The embryologists guide to advanced vitrification
Transcription
The embryologists guide to advanced vitrification
The embryologists guide to advanced vitrification Joe Conaghan PhD Los Angeles April 21st 2011 Introduction • • • • • • • Importance of cryo in ART Making good choices about what to vitrify Devices and solutions Open vs. Closed Collapsing and hatching blastocysts Can we do better? Conclusions Elective single embryo transfer (eSET) 1. Ability to culture embryos 2. Choice of embryos for transfer and cryopreservation 3. Reliable freezing Fresh IVF Cycles: Number of embryos transferred Day 3 ET Day 5 ET 2007 CDC Data: Own oocytes only Choosing your blastocysts Common question Do you freeze early blastocysts? Blastocyst grading Stage ICM Trophectoderm Early Good Good Average Average Poor Poor (cavity <50% vol.) Blastocyst (Cavity 50% or more) Expanded (Zona stretching) Hatching Can we agree on grading? Stage: ICM: TE: Can we agree on grading? Stage: Expanded ICM: TE: Good Good Grading survey Stage: ICM: TE: 119 Labs participated Results: Specimen 1 80 70 60 50 40 30 20 10 0 Morula Early Blastocyst Blastocyst Expanded Blastocyst Hatching Blastocyst Results: Specimen 1 80 70 60 50 40 ICM 30 TE 20 10 0 Good Fair Poor Grading survey Stage: ICM: TE: 119 Labs participated Results: Specimen 2 120 100 80 60 40 20 0 Morula Early Blastocyst Blastocyst Expanded Blastocyst Hatching Blastocyst Results: Specimen 2 70 60 50 40 ICM 30 TE 20 10 0 Good Fair Poor Results: Day 3 testing 60 50 40 30 20 10 0 7 8 9 10 11 12 Results: Day 1 testing 120 107 100 80 60 40 20 2 0 0PN 1PN 2PN 9 1 3PN 4PN Blastocyst quality • Prefer to freeze embryos that have a distinct ICM and TE • Early blastocysts may not have clear differentiated cell populations • Pity freezes Blastocyst quality • Likely agreement on freezing good or average • Agree not to freeze poor embryos • Disagree on relative importance of ICM and TE Which is the better blastocyst 1. Blastocyst with very nice ICM but only average TE 2. Blastocyst with very nice TE but only average ICM Formation of the ICM 8-cell 16-cell 16-cell 32-cell Cell Cell Cell Cell Cell Cell Cell Cell O O O I O O O I O O O I O O O I O O O O OOOO OOOO O O O O O O OOOO OOOO OOOI 12xO, 4xI O O I I I I OOOI I I I I I I I I Average embryo should have 20-22 TE cells and 10-12 ICM cells Moving from 32-cell to 64-cell, embryo can no longer make ICM cells if they don’t already exist Is trophectoderm more important? •Embryo puts more energy into making TE •If ICM is poor, embryo likely doomed •But TE relatively more important Transfer embryos with: good TE/average ICM or good ICM/average TE Beyond the 32-cell stage Trophectoderm cells can only make trophectoderm ICM cells may be able to make trophectoderm, but only until the 64-cell stage R. M. Schultz, Preimplantation embryo development, Molecular Biology in Reproductive Development 1999 Data from Marius Meintjes, personal commu Data from Marius Meintjes, personal communication Further reading Richter KS, Harris DC, Daneshmand ST, Shapiro BS. Quantitative grading of a human blastocyst: optimal inner cell mass size and shape. Fertil Steril. 2001 Dec;76(6):1157-67. Kovacic B, Vlaisavljevic V, Reljic M, Cizek-Sajko M. Developmental capacity of different morphological types of day 5 human morulae and blastocysts. Reprod Biomed Online. 2004 Jun;8(6):687-94. Criteria for vitrifying? •Loose criteria for D5 blastocysts •Tight control over D6 vitrification •No ICM = no cryo •Not keeping embryos until D7 •Assisted collapse used liberally After transfer, embryos assessed by 2 embryologists Early blastocysts can be challenging Is there a chance? What are my chances? …one out of a million. So, there is a chance So you’re telling me there’s a chance Yeeeeaaaahhhh Borderline embryos • Vitrifying poor embryos will hurt results • If you can’t decide, you should preserve • If your results are too good, you are being too selective • Recognize the importance of failure Given the choice, patients likely choose freezing Should we wait until D6? D5 and D6 differences (OD) Mean age = 43, n=177 35 30 25 20 15 Implantation rate (%) 10 5 0 D5 D5/D6 Implantation/transfer D6 D5 only D5+D6 D6 only 80/251 (32%) 8/33 (24%) 6/36 (17%) Differences not significant (D5 vs. D6: p=0.07) D5 and D6 differences Mean age = 33, n=290, own oocytes 35 30 * 25 * 20 Implantation rate (%) 15 10 5 0 D5 Implantation/transfer D5/D6 D6 D5 only D5+D6 D6 only 104/318 (33%) 29/107 (27%) 29/128 (23%) * p= 0.03 Choosing a device and protocol Open vs. Closed There is no authority that will knowingly approve an open system for storage of oocytes or embryos Closed devices Cryopette (Origio) Rapid-i (Vitrolife) Cryotip (Irvine Scientific) Implementation (2007) • Well trained staff • Practice • Vitrify good quality embryos • Artificial collapse? • Assisted hatching? Methods • Vit Kit and CryoTip • Straws labeled carefully • One blastocyst per straw • Room temp. Tip 1 : Examine straw carefully before starting Materials and Methods Vitrification Methods – Straw loading 1. Begin loading immediately after embryos in last drop 2. Medium to first mark, then embryo to 2nd mark 3. Continue loading medium to 3rd mark Materials and Methods Vitrification Methods – Cooling procedure We have settled on 8 mins in ES for all blastocysts Materials and Methods Vitrification Methods – Cooling procedure Materials and Methods Vitrification Methods – Straw sealing 1. Seal small end and check carefully 2. Seal large end and check carefully 3. If not sure about seal, reseal or load embryo into a new straw 2nd mark 1st mark Tip 2: Examine straw carefully after sealing Materials and Methods Vitrification Methods – Storage Must keep embryos in N2 at all times Have system where label can be read easily Avoid shipping embryos if possible Methods continued Straw warming 1. Check straw label while keeping straw submerged 2. Quickly transfer straw to water bath (370C) Tip 3: Make sure you use a large water bath. Stir straw in. Ice formation during warming 00C -1200C -1960C Methods continued Straw unloading 1. Cut large end of straw and gently attach Hamilton syringe 2. Dry off fine end and cut just above seal with fine scissors 3. Gently expel contents onto plate surface Materials and Methods Vitrification Methods – Warming Procedures Materials and Methods Vitrification Methods – Warming Procedures Tip 4: Culture in medium with 20% DSS post warming Blastocyst transfers in 2009 Who has embryos frozen? Patient age < 35 35-37 38-40 41-42 > 42 Number of Cycles 117 81 66 25 10 155 Number patients with embryos to freeze (%) Average number of embryos frozen 94 (80) 56 (69) 32 (48) 15 (60) 2 (20) 139 (90) 4.3 3.7 3.6 4.5 1.0 6.0 Usable blastocysts 6.0 5.8 6.2 7.3 3.5 7.4 Overall 338/454 with embryos to freeze (74%) 1,630 Blastocysts frozen Donor Warming results: First 2 years Patient age <35 >40 OD Cycles 164 80 76 21 217 Pregnancies 90 31 27 7 88 (mean) 55% 295 (1.8) 39% 145 (1.8) 36% 150 (2.0) 33% 51 (2.4) 41% 380 (1.7) Sacs 112 35 35 10 120 24% 23% 20% 32% Pregnancy rate Emb. Transferred Implantation rate 38% 35-37 38-40 When to warm and transfer Natural cycle hCG Controlled cycle Day or date 2PN’s D3’s D5 or D6 Mon Day -1 Day 0 Day 1 Day 2 Day 3 Day 4 Day 5 P4 Day 1 P4 Day 2 P4 Day 3 P4 Day 4 P4 Day 5 P4 Day 6 P4 Day 7 Tue Wed Thur Fri Sat Sun Mon Thaw ET Thaw/ ET Warm/ ET Blastocyst Recovery and Survival Results 2007-2010 Cycles Number of embryos warmed Number of embryos recovered Number of embryos survived 776 1543 1482 (96%) 1374 (93%) Implantation by stage SET only, n = 182 60 b 50 a 40 30 a, b 20 10 0 EB B XB HB Early Blastocyst Blastocyst Expanded Hatching 7/19 43/120 4/27 8/16 a, p = 0.04 and b, p = 0.03 Blastocyst survival • Blastocysts look very nice during and immediately after warming. • Most ET’s done within 1 hour of warming • Culture and ET in 20% SSS Why does artificial collapse help? 1. Some embryos do not collapse 2. Reducing cavity allows direct CPA access 3. Benefit may be from zona thinning Blastocyst Survival Results 2007-2010 Overall Cycles Number of embryos warmed Number of embryos survived Not Artificially Collapsed Collapsed 776 576 177 1482 1143 288 1374 (93%) 1042a (91%) 282a (98%) a p<0.05 Day 5 and Day 6 Survival 100% Not Collapsed Artificially Collapsed 98% 96% 63/64* 192/197* 94% 92% 90% 675/739 88% 200/225 86% 84% Day 5 Day 6 * p < 0.05 SET Implantation Rates (n = 276) 50 Not Collapsed Artificially Collapsed 45 8/17 40 35 30 25 5/13 13/37 47/144 12/36 20 15 10 4/29 5 0 Blast Expanded Blast Hatching Blast Implantation rates <35 Overall Cycles Number of embryos transferred Number of embryos implanted Not Artificially Collapsed Collapsed 224 172 52 376 302 74 143 (38%) 106 (35%) 37* (50%) * p < 0.05 Implantation Results, <35 120 Day 5 Not Collapsed Day 5 Artificially Collapsed 100 Day 6 Not Collapsed 80 Day 6 Artificially Collapsed 60 40 20 0 Survival Implantation Clinical Pregnancy Clinical Pregnancy Rate 80% Not Collapsed 70% a 60% Artificially Collapsed 50% 40% 30% 20% 10% 0% <35 35-37 38-40 >40 OD a = sig. higher than non-AC group Implantation Rates 60% 50% Not Collapsed a a Artificially Collapsed 40% 30% 20% 10% 0% <35 35-37 38-40 >40 OD a = sig. higher than non-AC group Blastocyst Survival Rates - 2010 Overall Cycles Number of embryos warmed Number of embryos survived Not Artificially Collapsed Collapsed 289 124 165 487 220 267 448 (92%) 186 (85%) 262* (98%) * p < 0.05 D5 embryos do better For patients <35 using own oocytes: PR = 58% (51/88) Mean of 1.8 embryos/FET IR = 41% (62/153) 9 x twin, 1 x triplet (20% multiples) Game plan: Freezing 1. 2. 3. 4. 5. Aggressively vitrifying early blastocysts Fairly “loose” in what we will vitrify Collapsing any blastocysts that we can Only one embryo/straw Results continuing to improve Game plan: Thawing 1. 2. 3. 4. 5. Aim is to thaw and transfer 1 Young patients, D5 embryos, collapsed Thaw 30-60 mins prior to FET Culture and transfer in 20% SSS Type of cycle not a concern Outcomes of natural cycles vs. programmed cycles for 1677 frozen embryo transfers.” Givens CR, Markun LC, Ryan IP, Chenette PC, Herbert CM, and Schriock ED. Reprod Biomed Online, 2009 Sept, 19(3): 380-384 Where are we in 2011 1. 2. 3. 4. 5. 4 years experience All 5 embryologists vitrifying and warming Very loose on what we will vitrify Collapsing most embryos Still reducing the number of embryos transferred 158 Blastocyst Transfers Frozen cycle outcomes 2010 Patient age < 35 35-37 38-40 > 40 Donor Number of Transfers 46 23 16 5 68 Pregnancies (clinical) 59% 57% 25% 20% 44% Embryos transferred 1.4 1.5 1.5 1.8 1.4 What are the problems that people are having? • • • • • • Not enough experience Getting independent training Using the device (straw sealing) Use >500 ml water bath for warming 20% SSS in post warm culture media Being aware of how quickly a straw will warm [email protected]
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