SART Fertility Experts - Behind the Scenes in the IVF Lab

The information and opinions expressed in this podcast do not necessarily reflect those of ASRM and SART. These podcasts are provided as a source of general information and are not a substitute for consultation with a physician. Welcome to SART Fertility Experts, a podcast that brings you discussions on important topics for people trying to build a family.

Our experts are members of SART, the Society for Assisted Reproductive Technology, an organization dedicated to ensuring you receive quality fertility care. Hi, this is Dr. Kelly Lynch. Welcome to SART Fertility Experts.

Today's guest is Dr. Sangita Jindal. Dr. Jindal earned her PhD in physiology from the University of Toronto, Canada and became a high complexity lab director in 1997. Dr. Jindal currently serves on the faculty of Albert Einstein College of Medicine as an associate professor and laboratory director in the Department of Obstetrics, Gynecology and Women's Health.

She has mentored grant-supported translational research projects for a number of trainees at academic programs and is also an off-site lab director of private and academic IVF labs across the country. Dr. Jindal was president of the Society for Reproductive Biologists and Technologists in 2011 and currently serves on the Executive Council of SART, SRBT and on the ASRM Practice Committee. Welcome, Dr. Jindal.

Thank you, Dr. Lynch. Pleasure to be here. Today's topic is about the reproductive biology lab.

Basically, what happens behind the scene in the IVF lab. Dr. Jindal, many patients choose an infertility program because they're referred to a specific physician, but talk to us a little bit about what they should look for in an IVF program. When it comes to the lab, what are these specific issues that patients should be aware of? So, the laboratory, to my mind, is the engine that drives the entire car.

It is the engine that drives the IVF program. So, the laboratory is really key to a patient's successful experience with an IVF clinic and with their physician. The physician is often backed by an excellent laboratory staff and protocols.

Laboratory professionals are very committed, actually, to patient care. Even if you don't meet lab professionals or speak with them directly, they are definitely there. They are trained professionals, and we can talk about training that they go through for this position.

Communication with the lab professionals, if you are able to do that, is very valuable. And it is, of course, with the hands-on technical experts. It's very direct communication with them.

So, that's always useful if you're able to communicate with the lab staff. Excellent laboratories follow their protocols quite strictly, I would say, with minimal protocol drift. The laboratories are adequately staffed, and they're able to troubleshoot patient samples, and they customize care as needed.

I would say the most important feature of a great lab versus a good lab is excellent communication. They communicate with their clinical team. They communicate with their lab team, often with the patient.

They work very diligently. They do not take shortcuts. Yeah, I think that's how I would describe an excellent IVF lab.

Thank you so much for sharing some insight into what happens in the lab. Our patients don't always realize exactly what is happening and who's working behind the scenes, because they may not have a tremendous amount of interaction with the lab. But can you talk a little bit about what a typical embryologist training involves? Sure.

So, the training of a lab professional, these are obviously science-based professionals. Laboratories in the U.S. do require a lab director and certified and educated lab professionals. So, usually the lab director will have actually an advanced degree, a PhD, or a degree in veterinary medicine, or even an MD.

And they must also have a specialized certification as a high-complexity lab director. So, you can imagine how many years of education go into this, and then they have to have years of training. They have to take an exam.

So, this is all to be able to run a laboratory. But the folks, the people in the lab, are really the heart of the lab, and they all must have a bachelor's degree with a science focus. So, again, they're college-educated.

They have to have graduated with a degree. There's also a specialized certification for those who are supervisors. So, it actually takes years, a minimum of two, three, four years of full-time work for them to become certified.

This is a very big commitment. People stay in the field for years. Once you're in, it's not something you can do casually or temporarily.

It's really something that's a calling for these people. And I have recruited and trained lab professionals now for over 25 years, and there's always certain qualities that I look for. These are candidates that already have things I cannot train, such as integrity, leadership qualities.

They are the ones who travel to work in the middle of the night when there's an alarm that goes off, when there's a natural disaster, when there's an emergency. Those are the people that are in the lab that are taking care of your embryos. Wow.

That's such a great description. I would probably add attention to detail. I'm sure that is something that you really look for as well.

Definitely. We hope you're finding this episode of SART Fertility Experts helpful. Remember, for more information on this and related topics, visit www.sart.org and click on the tab labeled Patients.

And now, back to SART Fertility Experts. What would you say is the difference between a good lab and a great lab, Dr. Jindal? Yeah, I think the great labs that I've seen, and there are a number of them across the country, they have a very strong quality of leadership. It's a sort of an atmosphere of leadership and community within the laboratory.

They work as a team. It's a team, but not everyone's equal. And so there's a really important focus on communication.

Again, people have to stick to protocols. I think if they're very strictly following protocols and they audit any kind of protocol drift, these are the things that can happen naturally as people get comfortable with protocols. And I think just real attention to detail, having a very strong quality management focus, making sure all the equipment is optimized, that all the reagents they use are within expiry, that the embryologists are trained adequately, and that their competency is evaluated regularly.

These are the things that really determine a great lab. Talk to me a little bit about lab safety. Many patients are concerned about the safety of their eggs and embryos in the lab.

Can you tell me a little bit of what you do in the lab to keep them safe and maintain the identification of them? Yeah, I understand this is a natural focus for patients, especially for a lab where they don't meet the lab staff or they don't see the lab. The laboratory is not patient facing, so it's kind of a black box, but patients should be reassured that there are very strict protocols that particularly SART member clinics follow. There are protocols that are all designed to reduce and minimize the performance of errors.

For example, we use plastic, sterile, disposable dishes. They are not reused. They are not washed.

Everything is used just for each patient, one time. We use two unique identifiers for each patient. Usually it's a patient name combined with something else like their date of birth or a medical record number, a unique identifying number.

All the media that we use is prepared commercially with very strict quality assurance. Nobody's making a homebrew in their lab and using dishes that they have stacked for a while. They keep things at the right temperatures.

Everything is labeled. The other piece that's very important is that we do witnessing. There's witnessing of all the main steps multiple times per cycle for each patient.

All the main steps where we are putting things in dishes, taking them out of the incubator, combining eggs and sperm, identifying embryos for transfer, identifying embryos for freezing, identifying embryos for thawing, multiple, multiple points in a cycle that we have witnessing either with an active witnessing process or using semi-automatic AI. They're able to have these witnessing systems that we're moving into AI now in the laboratory, artificial intelligence. We are able to witness more and more.

I think this should be of some comfort to patients. It's very technical. I wouldn't say foolproof, but it definitely offers a measure of security that there will be no mix-ups and it reduces errors.

That's great to hear, Dr. Jindal. Thank you for explaining that. Can you talk a little bit about how IVF has changed during the pandemic? We're in the middle of the COVID pandemic at this time.

What's different for you now? What's different is I don't always see the patients as much, which is unfortunate. The having their cycles through telemedicine and then when they come through the laboratory, we tend to really reduce the contact points. It's for everybody's safety.

We're meeting each other wearing masks. We meet each other from a six-foot distance. We do still have them witness their labels and make sure that everything is accurate.

We identify them actively by spelling their name. We do meet the patients and the patients should feel comforted that we are still identifying them and reaching them. In the laboratory, we are definitely augmenting cleaning protocols.

We have very augmented protocols now to clean surfaces, to reduce sharing of pens and paper. We maintain a social distance. We wear masks in bigger labs.

Actually, there are teams of people so that they create little bubbles so that they don't overlap staff in case somebody does fall sick. We wear gloves even more than we used to. Some of the airflow in the laboratory can be modified in order not to blow any viral particles out onto the lab staff working with samples.

Of course, we're cleaning surfaces more and more and just removing clutter. There's a lot of things we do. It's very detail-oriented to make sure that the lab area is very clean between patients for patients.

This is all due to the pandemic. Thank you for sharing that insight into all that you're doing. I'm sure it's reassuring for patients to hear that you're really giving it a lot of thought.

Can you talk a little bit about cryo tank and cryo storage safety? I know that's been a concern for some of our patients. They might like to hear how we manage that. Cryo tanks are basically big thermoses.

They're thermoses with insulated sides. They have a cork in the top. We store cryo-preserved embryos, eggs, sperm, tissue in liquid nitrogen, which is held in this cryo tank.

That's pretty typical for IVF labs is to have tanks that store at minus 196 degrees Celsius, which is in liquid nitrogen. These are standard manual filled tanks. I'd say they're the most common.

There are requirements that laboratories that are accredited must follow. There are requirements and there are recommendations. There are very strict protocols around cryo storage.

I can mention some of those. We actually physically have to check the tank several times a week. We also have to have a continuous alarm system that alarms 24 seven in case it detects a rise in temperature or a decrease in the level of liquid nitrogen.

This will alert the lab. This is why we get calls in the middle of the night with emails, texts, phone calls, and we have generator backups. We have things backed up in the cloud and we test the alarm systems.

These are all the things we do to ensure that the embryos for these patients are safe in our cryo tanks in each lab. A common question I get from patients is just how long can my eggs and embryos or sperm be stored? As far as I know, it is indefinite. If the liquid nitrogen level remains above the samples and the samples are not warmed inadvertently for any reason, they should stay intact.

I have seen in the literature reports of babies being born from embryos that have been frozen, now it'd be well over 20 years. That's great. I think that is a question that we are often asked and sometimes people have trouble believing it, but it really is true.

Finding a trustworthy source for fertility information can be overwhelming. Reproductivefacts.org, a patient website developed by the American Society for Reproductive Medicine, has the medical information you need for your family building journey. At reproductivefacts.org, you'll find up-to-date videos, fact sheets, and answers to frequently asked questions, all developed by medical experts based on scientific evidence without commercial bias.

For your fertility questions, turn to a source you can trust, reproductivefacts.org. I have a few other questions. You mentioned accreditation. Why is it important for patients to know about accreditation? Yeah, I realize that patients are referred to fertility specialists.

They go to clinics that their friends have gone to or their doctors recommended that takes their insurance, that their Instagram influencer tells them to go to. I understand all that, but really, as I said, the most important part to me of a successful cycle for a patient is that the laboratory supports the clinical stimulation that they get from their doctor. I think it's really important that patients do look at which clinics they're going to.

Approximately 85% of IVF clinics in the U.S. are SART member clinics. What that means is that SART clinics follow strict guidelines for outcome reporting and for lab accreditation. Particularly, the embryology labs are required to maintain accreditation.

They have to follow these requirements for quality assurance, quality improvement, quality control, cryo storage. These are things that are not always on the clinic website, but these are the things that are very, very important to an actual patient experience and the professionals taking care of their embryos. Just to restate, in order to be a SART member, your lab has to be accredited, correct? Yes.

All 50 states now, the laboratories must be accredited by two agencies, either the College of American Pathologists or the Joint Commission. Another question we sometimes hear from patients who have already received treatment in one place, if they move, is, should I move my embryos? This is a common issue as many people move around the for work, for family, for various reasons. What should they do if they have eggs or embryos in storage in another lab and they're moving away? Yeah, we understand in the laboratory that moving embryos and eggs is now a fact of lab life.

It never used to be, but it is now. I think it is not uncomplicated and it is not without risk. Yes, I understand it has to be done in some cases, but particularly eggs, I would say, are more fragile and I'll get to that in a minute.

The laboratory has to fill out a lot of paperwork. It's like filling out a car loan application to transfer a patient's embryos between clinics. We have to satisfy state requirements, local law requirements, FDA requirements.

We have to communicate the embryos that are being transferred, the cryo device, the media, the protocols. These are things that are very, very labor intensive actually for the laboratory to transfer things and receive things. Not to mention that they have to use these transport tanks, which are dry shippers.

There's liquid nitrogen in there and their embryos go in there and they're sealed and they're shipped, but there's always a risk when you transfer things. It's shipped by FedEx, for example. Is it standing upright like it should be? Is it sitting somewhere on a loading dock? These are things we can't control and we do worry about.

Embryos, though, are even more robust than shipping eggs. I know egg freezing can be an excellent option for patients. In recent years, there have been really reliable techniques that have been developed and patients can now buy frozen eggs from donor banks.

These are definitely shipped to clinics, but they are incredibly fragile. Even slight variations in protocol or temperature can really affect the egg survival and impact embryo development. While I understand that eggs and embryos can travel, have tank, can travel, but I would probably caution patients to think twice about transferring eggs between clinics.

I might recommend that they might want to thaw the eggs where they were frozen. I think that's really good advice. I think also getting the input of the lab that you're sending and receiving from and to is also a good idea too, because they may have their own opinions about this as well.

You want to make sure that they're comfortable, I'm sure. Dr. Jindal, I had one other question and that was just, could you talk me through a typical day in the lab? What happens when you come in in the morning? So I can tell you the best part of my job as a lab director is when I get to cover in the laboratory. It's actually, it's just a delight to be in there.

The lab has all this great high-tech equipment and a lot of white noise and it's very clean and it's very quiet and it's just, you're ready for the patient samples and it's a good start. When you meet the patients, you identify them at the time of egg retrieval. If you're able to do that, meet the patient at that time, you can meet this partner.

If you can at the time when they produce their sample, there's a timeout that happens when the lab staff are present in the procedure room so that everybody confirms the team that's doing the egg retrieval that it is the correct patient. Eggs are collected and the number is reported back in real time to the physician, the provider doing the retrieval. The total number of eggs is counted and then they're immediately placed in the incubator for several hours.

And these dishes have been prepared, as I said, labeled the day before for each patient. So they're put in the incubator and while the eggs are resting in the incubator, the sperm is processed. So in the afternoon, usually early afternoon, the eggs and the sperm are combined and everything is handled on heated surfaces in the laboratory.

We use high-powered microscopes and either the eggs can be placed in a dish with the sperm and put right back in the incubator or they can be injected by the sperm. So if you do do an injection which is ICSI, that's using a very high-powered inverted microscope and eggs are injected one at a time with one sperm each. And again, they're placed in the incubator overnight.

The next day, which is called day one of cycle, the eggs are checked for fertilization. And so the dish is removed from the incubator to a heated surface again with a high-powered microscope. We check for signs of fertilization and then these zygotes are returned to the incubator, usually until day five of culture, which is when they reach the blastocyst stage.

And then at that point, we make a decision about transferring them back to the patient or freezing them or biopsying them and freezing them. So we have very limited touch points with the embryos once they're created. It could be that the embryologist will check embryos on a day three of culture, but usually it's day zero, day one, day five, maybe day six.

So these are the days that we check the embryos, otherwise they remain undisturbed in the incubator. So the patient communication with the laboratory could be on day zero, day of retrieval, day one, day of fertilization when they're reporting the results, and then day five when they do the transfer or the freezing. So you mentioned the limited touch points.

I think that's really important. I think as patients, it can be hard to wait. We've talked in other podcasts about how hard it is to wait, but one of the hardest thing is waiting for embryos and culture to see what happens.

And can you explain why it's important to have those limited touch points? Well, the embryos are being incubated and the incubator is warmed at 37 degrees Celsius. It's kept in media. This is pH balanced for the embryo to experience as little stress as possible during its development during these early days.

So every time you remove an embryo from an incubator, you're taking it out of a warmed environment. You may be disrupting the pH balance because the temperature is dropping. Yes, you keep it on a warm surface and you look at it, but you really want to work quickly and put it back.

The other risk of increased touch points is you're disturbing the dish. It's possible the dish can be knocked. It's possible the dish can fall.

It's possible the dish can be put back in the wrong place in the incubator, which should not happen. But every time you touch it, something like that can happen. So the less you do to disturb the embryos, the better it sounds like.

And that's one of the reasons why there's only a few times when you'll be checking on the embryos. You also mentioned fertilization of eggs, and I just wanted you to touch on that a little bit more. IVF and ICSI, I realize those are whole separate topics unto themselves, but can you just talk generally about when IVF is done and when ICSI is done in the lab? Well, I should start by saying that I think nationally over 60% of cycles are ICSI cycles now.

So we did start out in the early days of IVF doing insemination cycles only before we had ICSI. ICSI came along in the early 90s, so we've been doing it a long time. But if a woman has a good reserve of eggs, and more importantly, the partner or donor sperm is a very good sperm count with good motility and morphology, there's no indication that the sperm has to be put into the egg.

They're able to be cultured together in a dish, the sperm is washed, the eggs are placed in clean media, and the sperm is added at a certain concentration, and one sperm is allowed to penetrate the outside of the egg and to establish fertilization. But they do it on their own without any assistance, and they don't completely bypass all the steps naturally that occur during fertilization. So that is just standard insemination.

ICSI is really indicated traditionally for couples with male factor infertility. Also, if you are using frozen thawed eggs, ICSI is indicated as well in order to breach the egg surface and the sperm to get inside. It's also indicated in cases where you do a biopsy and genetic analysis for genetic mutations.

So when you want to create an embryo for testing, ICSI is also indicated. So the ICSI procedure is much more invasive, obviously. We're loading a microneedle with manipulators under a high-powered microscope.

We're loading one manipulator with suction for an egg and the other one with one single sperm, and we're very carefully inserting and depositing the sperm into the egg, retracting the needle, and then leaving them again overnight for fertilization. Thank you for explaining the difference between standard insemination and ICSI. I think that's something that's important for patients to realize there is a difference, helping patients understand the different reasons why the different procedures might be performed.

Dr. Jindal, is there anything else that you'd like patients to know about what happens in the lab or any other parts of the process about selecting embryos for transfer? We are also opening the incubator only on the day of transfer or freezing. So it is unknown to us exactly what we'll find when we open the incubator and see which ones have developed. From the ones that fertilize, we do expect maybe 50% of them to form usable blastocysts on day five.

You have two ways, actually, of choosing an embryo for transfer or for cryopreservation. Well, transfer, either by morphology, the way that the embryo looks. We grade several different aspects of the blastocyst, which is really the most common and the most traditional.

And the other way of doing it is genetic analysis of the embryo, where we remove some of the cells, we freeze the embryo and send those cells off for cytogenetic analysis. That comes back and tells us which ones have a normal set of chromosomes, normal number of chromosomes. And those are the ones we choose for transfer.

So it can either be by morphology, which corresponds pretty well, actually, to the genetic health of an embryo, but not always, 100%. And also through genetic analysis. Those are the two ways.

Many patients, I'm sure, are wondering whether or not they should consider having their embryos tested for genetic abnormalities. And I realize that's also another whole discussion, but there are different types of screening available. One of the types of embryo screening is aneuploidy screening.

What are your thoughts about aneuploidy screening? What patients benefit most from it, or what do you think, and what is your impression in the lab? So aneuploidy screening has been developed over many decades now. It's reached a pretty sophisticated level where we do use it. I know, I think most programs use it at this point.

Whether or not they use it for all their patients or some of their patients, it's driven by each clinic. But I do think the evidence indicates that there is a use for genetic analysis for aneuploidy for older women who may have older eggs that are not always as chromosomally robust, women who've experienced recurrent pregnancy loss, and women who've been through a number of times and have experienced recurrent implantation failure. So I think these are very solid evidence-based indications for using genetic analysis for aneuploidy.

I can tell you in the laboratory, it is highly technical work, labor-intensive. There's way more touch points. It's always risky when you're biopsying a tiny, tiny embryo.

This is all done under high-powered microscope using manipulators holding tools. I there's always a risk that's introduced when you do something like that. So that's what I think.

I think a lot of people do have it, and I think there is an indication for it in some patients, but perhaps not all patients. So certain selected patients that you mentioned may really benefit from it for various reasons that they've had multiple miscarriages, or they haven't been able to conceive and the reason is not really understood, or they're older and may be more at risk for having embryos with genetic abnormalities, but it may not be necessary for every patient is what I'm hearing. That's correct.

That's what I think. Yeah, some patients, I think patients need to understand that too. I think there's such a confusing array of procedures and it's a menu, we call it.

There's so many things that are out there and many people wonder, do I really need this? Should I do this? And I think that's where we work together to try to help our patients figure out what's best and get you through this process. So, Dr. Jindal, thank you so much for taking the time to talk with me today about what happens in the IVF lab. This has been a really wonderful look into what happens behind the scenes.

Oh, it's been my pleasure, Kelly. Thank you so much. This is Dr. Kelly Lynch from SART Fertility Experts, and I've been speaking with Dr. Sangita Jindal from Albert Einstein College of Medicine.

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