Tag Archives: Embryo Transfer

Dr Shantabai Gulabchand Oration on Cross-Border Reproductive Tourism at the ET2010, Lavasa

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Indian IVF bill may stop gay couple surrogacy

In the name of the fathers ... John Allen-Drury, left, and his partner, Darren, nurse their son, Noah, who was born in India using a surrogate mother. Photo: Graham Crouch

If the parents of newborn Noah Allen-Drury are lucky, their son will sleep through the noise as their flight from India lands in Sydney this morning.

Noah’s gay parents, however, are aware of legal turbulence that could prohibit the surrogacy arrangements that fulfilled their wish for a child.

A growing number of male couples from Australia and other Western countries are hiring surrogates in India to bear children, but that might no longer be possible if a draft bill to regulate IVF in India becomes law.

R.S. Sharma, the secretary of the committee writing a bill to govern assisted reproductive technology (ART), told the Herald that unless gay and lesbian relationships are legalised in India, gay couples would be excluded from hiring surrogates.

Delhi’s High Court recently overturned a 150-year-old section of the country’s penal code that outlawed ”carnal intercourse against the order of nature”.

However, gay activists warn this ruling, which in effect decriminalised sodomy, does not legalise gay relationships, leaving the status of such relationships unclear.

“If our government does not permit gay relationships, then it certainly will not be permitted for foreign gay couples to come to this country and have a [surrogacy] agreement,” said Dr Sharma, who is the deputy director-general of the reproductive health and nutrition division at the India Council of Medical Research.

John and Darren Allen-Drury, who live in the Blue Mountains, raced to India earlier this month when their surrogate mother entered labour. She gave birth to Noah on April 8. John Allen-Drury said changes to India’s laws would be a great disappointment, if passed.

”It would prevent a lot of same-sex couples from coming here,” he said.

Although some gay couples sought surrogate mothers in the United States and Thailand, ”India really is the closest country to Australia that offers affordable surrogacy,” he said.

The draft bill could make it difficult for all Australian couples to use Indian surrogates.

One stumbling block would be a requirement that foreign countries guarantee they will accept the surrogate child as a citizen – before a surrogacy could begin.

Dr Sharma said foreign couples would have to obtain a document from their embassy or foreign ministry pledging the surrogate child citizenship of their country. “Only then will they be entitled to sign an agreement with a surrogate or an ART clinic,” he said.

Parents using a surrogate would also be obliged to accept the baby even if it was born with abnormalities.

”Under the Australian Citizenship Act, there are no guarantees,” a spokesman for the Department of Immigration and Citizenship said on Friday. ”What you can infer from this is that while it’s not illegal, we certainly wouldn’t be encouraging it by giving a rubber stamp to anyone who entered into such an agreement.”

Mr Allen-Drury said surrogacy in the US cost $200,000 or more. In India the arrangements could be made for $40,000 to $50,000. Thailand’s laws were changed last year to stop surrogacies for same-sex couples, although it remains legal for single males.

Mr Allen-Drury said a requirement for the Australian government to guarantee citizenship before a surrogacy could begin was impractical. ”That would just close the door,” he said.

Trevor Elwell and his partner, Peter West, have twin girls, Evelyn and Gaia, from a surrogate mother in Mumbai. Mr Elwell predicted parliamentary inertia meant the Indian laws were months or years off. But he was concerned that interim guidelines could be adopted and, in effect, exclude same-sex couples.

Mr Elwell said the citizenship proposal could pose an insurmountable hurdle.

”If you want to do that process earlier and confirm citizenship, you’re going to have to have a government process upfront,” he said.

The demand for a guarantee of citizenship meant the Australian government would have to grant it on the basis of a contract it did not recognise.

”It is a bit of a tangle, so it might affect heterosexual couples in the long run,” Mr Elwell said.

Since the publicity after they got their twins, Mr Elwell and Mr West say they have helped more than 100 couples – some gay, some straight – arrange a surrogate mother in India.

”The tip of the iceberg may have been us.”

 Source: The Sydney Morning Herald (26 April, 2010)

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The success rates of gestational surrogacy cycles

In India, especially in Mumbai, gestational surrogacy is helping many couples have children, which may not have been possible in the past.

At Rotunda, we have tripled our gestational surrogacy cycles in 2008, in conjunction with achieving exceptionally high success rates. Our success rates with fresh surrogacy cycles average around 50% per embryo transfer, and are as high as 70% per embryo transfer in cases where eggs from our young healthy donors are used.

Results of last six months’ surrogacy cycles at Rotunda:

Month (2008)

No. of Cycles

No. of Pregnancies

Pregnancy rate per transfer (%)

May

8

5

62.5

June

8

3

38.0

July

15

9

60.0

August

14

5

36.0

September

11

5

45.5

October

11

8

72.7

 

surrogacy-cycles

We understand that when a couple fails to achieve a pregnancy with surrogacy, the situation can be quite overwhelming due to the high expectation of success and the substantial drain on financial resources. Our team is always cognizant of these realities and every attempt is made to work with couples in the event of failure to help them realize their goal of building families.

Since there are potentially significant legal, financial, ethical, and psychological issues with surrogacy, couples should work with centers that have experience in selecting surrogate mothers and provide the infrastructure to deal with these issues. 

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The Frozen Embryo Transfer

Frozen Embryo Transfer (FET)

If you have recently gone through infertility treatments or if you are considering undertaking IVF, you may be wondering what will happen to any extra embryos that are created during the procedure. If you and your partner have extra embryos that are not used during initial IVF procedures, these embryos can be frozen and then transferred to your uterus at a later date. Known as frozen embryo transfer (FET), this procedure has helped many couples facing infertility achieve pregnancy.

What is Frozen Embryo Transfer?
This procedure takes embryos that have been frozen for a period of time and replaces them into your uterus after they have been thawed. FET is a relatively non-invasive procedure, which is why many couples choose to have it performed. It can be successfully performed on women who are experiencing either natural or controlled menstrual cycles.Why Choose Frozen Embryo Transfer?
Many couples choose to have FET performed if they have had extra embryos remaining from an initial IVF cycle. Some couples do not like the idea of destroying embryos simply because they are “left over” from an IVF cycle. Other couples know or suspect that they will need to do IVF again in the future and prefer to freeze their embryos in order to make future IVF cycles less stressful physically for the female. 

In order to perform IVF, numerous embryos are created in order to ensure that healthy and viable embryos are available for transfer. Many couples decide to freeze some of these embryos in order to allow them the opportunity to get pregnant again in the future or for use in a later IVF cycle. 

Embryo Freezing
The FET procedure involves having your embryos frozen, or cryopreserved. The freezing procedure is as follows:

 

  • Your embryos are placed inside of special glass vials, that look much like straws.
  • These embryos are then mixed with a special solution, called cryoprotectant. This cryoprotectant prevents ice from forming in between the cells of your embryo.
  • The glass vials containing the embryos are then inserted into a controlled freezer filled with liquid nitrogen.
  •  They are cooled slowly until they reach a final temperature of -196° C.

 

Embryo Thawing
Before FET can take place, your embryos must be thawed after the freezing process. When your reproductive endocrinologist decides it is time to begin the FET procedure, your embryos will be removed from the freezer and thawed.

 

  • The embryos are allowed to thaw naturally, until they come to room temperature.
  • The embryos are then steeped in four separate solutions to help remove any cryoprotectant used during the freezing process.
  •  Your embryos are then warmed to body temperature (37°C) and mixed with a small amount of culture medium.

The Frozen Embryo Transfer Procedure

The FET procedure is actually fairly straightforward. 

Before Embryo Transfer
Before your embryos can be thawed and transferred, you and your reproductive endocrinologist need to decide how many embryos to transfer into your uterus. The number of embryos transferred will directly impact the success rate of the FET procedure. Typically, between three and four embryos are transferred during each FET procedure.

Your health care provider will then monitor your body in order to determine the best time for the embryo transfer. We usually give oral estradiol tablets to prepare the uterine lining. The thickness is measured on ultrasound scan. Your embryos will be thawed the day before your FET procedure.

The Transfer
The actual transfer of the frozen embryos is painless and straightforward, and only takes about 15 minutes.

 

  • A catheter is inserted through your cervix and into your uterus.
  • The embryos are injected into the catheter and deposited in your uterus.

 

After the Transfer
After the transfer your reproductive endocrinologist will likely have you continue any fertility medications that you may be using. Twelve days after the FET procedure, you will return to your clinic for a pregnancy test. 

Success Rates of Frozen Embryo Transfer

The success rates of FET really depends upon a variety of factors, particularly maternal age and the number of embryos transferred. Typical success rates are around 20% per cycle. It is important to know that not all embryos will survive the freezing and thawing process though. About 70% of embryos survive cryopreservation, and this can sometimes impact the success rates of FET. This makes it important to freeze and thaw a number of embryos when performing the FET procedure.

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Prognosis ‘encouraging’ after total fertilization failure in IVF and ICSI

More than 40 percent of patients who experience total fertilization failure after an IVF cycle have a baby at a later attempt, researchers report.

Total fertilization failure after IVF or ICSI can be very frustrating for patients and clinicians alike.

Little information has been available about patients’ chances of success in the future or how changes in treatment could improve the likelihood of fertilization in later cycles.

To investigate, Donna Kinzer (Boston IVF, Waltham, Massachusetts, USA) and colleagues conducted a retrospective analysis of data for 555 couples who experienced total fertilization failure during conventional IVF or ICSI.

They found that 44 percent of IVF patients who chose to continue treatment eventually gave birth. This equated to a delivery after 25 percent of embryo transfers and 22 percent of cycles.

After ICSI, 36 percent of couples had a child, after 23 percent of their embryo transfers, in 18 percent of their cycles.

Results also showed that fewer mature oocytes were used in the transfers that ended in complete fertilization failure, compared with earlier or later transfers, Kinzer et al report.

They say these results suggest that “total fertilization failure is not related to sperm parameters but rather is a result of suboptimal response to ovarian stimulation.

They add: “If subtle improvements in oocyte yield can be effected, this may increase the chance of fertilization in subsequent cycles for these patients.”

Source: Fertility and Sterility 2008; 90: 284-8

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Embryo Grading

One of the trickiest jobs facing a clinical embryologist is the visual assessment of human embryos. Embryo selection prior to embryo transfer clearly has an enormous impact on the success of the treatment and embryo selection for cryopreservation is equally important to the future success of frozen embryo transfers.

 Patients are often awestruck when they see a photo of their embryos for the first time on the morning of their transfer. That morning each embryo is carefully observed under a powerful microscope and the information about the quality of the individual embryos is given to patients prior to their transfer. In general, the way we assess the “quality” of embryos at Rotunda is by determining 3 major components. Cell number, cell regularity (regularity of size), and degree of fragmentation. There are also other things that are also noted about the embryos appearance, such as multinucleation, presence of vacuoles, granularity, thickness of the zona around the embryo, etc. Using this information, decisions are then made about how many embryos to transfer and how many to freeze, and importantly, what to do with embryos that are not developing very well.

When eggs are retrieved from a patient’s ovaries, they are surrounded by thousands of cumulus cells that prevent us from seeing eggs directly or making any comments about quality. For patients having ICSI (Intra-Cytoplasmic Sperm Injection), we strip away the cumulus cells, but even then, very little information on quality can be ascertained. Only when eggs are of particularly poor quality are we able to observe obvious differences from healthy eggs. The vast majority of eggs do not show any characteristics to indicate quality. Therefore, the embryologist will not typically convey any information about egg quality.

 

Usually, determinations of “quality” are not made until about 48 hours (or later) after the egg retrieval. By 48 hours (“day 2”), we prefer that at least some of the embryos are at least 3 cells –  and preferably 4 cells or more. They must be at least 2 cells by then – or they have basically “arrested”. By 72 hours (“day 3”), we prefer that some of the embryos are at least 6 cells – and preferably at least a few that have 7 cells or more. At Rotunda, we have seen babies that came from an embryo as slow as a 4 cell on day 3, but the chances for pregnancy increase greatly as the cell number increases. 

 Fragmentation is a normal feature in embryos and only about 20% of embryos have no fragments at all. However, the absence of fragments does not guarantee pregnancy as there are many other factors involved in embryo quality. The degree of fragmentation and cell asymmetry is given as a grade, usually A,B,C 0r 1, 2, 3. Grade A  embryos look beautiful and normal in every way. Grade B  embryos will have a small degree of fragmentation and or unevenness, but are still considered high quality. Only if an embryo is in real trouble and has more fragments than cells, will we assign the dreaded Grade C. These embryos very rarely implant after transfer and are not considered viable enough to freeze regardless of how many cells they contain. Patients often ask whether embryos that were given a “low grade” by the embryologist will make “low quality kids”. The children born from low grade embryos are just as cute, intelligent, strong, etc. as those born after transferring high grade embryos. The only difference as far as we know is in the relative chance that the transfer of the embryo(s) will result in a pregnancy and a live birth.

Embryo quality as we see it under the microscope in the IVF lab gives us some reasonable ability to predict the chances for pregnancy from an embryo transfer. However, because there are many other contributing factors involved that we can not measure, these generalizations do not always apply. We see some cycles fail after transferring 3 perfect looking embryos, and we also see beautiful babies born after transferring low grade embryos. The true genetic potential of the embryo to continue development and the quality and receptivity of the uterine lining are really impossible to measure. Hopefully, that will be something for the future. 

Ultimately, the only true test of embryo quality is whether it implants and develops normally and eventually goes home from the hospital with mom. In other words, embryo grading systems are very imperfect, and we always need the pregnancy test to tell us much more about “quality” than the microscope can reveal.

Posted by : Goral Gandhi, MSc,

                   Laboratory Director,

                   Rotunda – Center for Human Reproduction (Pvt) Ltd

 

 

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