Transcript Quality management in IVF to optimise embryo transfer results James Catt PhD Scientific Director Optimal IVF Adjunct Senior Lecturer Dept of Obs and Gyn Monash University Melbourne Australia.

Quality management in IVF to
optimise embryo transfer results
James Catt PhD
Scientific Director
Optimal IVF
Adjunct Senior Lecturer
Dept of Obs and Gyn
Monash University
Melbourne
Australia
Quality is about continuously
rejecting the status quo and
is a journey, not an end
Definitions
Quality Assurance
Design of a process to deliver the
defined product
In IVF lab = design of all procedures to
optimise the chances of implantation
Definitions
Quality Control
Examines the product during the process
to ensure specifications are met
In IVF lab = monitoring individual
procedures to meet expectations
Audits
Third party monitoring of QA and QC
Auditor looks at procedure documentation
and results
Summary
Quality system - laboratory and unit
QA/QC
Staff education
Document Control
Risk Management
Audit cycle
Procedure design (QA)
• Provide optimal conditions
Equipment
Ambient conditions
Media
• Embryo selection
Procedure monitoring (QC)
Ie
What quantitative outcomes during
the IVF process can be used to
monitor the programme ?
Quality management of IVF
instrumentation
•Selection of appropriate equipment
•Validation
•Ongoing QC
Equipment selection
Availability, reliability, service then cost
Central question to ask is ‘what happens if
this piece of equipment fails?’ Backup!!
Selection: Should we believe
the manufacturers?
All equipment comes with specifications.
Do they truly reflect what the embryos
experience?
Eg incubators
Where are the temperature probes?
Should we believe the
manufacturers?
Behind here !
Validation: Should we believe
ourselves?
Independent equipment eg thermometers,
dataloggers, CO2 meters have to have
calibration traceable to a standard
Dataloggers
Short, medium and longterm fluctuations
occur in all equipment
Dataloggers measure these fluctuations
and therefore help determine suitability of
equipment
Datalogger
Center SE 309 4 channels 8 000 datapoints
Incubator 24 hr
38
37
36
Standard Incubator Thermal image
Benchtop Thermal image
Validation: pH
How do you measure pH ?
XpH meter X
Blood gas analyser
Colour
pH paper!!!!!
How do you use pH paper ?
Paper into medium
Read within 3 seconds
Validation: Toxicity testing
MEA?
Sensitized sperm survival assay (low
protein or CASA)
EQUIPMENT QC: How often?
As much as necessary!
Tendency to over audit
Eg incubator
Incubator overaudit
Incubator A set 37.0 acceptable ± 0.5 CO2 set 6.0 acceptable ± 0.05
JanuarySet temp Actual temp Set CO2 Actual CO2 Sci
1
37
36.9
6
5.9 JC
2
37
36.8
5.9
5.6 JC
3
37
36.9
5.8
5.8 JC
4
37
37
6
5.9 JC
5
37
36.9
6
6 JC
6
37
36.8
6
5.9 JC
7
37
36.9
6
5.6 JC
8
37
37
6
5.8 JC
9
37
36.9
6
5.9 JC
10
37
36.8
5.9
6 JC
11
36.9
36.9
5.8
5.9 JC
12
37
37
6
5.6 JC
13
37
36.9
6
5.8 JC
14
37
36.8
6
5.9 JC
15
37
36.9
6
6 JC
16
37
37
6
5.9 JC
17
36.8
36.9
6
5.6 JC
18
37
36.8
5.7
5.8 JC
19
37
36.9
6
5.9 JC
20
37
37
6
6 JC
21
37
36.9
6
5.9 JC
22
37
36.8
6
5.6 JC
23
37
36.9
5.9
5.8 JC
24
36.9
37
6
5.9 JC
25
37
36.9
6
6 JC
26
37
36.8
6
5.9 JC
27
37
36.9
6
5.6 JC
28
37
37
6
5.8 JC
29
37
36.9
6
5.9 JC
30
37
36.8
5.8
6 JC
31
37
36.9
6
5.9 JC
Comment
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Ambient conditions
Equipment in, set up and monitored
What about laboratory conditions??
Gametes and embryos spent some time
outside of incubators
Ambient conditions
Air purity
Temperature
pH
Volatile Organic Compounds
(VOC)
Therefore particles per se are not
detrimental until they have VOC adsorped
onto them. Therefore should only need to
monitor for VOC
Elimination
Filters or photocatalytic destruction
Ppb 
Ppm X
Data from clinic
16% FH/embryo ET
48% FH/embryo ET
100 ppb
100 ppb
Temperature
Surprising where variation comes
from !!
Laminar flow
Stage warmers
Pipetting
Laminar flow
Temperature drop
Laminar flow
Stage warmers
Stage warmers will not heat a dish for ~5 min !!
Petri dish
Air = insulation
Warm stage
Heat Transfer in Pipettes
(1) Liquid (37°C) into pipette
Lab Air
(2) Immediately heat is lost to
the walls the pipette
(3) The surface of the pipette
loses heat to the surrounding
air
Line of symmetry
What to do ?
Partial solution is to use plastic
pipettes
Other solution is to control
environment
Solution to most environmental
problems – control the environment!
The forgotten Oocyte
6
Sensitivity
5
4
3
2
1
0
Oocyte zygote
d2
d3
d4
d5
The forgotten Oocyte
Good oocytes make good embryos
Do NOT use simple media for
oocyte recovery
Eg saline, PBS etc
Inadequate sperm
Sperm have specific requirements
High glucose/fructose
High protein
Bicarbonate
Mixing media
DO NOT MIX MEDIA !!
All have different components and
will affect embryo homeostasis if
mixed
Quality control to select the
‘best’ embryos
Objective outcomes
Consistency
Attainable goals
Type
Fertilization check
Timing
(hours postinsemination)
17 ± 1
Expected stage of
development
Pronuclear stage
Expect 50% to be in
syngamy (up to 20% may
be at the 2-cell stage)
Syngamy check
25 ± 1
Early cleavage
check
27 ± 1
2 cell-stage
Day 2 embryo
assessment
44 ± 1
4-cell stage
Day 3 embryo
assessment
68 ± 1
8-cell stage
Day 4 embryo
assessment
92 ± 2
Morula
Day 5 embryo
assessment
116 ± 2
Blastocyst
Laboratory outcomes
Average number of oocytes collected*
Average number of oocytes suitable for ICSI
IVF fertilization rate*
ICSI fertilization rate*
ICSI degeneration rate*
Syngamy rate (25+/- 1 hpi)
FH per embryo transferred*
Utilisation rates
Percent survival of thawed embryos*
FH per thawed embryo*
FH per transferred thawed embryo*
* Denotes suitability for individuals
Human Embryonic development
OPU
Fertilization
syngamy
Day 2
ET
Day 3
Freeze
D5/6
Day 5
Day 4
Consistency
Good prognosis group
Age most important
‘Good prognosis ’ group should reflect the
majority of patients and exclude the
‘difficult’ ones
Eg <39 and < 3 previous cycles
How do we measure the
quality of oocytes entering
our laboratories??
SYNGAMY (or early cleavage)!!
Oocyte quality
Implantation rate
Early syngamy
40%
25%
syn before 25h
syn after 25
Other factors affecting
implantation
Day of transfer
Developmental stage
Results eSET (FH/embryo)
50
40
30
20
10
0
d2
d3
d4
d5
Conclusions
Single embryo culture and single
embryo transfer has enabled
important factors in embryo
development to be identified
Early cleavage and blastocyst
expansion are the best predictors
for implantation
Implantation rates for eSET can
exceed 50%
Cumulative pregnancy rates
The total number of fetal
hearts from a stimulated cycle
when both fresh and frozen
embryos have been transferred
Results
Day of
pregs
fresh ET
patients Cumulative Rate
3
913
1393
66%
5
228
356
64%
No significant difference
Conclusions
There is no decrease in the cumulative
pregnancy rate with extended culture
There are no ‘extra’ pregnancies with
extended culture
There are fewer transfers to achieve the
pregnancy
QC Summary
Know and control your equipment
Know and control your conditions
Quantitate your outcomes
Benchmark your outcomes