0:01

Hi, I'm Rachel

0:01

Sherriff, and welcome to the

0:03

fertility suite podcast. Our aim

0:03

is to educate and empower

0:07

couples who are struggling with

0:07

all aspects of fertility. By

0:11

giving you the information to

0:11

make informed decisions along

0:14

the way. We've had a little

0:14

rebrand since the last one we

0:17

were formerly the fertility

0:17

method podcast. But in this

0:20

second series, rest assured, we

0:20

still have the same high

0:22

standard of fertility experts

0:22

coming to share their knowledge

0:25

and support you. So if you are

0:25

struggling with fertility,

0:29

miscarriage or you just want to

0:29

arm yourself with the facts,

0:32

then this podcast is for you. Alright, everybody, and welcome

0:35

back to another episode of the

0:37

fertility suite podcast. So

0:37

joining us this week, we have

0:40

Victoria wiggly, and Victoria

0:40

runs an independent embryology

0:45

and IVF advice service called

0:45

all about embryology. She used

0:49

to work at the London Fertility

0:49

Centre and the CRG h and then

0:53

most recently at New Life. So

0:53

welcome, Victoria. Hello, there.

0:57

Hi. Thank you for having me on.

0:57

No, thanks for joining us. Do

1:00

you want to just let listeners

1:00

know a little bit more about

1:03

yourself? Just sort of elaborate

1:03

on the the intro I've given you?

1:06

I'm sure you can do a better one

1:06

yourself? No, of course. Thank

1:09

you. So yes, I've been an

1:09

embryologist for over 15 years

1:13

now. And as I say those are the

1:13

clinics that I worked out for. I

1:18

then decided about two years ago

1:18

that I wanted to come a little

1:22

bit more away from the clinical

1:22

side, because I started to

1:25

notice that there was quite a

1:25

gap in the patient care. And I

1:31

was finding that patients didn't

1:31

really understand the embryology

1:34

side of the treatment. And

1:34

because of this, they were

1:38

finding the treatment quite

1:38

stressful. And they weren't

1:41

really getting the advice they

1:41

needed. The mock there was a

1:44

minefield about all the add ons

1:44

and everything like that. So I

1:47

decided that actually I could

1:47

offer patients a consultation

1:51

style service, which will

1:51

actually help guide them through

1:54

the process. So that's when I

1:54

decided to launch all about

1:57

embryology, which was mid 2022.

1:57

I launched that. That's

2:06

amazing. That is such a well

2:06

needed much needed rather like

2:11

service. So many of the clients

2:11

that we work with, whether

2:13

that's in the clinic or online,

2:13

say that they didn't have access

2:17

to the embryologist and they

2:17

were having IVF or they're

2:19

asking us quite in depth

2:19

questions about embryology. So

2:22

to have someone that they can go

2:22

to independently and ask

2:25

questions to, you know, IVF is a

2:25

minefield, isn't it? Like it's

2:29

such an awesome, it really is.

2:29

And unfortunately, because the

2:31

embryologist clinical load is so

2:31

huge, we are behind the lab door

2:36

so much at that time, we have to

2:36

do our patient calls so quickly

2:41

that I wanted just to actually

2:41

spend time with patients

2:44

individually, explain results to

2:44

them, explain all the

2:48

terminology helped guide them

2:48

with their decisions, so helped

2:51

make them you know, really make

2:51

an informed choice themselves

2:54

and not feel pressurised into

2:54

anything you they've really got

2:57

to understand it. And

2:57

unfortunately, having a very

2:59

quick chat to an embryologist or

2:59

a short consultation with a

3:02

doctor sometimes doesn't give

3:02

them given that help. So yeah, I

3:06

feel like it is it is a needed

3:06

service. And often the need

3:10

actually comes sadly after an

3:10

unsuccessful cycle. And often

3:14

the only time you get to speak

3:14

to the embryologist is sort of

3:16

within that five day window when

3:16

you've had your eggs collected,

3:19

you know, and you're waiting about your blastocyst. So I think to have the opportunity to

3:21

speak to someone for a decent

3:23

length of time, perhaps after an

3:23

unsuccessful cycle is where you

3:26

can really sort of come into

3:26

your own and offer some advice.

3:29

Yeah, and review their cycles to

3:29

see all the details that perhaps

3:33

the doctor might not not pick up

3:33

on. So yeah, is something that

3:38

can actually really help

3:38

patients and then help them with

3:40

a sort of what next, you know,

3:40

side of things as well, you

3:43

know, what other treatments can

3:43

they look at? And, you know, is

3:46

it worth tweaking something for

3:46

a future cycle? So yeah, I can

3:50

really spend the time with them

3:50

to do that. So today, I think we

3:54

just want to bust some myths,

3:54

really, and talk about some

3:57

really common things that come

3:57

up certainly, in our clinic, and

4:00

I'm sure in yours as well, and

4:00

really sort of get the answers

4:04

to things that people might not

4:04

know. So I think we're going to

4:07

start with perhaps probably the

4:07

biggest question and the thing

4:10

that comes up, like the most is

4:10

like what does it mean to have

4:14

good egg quality? Like that

4:14

phrase, good egg quality is

4:17

bandied around on, ya know,

4:17

people will talk about oh, all

4:22

my eggs good quality, how do I

4:22

how do I have better egg

4:24

quality? What does that actually

4:24

mean? Ya know, it's a it's

4:27

definitely a tricky one. And

4:27

often it's one that people get

4:30

muddled with. So there's your

4:30

egg number, so your ovarian

4:34

reserve and your egg quality. So

4:34

often, people get confused with

4:40

this. So they'll do the testing,

4:40

you know, they'll look at their

4:42

Hmh levels and things like that.

4:42

That's actually determining what

4:46

your egg number is your ovarian

4:46

reserve. But the egg quality is

4:51

something that we don't usually

4:51

know about until we get those

4:54

eggs into the lab. So when we're

4:54

talking about good egg quality,

4:58

we're looking at how All the eggs appear so

5:03

that they've got the sub

5:03

cytoplasm in the middle. And so

5:07

you wanted to look to see if

5:07

there's any abnormal inclusions

5:09

in that if there's any vacuoles,

5:09

if it's granular, or if it's

5:13

nice and clear, the shell that

5:13

surrounds the outside of the egg

5:17

is that normal in shape and

5:17

thickness, or things like this,

5:21

the polar body, which tells us

5:21

it's the mature egg, you want it

5:24

to be a nice round polar body,

5:24

you don't want it to be

5:26

fragmented, or things like that,

5:26

what we look at to see if it's a

5:31

good egg quality, that that, as I say, is

5:34

something that's different from

5:36

your ovarian reserve, which is

5:36

how many eggs you have left in

5:40

the bank. So that's sometimes

5:40

what patients get getting bit

5:43

muddled about. And what are the factors that

5:45

affect good egg quality. So we

5:50

know that age and genetics play

5:50

a part but anything else, I mean

5:54

that yeah, they're the main

5:54

ones, you do generally see a

5:59

decline as we get older, in your

5:59

egg quality as well as your

6:03

ovarian reserve. And that's the

6:03

biggest, biggest factor really,

6:07

having said that, you can have

6:07

some patients who

6:11

are young, and they've got a

6:11

good ovarian reserve, but they

6:14

might have a poor air quality.

6:14

So sometimes, a typical one is

6:18

where a patient is, has

6:18

polycystic ovarian syndrome. So

6:23

she has multiple follicles. And

6:23

so then reserve will be very

6:26

high. But actually, sometimes

6:26

the quality is slightly poorer,

6:30

because the hormones are all all

6:30

slightly out of sync. So there

6:34

are different factors that can

6:34

affect the quality. And as you

6:38

touched on as well, genetics,

6:38

you know, sometimes it is, you

6:41

know, a predisposed thing. But

6:41

it is something that, generally

6:49

age is the biggest driving force

6:49

that we tend to see. Which is

6:54

why obviously, you know, as

6:54

patients get older, the chances

6:58

of, of miscarriage and

6:58

implantation failure will will

7:00

increase. So age and genetics

7:00

are kind of like the two that we

7:04

can't really do anything about

7:04

sadly. And then they're the sort

7:06

of biggest components. But it's

7:06

good to know that actually, your

7:09

hormone balance does play a part

7:09

in egg policies.

7:12

When you're having IVF, you were

7:12

talking about small margins a

7:15

lot of the time with IVF, right?

7:15

Like it's the small changes or

7:18

the small, you know, you don't

7:18

need big changes and things to

7:20

have a better outcome. Small

7:20

changes might get you a couple

7:23

of more good quality embryos and

7:23

maybe a couple more good quality

7:26

embryos is only need lewdly hormonal component is quite

7:28

small. But actually, if your

7:31

hormones are well balanced, then

7:31

that might be enough to get you

7:35

better quality embryos

7:35

accurately. It's just about

7:37

optimising every angle. And the

7:37

more we can optimise, you know,

7:42

things like certain supplements

7:42

that can now be the driving

7:45

force for the mitochondria,

7:45

which is sort of the energy hub

7:47

of the the egg, things like

7:47

that. People don't realise, but

7:51

actually, that is so important

7:51

as well to support. So as much

7:55

as some of it is predisposed,

7:55

that we can't control. There are

7:59

things that we can do to

7:59

optimise to ensure that really

8:03

were, you know, have the

8:03

patients in the best possible

8:06

position before they start.

8:06

Yeah. And would you agree that

8:09

like a three month prep time is

8:09

key given that we know that

8:13

follicular recruitment kind of

8:13

takes roughly around that time?

8:16

What are your thoughts on that?

8:16

Yeah, I mean, it's, it's the

8:19

same with men and women really,

8:19

for both of them, it would be

8:24

ideal if you could have that

8:24

prep time in advance of having

8:28

any treatment. So that you can get everything

8:30

balanced. You know, for

8:33

instance, with the men, they they even more so than the

8:36

women, they have this sort of

8:39

proper cycle, where the sperm

8:39

will completely be a whole new

8:44

batch for the next ones. And if

8:44

there are any environmental

8:46

issues, you can correct those

8:50

by sort of adapting lifestyle,

8:50

etc.

8:54

However, it's a tricky one.

8:54

Because if a patient comes to

8:57

me, and she's early 40s,

9:01

the risk of delaying her

9:01

starting could be almost worse

9:08

than giving her the time to

9:08

prep. So really, it's something

9:13

that in an ideal situation,

9:13

especially if patients are

9:15

younger, yes, having that prep

9:15

time is really important.

9:20

But it's a balancing act, you've

9:20

got to work out what the other

9:23

factors are before obviously

9:23

making that decision. And

9:25

obviously, the best thing to do

9:25

would be for them to be doing

9:28

that whilst they're trying to

9:28

conceive before they even

9:31

consider the IVF route. So that

9:31

they're in the right position

9:35

and maybe things aren't quite

9:35

working but they're not at the

9:38

point of wanting to seek out you

9:38

know, any, any professional help

9:41

yet to start having all of this

9:41

advice out there. You guys doing

9:46

these podcasts, things like

9:46

that, so people can get

9:50

themselves in that position,

9:50

making sure that they they're

9:53

doing all the right things in

9:53

preparation so that if they do

9:57

need to go down to treatment,

9:57

they're already there with their

9:59

OPT memorization. I think that that is that is

10:01

key. Really. Yeah. And you've

10:04

kind of just hit the nail on the

10:04

head with really what, like the

10:09

best approach to IVF should

10:09

always be like a tailored

10:11

individualised approach because

10:11

for example, you know, if you

10:14

know you have low Hmh, for

10:14

example, then actually, yes, you

10:19

might go into a cycle quicker,

10:19

but also, it's really important

10:22

that the sperm health is as good

10:22

as possible. Because if you've

10:24

got low MH, we need to, you

10:24

know, we need to make sure the

10:27

other side of the of the picture

10:27

is doing, or to help produce

10:31

good quality embryos, really,

10:31

really does need an approach

10:35

that's quite individualised. IVF

10:35

genuinely, really does. When it

10:40

comes to embryo grading. So,

10:40

like how subjective or how

10:45

important you could say is

10:45

embryo grading to a cycle

10:48

outcome? Because I think

10:48

patients are led to believe when

10:51

they have their eggs collected,

10:51

and you're in that five day wait

10:53

window, like you're waiting to

10:53

hear what grade they are, and

10:57

then you're, you're going over

10:57

in your mind like, oh, well,

10:59

I've only got so many of that

10:59

grade, or they will all grade

11:02

and I'm saying that in inverted

11:02

commas, like, how important is

11:05

this? And how is the grading

11:05

done? Yeah, so it's, it is

11:10

something that I see a lot of

11:10

patients put so much weight on,

11:14

and they really get themselves

11:14

in a bit of a pickle about it,

11:18

which I try to take them away

11:18

from, especially those gradings.

11:22

In those first two, you know,

11:22

two or three days, they aren't

11:26

the be all and end all.

11:26

Obviously, we're looking for a

11:30

whole number of things, we're

11:30

looking for the cell cell

11:35

numbers, so how the rate of the

11:35

developments or how fast the

11:39

Ember is growing, we don't want

11:39

it to go too fast. But we don't

11:42

want it to grow too slowly.

11:42

There are strict checkpoints in

11:45

the development. So we're

11:45

looking at that to make our

11:48

decisions, were looking to see

11:48

how much fragmentation there is.

11:52

So when a cell divides, it

11:52

should divide nicely into two.

11:57

And this should be nice, even

11:57

division, what can sometimes

11:59

happen is you can have little

11:59

pockets of fragments that come

12:02

away from the cells. And

12:02

obviously, that then makes it a

12:06

poor quality embryo in terms of

12:06

our grading. So they're the kind

12:09

of things that we look at when

12:09

we're in the early stages of

12:12

development. Up until day three,

12:12

then when they form a

12:16

blastocyst, that's when our

12:16

grading completely changes,

12:19

because the embryo looks so

12:19

different. So we're looking at

12:23

the outer cells being nice, and

12:23

even in a good number, we're

12:26

looking at how expanded it is.

12:26

And then a tight ball of cells

12:30

in the middle, which is the

12:30

inner cell mass. And we're

12:32

looking to see if that if you

12:32

know, there's a good cell number

12:34

in there that they're all nicely

12:34

compact together. So the grading

12:38

is very different. At that

12:38

point. The biggest factor I

12:42

would say to patients is rather

12:42

than getting fixated on the

12:46

actual grades, especially in

12:46

those early days, what we're

12:49

really wanting to look at is

12:49

your blastocyst development

12:53

rate. Now, this is something

12:53

that scares a lot of patients,

12:56

but we only expect about half of

12:56

your day three embryos to go on

13:02

to get to the blastocyst stage.

13:02

And that is completely normal.

13:04

And that's a message that I

13:04

constantly try and drive home to

13:08

patients not to worry that then

13:08

they haven't all made it. And

13:13

once they form blastocysts,

13:13

obviously, the blastocyst

13:17

quality is a little bit more

13:17

important at this stage. Because

13:21

you do need strong cell lines,

13:21

especially the outer cells,

13:26

which people don't often think

13:26

because they're not actually the

13:28

cells from the baby. But they're

13:28

the cells that make that initial

13:31

connection with the uterus. So

13:31

you want good strong cells at

13:35

that point, to be able to start

13:35

the process of implantation? Um,

13:39

so yes, good morphology is genuinely

13:42

linked to having a higher chance

13:48

of a conception. But it's not to

13:48

say it's not the be all and end

13:53

all. And certainly day three, we

13:53

can see some beautiful day three

13:57

embryos that then don't make it

13:57

to the blastocyst stage. And we

14:00

can see some that we would have

14:00

normally wanted to write off at

14:04

the early stages, but actually,

14:04

they're the ones that go on to

14:07

form Lassis. So I do whilst we

14:07

do tell the patients this

14:11

information, I do say to them,

14:11

you know, don't don't get too

14:15

fixated on it. Because it isn't

14:15

necessarily the most important

14:19

thing at this point. And if you

14:19

have lesser graded embryos, that

14:24

doesn't necessarily mean that

14:24

they won't work, right. Like I

14:28

have patients all the time who

14:28

have like less than what they're

14:31

worrying about the grading, they

14:31

have a transfer with an embryo

14:34

or blastocyst that maybe wasn't

14:34

great as high as they wanted it

14:36

to be. And they still go on to

14:36

have success, right? Absolutely.

14:39

Absolutely. And we wouldn't do

14:39

transfers or freezing on

14:44

blastocyst that have say for

14:44

instance, A B C grade, which

14:47

patients say oh, that's awful.

14:47

We wouldn't be freezing them or

14:50

transferring them if they didn't

14:50

have a chance of success.

14:54

Obviously, an AE will generally

14:54

speaking and average AAA over BC

15:00

we'll have a chance. But there

15:00

are so many other factors that

15:03

are involved in conception that

15:03

it isn't, you know, isn't

15:08

something that patients should

15:08

should worry about. If the

15:12

embryologist and the doctor are

15:12

happy that it is suitable for

15:14

transfer, ie it's not arrested.

15:14

So it's still showing signs of

15:18

development. And it's not

15:18

showing any signs of

15:21

degeneration. Though the two big

15:21

ones, the doctor and the

15:24

embryologists are happy with

15:24

that, then the patient has the

15:26

chance of a pregnancy. Am I

15:26

right in thinking over the last

15:30

sort of 510 years, we've become

15:30

much more stringent about what

15:33

we consider suitable for

15:33

freezing and transfer.

15:36

In terms of I mean, different

15:36

different clinics have different

15:39

policies. Really, the number one

15:39

thing is, most clinics now will

15:45

freeze at the blastocyst stage,

15:45

unless the patient's doing, for

15:48

instance, a package where they

15:48

freeze all at day three, and

15:50

then grow all of them up. If you freeze at the blastocyst

15:53

stage, the most important thing,

15:55

as I mentioned, is that it's

15:55

formed a blastocyst. So you

15:59

don't want to be on day six,

15:59

freezing a Morula, which is what

16:02

it should be on day four. That's the most important thing.

16:07

In terms of the actual

16:07

qualities, generally speaking,

16:11

as long as you can distinguish

16:11

between seeing in a cell mast

16:14

cells, and effective themselves,

16:14

the outer cells that generally

16:18

speaking is suitable for

16:18

freezing. But you have to So

16:23

most clinics will have a BC cut

16:23

off. So if it's a CC, the C is

16:27

the inner cell mass. And that

16:27

means you can't see clear in a

16:30

cell mass cells. Generally

16:30

speaking, that's what most

16:33

clinics will go by, that's the

16:33

grading system that they use.

16:38

At the same time, you don't want

16:38

to free something that is very

16:43

important, even if the

16:43

blastocyst because you're then

16:45

giving the patients false hope

16:45

that embryo is more likely to

16:49

not survive. But also, you don't

16:49

want to risk the patient having

16:54

too many embryos that then give

16:54

them all this hope that actually

16:57

these embryos are very poor

16:57

quality. So that's where you get

17:01

the discretion that comes in

17:01

with the embryologist and we do

17:04

we ask each other opinions,

17:04

they'll sometimes be a

17:07

borderline embryo that I would

17:07

call a colleague and say, Would

17:10

you freeze this? I'm not sure.

17:10

So it is something that you

17:15

know, we even we don't always

17:15

know whether it is worth it or

17:19

not. But yeah, it especially if a

17:21

patient gets there only once and

17:24

we'd be more likely to say,

17:24

let's give you a chance with

17:28

this rather than discarding it.

17:28

I think that five day wait is

17:32

like the hardest part of IVF?

17:32

For sure. And the one other

17:35

really hard thing with fertility

17:35

issues and fertility treatment

17:37

is there's so many grey areas,

17:37

right? And we don't know it or

17:40

we don't have all the answers.

17:40

And actually, the way most

17:43

people's brains work is we want

17:43

definitive answers. No one likes

17:46

a grey area, right. And that

17:46

five day window is such a grey

17:49

area, things can change. And,

17:49

you know, we've talked about the

17:52

things that can affect egg

17:52

quality, so age genetic

17:54

hormones, but like there's lots

17:54

of things that will affect how

17:58

many blastocysts you will get on

17:58

top of that. So, you know, the

18:01

sperm house right is really

18:01

important at that point like is

18:05

carries, you know, carries your

18:05

genetics to the egg. Basically,

18:07

it's 50% of the embryo

18:07

development. So that is another

18:11

big factor in how many classes

18:11

potentially going to get right.

18:15

Definitely. And actually,

18:15

patients don't often realise it.

18:18

But if we see good embryo

18:18

development up until day three,

18:22

which even though the sperm is

18:22

there, the development is

18:25

actually governed by the eggs

18:25

DNA up until day three, it's

18:29

only on day three, that the

18:29

sperm really kicks in, and it

18:33

becomes sort of an embryo in

18:33

itself with both the sperm and

18:38

the eggs. So if we see a high

18:38

arrest rate, which is, as I

18:43

mentioned before, is 50% is the

18:43

norm and that's what we expect,

18:46

if we're only seeing a 20 25%

18:46

conversion rate or less.

18:52

Actually, alarm bells, alarm

18:52

bells will ring on the sperm

18:55

side as well. And that's

18:55

something that 1020 years ago,

19:00

no one would think about at all.

19:00

As long as the man had a good

19:04

semen analysis, tick, everything

19:04

else must be down to the woman.

19:08

We're realising that is not true

19:08

now. And there is a lot more

19:12

emphasis on it things like

19:12

looking at not just looking at

19:16

the sperm counts and the

19:16

motility looking at sort of the

19:20

more of the the integrity of

19:20

sperm looking at the DNA

19:22

fragmentation levels, things

19:22

like that are really important

19:27

and optimising them the man as

19:27

well before the for the cyclists

19:31

is something that we never used

19:31

to do and now is becoming a lot

19:35

more sort of advisable. Yeah,

19:35

absolutely. For anyone listening

19:40

to this episode. By the time you

19:40

listen to this, the two previous

19:43

episodes will have been published and they were actually with Claire Mooney, who is also

19:45

an embryologist, but also she

19:50

works in a specialist fertility

19:50

urologist clinic, she runs a

19:54

clinic and she really knows a

19:54

lot about sperm and we talk a

19:57

lot about DNA fragmentation

19:57

infection

20:00

And then the episode before that

20:00

was with Olivia, who runs the

20:03

male fertility clinic. So if

20:03

you're listening and what

20:05

Victoria has said, has just

20:05

maybe made you think about

20:09

something that happened in your own cycle and you want a bit more information about the male

20:11

side of things, you can go back

20:14

and listen to the previous two

20:14

episodes, which will be very

20:16

helpful. So Victoria then how

20:16

important is the lab when

20:20

choosing an IVF? clinic? Like,

20:20

we've talked about this five day

20:23

window and actually watching

20:23

your embryos growing in the

20:26

blastocyst development? Like

20:26

what should be like the basic

20:30

requirement in a lab other than

20:30

our labs different depending on

20:33

where you go? When patients are

20:33

choosing an IVF? clinic? Should

20:36

they be asking questions about

20:36

the lab services? Like how

20:39

important is this in the

20:39

process? Yeah, no, it obviously

20:42

it's an embryologist I will say

20:42

is important.

20:45

The good thing about being in

20:45

the UK, is we are one of the

20:50

most tightly regulated clinics, clinical settings that

20:54

you can get worldwide, much more

20:59

so than in a lot of other

20:59

countries. So we are governed by

21:02

the hfpa. And they come around

21:02

and they do regular inspections

21:06

on clinics. And they will be

21:06

making sure that the clinic

21:10

level, including the laboratory

21:10

is up to standard. And

21:14

obviously, they have a power to

21:14

close the clinic down if they if

21:17

they were concerned. And obviously, that doesn't

21:20

necessarily apply overseas for

21:24

anyone if they were listening

21:24

overseas. But that is a good

21:27

thing in the UK. Having said that, there are

21:30

going to be differences between

21:33

clinics. And those differences

21:33

can be as a result of

21:38

differences in the laboratory.

21:38

So it is very important. And I

21:43

think patients have the right to

21:43

ask their clinic before they

21:48

decide to commit to treatment.

21:48

Questions about you know, what

21:53

the KPIs or key performance

21:53

indicators are? You know, they

21:56

want to be asking what the

21:56

laboratories Lassis rate is,

22:00

what their utilisation rate is,

22:00

do they monitor their

22:05

practitioner xe rates, for instance, because,

22:07

you know, some, some

22:11

practitioners might have a

22:11

better fertilisation rate, some

22:14

might have a lower degeneration

22:14

rate all these things, if they

22:19

are monitored, you can see

22:19

standard sleeping.

22:24

And you can't afford to have

22:24

standard sleeping in a

22:27

laboratory. And most

22:27

embryologist are incredibly

22:31

meticulous, real perfectionist top of the

22:32

game, but it needs to be

22:36

monitored, because there are

22:36

going to be people coming into

22:40

the labour lab that might not be

22:40

following the the SOPs as well

22:45

or, you know, they might not

22:45

have quite as good a practice.

22:48

And that needs to make sure it's

22:48

checked. And so by doing

22:52

practitioner KPIs, you're

22:52

picking up on that. And then the

22:55

general performance of the lab,

22:55

that's when you're going to see

22:58

things like the blastocyst rates

22:58

and, and the fertilisation

23:01

rates. And that's something that

23:01

a patient can ask for. And any

23:05

good lab will have that, you

23:05

know, if it's a smaller lab,

23:09

they might do it quarterly. If

23:09

it's a larger lab, they might do

23:12

it monthly, but they should have

23:12

up to date results.

23:16

So that's something that you can

23:16

look at, when you're when you're

23:20

choosing a clinic, because it

23:20

can then show you that you can

23:23

be confident in that lab and

23:23

that they'll look after your

23:26

your eggs and embryos and sperm

23:26

as well as they can. You could

23:30

argue that the blastocyst rate

23:30

is perhaps more important than

23:32

the life birth rate when they're looking at a clinic, right? Because you're not going to get

23:34

a life birth unless you've got the blastocyst in the first

23:36

place. So that's interesting,

23:39

and not something that I ever would have thought of actually. So that's really good to know

23:41

that, you know, if you're

23:43

looking at IVF, clinics, you

23:43

should be asking about

23:45

blastocyst rates, as well as

23:45

looking at the the life birth

23:48

rates, I think we will get a bit

23:48

hung up on stats with clinics.

23:50

And actually, there's so many

23:50

variables. And also, you know,

23:53

for clinic does a lot of

23:53

resource cycles, for instance,

23:58

they're going to be producing

23:58

embryos in the lab, but those

24:02

embryos won't ever be part of

24:02

your fresh results. So what

24:09

patients tend to look at what

24:09

gets published, and that's the

24:12

fresh embryo results. Frozen

24:12

ones have a lot of other factors

24:16

that patients don't tend to look

24:16

at those. So there is

24:21

variability in statistics as

24:21

well. Obviously, you know, you

24:24

can't deny it, you can present

24:24

results per embryo transfer as

24:30

opposed to per recollection. You

24:30

there's different ways of making

24:34

the clinic stats look better.

24:34

But if you get into the nitty

24:38

gritty with a lab and say to

24:38

them, I want to know your

24:41

internal KPIs about all the

24:41

embryos that you're growing in

24:45

the lab, how many of the eggs

24:45

are fertilising? How many of the

24:48

embryos are forming glasses, all

24:48

of that will give you a much

24:51

better overall picture of how

24:51

the lab is performing compared

24:55

to what they're putting on their

24:55

website, as to their results.

24:59

That's little nugget of gold that

25:00

little bit. Thank you. So let's

25:04

go back and talk a little bit more about the male side of things. And XE. So we're going

25:06

to talk about add on shortly.

25:08

But you could classic see as an

25:08

add on, right, but some for some

25:11

people, it's like what we call a

25:11

necessary add on. Obviously it

25:14

does add on to the cost of IVF.

25:14

But in certain scenarios, it

25:17

will get you a high

25:17

fertilisation rate, I'm assuming

25:19

so like, when would you use XE?

25:19

And what doesn't xe address? And

25:27

then, like, what should people

25:27

consider if they're being

25:31

offered? xe, sometimes xe isn't

25:31

so much offers, you're more most

25:35

told, aren't you? We're going to

25:35

use Excel, how does that process

25:38

work? So IXI is for anyone that

25:38

doesn't know the terminology X

25:44

is where we physically pick up

25:44

the sperm and inject it directly

25:47

into the egg. So that's

25:47

different is a different method

25:51

of insemination to conventional

25:51

IVF. So often, everyone talks

25:54

about IVF, as is the process.

25:54

But actually, conventional IVF

25:58

is one main way of doing

25:58

insemination and x is the other

26:02

way. So with conventional IVF,

26:02

you're mixing the sperm and the

26:05

eggs together in the dish. Now

26:05

that is usually the first method

26:11

that we will consider using and

26:11

less the patient has got a

26:16

couple of different factors. So

26:16

the biggest one is poor sperm

26:21

parameters. So if the sperm

26:21

concentration is low, or there's

26:26

not many sperm moving, so then

26:26

motility is low, or we're seeing

26:29

a high level of abnormal forms

26:29

in the sperm. If we try and mix

26:33

the sperm the egg together and

26:33

the dish, chances are they

26:37

aren't going to get good

26:37

fertilisation, because there

26:39

aren't going to be enough sperm

26:39

that to fertilise, we try and

26:43

mix about 100,000 motile sperm

26:43

in the dish per each well. So

26:49

you need those numbers to be

26:49

able to get good fertilisation.

26:54

So in those cases, obviously

26:54

picking up individual sperm and

26:56

injecting it will help the

26:56

patient's chance of

26:59

fertilisation. Other factors are

26:59

if they've had IVF, before

27:04

conventional IVF. And they've had a poor

27:06

fertilisation, so the sperm

27:09

might be good. And then might

27:09

the X might appear normal. But

27:13

the sperm and the eggs are just

27:13

not working together, you might

27:16

not be getting good sperm

27:16

binding on the outside of the

27:19

egg, things like that. It could be that there's a

27:22

hardening or or something or a

27:25

problem in the sperm head. So we

27:25

want to overcome that by putting

27:29

the sperm directly into the egg.

27:29

Now that's an effect that many

27:33

people but it can happen. And we

27:33

certainly do see it happening in

27:36

a small number of cases. And

27:36

then they have another cycle

27:39

with XE and it's successful.

27:43

And now another thing that we've

27:43

touched on before is the high

27:46

DNA fragmentation levels. So

27:46

even if

27:50

all the results on paper look

27:50

normal in terms of the counter

27:54

motility and everything, if

27:54

they've got a high DNA

27:56

fragmentation level, XE is a way

27:56

of us selecting the sperm that

28:04

are more likely not to have the

28:04

high DNA fragmentation levels.

28:09

So xe can help us in choosing

28:09

the better sperm for for the

28:15

insemination. So that's really

28:15

the main cohorts of people that

28:20

will need xe if we are looking at the

28:24

downsides to xe, so some people

28:29

might say, Well, surely you

28:29

would just do xe for everyone

28:32

then and risk, you know, the

28:32

chance that the patient might

28:36

have poor binding or something

28:36

like that. And to those people,

28:39

I'd say actually, no, I wouldn't

28:39

advise it for everyone. And the

28:43

reasons for this is, number one,

28:43

it's invasive. So with

28:48

conventional IVF, you're letting

28:48

the sperm swim around the eggs

28:50

and we're letting them fertilise

28:50

naturally overnight. With Dixie

28:54

we're having to get the needle

28:54

and put it into the egg. So five

28:57

to 10% of eggs may not survive

28:57

this process because you're

29:02

you're puncturing the membrane

29:02

and then the membrane might not.

29:05

So reform back together again in

29:05

the cell, the egg and might then

29:09

die. So that's the first reason.

29:09

The second reason is we can only

29:14

inject mature eggs. So sometimes

29:14

after you had your egg

29:19

collection, the doctor collects

29:19

as many eggs as they can do. If

29:22

they come from smaller

29:22

follicles, sometimes those eggs

29:25

aren't mature, but they can on

29:25

occasion mature on in the lab.

29:30

With xe we can only inject them

29:30

at the time if they're mature.

29:33

But it could be that two hours

29:33

later, after you've done the XE,

29:37

the immature egg may well have

29:37

matured on now with IVF. We're

29:40

leaving them surrounded by sperm

29:40

overnight. So if they matured

29:44

overnight, they've still got a

29:44

chance to go on and fertilise

29:47

whereas with xe we discard them

29:47

if we aren't able to inject

29:50

them. So that's the second

29:50

reason.

29:54

The third reason is as much as

29:54

embryologist are wonderful we

30:00

cannot guarantee that the sperm

30:00

that we're picking up and

30:03

selecting is a normal sperm.

30:03

Obviously, we look at it with a

30:07

morphology. You know, we look at

30:07

it on a higher level with the

30:11

sperm vacuoles in the head, but

30:11

we cannot say it's a normal

30:16

sperm. Whereas with IVF, there's

30:16

almost a level of natural

30:21

selection that goes on

30:21

obviously, an utmost normal

30:24

spend may well still fertilise,

30:24

but you're allowing the 100,000

30:27

motile sperm to be in a very

30:27

close proximity to the egg. So

30:30

there is going to be some level

30:30

of natural selection, where it

30:33

was the embryologist is the one choosing. And then my fourth and final

30:36

reason is it will add quite a

30:41

significant cost on to the

30:41

collection. So most clicks it

30:46

will be over 1000 pounds extra.

30:46

And obviously if you're already

30:50

spending that huge rack of

30:50

money, another 1000 pounds on

30:54

top when you might not need it

30:57

isn't worth it. And we see

30:57

comparable fertilisation results

31:01

between IVF and XE. So it's not

31:01

that x is going to give you a

31:06

better chance of fertilisation just because you're putting the sperm in there. It's only for

31:08

those people that the IVF may

31:13

not work for that it isn't

31:13

needed. Yeah. Okay. And so you

31:18

what you're saying is you could

31:18

still be selecting sperm that

31:22

had high DNA fragmentation and

31:22

like abnormal, and then perhaps

31:26

then the embryo doesn't go on to

31:26

develop genetically as it

31:28

should. So it's possible because

31:28

we can't see, we can look at the

31:32

indicators that are linked with

31:32

poor sperm. And obviously, we

31:37

would always deselect against

31:37

those. But we cannot guarantee

31:41

the sperm we're picking up is

31:41

going to achieve fertilisation

31:45

or go on and be able to result

31:45

in a healthy baby goes back to

31:51

about like the three months prep

31:51

and making sure that sperm is

31:53

Tip Top as good as it can be

31:53

before you go into a cycle.

31:57

Like let's talk about a little bit more in depth about

32:01

add ons, then because there's

32:03

loads of add ons right out there. So let's talk about

32:06

add ons that are perhaps worth

32:10

considering and add ons where

32:10

the evidence base is not quite

32:13

there yet. Add Ons is a really, really

32:16

tricky area. Because

32:21

in my mind, as a scientist, a lot of stuff will start off

32:24

its journey,

32:29

not necessarily having strong

32:29

evidence based results. And that

32:36

will be something that over time

32:36

when you have more and more

32:38

data, it may well be that it

32:38

goes on and

32:43

you know, it may be something

32:43

that then becomes the norm. So I

32:48

don't never want to rule off

32:48

things. And if a patient comes

32:52

to me, and they've had three

32:52

failed IVF cycles and the clinic

32:56

are just saying just keep doing

32:56

the same thing again and again.

32:58

And again, I get that you want

32:58

to maybe tweak a few things to

33:03

see if we can improve. Now, having said that,

33:05

unfortunately, I used to always

33:10

believe that you know, when the Daily Mail

33:12

and newspapers used to go to

33:15

town on saying how awful

33:15

fertility clinics where I used

33:20

to find it really upsetting to

33:20

read, because I was never in a

33:24

position where micro clinics I

33:24

worked at would do that.

33:29

Having now spent 18 months doing

33:29

my independent work, I'm working

33:34

with a lot of patients from

33:34

different clinics in the UK and

33:38

overseas. And I am realising

33:38

that add ons are being

33:42

unnecessarily put on patients.

33:42

And this is something that may

33:46

well jeopardise the safety of

33:46

the patient's embryos. And it

33:52

may be something that is giving

33:52

them false hope when there is

33:55

very little evidence. And it is

33:55

going to hugely increase the

33:59

cost of their cycles

33:59

unnecessarily. So this is

34:03

something that I am very

34:03

passionate about. Because whilst

34:07

I do think that there are some

34:07

add ons that have a place and

34:11

the hfpa do list the add ons on

34:11

their website, and they've given

34:16

them a grading system as to what

34:16

the evidence is like.

34:21

I do think that it's something

34:21

that patients really need a lot

34:24

more information about before

34:24

they make that decision. Because

34:28

if they're about to leave a

34:28

consultation with a doctor, or

34:32

you know, they see a

34:32

receptionist who's totting up

34:35

their bills, and someone says to

34:35

Oh, do you want to have this in

34:39

your cycle? Yeah, this was

34:39

briefly mentioned to you. And

34:42

the patient says, Oh, well, what

34:42

does it you know, mean? Should I

34:45

have it? Will it help? Well, it

34:45

can help you know, we've had

34:49

some patients that's helpful.

34:49

And, you know, if you want to

34:51

give everything, give yourself

34:51

the best chance and yeah, do it.

34:54

How many patients are going to

34:54

walk away and say, I'm not going

34:57

to do it? Because they'll

34:57

suddenly say, Well, if I don't

34:59

do it Am I the one to blame for it not

35:00

working. And putting that

35:04

pressure on patients is awful.

35:04

And it's something that I am

35:10

seeing does happen. And we

35:10

really, really, really have to

35:13

come away from that because it

35:13

is not fair IVF patients are so

35:16

vulnerable as it is. And

35:16

something that I think the more

35:21

people like yourself, and either

35:21

independent, I won't get

35:27

anything from my patients

35:27

choosing to do an add on or not

35:30

choosing to do an add on. You know, it's I have no

35:32

financial gain, I have no gain

35:35

in whether they get pregnant or

35:35

not. I am there to tell my

35:39

patients, what the evidence is,

35:39

what the pros and cons are, what

35:45

the risks are, what the costs

35:45

potentially are. And I then want

35:49

them to make the informed

35:49

decision and for them to then

35:51

turn around and say, if they do

35:51

it, and it works, what they do,

35:55

and it doesn't work, at least

35:55

they've gone into it with an

35:58

informed decision. And I think

35:58

we need more and more of that

36:01

when it comes to add ons. Yeah,

36:01

absolutely. And it comes back to

36:04

that tailored approach again,

36:04

right? Like, yes, a specific add

36:08

on might be right for one

36:08

couple, because of what their

36:11

clinical picture looks like or

36:11

what's happened in any previous

36:13

cycles or anything diagnosed

36:13

that we know about. That could

36:17

be completely different for

36:17

another couple. And I'll be like

36:20

what you said, just really hit

36:20

home a little bit. And that like

36:22

that puts the pressure on the

36:22

patient when you're giving,

36:25

dumping all that information on

36:25

them. And just sort of saying,

36:28

well, it might help. Like you

36:28

said, of course, people are

36:30

gonna then pay extra money for

36:30

that. It's not like, no one ever

36:34

wants to come out of a cycle

36:34

that's been unsuccessful going,

36:37

Oh, well, if only I'd spent the

36:37

money on that maybe I would have

36:40

had success. And that's the

36:40

impression we're giving people

36:43

when add ons are being sold

36:43

wires nowadays. And it's yeah,

36:47

it's a worry. So what's your

36:47

advice to people considering add

36:51

ons? You know, if they can't

36:51

access people like us to get

36:53

independent advice? Is there

36:53

somewhere they can go to find

36:56

more information about the add

36:56

ons? Like what what sort of

36:59

perhaps Yeah, but yeah, I mean,

36:59

that's what I go back to saying

37:01

about the hfpa website. So in

37:01

the UK, and even if you're, you

37:04

know, an overseas patient, you

37:04

can still access this online,

37:08

they do break it down into sort

37:08

of what the evidence is, which

37:13

patients it may be applicable

37:13

to. And you know, what you know,

37:18

that they also deem it is

37:18

whether it's something that is

37:21

worth considering for certain

37:21

cohorts. And I think that's

37:24

exactly what we go back to

37:24

saying. There are things, for

37:27

instance, PDGA, I'm very, very

37:27

passionate about it not being a

37:32

blanket thing that is offered to

37:32

patients when they don't need

37:35

it. And certainly I've seen some

37:35

patients being offered it where

37:38

it almost makes me angry,

37:38

they're being offered it because

37:40

they don't need it. Having said

37:40

that, I think it is a very good

37:46

tool. For certain patients. I

37:46

had a patient who transferred

37:50

her embryos to my clinic, because her clinic didn't offer

37:52

PDGA. And she had over 10

37:56

embryos in storage. And she'd

37:56

had seven miscarriages back to

38:00

back and read, they've screened

38:00

for everything else there was

38:04

there was no apparent reason why

38:04

she was having these

38:07

miscarriages. Is that lady going

38:07

to carry on doing 10 More

38:11

transfers with these glasses and

38:11

risking having 10 More

38:14

miscarriages. She was broken at

38:14

that point. And so yes, for her

38:20

screening, and we screened them,

38:20

I think about three or four came

38:26

back as normal. The first one

38:26

unfortunately didn't work. It

38:30

was just a failed implantation.

38:30

But the second one, she had a

38:33

healthy baby. And so in her

38:33

situation, yes, that was right

38:38

for her to do. Yes, she should

38:38

have spent the money. And yes, I

38:43

vouch for being involved in her

38:43

treatment for saying that that

38:46

was right for her applying it to a first time

38:49

patient who was 36 years old,

38:52

just to get them that best one

38:52

straightaway. No. So it's it's

38:57

something that patients can have

38:57

access to,

39:03

you know, advice, like the HFA

39:03

has to really see which patients

39:08

are the ones that it should be advised to and who

39:10

were the ones that you know,

39:13

don't don't need it. EDTA

39:13

testing is very expensive,

39:17

right? We're talking like 1500

39:17

pounds, and then 500 pounds per

39:20

embryo. Is that like, I mean?

39:20

Yeah, different clinics have

39:22

different different rates. But

39:22

yeah, it will add on a good old

39:26

black and on top of that, it

39:26

will automatically add freezing

39:30

to your cycle because you can't

39:30

do a fresh transfer. So then it

39:34

will also then add a frozen thaw

39:34

cycle onto your cycle. So if

39:39

patients see the cost of it,

39:39

again, they're not necessarily

39:43

given the right information because they've been given the cost of the testing of the

39:45

boxing. They need to then

39:48

consider that if they'd had a

39:48

fresh transfer. They wouldn't

39:51

have necessarily needed freezing

39:51

obviously if they had separate

39:54

glasses then yes, it would. But

39:54

all of these things aren't often

39:59

included them vacations for frozen for cycle

40:00

as well. And all of these

40:04

extras, the extra testings, you

40:04

know, for

40:08

all the steps along the way that

40:08

is not just the cost of the

40:12

actual biopsy and testing that

40:12

they need to consider. So whilst

40:16

Yes, I do believe it has its

40:16

place. It's something that

40:21

patients have to be be wary of

40:21

if they're offered it when they

40:24

don't think they need it. Yeah,

40:24

and it's something else that's

40:27

important to mention, I think

40:27

with PGT pgti testing is that if

40:31

you're going to spend all that

40:31

money on testing, you need to

40:33

make sure that the other more

40:33

basic things have been checked,

40:36

you know, is the uterus

40:36

environment healthy? There's no

40:39

point transferring very

40:39

expensively PGT, a tested

40:42

euploid embryo into an

40:42

environment that's not conducive

40:45

to implantation, right. So I

40:45

think sometimes people think PG

40:49

TA is a fix all solution. And

40:49

you're, you know, like you said,

40:52

it's a good tool for some

40:52

patients used in the right

40:56

scenario. So again, it's like

40:56

looking at that individual

40:59

couple and seeing what's for

40:59

them. I just wanted to touch

41:03

before we sort of finish up

41:03

about, like AI Artificial

41:06

Intelligence, because I have

41:06

read a little bit online about

41:09

how they're now using AI, in

41:09

embryology and I always say to

41:13

people like fertility, such a

41:13

fast moving area of medicine. So

41:17

I had my son by IVF. He's going

41:17

to be 11 this year. And in that

41:21

time, I look back so much has

41:21

changed. Like it's so fast

41:25

moving and I can't believe we're

41:25

now talking about using AI in

41:28

embryology like, what about

41:28

this? I know, maybe there's

41:31

probably but there's definitely probably still lots of grey areas? No, it certainly is a

41:33

fast moving field, as you

41:37

mentioned, and one that we don't

41:37

know yet. It's worth, there is

41:43

certainly, you know, patients who have

41:46

embryos growing in the time

41:49

lapse incubator, that's where

41:49

it's genuinely used, because you

41:53

have the camera that sits above

41:53

the embryos.

41:56

So AI can do a lot of the

41:56

embryologist work in terms of

42:01

looking at the timings of

42:01

division and things that we

42:03

might be laboriously going

42:03

through video reels working out.

42:08

What they're doing is they're

42:08

often using this information to

42:11

put algorithms together. And

42:11

this is something that lots of

42:13

clinics have been doing already.

42:13

But different companies are all

42:19

trying their own own methods,

42:19

even things like looking at some

42:24

things in the egg movement

42:24

patterns and things like that,

42:28

that we wouldn't necessarily

42:28

pick up on their show using AI

42:33

to try and detect now, I'm

42:33

absolutely all for anything that

42:37

can improve our selection

42:37

process. But it's something that

42:41

at the moment until the data is

42:41

there, you know, you've got to

42:46

sort of have a slight air of

42:46

caution on it, because you don't

42:49

want to risk saying to a

42:49

patient, right, you will

42:53

definitely be putting back that

42:53

embryo, even though it's a very,

42:55

very poor blastocyst over top

42:55

quality one, which we've known

42:58

for years would be our selection. If, if you see technology at

43:01

where it helps us select between

43:07

a couple of embryos that looking

43:07

very similar, then yes, this

43:10

technology is very helpful.

43:10

Obviously, we've been using the

43:13

time lapse now for a while, and

43:13

we're already doing our own

43:16

sieve analysis on it. So I think

43:16

it's just a step up from what

43:19

we're doing. But it's exciting to see, you

43:21

know, anything in the field

43:24

that, you know, has advances as

43:24

long as it doesn't completely

43:27

get rid of us embryologist. And into robots. Yeah. I mean,

43:31

that's, it'd be interesting to

43:33

see where that goes. Right. Yeah, just AI. So how can people get in

43:36

touch with you? Victoria, I

43:40

know, probably what you've said,

43:40

it's going to resonate with a

43:42

lot of people. And, you know,

43:42

there's certainly gonna be

43:45

people that want to get in touch with you. So what's the best way? No, of course. So I've got

43:47

a website that they can go and

43:51

have a look at. So that's WWW

43:51

dot all about embryology.co.uk.

43:57

And then I also run social media

43:57

channels. So I've got Facebook,

44:02

Instagram, and Tiktok. And

44:02

actually, I've just set up a

44:06

YouTube one where I try and put

44:06

all my videos in there.

44:09

So all of those are with the

44:09

handle at all about embryology.

44:13

So if you want to just get a

44:13

little bit of sort of guidance,

44:17

as you're going through just

44:17

looking at stuff, I've got some

44:20

videos from inside the lab and

44:20

things. So best place to do with

44:24

that is to go onto the social

44:24

media. I also you can drop me an

44:27

email, which you can find on my

44:27

website, if you just want to ask

44:31

a little bit more about what I

44:31

can offer. Or you can put the

44:33

consultations directly on the

44:33

website. And there'll be one on

44:36

one consultations, either over

44:36

the phone or over a video call,

44:40

whichever the preference is

44:40

where I can help guide you

44:43

through whether you're a first

44:43

time patient or whether you're a

44:46

few cycles in either way I can I

44:46

can help you through Ray and for

44:50

anyone listening. I'm going to

44:50

put all those details in the

44:52

Episode Notes as well so you'll

44:52

be able to find links to

44:55

Victoria's website in the

44:55

Episode Notes. So thank you so

44:58

much for coming on. That's been fascinating as always, I have

45:00

learnt a lot again.

45:05

That's my impatience. So thank

45:05

you so much Victoria. It was

45:07

lovely to meet you. Oh, my

45:07

pleasure. Thank you for having

45:09

me on.