1. Quality management in IVF to optimise embryo transfer results
James Catt PhD Adjunct Senior Lecturer Scientific Director Dept of Obs and Gyn Optimal IVF Monash University Melbourne Australia

2. Quality is about continuously rejecting the status quo and is a journey, not an end

3. Definitions Quality Assurance
Design of a process to deliver the defined product
In IVF lab = design of all procedures to optimise the chances of implantation

4. Definitions Quality Control
Examines the product during the process to ensure specifications are met
In IVF lab = monitoring individual procedures to meet expectations

5. Audits Third party monitoring of QA and QC
Auditor looks at procedure documentation and results

6. Summary Quality system - laboratory and unit QA/QC Staff education
Document Control
Risk Management
Audit cycle

7. Procedure design (QA)
Provide optimal conditions Equipment Ambient conditions Media
Embryo selection

8. Procedure monitoring (QC)Ie
What quantitative outcomes during the IVF process can be used to monitor the programme ?

9. Quality management of IVF instrumentation
Selection of appropriate equipment
Validation
Ongoing QC

10. Equipment selection Availability, reliability, service then cost
Central question to ask is ‘what happens if this piece of equipment fails?’ Backup!!

11. Selection: Should we believe the manufacturers?
All equipment comes with specifications. Do they truly reflect what the embryos experience?
Eg incubators
Where are the temperature probes?

12. Should we believe the manufacturers?
Behind here !

13. Validation: Should we believe ourselves?
Independent equipment eg thermometers, dataloggers, CO2 meters have to have calibration traceable to a standard

14. Dataloggers
Short, medium and longterm fluctuations occur in all equipment
Dataloggers measure these fluctuations and therefore help determine suitability of equipment

15. Center SE 309 4 channels 8 000 datapoints
Datalogger
Center SE channels datapoints

17. Standard Incubator Thermal image

18. Benchtop Thermal image

19. Validation: pH How do you measure pH ? XpH meter X Blood gas analyser
Colour
pH paper!!!!!

20. Paper into medium Read within 3 seconds
How do you use pH paper ?
Paper into medium
Read within 3 seconds

21. Validation: Toxicity testing
MEA?
Sensitized sperm survival assay (low protein or CASA)

22. EQUIPMENT QC: How often?
As much as necessary!
Tendency to over audit
Eg incubator

23. Incubator overaudit

24. Ambient conditions Equipment in, set up and monitored
What about laboratory conditions??
Gametes and embryos spent some time outside of incubators

25. Air purity Temperature pH
Ambient conditions
Air purity
Temperature pH

26. Volatile Organic Compounds (VOC)
Therefore particles per se are not detrimental until they have VOC adsorped onto them. Therefore should only need to monitor for VOC
Elimination
Filters or photocatalytic destruction

27. Ppm X
Ppb 

28. Data from clinic
16% FH/embryo ET
100 ppb
48% FH/embryo ET
100 ppb

29. Temperature Surprising where variation comes from !! Laminar flow
Stage warmers
Pipetting

30. Laminar flow
Temperature drop

31. Laminar flow

32. Stage warmers Stage warmers will not heat a dish for ~5 min !!
Petri dish
Air = insulation
Warm stage

33. Heat Transfer in Pipettes
(1) Liquid (37°C) into pipette
(2) Immediately heat is lost to the walls the pipette
Lab Air
(3) The surface of the pipette loses heat to the surrounding air
Line of symmetry 33

34. What to do ? Partial solution is to use plastic pipettes
Other solution is to control environment

35. Solution to most environmental problems – control the environment!

36. The forgotten Oocyte

37. The forgotten Oocyte Good oocytes make good embryos
Do NOT use simple media for oocyte recovery
Eg saline, PBS etc

38. Inadequate sperm Sperm have specific requirements
High glucose/fructose
High protein
Bicarbonate

39. Mixing media DO NOT MIX MEDIA !!
All have different components and will affect embryo homeostasis if mixed

40. Quality control to select the ‘best’ embryos
Objective outcomes
Consistency
Attainable goals

41. (hours post-insemination) Expected stage of development
Type
Timing
(hours post-insemination)
Expected stage of development
Fertilization check
17 ± 1
Pronuclear stage
Syngamy check
25 ± 1
Expect 50% to be in syngamy (up to 20% may be at the 2-cell stage)
Early cleavage check
27 ± 1
2 cell-stage
Day 2 embryo assessment
44 ± 1
4-cell stage
Day 3 embryo assessment
68 ± 1
8-cell stage
Day 4 embryo assessment
92 ± 2
Morula
Day 5 embryo assessment
116 ± 2
Blastocyst 41

42. Laboratory outcomes Average number of oocytes collected*
Average number of oocytes suitable for ICSI
IVF fertilization rate*
ICSI fertilization rate*
ICSI degeneration rate*
Syngamy rate (25+/- 1 hpi)
FH per embryo transferred*
Utilisation rates
Percent survival of thawed embryos*
FH per thawed embryo*
FH per transferred thawed embryo*
* Denotes suitability for individuals

43. Human Embryonic development
OPU
Fertilization
syngamy
Day 2 ET
Day 3
Freeze
D5/6
Day 5
Day 4

44. Consistency Good prognosis group
Age most important
‘Good prognosis ’ group should reflect the majority of patients and exclude the ‘difficult’ ones
Eg <39 and < 3 previous cycles

45. How do we measure the quality of oocytes entering our laboratories??
SYNGAMY (or early cleavage)!!

46. Oocyte quality
Early syngamy
40%
25%

47. Other factors affecting implantation
Day of transfer
Developmental stage

48. Results eSET (FH/embryo)

49. Conclusions
Single embryo culture and single embryo transfer has enabled important factors in embryo development to be identified
Early cleavage and blastocyst expansion are the best predictors for implantation
Implantation rates for eSET can exceed 50%

50. Cumulative pregnancy rates
The total number of fetal hearts from a stimulated cycle when both fresh and frozen embryos have been transferred

51. Results Day of pregs patients Cumulative Rate fresh ET 3 913 1393 66%% %
No significant difference

52. Conclusions
There is no decrease in the cumulative pregnancy rate with extended culture
There are no ‘extra’ pregnancies with extended culture
There are fewer transfers to achieve the pregnancy

53. QC Summary Know and control your equipment
Know and control your conditions
Quantitate your outcomes
Benchmark your outcomes