Thursday, September 21, 2017

Is it worth transferring poor quality Day 3 embryos into the uterus?

Some patients will end up with all their embryos being of poor quality on Day 3, and then they're not certain what to do. Traditionally , most doctors will want to put all of their embryos back into the uterus as quickly as possible , no matter what their quality.

After all, once they've done an embryo transfer, they can tell the patient, "Look , I completed your IVF treatment, and have done everything humanly possible " , so the patient is happy that the doctor did a good job. Of course, it's highly likely that the cycle will fail, but then they can say - Yes, your embryo didn't implant, but that's your bad luck/ kismet/ karma. We now need to study the reason for the failed implantation, so we will run additional tests, so we can improve the chances of embryo implantation for the next cycle."

Unfortunately, this just creates false hope for the patient , and causes a lot of harm.  After all, we know that the chances of poor quality embryos implanting are very poor, and that the reason for the failure was the poor quality of the embryos. However, after the failure, they convince the patient to go through a battery of very expensive, exotic tests , to check her uterus and her immune system, to make sure that her body is not "rejecting" her embryos. These don't provide any useful information at all, but it's not hard to take IVF patients for a ride, because they are so emotionally vulnerable .

So why do doctors do this ? This is because they're not confident about the skills of their own IVF laboratory. However, it's easy to justify transferring on Day 3 ( and even Day 2) by telling the patient - Rather than throw the embryo away, isn't it better to at least put it back inside your uterus ? This way you have a chance, even if it's low?

Ideally, these embryos should be grown to day five blastocysts, and if they arrest in the laboratory before this point, then there is really no point in doing an embryo transfer at all. After all, once the transfer has been done, we create false hope  in the patient, because she's optimistic that she may get lucky and the cycle may work for her. When it doesn't , she is heartbroken , and her willingness to start another cycle drops dramatically , because she has lost confidence , either in the doctor and in her own body.

Much more importantly, the ability to learn from the IVF cycle has been wasted. After all, once you put an embryo back in the uterus , you have no idea what's going to happen to it. On the other hand, if it's in the incubator,  we can monitor it. If it arrests, we can at least tell the patient, "Look , this is the reason why you are not getting pregnant". We can analyse this intelligently, so we can focus on what's important , which is usually the quality of the egg , rather than worry about uterine receptivity.  The truth is that the uterus is usually a passive recipient, and it's very rare that the uterus is the reason for failed implantation, especially when poor quality embryos have been transferred.

So why send patient on a wild goose chase? Why not be upfront and honest with her? This is because most gynecologists don't understand much about embryology , and they don't have full time qualified embryologists who are able to grow embryos to day 5 routinely in the lab. This is because many of them depend on traveling embryologists, who don't have the time or energy to culture embryos all the way to day five. Taking all these shortcuts ends up harming the patient.  Yes, of course patients do get pregnant after Day 3 transfers, but these are good prognosis patients, and it's not right to confuse the two.

Yes, if the embryo arrests in the lab , this does cause a lot of short term heartache, but it gives us valuable information , so we can make changes and maximize the chance of achieving a pregnancy in the next cycle. Patients may have to suffer some short term pain to achieve long term gains.

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  1. the way the article reads is that women should discard their day3 embryos and not even give them a chance? only to save themselves from "false hopes" or "not going through a battery of very expensive, exotic tests" (why should they opt for the expensive add-ons with no scientific backup anyway?)
    as a cell biologist i would dare to say that the effects of the cell culture (as well as simple human errors) are being widely underestimated in the IVF this, in some countries, clinics actually see better live pregnancy rates with day3's really all not that simple..."The live birth rates in singleton pregnancies conceived after day 3 and day 5 embryo transfers were statistically similar (p=0.594). "

  2. We are talking about poor quality Day 3 embryos in my post . The article you quote discussed good quality Day 3 embryos, and the two groups are not comparable

    The conclusion of the article also says - Performing blastocyst transfer may have benefits because it is associated with acceptable pregnancy rates and morphologic assessment on day 3 has limited predictive value for subsequent embryonic development.

  3. Anonymous9:08 AM

    The uterus is not a passive organ. It's a very elegant organ which itself senses the embryo and makes itself ready for implantation and then tells the embryo what to do.
    It makes sense to not to transfer grade 3 embryos as the uterus has a biosensor. It senses the embryo quality and decides to continue receptivity or terminate in menstruation.
    Let's not underestimate the uterus.

  4. Totally agre with doctor Malpani, many women think that it is better to transfer day 3 embryos no matter what, because there's no place like own uterus. In lab embryos maybe couldn't grow to day 5 but uterus is a perfect environment for them. I really don't know where is this came from....



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