Embryo Banking: Should I Stay (Keep Banking) or Should I Go (Start Transferring)?

Perhaps you’ve been told the maxim that you need 2-3 euploid embryos per desired live birth before you can start transferring embryos. 

In this controversial episode, I challenge that thinking and provide my more nuanced view of this important and complicated topic. Let us all move toward an abundantly practical mindset.

As always, please keep in mind that this is my perspective and nothing in this podcast is medical advice.

If you found this conversation valuable, book a consult call with me using this link:

https://calendly.com/loveandsciencefertility/discovery-call

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Please don’t let infertility have the final word. We are here to take the burden from you so that you can achieve your goal of building your family with confidence and compassion. I’m rooting for you always.

In Gratitude,

Dr. Erica Bove

Transcript

Hello, my loves and welcome back to the love and science podcast.

Today we're going to talk about a controversial topic and that is embryo banking.

I will say, you know, I helped to moderate a Facebook group for female physicians with infertility.

And one of the number one topics that comes up in that group is when do I start transferring my embryos and how many embryos do I need to ensure that I can have one child, two children, three children, whatever the number is.

Um, I will say that it's a balance because I think that in coaching school, I was always taught that we need to have an abundance mindset, not a scarcity mindset.

And that's how we manifest good things in the universe.

Hey, I know that sounds super woo, but I really think there's something to that.

I really do believe that we need to believe in possibility.

We need to believe in abundance.

I also think that at the same time we need to be practical in terms of taking practical steps forward to encourage that that abundance will come to fruition.

Right.

So it's sort of how do we get out of the scarcity mindset?

How do we get out of the super type A controlling fearful state and come to a more sort of peaceful, hopeful, and also at the same time, very practical and ambitious mindset in terms of doing all the things to maximize the chances that our ideal family size will come to be.

So this is a very controversial topic.

It's very hotly debated.

You can get probably five REIs in a room and everybody might have a different perspective on it.

So again, this is my perspective, not medical advice.

I've been doing this over a decade and I've also been able to see the rise and I will even say maybe start to fall of, of PGT technology.

Like I think that everything in medicine at some point gets very hot and then people start to see the limitations and it falls into favor.

So I'm old enough and seasoned enough that I've seen some of those cycles already.

And so what I'm going to give you is my best scientific perspective, my perspective based on experience.

And of course, with all things, my perspective that with anything medical, it requires a tailored approach, but it's not a one size fits all.

The same, you know, sort of clinical situation will not look the same in two different people who have different values and different goals and different maybe cultural values, like all those different things.

And so this is not an algorithm.

This is to say like these are the things to consider to help you make your best empowered choices as it pertains to like, how long do I stay on this sort of a train track of embryo banking?

And when do I start to transition to actually transferring these embryos in a way that I'm not panicking because I trust that there's enough there that I will be able to have my desired family.

Okay.

So let's go back to the basics in terms of like a U-plate embryo.

What is that?

Now I do have a full episode on this on PGT technology.

So please do listen to that episode as well if you want more background information.

But a U-plate embryo, and I say I'm starting here because I think when we talk about embryo banking, a lot of times we're talking about really banking U-plate embryos.

So a U-plate embryo is an embryo that has an egg that's been fertilized in the lab.

It's grown to day five, day six, and maybe even day seven, and a small sample, so like maybe, you know, three to five cells or so from the trophectoderm layer, which is the part that becomes the placenta.

Those cells are sent off for genetic analysis alongside while the embryo itself is frozen and safe in the freezer, such that say somebody makes like four or five embryos in an IVF cycle, you get a report that says, okay, embryo number one, you know, and you played for this reason, embryo number two, you played 46 XY embryo number three, and you played for this other reason, or maybe a complex anyploidy embryo number four 46 XX, you will excuse me, you played.

So I, you know, I think that we get the report and it says kind of what the data are, but the thought is that if something is anyploid, it's probably not going to make a viable pregnancy.

And so we focus our attention on the embryos that actually have, you know, a set of chromosomes we expect to be viable, such as 46 XX or 46 XY, and then we go from there.

Now, as I talk about in the other episode, this gets even more complicated because there's all sort of mosaicism that we can talk about.

So maybe, you know, some of the cells express certain chromosomal patterns and others express different patterns.

And so the question is like, with those sort of mosaic embryos, are they viable?

Are they not?

I think the bottom line would be that some are viable, some are not.

There's a little more efficiency in an embryo that's called fully euploid compared to mosaic, but you know, sometimes mosaic embryos are transferred and do result in live births.

And I'm of the mindset, we don't want to throw away any embryos that could potentially make babies, right?

That's sort of where I come from.

So again, with the patient's ideas in mind, the client's ideas in mind, but like, I think we want to err towards not throwing away good embryos if we can avoid it.

So when we talk about embryo banking, it's sort of this notion that, you know, the first euploid transfer has about a 65% chance of success.

The second euploid transfer, if that doesn't work, has about an 80% chance of success.

And the third euploid transfer, for those people who are lucky enough to make three euploid embryos, the third euploid embryo transfer has about a 95% chance of success.

That means that for people who have had three euploid transfers, 95% and by success, I mean like live birth, 95% of those people will walk away with a live birth.

Now, so when you're thinking about it, say you're 38 years old and you have PCOS and you want two children, you know, how many embryos do you decide to bank before you start transferring?

So say for instance, you know, you're 38, you have an embryo transfer, it works, you end up being pregnant for 10 months, you deliver, you breastfeed for a year, and then you wake up and you're 40 and you're like, oh my goodness, it's so much harder to make embryos at 40 than it was at 38.

Maybe I should have banked more embryos.

Like that is the situation that everybody is afraid of, like wanting more children, being older and having regret about not freezing more embryos on the sooner side.

Now the problem is nobody has a crystal ball and can say, well for you in particular, this is how many embryos you need to generate to get to your ideal family size.

And once, once a person's pregnant, I mean that's a kind of a big commitment.

You know, we're not supposed to even do IVF when breastfeeding.

I know it's controversial, but still like, it's kind of like you lose a couple of years at a time.

So there is this notion out there that you need two to three U-plate embryos per live birth that you desire.

Like somehow that got into the literature.

And I think, or that not even literature, like the sort of social constructs, I think it comes from a literature that I just cited that like, you know, after three U-plate embryos, there's a 95% chance of a live birth.

And so if you think about it, you're like, okay, well if I have three, that's a 95% chance.

And then if I have another three, that's another 95% chance.

And so people kind of get sort of sucked into this scarcity.

Like I only have two U-plate embryos that doesn't even equal one live birth.

And that is just not true.

Like it's, it's how our brains work.

Like is that we sort of think, okay, well I have to have three and I don't.

So it's not going to work, but two U-plate embryos could actually be two live births too.

I've seen that time and time again.

I mean, this is the thing is like, how do we proceed in a practical way while at the same time not being cavalier and saying like, well, obviously it's going to work for me.

So I'm going to just like move forward and hope for the best.

Right.

So there's like this, this line that we walk.

So here are the things that I think about to help each individual person.

Again, I want to chuck that two to three embryos per live birth out the window.

It like, it's like nails on a chalkboard when I hear it, because it's like people are not thinking.

It's like, think, think, think, like this is not like just blanket one size fits all medicine.

We have to look at each person in front of us and make the best decisions for those people, right?

Like, like help them make those decisions, but it's, it is not as simple as just two to three embryos per live birth.

Okay.

So the first question I start out with is like, what is your ideal family size?

Right.

I think about this much differently if somebody tells me one child versus if they tell me three to four children, those are very, very different goals.

And especially when pregnancy is as long as it is, and maybe people decide to breastfeed, like, you know, we have to think very proactively if somebody wants a larger family.

But I think if somebody wants one to two children, it's sort of simpler in terms of thinking about what the targets are, understanding that time is a continuous variable and time continues on.

So desired family size is like a really, really important question.

And I think it's also helpful to think about, okay, well, you know, our initial vision was four children, but I, but now, I mean, when after all this, I think we'd probably be happy with one, maybe two, you know, I'm not saying we give up on the vision because I think it's really important that if four children is really important to us, that we keep that, you know, top of mind.

I also think that sort of understanding if there's any flexibility with the original goal, that can also be really helpful because then it just gives a little bit more breathing room, a little bit less pressure in the situation.

And it just can be helpful for thinking outside the box about things.

Okay.

So desired family size is super important.

Agent diagnosis also very important.

So I think about something, somebody very differently if they're like 30 or 32 than I do, if they're like 39, 40, 41.

Like if you're 41 and you want two kids, like I want you to bank the crap out of those embryos as long as the cycles are going well, because, you know, we can't get back that time.

And even 41 and 43 are very different numbers.

But if somebody is 30 with decent egg reserve, then, you know, sort of we have more time, we have more ability to maybe do another cycle in the future.

And so, you know, all those things come to mind.

I think about the diagnosis as well.

I mean, diminished ovarian reserve is very different than polycystic ovarian syndrome.

So if somebody really does have diminished ovarian reserve, and I'm worried that that's going to get worse with time, I think about them with a little bit more urgency than I do somebody with PCOS who makes lots of lassasis who is expected to have, you know, good euplody.

I also think about endometriosis.

And so like endometriosis is one of those things that can be progressive.

It can make fertility less efficient.

You know, even, you know, there's some data that embryo transfers per for somebody with endometriosis are about 10% less than people without endometriosis in different diagnoses, like PCOS and male factor and such.

And so if somebody has endometriosis, and maybe they have pain, maybe they have more surgery coming down the pike.

Those are people that I sort of think about more critically in terms of like, okay, like what are the goals?

How many embryos do we have?

Like, you know, embryo and endometriosis tends to get worse over time, especially if it's been recently treated, do we just like get as many as we can and then suppress the heck out of that person and then do the transfers.

So that's another situation I think is really important to think about.

So that's the second question, what's the age and diagnosis?

The third question is, what did it take to get to those embryos in the first place?

Right.

So say somebody does like, you know, a cycle of IVF, but they are sick as a dog.

They got terrible ovarian hyperstimulation syndrome.

They had to miss two weeks of work.

They had to get tapped, you know, had to get anticoagulated, like all those things, like every single IVF cycle is not the same.

Every single person has a different threshold of how they tolerate it.

In my experience, people with more vigorous stimulations, you know, tend to have worse times of it.

And I also think that like, were there any complications?

Say somebody had a complication from IVF, like that person's probably going to be a lot less likely to move forward with another IVF cycle gingerly, right?

Like say somebody had a blood clot, say somebody had, you know, a bleeding event.

I mean, I know those things are pretty rare, but if that happened to you, I mean, I would be a little more gun shy about signing myself up for another IVF cycle right away.

So in that situation, I'd say, okay, well, what do we have at the present time?

And how does that align or not align with the goals?

Say somebody got eight untested embryos from an IVF cycle where they got really bad OHS, they might say, you know what, what are your goals?

Like let's proceed on.

But if somebody maybe got no embryos from that cycle, and they really want to have a family, I might say, okay, well, what could we change moving forward to make the cycle go better next time and be more tolerable?

So that question of like, what did it take to get to those embryos?

I think in terms of efficiency, I mean, some people will tell me, yeah, I have three point embryos, but it took me 12 IVF cycles to get there.

That's where I might say, okay, like, let's talk about that.

Because at what point does the process of IVF seem to be counterproductive?

Like, I've also had people tell me on my coaching hat, like, it's a lot easier to do IVF cycles and just show up and get the blood work at the ultrasounds, then deal with the potential of it not working, i.e. doing an actual cycle.

So I think sometimes we stay stuck in like embryo banking mode, because it feels safer when in reality, it's like, okay, you know, the efficiency is not very high, we're lucky to have these embryos that we do.

So maybe it might make sense at this point to like, obviously, do as much proactively as possible, but really start to think about transferring, especially when the body is telling us that, you know, more IVF may not be fruitful.

What else?

Finances.

I mean, some people have, you know, insurance coverage, and they are still able to get more treatment cycles covered.

And that's sort of one consideration.

Other people, maybe they had insurance coverage, and now they're out of pocket, and they have some reserve, but not indefinite reserve financially.

And then other people have been paying out of pocket the entire time.

And at some point, it's like, okay, you know, what other financial goals do we have?

And how much are we really willing to sink into this process?

Now, I'm of the belief that like a child, if that is your deepest desire, it does not matter how much, you know, we spend, because that is just the most beautiful blessing at the end of the day.

I wish that we had more universal coverage, of course, but like, I think that, you know, if your goal is to be a parent, and you're hoping for one child, I do think that like financially, it's like, okay, you know, let's do everything we can to make this a possibility, even if it's a loan, or like any of like, I understand like, these, this is, we don't want to live with regret, we want to do as much as we can.

And usually, the finances are not the issue.

But at some point, it's like, again, looking at that sort of ratio of like, how many cycles have we done?

How efficient have they been?

How likely am I to get another good embryo if we do another cycle?

And what other financial priorities do we have?

Especially, I've seen people sitting on like 560 point embryos in the freezer being like, oh my gosh, I think we have to do more.

I think at that point, it starts to become like that scarcity mindset, where it's like, are more embryos going to be beneficial?

Are they not?

Like, what happens if you reach your family building goals, and you still have four, you put embryos left, some people have serious moral and ethical, you know, opinions about that other people don't, but like, hey, I'm here to meet people where they are.

And if that is a concern that having access embryos actually might create a different sort of a problem, then we want to talk about that ahead of time, because embryo banking just indefinitely is not always the right solution.

So I think, you know, that sort of third question of what did it take to get to the embryos cycle tolerance, complications, efficiency, finances, those things are really important to think about.

Okay, fourth question is, what is the clinical history?

Like, has somebody been pregnant before with maybe a live birth and now they have a new partner and they're trying again?

Has somebody been pregnant before, but has never had a live birth?

Maybe they've had four or five miscarriages.

And so that's something to consider.

Has somebody had a prior transfer before, you know, if somebody comes to my office and they have recurrent implantation failure, they've had five embryo transfers and a mix of biochemical pregnancies and non pregnancy cycles.

I want to think about them very differently than I do somebody who is like a G2P2 in there, you know, maybe it's been a few years, but they have a new partner and they want another child, right?

Those are very different uterine environments, very different situations.

So the clinical history really does matter.

And then, you know, my next question is, can anything be optimized prior to the transfer?

So some people are as optimized as they can be, like they've had all the testing and, you know, everything else and they're like ready to go.

So what does that look like for me?

That looks like, you know, a uterine cavity test that's up to date, either a sono histogram or an office of thoroscopy or, you know, our hystroscopy, some sort of a recent cavity evaluation.

I liked them within six months.

I know some clinics say 12 to 24 months, but just really recent, a look to say the uterine cavity cannot be optimized anymore.

There's no polyps, there's no fibres, there's no retained tissue from any other losses.

There's no scar tissue.

Like all those things are set at the same time.

I also like a endometrial sampling if possible, right?

Especially if you're like, Hey, I want to make the best use of these embryos as possible.

It's not comfortable.

It's an endometrial biopsy.

It takes about five to 10 seconds to get that tissue and to send it off to pathology to look and see if there's any plasma cells, also known as CD138 cells, because we know that 8% of women walk around with chronic endometritis and in patients who are infertile or have recurrent pregnancy loss, if you treat the endometritis, then the clinical outcomes are better.

People get pregnant better more efficiently.

They stay pregnant more efficiently and they have higher life birth rates.

One weekend I pulled up and read every single paper I could on chronic endometritis.

I feel pretty up to date.

I even recently had a conversation with a GYN pathologist about it.

Thankfully, we as a field are coming around that this really does matter, but there was my Michigan accent coming out.

Listen to that.

I think that uterine health is really, really important.

If you've taken the time and the energy and the expense to go through these cycles to generate these embryos, you really want to make sure the environment is as optimal as possible.

Now, I will also say that there are people who do worry about what's called silent endometriosis, and I have a whole other podcast episode about that, so please do listen to that.

If there's any suspicion of endometriosis, I think it is useful to do either some testing ahead of time for endometriosis or even empiric treatment, spending two, three months on Lupron suppression plus minus some other adjuncts like Lettresol, iJustine, and really calm the inflammation down so that the environment is as optimal as possible.

It is very controversial, but I think that I see people blow through two, three, four uploid embryos or not pregnant.

I see in my coaching practice the 5%, most of my clients have already had at least a couple uploid embryo transfers and they're still not pregnant, so again, not everybody, but still.

I'm used to thinking about the 5% of people who are not in that live birth category yet, but I do think that an endometrial biopsy is a simple enough thing to do that I do think that even before a first transfer sometimes, I know that's controversial because there is some harm there, it's painful, but I think that making sure that there's no inflammation present before a transfer, it's a pretty low-hanging fruit, and I think that treating endometritis if present has been shown to improve outcomes.

Now the ERA test, I get a lot of questions about that, the ERA test endometrial receptivity array is a test looking at doing a practice embryo transfer cycle and everything is the exact same as it would be compared to a normal embryo transfer cycle, except on the day of the "transfer," the embryo is not thawed and endometrial biopsy is done, and then that tissue is actually sent off to a special company.

There's actually now a couple companies that are doing this to see if that endometrium is receptive, like at that time in terms of progesterone that we would expect the embryo to stick.

Now I do believe that the uterine lining endometrium and the embryo should be like velcro, they should sort of be able to stick together.

There are some situations in which the sort of velcro is a mismatch, it's a timing mismatch and the age of the embryo and the age of the endometrium, even if they line up on paper, don't line up molecularly that that can happen.

I think that is the sort of very small subset of patients.

In my whole career, I can only think of a handful of patients who have really needed ERA, in my opinion, I know it's controversial, to have their children.

And I think that there can be some harm too, like what if we say that somebody's window of implantation is like different based on the testing and it's not an accurate test and then we make them take less or more duration of progesterone and then that's not actually going to help, it's going to hurt.

So, unfortunately, the initial data that was very pro-ERA was proprietary and so the company that sold the ERA was the ones doing the research.

Again, it's so hard, gosh.

Again, on the day of this recording, there's whole all sorts of things going on with funding and research and how we get our scientific answers.

And so I do understand that industry does play a role.

I also think that some of the data that have come out after that, that have not been as biased and connected to the source of the outcome in terms of that conflict of interest, I think that that data has not shown in population levels to improve outcomes.

And so again, I think in general, I don't recommend ERA testing.

I think in somebody who's had, say, a couple of you played transfers and things haven't taken, it could be explored, but I also think the window of implantation is a lot more sort of wide and complex than we understand.

And so I'm not as much of a believer in the ERA as I used to.

I think that if there's sort of clearly not treatment success happening, it is something that can be undertaken to try to get some answers and try and maybe optimize the next cycle.

Similarly, with adenomyosis, I'm about to give a talk at my university about adenomyosis and fertility outcomes.

I think that that's something where sometimes on ultrasound, we can have a suspicion that it's present on MRI as well.

Looking at the junctional zone, most of us in our 40s are going to have some adenomyosis and previously it was thought to be a disease of like fertile women.

And so unless it's really bad or severe, I usually don't recommend sort of intervening.

Adenomyosis and endometriosis can go sort of be comorbid.

And so it is something to think about if there is adenomyosis on imaging, like if there's also endometriosis present as well.

But I tend not to get too worked up about adenomyosis, even though I know it is part of uterine health, unless it looks really severe on imaging or somebody has had unsuccessful transfers and nothing else has really come up in the evaluation.

So uterine health is definitely something to think about.

Can it be optimized prior to transfer?

I also look at lifestyle stuff.

I mean, the vast majority of my patients and clients are already doing everything that they quote unquote should be.

I think looking at weight, it's a controversial topic as well.

But like if somebody really has sort of a high BMI and it's thought that that could be optimized, we do know that at opacity is a pro-inflammatory state.

I spent my whole fellowship trying to understand these things.

We just had a lecture recently on BMI and outcomes.

And some studies show 10 to 15% decrease in pregnancy rates for women with high BMI.

And so it's like, okay, if you work so hard to make those embryos, let's really put them in an optimal state, whether that's initiating a GLP1 for a few months before doing a transfer.

Or in Paraglucose tolerance is another one of my favorite things.

It's like an A1CM5.9 is not ideal.

Embryos don't like the sugary environment.

And that's something that really can be reversed.

And so really just spending two, three months even optimizing that environment, I think can make a big difference for people with outcomes.

And the whole point is to understanding the efficiency is not a hundred percent to try to be as efficient as possible.

Stress reduction too.

I get a lot of questions about stress reduction.

It's so interesting to think about why women physicians have such high rates of infertility.

And I really do think that part of it is because of deferred childbearing.

I mean, that's undeniable in terms of medical school and residency and fellowships and all those things, but it doesn't explain everything.

I mean, even age matched controls, women physicians and women surgeons, actually especially have worse outcomes compared to non-physicians with the same age and diagnosis.

So there's something else that's going on that's beyond deferred childbearing that is playing a role.

And I mean, I think part of it is probably the stressful nature of the job and all the night shifts and all the long surgical days and that very stressful environment gets the adrenals going, gets the cortisol levels going.

And so yes, our jobs are very stressful.

How do you control for that?

I think that's a whole other conversation in terms of like maybe stepping back a little bit professionally while this process is ongoing, or maybe talking with your chief about reducing night shifts.

If you're say, an ER doctor or surgeon or an OBGYN or somebody else who sees a lot of nights, that is a whole other conversation.

But I think there's also a lot that can be done in terms of mindfulness and looking at negative thought patterns and shame and self-judgment.

We female physicians and women professionals, I know engineers, I have an engineer sister and an attorney sister.

I always think about them and their people too.

I think about how hard we are on ourselves and how our inner critic is so turned up.

We are just blaming ourselves all the time, not good enough, not smart enough, not fertile enough, whatever it is that we crack the whip on ourselves so much, too much in my opinion.

And so it's really turning that inner critic into an inner coach.

That's one of my favorite things to help people with.

So that internal environment is not as much one of stress, but one of self-compassion, truly.

Again, sounds very woo, but I promise you it works.

You kind of have to try it to believe it.

But that's one thing I help people with all the time is to turn down the dial on the stress.

And I think if there is something excessively stressful in your life, if there's a lawsuit or a sick family member or an impending move or something, I think about these very stressful situations, maybe take a break from the process for a few months and then re-engage once you know that you're not dealing with five million stressful things at once.

So that's my thought about stress reduction.

So in summary, we talked about a lot of things today.

We talked about basically the big topic being embryo banking and when to know when to start transferring the embryos.

And what I really wanted to do is debunk the myth that every single person on this planet needs three U-ploid embryos per desired child, because that's just not the case.

That's just not the case.

It depends on a lot of various factors.

It depends on age, depends on prior history, depends on what it took to get to those embryos and what can be optimized prior to a transfer.

So I think about this, say you have four U-ploid embryos in the freezer and you really want two children and you're like, I don't have six U-ploid embryos.

My doctor said I needed six U-ploid embryos before I started transferring.

I might take the approach like, hey, you have four U-ploid embryos.

So many people killed to have four U-ploid embryos.

Like that's amazing.

So why don't you do the first transfer after we make sure that every single thing is optimized that we can and see if it takes.

If it takes, guess what?

You know, you go on, you have your life birth, you have three U-ploid embryos in the freezer for your desired second child.

Done.

Case closed, right?

But if the first transfer doesn't work, and then you're like, okay, well thinking about maybe doing a second transfer, maybe that's a situation where you decide to do another embryo banking cycle, or maybe you decide to do the second transfer and then say, well, if that doesn't work, then I'm going to sort of go do another banking cycle too.

So I think there's all sorts of different sort of approaches, but I really wanted to say that in somebody who has good uterine health, especially in somebody who has had a pregnancy before, I even have clients who get like one U-ploid embryo and they only want one more child.

And they're like, you know what?

Like I'm going to transfer it.

I don't want excess embryos.

And if it doesn't work, I'm going to go right into another cycle.

I understand people can have miscarriages and their pregnancies can prolong and everything, but I really think we have to think outside the box about this.

I mean, we do that in every other aspect of medicine, like personalized care, cardiology, depression, all these other aspects, GI, like all these other places where we are understanding that each person's an individual, we really need that same tailored approach in fertility medicine.

I think we have to look at the whole picture and what somebody's goals are, what their person's situation is, what can be optimized, what can't be optimized.

My people know I'm obsessed with the Serenity Prayer.

What can we control?

What can we control?

And then make the best decisions.

So please, if you walk away with only just one thing, it's that, you know, that sort of maximum two to three U-ploid embryos per desired child, that is overly simplistic.

And you really need somebody who can help to look at you and look at your situation, look at your goals and help you create that abundant mindset and also be abundantly practical at the same time to really help you achieve your dream family and your dream goals.

So with that, I love you.

And if you have questions, send me a DM.

I'd love to help you in particular, start your situation.

More science episodes to come.

Bye.