of gametes or embryos should always be dis closed. According to one point of view, disclosure is discretionary if such errors do not harm the patients. According to another, ‘‘even trivial medical errors should be disclosed to patients, and decisions to withhold information need ethical justification’’ (3). We believe that the presumption should be to disclose, rather than not to disclose, mistakes that have potentially adverse effects for patients, even if the mistakes are seemingly minor. If, on the other hand, there is clearly no adverse effect, and if disclosure may unnecessarily compound the stress of patients, disclosure may be considered to not be obligatory.”

The potential problem with this two-pronged approach to disclosure is that someone within the organization must make a decision regarding whether patient harm has occurred. From a business perspective, it is never advisable to fully disclose because the patient may react in a manner that could harm your business. This being a fact, is it really sensible to expect that the business owner can set his self-interest aside or is it more likely that the bar for disclosure will be set high enough to avoid any adverse business effect?

Interestingly, the committee adds that “If the error is something that would or should be entered in the medical record, it should be disclosed.” By this standard, since the number and quality of embryos are charted on a daily basis in the patient’s medical chart, any loss due a lab mishap would clearly have to be disclosed.

The Ethics Committee also points out that the primary professional organizations such as the American Medical Association, the American College of Physicians, the American College of Obstetricians and Gynecologists and the Joint Commission on the Accreditation of Health Care Organizations all have standards of care that require disclosure of medical errors. They also remind us that we have a moral duty not to” lie, falsify records, or ask or require team or staff members to engage in deception or actions that prevent patients from being properly informed about their situation.”

Another ethical argument for full disclosure (if any more should be required) is that to not disclose is to cause patient harm by not respecting patient autonomy.  If patients are to be respected as autonomous individuals with the authority to make decisions about their medical care, patients must be given the information they need to make informed decisions.

The Ethics Committee also provides a blueprint for how to disclose errors to patients. Their recommendations include:

“Clinics should have a written policy regarding disclosure of medical errors which defines key events and terms, state who should be informed, how an investigation into root cause will be conducted and the timing and method of patient disclosure. statements about who should be informed, how further investigation will be conducted, and when and how information will be discussed with patients.”

Clinic policies should make clear that a culture of openness is encouraged and retribution against  “whistle blowers” will not be tolerated. Furthermore, clinic policies must include a method to convey to employees that consequences to the program and themselves are likely if errors are not disclosed or worse, steps are taken to “cover up”errors, for instance by creating false entries into the medical record.

Newt Gingrich, on the eve of the primary election in Florida, promised to ban stem cell research and raised questions about the practice of in vitro fertilization which can result in the production of excess embryos. He promised evangelical supporters that he would form a commission to study the ethics of in vitro fertilization. He suggested that creation of excess embryos which may be stored and never used- even discarded by the patients that created them- is unethical.  Once again, IVF is being batted around as a political catnip for the social conservatives. It seems to me that in a country that holds as sacrosanct the right for an individual to practice any religion (or lack thereof) they desire, any claim of a single religious authority to decide what medical care other Americans are allowed to have is un-American.

Some patients share these religious concerns and are completely within their rights to not participate in IVF treatment. Alternately, they may ask their IVF team to only attempt to fertilize as many eggs as they would be prepared to transfer, eliminating the risk of having any excess embryos being created. Their IVF team must also advise these patients that limiting the number of eggs that are fertilized reduces their chances of pregnancy. Furthermore, because of the natural attrition rate or loss of clinical specimens at each step of IVF (not all eggs will fertilize normally and not all fertilized eggs are guaranteed to develop in culture), it is possible they will have nothing to transfer. Because patients have a right to make decisions about their own healthcare, the team respects the patient’s right to choose to modify the procedure.

Excess embryos are stored in the lab for the use of patients but the clinical program does not own the embryos. Patients have the authority over the fate of their embryos in storage.  They can decide to use them in future attempts at pregnancy until they have completed their family. Most patients “use up” all their frozen embryos for their own reproductive efforts. If excess embryos persist after treatment is complete, currently patients have the right to decide to donate their embryos to another couple but are not currently compelled to do so. Alternatively, patients can currently decide to donate their embryos to stem cell research or thaw without use.

Florida voters have a choice to make tomorrow. Most if not all the voters heading to the poll tomorrow know someone who suffered from infertility and were able to conceive using IVF. They should ask themselves whether they want to support politicians who support the restriction or  elimination of existing patient rights to choose IVF and determine the fate of their embryos. I am reminded about the famous quote from the pastor  Martin Niemöller (1892–1984) who was referring to the indifference of the majority of the population when the government targeted people they didn’t care about so much.

First they came for the  communists,
and I didn’t speak out because I wasn’t a communist.

Then they came for the trade unionists,
and I didn’t speak out because I wasn’t a trade unionist.

Then they came for the Jews,
and I didn’t speak out because I wasn’t a Jew.

Then they came for the Catholics,
and I didn’t speak out because I was Protestant.

Then they came for me
and there was no one left to speak out for me.

We are more alike as Americans than we are different. We need to speak up for and protect the rights of all Americans to make choices about their healthcare and their family.

One of my readers had some questions about egg vacuoles in IVF so I thought I’d touch on this topic today.  Vacuoles look like roundish areas in the egg. They can be large or small, many or few. Sometimes they can be mistaken for pronuclei but unlike pronuclei, vacuoles are clear inside, and don’t have nucleoli (small dark spots) like real pronuclei do. You can see pictures of eggs with various abnormalities here.

What are egg vacuoles? The normal egg has a smooth shiny cytoplasm. Vacuoles are little round-shaped clear looking structures inside the egg that are not usually observed in normal eggs.  These structures appear to an aggregation of the smooth endoplasmic reticulum (SER) according to an article published in Human Cell which describes eggs analyzed using transmission electron microscopy or TEM.  The SER is an organelle found in lots of different cell types and has various functions such as synthesis of lipids and steroids, metabolism of carbohydrates, regulation of calcium concentration, drug detoxification, attachment of receptors on cell membrane proteins, and steroid metabolism– depending on cell type. The SER can also contain an enzyme called glucose-6-phosphatase which plays a role in the manufacture of glucose molecules in cells. Sometimes the SER is a network of tubules and vesicles and sometimes it shows up as enlarged sacs. I tried to find out which of these  functions might be egg-specific but couldn’t find much in a quick internet search.

In “Portrait of an oocyte: our obscure origin”, Roger Gosden and Bora Lee, paint a rather detailed picture of the human egg from a molecular perspective but little is mentioned about how vacuoles might arise except a brief mention that vacuoles may arise from ” obstructed ER (endoplasmic reticulum) tubes”.

What causes vacuoles to appear in eggs? The seem to be more common in eggs that are overly mature or aged in culture.  Age may also be a factor since in older eggs, the SER is more likely to aggregate into clusters. Two studies,  the “Ultrastructure of tubular smooth endoplasmic reticulum aggregates in human metaphase II oocytes and clinical implications” and  “The relationship between pregnancy outcome and smooth endoplasmic reticulum clusters in MII human oocytes“  conclude that having eggs with vacuoles is associated with impaired fertilization, poor embryo development and lower positive pregnancy outcomes. This article describes how the presence of various abnormal cytoplasmic inclusions (a variety of wierd structures that don’t belong) are associated with poorer fertilization rates using ICSI. If the vacuoles are  large or numerous, from a technical perspective, it may be hard to inject the sperm into the egg cyctoplasm without hitting one.  Also, at fertilization there is a lot of activity going on inside the egg, with the formation of pronuclei and then transporting the male and female pronuclei toward each other along microtubules that make up part of the cytoskelaton of the egg- toward their union (syngamy!!)  It is not too hard to imagine that big aggregates of anything inside the cell could interfere with these highly orchestrated events.

In another study, high estrogen levels in the IVF cycle were also associated with increased vacuoles in eggs.  Estradiol levels rise as the follicles grow in response to follicle stimulating hormone  (FSH). Bigger follicles make more estrogen. Sometimes estradiol levels can rise too much, too fast, increasing the risk that the patient may suffer ovarian hyperstimulation syndrome or OHSS  which could cause severe respiratory and cardiac issues due to extreme fluid retention which can even cause death, in extreme cases. To avoid the extremes of both hyperstimulation and poor stimulation, your physician must thread the needle between having you take too much or too little FSH  (typically FSH is prescribed as Follistim or Gonal F).  Too little and you never make mature eggs and too much, your eggs may become post-mature. Post-mature eggs are also more likely to have vacuoles.

In the case of my reader who asked about vacuoles, she shared that she is young (under 35 years old) so not automatically at risk for poor egg quality. She had a robust ovarian response, yielding 34 eggs at retrieval of which 27 were mature and 23 out of 27 mature eggs fertilized. She had adequate embryo progression with 16 embryos of good and fair grades on day 3 but on day 5, there were only 3 pre-blast embryos. The remainder did not progress to blast even on day 6. She mentioned that vacuoles were observed by the lab techs in some of the retrieved eggs. She also mentioned that her FSH level was cut in half near the end of her stimulation. Perhaps some of our reproductive endocrinologists may want to comment on this as a factor but I think it is safe to say that the desired stimulation endocrine profile is a slow but steady increase in estradiol levels. A sharp rise in estradiol, followed by a steep drop is not desirable for good egg quality.

So the appearance of vacuoles inside the egg cytoplasm may be associated with both over-ripeness (aged eggs) and overly high estradiol levels.

Generally speaking, egg quality is determined by a variety of factors including genetic health (normal chromosome number) , cytoplasmic health (the poorly understood components inside the liquid center of the egg that run the normal egg machinery) and the effectiveness of the stimulation protocol to “fool” mother nature into bringing about the final stages of egg maturation in response to prescribed stimulation medications.

Vacuoles in eggs are certainly not desirable. Because of the relationship of vacuole formation with overmaturity and estradiol levels, it seems reasonable that a different stimulation protocol may yield mature eggs without vacuoles in a subsequent cycle.

I get a recurring question from my readers, sometimes posed in the comments section and sometimes via email. Understandably, patients want a checklist of points to review for good clinics and a checklist of points or warning signs for the bad clinics. Coming up with a “naughty and nice” list is not so simple because there are a lot of ways to skin this cat. Clinics can achieve high pregnancy rates with various protocols; there is no one right way to do IVF that yields high pregnancy rates. Ways to do IVF badly can also be accomplished in a unique way by employing a variety of factors such as poor training, poor equipment, cheaper quality supplies, under staffing  or antiquated protocols.

In the US, we have voluntary practice guidelines issued by the medical professional societies such as American Society for Reproductive Medicine (ASRM) or Society for Assisted Reproductive Technology (SART). We don’t license IVF clinics in the US and we don’t have one standard of care that all clinics are required to follow. Every clinic is different and the choices they make regarding both clinical and lab protocols are based on the experiences and backgrounds of the physicians, nurses and laboratory director who shape the program.

Because there is a lot of variety in how clinics manage their care, reviewing the end result or pregnancy outcomes is probably the best method for consumers to evaluate IVF clinics. Congress thought so too when they established the 1992 Fertility Clinic Success Rate and Certification Act which requires that clinics report their pregnancy rates to the CDC annually.  These pregnancy results are public record and available through the Centers for Disease Control website , the SART website and at least one other private website.

In spite of the practice variations in protocols among clinics, I have tried to find common themes among good clinics. I have addressed this question in previous blog posts. Some of the most pertinent are linked below. If you want this information in a more concise format, you can find it in my e- book, Fertility Lab Insider, available through Amazon or Barnes & Noble. You can read this e-book on any computer with free software provided by the sellers, you don’t need to have an e-reader.  I love getting the positive feedback from readers who have found the blog helpful or who have appreciated my emails answering their questions.  So, dear reader,  if you feel you have benefited from my blog, please consider buying the book because book sales directly pay the web hosting fees. Thanks!!!

Finding a good fertility doctor- part one.

Using CDC reports to find a good fertility doctor- part two.

Common practices of the best IVF clinics

For those of you who want to look below the hood of your IVF lab, the nuts and bolts of  keeping a lab running in good order can be found at the link below but this is probably not very useful to most consumers because they don’t have access to these data when they choose a program. You can find out whether your lab has been accredited by CAP or JCAHO, which in theory at least, shows the  lab is adhering to expected standards of quality care.  If you want to know a little bit about the steps taken in the lab to maintain quality, this post discusses some of that in  Quality insurance in the IVF lab .

As this year draws to an end and 2012 arrives, I want to wish all my readers a very Happy (and Fertile) New Year!!

Carole

Recently one of my readers had a question that I think many patients who go through IVF may have. She wanted to understand what blastocyst grading means in terms of embryo quality and then, obviously the implications for her  chances of pregnancy. Her question was: ” I just had two expanded blastocysts transferred on day 5.  Both were graded CC.  With my last IVF we did a SET with expanded blastocyst, grade BB that resulted in a chemical pregnancy.  In your mind is it more important that they are expanding blastocyst or the grade? (would an early blastocyst grade AA be better)….should we consider implanting on Day 3 (when we had 8 embryos still around)?”

Probably the most widely used blastocyst grading system is the David Gardner system which separately judges the functional milestones the embryo reached (namely how expanded the embryo is and its progress in hatching out from the zona pellucida (1-6 with 6 being completely hatched) and the number of cells in the inner cell mass (A-C) and trophectoderm layer (A-C where an A means the greatest number and most tightly organized cells).

What is a blastocyst? A blastocyst describes an embryo stage reached usually after about five days of development post-fertilization. It has about 50-150 cells and has started to develop specific regions with different cellular destinies. The blastocyst is working hard; pumping fluids towards its center, creating a fluid-filled center and expanding like a water filled balloon. The inner cell mass is a clump of cells  protruding into  the middle of the fluid-filled cavity. This inner cell mass will continue to grow and ultimately will be the source for all the cells of the future baby. The trophectoderm cells line the inner surface of the zona pellucida (the glycoprotein shell around the embryo) and play a supporting role, supplying cells to form the fetal part of the future placenta. So the grading system takes into account how much progress the embryo makes in hatching from the “shell” and also how richly endowed the inner cell mass and trophectoderm are in terms of cell number and quality. More expansion is better than less and more cells are better than fewer cells.

The expansion grade scale ranges from 1 (least expanded) to 6 (completely hatched).

Grade 1: the fluid-filled cavity takes up less than half the space of the embryo.

Grade 2: the fluid-filled cavity takes up more than half the space of the embryo.

Grade 3: the blastocyst cavity has expanded into the entire volume of the embryo, pressing the trophectoderm cells up tightly against the inside of the zona.

Grade 4: Expanded blastocyst, where the blastocyst has increased beyond the original volume of the embryo and caused the zona pellucida “shell” to become super thin.

Grade 5: Embryo has breached the zona and is hatching out of its shell

Grade 6: Embryo is completely hatched.

So the embryo is given a number grade (1-6), followed by a letter grade for the inner cell mass and then the trophectoderm (A,B or C).

For the inner cell mass:

A: Many cells, tightly packed

B: several cells, loosely packed

C:  very few cells

The trophectoderm grading goes like this:

A: many cells, forming a cohesive layer

B: Few cells, forming a loose layer

C: Very few large cells.

So a blastocyst with grade 5AA is partially hatched with many cells in the inner cell mass (cells for the future baby) and many tightly packed cells in the trophectoderm.

One thing to remember is the grading also represents a continuum. A healthy blastocyst starts out unhatched with a small space and few cells, then progresses to a hatching blast with many cells. When we pick a blastocyst to transfer on day 5 of culture, we preferentially pick the most advanced embryos that seem most “eager” to implant. That doesn’t mean that a blastocyst with a lesser grade won’t implant. They do. Remember we are looking at  a snap shot of embryo development and not all embryos in a group started the developmental pathway at the same instant.

A picture is worth a thousand words.

Here are a group of expanded but not yet hatched blastocysts (grade 4AA).

Here is a partially hatched blastocyst (grade 5AA). You can see the clear zona pellucida shell barely attached to one end of the blastocyst.

For more pictures of  graded blastocysts in various stages of development, look at these  (copyrighted) embryo pics  at this link  http://www.advancedfertility.com/blastocystimages.htm . These pics should help clarify the grading system.

Regarding my reader’s question of whether the degree of expansion or whether the cell number is more important in a successful implantation and pregnancy…well, it’s not usually a question of one or the other. In a healthy embryo, they tend to go together. Typically, as the cell number increases, so does the level of expansion.  What is a deal killer is if we don’t see a clump of cells corresponding to an inner cell mass because that means that none of the cells in the embryo have been allocated to make the future baby. Other than that, there is a lot of flexibility in the embryonic program and I wouldn’t despair if my blastocyst had a lesser grade. I have seen morulas (the stage before blastocyst) transferred on day 5 result in pregnancies so our preconceived notions of where an embryo must be on day 5 are not always predictive. However,  if an embryo is delayed by more than a day- say 8 cells on day 5, it probably will not be result in a pregnancy because it has likely stopped developing.

Hope that helps demystify embryo grading. Best Wishes.

Ever wondered what your embryo was up to during the five days it spent in the IVF incubator? Well, here’s a beautiful time-lapse video of embryo development from pronuclear stage (when fertilization is determined) to the blastocyst stage (when the embryo is implantation-ready).

One of my most popular posts is about the progression of embryo development, “Embryo stages, progression and pregnancy outcomes”, with lots of embryo photos- courtesy of some very generous colleagues and friends in IVF-, so I know that my readers enjoy looking at photos of developing embryos as much as I do.

I found this embryo time-lapse video on a website describing a new device just approved by the FDA that combines an incubator environment with a camera that takes pictures of each embryo every 20 minutes over five days so that on-going development can be studied. According to the company website, this nifty device called an Embryoscope can track the rate of cell cleavage over time (they call it blastomere activity quantification), and oocyte/embryo respiration, both indicators of embryo metabolism,

Why this device and others like it that allow real time assessment of embryo development are so exciting to IVF scientists and clinicians is that we are looking for better tools to determine which embryos in our culture dish will produce pregnancies that go to term and which won’t. The current standard is morphological assessment which simply means we score embryos on how “pretty” they are. The prettiest embryos have even cells and no fragmentation and get a high score. These embryos are the ones we prefer to transfer. But this assessment has limited value because a less pretty embryo from a twenty year old woman is more likely to implant than a text book perfect embryo from a forty year old so obviously there are other things happening inside the embryo that we can’t see.

The emerging field of metabolomics may provide new tools for embryo assessment that really reflect embryo potential. Metabolomics is the measurement of various features of embryo metabolism such as the uptake of substrates for growth such as glucose, lactose or amino acids and also oxygen uptake. Real time assessment of metabolic milestones may be more valuable in pointing us to the healthiest embryos in culture.

Here are some on-line references if you want to read or hear more about metabolomics.

Metabolomics and its application  for non-invasive embryos assessment in IVF 

A new method for embryo selection: Metabolomics

Videopod cast about embryo metabolomics 

They didn’t reveal the price for the Embryoscope on the website (which brings to mind the adage. “if you have to ask, you probably can’t afford it”) so it is probably too expensive for routine clinical use. Hopefully, the Embryoscope and other real time embryo assays will be useful in a research setting to better understand what’s happening inside the embryo as it develops. This information could be used to develop better embryo culture systems and eventually allow better selection of the healthiest embryos for transfer to the uterus.

Every week, we field questions about using sperm donors from patients who can’t have a child unless they can use donor sperm and most buy sperm from a commercial sperm bank. They may be a married couple in which the man does not produce sperm or had a vasectomy that he doesn’t want to reverse or perhaps was reversed unsuccessfully. It might be a fertile couple in which the male partner knows he has a genetic disease or chromosomal abnormality that he doesn’t want to pass on and preimplantation genetic diagnosis is not an option for them.   It might be a single woman who doesn’t want to wait or can’t wait any longer for Mr Right to come along to have a child. They might be a lesbian couple. Whatever the need, ordering a vial of donor sperm is not uncommon and frankly, provides an immediate solution to a difficult problem.

If you go to any of the sperm bank websites, you can access information about hundreds of donors and buy sperm for your family tree with a few clicks of a mouse. Two of the largest and oldest commercial sperm banks, Xytex International and California Cryobank were incorporated in the US in 1975 and 1977, respectively. Here’s a typical donor information page from Xytex that allows you to look at donor stats before you select the donor.  You get lots of  information about the donor such as height, weight, eye color, hair color, ethnicity, race,  hairiness (yes really!) detached or attached ear lobes, etc. You also get some medical history background regarding the donor and his parents and grandparents but this history is self-reported and is not independently verified. The FDA requires that gamete donors undergo a battery of infectious disease risk factor screening and  infectious disease testing before they are permitted to donate.

Until fairly recently, donors anonymity was protected and donors were guaranteed that no one would ever know their identity. That is slowly changing in the US. Some banks now show photos of the donor as a baby, child and adult to prospective recipients. These pictures can be purchased for the “family” album. Again, not kidding. Increasingly, donors are giving permission to be contacted by their donor-conceived kids when they turn 18.

What is behind this greater openness about the identity of sperm donors? A growing number of adult children who were conceived with donor sperm want to know more about their biological roots and are making their needs known. The Donor Sibling Registry is a website started by a donor-conceived son and his mother to help donor-conceived kids find their siblings by posting their donor number on the site and finding others who were conceived from the same donor.

While the choice to remain anonymous or not is completely up to the donor in the US, other countries are banning anonymity. In 2005, the UK passed laws that banned anonymous donation and allowed donor-conceived children to find the identity of their donor once they turned 18 years of age. The law was not retroactive but only applied to new donors. Donors donating after the ruling, although no longer anonymous, would still be immune from any legal, financial or social obligations to the child conceived from their donated gametes.

In May 2011, British Columbia joined the UK,  other European countries and the state of Victoria in Australia in banning anonymous gamete donation.  Germany, likewise, forbids anonymous sperm donation. Italy goes even further, entirely banning the use of donor gametes, regardless of openness.  Interestingly, in Spain, where anonymous sperm donation is allowed, the choice of donor for a recipient is made not by the recipient but by her  medical provider!-  a practice that would be unacceptable in the US.  The wide variation in reproductive laws in various parts of Europe has resulted in another unintended consequence- medical tourism-  in which patients seeking anonymous donors will go to countries which permit anonymity to be inseminated or have IVF.

Anonymity of donations may have another unintended consequence – overuse of some popular and fertile donors.  The existing sperm donor system in the US, unlike Europe, Canada and Australia, is not regulated by federal law, but is subject only to voluntary guidelines published by the American Society for Reproductive Medicine.  ASRM guidelines recommend that sperm donors remain anonymous and that each sperm donor be limited to 25 births per population of 800,000 people. However, ASRM has also reported that most births are not reported to sperm banks so that voluntary donor limits can easily be exceeded. When the vial of sperm arrives in the clinic, it is accompanied by a feedback form that should be sent back to the sperm bank by either the lab, the physician office or the recipient when the outcome of the insemination is known. However, many times, if not most times, this form is not sent back because the initial positive pregnancy result is not known for two weeks and the final live birth outcome is not know for up to 9 months.  If there is no penalty for not reporting and no incentive to make the effort in today’s already over-burdened health care system, it should not surprise anyone that these forms are lost, forgotten or even discarded upon arrival because it is no one’s job to report the outcomes. How many kids could this affect? No one knows because births are not tracked very well but estimates range from approximately 30,000 to 60,000 sperm donor births a year.

On Sept 6, 2011, the New York Times published an article called “One Sperm donor, 150 offspring” which highlighted the inevitable result of weak to non-existent reporting of donor outcomes and the use of anonymous fertile donors.  Using the Sibling Donor registry, one family found that their donor-conceived child had 150 half-siblings, exceeding ASRM guidelines 6-fold. These guidelines were developed to reduce the probability of accidental consanguinity (incest) of related siblings from anonymous donors and also to prevent the spread of rare disease genes through the population.

The effect of unlimited conception on donors can also be negative; some report feeling betrayed by the sperm banks who told them initially that 5 kids per donor was typical and are then shocked to see that they have fathered many more children then they are comfortable with. According to the New York times article, one donor keeps track of his 70 offspring using a spreadsheet. What does family mean in that scenario? What rights do donor-conceived children have? When do their rights trump the rights of donors and their recipients who made the anonymity bargain before the children even existed?

Anonymity also carries potential medical risks to the children when they are ignorant of the evolving medical family history of their donors.  One recent case of the unintended consequences of anonymity involved a rare aortic defect that was passed on to 9 of 24 children conceived from sperm from the same donor. The donor, who donated sperm in his twenties, did not become aware of his cardiac condition until it almost killed him in his forties. Offspring of that donor were offered genetic testing to see if they inherited genetic mutation that caused the heart defect. One of the nine children who inherited the gene died as a toddler. Two other children, teenagers now,  have lingering medical problems and are, like their donor,  at risk of sudden cardiac death.

Because neither recipients nor donors can predict what medical or personal information needs a donor-conceived children may have in the future, it seems that at the very least, we should choose donors who are willing to open that door to the child when they reach adulthood.

In Mississippi, the Supreme Court approved a ballot initiative that, if successful, would define a fertilized egg as a human being. Specifically, if approved by the voters, the new law reads“The term ‘person’ or ‘persons’ shall include every human being from the moment of fertilization, cloning or the functional equivalent thereof.”

I blogged about this topic previously in the post “Reproductive Bills in the News” when Oklahoma tried (and failed)  to pass a similar bill. There are two problems with this legislation. First, it is based on assumptions about embryo biology that are not accurate. In order for a human being to be equivalent by definition to a fertilized egg, every fertilized egg must ultimately result in a living human. Those of us who work with human embryos every day know that many fertilized eggs do not result in human beings and that embryos can fail to continue their biological path at steps both early or late, before and after implantation in the uterus. Embryos routinely fail to cleave into multi-cellular organisms and can stay at the 2PN (fertilized egg) stage until they deteriorate. If they cleave once, there is no guarantee that they will cleave a second or third or thousandth time.

Furthermore, it is possible for an egg to start to divide after being chemically activated or stimulated by the intrusion of an additional sperm, both events that create embryos that are destined to end in failure, never ultimately creating any recognizable human being by any currently accepted definition. Yet these dividing embryos with no potential would be defined as “human beings”by this bill because it doesn’t even require normal fertilization but allows “cloning or equivalent thereof” to satisfy the requirements of fertilization.

The second problem with these attempts to define fertilized eggs as human beings is due to “unintended consequences” on current medical treatments. For instance, normally fertilized eggs that implant in the Fallopian tube instead of the uterus can not result in a living human because the embryos developmental program is doomed to fail if the embryo is not in the uterus. But before it fails, an embryo growing in the Fallopian tube will often cause a rupture of the tube and possibly fatal unstoppable bleeding in the  pregnant woman.

The only treatment for this deadly medical condition (ectopic pregnancy)  is to sacrifice the embryo by removing it (and often the tube) or by causing the embryo’s demise and reabsorption by the body by administering a cytotoxin. Remember that the ectopically growing embryo is doomed regardless of whether it’s mother lives or dies but if this embryo is legally a person, current treatments to save the mother would be legally defined as murder, not medicine,  and the mother would be doomed to die as well. Surely this is not what the citizens of Mississippi want?

Other possible repercussions from passage of these personhood laws is that common  in vitro fertilization procedures would likely not be legal. High pregnancy rates currently enjoyed by US IVF patients are due in large part to the fact that multiple eggs are recruited, fertilized and allowed to grow in vitro to a relatively advanced blastocyst stage, at which point the embryo is ready to successfully implant in the uterus. Having more fertilized eggs to start with than you are willing to transfer allows selection of the most robust embryos which increases the pregnancy rate. Ironically, medical treatments such as IVF which are designed to create human beings when other avenues to reproduction are closed could very well be rendered illegal by these so-called  “pro-life” personhood laws.

Excess embryos are created along the way in the current medical practice of IVF. These excess embryos are typically frozen for possible future use. Some of these frozen embryos may be ultimately discarded once the patient’s family is complete. If every embryo is arbitrarily defined as a human being, I expect that patients would lose the right to discard excess embryos because how do you “discard” a human being? You can’t. Patients would  have to cryopreserve them forever, making estate plans to continue cryopreservation and storage for generations after the originators of the embryos are deceased. There is no known “expiration date” for frozen embryos.   In Italy, where restrictions on IVF limit the number of eggs that can be fertilized to three and do not allow embryo freezing (only egg freezing), pregnancy rates are much lower than the average rates in the US because there is no natural selection of the most robust embryos for transfer.

Lab accidents causing the unfortunate demise of an embryo such as accidentally dropping a dish, failure of a freezing tank  or simply routine culling of  non-clinical (abnormally fertilized) embryos could all be re-classified as a kind of manslaughter under this redefinition of fertilized egg as person.

The article “Will Mississipi Ban IVF?” by Michelle Goldberg discusses the possible impact of personhood amendments on how IVF is conducted (or banned)  in Mississippi. Personhood USA, a political group is trying to get similar measures on ballots in Arkansas, Nebraska, Oklahoma, North Dakota, Montana, Colorado, Florida, Oregon, and Ohio. In the US, we have historically put a high premium on patient autonomy and held sacred the physician-patient relationship. Should our government be able to dictate the most personal reproductive decisions that its citizens’ make? In my humble opinion, laws that arbitrarily restrict medical practice and patient autonomy while preventing life-saving treatments really have no place in the United States.