What Can Blastocyst Do For You?
The advantage of a day 5 blastocyst transfer has to do with selection. These days most reputable programs are putting 2 embryos back in youngish women (I know what you’re thinking, but we’ll skip the octo discussion). Anyway, let’s say you’re lucky and have 5 nice embryos on day 3. Even though some may look a litter nicer than others, we really may not be able to tell which embryos are the best ones. So, we can wait 2 more days. In that time, some embryos may not grow well, but probably those embryos would not have survived in the uterus anyway.
The advantage here is that the embryos that do survive are probably stronger, and these can give you a better chance of pregnancy. It’s like a stress test, those that pass are probably better. One of my partners puts it nicely: just because a horse is leading ½ way around the track doesn’t mean it’s going to win the race.
But not all programs use the day 5 transfers, and some do it selectively i.e. only in some patients. Why is that? Some of it has to do with initial experience. At NYU, our initial experience was excellent, in fact better than expected, so we felt very comfortable continuing with it and this led to more and more cases and more expertise with time. Other programs had a bad experience initially. They were therefore less eager to increase their blast cases. Once something does not go well, especially in medicine, it’s really hard to go back to it.
Why would there be different experiences in different programs? Hard to say. I am prejudice in favor of the NYU lab, the people are all excellent, but there are other good labs around.
It may have something to do with the media. Media is the nutrient juice we grow your embryos in. We used to make it from scratch (what a pain), but now we buy it. An important factor making blast possible is the media. The old types of media could only support an embryo in culture for 3 days, and some very important changes in media composition were necessary to allow the embryos to grow 2 more days in the lab.
Initially, there was some variation in the new blastocyst media composition and quality, and there were batches that did not grow blastoctys well. So if you were an IVF lab who just happened to start out with an inadequate media batch, your outcomes would be lower, and you would be reluctant to explore blast culture further. Thanks to your lab directors and staff, we had a very careful process of testing media and analyzing which worked best. This allowed up to keep up the embryos quality in the face of variable conditions.
Among the programs that go to day 5, there is considerable variation in their criteria for going to blast. Some IVF centers need you to have 10 nice embryos on day 3 before they will consider growing the embryos longer. Others need you to have 6 day 3s, some 5, etc etc. Programs also put age in the mix; in other words less likely to go to day 5 the older you are. The more comfortable a program is with blastocyst, the softer their criteria will be.
Our criterion is that if you have more embryos than we want to transfer, you go to day 5. We transfer 2 embryos in most women which means if you only have 2 viable embryos on day 3 we do the day 3 transfer. If you have 3 or more, as is usually the case, you go to day 5.
Naturally, the obvious by-product of a good blast program is a lower multiple rate. Getting you better selected embryos, will help you become pregnant with fewer embryos. We started with blastocyst transfer in 1999. At the time we had a 20% of women under 38 had 3 embryos implant and now the rate is 1.9%. And many of those women had 2 embryos transferred, but had one of them split into identical s.
We went from putting in an average of 3 embryos per patient to two. Our pregnant rates would not be as high as they are if we put 2 embryos in on day 3. It’s just too hard to tell which are the best ones on day 3. Besides we have numbers to support our work. The implantation rate per embryo (this is a number that is used a lot. It’s the odds of each embryo sticking) was 34.5% in women under 35 and now its 43.4%.
So if your program is not doing a lot of blastocyst, does this hurt your chances? It really depends on the published pregnancy rates from your clinic. If they have great rates, but don’t do much blastocyst, that’s not so bad. Unless of course they are putting in more embryos per transfer to maintain the higher pregnancy rates. It’s not always easy to predict who will not get pregnant and who will get pregnant with triplets or quads. If you want to avoid 3s and 4s, your best bet is to not take the risk.
Sometimes there can be a diagnostic advantage to blastocyst transfer. If you are not getting pregnant with day 3 transfers, it may be time to try blastocyst. Occasionally, the embryos look much worse on day 5 than they did on day 3. This would not be not good news but at least you would know where you stand. It is also possible that they look just ok on day 3, but perk up very nicely by day 5, and this information might be of help to you.
Thanks for reading, and please see disclaimer 5/17/06.
Dr. Licciardi
The advantage here is that the embryos that do survive are probably stronger, and these can give you a better chance of pregnancy. It’s like a stress test, those that pass are probably better. One of my partners puts it nicely: just because a horse is leading ½ way around the track doesn’t mean it’s going to win the race.
But not all programs use the day 5 transfers, and some do it selectively i.e. only in some patients. Why is that? Some of it has to do with initial experience. At NYU, our initial experience was excellent, in fact better than expected, so we felt very comfortable continuing with it and this led to more and more cases and more expertise with time. Other programs had a bad experience initially. They were therefore less eager to increase their blast cases. Once something does not go well, especially in medicine, it’s really hard to go back to it.
Why would there be different experiences in different programs? Hard to say. I am prejudice in favor of the NYU lab, the people are all excellent, but there are other good labs around.
It may have something to do with the media. Media is the nutrient juice we grow your embryos in. We used to make it from scratch (what a pain), but now we buy it. An important factor making blast possible is the media. The old types of media could only support an embryo in culture for 3 days, and some very important changes in media composition were necessary to allow the embryos to grow 2 more days in the lab.
Initially, there was some variation in the new blastocyst media composition and quality, and there were batches that did not grow blastoctys well. So if you were an IVF lab who just happened to start out with an inadequate media batch, your outcomes would be lower, and you would be reluctant to explore blast culture further. Thanks to your lab directors and staff, we had a very careful process of testing media and analyzing which worked best. This allowed up to keep up the embryos quality in the face of variable conditions.
Among the programs that go to day 5, there is considerable variation in their criteria for going to blast. Some IVF centers need you to have 10 nice embryos on day 3 before they will consider growing the embryos longer. Others need you to have 6 day 3s, some 5, etc etc. Programs also put age in the mix; in other words less likely to go to day 5 the older you are. The more comfortable a program is with blastocyst, the softer their criteria will be.
Our criterion is that if you have more embryos than we want to transfer, you go to day 5. We transfer 2 embryos in most women which means if you only have 2 viable embryos on day 3 we do the day 3 transfer. If you have 3 or more, as is usually the case, you go to day 5.
Naturally, the obvious by-product of a good blast program is a lower multiple rate. Getting you better selected embryos, will help you become pregnant with fewer embryos. We started with blastocyst transfer in 1999. At the time we had a 20% of women under 38 had 3 embryos implant and now the rate is 1.9%. And many of those women had 2 embryos transferred, but had one of them split into identical s.
We went from putting in an average of 3 embryos per patient to two. Our pregnant rates would not be as high as they are if we put 2 embryos in on day 3. It’s just too hard to tell which are the best ones on day 3. Besides we have numbers to support our work. The implantation rate per embryo (this is a number that is used a lot. It’s the odds of each embryo sticking) was 34.5% in women under 35 and now its 43.4%.
So if your program is not doing a lot of blastocyst, does this hurt your chances? It really depends on the published pregnancy rates from your clinic. If they have great rates, but don’t do much blastocyst, that’s not so bad. Unless of course they are putting in more embryos per transfer to maintain the higher pregnancy rates. It’s not always easy to predict who will not get pregnant and who will get pregnant with triplets or quads. If you want to avoid 3s and 4s, your best bet is to not take the risk.
Sometimes there can be a diagnostic advantage to blastocyst transfer. If you are not getting pregnant with day 3 transfers, it may be time to try blastocyst. Occasionally, the embryos look much worse on day 5 than they did on day 3. This would not be not good news but at least you would know where you stand. It is also possible that they look just ok on day 3, but perk up very nicely by day 5, and this information might be of help to you.
Thanks for reading, and please see disclaimer 5/17/06.
Dr. Licciardi
posted by Dr. Licciardi at 10:31 AM
18 Comments:
Thanks for this interesting post!
Two questions about blasts, though:
1) I've been told that cryo'd blasts aren't as sturdy as day-3 embryos. Any perspective on this?
2) Pop survey question: what's better, a day-5 3BB or a day-6 4AA?
3) If a clinic has decent fresh statistics but poor (or just nearly nonexistent) frozen stats, is there benefit to having your frozen embryos transferred to another clinic? Is it more likely to be freezing technique or defrosting/transfer technique?
Thanks very much for any insight you can give!
Thank you for this site! I am 42 and planning IVF in August and knowing as much as possible helps in the process. Secondary infertility is my diagnosis (which in itself is so frustrating!) and we have a 4 year old son that I conceived naturally. All my tests are good (FSH of 4.3) and my husband's SA is also normal, so IVF seems to be our only option. Thank you again for your time in making this information available. I do have one question though - how can I find the success rates for my doctor in Canada?
This was a great post - thank you!
You posted back in November '06 about single embryo transfers and suggested that a preliminary study showed that in those with good prognosis, single embryo transfers had about the same pregnancy rates as two embryo transfers. In the 2-1/2 years since, how has this field progressed? Especially in relation to blastocyst transfer? More specifically, frozen blast transfer?
I am also curious to hear your thoughts about elective single embryo transfer with a good blastocyst. I did 7 IUIs with no success, then had success with eSET on IVF #1. It was very hard to choose to transfer only one, given that the "norm" is 2 and we wanted a baby so very badley, but we were concerned about premature birth and wanted to give eSET a shot first.
This was a very interesting and informative post and I've been around the block at least a time or two on IVF and your column was highly informative and gave information I haven't seen presented before. Thanks.
Great post. I have done ivf 8 times with 1 bio chemical preg. I am waiting to hear on Friday if I will go in for day 3 or wait for a day 5. I had 16 embryos yesterday. I was wondering what was best??
Hello Dr
Please could you answer my question. We have been trying for a baby for 12 months now. I have had bloods and scans which were all fine. My husband has sperm count of 143 million with 40% motility and only 2% normal morphology. The first doctor we saw wasn't concerned about these results and told us to continue trying. Another doctor has sadi we may need ICIS. We would really love to get pregnant naturally. What do you think our chances are?
Thank you
MRS W
Clomid 50mg for 3 mths, 100mg for one month. Normal periods since they began between 26 - 32 days. Started with an RE on 4/21. FSH level was 5.5, all other bloodwork was normal. HSG was clear (according to Dr performing test and my Dr looking at films). S/A is normal as well.
We do not have any coverage for IF. Dr. is looking to do IUI with Bravelle and Orivdel. I have two children already (1 with my husband) ages 16 and 2. I just turned 37 and I am concerned about success rates with IUI. Is there any way to predict the probability/or success rates of IUI? If $$ was a factor, would you recommend going right to IVF, or try once/twice with IUI??
Dr Licciardi, thank you! I've just spent the last week reading your blog from beginning to end and it was so informative. Your care and compassion is clear in your words.
I would like your honest opinion, if you have time.
I'm 43, unexplained (but suspected andometriosis and PCO), have had 6 failed fresh cycles but have got pg with 2 frozen cycles (1 nat m/c, 1 missed m/c). We've been trying for 7 years and have had every test under the sun, including immune and everything is normal. My FSH is around 7 and I have always managed 9-14 eggs with aprox 65% fertilisation and blastocysts. My lining is thin around 5/6mm (triple layer). I have 4 frosties (my last chance) and I am worried about wasting them. I don't know if I should have them put back or find a surrogate. I don't know if my eggs are abnormal and whether I should try donor or if it is a waste of time with my lining issues. My gynae sees no reason (apart from difficulty with my lining) why we can't get pg natuarally!
If you have any insight I would be most grateful.
Dr. Licciardi,
Thank you for a very informative blog. I posted my question in comments to your Oct. 04, 2008 blog where you wrote about lupron but I do not know how this blog works and will you ever read new comment to some previous post. As the part of infertility treatment I have taken lupron micro dose - 20 units a day (10 in the morning and 10 in the evening) for 10 days from April 15 to 24. My response was worse than without lupron. While on lupron (I took also Gonal F and Menopur) I had headaches and cold sweating immediately after starting the treatment, memory loss and too frequent urination.
Since I stopped lupron about 2 weeks agoI am much worse - I have cold sweat all the time, some kind of very unpleasant tingling in my face and upper part of head 24 hours a day and weird feeling between my my breasts that I don’t know how to describe. It feels like I have hot iron on my chest 24 hours what makes me me very nervous. I was always very calm and patient person. Also I have a pain in ovaries and uterus, still too frequent urination, my memory is worse than ever and I lost 3 pounds in about 10 days - I think it is just liquid that I lost from my body. I still did not get my period - stopped taking lupron on April 24. I read about side effects of lupron before I took it (obviously I did not read enough) but I believed my doctor that I would be OK.
My doctor has told me that I have taken 1/20 of lupron depot dose. He also told me that side effects I have are not caused by lupron, which I’m sure is not true. I called two pharmacies for infertility drugs and I was told that 20 units is equal to 1 mg. Does that means that I have taken 10 mg of lupron (50mcg is written on the bottle). Both pharmacists did not know how much is that compared to lupron depot which is given in 3.75 mg shots. Is lupron micro dose less strong than lupron depot even if the quantity I took in 10 days seems to be higher? I feel worse and worse every day. I feel like I am in menopause. Could you please tell me what time it takes usually for Lupron to get out of the body (if it ever leaves)? Is there anything I could take to make symptoms – especially cold sweat, burning in my chests and tingling in my face/head less severe? I am completely desperate, from trying to get pregnant I am now fighting to survive every single day. Side effects of Lupron are horrible.I know this letter is messy – I cannot think clearly any more. It is not worth living like this. Thank you for your time. I wish I have found your blog earlier.
I read your post from May 2006 regarding sperm morphology. I can't tell you the comfort it gave me. My husband's S/A was very poor. volume 2.2ml count 35.2 million motility 35% morphology 1% (strict criteria)
Do we have a shot at IUI working for us?? We can only afford to do 2 cycles (at most)?? Or, should we save the $8,000 (cost of 2 IUIs) and go for IVF??
After my postcoital test we found out that I have anti-sperm antibodies. Will I always have this or can it go away? I have IUI on Monday!
I have a question... My husband has fragmented DNA in his sperm.. Dr. says best chance is IVF. I have had 3 previous miscarriages. No babies.. Nothing wrong with me as far as they can find. Will IVF increase my chances of a baby???
Dr. L,
Thanks again for your blog. I do not have a blast question, I am just at a loss after three chemical pregnancies.
I have done 3 IVFs with a good clinic - not a lot of eggs retrieved, husband had vasectomy 15 years ago, did PESAs and ICSI. We had crappy fert rates - 50% at best - and I got pregnant with two of the IVFs - chemical pregnancies both times. First time at 4w4days, second time at 4w. 3rd IVF was negative. My RE felt it was the sperm - almost motionless, abnormal shape, etc. so we did one IUI with donor sperm - natural - and I got pregnant and had another chemical pregnancy even earlier - did not make it to 14dpo.
What do you think of 3 chemical pregnancies in a row - we have done some RPL testing, hsg, karotyping (results on karotype pending) and everything is coming back as normal.
I am so frustrated and I really am at a loss. I may have endo - horrible periods in the past and went on pill to help - would you recommend a laparoscopy? Also, if this next natural IUI does not work, would you recommend skipping clomid and moving straight to injectables?
Thanks again.
Thanks for the great blog!
I am 36, and in month 4 of trying naturally. I'm an ultrasound technician and have been monitoring my ovaries very closely around ovulation, so I know exactly when I ovulate and our timing is very good. I ovulate every month between days 13-15, my luteal phase is normal, and my uterus and ovaries have no abnormalities visible with US. For primarily financial reasons, I am eager to get on with the process (I would like to try to coordinate potential expensive procedures with my flex spending account for 2010).
It seems to me that my chances of getting pregnant naturally at this point are pretty low, so would it be adviseable or not to start clomid and/or further testing earlier than the 6 month mark?
Thanks for taking the time to answer our questions!
Hi Dr. Licciardi!
First of all, your blog is incredibly helpful, informative and comforting - thank you so much for taking the time to assist women all around the world! I am about to start a new protocol after two failed IVF cycles. Our first cycle was converted to an IUI due to poor response (5 follicles, all growing poorly), and our second IVF (flare protocol) resulted in the transfer of just one, 12 celled embryo on Day 3 (6 eggs retrieved, three immature, three ICSI’d, with only one fertilized). For our next cycle, my RE is placing me on the antagonist protocol, and adding estrogen priming (at my request - the clinic rarely, if ever, has done estrogen priming). You have briefly mentioned estrogen priming at various points in your blog - and I am wondering if you might give your views on this procedure. I have concerns that I was oversuppressed for both of my previous cycles, and yet I am still scheduled to take birth control pills for 21 days prior to stimming - according to the RE, it’s because bcps are part of the estrogen priming protocol. I would be highly interested in your thoughts on this matter.
Many thanks in advance for your response...
-Springroll
Thanks a lot Dr Licciardi. I would like to ask you a question. I'm about to perform my first FIV/ICSI. My Dr preferred to do day5. I ask her to include co-culture with green monkey cells but she said no "this time"... I would like to put all the energy in this so, what is the check point to include it or no?
Thanks a lot for your time!!!
Natalia from Argentina
Thank you for passing along the information. It is very useful
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