Quality management in IVF to optimise embryo transfer results

James Catt PhD Adjunct Senior Lecturer Scientific Director Dept of Obs and Gyn Optimal IVF Monash University

MelbourneAustralia

Quality is about continuously rejecting the

status quo and is a journey, not an end

Definitions

Quality AssuranceDesign of a process to deliver the defined product

In IVF lab = design of all procedures to optimise the chances of implantation

Definitions

Quality ControlExamines 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

SummaryQuality system - laboratory and unit

Document Control Risk Management

QA/QC

Staff education

Audit cycle

Procedure design (QA)

• Provide optimal conditionsEquipmentAmbient conditionsMedia

• 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 incubatorsWhere 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

38

37

36

Incubator 24 hr

Standard Incubator Thermal image

Benchtop Thermal image

Validation: pH

How do you measure pH ?

XpH meter XBlood gas analyserColourpH 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 overauditIncubator A set 37.0 acceptable ± 0.5 CO2 set 6.0 acceptable ± 0.05

JanuarySet temp Actual tempSet CO2 Actual CO2 Sci Comment1 37 36.9 6 5.9 JC OK2 37 36.8 5.9 5.6 JC OK3 37 36.9 5.8 5.8 JC OK4 37 37 6 5.9 JC OK5 37 36.9 6 6 JC OK6 37 36.8 6 5.9 JC OK7 37 36.9 6 5.6 JC OK8 37 37 6 5.8 JC OK9 37 36.9 6 5.9 JC OK

10 37 36.8 5.9 6 JC OK11 36.9 36.9 5.8 5.9 JC OK12 37 37 6 5.6 JC OK13 37 36.9 6 5.8 JC OK14 37 36.8 6 5.9 JC OK15 37 36.9 6 6 JC OK16 37 37 6 5.9 JC OK17 36.8 36.9 6 5.6 JC OK18 37 36.8 5.7 5.8 JC OK19 37 36.9 6 5.9 JC OK20 37 37 6 6 JC OK21 37 36.9 6 5.9 JC OK22 37 36.8 6 5.6 JC OK23 37 36.9 5.9 5.8 JC OK24 36.9 37 6 5.9 JC OK25 37 36.9 6 6 JC OK26 37 36.8 6 5.9 JC OK27 37 36.9 6 5.6 JC OK28 37 37 6 5.8 JC OK29 37 36.9 6 5.9 JC OK30 37 36.8 5.8 6 JC OK31 37 36.9 6 5.9 JC OK

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

EliminationFilters or photocatalytic destruction

Ppb Ppm X

100 ppb

100 ppb

16% FH/embryo ET

48% FH/embryo ET

Data from clinic

Temperature

Surprising where variation comes from !!Laminar flow

Stage warmers

Pipetting

Laminar flow

Temperature drop

Laminar flow

Stage warmers

Warm stage

Petri dish

Air = insulation

Stage warmers will not heat a dish for ~5 min !!

(1) Liquid (37°C) into pipette

Line of symmetry

(2) Immediately heat is lost to the walls the pipette

Lab Air

(3) The surface of the pipette loses heat to the surrounding air

Heat Transfer in Pipettes

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

0

1

2

3

4

5

6

Oocyte zygote d2 d3 d4 d5

Sen

siti

vity

The forgotten Oocyte

Good oocytes make good embryos

Do NOT use simple media for oocyte recoveryEg saline, PBS etc

Inadequate sperm

Sperm have specific requirements

High glucose/fructoseHigh proteinBicarbonate

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

Timing(hours post-

insemination)

Expected stage of development

Fertilization check 17 ± 1 Pronuclear stage

Syngamy check 25 ± 1

Expect 50% to be in syngamy (up to

20% may be at the 2-cell stage)

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 ICSIIVF fertilization rate*ICSI fertilization rate*ICSI degeneration rate*Syngamy rate (25+/- 1 hpi)FH per embryo transferred*Utilisation ratesPercent 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

Day 3

Day 4Day 5

ET

FreezeD5/6

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

Early syngamy

syn before 25h syn after 25

Imp

lan

tati

on

rat

e

40%

25%

Other factors affecting implantation

Day of transfer

Developmental stage

Results eSET (FH/embryo)

0

10

20

30

40

50

d2 d3 d4 d5

ConclusionsSingle 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

ResultsDay of pregs patients Cumulative

Ratefresh ET

3 913 1393 66%

5 228 356 64%

No significant difference

ConclusionsThere 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 SummaryKnow and control your equipment

Know and control your conditions

Quantitate your outcomes

Benchmark your outcomes