3. Why IVF with Donor Eggs may fail sometimes – reasons and prospects for patients

good evening everyone and welcome to our webinar today as well and today as you can see we have a topic on why IVF with donor eggs may fail sometimes and the reasons and prospects for patients our guests here today is dr. Natalia sharp from IVF Spain who you've had a chance to previously also see and during our past webinars I believe you are familiar with her with not you will have a chance to listen to her presentation and let me remind you that the presentation will take 20 to 25 minutes and after our presentation the Q&A session will follow so if you have any questions you can type them all in in our chat section and afterwards all the questions will be answered just also let me remind you that this webinar is being recorded so you will have a chance to watch it again tomorrow and it will be published on our site as well and if you have any questions just please go ahead and ask them just after the presentation and I guess let's not waste any more time and just start with the presentation I believe you can see dr. Natalia is right here with us dr. Natalia are you ready to start yes let's go perfect let's do it go ahead Karuna thank you so much for the great introduction for those who do not know us I'm having with exhumation friends about different topics in IVF in Agra donation and animatron issues immunological issues today we will discuss the reasons why people choose egg donation what the indications to egg donation and we have to be aware that egg donation is the highest step if infertility treatment which we can offer to our patients but there are some complicated cases where egg donation fails I will explain you why what are the reasons so let's get to the point the problem is that women now especially in Europe are very modern independent they study they grow their careers and they delay their maternity plans so through the development of birth control pills in the 60s we can move our cycles however we want to and it also allows us to grow our careers and at the age of 35 this is the Navarrete age were modern European lady thinks about having children the problem is that our biological clock is not aware of this changes of this political changes so we see that before we are 35 years old we generate about 50% all the embryos which are genetically normal which are healthy so the best age to get children is before you are 35 years old the problems start between 3540 years old we see that the at the age of 38 40 only 30% of all the embryos that we generate are healthy at the age of 41 42 just 17% and when we are older than 42 years old only 11% of the embryos are so basically an IVF Spain from 43 40 years old onwards we counsel people for egg donation the euploid urate by donors we have to be aware that even though the donors are young there are no donors with hundred percent you ploidy right I have seen in my career the same donor in one cycle having all embryos genetically normal and the same donor in the other cycle having just one embryo which was genetically normal the beauty of Spanish legislation and erotic medicine is that we are allowed to do troffer to their biopsies means we are allowed to develop embryos till day five till the blastocyst age perform traffic to their biopsy means our embryologists are trained to take 3-4 cells out of which embryo and examine those DNA of those cells to define which one of them is healthy so if we see the pregnancy rates of patients with their own eggs which are older than 35 years old without genetics without traffic to their biopsy the pregnancy rates are under 20% if we put technology to those embryos we see that if we define three genetically normal embryos of somebody older than 35 years the cumulative pregnancy rate per cycle is 91% if we have egg donation cycle ooh this curve we have to be aware that there are two ways of refining which of embryos that we have is the best one to transfer one is to put embryos to the special incubator called time-lapse that is watching if embryo has reached certain stages of development in a certain time we use it an area of Spain through Gary and then the pregnancy rate per transfer is about 70% when we perform genetic are testing of embryos means instead of watching them in incubator we allow ourselves to take couple of cells out of each embryo and see which one is healthy or not because we are aware that there is no donor in the world with 100% you ploidy then the pregnancy rate per cycle is over 90 percent when we focus a lot of our attention and the genetical quality of embryos the endometrium for a couple of years new productive medicine was kind of forgotten in IVF Spain even though we were performing genetic testing of embryos in some cases I was still not able to achieve pregnancy every patient in IVF Spain before transfer gets something called mock cycle test cycle where we put patients and oral or transdermal estrogen and on day 10 of the cycle we perform transvaginal scan to see how thick the lining is in complicated cases especially with recurrent implantation failure we need to perform the uterus lining biopsy means on day 21 of a substitute cycle where patients are estrogens and transvaginal progesterone we perform not only the scan but also the uterus lining biopsy in IVF Spain it's this is an office procedure were in gynecological chair the patient is put like through the simple sneer test we're with the people we aspirate a little bit of the uterus lining and we send it to immunological testing and to receptivity testing when we see the results what is it all about the results for receptivity are coming back and they're very straightforward means the patient with five and a half days of transvaginal of progesterone could be receptive pre receptive or post receptive in order for embryo to get accepted through the lining there has to be a certain timing for that we have to be aware that in the uterus lining there are immune cells that can see embryos a foreign body and k cells th1 th2 cells and also there has to be a search and communication between those cells and this communication is summarized through the test called and the matram receptivity assay where we know exactly if five and a half days progesterone opens implantation window if this is the perfect timing for embryo to arrive to the lining to get accepted or not I started performing in cross activity si about five years ago and it was a very complicated German patient that have never had a positive pregnancy test in Germany and also with us and with the second egg donation cycle the last embryo that we transfer was with the receptivity of seven days means the tests that we have done showed us that patient was pre receptive then we corrected the dose of progesterone confirmed the biopsy the confirmatory biopsy came out with seven days receptive and this was the first time where the patient achieve a pregnancy and live birth this encouraged us to perform receptivity sa test basically after first transfer that in egg donation did not achieve a pregnancy I do not wait for recurrent implantation failure in egg donation I do not wait for three transfers which fails basically if the first transfer with embryos of a good donor did not result in a pregnancy before the second embryos Johnson IVF Spain we perform the lining biopsy to failure with own eggs where the pregnancy cannot be achieved in their home countries they're coming for egg donation and then the egg donation through good quality of embryos of a young dawn or can be converted eventually to a good prognosis patient we have to be aware that in egg donation cycles the pregnancy rates are age independent means if somebody is 35 years old and suffers of premature ovarian failure or if there's a patient in her menopause in her late 40s early 50s we still can achieve the same pregnancy rate in order to talk to patients about certain quality and high pregnancy rates the key is blastocyst development genetical testing of blastocyst will define when in egg donation cycle it should be performed receptivity essay and immunology so day 5 embryos are called blastocyst there are a lot different from day three embryos day three embryos are called more ULA's they have just eight cells ten cells so you can imagine if somebody makes a progress from eight cells 250 200 cells in two days only only the strongest embryos are going to make it and this is the natural selection of embryos in IVF Spain egg donation is the highest level of a productive medicine which we can offer you there are certain steps of choosing the donor the classical matching of donors is performed in four steps the first step means that egg donation in Spain is anonymous we can only offer you anonymous donors you will never see a picture of a donor you will never be able to choose yourself a donor you have to have so much trust in a cenar team that we select a donor for you sticking to certain rules according to the Spanish law we have to generate a child that will explain the combination of you so when we meet one day and your child we run around us everybody has to think that you are a genetical mom so we have more than 500 donors available for you we speak regularly to young students that they should have children before they are 35 years old or they should perform social freezing to have extra set for themselves and then if somebody performs social breathing and decides to be our donor we offer then social freezing for free the donors that we have are tested also through psychiatrist know schizophrenia no major depression disorder no personality issues allowed genetical recessive diseases in European population like cystic fibrosis muscle dystrophy in the second step of donor choosing process you will be asked to fill in cannot type questionnaire where you will have to tick boxes how tall are you cut off hair cut off skin what is important for you which characteristic of yours yes donor shall have you will be also asked about the blood type match if you see it as something important or not we will also explain you how to speak to the child about egg donation if communicated to the child or not and in which way that the child is from my donation from Spain we also will need your pictures when we have all this information we put your data to the computer computer will show us 20 best donors available for you out of 500 and then eventually all the doctors that work in IVF Spain we meet every week every Tuesday we discuss all complicated cases with negative results and we also performed donor matching means before your donor is chosen I have to introduce your case to my colleagues my colleagues which speak different European language as they introduce their patients to me and this is how we find the best donor for you in selected cases we receive patients from African Americans from the United States with sickle-cell disease with thalassemia where we match donors also through genetical tests in order to be sure that donors are not only carriers of the most content this is the European population but also AB the population specific diseases for patients that did fail first egg donation cycle in IVF Spain or patients which we receive from different clinics which fail egg donation cycles in different clinics we do not only perform the phenotypic al match the way you look like but also we want to look deeper into your case we do not only perform your receptivity sa test of the uterus lining but we also perform the immunological testing there is the very well described here AAA inhibition through HLA c1 c1 embryos first published by my group in Chicago Hill Pierrot and in IVF Spain we were able to confirm it so sperm analysis and Rho G is very straightforward in IVF Spain we perform all always bass experiment Alice's according to the World Health Organization criterias from 2010 where volume concentration motility and morphology has to be examined we also perform more extensive tests where we perform DNA fragmentation if we see a high fragmentation and any issues with the sperm analysis the patients are put on vitamins we have a certain protocol and then are invited to fertilize eggs with the fresh sperm sample if we see that everything is okay that a sperm analysis and the day of first appointment comes back normal sauce per make everything is okay we freeze this sample and then we fertilize fresh eggs off at dawn or with the frozen sperm of a patient and we have the same pregnancy rates and same blastocyst rates at with with fresh results when the sperm quality is good so in order to talk about high success rates in egg donation cycles we have to develop average to the blastocyst and either put them to time-lapse incubators or to be more sensitive we have to perform genetic testing of embryos in the serious reproductive medicine in egg donation starts with exclusive egg donation programs when patients are offered 16 20 X of a donor in IVF Spain we give patient guarantee of 5 embryos blastocyst are guaranteed and then if we perform genetic testing of embryos we see that either one or all embryos could be genetically normal that's why statistically they euploid rate in a clinician cycles is about 70% if we have more than 6 blastocyst so complicated cases sometimes it takes them a longer time to understand why they cannot get pregnant especially when they have low AMH low ovarian reserve then we perform cycles cold and real banking means we generate three four blasters in one cycle three four in the following cycle in two-three months to achieve the magic number of six blastocyst and then as dependent we see there is four or one genetically normal this is what some patients achieve in couple of cycle donor basically achieves in in one cycle donors are young with high AMH in order to be done I don't know we have to have IMH more than two nano gram per milliliter more than six antral follicles and then your employer rate is about 6070 % so here are the pregnancy rates of IVF sparing in 2016 without genetic hair testing and with genetic testing so this are the clinical pregnancy rate per transfer without genetic are testing the clinical pregnancy rate per transfer is 60% clinical pregnancy rate per transfer with genetic our testing is about 75 last year it was 77% the cumulative pregnancy rate means pregnancy rate per cycle after three consecutive transfers is more than 90 percent in IVF Spain so the the problem that we have is the the major problem that we have is the genetic equality of embryos which is age dependent and you see here even though somebody's young can be a donor under 20 under 30 years old 28 years old we see that there is a low number of genetically abnormal embryos that this person can generate before coming to Spain I used to work 12 years in Germany and I remember from my own experience also young girls invading coming to two gynecologists looking for help because they were pregnant with trisomy 21 so in the older we are getting them more genetically abnormal embryos regenerate but also young patients and also donors can generate embryos which are genetically abnormal not as many as patients over 40 years old and so when shall we perform genetic testing of egg donation embryos so there was papers published two years ago showing that in the United States there are different centers with different euploid right here we have different countries in Europe so what we have seen in our egg donation program that you ploidy rates are very high are over 80% so basically when you're coming to IV of Spain in the first attempt with the first donor we do not perform genetic testing of embryos of this donor routinely but we are still aware and we inform our patients that there is a 20% unemployed your rate of embryos of an egg donor so when you see this paper and there are centers with 39 40 % euploid you write of course in such Center you should test Andrus of a donor routinely if you have a center that is specialized in egg donation you know if you explain we're on more than 600 tech donations itís a year then and you see this deployed you're right then PGs genetic our testing of egg donor donor embryos is performed usually when when the second egg donation cycle is done because the first didn't work out what the employer aid seemed to depend on and and the protocol which is used to stimulate to achieve the eggs of a donor we have to be aware that the protocols are AMH dependent each donor before it's allowed to be a donor is screened for for infectious diseases karyotype a.m. age and then when somebody has a MH to means good ovarian reserve you get to 25 units of hormones that stimulate the follicles grow when somebody has a MH 5 or 7 means you're you have a great ovarian reserve you're going to generate a lot of X so that's why at the goal in egg donation cycles is not to produce too many eggs the goal is to achieve 2025 X maximum to have a good quality of them and of course somebody with a MH 7 will receive just hundred 50 units of hormones to stimulate the follicles grow aspiration methodology is very important there are centers where there is a lot of things going on in operating theatres and the the negative pressure which is used is too high it what can we expect that that the eggs through this the negative pressure are changing the shapes and that the quality of this kind of embryos could be lower so it's very important to adjust the pressure when we perform the egg retrieval the culture medium and pH it a lot depends on the balls of the lab who is in charge I can tell that the rods that I work with are my blessing there are very well trained we have four senior embryologist we know each other professionally very well we are also friends but these people when they come to work they are very focused on this what they do they basically just perform biopsies of the embryos they have no time to perform egg retrievals with us or transfer that is these procedures are done by by young cambree ologist so the success depends a lot on the gynecologist that knows which dose of hormones should be given to certain donor would you say I'm going to dependent but also depends a lot on the lab how the lab is organized and the experience of people in charge here one of the last slides that I have for you today so as I discussed previously the serious reproductive medicine the serious pregnancy rates start with sixteen twenty fresh acts of had or nor the protocols FSH LH adjusted to your AMH in the last two years we performed more than 20 cycles PGS cycles and month especially when the second egg PGs needs to be performed when I leave Spain has such a high employer AIDS probably not I believe that in the future their clinics who will be able to show this kind of employer AIDS will be able to survive and PGs will be a factor which will allow to decide of the quality of this lab of course the prospective study with with the bigger numbers are are needed I think that's it for today thank you very much for for listening today we have in Spain bank holidays so it's a Spanish Father's Day if there are father's from Spain all around the world I wish you on that day take your decisions and become patient of IV of Spain thank you perfect thank you so much dr. Natalia for your presentation and explaining us everything I believe we will now go to our Q&A session there are many questions ready for you and so let's not waste time and go ahead with it what is this access per 8 percent for a 550 a that's just ok if I have the day five embryo without genetic are testing the clinical pregnancy rate means gestational sac where the heartbeat sixty percent of cases is positive when I have embryos with genetic are testing it depends in Aly explain our 2016-2017 it's about seventy five seventy seven clinical pregnancy rate for transfer all right thank you so much for the question as well as the answer let me have a look at the next one for you mm-hmm how to fight Donald transverse and war one era what difference does a second era make okay so you have to see when you have them they're different timing and dimension timing tests available the one that we use tells us exactly if you are pre receptive receptive or post receptive and indicate how many hours more or how many days more protester only you need to be receptive and the first test that we perform is with five and a half day progesterone the confirmatory biopsy is usually done with when the result comes out to be pre receptive and the confirmatory result is done with six point five days progesterone if the result comes back to receptive again then we recommend either seven or eight days progesterone seven is quite common eight in my entire career a dispro tester and I've seen maybe three times in my entire life so in selected cases especially when you belong to recurrent implantation failure in egg donation means three transfers with good quality blastocyst of a donor and not pregnant there's no mercy there is no chest it has to be verified the timing of the lining has to be verified very specifically I hope this is good to answer your question all right perfect thank you so much this question as well and let me have a look here it is the next one what is the price for fresh egg donation okay in IVF Spain we have prices depending on the quality of embryo the the day development of the embryo and how many embryos we guarantee the best programs that we have first one is called exclusive egg donation where we give you a guarantee of three blastocyst of a donor three day five embryos and the price is nine thousand seven hundred euro when we talk about exclusive plus a donation we give you a guarantee of five blastocyst this program gives you a lot security means if we see that the cycle with the dawn or to do gold the way we would expect that and we just have three day four embryos three blastocyst and you are not pregnant then the new donor has to be stimulated for you without any extra cost to fulfill the five Blastoise guarantee then in one package you can have two donors and it's ten thousand seven hundred euro we have Dimond program with pregnancy guarantee where we offer patients three different donors there are nine transfers in total the last cycle is with the sperm donor and this cost twenty five thousand euro thank you so much for explaining this to us as well and let me have a look and the next question for you here it is that's thyroid result matter mine was 2.44 thyroid results do matter in internal medicine we want TSH to be between zero point four and four in reproductive medicine we want TSH to be under two so basically if you are between two and four internal medicine doctor will say it's okay in reproductive medicine which read it why it's super easy to understand the baby in the first three months of development I need folic acid and thyroid hormone for the proper brain development so that's why the TSH in our productive I'm not sure if you guys can hear me there is a problem with a connection if you could just repeat it we didn't hear the last part of your answer okay yes internal medicine here sees thyroid not as strict as reproductive medicine in reproductive medicine we want TSH to be under 2 or all the results more than 2 hour treated all TSH under L thyroxine are controlled every 3-4 weeks the reason for this is that in the first trimester in the first 3 months baby for the proper brain development needs tyroid hormones and folic acid so that's why we need to give more thyroid hormones that's why TSH has to be lower alright perfect thank you so much for letting us know of course and let me have a look my first fresh donor egg transfer ended in a miscarriage and since had to fail frozen transfers last cycle had producing fredison progesterone protein or a baby aspirin Clare flexion and intra lipids and still failed only having one frozen embryo left what tests would you recommend okay the king has been covered – the first question is how old are you are the embryos transferred genetically normal or abnormal or this is an egg donation cycle and how high are the employee rates of this donation center the question is are our embryos healthy or not healthy some embryos look good have a good morphology but still are genetically abnormal so this will be my first question and the second question will be auto sterile doing what is the timing of your endometrium doing so I would consider before the last transfer the uterus lining biopsy to see how many days progesterone you need to open your implantation window last week you can imagine it was a very busy week for me for me I had one doctor visiting from one country I had two guys missing from from UK and what what happened was they were very interested in our receptivity testing so basically we send or give doctors that collaborate with us a kit for receptivity say and then if you want to we can send it home to you we can we can develop collaboration with your doctor to check it before that the next transfer so feel free to drop an email to our patients at IBS pain calm and then we'll be more than happy to help you thank you so much for this question and answering this one as well and let me have a look the next question for you here it is would you recommend one or two blasters is transfer to improve success I am 41 when we talk about blasters culture we recommend always single embryo transfer because the twin rate with blastocyst it's over 30 percent we have to be aware that twin pregnancy for us are always high-risk pregnancies it means you have to go to the doctor more often your cervix length has to be monitored and when the cervix is too short we forbid you to work we put you to the hospital that for you it means c-section in Europe and in the United States nobody delivers twins normally anymore okay so definitely single embryo transfer thanks so much we have another question here have adenomyosis and MTHFR gene mutation so would i have chance of implantation with adenomyosis I've had two miscarriage a stillborn and to find ivf your adenomyosis it's just an immunological factor for us in the first 12 weeks of pregnancy I don't know meiosis is endometriosis of the uterus wall so basically when patients are downregulated the endometriosis or other non meiosis is not growing anymore and when patients are put on basically prednisone in the productive time medicine is given until 12 weeks of pregnancy to make immune system come down so with with prednisone majority simple immunological issues we can take care of them very well the problem that you have met and I do not like it are two miscarriages and stillbirths the most common causes of miscarriages is genetical quality of embryos which is age dependent so you definitely if we still work with your own eggs you definitely need a cycle with genetic are testing of your embryos stillbirths i I'd not like it at all means patient with stillbirth are always counseled through hematologist for factor 5 mutations and some of them deserve even though in in Hemet o j– everything is ok but because of stillbirth i would consider in your case giving you clicks pain until you deliver so this is how you know knowing only this brief this simple information that you're giving here this is how I would approach your case all right let me have a look at the next question for you we have had three five donor i we have transfers and our clinic is now advising a ki r HLA test how will this improve our chances it depends which Kieren HLA are you if HLA is matched your Q properly this will bring you to pregnancy rates of everybody else in in egg donation the problem that we have with Kira and HLA is that here AAA is very well published and established here B I can tell you from experience we ourselves we struggle so if you're a curator case is pretty straightforward with kill B it's it still remains a challenge perfect thank you for this well and let me have a look and would you recommend pgs testing for all egg donation blacks must assist yes y-you can imagine I started doing myself PJs testing an egg donation because I received patients from Berlin and I'll never forget it this was a case that changed my life and changed reproductive medicine in IVF Spain upside down the patient was offered an exclusive egg donation program we were we generated six good-quality a be quality blastocyst and the patient kept having miscarriages and you can imagine I was trained in Berlin so it's a very small world doctors know each other the patient came back to me with a result of her genetic genetic examination from the miscarriage material and it turned out that she had a miscarriage with trisomy 13 embryo and there were embryos of the donors so you can imagine that after this kind of cases doctors get a lot more gray hair at once and I was nervous I was expecting a lawsuit but on top of this both of them were lawyers so the patient came back and said no we want to continue working with you we are happy but the second egg donation cycle that we have to do with we asked you to do it with PGs and the patient got pregnant with those PGs embryos transferred immediately the first trial born in Europe through egg donation was born in Berlin in a hospital which I know very well and this is how it started so in 2016 we reserved PJs for second egg donation in patients who failed first donor and we were able to see that with PGS we have better results shorter time to pregnancy then without so I think that teachers it's a future in IVF spend you have 80% you ploidy rate so if we should do it routinely in this moment in this moment no but I think in a future this will be a standard okay thank you so much for this and let me have a look at the next question straight away we had our last frozen embryo transfer November what's the best time to try again timing is one thing but the second thing is we have to focus why did the first transfer didn't work what happened is your endometrium growth proper they are not only the thickness is their timing that the receptivity has been performed or not this answers yes shall be given before the second transfer will be undertaken I do not like to transfer in the same protocol when the first transfer didn't succeed I always want to change something yeah and we can transfer every two three months but if we keep repeating the same we are you know it's like taking USMLE tests and repeating the same mistakes in the test so at the end you're gonna fail so you have to see you what have you done wrong to improve it and do try again right thank you so much let me have a look at the next question here is there a bad and good care result how does the care test helps you in egg donation no there is no bad and good here there are things this medicine that are examined and better known than the other ones so in transplantology when we transplant to somebody kidney or liver we have to make sure that the blood type matches that certain HLA are matched in a B subtypes with kirei a we know because he'll be at all from Chicago they published couple of years ago that kirei a accepts the c1 c1 embryos and he never explained I was able to confirm it about Kirby there's no papers published here B is very in homogenic means some Kirby's react as a be some as BB and then sometimes it takes two donors to find which immuno log immuno G the skill B accepts better so there is still a place for reproductive immunology – maybe not say kearbey but take a look to the kearbey genetic expression subtypes and saying this cure B if there is no D s for or the s5 this is here B which except c1 embryos and if the other receptors are missing this maybe except C c1 c1 so medicine needs to take like a deeper look to cure be cure a is known so it's not a problem at all alright thank you and we have follow-up to the question in fact so let's have a look at this now do you match the donor here to cure woman with the donor or care donor to HLA of the male partner how does the Kier HLA matching work we match here to HLA so you're here as a recipient is the one which decides which HLA of a donor you need we do not only match here to in egg donation cycles we also take a look at EF cycles and then if there is a cure mismatch then we put patients and in logical protocols the the reason for for immunological protocols with tacrolimus the medication which is allowed for kidney transplantation studies may be of sparing two years ago a friend of mine gynecologist was my patient and she needed my help she came with tacrolimus protocol from germany and I understood that certain care demands say it certain HLA of a donor but it's not enough you in order to talk about success with certain key HLA mismatch you you need not only prednisone but tackle is Milano's had protocols so in a tear-stained we have it defined which which with which problem Nordica problem what kind of protocol we recommend to our patients thank you so much and let me have a look at the next question how strong after a fate egg donor transfer can you try again basically you can try in the next cycle but the question is does it make sense I would recommend you to use one cycle to find out why the previous transfer didn't work what is your team you know what you're doing what is your receptivity doing and then transfer in two months so give yourself a month to find the diagnosis what has gone wrong and then transfer here's the next question for you I had to fight donor egg cycles in the last number of months and my clinic don't feel we need to do an era test and as I've had a successful pregnancy previously on egg you recommend prior to our next transfer I have seen in my career patients receptive with five days and they were getting pregnant with the first agglutination cycle and the same patients I've seen two three years later with seven days receptive with the second egg donation cycle and what can I say if you failed to donation cycles to you need to know water column is it a problem of low you ploidy rate of egg donation embryos in the cycle is it a problem of your immunology is there a cure HLM is that is the receptivity window yeah and these three factors need to be examined so if your clinic doesn't feel they need to do something after you failed to act on ours I'm not sure if this is the right approach I would like to know myself yeah what is the problem I would like to have one one drawn or more good quality embryos you other embryos day three day five development these are this you know details that need to be looked into deeper okay so if you feel psychologically strong enough for the third engine or cycle I I invite you to be a patient are fine yes pain to check this at least three main reasons why it has not worked before okay thank you so much for explaining this to us well let's have a look how old are your donors on average is it possible to have their name or some sort of contact in the future donors according to the Spence legislation have to be under 35 years old in area of Spain we want them to be under 30 years old no names no pictures no contact with donors are available we can only tell you age and blood up of a donor when you are pregnant nothing else perfect thank you for explaining that for us as well and let's see many doctors say yatta tears the implantation window only in the tested cycle what is your opinion no it tests implantation window in a test cycle but I perform this to transfer I performed the same type of cycle we in here Spain we do not transfer anything in first cycles anymore everything is in substitute cycles so patients receive 15 days estrogens five days estrogen and progesterone so I can move the knowledge from the test cycle to transfer cycle and from my experience and I used the receptivity essay or receptivity map now more than five years so from experience usually the error map that has that that we are using idea Spain held the same result for for a long time what what is changing the receptivity a miscarriage DNC birth of a child and even though you know somebody delivered a child and comes for the second one we repeat the protocol success and there are some cases that we repeat the protocol of success it's not working and then we verify another receptivity si so in some cases in 20% of cases 25% of cases the receptivity is changing through through these three things that I named thank you so much I am 45 and haven't had a period for two months can I still get pregnant with IVF what are my chances of success with my own eggs who has donor eggs okay amenorrhea means you do not have a period there are different reasons for amenorrhea if somebody doesn't have a period for two months it does not necessarily mean that you are menopausal you need to see your ovarian reserve him-8 antral follicle count yeah there are three factors of ovarian reserve now when your AMH is less than one nanogram per milliliter we know that getting pregnant with your own eggs it's going to be extremely difficult because you are not going to generate too many eggs and then your euploid urate means number of genetically normal embryos in your age is less than 10% you have to generate 20 X 10 blastocyst one of them will be genetically normal I can tell you from my experience I have never seen this kind of cycle in my life the you ploidy rate there the magic number for deployed embryos is maximum 43 I haven't seen anybody pregnant with own eggs older than 44 yes oh definitely because of your age and you ploidy rate you should go for egg donation and with your eggs without genetical testing the chance that you'll be pregnant is less than 10 percent if I find genetic normal embryos in your eggs that the pregnancy rate is 70 percent with egg donation the pregnancy rate is 70 percent but the problem is that in your age you are not going to generate genetic the normal embryos I'm sorry it's as cruel as it is but it's better to to see this chart age-dependent euploid right and be and be aware where you are and take proper decisions okay thank you so much for explaining this for us as well we you receive questions similar to this one so I guess all have been answer to and lets me let me have a look next question is very similar we had one before like this but if you could just shortly answer this no egg donation in Spain is anonymous means we can only tell your age and blood group of a donor when you are pregnant the child will never find out who the mother is in any age but according to the law of this country the child has to fit into your family has to have the donor has to have the same cut of hair cut of skin the same body shape as a patient so when the child is born everybody has to think that a patient is a genetic Imam I am aware that there are two worlds of egg donation first anonymous and the other one non anonymous this is something that we have in the United States or in UK that the child at the age of 18 years old can find out who is the mother in Spain absolutely not when you are becoming a patient of IVF Spain we teach you how to speak to the toilet well there tried is from there are beautiful books in English where at the age of 2 3 years old we recommend you to read a fairy tale to the child before going to sleep and in this fairy tale this is the first moment when the child understand that the part of the of of the child is from from Alicante at the age of 8 9 years old we recommend parents to go back to the clinic to show us – show the clinic people are coming back for Christmas bring us tons of chocolate I usually go with the children from you know one department to another – don't – – donors I cannot go to the nurses we go to the marketing department and then children take pictures with us they make like a family book they put these pictures with us inside and then I understand that there is a part of them from Spain so psychologically you have to know when to speak to the child the best is before 10 years old to have that identity process closed and yeah we'll be more than happy you know to have you on a board and explain you how can we choose the donor for you in an anonymous way without showing you information of a donor but how to make your life and the life of your child through the proper counseling as good as with an open ID donor perfect thank you so much for giving us an idea of how it all works I believe it is very important for everyone we do have a few more questions we will be slowly finishing but let's try to and answer some of them I'm 33 and a half premature ovarian failure I'm having menopausal symptoms instead considering starting HRT will that affect my chances of donor eggs working no HRT you know you have to be aware that there mean age for the menopause of women in Europe is 4550 years old you are too young to live without estrogens estrogens make us feel young make us look good and you cannot leave you know with that with the side-effects of of not having estrogens then we need to do egg donation cycle we will put you on a and a substitute cycle with estrogen and progesterone and you have the same success rates as as everybody else who who is having regular periods thanks so much and let me see we do have another question here we have had three fight IVF donor transfers on our last September we had an intimate room biopsy and in the scratch and each related infusion what would you propose going forward I may sound like a broken record there is the first thing do we know if the embryo of the donor that we are transferring are they three day five are the genetic normal genetically abnormal and then an emotion biopsy did the result came back receptive is the dolls at the time of that progesterone given to you being corrected in so deep it why NK cells have they been tested or not I would consider maybe prednisone out consider maybe blood clotting flexing aspirin to add and then if the first thing donations like is not working we have to see why excellent thank you so much and let me see we do have another question hi I haven't had my first implantation yet I live in UK and normally send my ultrasound or IVF Spain how will you know when my endometrium is ready for implantation as you mentioned about the right timing so after having our diagnostic history us copy my cycle is delayed should I be worried by the way I am 44 okay in egg donation cycles we erase your age so the pregnancy rates and inclination cycles are H independent and how would I know if your lining is working or not the first thing is a patient history where patients coming to you have to speak to your patient and the 80% of success you you you reach when you are a good listener if the patient tells you listen I have been pregnant four times in my life I had four miscarriages then you know that this lining is working then routinely we do not perform receptivity si before the first transfer if the patient comes to you and says to you I have never had a positive pregnancy test in your in my life so this is the moment where you should do the uterus lining biopsy or at least endometrial scratch to improve the implantation in the egg donation cycle so this is how I know somebody's in the bathroom is working or not working alright thank you so much and we have another question would you always recommend a fresh transfer over a frozen transfer okay I'm gonna say it and I'm gonna sign it in IVF Spain we have higher success rates with frozen genetically Norma embryos then with fresh ones so if I have a younger donor and I know this donor and I know that she has a high upload rate and I know that this lab has a highly ploidy right you can go for the first transfer but if if I have I hope you can hear me but if I have adorned or that is matching you for know typically but I know that she doesn't have how you ploidy right because I have seen you know couple cycles with her before then definitely you need P just and then you need you know embryos which are genetically selected for you thank you so much I had chemical pregnancy in my last de frozen amber transfer do you suggest I follow some protocol in my next transfer that's me having chemical pregnancy affect my next F et transfer the biochemical pregnancy is a very good news for us means that the uterus lining is working but you need to go further you need to allow yourself for one transfer more and maybe a melodica protocol maybe prednisone maybe flexing a spear into improved courting this will be the way to go in the next transfer perfect thank you and let's me do you accept HIV patients yes we do they're one of the most crazy presence which I've ever received were from my parents my mom a couple of years ago desperately wanted me to go back to the United States and you know over take her office it wasn't meant to be but I was closed for three weeks in very famous school in New York where I was preparing myself to USMLE and believe it or not the life expectancy of HIV people now through modern medication is the same as everybody else what I am very specific about and it has to be clear for everybody when we work with HIV positive male partners the sperm has to be washed because we have to be aware that even though in your blood the viral load could be low undetectable under five copies still in sperm in the white blood cells in sperm they there can be particles of HIV so our lab when we know that you are HIV positive is always doing sperm washing freezing making a piece year of the work sperm to make sure that other no HIV virus is in in the sperm so we always actually patients are always the fertilization takes place with the frozen sperm so this is the first thing this is the male part the female part it's super straightforward to in Europe and in the United States we have centers for HIV patients you have to go to your doctor every six months and then the the medication has to be adjusted to you so the viral load is low so you will have the same life expectancy as everybody else and then on the day of a transfer when we have a female hiv-positive patient then we're taking the look when half she had the last HIV testing in blood and how high the virus viral load was and I'm famous in clinic for counseling patients that if the viral load is high you cannot have a transfer and the Deauville transfer you have to be undetectable your HIV viral load has to be under five copies in a milliliter and yet all the children that we have in IV of Spain born from hiv-positive parents are HIV negative so through this hard work sperm washing sperm breathing HIV undetectable on the day of the transfer we have all children born healthy thank you so much for explaining this for us as well we have only a few questions left let's have a look I have two frozen Amber's already and three be blue all I need hatching for my first implantation it's usually decided by the doctor and embryologist yeah the hatching embryos seem to implant better so if the first transferred in the work out yeah maybe hatching here in North Africa and blood clotting support maybe this is going to help a perfect thank you so much we have two short questions from the same patient first one is what is the age limit and the next one is is there a weight limit at the clinic okay age limit is 50 years old and 11 months you can imagine that the oldest patient that we had an idea of Spain was 54 ah so this moment in your life where you have to see the law but also a case and individual support for patients weight can be mi there is no weight limit we transfer embryos the first transfer is done and the patient weight is not important if we see that you are more than you know 90 kilos then we recommend you to choose your weight we we have one of the nurses working with us was my personal trainer and my nutritionist and me myself I lost more than 20 kilo with her so we have a protocol and we teach you how to eat you have to have five minutes a day three big ones and two small ones and then the weight training everybody's like afraid of weight with weight training you can lose a lot more than I would cardio yes so if we need to talk about it we'll be more than happy to support you thank you okay we have three questions left so let's not waste time and here it is and there is just me in the UK stating that intro lipid infusions are not effective and as a result many UK clinics no longer offer it what is your opinion yeah the intra lipid with MK cells there are no big prospective studies showing that intra lipid improves pregnancy rates and aware of the study but I'm also aware of cases of patients with high end chaos in there in endometrium with with intra lipid they got eventually pregnant so in IVF Spain when we see high NK cells in endometrium will still perform in television fusions but in endometrium are there any exceptions and the chart can and the information about the genetic or instance some genetical disease or other cases yeah a very good question routinely never child can get to know who are whose genetic on mom if we have life-threatening disorder somebody needs a bone marrow transplantation super serious serious cases I don't wish is anybody we have to go to the court and then the judge decides if we can give you an identity of a genetical mother and of the family then we have to go very individually but routinely never the identity of the mother can be known through the trials and a family never thank you so much for explaining this and this will be our last question for today look Spanish shoes are often dark hair olive skin what is the volume of squares confer blonde hair blue green eyes egg donors look at me there is a lot of international students now in Spain in universities in the clinic when you see our pictures on Instagram or Facebook you can imagine that we are very international so majority women so there is a big Ukrainian immigration now Tori Conte in order to work correctly with patients the 500 donors that we have are divided into four groups cannot help one goes with blue eyes no type to green turn or type 3 brown eyes no type 4 goes from Asia and Africa difficult phenotypes so our donor department has to make sure that we give a balance in all the phenotype groups yeah so it's super easy to find donor with you know brown eyes so – to fulfill you know to make the fennel type 3 group complete it's super quick for our donor department if we see from type 1 or 2 it's more difficult but in order to run so many cycles knowing that donor can have eight cycles or six live birth donor department has to find donors with don't hair blue eyes and green eyes so we can run the clinic properly it's more challenging but through collaboration with with universities talking to students and then it's worked miles1 with us good experience she recommends us to her cousins to her family so the percentage with phenotype one two and three even it has to be 150 donors in each group phenotype for girls from Asia and Africa are more challenging African donors we have we differentiate patients very well we understand that a girl from Nigeria needs a different donor than a girl from Ethiopia on top of this one of our colleagues except Africa and she a doctor so she differentiates different shades of black I grew up in Detroit area so I'm also aware when I look at somebody where where this patient is from girls from from Asia are more challenging waiting time is about three four months but it's still doable all right perfect thank you so much we had all the questions answers I believe but of course if you have any other questions remember you can forward them to ours to our email patient at egg donation friends calm and we will forward them to dr. Natalia and I'm sure she will be able to get back to you okay I believe and that will be all for today thank you for joining us thank you for your questions and of course thank you dr. Natalia for being here and for your expertise and answering all the questions it is always always a pleasure and I can't wait for the next time there's is there anything else you would like to add thank you very much for listening in the Spanish Father's Day I wish listening to your future father's to support their female partners in their dream of making family complete come true I didn't have a chance today to talk much about on Georgie but when you will come try the F Spain we'll be more than happy to have you help you and and explain you what can we do for you better perfect perfect summary so thank you again and have a good night everyone hope to see you next week as well during our next webinar thank you bye bye you good night good night

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