We're here to discuss about a great topic, the lab process of embryo creation and we're happy to answer any questions you guys have. We'll discuss today a little bit about age and what that has an impact on egg and sperm quality, how we do a detailed medical history and testing, optimising our body before IVF, timelines and the process and the embryo creation in the lab and freezing of embryos and what to expect for the embryo transfer day.

At Medline Academics, we have a firm belief that a clear understanding of the science of embryo development enables clinicians and embryologists to take patient care to the next level. Through our comprehensive Fellowship in IVF, we are successfully bridging the educational divide between theoretical knowledge and actual practice. Our Andrology training in India ranges from stimulating protocols to actual hands-on training in techniques such as ICSI, blastocyst development, PGT, and cryopreservation. Our mission is to enable fertility experts to gain greater clarity, confidence, and skills in decision-making to help couples with unmatched accuracy, safety, and compassion.

We'll talk about what is infertility? So, in a couple where the woman is under 35 and they've been trying for a year with regular periods, that is considered infertility because typically we would hope there would be a conception by then. When we're over 35, the ovarian function starts to change quicker in terms of lowering our egg reserve, our egg quality and things like that. And so it's important to recognise that when you've been trying for six months, it may be important to talk to your OB-GYN about pre-testing to understand your ovarian reserve tests, as well as discussing the options of evaluating the fallopian tubes and a detailed semen analysis.

What I think is fascinating is that when we're in our 20s, unprotected intercourse, the chance to conceive is in the 20s, 25%. And so it starts to go down as time goes by. Our average age of patients here is in the 39 to above 40. And so most of our patients tend to be on the older side, but it is important to recognise that there's this momentum to understand our hormones and fertility and people are checking and discussing it more than in the past too. So, age and female fertility. So as time goes on, our chance of conception per month starts to change.

We tend to be very optimistic. So every month has a chance to have the golden egg and the opportunity to get a healthy pregnancy, but it is important to understand to get a check-up. And as you can imagine, the genetics of those eggs that have been in our body since we were a baby, they start to change. The mitotic spindle starts to get a little more sticky. And so, when fertilisation happens, an extra chromosome could get carried during that process and that can cause a trisomy or an abnormal pregnancy. And so, the genetics of our eggs also start to change, especially when we turn 35 years old.

So when we were born, we had 7 million eggs in the ovaries. And as time goes by, by the time we hit puberty, we start to have around 400,000. And during our fertile window, we have about 400 to 500. People, every time we ovulate one egg, usually per month naturally, but in general, we may have follicles that could have many, each follicle can have an egg, and you may have a chance to get more eggs with the IVF process because you can take follicle stimulating hormone, which excites those follicles. So that instead of ovulating the one egg for the month, we're hoping to get a pool of eggs. We do take a detailed medical history.

We want to make sure you're up to date with your pap smear and annual physical exam with your primary care doctor. We'd like to make sure you're as fit as possible, exercising, eating a healthy diet, thinking about all the vitamins that are helpful, especially folic acid, which can prevent spina bifida.

Male

Some men are on blood pressure medications or Propecia or Finasteride and Rogaine, and those can have ramifications for sperm quality too. We do a lot of testing here, including the HSG or fallopian tube test, as well as the semen analysis or sperm DNA fragmentation testing. So we're asked every day, what is AMH? AMH is called anti-malarian hormone level. It's produced by the granulosa cells or the cells around the egg. And those cells produce a hormone that give us a reflection of egg supply. It was never intended to be used as a test to predict who would conceive.

And so sometimes patients do some of the home tests or get an alarming level with their OB, and then they go and try unprotected intercourse and they get pregnant right away. And so, it was never used as a tool to predict who's going to conceive. It's used as a tool to tune into your ovarian reserve. And so, we have certain targets we're hoping for. When your age 26 to 29, we want the AMH 1.96 to 5.88. When you are 30 to 35, we want 1.4 to 4.2, 36 to 39, 0.84 to 2.8, but above one is ideal. And then 40 to 44, it tends to go downward, but at 0.42 to 1.4 is normal. Over 44, there are still chances. It's just the AMH, which is the reflection of egg supply is 0.14 to 0.42, so it starts to trend downward. On the ultrasound image here, you see each little black circle there has one microscopic egg that's smaller than a grain of salt.

And sometimes if we are heavy tobacco users or vaping or CBD oil, sometimes we notice that the follicle count could be impacted by toxins. And so, it's important to recognise that lifestyle modifications may be encouraged. Every person is unique, and so there's no clear thing. You talk it over with your doctor and think it through for your personal situation too.

We encourage vitamins, prenatal vitamins, because it improves pregnancy outcomes. CoQ10 is a supplement that improves mitochondrial function. And so, your doctor may discuss this with you. We do like vitamin D because in the male factor or female, we like that the vitamin D level is 30 to 50. And so, it's good to check your vitamin D levels and keep them at a good target too.

So, what's involved with the semen analysis? So, we like men to abstain two to five days before their appointment. We like the volume above two millilitres, the concentration over 20 million per millilitre, the motility, which is how fast they're swimming, 50% and above, and the morphology to be 14% and above. And it's important to understand that we do catch male factor or male infertility as the cause of couples struggling for about a third or 40% of the couples. And so, it tends to be important to get tested because it does take some time to improve sperm quality.

And we work closely with urology if there's any varicoceles or any problems or any hormone imbalances. And sometimes in some men will catch a thyroid dysfunction or prolactin. And so we work closely together with the urology team.

Men can think about taking CoQ10 and vitamin D. And then there is a vitamin that's specific if the semen analysis has anything abnormal that we talk about called Proxy Plus. Not everybody has to take this because sometimes it's too much of a good thing, but it does have some benefits for male factor infertility too.

We work very closely with nutritionists. There’s a patient always who skips breakfast and really does intermittent fasting for 16 hours. And some people that makes the hypothalamus and pituitary not want to ovulate as regularly. And some people it works fine, but it's just good to think about it because there might be something that may benefit you. Meditation, mindfulness, journaling. I've had a few patients, even for myself, when I was trying, I felt like it helped me break the fear factor of what if something happens or what if something is problematic. And so it kind of helps you recognise that we'll do everything work together. And our teams here are wonderful and very dedicated to making sure you feel cared for.

In terms of nutrition, we do recommend lots of fruits and vegetables, colourful fruits and vegetables, really avoiding fried food, avoiding too many white carbohydrates and starchy things, amping up protein in your diet. If you're vegan, sometimes we may have to have a discussion about some options to improve some of the amino acids that may be missing. And then pescetarian, it's harder because sometimes too much fish can have mercury. So, we always want to balance out what we're doing in terms of, and it's a specific discussion with your doctor.

It's important to avoid too much alcohol, cannabis, if we can, and avoiding tobacco. With men, it does take about two to three months to improve sperm if we're smoking. And some men need Chantix to talk it over with their primary care doctor.

The egg retrieval

So, we prepare you for a month or two with lifestyle, get the genetic screening done, make sure your pap smear if needed and mammograms up to date, prepare your body. And with IVF, it's a two-step process.

The first is ovarian stimulation, which takes 10 to 12 days of injections called follicle stimulating hormone. There are about five or six important visits to recognise how the follicles are growing and your estradiol level.

And then the retrieval day, you can't go to work that day. And we can predict it by 90% the retrieval day. That day you have light anaesthesia or anaesthesia to feel comfortable during the procedure.

And then for that week afterwards, you're pretty bloated and sore, some breast tenderness. Occasionally people have constipation. So, it's good to get ahead of it with fibre or magnesium if needed.

The egg retrieval is a thin needle through the vagina under propofol sedation. And so, we carefully get each egg out. And I always say the furthest away one, the hardest one to get will be the baby. No, it's just, we try everything in our power to get every single potential egg that we can possibly get.

What kind of goes on in the IVF lab? We count day zero as the retrieval day. And also if you're doing an IVF cycle, the sperm preparation day. And that's also the same day that we do insemination, whether that's ICSI or natural insemination. And if you're doing an egg freeze case, the eggs are frozen on the same day as well. And then we move on to day one, which is when we check everything we've inseminated and we check to see if there's fertilisation that occurred.

And from days 2-4, we like to keep them in the incubator undisturbed. So that way they're provided with the best environment to grow and to develop into blastocysts. And then once we get to day five, six, and seven, that's when these embryos have hopefully turned into blastocysts.

And for a genetic testing cycle, this is when we look at them and decide whether or not they're ready to undergo the testing process. Or sometimes without the genetic testing, we just freeze them. This is also a day we can do transfers as well.

And then if you are doing a PGT cycle, around day 15 is when we get those results back. And usually, your physician will give you a call. Dr. A will call you with the news of the results. So, on day zero, which is retrieval day, once Dr. A collects all those eggs for us, what we do inside the IVF lab is we clean off those eggs, which enables us to determine which ones are mature or immature. And we have about 70 to 80% of the eggs that are collected during the retrieval will end up being mature. And only mature eggs can be fertilised.

So for ICSI, we're figuring out which ones are mature, and then we're proceeding with the insemination. And right here is just a quick video of what an ICSI looks like. And as you can see from the picture on the top, the left-hand side is where you're holding pipette is, and then you have your egg, and then you have your actual ICSI needle, which carries one single sperm inside of it, and you'll see the sperm dropped off. And this is all done under 100 magnifications under a microscope because that egg is so small. So, you can see that ICSI needle on the right side, and that little dark dot is what the sperm is. And you'll see the needle go into the egg, and then it'll drop that sperm off. And then immediately after the procedure is finished, you can't even tell anything occurred, and there you have it. So day one is our fertilisation check. And there's a variety of different ways an egg, or now we call it a side goat, can fertilise.

And then around day four, all of those cells kind of mould together into one ball. And then towards the end, what you see is a blastocyst. And blastocysts have two cell types. They have the inner cell mass, which is the tight ball. And that's what actually creates the baby. And the second set of cells are the trifecta derm cells. And those are what produces and creates the placenta. And if we're doing PGT, the genetic testing, we don't touch the ICM. We're only going for the trifecta derm cells.

And a blastocyst has about 200 cells at that stage. And for the genetic testing, we remove anywhere from six to eight cells. So it's insignificant for the blastocyst. And again, they recover and you can never tell anything occurs.

Some will have degenerating cells. Some will not have enough cells. So,  we create and assign grades to each one of these.

And then we have a threshold that if something is below the threshold, it means that it won't be able to survive the process of biopsy, or it won't survive the thaw-freeze process as well. So unfortunately, just because something is fertilised, it doesn't mean that it's going to reach this great blastocyst quality size that will be usable for the future.

We have our paperwork that states the patient's name and date of birth, and then also a unique identifier, which in this case is the EMR number. And that's on, so that information's on your paperwork. It's on the device itself, which each embryo gets its own device.

And then it's also on the cane, which is kind of the item that we use to store the devices in. And you'll see this in the video. And I'll point out in the video as well, our monitoring system, because all of these tanks are monitored 24 seven. We also, an embryologist checks on them multiple times a day. We want to make sure everything is safe. And so that does require daily maintenance.

So, the white box is the alarm system, and you'll see a probe that goes into the tank. And if any temperature has changed, that's when we are notified that something is not within our threshold. And this is the cane that each device is in. And typically, this will have a label on the outside, on the top of the cane and on the outside of it as well. And then inside this cane, in this case, it's a yellow device. And then you'll see the white label as well.

Everything is made sure that it's matching during the thought itself. There's a double witnessing. And then again, at time of transfer, and also for transfers, we have a monitor in the room. So, every patient is able to see for themselves that the dish that the embryo is stored in has the correct patient’s name and date of birth as well. And this video will show you kind of what goes on behind in the IVF lab at time of transfer. So, you see the embryologist has a second person where they check the label, the paperwork and the dish themselves.

They make sure everything matches up. And then this is usually what the patient will see on the screen of the name and date of birth. And then this centre part is where the embryo is. Catheter - it's pretty soft at the tip and the embryo will load or the embryologist will load the embryo into the catheter. And then she hands it off to the physician.

And then Dr. A is going to finish it out with her side of what occurs for the embryo transfer. It's like breath-taking because we on our side worry so much about which protocol is going to get the best quantity and quality of eggs and how are we going to keep the patient safe for the retrieval and keep all the systems ago. And then we work so closely with you guys because it's so beautiful. So, we need about three months prep time for an embryo transfer because we want to make sure your BMI is ideal, that you're not iron deficient, your vitamin D is healthy.

We want to make sure you're up to date with your pap smear mammogram, as well as making sure you've been on prenatal vitamins and that your system's as healthy as possible in preparation for the.