Embryo Development 101

When an egg is retrieved from the ovaries, it is fertilized either through putting the egg and sperms in the same space (usually a petri dish) so it will naturally fertilized or through a process called ICSI, where one sperm is injected into an egg.  Once the egg and sperm had a chance to merge, the new product is called an embryo.

Here is a pictorial view and explanation of what our embryos are expected to look like day to day and the names used (by the way — this is the same whether it is inside the body or outside the body):

Embryo development - 5 days overview

Post egg retrieval

Day 1: 1 cell with 2 dots in the middle.  This indicates a normally fertilized egg with each dot representing genetic materials from the mom and the dad.

Day 2: usually 2-4 cells.  The cells are expected to double every 24 hours or so.   

Day 3: usually 6-8 cells. Sometimes more cells.  Same doubling effect.  This is when fragmentation can be observed (small dots, not clean cell divisions) representing abnormal cells.  I’ve read somewhere that chromosonal abnormality can be around 25-70%. 

Day 4: Morula or compacting cell stage.  This is when the cells have doubled to around 16 and the individual balls are starting to expand and blend with the others.  You can see the bumps still.

Day 5: Blastocyst.  This is when we see 3 distinct parts – the shell, one dense bunch of cells (the baby), and the lighter cells (the placenta).  The blastocyst is ready for implantation but first it has to hatch from the shell.  The picture on the bottom right is a hatching blastocyst (can happen naturally or with the help of your embryologist – assisted hatching, like ours in IVF#1).  The hatched blastocyst should implant within 12-24 hours to the uterine lining.

Scan – 2 days post ER

No fertilization report today but Dr. N mentioned 10 or so from the embryologist as of this morning.  It is still better than the 8 we were expecting for day 1 so we’re happy.  We’ll wait till tomorrow for our next embryologist update – the two critical milestones are 3 days post and 5 days post ER as many embryos konk out around day 2 and 4.

We scanned about 15 different way today to see if my lining was ok.  We tried it with a half full bladder, then an hour later with a super full bladder, then 5 minutes later with a semi-full bladder (I cannot begin to tell you how hard it is to pee a bit and hold in the rest for another 5-10 minutes while Dr N presses the ultrasound probe on my belly).   We got different measurements of the lining from different views.  I don’t think my uterus has ever been through such a thorough examination from every conceivable angle.

In the end came decision time (after I ran out again to relieve myself — so I can really concentrate on what Dr. N had to say).  The verdict – my lining is not looking fantastic – borderline in Dr. N’s opinion.  He left the decision to transfer or not to be a joint decision and offered 3 options:

Option 1: we go ahead and transfer the 2 best blastocysts (day 5) on monday (same cycle)

Option 2: we postpone the transfer to another month where my lining is ideal through a frozen embryo transfer (May/June or June/July)

Option3: option 2 but on monday we also transfer 1 average blastocyst (ie. freeze the best ones for another month) and take a punt a so-so embryo

Having discussed this with DH already, we thought option 2 was the best.  Only the ones that are viable for transfer will be frozen so we are unlikely to have non-viables ones for transfer (plus the likelihood of sticking).  Both factors of good embryo and good lining are important.  Even the best looking embryos won’t stick to yucky lining — as we have proven.  Plus I don’t want to go through another BFN with non-ideal circumstances and not give all our embryos a true fighting chance.  What do you think?  What would you do?

In the end, we decided that we’ll go with option 2 but more info cannot be bad info so we are also going back for a day 5 scan on monday.  Things are not likely to change much but if they change drastically for the better, we may go ahead and transfer monday afternoon (5 days transfer).  We’re not counting on it but it’ll be good to know how my lining changes from ER to ET with the progesterone now kicking in.  Another fun day with my bladder.

Being such a good patient, our consultation fees were even waived today.

Medications: 2000 IU pregnyl shot (in the butt) every 3rd day, crinone 2x daily (suppository), Utrogestron 3x daily (oral), baby aspirin

[Update] Fert Report#2: embryologist just called.  10 embryos at the 4 cell stage and 4 are developing but at a slower pace and abnormal.

Fert report#1 (1 day post ER)

Our embryologist called this morning with our fertilization report — out of the 19 eggs retrieved, 14 has fertilized!

Yes – 14!!

Ummm — didn’t we have only 13 mature eggs?

Apparently on closer look, we had 16 mature eggs and of the 16, 14 fertilized!  wow!  2 are not looking that great and it is hard to tell at this stage how many will make it day by day as there can only be drop outs but we are already starting with a much higher number than last time.

Last time, we had 15 eggs of which 8 was mature, and 5 fertilized. 

This time, we have 25% more eggs (19), 100% more mature (16) and 180% more fertilized (14). 

The verdict is still out since we don’t know the quality yet and will hold out till day 5 but the long lupron protocol seems to produce more fertilized eggs for me.  Tomorrow, we’ll go in for a scan since my lining seemed to have thicken again during the ER scan and the transfer may have to be postponed.

Grow little embabies, grow.

ER done

Egg retrieval done.  13 mature eggs out of 19 eggs retrieved.

The whole process went quite smoothly and even started on time – 11:05am.  I was out with anesthesia and was woken up around 11:45am.  The only real complaint this time was the cramping pain and with 2 painkiller shots in the butt later, I was good to go.  We even headed home sooner than last time – by 3pm.

However — the taxi ride home was quite a rollarcoaster and I got car sick on the way.  2 puking incidents later at home, I am feeling better and anxious on the fertilization report.  We are hoping for our lucky 8.

Blah (T-1)

I am feeling blah today.  I just feel exhausted and my belly hurts from things being swollen inside.  I don’t even want to know what it’ll feel like if I jumped.  On the positive note, no injections today.  Is it strange to say that it’s odd to be missing this part of our daily routine?

ER (egg retrieval) tomorrow at 11am.

day 9 check

Lots of eggs are cooking inside my ovaries, our day 9 report:

Party inside my ovaries

Ok — not quite that many but possibly that many characters hence the discomfort.  But we found 23 in total!!  (last time I only had 15)  I feel like I’m doing almost 2 years of work in 9 days.

Right side: 10 measurable follicles – 2x 17mm, 16, 2x 13mm,2x 12mm, 11mm, 2x 10mm

Left side:  13 measurable follies – 2x 17mm, 3x 16mm, 15m, 2x 14m, 13m, 12m, 11m, 2x 10

Lining: 10.7 and triple layered!!  Yay…..It measured and looked different today due to the angle of the uterus relative to the vag cam.  Dr. N said the lining looked good (hopefully it’s sticky as well) and we’ll be doing a transfer in the same cycle. (fingers crossed).

All in all, I’m so excited that I’m producing more eggs – from the change in protocol and the higher medication dosage but I am also hoping that some of the little ones will miraculously grow and mature.  The cut-off for us last time between mature and immature ones was 14mm on the day of trigger.  Based on the measurements today, we are looking at around 10 mature eggs with 23 eggs to be retrieved in total.  Fingers crossed for the 13 smaller ones – grow eggs grow.

Trigger is tonight at 11pm for retrieval Wednesday at 11am.  The trigger is a shot in the butt to “ripen” the egg so that the eggs would ovulate 48 hours later.  The trick is for the Dr. to go in to retrieve the eggs before they are all released naturally — hence the timing is absolutely critical.  The shot is ideally administered by a professional since there are too many horror stories about the shot going wrong.  One story we heard is of a couple who shattered the medication by accident due to nervousness (the medication comes in these tiny little glass vials you have to snap off the top and mix) and they had difficulty finding the replacement medication in pharmacies that night.  Once they managed to find the medication, the couple then had difficulty injecting the medication into the wife’s butt because her butt was too muscular from being a fitness trainer.  Somehow they managed in the end but these type of things is one less stress we need.  We are going to the hospital’s accident and emergency department (or ER), pay $20 and get them to shoot me in the butt.

Medication: no more shots – only antibiotics (last day tomorrow).  Pregnyl at 11pm tonight – 10,000 IU.

The future

I met up with our friend who referred us to Dr. N.  She went through fertility treatments many years ago and now has a pair of boy girl twins who are 2.  She’s been really wonderful and caring, asking us how we are doing and sharing stories of her and her other friend’s experiences.  And it is through stories like this that gives us a hope and a reason to walk down this path for the chance to conceive.

One of her friends went through many many rounds of IUIs and IVFs and had enough.  3 months after the last fertility treatment, she got pregnant naturally.

Another friend of hers went through IVF and wasn’t successful in producing any viable embryos and was advised by the Dr to not transfer the one poor quality embryo she had as it wasn’t likely to be viable.  They stuck to their guns and that poor quality embryo stuck.  It really only takes one and it doesn’t have to be the best quality one.

There are so many stories we hear about that gives us a glimpse of our possible successful future.  But there are also so many stories of people who didn’t have a successful outcome but was able to open their hearts to the possibility of adoption or surrogacy.  It is never an easy journey and the one thing we have plenty of is the time to think of all the possibilities, especially while we are waiting in the waiting room for the never-ending appointments. 

It is possible that we’ll go through all this and end up with nothing.  We just don’t know and the our inate curiousity and patience gets the better of us.  I guess the trick is to keep our minds focused on the positives and stay patient (and sane) somehow in the meantime.

day 7 check

Bright and early at 8:30 this morning.  After trip #2 to empty my bladder (I went only 30 min earlier and didn’t drink a drop), the report as of 9:15 this morning:

Right side: 7 measurable follicles – 14mm, 13mm, 12mm, 11mm, 10mm, 2x 9mm

Left side:  8 measurable follies – 2x 13mm, 12mm, 2x 11mm, 9mm, 2x 8mm

Lining: 11.7 (and thicken – not the triple layer stripe RE likes to see)

To be honest, I am pretty happy with the number of follicles.  Last time at day 8 (one day later), we had only 15 follicles and those ended up being the 15 eggs retrieved.  I will likely stim for 3 more days so there is a chance there may be more follicles by the time of retrieval and the size seems ok that hopefully some of them would grow beyond 14mm — the smallest size of the mature follicle at the time of trigger. The rule of thumb is around 1-2mm per day of growth – so if I trigger on tues, we wil have 3 more days (ie 3-6mm) of growth.  Of course, I hope they are the same or better quality eggs than last time and the quality is not compromised because of the quantity.

Since I enjoy looking at data, I’ve trended the follicle sizes by comparing day 5 to day 7 and observed the following: 

• On my left side, the larger the follicle, the faster the rate of growth.  For example my largest follicles from day 5 and day 7 grew 4mm from 9mm to 13mm (2mm per day)
• On the right side, the larger follicles grow slower than the smaller follicles.  The largest one grew 2.6mm from 11mm to 13.6mm (1.3mm per day) while the smallest one from day 5 grew 4.4mm from 7.7mm to 12.1mm (2.2mm per day)

Weird huh?  To top it off, one of my ovaries is on top of my uterus.  I didn’t know ovaries can float around and end up in weird positions like that.  Apparently it happens and sometimes it can even end up under the uterus!  I suspect this may be why I’m getting some pain and discomfort in my abdomen.

Medications: continue 300IU Gonal-F, 5IU Lucrin, Baby Aspirin, and Antibiotics.

Day 9 check on monday.

The Bloat

A balloon — exactly how I feel today.  And not a happy cow.

Somehow, I’ve bloated up since yesterday and look/feel 4 months pregnant (what a mind game).  Not sure if it is from the increase of the stim dosage (225IU to 300IU) or if my ovaries decided to work overtime in the last 24 hours.  I know I bloat but I don’t remember it being so sudden.

The worst is knowing that this bloat is here to stay for the next 3 weeks.

Day 5 check

Day 5 check was today.  It was great being the only patient (as opposed to the usual 2 hour wait). After 3 pokes (2 meds + 1 bloodwork), 1 visit with the vag cam, the results:

Right side: 3 measurable follicles – 11mm, 9mm, 7mm (lots of small small follies – after all I am polycystic on my right side)

Left side:  7 measurable follies – 9mm, 3x 8mm, 2x 7mm, 6mm

Lining: 8.7 (on the thicker side)

The interesting thing with the long lupron protocol –  my left side is producing a few more follies (7 vs. 3) while my right side is surpressed (3 vs. 9).  This is good since my left side is generally the side I ovulate from.  However, the same trend persists – I have 1 follie on my right side which is an “eager student” and is growing faster than the others.  The issue with this is that the lead follicle is what determines when to trigger and when it grows way faster, the rest do not have a chance to catch up.

My lining was an issue for IVF#1 and seems to be thickening faster again.  During a regular, non-medicated cycle, my lining thickness is around 7.  With my last IVF, my lining peaked at 17 at the time of trigger but then compacted to 14 at transfer.  Yes – I have a compactable lining.  

I do believe my lining was one of the main reasons for our failed cycle.  I’m not sure if any embies would want to park themselves in an over-medicated, hormonal lining and call it home — I know I wouldn’t after experiencing the nasty AF.  Now that we are  heading down the same path again, I’m leaning towards retrieving the oocytes but delaying the transfer until the following cycle using a natural FET.  Dr. N feels that if things look good, he doesn’t want to waste the opportunity to transfer.  But with the limited oocytes we are likely to retrieve, I’m inclined to bet all of them for an FET rather then use them during this fresh cycle and have none leftover, thus having to do another fresh cycle with no new learning on my lining.  Urrghhh.

I guess we’ll have to wait and see how we progress on saturday (day 7).  In the meantime, we’ll keep our fingers crossed for more follicles to miraculously appear.

Medications: 300IU Gonal-F (topped up the 75IU today – poke #4), 5IU Lucrin, Antibiotics, and baby aspirin.