Are you planning to start IVF treatment using donor eggs? Do you have lots of questions about egg donation, donors and the qualification process? You are in the right place. Watch the webinar by EggDonationFriends and Assisting Nature Greece: “Donor eggs – it’s all about quality, no. of eggs & qualification process“. We have again invited Dr Robert Najdecki, MD, PhD, Co-Founder and Scientific Director of Assisting Nature, fertility clinic located in sunny Thessaloniki, Greece.
Donor eggs – Questions & Answers
How many blastocysts do you discard after PGS?
It depends. In a case where we have very good sperm and a confirmed donor, the chance of having a good blastocyst with a good EGS is very high. In this case, it may be 100%. Where sperm is abnormal or of a lower quality, the chance of aneuploidic blastocysts is much higher. PGS is the answer to our patients and a transparent the way to answer whether they have a normal blastocyst. In this case, we would have over 60% possibility to have good test results and a normal implementation.
What do you use DNA fragmentation test results for? To decide to do ICSI or to tell the couple to use a sperm donor instead?
The DNA fragmentation test is a way to tell the percentage of damaged sperm in the sample. Through DFI we are able to determine the percentage of damaged sperm and, if this is under 30% we are okay to proceed. If the DFI index is over 60% we have a problem and we must inform the couple that there is a high chance of having an abnormal blastocyst. We then help them decide what to do; whether they want to perform IVF with the husband’s sperm, knowing the risks, or to proceed with the donor sperm.
Do you do an antibody screen test of the recipient to check if it is of relevance to choose by blood type or not?
Of course, it’s possible but actually, we don’t use it every day. The quality of IVF treatment and positive outcomes depends, in general, on blastocyst quality. We perform a hysteroscopic evaluation with some scratching and, if we have checked the recipient’s uterus for any complications, such as fibroids, the chances of having a negative result due to antibody reaction is very low. In these cases, we would use, at the time of embryo transfer, an intralipid infusion.
Why do you match between blood type and Rhesus type?
Under Greek law, we are obliged to match the blood type and rhesus type of the donor and recipient. I think that from the point of view the couple, this of value as you know you will never have problems related to this.
Do you have some quality system for the eggs in your clinic?
At every stage, we have an assessment of eggs and, afterwards, of the embryos themselves. After collecting the eggs, there is an assessment to be sure that they are mature and are ready for vitrification. There is a very simple biological test for this and an egg which is not mature or is abnormal does not proceed to the process of vitrification: only good eggs are made ready for further procedures.
How long will we have to stay there after an embryo transfer?
We keep patients for one hour in our unit to rest after which, they are ready to go home. In Greece, there is no obligation to stay for a long period of time and there is no connection between pregnancy rates and resting periods after embryo transfer. This is a very short procedure and, if there are no complications, the blastocyst, which is placed in the endometrium is ready to start implantation, exactly as in the normal process of fertilization. We prefer to not keep the patient in for a long time and, as I said, there is absolutely no connection with positive or negative outcomes.
Do you transfer one or two blastocysts per time?
This is something we discuss with the patient to decide what they want to do. If we have good blastocysts, it may be that a single blastocyst transfer is best, to avoid the risk of twins. If the blastocysts are of lower quality, or if we need to perform a second embryo transfer, maybe, in this case, we will transfer two blastocysts. However, in every case, this is a matter of discussion between the patient and doctor.
What are your missed abortion rates?
It’s about 8% in our clinic.
Do you work with vitrified eggs only?
No. As I explained in my first webinar, we have many options. Which eggs we use depends on an agreement with the patient and whether the patient is able to be here to be involved in the process of sperm sampling or for the donor pick up. We prefer to have a frozen sperm sample and to use fresh eggs, but whether we use vitrified eggs or not isn’t really the point. The point is to have very good sperm and with very good synchronization and conditions.
Do you use Prednisolone, Aspirin or Embryo Glue in your clinic? When and why?
Yes, we use these drugs and medicines in the process of preparing for embryo transfer. We start to use the corticosteroids, aspirin and sometimes heparin injections from the moment of fertilization; that is five or six days before the embryo transfer and continuing until we have a positive test. Afterwards, we review this on a case-by-case basis.
How many days before transfer do you start to give the recipient progesterone?
We start with estrogen from the first day of the patient’s period and progesterone on the day that we start fertilizing the eggs. If Day Zero is the patient’s normal day of ovulation, we would perform this 6 days before the transfer. We give normally give progesterone vaginally, with a vaginal cream, or with subcutaneous infusion or injection, depending on the patient. We continue with progesterone until there is a positive pregnancy test and we can detect a heartbeat. After that, we decrease the dose step by step.
I had a frozen embryo transfer, 5-day PGS tested blastocysts. I had an endometrial scratch. My endometrial lining was described as perfect. What do you think went wrong?
Not every blastocyst has the implantation ability, even though they have tested euploid. Not all blastocysts are equal. The endometrial lining was described as perfect, but what about at synchronization? In every patient, we measure the progesterone and levels of estradiol. If the level of progesterone is high, we stop the transfer and start again from the beginning. This is very important for synchronization and we have had cases like this, which can lead to negative results. In conclusion, synchronization of the transfer involves a very detailed hormonal assessment regarding substitution protocols and needs to be checked at least two or three times to see what the progesterone level is. Of course, it is important to have very good endometrium and to be sure that the measurements are good, using the same doctor and the same ultrasound equipment. I have also seen cases where the endometrial scratching which was not absolutely normal, so we prefer to do a hysteroscopy evaluation here, to see the endometrium and to be absolutely sure that we able to evaluate the condition of the uterus.
Is there a need for immune suppressant medications? If not, why not?
We use corticosteroids, usually two tablets per day, and in our opinion, this is enough to have the very small suppression effect required. We start this medication five or six days before the embryo transfer. In very rare cases with immunological problems, there is the option to start this medication from the beginning of the cycle.
What if the pregnancy test comes back negative? Should the patient stay in Greece until pregnancy is confirmed?
No. It’s not necessary. Most of our patients return to their countries the same day, or the day after the embryo transfer and then continue medication and wait for the results of the test done in their own country. It’s not necessary to stay here only for this reason. You can combine the treatment with a vacation in Greece, of course, and there are very many attractive places here with many well-known tourist resorts within 100 kilometres of our clinic.
How important is it to match is the height, weight, hair and eye colour?
If this is of importance to the patient, and for some, it is not, we will do all we can to find the best match: height, weight, eye colour and hair colour. This is an absolutely normal procedure.
Do you recommend doing PGS?
Yes, we do. In our opinion, PGS is a very good way to answer certain questions and to be more transparent with our patients. We can say with certainty that the blastocyst is euploid, and, if a blastocyst is euploid, we have a greater chance of a successful pregnancy. However, with a negative pregnancy result, where the PGS was normal and we transferred, say, two euploid blastocysts, we must look elsewhere for a diagnosis, perhaps some dysfunction in the endometrium and perhaps perform hysteroscopic scratching. PGS in IVF procedures is the future for us. At the moment, it is an expensive procedure and this is the problem. Probably, in the next five years, the price of PGS will be more acceptable to more patients and will become a routine procedure in all IVF centres. It has real value for doctors and for patients.
How do you match the donor, besides blood type or hair colour, etc?
The first step is to collect all the recipient’s patient details and, of course, by law, we are required to match by blood type and rhesus. This is the first step. The second step is to look at the height and weight, eye and hair colour. For some of our patients, education is very important. In very rare cases, a recipient will request a donor from Africa, not always easy for us. With our recipient patients’ concerns in mind, we try to match the donor accordingly. However, the most important thing is matching the blood type and rhesus group because this is obligatory in Greece.
Do you recommend ERA MAP?
Every further test is very good information for us and has a value, and, of course, the endometrial receptivity test, from a genomics point of view, is a very precise test. There is great discussion about this test; it’s not for all patients, not in very simple cases or if the patient is going to have their first embryo transfer. However, if we notice that there are some problems with synchronization, with rising progesterone levels, it is very important to determine the implantation window, something which is very different for every patient. In these cases, we would we recommend ERA, but only in certain special cases, not as a routine procedure.
How do you check the family medical history of the donor?
Donors spent a long time here completing a history which we double check. They then complete another medical history and all of this data collected is checked and cross-referenced. We collect a deep family medical history based on CRM American Society of Medicine guidelines. We test and the donors talk with the staff in our donation office in a very detailed, very involved process. The donor visits our clinic many times to be confirmed to the next step in the process. All this data is checked again and again. We have three levels of checking their medical history in setting the status of the donor.
Do you control the level of Progesterone during simulation?
Yes. We routinely control the level of Estradiol, LH, and progesterone during donor stimulation and of course during substitution protocols in our recipient. We also routinely check Estradiol, LH, and progesterone to have a balance between the levels of hormones. This is very important to us.
Who selects the donor, the clinic or the recipient?
We select for the recipient and in most cases, we prepare files on between two and five donors for every recipient. We allow them to think it over and to choose the donor, with our advice.
How many blastocysts do you guarantee in your egg donor program?
Since we started our programme, we have gathered some statistics showing that three blastocysts is the average, and, of course, more if the sperm is good. Three blastocysts it’s a minimum for a woman to have at least two embryos to transfer and then have an over 65% cumulative pregnancy rate in our clinic.
How can you make sure the information the donor gives you about her condition and family medical history is correct?
We have a two-step confirmation of this data. During the first meeting, we collect some information and afterwards we give them a very detailed medical history to take home and to bring to their next visit. We match what they wrote in the first meeting against what they answered at home. If the donor is confirmed to the third step, this process is repeated with another staff member and checked for the third time. It would be a very rare donor who could give incorrect or unrealistic data on three occasions, at three different times to three different staff members; we haven’t had any such case.
How thick should the endometrium be?
It depends on the age of the patient and the normal function of the endometrium. It’s not easy to count and say that this patient must have seven or eight or nine millimetres thickness. In some cases, for some patients, seven millimetres is enough and this is their thickest possible. For another patient, 10 millimetres maybe low. It is very important to check it and to have a monitoring cycle, sometimes without medicines, or in some difficult cases or special cases, with the use of some medicines to see the reaction of the endometrium to the medicine. This is not a routine procedure but it’s within our strategy of personalizing reproductive treatments. We must see every patient as an individual, to check everything from the beginning as no two patients are the same. It is absolutely critical to prepare procedures for every individual patient, but the short answer is that we prefer the endometrium to be over seven millimetres.
Which freezing medium do you use for blastocysts? Do you do collapse by laser before freezing and do you do AHA when thawing?
We routinely use Kitazato freezing solution for blastocysts and after thawing we do assisted hatching or collapse by laser before freezing, but not both: one technique is enough. We have done some research and the results show that it’s very important to leave the blastocyst after thawing for over three to four hours to see the condition of the blastocyst after thawing. Then, if you wait longer you can have the normal hatching, natural hatching without intervention from us. I can say that in half the number of blastocysts, we have noticed this process of natural hatching. This is the answer to patients who are here and who are waiting for embryo transfer. In many cases, the lab waits to see natural hatching. This is the reason that we prefer to wait some hours, but in many cases, this is not easily synchronizable with the patient; some blastocysts may be ready in three or four hours, and others need five or six hours. Then we use all available procedures, natural hatching or laser hatching, depending on the decision of our lab director.
Is there a possibility to receive a blood sample of the donor in order to eliminate mutations that cause cancer?
Yes, of course. It is a new trend and good practice to prepare genetic panels which have all the available mutations of the same nationality, for example for Europeans, North Europeans or East European. We use this panels here with, as example antigens for breast cancer, very common now, and of course for many others. We have a test which we call the Colour Test where we are talking about 30-40 types of mutation which involve the breasts, ovaries, endometrium, stomach, colon and other organs. I think that it’s the future in screening of not only donors but all IVF patients. Its use will grow because it is of real value to all of us.
Is Igenomix pregenetic testing of the egg donor or the male partner required if you are doing PGS of the embryo?
Pre-implementation genetics screening will show us if the embryo is euploid, that it has a normal karyotype, that we will have no problems with some genetic diseases based on karyotype. Pregenetic testing and those panels we discussed earlier are about other mutations which are, for example, in one of the partners or in general in the population living in the one place in the world. This may be a monogenetic disease and we must say here that, while we try to test for all of these, this is impossible at the moment. There are very many monogenetic mutations which are very difficult to test for and therefore exclude donors from the pool. The tests which we perform now every day are getting better and better, but still, we have many monogenetic diseases that we can’t test for before the procedure. I think that in the next few years further research will improve the situation, but at the moment we must say, while we do all our best to examine the donor and recipient and, afterwards, the blastocyst, it’s still not enough to have all genomic information. It’s getting better and it’s not the end of the story.
The doctor’s experience
Dr Najdecki’s vast experience in reproductive gynaecology and embryology has contributed greatly to his achievements in the field, e.g. the second baby birth through IVF technique in Poland and the first transvaginal, ultrasound OPU (oocyte retrieval), which resulted in second IVF baby being born in the nation. These successes opened new doors to a new era in IVF techniques that continues till now. During the webinar you had a chance to get to know more about the importance of egg quality, egg quantity, and about the number of eggs guaranteed in the fresh and frozen egg donation programs offered by Assisting Nature. Dr Robert Najdecki also talked extensively about the process of egg donor qualification and testing performed at his clinic.
Assisting Nature and egg donors
Assisting Nature is a clinic that not only looks after their IVF patients/egg recipients. The clinic is proud to have a list of excellent oocyte donors and very short waiting lists (approx. two months). The clinic’s staff maintains close contact with all egg donors and even provides them with free medical services. The present and past egg donors of Assisting Nature can benefit from free medical check-ups such as mammography, breast ultrasound scanning, cytology and blood tests. Egg donors in Greece are surrounded with top quality care – in some serious cases the clinic also performs minor surgeries like hysteroscopic polyp extraction or breast adenoma extraction when a donor needs it. These services are free of charge.
Egg donor psychological tests at Assisting Nature
This fantastic relationship between the clinic and the donors has been drawing the best egg donors to Assisting Nature. The clinic is known for its transparency and has also implemented standardized psychometric tests for their egg donors. Donors personality and psychopathology is tested by certified psychologists and psychiatrists. The test is time consuming but the egg recipients are sure they receive oocytes of a thoroughly tested person.
The concept is to offer IVF patients an oocyte donor with her eggs and not just a product: eggs of an unknown person. Interested? Contact the clinic for more information.
About an author:
Robert Najdecki MD, PhD is a Reproductive Gynaecology Specialist. His experience in diagnosis and treatment of fertility disorders, such as endoscopic surgery is long and extensive and includes more than 6000 stimulated cycles. Assisting Nature IVF clinic provides international couples who are struggling to conceive with the most advanced donor eggs programs in Greece.