Canadian Infertility Awareness Week (CIAW) is April 24^th until April 30^th this year. This is an incredibly important week for the TTC community, a time for recognizing the unique difficulties fertility patients face and discussing for how we can collectively do better for patients building their families through fertility treatment.

Anova Fertility and Reproductive Health’s CEO Dr. Marjorie Dixon, REI, is the driving force behind Anova’s 4 fertility centres in the GTA and a former IVF patient herself. With 1 in 6 couples dealing with fertility issues in Canada, Dr. Dixon shares her insights with the Globe and Mail about the changes needed across the country for better patient outcomes by improving education and access. Read the full article.

Endometriosis is a condition where tissue similar to the lining of the uterus starts to grow outside of the uterus. Typically, it grows in areas like the ovaries, fallopian tubes, and the tissue that lines your pelvis, but cases have been found in nearly every organ of the body. Endometriosis can cause severe pain, especially when menstruating. Fortunately, there are effective treatments to help manage symptoms.

How does it happen?

The inner lining of the uterus, known as the endometrium, is a key player in the reproductive system. With each menstrual cycle, endometrial tissue thickens and renews itself in preparation to receive an embryo. During pregnancy, it provides an embryo or fetus with vital oxygen and nutrients.

While the tissue involved in endometriosis is not exactly endometrial tissue, it looks and acts similarly. During the menstrual cycle, this tissue can become inflamed and lead to swelling and scarring of the healthy tissue around the deposits. If affecting the ovaries, cysts can form called endometriomas.

Pain Management

Each case of endometriosis is different. Therefore, treatments that are effective in relieving the symptoms of one person might not have the same effect on another. It is important to work with a health care provider to develop personalized treatment plans that can help relieve your symptoms.

NOTE: It is important to remember that these therapies do not stop progression or offer a “cure” for endometriosis. However, they can provide a break in symptoms that patients might find helpful for their physical and mental health.

Below are 5 different ways to manage pain from endometriosis, from simple solutions to more advanced treatment options:

1. Heat and comfort: Applying heat to the lower abdomen by using a heating pad or taking a warm bath can increase blood flow and relax muscle contractions, both of which can help reduce pain.

2. Over-the-counter pain medication: Taking nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or other over-the-counter pain relievers can help during a flare-up. However, these should only be considered as a short-term solution as NSAIDs should not be taken more than 10 days in a row for pain unless directed by a physician.

3. Lifestyle changes: While the following lifestyle changes will not cure or reduce endometriosis, they might help ease some of the associated pain and improve mental health.

• • Exercise. Some studies show a moderate improvement in pain for individuals that engage in regular physical activity¹. As an added benefit, exercise has also been shown to reduce depression and anxiety². This is especially important as individuals experiencing chronic pain like endometriosis are at a higher risk of developing these conditions.
  • Diet. It is common for people with endometriosis to experience gastrointestinal symptoms like constipation, bloating, diarrhea, and nausea, which contribute to pain experienced with endometriosis. Some find that following a low FODMAP diet helps reduce these symptoms³. FODMAP stands for “Fermentable Oligosaccharides, Disaccharides, Monosaccharides And Polyols”, which are sugars that produce large amounts of uncomfortable gas when digested in the bowel and can cause gas, pain and diarrhea.
  • Stress relief. Stress can increase overall inflammation in the body, which might exacerbate symptoms of endometriosis. Reducing stress through things like yoga, getting good-quality sleep, and practicing mindfulness may be beneficial for those with this condition.

4. Hormone therapy: some hormone treatments have been shown to reduce pain associated with endometriosis

• • Birth control. Birth control. Contraceptives containing the hormones estrogen and/or progestin (the synthetic form of progesterone) can be prescribed to help lighten and shorten menstruation. Progestins alone, taken as a pill, injection, or intrauterine device (IUD), has also been shown to reduce endometriosis pain.
  • Gonadotropin-releasing hormone (GnRH) medication. Medication called elagolix (brand name Orilissa) suppresses the production of certain hormones from the ovaries, which stops ovulation and menstruation. This causes the body to go into a “menopausal” state and can slow the growth of endometriosis.
  • Testosterone therapy. While some think of testosterone as a ‘male’ hormone, all individuals have testosterone. The medication Danazol (brand name Danocrine) stops the release of hormones involved in the menstrual cycle to lighten or stop periods.

5. Surgical treatment: Studies show that certain surgical treatments can provide significant relief from severe endometriosis pain. Though, this is only a short-term solution. During surgery, a physician can examine the tissue growths and remove them if necessary.Physicians typically suggest the following surgical treatments:
   • A Laparoscopy is a minimally invasive procedure where the surgeon can remove the lesions and scar tissue manually or destroy them using intense, focused heat.
   • A Laparotomy is a surgical procedure where a large incision is made in the abdomen. This may be used if the lesions are too small to be seen through a laparoscopy.

   Some surgical procedures cannot be reversed and can impact fertility. Therefore, it is important to discuss all options with your healthcare provider before deciding on a treatment.

Takeaway

Everyone’s experience with endometriosis is different. While this condition does not currently have a cure, your healthcare provider can help develop treatment plans targeted to your specific needs and future family-building goals.

Resources & Support Groups

Endo Network of Canada

Endo Foundation of Canada

Nancy’s Nook

Endo Education Organization of Canada

Extra Pelvic Not Rare

Endo Support Group

Do you have more questions about endometriosis? Our fertility specialists are happy to answer them. Book a consultation today!

Each step of IVF treatment comes with new, important choices that must be made. One key decision is whether to choose a fresh or frozen embryo transfer.

Whether you choose a fresh or frozen embryo transfer, the initial steps of your IVF treatment will look quite similar.

In a “stimulated” IVF cycle, you will take medication that stimulates your ovaries to grow many mature egg follicles. Your cycle is monitored to watch the growth of the uterine lining (endometrium) and follicles.

When enough follicles are an appropriate size, your eggs will be retrieved in the clinic. For patients choosing a fresh embryo transfer, the uterine lining will also be evaluated to ensure it is thick enough to support the embryo after transfer.

The retrieved eggs are fertilized using sperm from your partner or donor and the resulting embryos develop for 5-7 days, with embryologists monitoring their growth and relaying information on their development back to you.

Now, you can either choose to:

• 1. Freeze the well-developed embryos in the lab for future use
• 2. Immediately undergo a fresh embryo transfer

Is one method more successful?

In 2016, the Canadian Fertility and Andrology Society reported on the success rates of fresh vs frozen embryo transfers in clinics across Ontario and Quebec. For each transfer method, the chances of achieving one live birth per round of IVF are reported in the table below.

(CARTR-BORN Database, 2016)

When looking at the above success rates, it seems that choosing a fresh-embryo transfer would be a no-brainer for individuals under 40 years of age. However, as expected, the decision is more complicated than this. Studies have shown that there are many reasons why a frozen embryo transfer (FET) might be more beneficial than a fresh transfer.

Ovarian Hyperstimulation Syndrome (OHSS)

Specifically, FET might be recommended for women at risk of developing ovarian hyperstimulation syndrome (OHSS), a complication of stimulated IVF cycles. Cases of OHSS fall into one of two categories: early-onset or late-onset.

• Early-onset OHSS can sometimes result from the medication used to stimulate the ovaries before an egg retrieval. While FET cannot prevent early-onset OHSS, it allows for time to manage the condition without impacting the pregnancy¹.
• Late-onset OHSS occurs after implantation and pregnancy and is caused by hCG release from the placenta. This type of OHSS is more likely to cause serious symptoms but can be almost entirely prevented through FET¹.

Polycystic ovary syndrome (PCOS) is a condition known to increase the risk of developing OHSS, so individuals with this condition may benefit from transferring frozen embryos. A 2018 study from the New England Journal of Medicine found that for PCOS patients, FET was associated with a higher rate of live births and a lower risk of OHSS².

The window of receptivity

Before egg retrieval, medication stimulates the ovaries to release as many mature eggs as possible. This process affects the timing of the “window of implantation,” which refers to the menstrual cycle days where the endometrium is ready to receive a fertilized embryo. This window usually falls about 8-10 days after ovulation. However, when the ovaries have been stimulated to produce many eggs, progesterone and estrogen levels can increase ten times higher than usual. The endometrium rushes to prepare itself to receive an embryo in response to these high levels. Studies have shown that this shifts the window of implantation, with it arriving sooner than normal³.

It is important to remember that even after egg retrieval and fertilization, the embryos must still develop for around five days before they will be ready for transfer. With a window of implantation shifted sooner than expected, the endometrium might not be receptive anymore, and the chance of implanting could be lower. Conversely, a frozen cycle allows the individual’s hormones to rebalance before transferring an embryo. This means that the window of implantation can return to its expected timing before transfer.

Are there any other factors to consider?

When making your decision on whether to pursue a fresh or frozen embryo transfer, you should first ask yourself some essential questions:

Does my clinic offer both options for transfer?

Many clinics universally recommend freezing embryos. This rest period allows the body to recover from stress associated with the procedure and pre-IVF medication to increase the chance of successful implantation. For this reason, not every clinic offers the option of fresh embryo transfer. If you are deciding between the two methods, you should first ask your clinic if both options are available.

Do I want to perform genetic testing on my embryos?

Embryos will typically need to be frozen if you elect to have genetic testing performed on them. Pre-implantation genetic testing (PGT), such as PGT-A or PGT-M, is a valuable screening tool to identify abnormal chromosome numbers or the embryo’s likelihood of developing a genetic disease.

What are my progesterone levels before egg retrieval?

As previously mentioned, high estradiol and progesterone levels before egg retrieval can shift the window of implantation. If you have an abnormally high progesterone level before your egg retrieval, your doctor may suggest a frozen embryo transfer to allow your body and hormonal balance to recover.

What will my embryo transfer process look like at Anova?

Anova Fertility offers both fresh and frozen embryo transfers. We encourage our patients to discuss both options with their physician, as one may be better suited to their fertility goals. Although there is a small chance of an embryo not surviving the thawing process, frozen embryo transfers have the added benefit of allowing the patient’s body to recover and the option to proceed with PGT-A and/or PGT-M testing. While both types of transfers are offered, it is highly dependent on the personalized plan created for you by your physician, with your best interest in mind.

Are you looking into IVF and have more questions about fresh vs frozen embryo transfers? Our embryologists and doctors are happy to answer them. Book a consultation today!

Thank you to Samantha Pena, one of Anova’s dedicated embryologists, for providing insights into what embryo transfers look like at Anova Fertility.

It is estimated that over 30% of couples experiencing infertility that are referred to a fertility clinic will be given a diagnosis of unexplained infertility. In short, this diagnosis means that the standard fertility evaluation did not show any abnormal results that explain why a patient is having trouble conceiving. On paper, the uterus and fallopian tubes look normal, there is evidence of consistent ovulation, and the semen analysis shows sperm of adequate motility and quantity.

For most individuals, this can be a frustrating diagnosis to receive, as it is both good and bad news. On the one hand, your doctor did not detect any abnormalities that would hinder pregnancy. However, treating infertility can be more difficult for doctors when there is no obvious problem to treat. In other words, if it is not “broken,” how do you begin to fix it?

What could be causing my unexplained infertility?

The factors investigated in a standard fertility evaluation are common culprits behind infertility, such as a partner having reduced quantity or reduced motility of sperm or the presence of a fibroid in the uterine cavity. However, other subtle defects can occur in the reproductive process for which there are no definitive tests. This can include factors like:

1. Oocyte quality or ovarian reserve: Both factors decline with age and are closely linked with fertility potential but cannot be directly tested. Oocyte quality is closely related to age. As one ages, egg quality declines. Ovarian reserve (or egg count) also is related to age but has much more variability even among women of the same age.
   • Note: An Anti-Mullerian Hormone (AMH) test can act as a proxy for ovarian reserve but is not part of the standard fertility evaluation covered by the Ontario Health Insurance Plan (OHIP).
2. Endometriosis: Sometimes, mild endometriosis can occur without obvious physical signs like tubal defects or abnormal tissue deposits. This may lead to trouble conceiving for some individuals but can be challenging to diagnose.
3. Autoimmune factors: where your body’s immune system perceives elements of its reproductive system as “harmful” and attacks them. This can prevent pregnancy from occurring.
4. Sperm DNA damage and other male factors: A typical semen analysis can give valuable information on the number of sperm, their motility, and their appearance. However, it has been shown that other factors, such as DNA damage, can impact fertility. Further testing, such as a DNA fragmentation index (DFI), can be ordered to gain insight into the integrity of the sperm’s DNA.

What are the treatment options for unexplained infertility?

Studies have shown that individuals or couples diagnosed with unexplained infertility have a significantly lower chance of achieving a pregnancy without treatment. After five years of trying to conceive, a couple diagnosed with unexplained infertility is estimated to have less than a 10% chance of achieving pregnancy on their own. This chance is compounded even more when the woman is older than 35.

Many of these couples opt for treatment to increase their odds. A randomized control trial called “FASTT” investigated which fertility treatments were the most successful for couples with unexplained infertility after three cycles: IUI + Clomid, IUI + gonadotropins or IVF¹.

The chance of pregnancy per cycle for each treatment was:

• 6% for IUI + Clomid
• 8% for IUI + gonadotropins
• 7% for IVF

This study found that if couples were unsuccessful after three rounds of IUI + Clomid, couples that proceeded directly to IVF treatment significantly saved time and money¹.

How can IVF explain some of my unexplained infertility?

In addition to IVF having high success rates for those with unexplained infertility, it may reveal more about why you’ve been having difficulties.

IVF is performed in a laboratory, which means that embryologists can monitor the entire fertilization and implantation process to see where the subtle defect might be occurring.

• Poor egg quality: In the lab, egg appearance is evaluated for the first time and can give us insight on egg quality. Frequently, we see that poor egg quality is behind recurrent failure to get pregnant without IVF.
• Pre-implantation Genetic Testing (PGT): New technology allows the lab to determine the genetic quality of the resulting embryo after fertilization has occurred. Many times, couples with unexplained infertility are found to be making an abnormally high number of embryos with poor genetic quality, which will impact their ability to implant in the uterus.
• Implantation issue: Alternatively, transferring a fertilized and well-developed embryo but still not achieving pregnancy could pinpoint the issue at the implantation step.

It is important to remember that unexplained infertility does not mean untreatable! Many of our patients diagnosed with unexplained infertility can achieve their fertility goals through different treatment options.

If you have any questions about unexplained fertility and how IVF can help, book a consultation today!

Dedicated to all the IVF warriors out there. We hope you enjoy this cute digital IVF warrior sticker pack, available for instant download and sharing 🙂

Download Sticker for WhatsApp and iMessages

Download on Giphy

The COVID-19 virus is known to infect and destroy many different types of cells, and new research suggests that infection may impact sperm quality.

Since the arrival of the pandemic in 2019, there has been widespread research on how the virus impacts the body upon infection. One area of research has focused on the impact of COVID-19 on male reproduction, specifically sperm quality.

How can a COVID-19 infection affect sperm quality?

Currently, there is no evidence that COVID-19 can spread through semen or vaginal fluids. However, it appears that infection with COVID-19 may result in a temporary reduction in testosterone levels and measures of sperm quality in some individuals. The level of these decreases seems to depend on infection severity.

One study by Holtmann et al. (2020) analyzed sperm samples from 18 patients one month after recovering from a COVID-19 infection and 14 control patients¹. They found that:

• Patients with mild infections that did not require hospitalization did not show any difference in sperm quality after one month¹
• Patients who had moderate infections showed a decreased concentration of sperm, less sperm per ejaculate and a general decrease in motility¹
• Up to 19% of COVID-19 patients experienced testicular pain, which may indicate viral orchitis (inflammation of one or both testicles)¹

While these are not typical symptoms of a COVID-19 infection, all of the above effects may be associated with reduced fertility.

However, is this decrease in sperm quality due to the virus itself, or does it have more to do with the body’s reaction to the virus? It turns out, infections such as human immunodeficiency virus (HIV), STIs, urogenital infections and human papillomavirus (HPV) are also associated with a reduced quality or quantity of sperm².

When the body is actively fighting off a virus, it leaps into action and initiates the production of immune cells to fight the invading pathogen cells. These immune cells release “danger” signals that trigger inflammation in the body. While inflammation helps to join the fight against the pathogen, it  can also cause damage to healthy tissue. In the reproductive system, this might be the glands or tubes that help produce or transport healthy sperm cells and seminal fluid². This is why infections triggering significant amounts of inflammation may temporarily harm sperm production and function.

How does this affect individuals going through fertility treatments?

There is no question that the pandemic has tremendously impacted fertility care, whether it be due to cycle interruptions, extra mental health burden due to restrictions, or other measures. However, there is one significant concern among fertility care teams: does COVID-19 impact male and female reproductive health? More specifically, is there a risk of COVID-19 cross-contamination in the embryology lab?

Fortunately, studies have found that the COVID-19 virus is not found in semen or vaginal secretions. In a fertility clinic setting, this means that there is likely little to no risk of cross-contamination³. This is good news for medical team members because if cross-contamination was possible, eggs could become infected in the laboratory, or eggs/embryos might infect others while being stored frozen.

The COVID-19 vaccine doesn’t appear to affect sperm quality – why? 

One driving force of vaccine hesitancy is the fear that it may negatively affect fertility. However, infection-associated changes to sperm quality were not seen after the mRNA vaccine.

As the vaccine is mRNA-based and does not contain a live virus, these results are intuitive. The COVID-19 vaccines are designed to stimulate an immune response and a “memory” of infection without contracting a COVID-19 infection. The immune response triggers the production of immune cells specifically designed to attack an actual COVID-19 virus. These cells then circulate, lying in wait for a virus to enter your system. As these immune cells do not mount an attack without an invading virus, they should not cause damage to reproductive tissue, and thus sperm quality and quantity should not be affected.

To avoid potential infection-associated effects of COVID-19, every individual is recommended to be vaccinated against COVID-19 if they are able to. Given a possible association between a COVID-19 infection and reduced sperm quality, it is especially important that those who are looking to conceive are vaccinated against the virus.

In recent weeks, the highly contagious Omicron variant of COVID-19 virus has resulted in a surge of new cases across Canada. Unfortunately, these numbers are expected to continue to rise in the coming weeks. At Anova, the safety and health of our patients and medical team is our top priority.

Firstly, we are happy to announce that all fertility services will remain available at Anova clinics throughout January 2022. However, we have updated our safety measures in the clinic to better protect our staff and patients, in accordance with new public health guidelines:

• Additional protective measures: Staff members who cannot maintain a 2m distance from patients are required to wear an isolation gown, N95 mask, eye protection, and gloves to minimize transmission.
• Rapid testing for staff: We will be conducting regular Rapid Antigen tests on all our clinic staff members.
• Mandatory vaccine policy to Anova staff– In addition to the existing precautions and safety measures we have implemented a vaccine policy for all of our team members.
• COVID-19 Screening – All staff must complete COVID-19 screening forms daily before entering the clinic.

With these updates to our clinic processes, we are confident that we can continue to offer all fertility services while maintaining a safe clinic environment for patients and staff. As always, we will continue to monitor public health guidelines for any changes to required clinic procedures and update you accordingly.

For patients currently undergoing treatment, help us keep the clinic a safe environment by:

• Self-monitoring for COVID-19 symptoms and completing our required pre-screening forms before appointments. Please do not come to the clinic if you are experiencing any symptoms or are feeling unwell.
• Getting vaccinated to decrease your risk of developing a severe COVID-19 infection and reduce your risk of transmission. Recent public health initiatives have expanded vaccine eligibility, and we encourage all of our patients (whether they are trying to get pregnant or are already pregnant) to book appointments to receive their 1^st, 2^nd or booster dose when available.
• No guest/visitor policy – In compliance with public health guidelines, we continue to carefully minimize the number of people in our clinics at any given time. To mitigate the risks of exposure for everyone, we continue to enforce a no visitor policy in all our locations.
• Personal safety measures – We encourage all our patients to maintain social distancing, practice good hand hygiene and be diligent about social gatherings. All patients will be required to wear a medical face mask at the clinic. If a patient arrives without a suitable mask, a medical mask will be provided.

We greatly appreciate your continued patience throughout this new phase of the COVID-19 pandemic. We know that things such as reduced capacities and frequent changes to clinic procedures can make an already difficult fertility journey even more stressful. Please know that we are doing everything in our power to make your journey as smooth as possible while ensuring that you remain safe and healthy.

We look forward to helping you achieve your fertility goals in 2022!

FAQ

Take a look at the Q&A below and see if your question has been asked before

Why is the Omicron variant of COVID-19 so contagious?

There are a few reasons why the Omicron variant is more contagious than past variants of COVID-19. Firstly, the mutations that have occurred in the virus have allowed it to be more efficient at infecting individuals and replicating itself. So far, the Omicron variant appears to result in more mild symptoms than previous variants. Initial research suggests that this may be because the virus cannot infect the lungs very well, so it typically stays in the upper respiratory system¹. However, it is unclear how this variant will affect the unvaccinated population.

Can the COVID-19 vaccine affect the menstrual cycle?

When COVID-19 vaccines became available to the public, some individuals noticed changes to their menstrual cycle. Some found that their cycles were longer or shorter than usual or noticed slightly more cramping. Researchers sought out to investigate if this was a true phenomenon. A recently-published study by Edelman et al. (2022) did in fact observe a change in the menstrual cycle after vaccination against COVID-19, however the effect was small and only temporary². On average, the first vaccine dose appeared to be associated with a cycle length increase of 0.71-day and the second dose a 0.91-day increase². These effects appeared to diminish within two post-vaccination cycles². While this effect may be negligible for most, this is an important finding for those who rely on accurate menstrual cycle predictions to plan or avoid pregnancy.

Can infants and young children become ill with COVID-19?

Children of any age can become ill with COVID-19, but Ontario hospitals have warned of a recent increase in infant hospitalizations. While infants becoming sick with COVID-19 was a rare occurrence earlier in the pandemic, the surge in cases of the extremely transmissible Omicron variant appears to be affecting more infants and young children. Vigilance in monitoring yourself and your children for COVID-19 symptoms is crucial. For newborns, these symptoms may manifest as a runny nose, sore throat, fever, looking or feeling lethargic, dehydration, sunken eyes or producing less than 5 wet diapers each day. For children over 1 year of age, addition symptoms may include persistent fever, lack of appetite or thirst, vomiting, severe diarrhea, dry mouth and tongue or trouble breathing.

Can COVID-19 vaccination during pregnancy offer protection to my baby when it is born?

One of the best ways for parents to protect themselves and their child from COVID-19 is by getting vaccinated. This is especially the case for pregnant or breastfeeding mothers, as antibodies from the COVID-19 vaccine can pass to the baby through the umbilical cord and breastmilk to allow for some protection against the virus³.

When is the best time to get the COVID-19 vaccine during my pregnancy?

The best time to get the COVID-19 vaccine during pregnancy is now! Recent studies have found that pregnant individuals that are fully vaccinated (2 doses) pass COVID-19-fighting antibodies to their baby at the time of delivery, regardless of when they got their first dose^4,5. Those who received a booster in addition to their vaccinations demonstrated the highest levels of antibodies in the blood and umbilical cord. Although some individuals feel that they should wait until the third trimester to get vaccinated so that the antibodies are more “recent” when they give birth, studies have found that this is not factual. In fact, experts suggest that it is not advisable to wait until the 3^rd trimester to get vaccinated. Individuals who received two doses of the vaccine early in their pregnancy appeared to have more antibodies (and are better protected) than those who only received one dose in the third trimester.

Is the vaccine safe if I am trying to conceive, pregnant or breastfeeding?

Absolutely! Studies have found that the COVID-19 vaccine does not pose a risk to individuals who are trying to conceive or already pregnant or their babies. There is no evidence that the COVID-19 vaccination has any effect on male or female fertility, now or in the future. It is recommended that all individuals who are trying to conceive get vaccinated to protect themselves and their future baby from known adverse outcomes associated with contracting a COVID-19 infection. Vaccination builds antibodies that can not only decrease your risk of getting a severe infection but can also be passed to your baby through the umbilical cord and breastmilk for their protection upon delivery.

Incredible advances have been made in genetic testing technology since the 1950s discovery that one extra copy of chromosome 21 can cause Down syndrome, especially for prenatal screening. Read more to learn how screening an embryo’s genetics before a transfer can maximize your chances of a successful pregnancy.

How do genetic abnormalities affect my chances of successful implantation and pregnancy?

One way to gather information about an embryo’s health is by examining its genetic content. More specifically, looking into the number of chromosomes each embryo contains during early development. A healthy embryo should contain 46 total chromosomes, 23 from the sperm and 23 from the egg. This is referred to as euploid. However, if the sperm or egg have an abnormal number of chromosomes, the resulting embryo will also have an abnormal number, known as aneuploid. Most aneuploidies are lethal to a developing embryo and result in a failed implantation or pregnancy loss¹.

Aneuploidy can happen to anyone, regardless of age. However, it appears to be more common as we age. A 2013 study from Franasiak et al. determined that for women aged 26 to 37, approximately 2-8% of embryos were aneuploid. By age 42, this rate increased to 33% and at 44, 53%. With a significant impact on fertility, new technology has been developed that allows embryologists to check whether an embryo is aneuploid before transfer. This technique is known as Pre-Implantation Genetic Testing for Aneuploidy (PGT-A).

In addition to PGT-A, parents may opt to have Pre-Implantation Testing for Monogenic disorders (PGT-M) performed on the embryos to test for certain genetic disorders. For parents who are known to have conditions like cystic fibrosis, Huntington disease, Duchenne Muscular dystrophy, or sickle-cell anemia, PGT-M can be used to identify which embryos have received the gene associated with the condition². Embryos that are unaffected by the disorders can then be safely transferred.

Normal and abnormal might not be so obvious – what about mosaicism?

Not all embryos are deemed “normal” or “abnormal.” Sometimes, PGT reveals that an embryo is a mix of both or mosaic. There has been widespread debate as to what to do about embryos that fall in this category.

When an embryo grows and develops, one cell doubles its genetic content and splits into two genetically identical cells. By the time an embryo reaches the blastocyst stage, it is composed of over 100 cells! However, sometimes errors occur during cell division within the embryo, resulting in some cells being “normal” and others “abnormal.” So, what does this mean for the health of the embryo as a whole and its likelihood of implanting? At Anova, when our partner geneticists at Igenomix encounter mosaic embryos, they grade them according to the following criteria:

• If less than 30% of cells are abnormal, embryo is labeled “normal”
• If 30-50% of cells are abnormal, embryo is “low-level mosaic”
• If 50-70% of cells are abnormal, embryo is a “high-level mosaic”
• If more than 70% of cells are abnormal, the embryo is labelled “abnormal”

Typically, mosaic embryos are considered for transfer only if there are no other embryos available. However, there are some exceptions to this rule. In cases where the mutations could lead to a child with significant congenital abnormalities or health issues, embryos are not transferred, even if they are low-level mosaic.

How does PGT work?

 If you choose to have PGT-A or PGT-M performed on your embryos before your transfer, your IVF treatment protocol will largely remain the same. Retrieved eggs are fertilized using IVF or ICSI to create embryos and grown until the blastocyst stage. This occurs approximately 5 to 6 days after fertilization. At this stage, PGT can be performed on fresh or frozen embryos.

A tiny sample of cells is removed from the outer region of each embryo, which will form the placenta. Next, these cells are sent to a lab for genetic testing to determine which embryos are genetically normal. These embryos can then be used for an upcoming transfer.

How does PGT-A increase pregnancy rates?

For patients undergoing IVF treatments that have experienced recurrent pregnancy loss under 12-week gestation or recurrent failed implantations, there is a significant chance that it may be due to the transfer of aneuploid embryos. PGT-A allows aneuploidy to be removed from the equation, which typically results in significantly higher implantation rates.

 Unfortunately, PGT is considered a fertility add-on and is not covered by the Ontario Health Insurance Plan (OHIP). As PGT adds extra steps to a typical IVF treatment plan, there are associated costs that the patient must pay for out of pocket. However, PGT is generally considered cost-effective, as it can decrease the number of failed IVF cycles, saving patients both time and money.

Pre-Implantation Genetic Testing is not required in every case but can be helpful for patients who are experiencing recurrent implantation failure or pregnancy loss. It is important to speak with your fertility physician to determine if PGT could help you on your fertility journey.

If you have any questions about pre-implantation genetic testing, book a consultation today!

Across the globe, more women are choosing to delay having children. As ovarian reserve and egg quality are known to decrease with age, many opt to preserve their eggs for future use. Egg freezing allows autonomy over education, work or building relationships without pressure from a biological clock.  

Why should I freeze my eggs?

There are many reasons why an individual may opt to have their eggs frozen:

1. You are preserving good-quality eggs to use in the future¹. After age 35, there is a steeper decline in egg quality and number. For those 35 and older, the remaining eggs are more likely to have chromosomal abnormalities, affecting the chances of achieving a successful pregnancy. Egg freezing allows individuals to capture these eggs in their “younger” state to be used later.
2. You are undergoing gender-affirming hormone therapy¹. Many transgender or gender non-conforming individuals choose to undergo a medical transition like HRT. After approximately six months of testosterone therapy, ovulation and menstruation typically come to a halt. Egg freezing before HRT protects the eggs from any damage that may arise from gender-affirming HRT while providing individuals with a variety of conception options in the future.
3. You have a condition or are undergoing a treatment that can affect future fertility¹. Certain conditions and treatments can impact fertility, such as autoimmune disorders, stem-cell transplants to treat sickle-cell anemia, or chemotherapy and radiation to treat cancer. Many choose to freeze their eggs early in their diagnosis or before treatment to protect them from any damage.

At what age should I consider freezing my eggs?

Many have the misconception that egg freezing is only applicable for those in their 20s. However, this is not necessarily the case. A Spanish study by Cobo and colleagues (2016) investigated a group of 1500 women freezing their eggs for social reasons (not due to cancer treatment or other illness-related reasons) to discover the average ages that women freeze their eggs. Researchers found that the average age of these women was 37, with 63% freezing between ages 37-39 and 16% freezing over age 40. Interestingly, ages 26-30 only accounted for 1.6% of total women that opted for egg freezing.

However, egg freezing might look different depending on a patient’s age. Two of the most important factors determining success with the eggs in the future are:

1. The age at which you freeze your eggs
2. The number of eggs you freeze

As we get older, our egg quality declines and eggs become more likely to create aneuploid embryos, which are not usable for transfer. Therefore, physicians usually recommend that older patients freeze more eggs to increase the number of embryos eligible for transfer. In the previous study by Cobo et al. (2016), researchers found that women under 35 who froze 15 eggs had an 80-90% chance of achieving a live birth from the eggs². Conversely, for women over 35 that froze the same number of eggs, this rate dropped to 30%.

Knowing this, naturally, one might think that preserving eggs as early as possible is the best option. While this might be true if you have reason to believe you might need IVF in the future (such as the reasons highlighted above), most women in their early 20s have a large window of opportunity ahead to conceive naturally. If patients at this age were to freeze their eggs, there is a good chance they would not return to use them.

However, for patients who have difficulty conceiving later in life and require IVF, preserved eggs can save time and money. Younger eggs are more likely to create better-quality embryos, which can increase the likelihood of implantation. In the long run, these eggs may decrease the number of failed IVF cycles a patient must go through, as they are more likely to result in a successful pregnancy.

How does the process work?

After being referred to a fertility clinic, a physician will order a fertility assessment to determine if egg freezing is right for you. Here, blood tests and a vaginal ultrasound will help a fertility physician establish your unique fertility baseline. After your assessment, if you decide to pursue egg freezing, the whole process should only take two weeks.

For ten days, you will receive hormone medication that stimulates the ovaries to produce many eggs. The resulting changes to hormone levels can sometimes produce side effects such as nausea, headaches, bloating, fatigue, and bruising around the injection site. Occasionally, these injections can lead to a condition known as ovarian hyperstimulation syndrome (OHSS), where the ovaries swell and begin to leak fluid into the body. This condition can lead to more serious complications if severe and left untreated, so it is essential to discuss the signs and symptoms with your doctor before treatment.

When the eggs are ready to be extracted, egg retrieval is performed in the clinic. This is a quick process, usually only requiring 15-20 minutes under conscious sedation. During the procedure, a vaginal ultrasound is first inserted to visualize the follicles storing the eggs. A needle with a connected suction device is then used to harvest the eggs. Shortly after harvesting, the eggs are “vitrified” or flash-frozen in liquid nitrogen, using agents that protect the embryo from ice crystal formation. This process preserves the eggs and halts the aging process for later use.

If you return to use your eggs in the future, the process looks similar to a traditional IVF cycle. The frozen eggs are thawed, combined with sperm, and incubated to allow the embryos to develop. After approximately six days, an embryo can be transferred into the uterus. The remaining embryos can be refrozen for future use.

Is egg freezing a guarantee?

Like natural conception, not every frozen egg will become an embryo. Some will fail to pass the milestones that must occur before implantation. First, an egg must be successfully fertilized, and the resulting embryo must develop to the blastocyst stage. Even after passing these checkpoints, an embryo may still fail to implant. Therefore, most clinics typically recommend that younger individuals aim to freeze approximately 20 eggs. For individuals 35 and older, this number is generally even higher.

However, these numbers are not always realistic for every patient in one retrieval cycle, depending on their unique fertility baseline or the presence of other health conditions. Your fertility doctor will use information gathered from your fertility assessment to give you a better idea of what you can expect from your egg retrieval.

If you have questions about preserving your eggs or are interested in discussing your options with one of our fertility specialists, book your consultation today.

In-Vitro Fertilization (IVF) is a complex process that has seen significant advances in technology over the years. One emerging add-on is known as EmbryoGlue. This technique is used in the final step of an IVF treatment protocol, the embryo transfer, to improve an embryo’s probability of implanting.

The final and critical step of IVF treatment is the embryo transfer, where a fertilized egg is transferred into the uterus through a catheter. Here, a good-quality embryo and a receptive uterine lining (endometrium) can produce successful implantation and pregnancy, like planting a seed into the soil. However, if the embryo is genetically abnormal or if the endometrium does not provide a suitable environment for the embryo to implant, a failed implantation can result.

Many available “add-on” techniques to the IVF treatment protocol can be prescribed to give an embryo the best possible chance of implanting. Some methods aid the embryo itself, such as assisted hatching, while others involve improving the endometrial environment, like endometrial scratching.

What is EmbryoGlue?

Firstly, EmbryoGlue is not an actual glue! It is made from a substance called Hyaluronan, or hyaluronic acid. It is a carbohydrate naturally produced by the body, and while it can be found in every cell and tissue, it is most abundant in the skin, joints, and eyes¹. Hyaluronic acid functions to lubricate our joints, deliver nutrients to cells and hold moisture¹.

In addition to these locations, hyaluronic acid is also present within the fallopian tubes, uterus, and cervix¹. The substance helps to produce a thicker mucus, especially around ovulation¹. Notably, right before implantation, the uterus produces an abundance of hyaluronic acid. It is thought that this substance helps to encourage the development of an embryo after fertilization but before implantation¹. After implantation occurs, hyaluronan levels will fall back to normal.

This idea led researchers to consider that incorporating Hyaluronic Acid into IVF treatment protocols could aid embryo implantation due to its thick and sticky properties. Additionally, it could better mimic a real uterine environment while growing the embryo in the lab.

How is EmbryoGlue used in IVF treatments?

In an IVF treatment, a newly created embryo is grown in a complex liquid solution called a cell culture media. This media is full of nutrients that a developing embryo needs to survive and develop. If EmbryoGlue is used in the treatment, it will replace the traditional media. EmbryoGlue contains these essential nutrients and includes a high concentration of hyaluronic acid to mirror the high levels seen in the uterus during implantation². After implantation, Hyaluronan’s sticky nature helps the embryo better adhere to the endometrium, minimizing movement to increase chances of implantation².

Does EmbryoGlue work?

When EmbryoGlue initially became available for clinical use in 2003, it was met with conflicting scientific results on whether it truly improved implantation rates. Of research available so far, most studies have found that hyaluronic acid improved implantation and pregnancy rates^3,4,5,6,7,8, but some found that the use of EmbryoGlue did not produce significantly higher implantation rates^9,10. However, studies concluded that EmbryoGlue is a safe addition that does not pose a risk to the parent or the child born from the treatment.

The Human Fertilisation & Embryology Authority (HFEA) lists EmbryoGlue as “Amber” on its traffic-light system of rating fertility add-ons. This amber rating reflects that while the treatment is safe for both parent and child, there is conflicting scientific evidence as to whether it truly improves implantation rates.

At Anova, our doctors have had success with EmbryoGlue, especially in patients with recurrent implantation failure (RIF) or those with naturally lower levels of hyaluronic acid due to age. In Ontario, it is important to note that fertility add-ons such as EmbryoGlue are not covered by the Ontario Health Insurance Plan (OHIP) and require an additional cost. Therefore, we feel that it is essential to provide our patients with all available information to make an informed decision on the use of EmbryoGlue in their IVF treatment.

Should I use EmbryoGlue?

EmbryoGlue is not required for all patients undergoing IVF treatments. Instead, this treatment is only recommended to patients based on their medical and fertility treatment cycle history. It is important to speak to your doctor to determine whether EmbryoGlue could benefit your fertility journey.

To learn more about EmbryoGlue, book a consultation today!