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      • Egg and Embryo Freezing: Vitrification is a Giant Leap

      Dr. Geoffrey Sher Recommends

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      Freezing (cryopreservation) of human embryos has been around since the early 1980s but results have not been good. Conventional cryopreservation is a technique still being widely practiced by many IVF clinics. It involves slowly cooling down the embryo until it finally freezes. A major disadvantage of this aproach is that it causes ice crystals to form inside the embryo’s cells (blastomeres), damaging them and thus reducing viability.

      A few years ago, a breakthrough was reported in the embryo cryopreservation arena. Termed Vitrification, it involves freezing the embryo about 600 times faster than ever before. This ultrarapid process is so fast that it literally allows no time for intracellular ice to form. As a result, vitrification avoids trauma to the embryo. In conventional (slow) freezing, 20-30% of embryos do not survive the freeze-thaw, and those that do survive have less than half the likelihood of generating a pregnancy as do fresh embryos. In contrast, vitrified embryos have a better than 95% freeze-thaw survival rate, and a pregnancy generating potential that is comparable to fresh embryos.

      At SIRM, we have been using vitrification for a number of years to cryopreserve both embryos and eggs. When it comes to embryo cryopreservation, we freeze advanced embryos (blastocysts) almost exclusively, since our recent research has shown that embryos failing to advance to the blastocyst (day 5-6) stage are virtually always chromosomally abnormal (aneuploid). Because of this fact, it would be useless to store them or transfer them to the woman’s uterus. By waiting until the blastocyst stage to freeze embryos, we allow non-viable (aneuploid) embryos to be culled out, leaving only those with the best potential to be preserved for future use.

      Staggered IVF (St-IVF)


      This recent advance in egg/embryo freezing technology came at an opportune time for us at SIRM. We had been working on adapting a genetic testing process called Comparative Genomic Hybridization to check for chromosomal abnormalities in eggs and embryos, but hadn’t found a way to perform the testing in less than a few weeks. In order to use CGH to select chromosomally normal embryos for transfer in an IVF cycle, the turnaround time on the test would have to be less than 5 days. The only other option was to extract the genetic material from the egg/embryo, and freeze the egg/embryo while the test was performed. Prior to the introduction of vitrification, the freeze-thaw survival rate was not high enough to justify the risk of freezing. By combining the two technologies, we could use CGH to identify chromosomally normal embryos for transfer in an IVF cycle and give women a much better chance of having a baby. Enter Staggered-IVF…

      Staggered IVF is a form of IVF in which the cycle is split into two segments in order to allow time to genetically test the embryos for chromosomal normality.
      The 1st segment of the St-IVF cycle involves ovarian stimulation, egg retrieval, fertilization, biopsy of the day 3 embryo folowed by vitrification of all expanded blastocysts on day 5-6. After the blastocysts have been frozen, the CGH testing is performed on the genetic material.

      The 2nd segment of St-IVF involves preparing the woman and then transferring one or two CGH-normal blastocysts to her uterus at a time of her choosing (usually a few weeks or months later). Again, the reason for the delay in transferring the embryo(s) is due to the fact that it takes several weeks to perform CGH testing .

      While the treating RE might recommend to patients when their embryos should be frozen, it ultimately is the patients’ decision to make. Some RE’s recommend that fertilized eggs (pronucleates or zygotes) be frozen even before cell division takes place. Others prefer to freeze day-3 embryos. The argument given is that by early freezing, there will ultimately be more embryos available for post-thaw processing. While it is a fact that many zygotes and early embryos will not survive to the blastocyst stage, it is also true that those that don’t make it to blastocysts are almost invariably chromosomlly abnormal (aneuploid) anyway and would either fail to attach, or eventually miscarry if they do initially attach.

      All available evidence suggests that pregnancies resulting from warmed/thawed embryos are not associated with any increased risk of birth defects.

      How We Prepare and Conduct Frozen Embryo Transfer (FET) at SIRM


      Within a few days of starting her menstrual period, the recipient begins taking the birth control pill (BCP). 2-4 weeks later she overlaps the BCP with daily injections of a GnRH agonist (Lupron) for 2 days and the BCP is stopped . She continues taking the Lupron until menstruation begins (usually 2-3 days later), whereupon the Lupron dosage is lowered and twice weekly slow-release, intramuscular estradiol valerate (Delestrogen) is administered for about 10 days. The objective is for her blood estradiol (E2) concentration to stabilize at 500pg/ml-1000pg/ml and for her uterine lining to attain a 9mm thickness by ultrasound examination. In cases of inadequate endometrial thickening, vaginal Viagra suppositories are prescribed. This, by improving uterine blood flow will often improve the lining. Intramuscular and/or intravaginal progesterone is administered daily starting about 6 days prior to the FET and continued along with twice weekly intramuscular Delestrogen until until the 10th week of pregnancy or until pregnancy is discounted. Progesterone in oil (PIO) injections are not fun! They hurt and, while remaining the recommended treatment, some women will not tolerate this regimen. In such cases we often recommend vaginal progesterone (e.g. crinone 8%) twice daily.

      We recommend oral corticosteroid (dexamethasone or prednisone) supplementation throughout the FET cycle to try and improve immune-receptivity of the uterus. Administration of immunotherapy (with heparin/prednisone and/or Intralipid) is selective and based on a valid medical indication

      The thaw/warm of selected vitrified blastocysts is done several hours prior to the scheduled FET. The aim is to transfer one or two of these at a time.

      Blood pregnancy tests are performed 13 days and again 15 days after the first progesterone administration. Contingent upon the detection of properly rising levels of blood hCG levels and subsequently upon the ultrasound confirmation of a viable pregnancy, the administration of daily progesterone and twice weekly Delestrogen are continued until the completion of the 10th week of pregnancy. Needless to say, if pregnancy does not occur, is non-viable or is lost, all medications are appropriately discontinued.

      The introduction of Vitrification represents a major “paradigm shift” in the field of human In Vitro Fertilization (IVF). As a result, for the first time we are able to freeze and bank embryos safely and reliably.
      Vitrification has also vastly improved the potential to successfully bank human eggs. This when combined with the use of CGH on DNA derived from the polar body (PB) of the egg has allowed selective banking of only genetically “competent” eggs, thereby significantly enhancing the birth rate per frozen egg.

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      17 Responses to “Egg and Embryo Freezing: Vitrification is a Giant Leap”

      1. Hyeon Jeong says:
        July 5, 2009 at 5:46 pm

        Your post inspired me of a very excellent point of view to treat patients who repeatitively failed over 10 cycles. I'd like to try 20% intralipid instead of IVIG because one of my patients recently failed one more cycle with IVIG. 20% intralipid solution of 250ml/ a bag is available here, South Korea. Do you mix this solution in 500 cc normal saline or just give two bags?

        Reply
      2. Geoffrey Sher, MD says:
        July 7, 2009 at 11:08 am

        Thank you very much!

        We mix in 500CC NS.

        Geoff Sher

        Reply
      3. Kami says:
        July 24, 2009 at 12:47 pm

        Please correct me if I am wrong, but vitrification does not actually involve freezing – that is there is no change of state from liquid to solid, but rather an additive allows they liquid to become extremely viscous. Since there is no change of state, there is not the risk of ice crystals forming in the embryo.

        Reply
      4. Geoffrey Sher, MD says:
        July 24, 2009 at 5:41 pm

        That's about it!

        Geoff Sher

        Reply
      5. melissa says:
        November 18, 2009 at 6:51 am

        I would like to know if there is a minimum or an optimal time that embryos should be frozen before pursuing FET.

        I had ET in late September and have 3 frozen. The one embryo that was transferred resulted in an ectopic pregnancy. I have yet to have my first period since the emergency lap (38 days since last period, 27 days since lap)

        Is it normal for one's cycle to be out of whack after an IVF cycle and then an ectopic?

        I would like to try a FET in December (after one regular cycle) if possible.

        Your opinion is greatly appreciated:)!

        Reply
      6. Geoffrey Sher, MD says:
        November 18, 2009 at 1:01 pm

        There is no waiting period required and yes it is quite common to have irregular ovulation and disrupted menses after a cycle of stim.

        Good luck!

        Geoff Sher

        Reply
      7. melissa says:
        January 22, 2010 at 9:11 am

        I am posting again as I am about to undego my first FET, looking for some more advice. I need some help and have a two-fold question.

        Unfortunately, the lab and clinic do not use vitrification, rather the old-fashioned method. They also put all three of my remaining embryos in the same straw, but are only legally allowed to implant two. I am aware that there is less than a 50% chance that they will survive the 'freezing' and 'thawing'.

        I have been taking estrogen via tablet form and I went in for blood work and an ultrasound today (DAY 12) so I was surprised that my lining and my labs came back with results good enough (I suppose) to do the ET on Monday morning (making it DAY 15). I know that my clinic normally performs ET on day 17 or 18, so I am a bit confused. I have to start on progesterone suppositories today. Isn't this quite early or is it on contigent on my hormone levels and lining measurement?

        Also, please offer your opinion on the amount of time that a woman should remain prostrate after a transfer? In addition, how many days bed rest do you require that your patients take after transfer, after FET or fresh cycle. The info out there is very contradicting: anything from 2-3 days bed rest to no bed rest, but just no lifting, exercise or bending.

        Thank you so much, Dr. Sher!!!

        Reply
      8. Geoffrey Sher, MD says:
        January 27, 2010 at 4:21 pm

        What a pity your clinic does not vitrify embryos…but I guess that is "water under the bridge".

        I answered the rest of your queries elsewhere.

        Geoff Sher

        Reply
      9. Lori says:
        February 26, 2010 at 2:44 pm

        That you offer your time to answer questions for women wanting to be mothers is noble and kind. Thank you.

        I just wondered why a clinic would require 14 days to take the first beta test after a FET of a 5-6 day blast, as my well-known clinic in the DC/MD/VA area does? For my fresh cycle last year (which was successful but I lost my full-term son 8 hours after he was born due to undiagnosed vasa previa), I took my beta 13 days after a fresh 3-day transfer. I am scheduled to transfer remaining blast embryo from my batch last year on the 4th and have been told to avoid false negative, I had to wait for 14 days for beta this time. Confused.

        As I mentioned vasa previa, do you have any thoughts about the theory that it is more prevalent in IVF (though still obviously very rare) pregnancies? I searched Vasa previa on your blog and the SIRM site and didn't see anything related to that.
        Thank you again for your time and consideration.

        Reply
      10. Geoffrey Sher, MD says:
        March 8, 2010 at 10:50 pm

        Vasa Previa is NOT more common with IVF. The beta results should start coming in 1 week after a blastocyst transfer.

        Geoff Sher

        Reply
      11. Nwanyi says:
        April 25, 2010 at 8:41 am

        Dear Dr Sher,
        I lost 5 frozen blastocyst embryos because they did not survive the thaw. We were quite devastated! The clinic still uses the old freezing system. When I asked why they won't upgrade to vitrification, the doctor told me that he is afraid of DNA damage from vitrification. From what I have read, you use this method successfully. Is there any truth to the assertion that vitrification may result in DNA damage? Thank you kindly for your response.

        Reply
      12. Geoffrey Sher, MD says:
        April 26, 2010 at 4:34 pm

        That is regretable! No truth whatsoever in my opinion.

        Geoff Sher

        Reply
      13. the infertile breeder says:
        February 4, 2011 at 7:41 am

        Can embryos survive the freeze-thaw cycle more than once?

        We have 4 blastocycsts, frozen in pairs (vitrified). If we try for another child, there's no way I would transfer 2 blasts given our strong track record (3 SETs = 2 babies and one m/c). I wonder whether we could thaw 2 blasts (transfer 1 and refreeze 1) or thaw all 4 for genetic testing, refreeze and future SET. What would you do?

        Reply
      14. Tyler S. says:
        June 5, 2011 at 10:11 am

        lets say a lady does this. and they freeze 8 eggs. on the 1st try she gets pregnant. what do they do with the 7 other fertilized frozen eggs?

        Reply
      15. Me says:
        June 27, 2011 at 9:11 pm

        I recently moved from TX to CO and have 6 embryos sitting in TX. my doctor informed me today that since they used the vitrification process, the frozen embryos have no chance of survival during the shipping here and hence they wont release them. is this true? he mentioned something about using a kind of straw that does not permit the shipping. this is news to me as he never discussed this method of freezing with me.

        Reply
      16. Fran B says:
        March 13, 2013 at 10:43 am

        I’m 52 years old. I am using the donor eggs, and from 6 donor eggs only one gets to be blastocyst. So not too much chance. I used viagra 25 mg/ suppositoy 4 time a day and my thin lining still around 6.5, I also useed Estradiol 2 mg one tablet vaginaly and one per mouth with one baby aspirin/ a day. I did this therapy for 10 days and my lining did not get more than 6.5 or 6.8, my estrogen 170. Form yesterday my Doctor put me for another week on the same vaiagra suppository 100 mg/ a day and rise my estradiol to 4 mg vaginaly and 2 mg orally . Do you think there is any hope for me? Can I extend the Viagra therapy extend for another week or month? Please help me if there is anything else I can do?

        Reply
        • Geoffrey Sher says:
          March 14, 2013 at 5:35 pm

          Women who have been menopausal for more than 6 months will often have uteri that have shrunken (involuted), often to a third of their original size, and have thin endometrial linings that are resistant to growth in response to estrogen. In such cases, only through cyclical administration of estrogen over several months will such a uterus regain its regular size and the endometrium, its ability to develop and thicken adequately. Initially, (during the 1st few hormone replacement cycles, neither Viagra therapy nor increasing the dosage of estrogen will improve the lining. However after several months of HRT, the uterus will grow and the lining will become responsive to estrogen again.

          A menopausal woman contemplating an embryo recipient cycle (FET or fresh transfer of embryos) should always consider the possibility that through chronic estrogen deprivation, her uterus might not be able to permit proper implantation to occur and/or fail to accommodate a rapidly growing conceptus. This could prevent pregnancy from occurring or result in miscarriage, premature birth or intrauterine growth retardation. My advice to all such women is to prepare for the upcoming ET by first undergoing a few hormone replacement cycles in advance of the ET.

          Please go to the home page of this blog, (www.IVFauthority.com). When you get there look for a “search bar” in the upper right hand column. Then type in the following subjects into the bar, click and this will take you to all the relevant articles I posted there.

          1. Endometrial Lining and Viagra Therapy”

          2. “Egg Donation”

          Consider calling 800-780-7437 or 702-699-7437 to arrange a Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail.

          Geoff Sher

          Reply

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      My IVF Cycle Failed – What Went Wrong? Question #16: Why did my hCG levels stop rising properly?
      This is the 16th in a series of answers to common questions about failed IVF. Immediately following implantation, the root system (trophoblast) of the embryo begins to release the pregnancyhormone, human chorionic gonadotropin (hCG) into the surround... more
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      My IVF Cycle Failed – What Went Wrong? Question #15: Might My Mental State Have Played a Role?
      This is the 15th in a series of responses to common questions about failed IVF There is little doubt that stress and emotional lability plays a role in the normal physiological/hormonal regulation of the menstrual cycle.After all, Eskimos often stopp... more
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      My IVF Cycle Failed – What Went Wrong? Question #14: Could it Have Been Due to Inadequate Hormonal Support After the Egg Retrieval & Embryo Transfer?
      This is the 14th in a series of answers to common questions about failed IVF. In vitro fertilization establishes an abnormal hormonal environment in the uterus.In some cases (especially older women and those with a diminished ovarian reserve), high o... more
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      My IVF Cycle Failed – What Went Wrong? Question #13: Did the Number of Embryos I Had Transferred Play a Role?
      This is the 13th in a series of answers to common questions about failed IVF. Virtually everyone recognizes that pregnancy with multiples (especially triplets or greater) is associated with a high incidence of premature delivery that has serious cons... more
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      My IVF Cycle Failed – What Went Wrong? Question #12: Might the Timing of Embryo Transfer – Day 2-3 (Cleaved) vs. Day 5-6 (Blastocyst) Play a Role?
      This is the 12th in a series of answers to common questions about failed IVF. (Note: I’ll be hosting a live video chat on Aug. 2 on the topic of Failed IVF where I’ll discuss the issues addressed in this series of posts and take your ques... more
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