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Assisted Embryo Hatching

Assisted hatching is a relatively new technique used during certain IVF procedures. It is performed in order to help an embryo hatch out of its protective layering and implant into the uterus.Assisted hatching is an IVF technique in which the zona is treated prior to embryo transfer in order to weaken the wall of the embryo and thus improve the likelihood of successful hatching and embryo implantation.

Initial controlled trials at New York-Cornell Medical College showed a marked increase in implantation in women over age 35 and particularly over 38 or with an elevated FSH level on day 3 of the menstrual cycle. Couples with multiple failed IVF cycles also appear to benefit from assisted hatching. Assisted hatching may be helpful in these infertile couples because their embryos lack sufficient energy to complete the "hatching" process. It is thought that some women may fail multiple cycles of IVF because their eggs have a thicker shell, therefore they have a better prognosis with assisted hatching. In addition, hatched embryos implant one day early, which may allow a greater opportunity for implantation to occur.

Assisted Hatching Indications

• Elevated maternal age.
• Elevated follicle stimulating hormone [FSH] level.
• Evidence of a thickened zone pellucida of the embryos in IVF.
• Unexplained implantation failure after two or more embryo transfers.

Who Can Go For Assisted Hatching ?

1. Advanced maternal age.
2. Couples who have repeated IVF failures.
3. Women with Elevated basal FSH.
4. Couples who have thick Zona pellucida.
5. Frozen thowed embryo.
6. Excessive fragmentation >20%.

Advantages of the Assisted Hatching Procedure

Many couples elect to pursue assisted hatching during their IVF procedures. This is because the technique is associated with a number of benefits including:

• fewer embryos required for transfer
• increased implantation success rates
• allows for blastocyst culture

How is Assisted Hatching Performed ?

Assisted hatching is a very delicate procedure, requiring immense skill. It is performed using micromanipulation techniques, under a microscope, during the fourth day of embryo development.
The embryo is first placed in a petrie dish containing culture solution. A special pipette is then used to hold the embryo in place. The embryologist takes a hollow needle that contains an acidic solution and places it next to the zona pellicuda. A tiny bit of this acidic solution is released from the needle so that it comes into contact with the zona pellicuda. This acidic solution begins to slowly digest the protective layering, creating a small hole. The embryo is then washed in a special solution and placed back inside an incubator until embryo transfer can take place.

Success Rates of Assisted Hatching

Assisted hatching is associated with a fairly high success rate, especially when performed by a skilled micromanipulator. In fact, pregnancy rates are as high as 49% in women who are between the ages of 35 and 39. Women who are over the age of 40 generally have lower success rates, but assisted hatching still provides them with a better opportunity for conception than would IVF performed without the procedure.

 

Implantation failure

It is defined as the embryo’s failure to implant during the IVF cycle. Implantation failure is a part of the in vitro fertilization procedure that is not very well understood because patients succeed to produce healthy embryos but at the implantation phase things go wrong for inexplicable reasons.
Failure to achieve a pregnancy following 2-3 IVF cycles in which reasonably good [ high embryos] embryos were transferred is termed as implantation failure.
Embryonic loss which occurs repeatedly after Assisted Reproduction may be attributed to many factors.
There are three main causes of IVF implantation failure:

1. Decreased endometrial receptivity

   Studies show that the toxins coming into the uterus from infections (current or previous) have a high impact on embryo implantation. It is very difficult to determine the cause of the infection. Some doctors take a sample from the uterine cavity using a catheter inserted through the vagina and the cervix but this is not a very efficient way because the catheter could collect bacteria from the cervix and the vagina not only from the uterine cavity. Other specialists treat the uterine infection with antibiotics when the correct antibiotic can be precisely identified.

   Decreased endometrial receptivity

   • Uterine cavity abnormalities
   • Thin endometrium
   • Altered expression of adhesive molecules
   • Immunological factors
   • Thrombophilas

   Causes

   • 18-27% women reveal uterine abnormalities, mainly hyperplasia polyps, endometritis, synechiae and leiomyomata
   • Effect of leiomyomata on implantation is uncertain
   • Impact of intramural lesions or myomas < 4 cm on implantation failure remain controversial
   • Presence of thin or hyperechogenic endometrium or persistent endometrial fluid impaired the outcome in tubal factor
2. Embryonic defect

   For several years it was believed that the best time for embryo transfer was in the third day after the egg retrieval. There are embryos that look very good in the third day, but they might lead to implantation failure afterwards. On the other hand some embryos might look poorly in the third day but they can develop very well by the fifth day. That is the reason for which blastocyst transfer appeared.
   
   Another issue is the embryo’s hatching. Before the implantation can start the embryos has to get out of its shell and afterwards make contact with the uterus cells. It is believed that implantation failure can be caused by the fact that the embryo is not able to hatch from its shell. That’s why the concept of assisted hatching was introduced. The assisted hatching “helps” the embryo by creating a small opening in its shell. However the risk of identical twins appears along with this technique due to the fact that the embryo can divide easily when its shell is removed. So the assisted hatching remains at the stage of experiment in treating IVF implantation failure.

   Defective Embryonic development

   • Genetic abnormalities [Male / Female / gametes/ embryos]
   • Zona hardening
   • Suboptimal culture conditions

   Causes

   • Chromosomal abnormalities of the male or female partner, the gametes or the developing embryo may burden embryogenesis.
   • Increased frequency of female chromosomal abnormalities such as translocations, mosaics, inversion, deletion and chromosomal breakages, particularly at the centromere region in young women with implantation failure have been found.
   • Increased incidence of sperm chromosomal abnormalities in patients with normal karyotype & Recurrent implantation failure was also observed.
   • FISH for chromosomes 13,16,18,21,22, X & Y on blastomeres from biopsied embryos → showed % of embryonic aneuploidy higher in implantation failure group.
   • 60% of the blastomere biopsies showed abnormalities in implantation failure groups.
   • Disruption of chromosomal replication & segregation caused by maternal cytoplasmic factors or mutations in cell cycle control genes can be common causes for Recurrent implantation failure.
   • Despite good morphology and development rate, chromosomally abnormal embryos fail to implant.
   • Zona pellucia which surrounds the mammalian oocyte, hardens naturally after fertilization to prevent polyspermic fertilization and to protect the integrity of the pre-implantation embryo.
   • Increased zona thickness was associated with lower implantation rates.
   • Zona hardening induced by invitro culture or invivo aging affect hatching [failure of the zona to rupture] causing implantation failure.
3. Factors with combined effect

   Multifactorial effectors

   • Endometriosis
   • Hydrosalpinges
   • Suboptimal ovarian stimulation

   Multifactorial causes

   • Endoemtriosis leads to implantation failure
   • All markers of reproductive process, including ovarian response, embryo quality, implantation and Pregnancy rates are decreased in endometriosis and the decrease is directly proportional .

   Psychological assistance

   • Stress can interfere with infertility treatments
   • Psychotherapy [individual or group] reduces anxiety and depression and possibly enhances conception success.
   • We recommend psychological interventions and various relaxation techniques, but proof of their efficacy is lacking.

   Our experience

   There are many reasons for implantation failure.
   • We believe that we do not have the tools to diagnose in each and every case the exact cause for the repeated failure. After failure of three transfers of good quality embryos in a unit with a PR of atleast 30% one should take some special measures .
   • Each individual case should be analyzed specially to see the reason and the treatment tailored according to the needs to enhance the pregnancy outcome.
   • Everyone agrees that taking a different approach achieves a pregnancy in many cases that failed repeatedly.
   • After three failures repeated hysteroscopy and atry of blastocyst transfer are highly recommended
   • Change in the stimulaton protocol has a place.
   • AH, PGS and co-culture are probably beneficial in experienced hands.
   • Long –term use of danazol or GnRH agonists probably has a place in repeated failures with endometriosis
   • Frozen embryo transfer can also be considered.
   • Use of IVIG is controversial but may be justified after many failures in specific cases
   • Steroids might have place in patients with any sign of autoimmunity, and ZIFT has a place in cases of difficult embryo transfers.

Semen and Embryo Freezing

Semen cryopreservation (the freezing of sperm) is a way to store sperm for future use. Sperm is routinely frozen and maintained in the Center for Reproductive Medicine Andrology Laboratory. Your physician or another member of your health-care team will work with the Andrology Laboratory to arrange for semen cryopreservation, should you decide to participate in this process. In practice, frozen sperms are stored at the temp. of -196°C in liquid nitrogen.
We can now also offer egg freezing for women who wish to delay childbearing, and who want to preserve their fertility for the future. Although the freezing of embryos has been quite reliable, the freezing of eggs was for a long time only experimental, and, until recently, not very successful.

Sperm cryopreservation Indications

Frozen sperm can be divided into two categories

• Semen for auto conservation and
• Donor semen

Who should consider semen cryopreservation ?

• Radio or chemotherapy – which might lead to sterility
• Surgical sterilization by vasectomy "short – term" storage of sperm can be useful in case of ...
• stress with regard to collection of semen on demand on the day of IUI or IVF
• Absent husband during the wife's treatment and
• Large variations in individual sperm quality.

Sperm Banking at our Centre

Cryobanks are the vehicles used to realize the clinical and research application of cryopreserved cells . A most important component of sperm bank is its usefulness to infertile couple. Here at our centre following facilities are available.

• 'Long-term' & 'short term' semen cryopreservation
• Concentration for oligozoospermia
• Standard and pre-processed Anyonymous donor semen bank.

Embryo Freezing or Vitrification

Cryopreservation of the embryos is an important component of routine assisted reproductive programs (IVF). Cryopreservation of surplus embryos increases the opportunity for patients to conceive and improves the cumulative pregnancy rates. Recently, IVF centres in many countries have reduced the number of embryos that are transferred into the uterus to two or even one. With this, many embryos are available for freezing.
Efficient embryo cryopreservation has several advantages. It helps to reduce costs and increases cumulative pregnancy rates.

• Cryopreservation of embryos has greatly enhanced the preganancy rate and cumulative conception rate possible for a couple following a single cycle of ovarian stimulation and IVF.
• Possibility of avoiding fresh embryo transfer in stimulated cycles with a potential for ovarian hyperstimulaton syndrome.
• Factors which jeopardize implantation like bleeding, unfavourable endometrium, polyps or extremely difficult embryo transfer.
• Women who are undergoing chemo or radio therapy.
• Excess embryo per cycle.

What is Vitrification ?

Vitrification is the Solidification of solution into a glassy vitrified state. Vitrification of water inside cells can be achieved by Increasing the speed of temperature conduction. Use of high concentration of cryoprotectant helps to bring extremly high viscosity during cooling.
This new technique of freezing called "vitrification" avoids the damage caused by ice forming inside the cell by not trying to pull every last molecule of water out, because it is impossible to do this 100%. In fact, 70% of the cell is water, and at best you can reduce that to 30%. So with the conventional controlled rate slow-freezing technique, there is always going to be some intra-cellular ice crystal formation, causing some damage to embryos, and severely damaging most eggs. Vitrification uses a super high concentration of antifreeze (DMSO and ethylene glycol), and drops the temperature so rapidly that the water inside the cell never becomes ice. It just instantaneously super-cools into a solid with no ice crystal formation at all. Using this vitrification technique for freezing, we can reliably preserve eggs as well as embryos so that the pregnancy rate is no different than if the eggs or embryos had never been frozen. This allows us to preserve the fertility of young women for the future if they wish to delay childbearing, but not lose their fertility as they age.

Vitrificaiton Benefits

• Direct contact between cells / tissue and Liq.N2
• No ice crystallization
• Utilizes higher concentration of cyroprotectant that allows shorter exposure time to the cryoprotectant.
• Rapid vitrification / warming.
• Small volume used provides a significant increase in the cooling rate.
• Cooling rates from -15000 to 30000C / min
• Minimizes osmotic injuries
• Reduces the time of cryopreservation procedure (duration from 2 to 10 mins)
• Very simple protocols
• Eliminates the cost of expensive programmable freezing equipment.

Sperm, Egg and Embryo Donation

Many couples experiencing male factor infertility may choose to undergo donor insemination for IUI or IVF procedures in order to achieve pregnancy.

Sperm Donation

is a procedure by which the egg of a female is fertilised, using artificial insemination techniques or IVF, with sperm from a healthy male that has been donated and kept frozen in a sperm bank. The resulting embryo may then develop into a foetus inside the uterus. This way, a couple gets a chance to conceive a child who has genetic traits of one of the parents and the mother can experience pregnancy.

Why sperm donation ?

• If there are significant abnormal semen characteristics
• Irreversible azoospermia
• A previous vasectomy
• Previous radiation or chemotherapy treatment or another irreversible male fertility factor
• Carriers of a known hereditary or genetic disorder
• If the female is Rh sensitized and the male is Rh positive
• Single women who desire pregnancy.

Becoming a Sperm Donor

Young, healthy men between ages of 21 to 45 years are eligible as semen donors have at our center. We have few selection criteria that should be fulfilled before becoming a donor.

• A complete application form with consent of not disclosing the identity.
• In the application form donor characteristics like blood group, height, weight, complexion, occupation, education, and complete semen analysis should be filled up.
• A thorough semen analysis with sperm count > 60 million with 60% motility and normal morphology.
• Screening for HIV, VDRL , Hepatitis
• He should not be a drug addict
• Screening for any hereditary disorder & Genetic condition.

Egg donation

is a well-established form of assisted conception treatment. It offers hope for a large number of women who previously thought they could never become pregnant and have children. In the United Kingdom at is a legally accepted form of treatment. In some countries, egg donation is not allowed.

Why egg donation ?

• Poor fertilization of eggs inspite of good quality sperm.
• Failure to achieve a viable pregnancy following repeated attempts at IVF or other assisted reproductive technologies.
• Absent ovarian function due to previous surgery, radiation, or chemotherapy.
• Premature ovarian failure.
• Menopause
• The presence of genetic disorder that have high likelihood of being transmitted via the women's eggs to the offspring.
• Women over the age of 40
• Elevated follicle stimulating hormone levels (greater than 12 mIu/ml) on 3rd day of the menstrual cycle.
• Poor responders (less than 3-4 eggs).
• Unexplained failure of IVF consecutively (3 cycles).

Becoming a Egg Donor

Young, healthy women between ages of 21 to 32 years are eligible for egg donation program here at our center. We have few selection methods which are as follows.

• The prospective donor should be in general good health
• Should not have any major malformation or genetic disorders.
• Medical screening for any physicial or mental ailments.
• A physical examination, endocrine profile, ultrasound examination or pelvis.
• Screening test for HIV, HbsAg, VDRL & hepatitis
• A written consent form confirming the full understanding of the egg donation procedure.
• We understand that donor may have several questions to be asked we shall try to include few once we share our opinion about egg donation.
• We surveyed few women – out of that 91% were moderately to extremely satisfied with the experience
• Our study assessed the motivations of oocyte donors and found that they were guided by an over all ethic of giving.
• Oocyte donor has the satisfaction of giving completeness to the couple by addressing them proud parents.

Embryo Donation

Many couples choose to pursue embryo donation in order to increase their chances of having a child. Embryos are often donated by anonymous couples who have extra embryos remaining from previous IVF treatment cycles. Donated embryos can also be created by using donated eggs and sperm. Most donated embryos are used in a process called frozen embryo transfer.

Why Embryo donation ?

• For menopausal or perimenopausal women with a sub-fertile partner
• Recurrent IVF failures
• Patients who are carriers of genetic disease or chromosomal abnormalities.

Our approach

We at Raipur Fertility Research Center provide an excellent facility for helping infertile couple achieve their life's dream to having a baby. Our team incorporates dedicated physicians, Embryologist, clinical coordinators nurses and administrative personnel. We are committed to providing the highest quality medical care in a sensitive and caring environment.