Hatching a Plan

Hello and welcome to another
episode of Hatching A Plan.

My name is Simon Tom.

I am Emma, the Embryologist husband,
and my name is Emma and I am.

Emma the embryologist.

Right.

Which is always a bit odd.

Yeah.

Well, you know, that's,
that's your official name.

Yeah.

Yeah, yeah.

We could change it by Deepak.

Yeah.

The surname, the . Embryologist.

Yeah.

The, yeah.

Anyway.

All right folks, let's dive into this.

, We've got a lot to cover today,
and it's an important topic.

We are going to discuss some unspoken
outcomes when IVF doesn't go to plan.

So what do we mean by that?

Well, we're gonna ask some questions.

Well, I'm gonna ask Emma some questions
and she's gonna take us through

her thoughts and her experiences.

Things like, what happens when IVF
stops unexpectedly before transfer?

What assumptions are
people making about IVF?

And the assumptions they might make
around how things are gonna play out.

I'm also gonna encourage Emma to
tell us what a typical process is.

, Go through the steps.

What is the IVF funnel?

And also with that funnel, we are gonna
look at some of the biological hurdles

that can happen with the IVF funnel.

So let's get stuck in.

So Emma, when some of your patients
or you see people on the internet

talking about IVF, what is it they
really mean when they say that?

Well, IVF stands for
in vitro fertilization.

So it is literally, in its
most literal sense it is.

Creating human life or the potential
for human life outside of the human

body in vivo means inside the body
in vitro means outside the body.

So in vitro fertilization is
outside the body fertilization.

Got it.

So that's what it is, but it's obviously
a lot more complicated than that.

So do you think, and correct me if
I'm wrong here, that it's like a

blanket term that covers everything
to do with fertility treatment?

Is that how it sort of, those people use
the term when they say IVF treatment?

I think it's, I think it's
used a bit too loosely.

My favorite thing that you
see is just do IVF, right?

There is no, just about IVF.

It's complex, it's nuanced, it's
layered, it's different for everyone.

Yeah, everyone coming to this has got
their own, they're all different people.

They've all got their
own individual story.

So it's not just,
there's no just about it.

It's, it's, it's tough.

And what would you say if someone
is very new to IVF, what would be

the typical process that you, you'd
say, this is what can happen, and

then this is what could happen.

Like how do you have that
conversation with a patient

when they're very new to it?

It's very overwhelming.

It's highly emotional and emotive.

We just gotta try and I suppose what we
try and do is break it down into stages

and try and get people to, to walk the
steps and just do it in stages rather

than trying to see it as this overwhelming
process, which it is, is trying to break

it down into the steps and the next
day and the next day and the next day.

So IVF is a, is a, is a stage where a,
a lot of the journey, once you start

the IVF post process, the patient is.

In control for a couple of weeks because
they are having to give themselves

medications to allow themselves
to be stimulated on these drugs.

What I call, what we, what we term
stimulation is we need to create

follicles on the ovaries that have
eggs in them that we can then retrieve.

That process takes between
two and six weeks, depending

on what protocol you're on.

And then.

Those eggs are harvested or collected,
however you want to term it, and those

eggs go into a laboratory where we live,
and that's where it gets really clever.

So when you say we, just to clarify,
that is the role of the embryologist?

Yes.

Got it.

So the doctors and the nurses
lead the bit before and then.

Once the gametes, gametes
mean eggs and sperms.

So eggs from the female, the biological
female, sperm from the biological male.

Those are your gametes.

They are used in the
laboratory to create embryos.

And then there is a pattern of
growth and development that gets

us to a point where we are able to
put embryos back in the hope that

we can achieve a pregnancy for you.

But it's, it's so much more complicated
than that, and I think that that

whole concept of just do IVF is.

Probably what this will all be about.

Yeah.

I got it.

So when you think about, and you talk
about this often on your Instagram,

when IVF stops unexpectedly,
what, what does that really mean?

Is that about some
hurdles that can happen?

Yeah, take us through some of those.

So I think the problem with.

The misunderstanding of IVF is that
it is just a straightforward process

that everyone's gonna get eggs,
everyone's gonna get embryos, everyone's

gonna have an embryo to transfer,
and then there'll be a positive

test and a a pregnancy at the end.

I think people are really aware that
they might not get pregnant from IVF.

I think that people are really.

They know that that is a
possibility that it, when they

talk about it might not work.

That is where people think it might not
work, that they won't get the positive

test at the end of the treatment.

It is a treatment, we call them cycles.

So every time you retrieve eggs
or you put an embryo back, whether

that's fresh or frozen, 'cause we'll
talk about frozen embryos as well,

is called a cycle of treatment.

Yeah.

For me, a full cycle of treatment
is when we are collecting

eggs and creating embryos.

Frozen embryo transfer tends to be a bit
different because you don't always need

all the drugs that you get in there.

And why would you do a
frozen embryo transfer?

What's that all about?

So if your first transfer, if you
have a fresh transfer off the back

of an IVF cycle doesn't work, we
freeze surplus embryos and then they

can be put back in future cycles.

Or some people will have, and this is
probably gonna be bonkers for people

listening to this, some people will
have actually two or three children

from one cycle of a collection.

So.

So it's about where I think
the misconception a bit is that

they, people believe that it is a
straightforward process that ends with

a positive or negative pregnancy test.

Right?

It, it is not that simple.

It's not, it just, it didn't work or
it did, there's between eight and nine

biological hurdles that have to happen.

Before we even get to the possibility
of you taking a pregnancy test.

And I think the shock factor that
comes with that ending before you've

got to that transfer process, that
completion of a cycle as people

perceive it, understandably so, is
what we need to unpick so that people,

because shock is, shock is awful.

This process is already really
triggering and really awful.

And actually, if we can try and.

And this isn't to scare people,
but it can actually fail a lot

sooner than the transfer stage.

So that's the reality.

That's really why we are
talking about this today.

Mm-hmm.

To set that expectation so
it's not a surprise or, or as

much of a shock as it mm-hmm.

Could be.

So when you talk about these biological
hurdles, you mentioned there's,

you mentioned eight or nine, so.

Take me through some of those hurdles and
like, are some more common than others?

Is it a certain demographic or age, or,
you know, I'm completely, I'm gonna ask

you some questions where I, you know,
I know nothing about these hurdles.

So what are, what are a, what are
the hurdles, and B, what factors

influence those hurdles from happening?

So the first hurdle is
probably the stimulation phase

is can you be stimulated?

Which means can we actually use
the drugs effectively to create

follicles that will give us eggs.

So some people will go in with the full
intention of starting a cycle of IVF, and

there's a lot of work that goes into that.

There's, especially if you're in the
NHS system, there's a lot waiting

to then find out that actually.

You can't even be stimulated.

Maybe your hormones are off.

Maybe something doesn't look
right, and it might be that month.

It might be all the months.

It might just be that it's not
the right time and we need to come

back to it in four to six weeks.

Whatever that looks like, that's, that's
for, that's, that's hurdle number one.

Can we even get the drugs to do
what they're meant to do, which is

stimulate the ovaries to give us a
group of follicles that is worth us

collecting In the aim of trying to
retrieve eggs that will create embryos.

That's one.

The second one will probably be
that you get to a point where you

are going into egg collection.

So it takes about two weeks to
stimulate the ovaries, and then we

go into an egg collection process,
which is normally like sedation.

It's a very straightforward process, so.

Anyone listening, you
shouldn't be scared of it.

I know it's really nerve wracking, but it
is actually very, very straightforward.

Takes about 20 minutes.

And then to wake up from that sedation and
find out that no eggs have been collected.

Hmm.

That must be heartbreaking.

Yeah.

Because we don't take people
to egg collection unless we

think we're gonna get eggs.

Yeah.

We, we wouldn't do that because that
would be an unnecessary medical procedure.

So we are, we we're 99% certain
we're gonna get eggs when we

take people to egg collection.

We don't, we don't do it otherwise.

So the demographic around
that is, that normally happens

when there's less follicles.

So if your ovarian reserve is low, and
we haven't been able to recruit as many

follicles, there is always, there is
always a risk that actually you can.

So to put it in as most basic form, to
be able to collect those eggs, we have

to make those follicles ripe and ready.

Think about it like seeds in
a fruit, and it sounds really

strange, but that's exactly what
the eggs are inside our ovaries.

And then to try and collect
those eggs, we have to trigger

the ovulation process to start.

And then we go in and harvest those eggs,
take those eggs before they are released.

Now, sometimes that timing doesn't
work for your body and actually you

do ovulate before you get into the air
collection room, so it tends to happen

more so with lower numbers of follicles
than bigger numbers of follicles.

So women that are advancing
maternal age or lower ovarian

reserve, so that's, that's sort
of biological hurdle number one.

I think that's one of the
biggest ones, actually.

I don't think people ever
expect that to happen.

Mm-hmm.

And is it, so your context is UK based
or, or your experiences has been in

the uk, however you are well connected
to the international world of IVF.

So for some of our international
listeners, are, are there subtleties

with that or would you say this is kind
of this, this happens across the globe?

Yeah.

Yeah, it definitely
happens across the globe.

I think it happens.

This is where we always come back into
our conversations about pa, patient like

context and patient like focus care.

I think it happens less when you are
heavily monitoring patients, and by

that I mean doing regular blood work,
making sure people have regular scans.

You definitely have less scans in the
NHS cycles because of the financial

implications of doing all those scans.

And you do in the private
sector, you will definitely have.

More scans in the US than
you will in other countries.

Yeah.

So yeah, that, that's definitely
leads into this happening.

Um, but no, this is, this is global.

This happens, this happens
all around the world.

And if someone, you know, what advice
would you give to our listeners where,

you know, what sort of questions can they
ask around this to give them confidence?

Like what, how could they get more
information from their clinic about

it, about this specific process within.

The clinic that they happen to be at.

So we, so you'll definitely
have, clinics will have their

own policies about who they will
and won't take to air collection.

So some clinics will have a minimum
number of follicles that they

want to take to air collection.

That might be three, that might be four.

Where I work, it's one, it's about,
you know, so that demographic and

also who are they treating, right?

You have certain patients that can't
access NHS funded treatment because

they are less likely to respond.

So maybe it doesn't happen as often there.

I don't know.

But that those patients end up in the
private sector a little bit more so they

can ask the question of what the clinic's
experience is of not retrieving eggs.

And the clinic should, and the
doctor should be very, very well

versed with what the percentage
chance of this not working out is.

And do those percentage
chances get published?

No.

No, no.

It's really interesting.

They don't get published.

We have to report on them in the
UK because we have to report on

cycles that we try or attempt an egg
collection on that don't retrieve eggs.

We, we definitely do have
to report on that and.

Who is the reporting body
that's asking for that?

The HFEA.

And what does that stand for?

The human fertilization and
embryology authority in the uk.

Got it.

And they, it's not, it's not a
bad, like, it's not a negative

thing, like, how do I put this?

It's not a, it happens.

It does happen.

I'm not clinical enough
to know exactly why.

It always happens.

I see it happen, thankfully,
not very often, but it is.

Definitely hurdle number one.

Got it.

So another hurdle.

So you get eggs.

Yeah.

And those eggs go into the laboratory
and those eggs are not mature.

Now for fertilization to even
contemplate starting in the lab, you

have to have eggs that are mature.

And what we mean by eggs
being mature is when eggs are.

In follicles.

They are all immature entities
and the the drugs that we give

you grow these follicles and
thus mature the eggs within them.

And the trigger injection you're giving
then completes that maturation phase

so that the eggs you collect in the
laboratory and then go into the laboratory

should be what we call metaphase two eggs.

I'm not gonna go into what that means.

It's sounds very sciencey.

It's really sciencey and I could
be here all night talking about it,

but it's to do with the maturity.

So eggs have to be mature to fertilize.

Whether that maturity happens at the
point of recollection or it happens within

a couple of hours of the egg retrieval
process, they tend to do quite well.

People will read about things
called in vitro maturation.

Again, this is new technology.

I haven't got time to go into it.

It's not overly, we haven't done
a lot of work and it's in the

research phase at the moment.

And there has been some success with it.

But as a rule in an IVF
clinic, eggs need to be mature.

So that we can as embryologists work with
them to allow fertilization to happen.

So I think, I don't know
if that's worse or better.

I don't, I don't know if any of this
is worse or better, but to get eggs and

then be told none of them are usable.

Yeah, that's, that's pretty awful.

That's heartbreaking.

And that either happens on the day
when you've had the collection,

if you're doing ixy or it happens
the day after if you've done IVF.

'cause we won't know until the next day.

That's brutal.

That is brutal.

I was gonna ask, actually, you reminded
me, should I ask you more about timings

of when these things happen or when
you get an indication of problems?

Like is it normally it's on the
same, so you trigger a patient 36

hours before, 35, 36, 37, depending
on clinical reasons before you take

them to the air collection process.

And then so trigger, what do you mean?

Say trigger?

Trigger is when we inject a drug
to mature the follicles that we

have grown for the past two weeks.

Got it.

So that's the end of
the stimulation phase.

That's the last thing the
patient's in control of.

I think it's the one thing that
is, it feels real to the patient.

'cause after that it
gets handed over to us.

And does the patient trigger
themselves or, yeah, it's an injection.

They little I inject, yeah, the
nurses will do if you need them

to, but, and it's normally done
at like 10, 11 o'clock at night.

So it's normally done at home.

And what's the drug?

Is it always the same or does
it depend on No, it's, no, no.

I, oh, no, we haven't
got time to go into that.

Okay.

Right, right.

Folks, that's gonna be another episode.

There's no, no, no.

And actually you're gonna have to
get someone like Ed Coates to do that

conversation because actually that's
a very, like, why you trigger with

different drugs is a very doctor.

I, I understand.

I understand that.

So that's a clinical doctor.

Absolutely.

Specialism.

So yeah, it's all to do
with what patient needs.

So you want you to stay in
your lane and not go there.

I'm gonna stay in my lane
and ask Ed to do that one.

Got it.

For folks who know Emma she's a big
advocate of certain roles within the

fertility world, staying in their lane.

Uh, which is a good thing 'cause that's
sort of saying these professionals

are a, are a group of experts on lots
of particular topics, and, and they,

they should be the people that, that
share the advice and recommendations.

Hence why Emma being a specialist,
embryologist is able to talk about

what she's talking about today.

'cause she knows it and lives
it and breathes it day in,

day out for many, many years.

So yeah, it's kind of get, I guess
my point is get advice from people

who have authority to share advice.

That's the point you're making.

The drugs.

Yeah.

Always the drugs.

Anything really, you shouldn't
be, you can't get embryology

advice from your mates.

You can't.

No.

You really can't.

And you could try.

I know, and everyone's got
a different IVF experience.

If someone will say something like.

Oh, well in my IVF cycle this happened.

And it's like, well, that's very
nice, but that's not your context.

So, so context is so important like that.

I want a t-shirt with
context written on that.

Yeah, I think, I think you
should, context is key.

Context is key.

Everyone's context is different.

So, and how do you, is is that
just based on like data points,

so many different data points that
allow you to establish context.

You're such a tech geek.

Um, we don't talk about
patients as data points.

Well, no.

Okay.

Okay.

I don't mean it like that.

I mean like, not the
patient is a data point.

I mean, like a variable, like my
assumption is there's a whole ton

of variables and if variable A,
B, C, and H exists, and therefore

you go down this certain route.

Yeah, for sure.

It's, it's a decisions.

Very, very few patients
all fit into the same.

That's what makes our job so interesting.

Yeah.

Yeah.

Anyway, crack on.

Okay, crack on.

So let's, uh, let's go through
another biological hurdle.

So you've got eggs and you've
managed to get mature eggs, and we're

either doing IVF or ixy depending
on what your treatment plan is.

And there's lots of reasons that
we choose one over the other.

I have particular thoughts that maybe
we should do a whole podcast on about

why I'm actually a big ixy advocate.

I think it's an incredibly safe process.

And then the next stage, and actually
there's probably one in the middle here.

Because we're focusing
quite heavily on the female.

There is, there is a hurdle, and
that is getting sperm because we

have to have sperm to create embryos.

Mm-hmm.

Now, most of the time, this
is not an issue at all.

We, we know what we're going to, we,
we've already assessed the male or the

donor in this, in this treatment journey,
and we know what we are expecting.

But I would be lying if I have,
don't say that there has been days

where I have had eggs and no S foam.

Alright.

Okay.

So what happens when that happens?

So you either get a, the male partner
is unable to produce on the day,

which is pretty awful for them.

Nice.

Oh, that's tough.

And that doesn't happen
very often, but it.

It does happen and you actually do
get the odd occasion where the male

in the relationship is able to produce
and there is no sperm in the sample.

Yeah.

We normally know that that's a risk and we
normally do frozen backup, which is when

we'd bring them in before to do freezing.

But I have, I could tell the story.

I had a, a case once, my God,
I'm going back 15 years and.

The man in the relationship.

It was a heterosexual couple coming for
IVF, and he was so petrified about being

able to perform on the day that he went
to see, I'm gonna use the word rogue

doctor, right, who gave him an injection
of testosterone to help his libi.

Wow.

Okay.

Testosterone makes you sterile.

I was gonna say it.

That's the opposite, right?

I'm not.

I'm so this doctor.

Yeah, zero scientist.

But I'm sure it works
the other way around.

So, yeah.

'cause your body's got like a natural
balance of hormones and if you give

a guy testosterone, the brain thinks
they've got enough so they stop.

Yeah.

Producing testosterone and that stop.

And he didn't have any sperm on the day
and it was it anyway, it was crushing,

but it doesn't happen very often.

But it's definitely worth
mentioning that it on occasion.

It does happen where you can
actually have eggs and no sper and

for same sex couples donor root.

Yeah.

That donor donor will guarantee
that a sperm, uh, there's

no such thing as guarantees.

Okay.

IVF doesn't have guarantees.

Right.

But you are.

I've never, I've never in my entire
career come across a donor sample that

hasn't thought well enough to use.

Yeah.

And that's on the donor bank itself.

Mm-hmm.

To provide sperm that will will.

Yeah.

Will be not successful.

Wrong use will be able to be used.

Yeah.

Yeah.

I've never, I've never
had that problem before.

Yeah.

Okay.

I'm sure it's happened, but I, in
24 years have not had that problem.

It's always been, I, I've sometimes
gone from IVF to iy, which means I

maybe haven't had the numbers I thought
I was gonna get, but I've, I've always

had some very quickly, for listeners
who dunno what ixy is, gimme a.

One liner.

What is Ixi one liner about?

The most complicated process that we
do, um, is when we are able to use

very, very small numbers of sperm.

'cause we are able to isolate the
sperm one at a time and inject them

into the egg to create fertilization.

There you go.

One liner done.

Is that straightforward?

Right, tshirt.

Okay, well let's, let's jump
back into these hurdles.

So, what, what from your experience,
experience of of patients kind

of gone Ah, that's a surprise.

We didn't expect that.

No one told us that would
happen, but it did happen.

No, mature eggs is definitely
one of those things.

The next, so because we don't talk about
it and it's so niche in the lab that

we just don't, it's just not something
that comes up that often, honestly.

And it's so hard to describe.

And it doesn't ha in, in all honesty,
it doesn't happen very often.

It tends to happen when you've
got one, two, or three eggs.

If you can imagine.

The lower the, the cohort.

The more so in any group of eggs,
for example, if I got 10 eggs,

I'd expect eight to be mature.

Right.

Okay.

It's about 80% normally.

And that's, that's quite, that's
quite normal across the field.

So if you collect one or two,
then if you get both of them are

mature, then that's it of I see.

So it, so it's, it does definitely
become, there are definitely genetic

conditions that cause problems with
maturity in women, and you do get

women that come through like repeatedly
and have no maturity and then.

That's really challenging.

'cause that's normally a biological
intercourse that we can't,

we, we, we can't always fix.

That was gonna be my next question
for those people where it is, you only

collect one or two and both are immature.

Mm-hmm.

Then what?

So we will keep them overnight and see
if that, we can mature them in the lab

overnight, but realistically, even if
they do mature overnight, we can then do.

An IIE process on them overnight, uh,
the next day so we can keep 'em 24 hours.

But the outcomes are normally quite poor.

It's what we call Dixie Day after iie.

Ah, right, okay.

Yeah.

Yeah.

So that's another term I
think we need to get on.

The glossary.

The glossary, Dixie?

Yeah.

So folks who are unfamiliar, Emma
has a wonderful glossary on her

website, Emma the embryologist.com.

Look for the post that says, words
you might hear in an IVF clinic.

It's a big old glossary with
lots of lots of fancy words.

Emma's written it to debunk a lot of
assumptions about certain terminology.

So do go check it out.

And if you know, if you do have
a question about any of this.

I would say get in touch with
Emma through her Instagram.

Mm-hmm.

At Emma the embryologist.

So next hurdle would be fertilization.

So when embryos to create embryos,
we have to achieve fertilization.

And fertilization is the stage that
the egg and the sperm come together

and they, it normally happens
between 16 and 22 hours after you've

either done the IVF or the ixi.

You can see fertilization.

And it's normally the
presence of two nucleuses.

One comes from the egg, one comes from
the sperm, and that leads us into a visual

tick box that we have got fertilization.

It needs to be said.

I've done quite a lot of
work on this on Instagram.

I'm not gonna go into it now.

There is lots of variations of
what fertilization looks like.

Ultimately, the aim is to keep
everything until you are sure.

That the embr, I either hasn't
fertilized or it's not viable.

So failed fertilization is a real thing.

It is.

I can honestly say it's one of
the hardest phone calls to make.

I bet.

In certain cases, in one egg cases,
in two eggs cases, for example,

you are having that conversation
quite soon because you're up against

sort of an 80%, again, a statistic.

You're coming up against a statistic
and you can only roll the dice.

In favor so many times.

So, but failed fertilization
happens if you do.

I believe if you do IVF
without thinking beyond.

So IVF is when you mix the sperm and
the eggs together and you hope that.

I, I don't like the term nature because
at the end of the day, this is happening

in an incubator in a plastic dish.

I do not believe we can mimic exactly
what happens inside the fallopian tubes,

but IVF is the mixing of sperm and eggs
together, and then you close the incubator

flick on some berry white and off you go.

Don't, but you kind of do.

Um, and the next day we
look for fertilization.

Now in couples that aren't conceiving
or have never conceived, I would

move towards IIE quite quickly
because I don't want to make.

A failed fertilization phone call.

And it isn't notoriously that if it's
not in low egg numbers, you do tend

to see failed fertilization in high
egg number patients where you've got

a history of no conceptions at all.

And ultimately what you're doing then
is diagnosing the cause of infertility.

I don't need to diagnose
your cause of infertility.

I need to make you some embryos.

So if I've got concerns that
IVF isn't gonna work, I will

move to XXI quite quickly.

That is not, that is,
that's, what's the word?

That is not a popular opinion.

Interesting.

So as, so popular opinion, I'm assuming
with your industry, not your patients.

'cause the patients were
like, do whatever it takes.

I assume the study, the studies show that
there's no difference between IVF and xe.

I, I genuinely believe that you.

Will end up with 5% of your IVF
patients having failed fertilization.

If you just, if you just blind blanket
IVF for everyone that's got a normal spam

count, you will that, that is the stats.

You will have a 5% failed fertilization
and I don't want to have to make

five out of a hundred phone calls.

Yeah, because they are
awful to make I bet.

And they're awful to be
on the receiving end of.

I absolutely can imagine.

And if that's your only NHHS cycle.

That's it.

My next question around that is the
constraint where clinic will, will go

down the IVF route 'cause it's cheaper.

Is that the reality?

Yeah.

I mean, ixy is something that we are all,
you know, not all embryologists can do.

Ixy.

It's something you learn in about
your fourth or fifth year of training.

Okay.

So it's not, not like.

You come out of embryology
school and you're like, yeah,

I can do Ixy embryology school.

I love that.

It is embryology school.

Yeah.

No.

So no, they, they don't normally
come out trained in Ixy.

They normally do their ixy
training after they've qualified.

We've got a program in the UK called, the
Scientific Training Program is different.

The, the training process for
embryologists across the globe

is, is notoriously different.

But in the uk they won't come out trained.

No.

They'll come out embryology trained, but.

Ixy something that takes a length of
time to train in to be competent in.

And even then it takes months
to become like validated in.

Yeah.

So, but failed fertilization
can happen with Ixy as well.

I'm not, I'm not taking away that at all.

But it is that, is it that,
that's, that's the end.

You can try something called Rescue xy.

If you've had IVF and there's no
fertilization, but again, you're

dealing with exit at 24 hours old.

There's, there's lots of
variations of this rule.

I'm not, I'm not gonna go
into rescue ixy too much.

It, it can be done successfully.

It's a very, very viable thing to do
if you've got failed fertilization.

But it's notoriously less successful
than getting fertilization from the

offset on that day of a collection.

So when you say that's it, you're done
of that cycle, you don't mean done, done.

No, you can never, no, no, no, no.

I mean, so because there's
still hope for someone to try.

So there'll, that will definitely be
people listening to this that have

had failed fertilization with IVF
and then get told, oh, that's okay.

We'll just do XXI next time.

Right.

And that will fix the problem.

Right.

For me, that's, I, I wish we never
had to get there in the first place.

Yeah, yeah, yeah.

Sometimes it's completely
unavoidable that sometimes we, we

have no idea this is gonna happen.

But how do you identify that?

How could you identify that before?

I think if you've got a young couple with
no known fertility issues that have been

trying to conceive at regular intervals
and have all have done everything right,

and it's been three years without a single
conception, I, I would be doing ixy.

Ah, I see what you mean.

Okay.

I wouldn't, I wouldn't be playing
that game of Russian roulette.

So you understand.

Again, it all comes back
to understand that context.

To help you make a decision whether they
go II straight away or try IVF first.

Some people feel really strongly
about IVF and that's absolutely fine.

Yeah.

Um, and I don't think it's risky.

I just think that the stats tell
us that 5% of IVF cases will end

up with failed fertilization.

That's, that's fact.

Yeah.

Okay.

So let's move on to another hurdle.

Tell us about another one.

So you fertilized, you got the
call to say they fertilized

and then the following day.

They haven't divided.

So what embryos should do is they
should fertilize and then they

should start to form embryos.

They should start to form cells because
ultimately what happens with fertilization

is these two nucleuses fused together
to create an entire new entity.

And then that.

Initiates the start of cell division.

Now embryos are just cells
dividing at the very beginning.

They're not differentiated.

That means that the none of the cells
have a design of what they're gonna be.

They're literally just
trying to get bigger.

They're trying to make more cells.

So in about 24 to 30 hours after you have
put sperm and eggs together, however that

came about, you should get your first,
what we call cleavage division, which is a

cell that goes from one to two, which is.

Absolutely mind boggling
that that happens.

Blows my mind.

And then it goes two to four, I mean
four to eight, and then it carries on.

What?

Yeah.

It's quite, quite, does it,
does it still blow your mind?

Yeah.

It's like fireworks and everyth.

No, it's not.

Um, when you see it right, and you can
see that in whether you are, you are

seeing it on a time lapse or however
you see it in your lab, it must still

blow your mind that that is happening.

Yeah.

Wild, wild, but it doesn't always happen.

And again, now come back to
our low numbers of eggs again.

So we've managed to jump all
these hurdles with our low number

of eggs, and then there's no
division or no positive division.

Again, you can have aberrant
divisions, which means that

they don't divide normally.

And there is a, there is a thing
right at the beginning of embryo

development where if an embryo goes
from a single cell straight into

three, it's called a multipolar
division that is actually embryo fatal.

So it's, they can't recover from that.

So that failure at that point
almost just feels really cruel.

That's harsh.

You see it a little bit more
in frozen eggs, actually.

So frozen eggs, if you're using
thawed eggs for treatment.

The, we call them failure to cleave
division, however you wanna use it.

Cleavage is probably a Latin word,
but we use that term quite a lot.

Um, and you see it a little bit
more in frozen eggs because freezing

damage eggs, eggs are unfortunately
very difficult to freeze.

So you can get freezing damage that shows
itself by them not being able to, they can

fertilize, but they can't go any further.

Um, so you see it a little bit more in
frozen eggs than you do in fresh eggs.

90, over 90% of, if not over 95% of
fertilized eggs in a fresh scenario, fresh

means collected, fertilized will divide.

But yeah, they're pretty awful phone
calls to make as well, because those

are the phone calls that the phone
rings and no one's actually expecting

to hear from you because they just
think, oh, I'll just wait to hear.

The things are moving
in the right direction.

We're getting to blast assist.

Everything's good.

So, yeah, that doesn't happen
very often, but it does happen.

So at Blasis, I've mentioned it.

Mm-hmm.

So no, blaster assist
is another one, right?

Yeah.

So Blaster Assist is the stage that
an embryo has to reach to make you

pregnant, to be transferred to, so I,
I'm not taking, so you can actually

put embryos back before the blaster
assist stage, but ultimately they will

still have to form a blaster assist
inside you to make you pregnant.

You can't jump past that stage.

And, and what day or hour is this from?

So day, we call it day
five, day six, day seven.

That's what we call our blaster
stage in the lab actually days.

Mean very little to us.

It's, it's all to do with the
hours since embryos were created.

So 115 to 123 hours is what we would
term a day five blast assist stage.

I love that.

It's that short window of hours.

Well, it's the eight hour day.

Right.

But if you, if you, I always say
to, someone asked me the other day

is I had a four cell on day three.

Is that normal?

And I said, when on day three?

Because actually if you had a three
o'clock ixy and then someone phoned you at

eight o'clock on the morning of day three.

That embryo is not
anywhere near 72 hours old.

It's actually about 58 hours old.

Yeah.

So it's a completely different,
so it's to do with, yeah.

So ultimately embryo should be
reaching or reached blasts stage

around day five, sometimes day six.

And we actually keep them till day seven.

They are less likely to work
the longer they take to grow.

Right, because that is more in keeping
with if an embryo is struggling to

develop, that's more in keeping with
genetic abnormalities, et cetera.

So

we can get in on the morning of day
five and realize very quickly that

there are no developing embryos.

Or we may think that they are developing,
but they need another day and then

they stop overnight or ultimately.

There are a number of cycles in
any clinic that will not have blast

cysts at the end of that culture.

And that I can guarantee you
in the UK that is not because

they're in the incubator.

I think that needs to be
said as loudly as possible.

I think that people blame themselves
for allowing embryos to stay in the lab.

I see.

It's, it's not, they're,
they're inside a shell.

They do not need a blood supply.

We can support them and there's
nothing wrong with putting

embryos back early, but.

It won't ultimately change
the overall outcome because

the embryo still has to grow.

And you can understand if someone does
receive that call that they're gonna

be like, ah, well, what could have I,
what could I have done differently?

Is it my fault?

Is it my mistake?

Or is it something the lab
did that was incorrect?

And this is where time-lapse is
really powerful because actually

with the time-lapse, which is the
videos that watch the embryos grow,

you can start to see why that failed.

And so the next time you can
then make a better conversation.

You can start, you can make assumption.

So you can definitely see the embryos.

So for example, in a young couple
where they all reach day three

beautifully, and by beautifully I
mean two, two cells, four cells, eight

cells, these normal division patterns.

And then they start to really deteriorate.

And the reason I use the word in young
maternal age is because I'm not expecting

genetics to be a problem at this stage.

I would then start to.

Heavily look at have we
investigated the man properly?

Is there something that we're
missing in the male side?

As women age, their eggs become
less genetically competent.

And what you see is again, this
failure to grow to blaster stage

because the blueprint isn't correct.

And the blueprint, I mean, is
the genetics inside the embryo.

Nature's actually very
good at quality control.

It sounds really sciencey
and without emotion.

And I'm putting emotion in
a box in a corner somewhere.

Yeah.

Yeah, I get that because.

It's very good at quality control.

It is trying to stop you becoming
pregnant with abnormal embryos.

Mm-hmm.

And sometimes we see it in the lab.

I got it.

That's, those are really, really awful
phone calls to make because you've come

so far and you've been waiting, waiting
for this phone call for five days.

It must be absolutely heartbreaking.

How, honestly, how do you, how do you make
that call and, and deal with the emotion

you're receiving from a patient as well?

Um, you get quite used to knowing
very quickly what the patient's

need is at the end of the phone.

Yeah.

And a lot of that is, I'm
giving you a lot of information.

I normally, I tend to phone
people back in a couple of hours.

Yeah.

As in you tell them the bad news
and you say, I'll call you back.

Well, just.

Yeah.

Yeah.

Make some phone calls
and Yeah, go back to it.

Yeah.

It doesn't get any easier, even
after 25 years, it doesn't get

easier to make those calls.

No, I can imagine.

That's, that's really, but it's
much harder to receive them.

So we, we are actually trained in this.

Yeah.

Well, we do, we do get there.

Is it, would it be considered like,
um, breaking bad news courses?

Breaking bad news?

Yeah, yeah, yeah.

We do have courses on it and
stuff to try and help us because.

Doctors obviously get that quite
routinely in their medical practices,

but it's something that we've campaigned
for quite heavily with embryologists.

Hmm.

I make sure all of the girls
in my team, I say girls, 'cause

my team is entirely female.

Yeah.

Have this with a, they, like
counselors do it, clinical

psychologists do it and they help us.

So it's important.

It's important that you get the
right level of training to deal

with those difficult conversations.

Yeah.

Yeah, for sure.

They don't, they don't, you
think about them all the time.

They're not, they're
not easy calls to make.

Mm-hmm.

Solid humans.

All of you embryologists out there who
are listening to this full respect.

Okay, so let's go back to
another biological hurdle.

Where would you like to go next?

Well, I suppose we get to the, the,
the end point where you've had.

You know, you've got these embryos
and it might be that you're having

a transfer of one of those blast
assists and that, that I think is

a very succinct part of a cycle.

It's a completion to sort of many
people, is to get to that transfer point.

But a lot of people now are coming to
this journey a bit older, and when I

say older, I'm talking about female age.

The average age that I work with is 38.6.

As we become older females,
we are more likely to have.

Genetically abnormal embryos that either
result in no implantation or miscarriage.

So we are doing a lot of PGTA
testing now, which is the testing of

embryos for chromosome copy number.

And so we would send off, if a, if
a patient does create a group of

embryos or even one embryo, we will
take a sample of those cells and

then run a genetic screen on that.

And I'm not talking about genetic disease,
I'm talking about the basic chromosome

copy number, the things that cause.

We use Down syndrome 'cause
people know what it is.

Yeah.

So that's three copies of Chromosome 21.

You can also have Edwards syndrome.

People might know what that is.

That is three copies of chromosome 18.

It actually happens to every chromosome.

They just don't all have names.

Yes, I see.

So three copies of
chromosome one does happen.

The most likely outcome of that,
from my understanding, is you, you

could transfer that embryo and you
would end up with a negative test.

They don't tend to keep going
because chromosome one is such a

big beast and it's got a massive
thing to do with development.

But when we do PGTA on
embryos, we see these entities.

So they don't all have names, but
they are always 90% of the time,

they either result in incompatibility
of ongoing human life or.

Severe disability apart from sex
chromosomes, which I won't go into,

but yeah, it's, it's, so, PGTA is
something we're doing on embryos now,

and so patients are, I think when you've
got an older patient and you've got

less embryos, then we are very much.

We are have, we're not.

We're not, we are always trying to
manage expectations, but I had a

patient just recently who had eight
beautiful day five, I mean, very good

quality embryos on the blasts stage,
and they all came back abnormal.

Wow.

Oof.

And that is unusual.

Yeah.

But again, it happens.

And I think that that is, that can
be, you've come so far by that point.

Yeah.

And then I suppose the final hurdle, which
for me actually is probably the hardest

hurdle is a patient that has come all
this way and maybe only has one embryo

that is usable for whatever reason.

And then it is frozen because
that's a lot of the cycles now that

we do are what we call freezes.

We've seen quite a nice correlation.

It it is, again, it goes back to
what I was saying earlier about

staying in my lane about protocols,
but there are certain protocols

that do not allow us to do an embryo
transfer in the fresh scenario.

And there are certain protocols that
do, and I'm not gonna go into that.

But you've come all this way, you've
got your frozen embryo, and then it

doesn't survive the freezing and thawing.

Yeah.

Geez.

That is incredibly rare around
blaster assist are incredibly robust.

They're incredibly tolerant.

We, the UK routinely use vitrification
now, which is a process to freeze

embryos, which is incredibly successful.

But you will always have that
odd embryo that doesn't survive.

There's always gonna be an outlier, is
what you say.. And that's really cruel.

And again, with all of these situations,
you then assess what happened.

You try and pull in as much
data as you can and then

offer options to that patient.

Yeah.

As to what I think their
next cycle options are.

Is it simple as that?

Oh, for sure.

For sure.

If the, if the hurdle was like
failed fertilization and it was

IVF and we know we can do ixi, then
yes, of course there's, there's.

Answers.

But I think the hardest bit about
our job and for the patients is

we don't always have the answers.

Yeah.

Sometimes we sit there and we
actually use the phrase, I hate it,

but it's, I just don't know why.

Wow.

And that's, that's the reality.

And this isn't meant to scare people.

It's meant to prepare.

And actually I, I think this is a
sort of episode that people going

through IVF should allow other
people to listen to because it's.

It's just not that straightforward.

As you have some eggs collected, we put
an embryo back and everyone has a baby.

Yeah, yeah.

I get, and it's so much more
successful than it used to be.

When I started doing embryology.

We were, which was when?

Which year?

Oh God.

I could tell everyone my age, um, 2000.

Three.

Amazing.

I started doing embryology 20, amazing.

Three years ago, 23 and
a half years ago, nearly.

Um, so no icky at that
point, or it just started?

No, I, we just started doing iie, but we
were really, really reluctant to use it.

And we were, we couldn't grow
embryos to the blasters a stage.

We were, we were only getting
them to day two and day three,

and then shoving loads back.

And that's why our multiple
pregnancy rate was 30%.

Oh, of course.

Yeah.

So there was lots of twins and triplets.

Twins and triplets.

Yeah.

Um, but actually the pregnancy rate
overall was around 15, 20% per cycle.

And now we're knocking 50 odd
percent in the right situations.

So, you know, we've come here, we've
come so far and we know so much more.

And all of these things that I'm
talking about are rarer by the year.

Like we're definitely starting
to and I'm definitely a bit more

about trying to work all this out
before anyone starts treatment.

Yeah.

Because I genuinely believe
that you shouldn't be using

IVF as a diagnostic tool.

We shouldn't be, we will learn
things unfortunately, but.

We should try not to learn if
we could have learn before.

Brilliant.

Okay, folks, well thank you for tuning
into this episode of Hatching A Plan.

Maybe we could end on
a, a couple of things.

Do you have a good news story to
share fairly recently that happened?

Yeah, I've had some amazing wins recently.

I, I wondered actually whether I
should start doing these as case

studies, like, just to give people
some really incredible hopes.

So, for people that don't know, I'm
actually a genetic disease expert.

So my, my background is I've got
a degree in biomedical science.

I've got a master's in human reproduction,
but I've also got a postgrad in genetics.

So I look after all the
genetic disease cases in.

My clinic, the Eve.

Well, and very, very recently, I've had
one of the nicest people I've ever met.

She's got breast cancer and she
carries a gene that is what we

call dominant, which means 50% of
her embryos will have this gene.

Now, most genetics are quite
straightforward to find it in the

embryo, and this one has taken us over
six months to create something that

will allow us to test her embryos.

And we are on Sunday now.

And on Friday I found out that she had
four embryos she could use that will

remove this disease from her family.

Wow.

And we've been through a lot together.

So yeah, I opened the
results and burst into tears.

I phoned her and she burst into tears.

So yeah, that was my good
news story this week.

I dunno.

That's awesome.

But there's lots of them and they
need celebrating and they are.

Because it's tough.

Some of it's genetic diseases are really
tough, especially when you have relatives

that have passed away from these diseases
or you've lost babies from these diseases.

So they're always, they always sit quite
deeply emotionally with me, to be honest.

I get it, of course.

And tell us a little bit
about Fertility action.

So what is fertility action
first and what's been happening?

So, fertility Action is the
charity that the wonderful Katie

Rollins set up who, if anyone gets
the opportunity to speak to her.

She is just a powerhouse of a
human, and she asked me to join the

charity as the chair of trustees.

To which I literally went, I'll, I'll
literally do anything for you, Katie.

Um, so Cha Fertility Action is a
relatively new charity, but within

12 months we have managed to make
some serious waves in Parliament.

We are trying to advocate for
patients in the space of funding NHS

funding for fertility provisions.

And it, it's, it's a battle.

It's a real battle because there
just isn't enough money in the NHS

to support patients like we want to,
the nice guidelines say three cycles.

There are now, apart from in the
Scottish contingents part of that part

of our uk, they're the only people as,
as far as I know now, offering three.

So we are trying to.

Change that and we've got a massive
fight on our hands, but it is a charity

that we are working to get money into.

So if you can chuck a five in any
pots, it's great because everything

we're doing is so fertility action.

Also offering support groups, um,
free accessible support groups and

there are lots of different supports
as a trying to conceive group.

There are a group of
positive tests and beyond.

There is a southeast Asian group.

There is lots of different groups.

That Katie has together with
clinical psychologist forms so

that people can access other people
going through the journey at the

same time and get some support.

Brilliant.

And if folks wanna learn more
about that, they can head

over to fertility action.org.

That's fertility action.org.

Okay, everyone.

We're gonna wrap up today's episode.

Thank you so much for listening.

If you have any thoughts or feedback, do
get in touch with Emma via her Instagram.

And if you're not signed up to
the newsletter, I do recommend

that if you head over to emma the
embryologist.com., Pop your email

in there, and whenever Emma posts.

A helpful article or a link to a new
podcast episode, you will receive an email

to let you know that that's happened.

It's definitely worth checking out.

There's some really good resources
on there already, including that

glossary that we mentioned earlier on.

Do go check it out.

It's emma the embryologist.com.

Okay, we're gonna sign off for today.

Any final thoughts, , good luck everyone.

We're in it with you.

That's what I would say.

Absolutely.

Take care folks.

We'll speak to you soon.

Bye for now.