I never understood the presumed science behind embryo grading. In fact the 'science of embryo grading' may be an oxymoron. Embryo grading is theoretical but not scientific. It is my experience that embryo grading gives patients fall hopes and also lowers hopes of patients inappropriately. There have been many 4 cell embryos transferred on day two back in the 1980's in the U.S., which resulted in live births. There are many 6 cell embryos with up to 25% fragmentation which yield live births. There are countless grade A blastocysts which do not yeild a pregnancy or do, but with resultant miscarriage. Yes, if an embryo has > 45 or 50% fragmentation it can be safely assumed that won't result in a pregnancy or live birth. But without such an extreme presentation, it is really not possible to predict an outcome.
I would rather the 'line' that reproductive endocrinologists offer their patients be "we have transferred 3 embryos successfully into your uterus. In 2 weeks we will know if you are pregnant. Let's keep our fingers crossed and hope for the best." This way the patient has no expectation other than the fact that she will or will not become pregnant. This is an issue of 'patient management' and one, which in my opinion, should be adhered to.
It is possible to determine a poor embryo. For example a 3 cell embryo with 40% fragmentation probably won't yeild a pregnancy or a live birth. However, it is impossible to determine a good quality embryo if by good quality it means that a reasonable expectation of pregnancy can be expected. The underpinnings of what makes a good embryo good have yet to be parsed out scientifically. This is equivalent to an acupuncturist feeling a pulse and telling the patient that they are pregnant. The acuracy of this endeavor is rarely experienced. However, a very experience acupuncturist probably can tell by pulse palpation whether a patient is pregnant before a reproductive endocrinologist can prognosticate the outcome of an IFV ET based upon visual inspection of an embryo.
The take-home message is this: do not be excited when you have an IVF-ET and your doctor raves about the beauty of your embryos just transferred, nor be dismayed when you are told that they are a grade C. You must clear your mind of expectation and 'be' and wait. It is very difficult to go through the day without an expected outcome. Expected outcomes are derived from your output which typically yeilds a result. This is an example of 'control' which we all thrive on and feel so lost without. In the case of IVF-ET your output nor that of your doctor has any prognostic value. You must 'be' and wait and have no expectation. You can hope; and that's it.
This is also the case of the endometrium. Your doctor will tell you that you have a "beautiful 10 millimeter lining." You are 30 years old and so is your husband. His sperm is healthy, you are hormonally within-normal-limts and both you and your husband are anatomically normal. You have tried to conceive for two years with intercourse, you have done 4 intrauterine inseminations and two invitro-fertilization-embryo-transfers and you have never gotten pregnant. There is a good possibility that your endometrium is defective and can only be properly diagnosed via an endometrial biopsy. Remember the things needed for a successful pregnancy and a live-birth are good egg, good sperm, good lining, anatomic normalcy and absence of pathology which can mitigate conception. Pathology which can mitigate conception is often under-diagnosed. A perfect example of this is endometriosis. The mean-time to diagnosis for endometriosis in 10.3 years. Imagine this: a couple is idiopathic meaning that there is no known casue for their inability to conceive. After multiple attemps via assisted-reproductive-technology-interventions the reproductive endocrinologist states "it's time for you to consider using a donor egg" You are devastated, but you MUST HAVE THAT BABY! So you proceed and the transfer is negative. Then, after six years of trying, a doctor recommends a diagnostic laparoscopy to rule out endometriosis and you are found to have stage four endometriosis which is why, all along, you have not been able to conceive. But now you're forty-years old. So even though the endometriosis has been resceted, you have 40 year old eggs and your chances of conceiving with your own eggs are about 8-10%. You were robbed of your opportunity to conceive becasue of the ultra-conservitism, ignorance or ego of your doctor. I am not suggesting that at the drop of a hat a diagnostic laparscopy should be scheduled. What I am suggesting is that many reproductive endocrinologists (just as is the case with acupuncturists and every other type of health-care-provider) are too conservative and think-out-of-the-box when it's too late.
I had a doctor tell me recently that mild endometriosis doesn't interfere with conception. This is not true; it does. "Endometriosis is likely the most the common cause of endometrial receptivity defects, especially in cases of minimal or mild disease for which mechanical reasons do not explain the loss of fertility." This is from the September, 2011 issue of Fertility & Sterility, Vol 96, No 3, page 524. When I brought this to the attention of the doctor, he replied with "Fertility & Sterility is a lousy journal." It is not. In fact, most American reproductive endocrinologists read it and respect it.
It is very difficult to find a good doctor in any field. I know most of them, especially in New York City. If you would like guidance in finding one with an open mind, an agressive outlook and that has you in mind rather than protecting his or her ego I wouuld be happy to offer it to you.
Mike Berkley, L.Ac., FABORM
http://www.berkleycenter.com/
212-685-0985
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