Assisted Hatching

What is assisted hatching, and why is it done?

In vitro fertilization (IVF) and intracytoplasmic sperm inection (I!"I) rely #pon the implantation of
one or more em$ryos $eing transferred to achieve pregnancy% In order for this to happen, an
em$ryo needs to hatch o#t of its s#rro#nding soft shell, the zona pell#cida, when it reaches the
$lastocyst stage at &'( days old%
)here is evidence to s#ggest that this hatching process may $e a pro$lem for some patients*
em$ryos, where a thic+ened or hardened zona may not allow it to occ#r%
Assisted hatching is a la$oratory techni,#e where a small hole or slit is made in the shell of an
em$ryo shortly $efore em$ryo transfer% When an em$ryo reaches the $lastocyst stage, this hole
then allows the em$ryo to emerge (hatch) which may help it implant and esta$lish a pregnancy%
Who is assisted hatching s#ita$le for?
)he maority of patients do not re,#ire assisted hatching% "t#dies indicate there may $e improved
implantation and pregnancy rates for certain gro#ps of patients, incl#ding the following-
)hose who have failed to conceive following three or more IVF . I!"I cycles
If the zona pell#cida appears thic+er than normal
Assisted hatching is a delicate techni,#e re,#iring specialist e,#ipment and s+ill, so there is an
additional charge for this proced#re% /lease see */rices0 for details%
Are there any ris+s in assisted hatching?
1eca#se the assisted hatching proced#re involves c#tting a hole in the zona, it is possi$le that
one or more em$ryos co#ld $e damaged d#ring the proced#re, altho#gh every effort is made to
avoid this%
)he damage rate is less than 23, and affects one or more cells of an em$ryo% )hese em$ryos
can still $e transferred if necessary and may retain f#ll potential despite some damage, altho#gh
we wo#ld #s#ally select another s#ita$le em$ryo to ta+e their place if availa$le%
"ince the techni,#e may increase the implantation rate it may also res#lt in more patients having
m#ltiple pregnancies% It is also possi$le that a very small proportion of these m#ltiple pregnancies
co#ld involve identical twinning, when a single em$ryo splits into two thro#gh the hole made%
1lastocyst !#lt#re
$lastocyst c#lt#reWhat is a $lastocyst?
A $lastocyst is an em$ryo that has $een allowed to develop for & days or more after egg
collection . insemination% It loo+s li+e a hollow sphere and has 4 cell types, the cells aro#nd the
s#rface of the sphere (*trophectoderm*) which form the placenta, and an inner $all of cells, the
*inner cell mass* which forms the fet#s itself%
5ntil day & or ( of development (days from egg collection) the $lastocyst remains within the soft
shell'li+e protective coating, the zona pell#cida% 1efore a $lastocyst can implant within the #ter#s
it m#st hatch o#t of this coating%
Why c#lt#re $lastocysts?
)here are a n#m$er of reasons for s#ggesting $lastocyst c#lt#re% Firstly, em$ryo selection-
em$ryos that have developed as far as the $lastocyst stage are fitter and stronger and th#s may
have more chance of implanting after transfer%
"econdly, the timing of a $lastocyst transfer mimics nat#ral conception, as the em$ryos are
replaced at the time they wo#ld normally reach the #ter#s (when they are almost ready to
implant), so we +now that #terine conditions at this time are ideal for the em$ryos%
6varian Hyperstim#lation "yndrome (6H"")
For some patients who appear to $e at ris+ of developing 6H"", +eeping the em$ryos growing in
the la$oratory for longer gives clinic staff e7tra time to see if 6H"" is li+ely or not% If so, and a
patient is not well eno#gh for em$ryo replacement, we can safely freeze all em$ryos for #se at a
f#t#re date, or if 6H"" symptoms are only mild and we consider it safe to do an em$ryo transfer
we can proceed as originally planned%
Finally, for those patients who definitely do not want a m#ltiple pregnancy, we can transfer #st
one em$ryo at the $lastocyst stage and still have a reasona$le chance of pregnancy%
Who is s#ita$le for $lastocyst c#lt#re?
)his techni,#e is s#ita$le only for some patients, as it depends on the n#m$er and ,#ality of a
co#ple*s em$ryos seen in the la$oratory each day% 8any em$ryos do not contin#e developing for
five days in the la$oratory and o#r e7perience has shown that less than half of em$ryos are
capa$le of development into $lastocysts%
Very occasionally no em$ryos reach this stage of development% )h#s in order to progress with
$lastocyst c#lt#re, we assess em$ryos daily to see if there are at least ( top ,#ality em$ryos each
day% If not, we carry o#t em$ryo replacement on day 4 or 9 as #s#al%
/atients who do not have s#fficient em$ryos for $lastocyst c#lt#re are not at a disadvantage : the
s#ccess rate for $lastocyst c#lt#re and transfer is very similar to standard IVF%
What are the ris+s of $lastocyst c#lt#re?
As mentioned a$ove, there is the possi$ility that none of the em$ryos s#rvive to day &%
5nfort#nately for a very small n#m$er of co#ples, the em$ryos stop developing after day 9 and
treatment stops at this point, witho#t an em$ryo transfer $eing possi$le%
;m$ryo via$ility
)o minimise this ris+ we monitor em$ryo development daily, and on day 9 we tend to $e e7tra
ca#tio#s $y recalling patients for transfer if we have even the slightest do#$t as to the ongoing
via$ility of the em$ryos% It is tho#ght that as yet #nidentified #terine factors can help *resc#e*
em$ryos that appear to $e slowing in their growth, since some em$ryos that have seemed to $e
arrested in development early on have res#lted in healthy normal pregnancy after transfer%
1eca#se less than half of all em$ryos reach $lastocyst stage, we tend to freeze fewer $lastocysts
than em$ryos at day 4 or 9 of development% However, any e7cess good ,#ality $lastocysts
remaining after transfer can $e frozen, and pregnancy rates for frozen $lastocysts are similar to
em$ryos frozen at an earlier stage%
;m$ryo )ransfer
What happens d#ring my em$ryo transfer?
)he em$ryo transfer ta+es place here at 1ath Fertility !entre< it0s a ,#ic+ and pain'free proced#re
and only ta+e &'2= min#tes% >o#r partner can $e with yo# at the time of the transfer%
)he em$ryos are loaded into special transfer catheters and are replaced into the #ter#s $y a
mem$er of the n#rsing team% If more than one em$ryo is $eing replaced, they will $e transferred
together in a tiny droplet of fl#id% 6nce the em$ryos are inside the #ter#s they will settle into a
niche in the lining where we wo#ld hope that they contin#e their development%
As with all appointments at the clinic, we as+ that yo# refrain from wearing perf#me, aftershave or
strong smelling cosmetic prod#cts%
When will my em$ryos $e transferred?
)he e7act day of em$ryo transfer will depend on the n#m$er and ,#ality of em$ryos availa$le for
selection% ;m$ryo transfer may ta+e place on day 4, day 9, day ? or day & of development%
)he final decision a$o#t the most appropriate stage for em$ryo transfer may $e made following
em$ryo grading on the morning of the transfer% An element of fle7i$ility when planning transfers
will $e re,#ired, as it is the development of the em$ryos that will dictate the $est day for transfer%
How many em$ryos are transferred?
/atients #s#ally chose to have one or two em$ryos transferred in a single cycle% )hree em$ryos
may $e transferred in patients over ?= years of age in e7ceptional circ#mstances%
)he n#m$er of em$ryos recommended for transfer will depend on individ#al circ#mstances% >o#r
age, treatment and o$stetric history, and any #nderlying medical conditions will all $e ta+en into
consideration% ;m$ryo ,#ality will also g#ide the em$ryologists and clinicians when
recommending the n#m$er of em$ryos for transfer%
We will as+ yo# to formally consent to the transfer of em$ryos and the n#m$er that yo# wo#ld li+e
transferred%
"ingle em$ryo transfer
Where the chances of conception are high, the team may s#ggest that a single em$ryo $e
transferred< this will virt#ally eliminate the ris+ of a twin pregnancy occ#rring, witho#t s#$stantially
decreasing the chances of $ecoming pregnant% For those patients choosing to have a single
em$ryo transferred, the c#rrent ongoing pregnancy rate is 9@3%
"ingle em$ryo transfer sho#ld $e viewed as a positive step< it means that the chances of s#ccess
are high%
If I choose to have a single em$ryo transferred, can the other em$ryos $e frozen?
"#rpl#s em$ryos can $e stored for f#t#re #se if they are deemed to $e of good ,#ality% If a single
em$ryo is $eing recommended for transfer, the overall ,#ality of the cohort of em$ryos is
generally good%
6pting for a single em$ryo will not res#lt in the other em$ryos $eing Awasted0< they will simply $e
stored for later #se% "ee section on ;m$ryo Freezing for f#rther details%
;m$ryo Freezing
li,#id nitrogenWhy freeze em$ryos?
If there are em$ryos of s#fficient ,#ality remaining after em$ryo transfer, we will contin#e to
c#lt#re them to the $lastocyst stage of development prior to freezing% Any $lastocysts that have
developed can then $e frozen or cryopreserved for f#t#re #se%
5sing stored em$ryos for f#t#re treatment avoids the need for stim#lation, egg collection and
fertilisation, and ma+es ma7im#m #se of these very precio#s reso#rces%
How are em$ryos frozen?
)he cryopreservation process #ses a series of specially designed sol#tions that wor+ to ,#ic+ly
dehydrate and sta$ilise the em$ryos $efore they are pl#nged directly into li,#id nitrogen< this is
+nown as Vitrification%
"torage
;m$ryos are stored in small containers that hold a ma7im#m of two em$ryos% )his is followed $y
storage in large tan+s of li,#id nitrogen at the e7tremely cold temperat#re of min#s 2@( degrees%
All tan+s are fitted with alarms that notify #s 4? ho#rs a day of any change in temperat#re that
may re,#ire o#r attention%
Becisions
1efore em$ryos are stored, we as+ yo# to ma+e some decisions s#ch as- how long yo# wish to
have them stored for< and what to do with them in the event of divorce, separation, incapacitating
illness or death%
)hese are all important decisions for yo# and yo#r partner to consider, and we will contact yo#
each year that yo#r em$ryos remain in storage at 1ath Fertility !entre, to chec+ that yo#r wishes
remain the same% If yo#r circ#mstances have changed or yo# change yo#r mind, yo# can contact
#s at any time to vary the conditions of storage%
Will my em$ryos $e frozen?
6nly the $est grade em$ryos have the potential to withstand the freezing process, which is
somewhat stressf#l to the cells% We e7pect an average C&3 of em$ryos to s#rvive freezing and
thawing%
Dather than cryopreserve em$ryos that may not have the potential to contin#e their development
and res#lt in a pregnancy, we aim to c#lt#re all good ,#ality s#rpl#s em$ryos #ntil day &% At this
stage in their development we wo#ld e7pect the em$ryos to have reached the $lastocyst stage%
Via$ility
Bespite their apparent good ,#ality in earlier stages of development it may $e that very few or
possi$ly none of the em$ryos will reach the $lastocyst stage, meaning that the em$ryos co#ld not
$e frozen% All s#ita$le $lastocysts will $e stored for f#t#re #se%
;m$ryo freezing sho#ld $e regarded as a $on#s- only a$o#t a third of co#ples will have em$ryos
frozen in any one treatment cycle% )here is no charge for the initial freezing of em$ryos and the
first year of storage% "#$se,#ently there is an ann#al storage fee (c#rrently E2F&), paya$le in
advance%
How do I #se my frozen em$ryos?
Frozen em$ryos can $e transferred in two types of treatment cycle- if yo# ov#late relia$ly,
em$ryos can $e replaced in yo#r nat#ral cycle< otherwise, yo# will need an *artificial* cycle #sing
dr#g therapy, to prepare the endometri#m to receive the em$ryos%
;m$ryo thawing and transfer
;m$ryos will $e caref#lly thawed at a time appropriate to their cell n#m$er, and the em$ryo
transfer will $e sched#led very caref#lly so that em$ryo stage and #terine receptivity coincide to
ens#re the optim#m chance of s#ccess% )he em$ryo transfer will $e performed in the same
manner as for yo#r fresh em$ryos%
How s#ccessf#l is freezing em$ryos?
/regnancy rates for frozen em$ryos transfers are significantly lower than for fresh em$ryo
transfers, $#t depend on the n#m$er and ,#ality of em$ryos frozen% )ypically they are $etween
2='4=3 per em$ryo transfer depending on the n#m$er, stage and s#rvival of em$ryos frozen%
/otential ris+s of freezing and thawing em$ryos
As already mentioned, the greatest ris+ with freezing and thawing em$ryos is damage ca#sed $y
the process itself, despite the care we ta+e to minimise this% Got all em$ryos are a$le to withstand
the stresses of the necessary dehydration for freezing and rehydration d#ring thawing, hence a
red#ced s#rvival rate and s#$se,#ent fail#re to res#me division and growth for some em$ryos%
)his also acco#nts for the lower pregnancy rate following transfer of frozen'thawed em$ryos%
In a very few cases no em$ryos s#rvive, or they may s#rvive $#t all stop developing early% )his
means for these patients no em$ryo transfer ta+es place%
)o date there is no concl#sive evidence that freezing and thawing em$ryos ca#ses long'term
damage to them, $#t as with all assisted conception proced#res the technology is relatively new,
and there have $een no really long'term st#dies carried o#t% )o the $est of o#r c#rrent +nowledge
the techni,#es employed are safe and not harmf#l in any way%
Intra !ytoplasmic "perm Inection (I!"I)
What is I!"I, and who is it s#ita$le for?
I!"I : Intra !ytoplasmic "perm Inection : is a techni,#e where sperm are inected singly into
each egg% It is ro#tinely offered to co#ples who do not have s#fficient good ,#ality sperm for IVF%
Fertilisation rates with conventional IVF may $e red#ced, or there may $e no fertilisation at all,
when-
"perm co#nt is too low%
"perm have low or slow motility%
"perm have a very high proportion of a$normal shapes%
High levels of antisperm anti$odies are present%
)he reasons for non'fertilisation are not always clear, altho#gh it is +nown that the sperm
fertilising f#nction can $e affected $y all the a$ove factors% Dather than ris+ the disappointment of
no fertilisation after egg collection, if a semen analysis shows one or more *male* factors, we
recommend I!"I as the treatment most li+ely to give a s#ccessf#l o#tcome%
I!"I is #sed to overcome these pro$lems $y caref#lly inecting each ripe egg with a single sperm
pic+ed #p in a very fine glass needle%
6ccasionally, IVF #sing sperm considered normal may res#lt in #ne7pected lac+ of fertilisation% In
these rare cases we recommend another attempt #sing I!"I, even tho#gh there does not appear
to $e any o$vio#s male factor present% )his way, if there is a pro$lem with the sperm and egg
attaching together $efore the sperm enters the egg, we are a$le to try to overcome it $y placing a
sperm directly inside each ripe egg%
Where testic#lar sperm is #sed in cases of failed vasectomy reversal, o$str#ctive azoospermia, or
other ca#ses, I!"I is necessary% "perm retrieved s#rgically ($y /;"A or );";) is #s#ally
immat#re and present in ins#fficient ,#antities for standard IVF%
What happens d#ring I!"I treatment?
From the patient viewpoint, I!"I is very m#ch the same as IVF% It is what happens in the
la$oratory that differs% ;ggs are retrieved as descri$ed on the IVF page of this site% A semen
sample is prod#ced $y the male partner (in most cases), and then $oth eggs and sperm are
specially prepared for I!"I%
"ome ho#rs after egg collection, each mat#re egg (generally at least C=3 of those collected) is
inected with a single sperm #nder a very high'powered microscope% We try to #se sperm that are
seen to $e motile and normal in shape%
Inc#$ation
After the I!"I proced#re the inected eggs are placed in an inc#$ator and inspected the ne7t
morning to see how many have fertilised% )his is typically aro#nd (=3 of those inected, similar to
conventional IVF, altho#gh it varies from case to case% 8ore than @=3 of co#ples having I!"I can
e7pect at least some of their eggs to $e fertilised%
Following the fertilisation chec+, the early I!"I em$ryos are grown in the la$ and #sed in e7actly
the same manner as those from IVF%
"#rgical sperm retrieval
For some men with no sperm in the eac#late it is necessary to perform a s#rgical sperm retrieval
$efore the day of egg collection< o#r "#rgical sperm retrieval we$ page has more information%
As I!"I is a delicate techni,#e re,#iring specialist e,#ipment and e7pertise, it costs more than
straightforward IVF%
)he li+ely s#ccess and possi$le ris+s of I!"I
I!"I s#ccess rates are very similar to those achieved with conventional IVF%
I!"I shares some ris+s with IVF treatment% )hose ris+s more specifically associated with I!"I
incl#de-
)he inection techni,#e may sometimes permanently damage individ#al eggs% )he overall
damage rate is low ($elow 2=3) $#t can $e higher for some patients depending on egg ,#ality at
the time%
Very occasionally there may $e a complete and #ne7pected lac+ of normal fertilisation of any of
the eggs collected and inected, even with I!"I% When this happens with a good n#m$er of eggs
in an I!"I cycle, or if it occ#rs in more than one I!"I treatment, it wo#ld appear to $e a more
comple7 pro$lem than first tho#ght% We may consider recommending the #se of either donated
sperm or eggs for f#rther treatment in some cases, depending on individ#al circ#mstances%
/lease see Bonor )reatments for more information a$o#t #sing donated gametes%
It has $een reported that the ris+ of miscarriage seems to increase in proportion to the severity
of male s#$fertility, especially where s#rgical sperm retrieval is necessary%
I!"I is still a fairly new techni,#e- it has only $een in ro#tine #se since the early 2@@=s% )here
have $een some concerns regarding the safety of the techni,#e : does inecting a sperm right
inside an egg ca#se long term damage to the egg? !an selecting a sperm for inection $ypass
some of the nat#ral selection processes that normally ma+e it #nli+ely that an a$normal sperm
wo#ld res#lt in pregnancy? If sperm from a s#$'fertile man is #sed to achieve a pregnancy that
res#lts in the $irth of a son, will the child inherit his father*s fertility pro$lems?
)here have $een n#mero#s st#dies carried o#t to try to find answers to these ,#estions% "ome
have shown that $a$ies $orn after I!"I show new chromosomal a$normalities in #p to 93 of
cases% 6thers have s#ggested that there may $e a slight increase in the n#m$er of minor $irth
defects in I!"I $a$ies compared to the general pop#lation, altho#gh these may $e more
associated with premat#re $irths and m#ltiple pregnancies than the I!"I proced#re itself% "everal
st#dies have compared the development of I!"I $a$ies with that of children conceived nat#rally
and from IVF, and altho#gh there were some early s#ggestions that I!"I children develop slightly
more slowly than their non'I!"I co#nterparts, other more recent st#dies have not $orne this o#t%
Bifferent st#dies have shown a higher rate of *se7 chromosome* a$normalities, possi$ly d#e to
the fact that the sperm #sed for I!"I carried these a$normalities and may have $een the reason
why the co#ple co#ld not conceive in the first place% It is now +nown that some men have >
chromosome deletions that affect their sperm f#nction and hence fertility, which may $e passed
on to any sons conceived with I!"I #sing this sperm% "ome men who have no sperm in the
eac#late may $e carriers of genes lin+ed to !ystic Fi$rosis%
In the light of these findings we strongly recommend that co#ples #ndergo genetic testing
$efore starting treatment if the man has severe oligospermia (low co#nt) or azoospermia (no
sperm in eac#late #nless d#e to vasectomy)% )his involves a $lood test and genetic co#nselling if
needed%
If yo# have any concerns regarding these important iss#es please raise them with #s : $#t also
$ear in mind that I!"I is relatively new and we may not $e a$le to provide definitive answers for
some years to come%
I5I
Intra'5terine Insemination (I5I)
Intra'5terine Insemination (I5I)
What is I5I?
Intra'#terine insemination (I5I) involves placing motile sperm close to yo#r eggs at the time yo#
ov#late, to ma7imise the chances of sperm reaching an egg for fertilisation to occ#r% Altho#gh the
proced#re itself is straightforward, the timing is very important%

I5I s#ita$ility and treatment
I5I is s#ita$le for women who do not have t#$al damage, as there m#st $e a means of the
ov#lated egg.s reaching the #ter#s thro#gh the Fallopian t#$e% It is advisa$le for the man to have
a normal or only mildly s#$optimal semen analysis, as we need to $e reasona$ly certain there are
no male factors present that co#ld prevent fertilisation%
"tarting treatment
1efore commencing treatment, an #ltraso#nd scan is carried o#t to chec+ the appearance of yo#r
ovaries, and providing this is normal yo# wo#ld start inecting a low dose of fertility dr#gs to
stim#late the prod#ction of one or more follicles%
A wee+ after yo# have started yo#r inections, yo# will have another scan to chec+ how many
follicles yo# are growing and their size% We are aiming for a ma7im#m of 4 large follicles and no
more than 4 smaller% If yo#r scan shows this, yo# will $e as+ed to give yo#rself a final inection of
a different hormone that will ma+e yo# release the egg(s) 9?:?= ho#rs later% Insemination will $e
timed to coincide with this% >o#r partner will need to attend the clinic on the day of I5I treatment to
prod#ce a sperm sample for preparation $y the la$oratory%
If yo# have grown more than the re,#ired n#m$er of follicles yo# may have to stop treatment%
)his is $eca#se there co#ld $e a high ris+ of m#ltiple pregnancy occ#rring if treatment were to
contin#e% "ee $elow for more a$o#t ris+s with I5I%
Insemination
)he insemination is done #sing a fine catheter that is passed into the wom$ thro#gh the cervi7%
)he sperm is then inected slowly #sing a syringe% )he proced#re itself only ta+es a few min#tes
altho#gh we li+e yo# to rest for ten min#tes or so after the I5I%
I5I s#ccess rates and ris+s
/regnancy rates for I5I #sing a partner*s sperm are aro#nd 2&3 per treatment cycle% )his is
lower than with IVF.I!"I, as we are not a$le to $e certain that fertilisation has ta+en place
following insemination% For this reason I5I treatment is #s#ally limited to 9 cycles of treatment
$efore we recommend progressing to IVF%
Dis+s
6ccasionally some women over'respond to the fertility dr#gs #sed, prod#cing too many follicles%
If insemination were to ta+e place after several large follicles have ov#lated there wo#ld $e a ris+
of a m#ltiple pregnancy involving more than 4 em$ryos%
In order to avoid this we wo#ld therefore stop yo#r treatment and advise yo# that yo# m#st either
ta+e contraceptive preca#tions (#se a condom) or a$stain from interco#rse #ntil yo# have yo#r
ne7t period% For s#$se,#ent treatment cycles the amo#nt of dr#gs will $e red#ced to try to ma+e
yo# grow fewer follicles% In rare cases 6H"" may occ#r and treatment wo#ld $e stopped and
restarted when safe to do so%
"ome planned I5I treatments need to $e cancelled d#e to lac+ of response to the dr#gs #sed to
stim#late follicle prod#ction% In this case the amo#nt of dr#gs yo# ta+e wo#ld $e ad#sted to try to
ma+e yo# grow more follicles in another treatment cycle
)here is a small ris+ of pelvic infection res#lting from the insemination proced#re% >o# sho#ld
contact #s if yo# e7perience s#dden or severe pain, or if yo# feel feverish and have a high
temperat#re%
IVF
In Vitro Fertilisation (IVF)
In Vitro Fertilisation (IVF)
What is IVF?
Fertilisation in vitro literally means fertilisation *in glass%* )he fertilisation process act#ally ta+es
place in plastic dishes and not in glass test t#$es, which is a pop#lar mis#nderstanding%
)o achieve a pregnancy thro#gh IVF, the female partner commences daily inections of hormonal
dr#gs to stim#late her ovaries to prod#ce a higher n#m$er of eggs than the #s#al one or two%
6ver the ne7t 2= days to 4 wee+s, #ltraso#nd scans are performed to monitor development of the
egg'containing follicles within the ovaries% 6nce scans show the follicles have reached s#fficient
size (which indicates li+ely mat#rity of the eggs within), a last inection is given to trigger the final
ripening of the eggs, and the follicles are drained some 9('9C ho#rs later, #nder sedation in o#r
/roced#res Doom%
Fertilisation
)he eggs are caref#lly identified in the la$oratory and placed in plastic dishes, $efore $eing mi7ed
with the male partner*s sperm which has $een s#ita$ly prepared% Fertilisation sho#ld then occ#r
several ho#rs later, and is assessed the morning after the egg collection< on average we e7pect
&='(=3 of eggs to fertilise normally% Hreat care is ta+en to +eep the fertilised eggs (now termed
em$ryos) in optimal conditions for development, with minimal dist#r$ance and caref#l monitoring
of the inc#$ators and c#lt#re media they are grown in%
)he em$ryos are assessed on the second and.or third day after egg collection (see ;m$ryo
grading), and one or two of the em$ryos that are #dged $est ,#ality are replaced inside the
#ter#s in a proced#re similar to a smear test%
Who is IVF s#ita$le for?
IVF was originally developed to $ypass $loc+ed or damaged t#$es%
It has also $een fo#nd to $e an effective form of treatment for co#ples where-
)here may $e a mild pro$lem with the sperm%
Where the female partner has endometriosis%
Where infertility is #ne7plained%
)here may $e more than one factor ca#sing fail#re to conceive%
1ath Fertility !entre0s IVF s#ccess rates are p#$lished here%
Are there any ris+s with IVF?
)here are some ris+s associated with IVF< these incl#de-
Iac+ of response $y the ovaries to the dr#gs #sed to stim#late follicle prod#ction% )his is most
often lin+ed with age and.or with a raised level of the hormone F"H, $#t also occasionally occ#rs
#ne7pectedly and may res#lt in few eggs $eing retrieved and so less em$ryos $eing availa$le for
replacement% In some cases it may $e prefera$le to a$andon the stim#lation attempt and
recommence treatment #sing a higher dose of dr#gs, which in t#rn may have implications for the
cost of treatment%
!onversely, over'response of the ovaries occ#rs in a small n#m$er of women% "ee 6H""
Very occasionally there may $e a complete and #ne7pected lac+ of normal fertilisation of any of
the eggs collected% )his can $e d#e to oocyte immat#rity, or pro$lems with the sperm attaching to
the eggs prior to penetrating them< sometimes it is diffic#lt to pinpoint the e7act ca#se and it is
#nclear whether the pro$lem lies with the egg or the sperm or $oth% When there is no fertilization
and conse,#ently no em$ryo for replacement the treatment ends ,#ite a$r#ptly, which can $e
distressing% We wo#ld generally s#ggest another treatment attempt #sing sperm inection (I!"I)
to try to overcome any diffic#lties in sperm'egg interactions% )his is #s#ally more s#ccessf#l in
achieving fertilisation, and if on the day of egg collection we have any ca#se to s#spect potential
pro$lems we will disc#ss it with yo# and consider changing yo#r IVF treatment plan to I!"I%
Darely, and #s#ally only when there is a very low n#m$er of eggs and em$ryos, there is a
complete lac+ of development of the fertilised eggs into m#lti'celled em$ryos, and hence no
em$ryo replacement% In s#ch cases we recommend one f#rther treatment attempt to see whether
more oocytes can $e o$tained to avoid the same pro$lem%
)here is a small ris+ of pelvic infection res#lting from the egg collection% Whilst most women do
e7perience some discomfort after this proced#re yo# sho#ld contact #s if yo# e7perience s#dden
or severe pain, or if yo# feel feverish and have a high temperat#re%
8ale )reatment : "perm "torage
Freezing or storing sperm
"ometimes it is necessary to freeze or store sperm, when it is apparent that the male partner is
#na$le to prod#ce a sample on the day of treatment% )his can happen if the man is ill, has
e7treme diffic#lty in prod#cing a sample, or is li+ely to $e o#t of the co#ntry at the time of
treatment%
We also operate a storage facility for men with cancer who are to receive chemo' or radiotherapy,
which may affect their f#t#re fertility%
/re'treatment and costs
"perm storage needs to $e arranged some time in advance of treatment, as an appointment m#st
$e made to share information regarding storage, and to sign several consent forms $efore the
sample is prod#ced for freezing%
All screening tests for hepatitis and HIV m#st $e complete with negative res#lts, $efore storage
can $e #nderta+en (see information on screening)%
)he initial freezing of the samples and the first year of storage costs E9&=% If samples are $eing
stored pre'vasectomy there is a E&== storage charge% After that yo# will $e charged an ann#al
storage fee (c#rrently E2F&), to cover the costs of administration and maintaining storage%
)he sperm sample will $e frozen and a small portion thawed as a test to chec+ s#rvival< #s#ally
a$o#t half the sperm will s#rvive% Bepending on the ,#ality of the sample frozen and the res#lts of
the test'thaw it may $e necessary to provide f#rther samples% Ia$oratory staff will arrange this
with yo#%
!onsent
For sperm stored for #se in treatment, the samples can $e stored for #p to 2= years, provided that
yo# renew yo#r consent to storage each year%
If the male partner dies or a co#ple divorces or separates, the fate of the frozen sperm will $e
dependent on consent given on the relevant HF;A forms% Additionally, the law now allows for the
man*s partic#lars to $e entered on the $irth register for a child who is $orn as a res#lt of fertility
treatment #sing frozen sperm that ta+es place after his death, provided prior consent has $een
given on the appropriate form% >o# will $e given a copy of yo#r consent forms and it is a good
idea to +eep them in a safe place%
6ncology patients
"ome of the treatments involving chemotherapy or radiotherapy can affect a man*s f#t#re a$ility
to father children% 8en who are a$o#t to #ndergo these treatments may wish to consider storing
samples of their sperm, which co#ld $e #sed at a later date if needed%
"creening
>o#r doctor, or a n#rse from the clinic, sho#ld refer yo# to the 1ath Fertility !entre $efore yo#
start yo#r chemo' or radiotherapy treatment% )hey sho#ld also arrange screening for HIV and
hepatitis $efore yo# attend 1ath Fertility !entre the first time% We are #na$le to store sperm from
men who have not $een screened, altho#gh we do have a system of ,#arantining samples #ntil
screening res#lts are +nown% If screening tests prove negative the samples can then $e placed in
long'term storage% If, however, screening tests prove positive we wo#ld not $e a$le to store the
samples here% We sho#ld $e a$le to arrange for the samples to $e stored at another hospital%
/roced#re
When yo# are referred for sperm storage yo# will $e attending the 1ath Fertility !entre within a
few days, so that the sample(s) can $e stored $efore yo# start yo#r treatment% >o# will meet a
mem$er of the la$oratory staff who will e7plain the storage process and ens#re that the
appropriate consent forms are completed%
After yo# have prod#ced yo#r sample the la$oratory staff will assess the ,#ality of the sperm and
disc#ss this with yo#% )he sample will $e frozen in several small ampo#les, and a small portion
thawed as a test to chec+ s#rvival< #s#ally a$o#t half the sperm will s#rvive% It may $e possi$le to
freeze more than one sample depending on when yo#r treatment starts%
Iength of storage
"amples will $e stored for 2= years provided that yo# renew yo#r consent to storage each year%
"torage may $e e7tended #p to a ma7im#m of && years if yo# $ecome premat#rely infertile e%g%
as a res#lt of chemotherapy%
What happens to the stored samples if a patient dies depends on the conditions indicated on the
consent forms% If the forms indicate *allow to perish* then the stored samples will $e destroyed% If
the form states *contin#e in storage* (for partner*s #se) the sperm will $e stored for a ma7im#m of
2= years after death, providing a named partner writes ann#ally re,#esting storage to contin#e%
)he law now allows for the man*s partic#lars to $e entered on the $irth register for a child who is
$orn as a res#lt of fertility treatment #sing frozen sperm that ta+es place after his death, provided
prior consent has $een given on the appropriate form% >o# will $e given a copy of yo#r consent
forms and it is a good idea to +eep them in a safe place with yo#r Will or other important
doc#ments%
6v#lation Ind#ction
What is ov#lation ind#ction and follicle trac+ing?
6v#lation ind#ction (6I) and follicle trac+ing involves #sing fertility dr#gs to stim#late the
development of a few follicles, which are *trac+ed* or monitored $y #ltraso#nd scan%
When s#fficient follicles are #dged to have reached the optim#m size, a final inection is given to
trigger ov#lation, and interco#rse is planned to coincide with ov#lation to ma7imise the chance of
sperm reaching a ripe egg for fertilisation to occ#r% Altho#gh the proced#re itself is
straightforward, the timing is very important%
6v#lation ind#ction is s#ita$le for co#ples where the female partner may not ov#late relia$ly $#t
has normal healthy t#$es, and the male partner has a normal or nearly normal semen analysis%
What is involved in this treatment?
1efore starting yo#r treatment, an #ltraso#nd scan is carried o#t to chec+ the appearance of yo#r
ovaries, and providing this is normal yo# wo#ld start inecting a low dose of fertility dr#gs to
stim#late the prod#ction of one or more follicles%
A wee+ after yo# have started yo#r inections, yo# will have another scan to chec+ how many
follicles yo# are growing and their size% We are aiming for a ma7im#m 9 large follicles and no
more than 4 smaller% If yo#r scan shows this, yo# will $e as+ed to give yo#rself a final inection of
a different hormone which will ma+e yo# release the egg(s) 9?'?= ho#rs later% Interco#rse will $e
timed to coincide with this%
If yo# have grown more than the re,#ired n#m$er of follicles yo# may have to stop treatment%
)his is $eca#se there co#ld $e a high ris+ of m#ltiple pregnancy occ#rring if treatment were to
contin#e% "ee $elow for more a$o#t associated ris+s%
How s#ccessf#l is it?
/regnancy rates for ov#lation ind#ction are aro#nd 2='2&3 per treatment cycle% )his is lower
than with IVF.I!"I as we are not a$le to $e certain that fertilisation has ta+en place following
ov#lation and interco#rse% For this reason 6I is #s#ally limited to 9 cycles $efore we review yo#r
progress%
Dis+s associated with ov#lation ind#ction
6ccasionally some women over'respond to fertility dr#gs, prod#cing too many follicles% If
interco#rse were to ta+e place after several large follicles have ov#lated there wo#ld $e a ris+ of a
m#ltiple pregnancy involving more than 4 em$ryos% We wo#ld therefore stop yo#r treatment
immediately and advise yo# that yo# m#st either ta+e contraceptive preca#tions (#se a condom)
or a$stain from interco#rse #ntil yo# have yo#r ne7t period%
For s#$se,#ent treatment cycles the amo#nt of dr#gs wo#ld $e red#ced to try to ma+e yo# grow
fewer follicles% In rare cases 6H"" may occ#r and treatment wo#ld $e stopped and restarted
when safe to do so%
"ome planned ov#lation ind#ction treatments need to $e cancelled d#e to lac+ of response to the
dr#gs #sed to stim#late follicle prod#ction% In this case the amo#nt of dr#gs yo# ta+e wo#ld $e
ad#sted to try to ma+e yo# grow more follicles in another treatment cycle%
A$andoned cycle- An IVF or I!"I treatment cycle which is cancelled after ovarian stim#lation has
$eg#n $#t $efore egg collection%
A$stinence- )he n#m$er of days since last eac#lation%
Adhesions- "car tiss#e which forms following s#rgery, infection or tra#ma and which ca#ses
pelvic organs to stic+ together%
Anosmia- Ina$ility to smell, may $e associate with some azoospermic conditions
Antisperm anti$odies- )he imm#ne system of some patients may recognise sperm as *foreign*
cells and prod#ce anti$odies against them% If this happens the anti$odies can coat the o#tside of
the sperm which may prevent the sperm from attaching to the egg and therefore inhi$it
fertilisation%
Assisted hatching- A techni,#e #sed to help the em$ryo escape from its zona pell#cida (shell)% An
em$ryo needs to hatch $efore implantation can occ#r%
Asthenozoospermia- )erminology #sed to descri$e s#$fertility where sperm have red#ced motility
(movement)- less than &=3 motile sperm or with sperm showing slow progression%
Azoospermia- )he disorder where the eac#lated semen does not contain any sperm cells< this
may $e d#e to a $loc+age (as in vasectomy) or a fail#re in prod#ction of the sperm%
1
1lastocyst- Defers to an em$ryo that has $een developing for & : ( days following fertilisation%
!
!ervi7- A narrow passage connecting the vagina to the wom$ (#ter#s)
!hromosomes- !hromosomes are thread'li+e $odies of BGA which contain the genetic code in
genes% Half of the chromosomes will $e inherited from the mother and the other half from the
father%
!hlamydia- A se7#ally transmitted disease that may affect $oth males and females< there may $e
few symptoms and if left #ntreated the disease can often lead to infertility%
!leavage- !ell division in early em$ryos necessary for development
!lomiphene- An anti'oestrogen dr#g that helps to stim#late the prod#ction of follicles, often #sed
to treat anov#lation and in BI and I5I cycles%
!ongenital malformations- 8alformations seen at $irth ($irth defects) d#e to inherited or
environmental ca#ses%
!o#nselling- !o#ples see+ing fertility sometimes re,#ire emotional s#pport to help them thro#gh
what can $e a diffic#lt time% A co#nsellor will help co#ples to #nderstand the implications of
treatment and its conse,#ences%
!ryopreservation- ;m$ryos, sperm and eggs (only offered $y some clinics) can $e frozen and
stored in li,#id nitrogen at min#s 2@( degrees for #se at a later date% )hey are passed thro#gh a
series of specially designed sol#tions which help to protect the cells from damage d#ring the
freezing and thawing processes%
B
BI : Bonor Insemination- Bonor sperm is introd#ced into the vagina, cervi7 or #ter#s #sing a
catheter% It may $e #sed to treat co#ples where the male partner is #na$le to prod#ce his own
sperm, single se7 co#ples, or single women%
Bonated em$ryos- ;m$ryo donation provides a chance for co#ples for whom no treatment is
availa$le to help them% Fertility is an iss#e for $oth partners, hence the only chance of a
pregnancy is thro#gh em$ryo donation%
Bonated eggs- If a woman is #na$le to prod#ce eggs of her own, or is prod#cing eggs of poor
,#ality, it may $e possi$le to #se eggs that have $een donated from another fertile woman%
Bonated sperm- "emen donated $y sperm donors and frozen $efore $eing #sed to treat co#ples
when the male partner is #na$le to prod#ce ade,#ate sperm% 8ay also $e #sed to treat single
women or same'se7 co#ples%
Bonor- A person or co#ple who chooses to provide their eggs, sperm or em$ryos for #se $y
others% All 5J donors m#st $e screened for +nown infectio#s diseases, and have no legal right or
o$ligation to any child $orn as a res#lt of treatment given in a 5J licensed clinic
;
;ctopic pregnancy- Where a pregnancy occ#rs o#tside the #ter#s, #s#ally in the fallopian t#$es,
and may occ#r $oth in nat#ral pregnancies and those following assisted conception%
;gg (oocyte)- )he gamete prod#ced in the ovary of a woman, generally one egg is made each
monthly cycle
;gg collection (retrieval)- 8inor s#rgical proced#re to collect the eggs prod#ced $y the ovaries
(#s#ally after ovarian stim#lation)% 8ostly done #sing #ltraso#nd to vis#alise the ovaries and
follicles containing the eggs, $#t may $e done #sing a laparoscope% )he fl#id'filled follicles are
drained with a needle and the fl#id e7amined in the la$oratory for eggs%
;gg donor- A woman who donates her eggs for the treatment of others%
;ac#lation- )he release of seminal fl#id following se7#al aro#sal%
;m$ryo- An em$ryo is formed following s#ccessf#l fertilisation of an egg $y a sperm%
;m$ryo grading- In the la$oratory em$ryos can $e *graded* according to their appearance% )he
n#m$er, shape and symmetry of the cells and any fragmentation is assessed and compared to
the e7pected stage of development< this may give an indication of em$ryo ,#ality and the
potential of an em$ryo to develop into a pregnancy%
;m$ryo transfer- /roced#re of replacing em$ryos in the #ter#s
;ndometriosis- A condition in which small parts of endometri#m, which #s#ally provides the lining
of the wom$, grow in other places within the pelvic cavity% )he severity of endometriosis varies
depending #pon the areas and amo#nt of endometrial growth< it can ca#se $leeding, pelvic pain
and pro$lems with fertility%
;ndometri#m- )he lining of the wom$ which develops each month ready to receive the implanting
em$ryo, $#t shed in a period of no implantation occ#rs%
;pididymis- sperm storage and transport t#$e in the testis
F
Fallopian t#$es (6vid#cts)- )he fallopian t#$es connect together the ovaries and the #ter#s% In a
nat#ral cycle this is where the sperm and egg meet and fertilisation occ#rs%
Fertilisation- 6cc#rs when an egg and sperm meet s#ccessf#lly to form an em$ryo%
Folic Acid- A dietary s#pplement that is advisa$le for women planning a pregnancy and those in
the early stages of pregnancy that helps to red#ce the chances of ne#ral t#$e defects s#ch as
spina $ifida%
Follicles- )he small fl#id filled sacs that develop on the ovaries and #s#ally contain eggs%
F"H ' Follicle "tim#lating Hormone- A hormone prod#ced $y the /it#itary Hland in the $rain that
stim#lates the prod#ction of follicles containing eggs on the ovaries% )he dr#gs that are given
d#ring IVF and I!"I cycles to stim#late the prod#ction of lots of eggs contain F"H%
H
Hamete- A Hamete is the generic term #sed to descri$e egg and sperm cells%
H
HF;A ' H#man Fertilisation and ;m$ryology A#thority- )he HF;A is a $ody that was set #p in
2@@2 following the 2@@= Act of /arliament to reg#late all assisted conception proced#res in the
5nited Jingdom % All clinics providing assisted conception treatments in 5J are inspected and
licensed $y the HF;A and m#st wor+ within the HF;A !ode of /ractice%
Hormone profile- A $lood test #sed to meas#re the levels of certain hormones in the $lood that
are related to reprod#ctive f#nction%
Hysterosalpingogram- A diagnostic proced#re #sed to assess whether the fallopian t#$es are
$loc+ed or open% A dye is inected into the t#$es, this dye can then $e pic+ed #p on an 7'ray and
will show whether the t#$es are patent (open)%
I
I!"I : Intra'!ytoplasmic "perm Inection- An individ#al sperm is inected directly into the middle
of an egg #sing a sophisticated microscope and micromanip#lation tools% )his proced#re may
increase the chances of fertilisation occ#rring in cases of male factor infertility%
Implantation- occ#rs when an em$ryo attaches to the endometri#m, or lining of the wom$%
Inner cell mass- )he area of cells inside a $lastocyst that will go on to form the developing foet#s
Insemination- the introd#ction of sperm in the pro7imity of the oocyte.s (eggs)
I5I : Intra'5terine Insemination- A small vol#me of sperm sample that has $een prepared in the
la$oratory is introd#ced into the #ter#s thro#gh the cervi7 #sing a fine catheter (t#$e)
In vitro- Iiterally meaning *In'Hlass* or in the la$oratory%
In vivo- 8eaning inside the $ody%
IVF : In Vitro Fertilisation- 8i7ing of eggs and sperm to achieve fertilisation o#tside the $ody%
K
J
Jaryotype- microscopic image of a set of chromosomes so their n#m$er and size can $e
chec+ed%
I
Iaparoscopy- A s#rgical proced#re in which a telescopic camera (laparoscope) is passed thro#gh
a small incision in the navel to loo+ at the pelvic organs< may $e #sed to investigate ca#ses of
infertility%
IH : I#teinising Hormone- IH is involved $oth in egg and sperm prod#ction% In women it helps
the developing egg to ripen and reach the right stage of mat#rity for fertilisation to occ#r and $e
released% In men it stim#lates the testicles to prod#ce testosterone% A sharp rise in IH is detected
in ov#lation prediction tests%
Iive $irth rates- )he n#m$er of live $irths per 2== treatment cycles%
8
8ale factor- /ro$lems with sperm prod#ction can $e classed together as 8ale Factor infertility%
)hese may incl#de low sperm co#nt, high levels of a$normal sperm, pro$lems with swimming
patterns, a vasectomy or failed vasectomy reversal or $loc+ages%
8orphology- 8ost often #sed to descri$e the shape of sperm $#t can also $e #sed to descri$e
the appearance of the cells within an em$ryo%
8otility- A term #sed in semen analysis to descri$e the movement of sperm% )he percentage of
sperm swimming is assessed and the speed with which they are progressing is meas#red%
8#ltiple pregnancy- A pregnancy in which there is more than one foet#s developing% Fertility
treatment may res#lt in a m#ltiple pregnancy if more than one em$ryo is transferred or if more
than one follicle develops d#ring ov#lation ind#ction%
G
G#cle#s- /art of a cell which contains the chromosomes%
6
6estradiol (6estrogen)- )he female se7 hormone that is prod#ced $y the ovaries%
6H"" : 6varian Hyperstim#lation "yndrome- )he dr#gs that are given to stim#late the
prod#ction of eggs for a treatment cycle, altho#gh caref#lly prescri$ed, may occasionally ca#se
the complication of 6H""% )his is where too many follicles and eggs are prod#ced and may
mean that a cycle has to $e a$andoned #ntil symptoms s#$side, or if egg collection proceeds the
em$ryos may all $e frozen #ntil the ovaries have recovered and it is safe to contin#e treatment%
6ligozoospermia- )erminology for a condition when the semen sample has a red#ced
concentration of sperm< the co#nt is less than 4= million sperm per millilitre of eac#late%
6ngoing pregnancy- Defers to those pregnancies confirmed $y #ltraso#nd scan
6ocyte (egg)- )he gamete prod#ced in a woman*s ovaries< generally one egg is made each
monthly cycle
6vary- female reprod#ctive organ where eggs are prod#ced in follicles
6v#lation- )his is where a ripe egg is released $y the ovary and $egins it o#rney down the
fallopian t#$e towards the #ter#s%
6I : 6v#lation Ind#ction- Br#gs are #sed to stim#late the ovaries to prod#ce and release one or
more eggs prior to insemination or timed interco#rse to ma7imise the chance of conception%
/
/IB : /elvic Inflammatory Bisease- "e7#ally transmitted infections may ca#se inflammation and
damage to the reprod#ctive organs and lead to diffic#lties with fertility%
/;"A : /erc#taneo#s "perm Aspiration- A fine needle is passed into the epididymis (the t#$es in
the testes which store sperm)< the fl#id is aspirated and e7amined in the la$oratory for the
presence of sperm%
/!6" : /olycystic 6varian "yndrome- A comple7 condition in which the ovaries prod#ce many
small cysts or follicles which can ca#se a hormone im$alance, pro$lems with ov#lation and
conse,#ently with fertility%
/lacenta- )he placenta provides the connection $etween the mother and the developing foet#s
/regnancy rate- n#m$er of pregnancies for every 2== treatment cycles started%
/rogesterone- Female hormone responsi$le for preparing the lining of the wom$ for pregnancy% If
pregnancy does not occ#r, progesterone levels fall and the lining of the wom$ is shed (a *period*)%
/rogression- Defers to the direction and speed with which the sperm are swimming%
L
L#ality control- "ystem to ens#re safe and effective delivery of all processes #sed in treatment of
patients
D
Detrograde eac#lation- )he prod#cts of eac#lation are not released normally $#t are deposited
in the $ladder% It may then $e possi$le to isolate the sperm cells from the #rine in the la$oratory%
"
"emen analysis- 5sed to assess the parameters in seminal fl#id prod#ced at the time of
eac#lation% )he n#m$er of sperm, how many of the sperm are swimming (and how ,#ic+ly) and
the shape of the sperm are assessed% 6ther val#es s#ch as the vol#me, the pH, viscosity and the
presence of antisperm anti$odies are meas#red%
"e7 selection- techni,#e offered $y some clinics to determine the se7 of an em$ryo $efore
replacement% 5sed to avoid transferring em$ryos which may carry se7'lin+ed diseases%
"perm- the male gamete prod#ced in the testes%
"perm co#nt- )he n#m$er of sperm is co#nted #nder the microscope< a normal co#nt sho#ld $e
more than 4= million.ml%
"perm donor- A man who donates his sperm for #se in treatment $y others%
"tim#lation.s#perov#lation- /rocess of #sing dr#gs to ind#ce the ovaries to prod#ce m#ltiple
follicles%
"#rgical "perm Detrieval- If there is a $loc+age in the sperm transport d#cts that prevents sperm
from $eing released d#ring eac#lation it may $e possi$le to e7tract the sperm directly from the
testes #sing /;"A or );"; d#ring a minor proced#re%
"#rrogacy- )he act of getting pregnant and carrying a child on $ehalf of someone who for medical
reasons cannot carry a pregnancy themselves%
)
)a+e home $a$y rate- )he n#m$er of cycles that res#lt in a live $irth per 2== treatment cycles%
)eratozoospermia- B#ring semen analysis the shape of the sperm head, midpiece (nec+) and tail
is compared to a *normal* sperm model and the sperm classed as a$normal or normal%
)eratozoospermia is a term #sed to descri$e s#$fertility lin+ed to semen with raised levels of
a$normally shaped sperm (greater than C&3)%
);"; : )estic#lar "perm ;7traction- A small sample of testic#lar tiss#e is ta+en #sing a needle
d#ring a minor operation% )his tiss#e is then processed in the la$oratory to e7tract any sperm that
are present%
)estis (testicle)- male reprod#ctive organ where sperm are prod#ced
)estosterone- )he male se7 hormone that is prod#ced $y the testicles%
)rophectoderm- )he layer of cells that form aro#nd the o#tside of a $lastocyst on day & or day (
of development% )hese cells event#ally form the placenta and are responsi$le for implantation in
the #ter#s%
5
5ltraso#nd scan- High fre,#ency waves are #sed to see inside the $ody and allow doctors and
n#rses to vis#alise str#ct#res s#ch as the #ter#s and the ovaries% 5sed to monitor development of
follicles d#ring ovarian stim#lation, and to *see* the follicles d#ring egg collection, as well as to
confirm the presence of an early pregnancy%
5terine receptivity- )his refers to the readiness of the lining of the wom$ (the endometri#m) for an
em$ryo to implant and pregnancy to $egin% It is only in pea+ condition for implantation for a short
time in each monthly cycle%
5ter#s- )he #ter#s or wom$ is the female organ which s#pports the growth of an em$ryo and
event#ally a $a$y%
V
Vas deferens- "perm transport d#ct in the testis%
W
Welfare of the !hild- social and ethical aspects #sed in assessing the well'$eing of any child (new
or e7isting) #nder 2C who may $e affected $y fertility treatment
M
M chromosome- )he M chromosome contains female genes% A maternal M chromosome is always
passed on $y the egg, and the fertilising sperm may pass on another M chromosome, or a >
chromosome%
>
> chromosome- )he > chromosome contains male'specific genes from the father% "perm carry M
or > chromosomes- if an egg is fertilised $y a sperm that has a > chromosome a $oy will $e $orn,
if the sperm has an M chromosome a girl will $e $orn%
N
Nona pell#cida- )he zona pell#cida is the protective shell'li+e coating of the egg%
Nygote- Game for the very early one'cell em$ryo formed when the egg and sperm fertilise%
At 1ath Fertility !entre we achieve consistently high s#ccess levels with o#r fertility treatments :
we*re pro#d that o#r res#lts ran+ #s amongst the top fertility clinics in the co#ntry%
1elow are o#r clinical pregnancy and live $irth rates% Des#lts per em$ryo transfer and per
treatment cycle started are different as not all women reach egg collection and some will not have
an em$ryo transfer : some may have all their em$ryos frozen or may have no fertilisation%
6#r c#rrent s#ccess rates
6#r ongoing clinical pregnancy rates since we opened o#r new premises (8ay 4=29) are-
5nder 9C 9C'9@ ?='?4
/er em$ryo transfer

?4%=3
((9.2&=)
?=%?3
(2@.?F)
2C%C3
((.94)
/er cycle started

9F%&3
((9.2(C)
9F%93
(2@.&2)
2C%43
((.99)
Implantation rate

9F%43
4?%F3
2=%23
;lective single em$ryo transfers

F=%F3
4F%F3
9%23
8#ltiple pregnancy rate

@%&3
&%93
2(%F3
Iive 1irth rates
)he fig#res $elow show live $irth rates at 1ath Fertility !entre and nationally for the period 2 K#ly
4=22 to 9= K#ne 4=24, as verified and p#$lished $y the HF;A on their we$site www%hfea%gov%#+

5nder 9&
9&'9F
9C'9@
?='?4
?9'??
1ath Fertility !entre
per em$ryo transfer
?2%?3
9F%&3 4&%=3 29%93
99%93 (2.9)
Gational average
per em$ryo transfer
9F%43 92%F3 4?%23 2(%=3 &%(3
1ath Fertility !entre
per cycle started
9(%?3 99%C3 49%23 24%&3
4&%=3 (2.?)
Gational average
per cycle started
94%(3 4F%@3 4=%C3 29%(3 ?%&3
History
In 2@F9, Be Jretser and colleag#es descri$ed the first IVF pregnancy that was achieved in 2@F4%
)he oocyte was o$tained $y way of laparotomy% "ince this was a tra#matic approach, it was d#e
to the laparoscopy e7pertise of /atric+ "teptoe, that res#lted in his s#ccessf#l partnership with
Do$ert ;dwards, and as a conse,#ence in the $irth of Io#ise 1rown in 2@FC% )his change in
oocyte collection was rapidly applied aro#nd the world, and was #sed in the collection of eggs for
the 8onash team, that converted IVF from a research tool to clinical treatment% It was also #sed
$y Kones0 team when in 2@C4 they achieved the first pregnancies in the 5"A%
"ince the early 2@C=s, laparoscopic oocyte collection has $ecome a worldwide proced#re, #ntil
the pioneering wor+ in 2@C? of "#san Ienz in !openhagen, and Wilfred Feichtinger, in Vienna,
which changed oocyte collection to a transvaginal, #ltraso#nd'g#ided techni,#e% "ince then,
oocyte collection g#ided $y vaginal #ltraso#nd has $ecome the method of choice%
;,#ipment
1erger and colleag#es devised a special aspiration #nit, with a 4='ga#ge, 2='inch needle
connected to a 2= mm vac#tainer $y a polyethylene t#$e, which was then connected to a vac##m
$ottle with an ad#sta$le press#re ga#ge% )oday, sophisticated s#ction p#mps with ad#sta$le
aspiration press#re are e7tensively availa$le commercially%
)echni,#e
Dapid oocyte collection (D6!)
Aspiration of one follicle after the other, and follic#lar fl#id from the ne7t follicle often fl#shes the
oocyte into a collection t#$e%
It is possi$le to #se a do#$le l#men needle to fl#sh the follicles with medi#m in order to retrieve
the oocyte% )his method is reserved for cases where very few oocytes are e7pected%
It is important to +now that d#ring aspiration, the temperat#re of follic#lar fl#id drops $y F%F O
2%9=!% Bissolved o7ygen levels rose $y & O 4 vol3% )he pH increased $y =%=? O =%=2% )hese
changes co#ld $e detrimental to oocyte health, and efforts sho#ld th#s $e made to minimise
these%






Anesthesia.Analgesia
"ince the time of egg collection thro#gh the vagina, rela7ant analgesia has no longer $een
re,#ired% !#rrently there are vast variations in the type of analgesias #sed for oocyte collection%
In some areas oocyte collection is #nderta+en witho#t any analgesia (s#ch as in !hina), whereas
elsewhere para'cervical $loc+, local anesthesia, intraveno#s sedation, or even general
anesthesia is administered% 1asically, this depends on c#lt#ral e7pectations, the facility #sed for
oocyte collection, and the medical financial re$ate system%
egg collection
;gg aspiration proced#re in progress ' an egg is $eing aspirated from a follicle
)he needle is the $right white str#ct#re (right side)%
oocytecollection4
!omplications
Altho#gh rare, several possi$le complications of transvaginal oocyte collection have $een
reported%
)he most common operative complications are
P Hemorrhage
P )ra#ma to pelvic str#ct#res
P /elvic infection
P Anesthetic complications
)he incidence of ac#te a$domen following egg collection is reported to $e $etween =%23 and
2%&3%
In Vitro 8at#ration (IV8) in a clinical setting
Introd#ction
IV8 is defined as the primary intention to collect immat#re oocytes from hormonally #nstim#lated
or minimally primed follicles to achieve a live $irth%
)he $asic concept of IV8 is that immat#re oocytes are collected from small antral follicles $efore
spontaneo#s ov#lation, and the oocytes are then allowed to mat#re in vitro after which ro#tine in
vitro fertilization (IVF) or intracytoplasmic sperm inection (I!"I) and em$ryo transfer can $e
performed% )he immat#re eggs are then mat#red in the la$oratory for 4?'?C ho#rs #sing c#lt#re
medi#m with added small ,#antities of hormones% )he proced#re is $ased on the o$servations of
/inc#s and ;nzmann in 2@9& and later on $y ;dwards in 2@(& that oocytes #ndergo
spontaneo#s n#clear mat#ration when removed from the follic#lar milie#% IV8 has $een practiced
in a clinical setting for over a decade, $#t only recently information have $een acc#m#lated on the
clinical o#tcomes% )he proced#re is simple, lac+ of hormonal stim#lation and the ris+ of ovarian
hyperstim#lation syndrome (6H"") theoretically does not e7ist% IV8 may also $e less costly as
there is no need for the dr#gs to stim#late the ovaries%
"ince !ha et al% (2@@2) reported a$o#t the first pregnancy from in vitro mat#red oocytes, derived
from a caesarean section donor, fertilization, em$ryo development and pregnancy%
/atient selection
IV8 was primarily developed to ma+e IVF safer and simpler for women with polycystic ovaries
and high ris+ of 6H"" #sing conventional stim#lation protocols% Decently, the indications for IV8
have $een e7tended to other ca#ses of infertility s#ch as avoidance of the side effects res#lting
from gonadotropin stim#lation incl#ding the ris+ of 6H""
P 1eing less costly and safer
P "implified treatment
P Alternative to IVF for yo#nger women with normal menstr#al cycles%
P Women who have a poor response to stim#lation
P 5ne7pected poor ,#ality em$ryos
P /revio#s failed IVF cycles
P Fertility preservation in yo#ng cancer, with hormone'sensitive t#mors, who are going to
receive chemotherapy or radiotherapy
P Deserving fertility capa$ility (6ocytes retrieved can $e vitrified, or em$ryos created can $e
cryopreserved)
P 8ale factor infertility when the woman does not re,#ire fertility dr#gs
However, /!6" is the most widely #sed indication for IV8% It is the antral follicle co#nt rather
than the diagnosis of /!6" itself which is an important predictive factor of the n#m$er of
immat#re oocytes o$tained from an #nstim#lated cycle and sho#ld $e #sed as a main criterion to
select patients for IV8% Women who will $enefit most from in vitro mat#ration are women aged
9& and yo#nger and have antral follicle co#nt of 2= or more%
)he #se of IV8 in women with reg#lar cycles and normal ovaries is more controversial% Altho#gh
IV8 has $een applied to IVF poor responders it has mostly $een #sed in yo#nger patients with
none or a few previo#s IVF attempts% )he most important prognostic criteria for IV8 seems to $e
the n#m$er of antral follicles in a $aseline #ltraso#nd scan% If the antral follicle co#nt is less than
five per ovary, IV8 is not recommended% )h#s, low ovarian reserve can $e considered as a
contraindications for IV8% )he clinical e7perience th#s far s#ggests that IV8 is a first line
treatment rather than the last resort%
Hormonal priming
Altho#gh only a single follicle #s#ally grows to the preov#latory stage and releases its oocyte for
potential fertilization, many small follicles also develop d#ring the same follic#lar phase of the
menstr#al cycle% It seems that appro7imately 4= antral follicles are selected and contin#e to grow
thro#gh to the preov#latory stages of development d#ring each menstr#al cycle%
)he initial p#rpose of IV8 was to o$tain immat#re oocytes from antral follicles witho#t any prior
hormone stim#lation% However, as the pregnancy rates initially were low there was a need to try
to increase the n#m$er of good ,#ality oocytes availa$le for IV8 and s#$se,#ent IVF';)% 6ne
approach was to #se mild ovarian stim#lation with gonadotrophins% )heoretically early follic#lar
phase F"H.H8H priming of the follicles co#ld enhance oocyte mat#ration, increase the oocyte
yield and ma+e the collection of the oocytes easier% As a res#lt, vario#s priming protocols have
$een st#died $oth in women with irreg#lar cycles and /!6", and reg#lar cycles and normal
ovaries% In a st#dy $y 8i++elsen et al% they #sed F"H 2&= I5 on cycle days 9'&, whereas Iin et al
#sed $oth F"H (F& I5 for ( days) and H!H priming%
)he main reason to #se h!H priming in women with /!6" has $een the finding that in vivo
administered h!H enhanced the n#clear mat#ration of the oocytes% In non'/!6 women with
reg#lar cycles, h!H priming has not $een shown to have any $eneficial effect%
ivm2 ivm4
Immat#re 6ocyte Immediately after retrieval 8at#re 6ocyte After 9( ho#rs of Detrieval
ivm9
B#ring !6! sliding, it is possi$le to o$serve clearly whether or not the oocyte cytoplasm contains
a germinal vesicle
(HV) (A and 1) or the oocyte has e7tr#ded a first polar $ody (2/1) into perivitelline space (/V")
(B)% If neither HV is
seen in the oocyte cytoplasm nor 2/1 fo#nd in /V", then the oocyte is defined as germinal
vesicle $rea+down
(HV1B) or metaphase'I stage (8'I) (!)%
!ycle monitoring and timing of oocyte collection
)he management of an IV8 cycle depends on whether it is an ov#latory or an anov#latory cycle%
5ltrasonography remains the $est method to monitor the cycle for the timing of immat#re oocyte
collection% In women with /!6" the cycles are #s#ally anov#latory witho#t dominant follicle
development in which case the monitoring of the cycle and the timing of the oocyte pic+'#p are
more fle7i$le than in an ov#latory cycle% )he criteria for oocyte pic+'#p in anov#latory patients is
the thic+ness of the endometri#m which sho#ld $e greater than ( mm, altho#gh s#ccessf#l
pregnancies have $een reported with an endometri#m as thin as 9 mm% )h#s, the day of the
cycle does not play a role in the timing of the oocyte pic+'#p in anov#latory cycles of /!6"
women allowing more fle7i$ility in sched#ling considering the IVF la$oratory and the clinic%
1ased on the p#$lished literat#re the size of the leading follicle with s#ccessf#l o#tcome varies
$etween less than 2= mm to 2? mm% When the leading follicle has reached 29 mm in diameter,
significantly less oocytes were collected, mat#red and fertilized and fewer em$ryos transferred
than in cycles with a leading follicle smaller than 29 mm, whereas others have recommended
cancellation of the cycle if the leading follicle is larger than 2= mm %
6ocyte collection
)he oocyte retrieval is done #nder #ltraso#nd g#idance with a single'l#men aspiration needle%
)he aspiration press#re is red#ced to F%& +/a% )he follic#lar fl#id is collected in c#lt#re t#$es
containing =%@3 saline with 4 5 of heparin% 1eca#se immat#re oocytes are enclosed in tightly
pac+ed c#m#l#s cells, c#rettage of the follicle wall will dislodge the c#m#l#s oocyte comple7% )he
aspirates are #s#ally $lood laden and the tightly compacted oocyte comple7es are diffic#lt to
identify< therefore, filters can $e #sed to increase oocyte yield% As mentioned, m#ltiple needle
p#nct#res are needed $eca#se lower aspiration press#res are #sed and $loody aspirates may
$loc+ the thin needle l#men% )he needle is therefore withdrawn from the vagina after aspirating a
few follicles to fl#sh and clear any $loc+ and the proced#re is repeated #ntil all follicles are
aspirated%
)he immat#re oocyte collection techni,#e differs from the aspiration of large mat#re follicles% )his
new technology needs-
P A lower aspiration press#re
P Immo$ilisation of the ovary $y press#re or special holding needle
P Filtering of the aspirate to recover the immat#re oocytes
)he aspiration press#re for IV8 sho#ld $e lower than that #sed in the conventional oocyte
retrieval% )he range for optimal aspiration press#re is pro$a$ly wide and depends on the
e,#ipment and the type of needle #sed% Immo$ilisation of the ovary $y e7ternal press#re may $e
necessary, $eca#se the #nstim#lated ovary is smaller and potentially more mo$ile than the
stim#lated ovary% Alternatively a special do#$le l#men holding needle can $e #sed% As the
immat#re oocytes do not have a large, e7panded c#m#l#s cell comple7 they are more diffic#lt to
see in the aspirate which contains more $lood than the follic#lar fl#id from large follicles%
)herefore, the aspirate is #s#ally filtered after which the immat#re oocytes can easily $e
recovered% )his means that there is a longer time interval $etween the oocyte collection and the
time the total n#m$er of retrieved oocytes is +nown compared to the oocyte pic+'#p proced#re in
conventional IVF%
ivm?Follic#lar aspirates collected into t#$es (2= ml, Falcon)
containing appro7imately 4'9 ml of heparinized warm (9FQ!) fl#shing medi#m
In vitro mat#ration followed $y insemination or microinection
)he c#lt#re medi#m for the collected immat#re oocytes has $een s#pplemented with a range of
gonadotropins, growth factors, steroids, ser#m and proteins from vario#s so#rces% 8any
la$oratories have #sed their in'ho#se developed c#lt#re medias an co'c#lt#re systems and a few
commercial IV8 c#lt#re medias are c#rrently availa$le% )he in vitro mat#ration times #sed have
varied $etween 4C and &4 ho#rs% )he oocytes which mat#re within 9= ho#rs after retrieval have
$een shown to $e developmentally more potent than the ones mat#ring later% It is diffic#lt to draw
definite concl#sions on the optimal mat#ration time from these st#dies $eca#se of the variations
in c#lt#re conditions and st#dy endpoints% For practical p#rposes a mat#ration time $etween 9= '
9( ho#rs is mostly #sed% )he ,#ality of the oocytes at the time of collection seems to $e the
most important sing#lar factor affecting the mat#ration rate% 6ocytes s#rro#nded $y intact
c#m#l#s cells show $etter mat#ration rates than oocytes with scanty or no c#m#l#s cells%
Intracytoplasmic sperm inection (I!"I) has $een tho#ght to $e necessary for fertilization of in
vitro mat#red oocytes even in conditions where sperm parameters are not impaired% Another
reason for #sing I!"I instead of insemination after IV8 is that the assessment of oocyte mat#rity
is more diffic#lt with intact c#m#l#s cells% However, insemination may $e a good alternative after
IV8 when the sperm is s#ita$le for IVF% It can $e spec#lated that the intact c#m#l#s cells
somehow enhance cytoplasmic mat#ration and developmental competence of the oocytes%
;m$ryo transfer and endometrial preparation
6ne of the challenges of IV8 is to prepare the #ter#s for implantation in only a few days $etween
the oocyte retrieval and em$ryo transfer% 1eca#se immat#re oocytes are #s#ally retrieved $efore
the dominant follicle develops, the endometri#m is e7posed to relatively low levels of estradiol $y
the time of oocyte pic+'#p% As a res#lt, there is a dyssynchrony $etween the phase of the
endometri#m and the cleavage stage em$ryo% )herefore, ade,#ate preparation of the
endometri#m is of cr#cial importance in an IV8 cycle $eca#se of the a$sent IH s#rge at the time
of oocyte collection% )he most commonly #sed protocol for endometrial preparation consists of
estradiol valerate 4'? mg daily from the day of immat#re oocyte collection and progesterone
intravaginal started ?C ho#rs later at the time of microinection or insemination%% In case of
pregnancy, it is important to contin#e the hormone s#pplementation long eno#gh as there is no
endogeno#s pit#itary or corp#s l#te#m s#pport%
!linical o#tcome and follow'#p of children
)he clinical o#tcomes of IV8 have contin#ed to improve after the modest res#lts of the early
st#dies% )he average pregnancy rates in women with /!6" have $een reported $etween 44 and
9=3, and in women with normal ovaries $etween 2C and 9=3, Decently a pregnancy rate per
em$ryo transfer as high as &43 and implantation rate of 4F3 was reported after IV8 and
$lastocyst transfers in highly selected cases%
It has $een estimated that appro7imately 29== IV8 $a$ies have $een $orn worldwide, $#t the
$irth and perinatal o#tcome of only some ?== $a$ies have $een reported% Deports on o$stetric
and perinatal o#tcome of IV8 pregnancies show very few complications% /remat#rity occ#rs in ?'
29 3 of the pregnancies which is no different from spontaneo#s pregnancies% )his is tho#ght to
$e associated to fewer m#ltiple pregnancies compared to standard IVF treatments%
!ryo$iology
)heoretical $ac+gro#nd
)emperat#re is a meas#rement of internal energy in a physical system% It is this internal energy in
the system that allows molec#les in fl#ids to t#m$le, twist, disassociate themselves from each
other, move from place to place in the fl#id, and to chemically react with other molec#les% As the
temperat#re is lowered, energy $ecomes greatly red#ced in the system, there$y failing to
facilitate these types of molec#lar motions%
As descri$ed $y /olge et al%, in 2@?@, the first h#man sperm cells were s#ccessf#lly cry
preserved% )he process of crypreservation incl#des initial e7pos#re to, and e,#ili$ration with the
cryoprotectants, cooling to s#$zero temperat#res, storing, thawing, and finally, dil#tion and
removal of the cryoprotectant with ret#rn to the physiological environment that will prod#ce the
possi$ility of f#rther development%
;vents B#ring Freezing
Freezing of any a,#eo#s system involves n#mero#s sim#ltaneo#s changes%
As the temperat#re is red#ced-
R Ice crystallizes
R Viscosity increases
R Demaining sol#tion is red#ced in vol#me, introd#cing the possi$ility that some
sol#tes may reach sat#ration and precipitate, or if containing gases, may form $#$$les
/arameters that are dependent #pon more than one of these varia$les (e%g%, pH or osmolality)
may change in a comple7, nonlinear fashion% When a cell is cooled at a temperat#re of $etween
'& and '2&o!, ice is formed first in the e7tracell#lar medi#m%
"ince the ice crystals are #na$le to cross the cell mem$rane, n#cleation of intracell#lar ice is
prevented% )he cytoplasm itself s#per cools, and then has, $y definition, a higher chemical
potential than the water of the partly frozen e7ternal sol#tion% "ince the cell mem$rane is
permea$le to li,#id water, $#t not to ice, water is eected from the cell at a higher region than that
of lower chemical potential, and freezes e7ternally%
If the cell is cooled at a s#fficiently slow pace, a massive amo#nt of water will $e transported o#t
of the cell, with a red#ced chemical potential difference across the cell mem$rane, res#lting in
progressive dehydration that ma+es formation of intracell#lar ice #nli+ely%

1asic Befinitions
!ryo$iology-
"t#dy of life at $elow'normal temperat#res% 5s#ally cryo$iology is considered as having the a$ility
to deal with the effects of freezing and thawing% However, any temperat#re $elow normal for any
given living system falls into the realm of cryo$iology%
!ryopreservation : A process of preserving and storing living systems in a via$le condition at low
temperat#res for f#t#re #se% )raditionally, the meaning of cryopreservation is Apreservation $y
freezing0, and the word is still #sed in many cases% However, the term can also $e #sed for
covering preservation $y vitrification, or ice'free cryopreservation%
!ryogenics- A $ranch of physics that st#dies the ca#ses and effects of e7tremely low
temperat#res%
!rystal- In many systems, e%g% p#re water, temperat#re red#ction $elow a certain point res#lts in
an a$r#pt reorganization of the fl#id medi#m into an organized solid lattice +nown as a crystal%
)his is recognized as freezing%
Vitrification ' /reservation at e7tremely low temperat#res witho#t freezing% Freezing involves ice
crystal formation< however, vitrification involves the formation of a glassy or amorpho#s solid state
which, #nli+e freezing, is not intrinsically damaging even to the most complicated living system%
Hlass )ransition )emperat#re- In other systems, this does not occ#r% Instead, temperat#re
red#ction merely ca#ses increased slowing of molec#lar motions, decreased molec#lar mo$ility,
and sl#ggish chemical reaction rates #ntil a critical temperat#re is reached% 1elow this
temperat#re energy is ins#fficient for the most mo$ile molec#les in the fl#id to move apprecia$ly
over the time scale of a typical la$oratory o$servation% At this Sglass transition temperat#re,T the
system loses its fl#idity almost completely and $ecomes a Ssolid li,#id,T more formally +nown as a
Sglass,T and is said to have Svitrified%T
Vitrification prevents damage related to ice formation% )his incl#des- mechanical disr#ption of
e7tracell#lar str#ct#res in organized tiss#es and organs, cell#lar osmotic dehydration and
shrin+age d#ring slow freezing, intracell#lar ice formation and destr#ctive intracell#lar ice
recrystallization d#ring rapid freezing and d#ring thawing, and e7pos#re to elevated intracell#lar
and e7tracell#lar sol#te concentrations that can prod#ce harmf#l effects or precipitate these after
e7ceeding their sol#$ility limits%
)he physical phenomenon of vitrification ta+es place when the solidification of the sol#tion occ#rs
not $y ice crystallization, $#t $y e7treme elevation in viscosity, where$y a vitreo#s consistency is
achieved and is very similar to that of glass% Vitrification re,#ires high cryoprotectant
concentrations, and high concentrations tend to $iochemically dist#r$ living systems, prod#cing
to7ic effects%
!ryoprotectants - When a cell is permeated $y cryoprotectants in concentrations high eno#gh to
facilitate vitrification, all the molec#lar constit#ents of the cell $ecome loc+ed into the glass as it
forms, and therefore over time are #na$le to change%!onventional cryoprotectants are glycols
(alcohols containing at least two hydro7yl gro#ps), s#ch as ethylene glycol, propylene glycol and
glycerol% )he to7icity of glycerol is temperat#re dependent%
Bimethyl s#lfo7ide (B8"6) is also regarded as a conventional cryoprotectant% )his is a low'
molec#lar'weight nonelectrolyte, that with slow freezing and slow thawing, s#rvival is $etter than
the #se of glycerol% Hlycerol and B8"6 have $een #sed for decades $y cryo$iologists to red#ce
ice formation in sperm and em$ryos that are cold'preserved in li,#id nitrogen% 8i7t#res of
cryoprotectants have less to7icity and are more effective than single'agent cryoprotectants% A
mi7t#re of formamide with B8"6, propylene glycol and a colloid was, for many years, the most
effective of all artificially'created cryoprotectants%
!ryoprotectant mi7t#res have $een #sed for vitrification, i%e% solidification witho#t any crystal ice
formation% Agents that red#ce electrolyte concentrations in the #nfrozen portion of the s#spending
sol#tion protect cells from freezing in#ry d#e to sol#tion effects% )hese cryoprotectants s#ppress
the concentration of salts as a conse,#ence of their colligative properties and the phase r#le%
!hilling or !ooling In#ries- )he nat#re of these in#ries is not #nderstood, $#t co#ld $e related to
lipid phase transitions, protein cold denat#ration, or other phenomena% )he factors primarily
responsi$le for freezing in#ry to cells are ice formation within the cell and sol#tion effects% )he
degree of cell#lar in#ry is determined $y the total vol#me of ice within each cell, rather than $y
the size of individ#al crystals%
)hawing- two pro$lems that occ#r d#ring thawing can red#ce the s#rvival of frozen cells, i%e%
recrystallization with intracell#lar ice formation, and osmotic shoc+%

6ocytes
When cells s#ch as oocytes are incl#ded, the system $ecomes m#lticompartmental, in which the
sections differ in content and are defined $y the properties of the $iological mem$ranes% )his
matri7 of inter'related phenomena sho#ld $e $orne in mind when eval#ating e7perimental
evidence on the efficacy of partic#lar cryopreservation regimes%
Introd#ction 6ocyte cryopreservation is an emerging technology with a promising f#t#re, $#t still
re,#iring m#ch developmental wor+ to improve the s#rvival rates and e7pansion potential of
frozen'thawed oocytes%
Indications for 6ocyte Freezing
R Improve the efficacy of IVF
R Alternative to em$ryo freezing
R 6ocyte preservation for patients with ovarian hyperstim#lation syndrome
R For oocyte donation programs
R For treatment of congenital infertility disorders
R )o prevent fertility loss thro#gh s#rgery
R For treatment of premat#re ovarian fail#re (/6F)
R In the case of patients who face infertility d#e to cancer therapy
B#ring the process of cryopreservation, cells are e7posed to a n#m$er of vario#s forms of stress,
which co#ld res#lt in lethal damage to the cell and incl#de-
R 8echanical
R )hermal
R !hemical
6ocytes in general are more sensitive to freeze.thaw damage than later em$ryonic stages% Any
change in the chromosomal complement (as may res#lt from scattering or displacement from the
spindle) co#ld res#lt in ane#ploidy, with potentially severe conse,#ences for s#$se,#ent
em$ryonic or fetal development%
6ocyte Freezing and "torage
H#man oocytes can $e stored as-
R Ben#ded individ#al oocytes at metaphase'II (8'II)
R !#m#l#s enclosed at germinal vesicle (HV) stage immat#re oocytes
)he protocol of freezing depends #pon the stage of n#clear mat#rity of the oocytes% When mat#re
8II oocytes are harvested, the gametes are commonly den#ded prior to freezing to confirm their
n#clear stat#s% However, it wo#ld $e physiologically far more appropriate to freeze immat#re
oocytes with intact germinal vesicles with their c#m#l#s cells for $etter in'vitro mat#ration after
thawing%
8at#re 8etaphase II 6ocytes
At this stage, oocytes have #ndergone n#clear and cytoplasmic mat#ration, the first polar $ody
has $een e7tr#ded and chromosomes are condensed and are arranged on the delicate 8II
spindle% 8at#re oocytes have a short fertile life, are very sensitive to chilling, and have little
capacity for rec#perating from the cryo'in#ry $efore fertilization% 6ther recent st#dies provided
improved res#lts with vitrification as an alternative to slow freezing protocols%
Immat#re Herminal Vesicle 6ocytes
Herminal vesicle'stage oocytes are f#ll'sized, $#t their chromatin is at the diplotene stage of first
prophase, and #nli+e mat#re 8'II'stage oocytes, do not have spindle apparat#s% )hey re,#ire a
period of mat#ration to ind#ce the re,#ired n#clear and cytoplasmic changes $efore $eing
capa$le of #ndergoing fertilization and s#pporting early em$ryo development%
;ffects of !ryopreservation on 6ocytes
!hromosomes and meiotic spindles comprise fragile fi$res originating from the centriole at the
opposing poles, and e7tending to the chromosomes% A loss of microt#$#les d#ring freezing co#ld
separate chromosomes and ca#se ane#ploidy% )he often red#ced percentage of fertilization, and
the rather higher incidence of anomalies and fertilization in cryopreserved oocytes, have $een
hypothesized as $eing related to possi$le damage of the zona pell#cidae and cortical gran#les
that interfere with the correct interaction $etween them and spermatozoa% I!"I has $een
proposed as a sol#tion for this pro$lem%
Heneral "afety Aspects
)he H#man 6ocyte /reservation ;7perience (H6/;) Degistry is an initiative of ;8B "erono, Inc%
which aims at systematically trac+ing the o#tcomes of oocyte cryopreservation cycles, and
validating the efficacy and safety of techni,#es to freeze and thaw oocytes%

"afety Aspects : !ryopreservation of 8at#re 6ocytes (8etaphase'II "tage)
/resence or a$sence of the c#m#l#s gran#losa cells d#ring the freezing process may have a
direct impact on metaphase II oocyte s#rvival after thawing% 8'II oocytes are v#lnera$le to cryo'
in#ry $eca#se the meiotic spindle, to which the chromosomes have $ecome aligned, is act#ally
temperat#re sensitive% 6ocyte freezing can therefore increase the incidence of ane#ploidy after
e7tr#sion of the second polar $ody thro#gh nondis#nction of sister chromatids% )his d#plication of
the cytos+eletal architect#re may also lead to a$normal cyto+inesis, retention of the second polar
$ody, and alterations in the organization and traffic+ing of the molec#les and organelles%
While the deleterio#s effects on the cytos+eleton as a res#lt of chilling may $e avoided $y
cryopreservation of HV, this has proved that the chromosomal integrity is not lost and there is no
damage to the spindles%
"afety Aspects : !ryopreservation of /rimordial 6ocytes )hese HV'stage oocytes appear to $e
less v#lnera$le to cryo'in#ry than 8II'stage oocytes, as they are smaller, lac+ zona pell#cidae
and cortical gran#les, and are relatively meta$olically inactive and #ndifferentiated%