Our laboratory guide for you and your embryos

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1 Lab guide

2 Our laboratory guide for you and your embryos We hope that this guide will give you a better understanding of the journey you and your embryos will take through our laboratory, and help you contribute positively towards your treatment. We are with you every step of the way. Each day is described in detail, starting with the day of egg collection. Contacting the IVF Laboratory: Direct telephone: We routinely call patients between 8am and 10am daily. If you are waiting for a call from an embryologist to update you on your embryos then please wait until after 10am before calling if you have not heard from us.

3 Day 0 Day of egg collection Today your eggs will be collected and the semen specimen will be prepared for insemination. After egg collection we will confirm with you the number of eggs collected, the quality of the semen prepared, and the chosen method of insemination. We will also confirm the most likely time the embryologist will call you tomorrow to report on your eggs fertilisation. Based upon the quality of the semen sample and your reproductive history, one of two treatment options for the insemination of your eggs will be used today: 1. In-vitro fertilisation (IVF) 2. Intra-cytoplasmic sperm injection (ICSI) Following the result of your semen analysis at your initial consultation you would have already been told the most likely treatment option from the two listed above by your lead consultant. 1. IVF Your semen sample is prepared for insemination by washing, removing unwanted cells and debris. If the semen parameters are normal on the day of egg collection and the specimen prepares well, we will inseminate your collected eggs by IVF. 2. ICSI Couples requiring ICSI will normally be advised of this treatment option at the time of initial consultation based on their past history and/or semen analysis with us. Please note that we may need to recommend ICSI if the semen sample you provide on egg collection day is significantly poorer than in previous samples. ICSI is a method by which a single sperm is selected and injected into a single egg under microscopic control. This method assists sperm which may otherwise struggle to fertilise the eggs when using conventional IVF. Only mature eggs with the capacity to be fertilised by sperm are able to be injected using ICSI. Following the injection procedure, the inseminated eggs are stored in the incubator overnight, and we check for signs of fertilisation tomorrow morning. On average, as with IVF, we expect 60-70% of injected eggs to fertilise normally. This average may be slightly lower for men who have undergone surgical sperm retrieval or for frozen-thawed samples. Please note that ICSI is necessary for all patients booked for surgical sperm retrieval. In IVF a known concentration of prepared sperm is added to your collected eggs, and these are then left overnight in the incubator to allow time for the sperm to fertilise them. On average, we expect 60-70% of eggs collected to fertilise normally. Please do not worry if the semen sample provided on the day of egg collection is significantly poorer than your previous analysis, as under such circumstances we can convert the treatment to that of ICSI instead. If these circumstances present, we will discuss the situation fully and guide you and answer any questions you may have. IVF insemination Intra-cytoplasmic sperm injection

4 Day 1 Day after egg collection Day 3 Three days after egg collection Regardless of the method of insemination carried out yesterday afternoon on the day of egg collection, all eggs are checked for signs of fertilisation this morning. Signs of normal fertilisation We look for the presence of two small circular structures (see picture top right) called pronuclei (PN) inside each inseminated egg (each partner contributes one pronucleus). From this stage onwards, only eggs with normal signs of fertilisation are kept. All unfertilised/ abnormally fertilised eggs (e.g. too few or too many pronuclei, see the image to the right) are discarded. We will call you with the fertilisation news as soon as we have checked the eggs in the morning. Today we will call you by 12 noon. If you have not heard from us by 12 noon, please call the laboratory on our direct line Day 2 Two days after egg collection This morning we will check if your normally fertilised eggs (embryos) have developed further and are growing at the expected rate for their age. Today, we expect your embryos to be between two and four cells. We will call you in the morning, normally between 8am and 10am, to update you on their progress and we will give you an indication of their quality. We use a grading system ranging from 1 to 4 based upon a number of criteria as assessed under the microscope. A normally fertilised egg An abnormally fertilised egg with too many PN Your embryos will be checked again on the morning of day 3 and we will call you to update you on their progress. For the majority of patients this is the morning when we will decide with you whether your embryo transfer should take place today or in two days time on day 5. In anticipation of a possible embryo transfer on day 3, it is important that you make arrangements to be able to come to the clinic at short notice if advised to do so by the embryologist. Today we would expect your embryos to have divided further from yesterday, ideally between six and eight cells, and be of a similar or improved quality to yesterday. If you have a group of embryos developing at the expected developmental stage this morning and of good quality (grades 1 or 2), we will recommend culturing your embryos in the laboratory for a further two days to the blastocyst stage (day 5). This is because when there are a number of embryos growing at the same speed and of similar quality it is often difficult to predict which embryo/s will give you the best chance of achieving a pregnancy. So leaving your embryos for two extra days to develop further in the incubator will allow us to see which have the true potential to succeed. Day 3 embryo transfer If on checking your embryos this morning it is obvious which is the strongest embryo/s from the group, then the necessary laboratory selection has been made and we will advise you to come in for your embryo transfer today. We will continue to culture any remaining embryos not transferred today for a further two days. If by day 5 any of your remaining embryos have developed into good quality blastocysts then there will be the added opportunity, with your consent, to freeze your blastocysts for replacement at a later stage. A seven cell embryo Ideally we like embryos to be at the top end of the range in quality (either grade 1 or 2), but we do not expect all embryos to be of good or equal quality. Pregnancies are still obtained in patients with only average grade embryos such as grades 2-3, and even with poorer quality embryos such as grades 3 and 4. Day 4 Four days after egg collection The most important criterion today is that your embryos have started to grow. Day 2 embryo transfers Transfers will take place today for patients with a small number of fertilised eggs and in those cases where it is obvious which embryo/s are to be selected for transfer. A four cell embryo Today we will not look at your embryos, whether they are leftover embryos from day 3 transfer or embryos still being cultured for transfer on day 5. This is because there is limited information we can achieve by looking at embryos on day 4 so they are best left undisturbed in the incubator. You will not therefore receive a call today. A day 4 embryo

5 Day 5 Five days after egg collection Blastocyst transfer By day 5 your embryos should have developed into blastocysts which look very different to the earlier cleavage stage embryos. The blastocyst is an embryo that has reached the stage of development where it is ready to hatch and then implant in the lining of the womb, just as in natural conception. Two clear structures can be seen in a blastocyst: a group of cells called the inner cell mass which progress to form the fetus, and the cells lining the periphery (the trophectoderm cells) which develop into the placenta. As blastocysts are more advanced embryos than cleavage stage embryos, we know their potential to implant is higher. Therefore we will replace just one blastocyst in those female patients below 38 years of age. This will both maximise the chances of delivering a healthy baby and minimise the risks to both mother and baby which are dramatically increased in multiple pregnancy. Blastocyst freezing Good quality blastocysts may be frozen on day 5 or day 6, if you have consented to freezing. These could be blastocysts from today s transfer or those that have progressed following a day 3 transfer. We only freeze good quality blastocysts that have the potential to produce a pregnancy, in order to maximise your chances of success in a later frozen embryo replacement cycle. Single embryo transfer (SET) The aim of undergoing infertility treatment is the birth of a healthy baby with minimal risks during pregnancy. To achieve this does not necessarily mean that more than one embryo needs to be replaced. Twins or triplets can appear to be the ideal outcome when having infertility treatment, but multiple pregnancy is the biggest health risk for IVF babies. One in every twelve twin pregnancies results in at least one baby dying or having a significant disability. The Herts & Essex Fertility Centre are pioneers in blastocyst culture and transfer. Thanks to our wellestablished and extremely successful blastocyst programme, we are able to reduce the number of embryos replaced to just one in a select group of patients. These are the patients we have identified most at risk of a multiple pregnancy. The replacement of one blastocyst in these patients will not compromise the excellent chances of success but will act to safeguard both mother and baby from the risks of multiple pregnancy outlined opposite: An expanded blastocyst Increased risks to babies from multiple pregnancy: premature birth perinatal mortality neonatal care respiratory distress cerebral palsy delay in language acquisition disability Increased risks to mothers from multiple pregnancy: miscarriage hypertension pre-eclampsia gestational diabetes For further information relating to the risks of multiple birth please visit congenital malformations Currently our policy is to transfer just one top quality blastocyst for the following groups of patients having a blastocyst transfer: patients under 38 years old on their first, second and third attempts egg donors egg recipients patients at risk of ovarian hyperstimulation (OHSS) Many patients mistakenly believe that replacing just one blastocyst instead of two will dramatically lower their chances of falling pregnant in the first instance. Actually, adding a second blastocyst does not greatly enhance your chances of becoming pregnant, but it will significantly increase the risk of having a multiple pregnancy, and with it the associated risks. This is clearly supported in the data shown in the graph (right): Single Blastocyst n CPR - clinical pregnancy rate 56.0 Double Blastocyst n MBR - multiple birth rate This data includes all patients less than 38 years old having a blastocyst transfer between 1 Jan 2011 and 31 Dec 2012.

6 Advice following embryo transfer Following the embryo transfer it is vital that you continue your medication as instructed and prescribed, until the date of your pregnancy test. The pessaries, taken daily, morning and evening, act to thicken and maintain the lining of the womb in preparation for embryo implantation. The pessaries can be taken either vaginally or rectally. Please ensure you contact the nurses with the result of your pregnancy test, who can advise and prescribe any further medication where indicated. The pessaries you will be taking act to maintain the lining of the womb, and for this reason it is unlikely that you will bleed heavily prior to the pregnancy test. Some spotting may occur during the few days following embryo transfer and before the pregnancy test, and some period-type pain can be experienced. This is quite normal. If sanitary protection is needed please use sanitary pads and not tampons during this time. For any discomfort, paracetamol may be taken, following the dosage instructions on the packet. Should you have a heavy period-like bleed please contact the nurses for advice; you will still need to continue your pessaries until the date of your pregnancy test, and must carry out a pregnancy test regardless of any bleeding experienced. You will be given the date of the pregnancy test in your summary sheet handed to you by the embryologist at embryo transfer. The test is 14 days from egg collection, and the first morning urine sample must be used to ensure an accurate result is given. Please do not be tempted to test early, as the hormone present in the Ovitrelle injection interferes with the pregnancy test and may give a false positive reading. By waiting the two weeks we can ensure the result is due to a pregnancy, as the drug will be out of your system by this time. Please purchase a pregnancy test kit from a local pharmacist. We recommend a non-digital test kit be used for your pregnancy test. There may be circumstances where a blood test is necessary or indicated and we will advise you accordingly if you require a blood test on the date of your pregnancy test. Other recommendations: You should continue to take folic acid tablets daily The pessaries can cause bloatedness and constipation; please ensure your diet contains plenty of fruit and fibre to help prevent this, and keep hydrated The antibiotics taken from the day after egg collection can sometimes upset your stomach and cause nausea and vomiting. For this reason you should take the antibiotics with food. If you have repeated problems caused by the antibiotics these may be stopped prior to completing the full course after speaking to a nurse. The antibiotics act to prevent any risk of infection following egg collection, which is a very minimal risk You should not smoke or consume alcohol You should avoid eating foods containing uncooked eggs, soft pâté and blue-vein cheese Recent research evidence suggests that semen promotes implantation, however we advise that you wait at least 12 hours after embryo transfer before sexual intercourse You should avoid any heavy lifting or strenuous activities. Gentle exercise can be continued, and this will promote blood flow which is important. Wherever possible we recommend you continue with your normal daily activitites We do not recommend women to have their hair dyed; the chemicals are absorbed straight into the bloodstream We do not recommend swimming due to the possible risk of infection Try to avoid activities which will significantly raise your body temperature, e.g. extremely hot baths/saunas/steam rooms For those patients at risk of hyperstimulation who have had a large number of eggs collected/numerous follicles, please refer to the information provided, when you were placed for egg collection, instructions for Ovitrelle for reference purposes and advice Should you experience any problems following the embryo transfer, please speak to one of the nurses for advice. Please note the on-call nurses mobile is and is for EMERGENCIES ONLY. All other calls should be made during normal opening hours.

7 HERTS AND ESSEX FERTILITY CENTRE Bishops College, Churchgate, Cheshunt, Hertfordshire EN8 9XP T: E:

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