Why were my embryos of such poor quality ?

While a good IVF clinic is good at making good embryos, sometimes we will encounter patients whose embryos are all of poor quality.

What's a poor quality embryo ? This is one which divides slowly ( for example, one which has only 4 cells on Day 3) ; or one which has a lot of fragments. ( This is why you must ask your clinic for photos of your embryos, so you have documentation of the quality of your embryos ! )

Why does this happen - and what can you do about it if it happens to you ?

Remember that there are only 3 variables which influence embryo quality - eggs; sperm and the lab. This means that poor quality embryos could only be because of the 3 following reasons:

poor quality eggs;
poor quality sperm; or
a poor quality lab

Surprisingly, experience has shown us that the sperm are not important at all as regards the quality of the embryo. Thanks to ICSI, where we need only one sperm to fertilise one egg, we routinely get great quality embryos even from extremely poor quality sperm !

It seems that once the sperm has been injected into the egg and fertilisation achieved, the sperm does not play an important role in further embryo development. This is quite surprising and very counterintuitive - after all, sperm do contribute 50% of the embryos DNA ! This is an oversimplification, and there may be some exceptions, but it's true for the vast majority of patients ! If you stop to think about it, given the fact that the cytoskelton and mitochondrial energy needed to drive cell division ( for embryo cleavage ) comes from the egg, this is actually quite understandable

This means that the majority of the time, if you have poor quality embryos after ICSI, you can rule out a problem with the sperm - no matter how high your sperm DNA fragmentation levels are and how poor the sperm morphology !

This leaves us with only 2 possible suspects - poor eggs and poor lab conditions.

Since it's the egg which provides the machinery for embryo division, it's hardly surprising that poor quality eggs are the commonest cause for poor quality embryos .

Older women ; women with low AMH ( and high FSH levels); and poor ovarian responders are likely to have poor quality embryos, and this is to be expected.

However, sometimes the reason for the poor quality eggs may be because of a clinical problem, because the patient was not superovulated properly. This could happen because of many reasons:

Poor quality drugs used for superovulation
Using the wrong protocol for superovulation
Not using the right dose of meds for stimulation
Not timing the HCG properly ( giving it too early, or too late).

The last is a particularly common problem with PCO patients. Many doctors are so scared of
OHSS, that they end up mistiming the HCG injection or use prolonged coasting ( during which the estradiol levels drop and the eggs undergo atresia because of the absence of hormonal support) , as a result of which they get few poor quality eggs and therefore poor quality embryos.

A major role in creating poor quality embryos is a poor quality IVF lab. However, this is a reason which is often not openly discussed. For one thing, patients do not understand much about what goes on behind the closed doors of the IVF lab. Doctors also do not bother to explain too much, as a result of which there is little transparency and very poor documentation.

While it's true that having poor quality embryos because of a poor quality lab causes major heartburn, the good news is that this can be corrected the next time around !

If you have poor quality embryos, it's very important that you ask for documentation.

What were the meds which were used for superovulation ? What was the dose used ? How many follicles did you grow on ultrasound scanning ? What were their sizes ? What was the endometrial thickness and texture ? What was the E2 ( estradiol) level in the blood ? How many eggs were collected ? How many embryos were transferred ? What was the embryo quality ? Please ask for photos of your embryos !

Ask for a printed treatment summary from your IVF clinic - this is very useful when you need to get a second opinion ! I am happy to provide a free second opinion as well !

I need more information.

Could you please send me your medical details by filling in the form at
www.drmalpani.com/malpaniform.htm so I can guide you better ?

If you have poor quality embryos, you need to make some changes for your next attempt.

Your choices include:

Stick to the same clinic , but use a different protocol
Change to a different clinic
Use donor eggs, if you are willing to consider this option

These are all difficult choices, but going through them systematically will help you get the best possible medical care !