A guest post by Dr. Saiprasad Gundeti, Chief Embryologist, Malpani Infertility Clinic which discusses what makes a top quality embryologist.
Embryos are graded in the IVF lab routinely, according to their appearance ( morphology) under the microscope. Good embryos are called Grade A embryos, and have a higher chance of becoming babies.
Strong practical and theoretical knowledge
The scientists who are responsible for taking care of your embryos in the IVF lab are called clinical embryologists. We are involved in fertility treatment and reproductive research and need a practical and theoretical understanding of human reproductive biology, embryology, infertility and assisted reproductive technology (ART).
We also need to keep up to date with current regulations and legislation involving these subjects. Just like you have Grade A embryos and Grade B embryos, you have good embryologists - and bad ones. Unfortunately, patients don't know much about what happens in the IVF lab and what embryologists do, so this article will shed some light on the role we play in your treatment !
What skills does an Embryologist need to have in order to do the job well?
- One should have a solid scientific background - a basic degree in the life sciences is a must
- At least 1 year of supervised hands-on practical training on the job.
- One needs good hand-eye coordination and excellent spatial and motor skills. Your eggs and embryos are microscopic, and need to be treated with love and respect.
- An obsessive-compulsive personality. The success of IVF depends upon an obsessive attention to detail. Embryologists need to be anal-retentive, and each embryo needs to be treated as an individual patient
- Patience. Biological processes cannot be hurried, and we need to respect nature and work with it
- Curiosity. We need to learn all the time. IVF is advancing rapidly, and we need to read journals and attend conferences, to keep upto date
- Empathy. We interact directly with patients when we show them their embryos, prior to transfer. We need to understand our patient's fears and anxieties - and educate them about what we do, so they have realistic expectations about their treatment.
What's a typical day like ?
- We work for roughly 8-9 hours every day, but some days can be much busier ( for example, if there are a lot of egg collections on one day). A good embryologist never looks at the clock when in the lab- he focuses all his energies on his work !
- IVF treatment works to a strict timeline. Procedures such as fertilization checks , and freezing and thawing , need to be done at a specific time, based on the embryo's development
- There are many regulations, so I make sure we record everything we do, and sign off each procedure.
- We document everything carefully. I give patients an update about their embryo development ; and provide them with photos of their embryos routinely.
- We have an active freezing program, and routinely cryopreserved eggs and embryos.
Typical work activities
The work of a clinical embryologist involve:
- The collection of eggs and sperm (gametes) from patients for processing
- It is critical that the embryologist double checks the name of patient who is undergoing egg collection with the surgeon and the OT team
- The embryologist needs to scan the follicular fluid that comes from the operating room into the IVF lab. It is critical that the embryologist takes his time while screening this fluid under microscope, so that he doesn't miss an egg. You need to be patient and thorough and cannot allow the surgeon to rush you. Each egg is precious, as each represents a potential baby!
- The collected eggs should be placed in HEPES buffered medium to ensure there is no drop in pH
- The collected eggs should be immediately transferred to CO2 incubator
- The dishes should be properly labelled with the patient's name.
- When the sperm sample arrives in the IVF lab for processing, the embryologist should ask for the patient's file to cross check the name on the container with that on the patient's file
- Once the sample is processed, it should be immediately kept in the incubator.
Sperm preparation after Surgical Retrieval ( PESA and TESE)
It is now possible to retrieve sperm directly from the testes and the epididymis for men with azoospermia ( a zero sperm count). Epididymal are usually motile, so processing them is usually straightforward. However, identifying and retrieving testicular sperm can be quite challenging, especially in men with testicular failure.
You may need to look for hours - and have to process multiple biopsies to find the sperm, if there are any. Clever techniques such as using RBL lysis buffer to remove the red blood cells; and enzymes to dissolve the tubular tissue can help to make dissection easier. Many embryologists do not have the skill or patience to be able to handle these difficult samples.
It is critical to handle the gametes and embryos under controlled conditions. They should be handled only in the laminar flow hood workstation to prevent contamination
While doing IVF is easy, how well an embryologist can do ICSI separates the true experts from the merely competent. ICSI requires a lot of dexterity and patience - especially when there are very few sperm. It's very easy for novice embryologists to kill the eggs during ICSI by applying too much pressure - or to fail to do the ICSI properly by not applying enough !
Lots of hands on experience - and doing at least 200 ICSI cycles annually are essential to maintain the high degree of skills needed to do ICSI properly. This is not something which can be rushed !
- The fertilization check should be done by inspecting the zygotes on an inverted microscope under high power , to differentiate a normal 2pn embryo from an abnormal 3pn embryo. This high power magnification also enables accurate scoring of zygote quality.
- It is critical that we evaluate the embryos every day and grade them.
- We give patients an update about the development of their embryos; and discuss the possibility of cryopreservation of their supernumerary embryos.
- Which embryo to transfer ; which to discard; and which to freeze is one of the most important decisions an embryologist needs to make ! The embryos should be evaluated on the inverted microscope , one by one.
- We need to discuss how many embryos to transfer - and on which day to transfer them - Day 3 or Day 5. This will depend upon many factors, including: the law; the clinic policy regarding SET ( single embryo transfer) ; the patient's preferences; and the embryo quality.
- Patients should be shown their embryos , so they can admire them !
- A summary of the IVF cycle , including the pictures of embryos should be printed and given to the patient; and stored in the EMR ( electronic medical record).
- Cryopreservation of eggs and embryos should be done after taking consent from the patient.
- Records need to be diligently kept, regarding the grade of the frozen embryos, their unique ID number, and where they have been stored in the liquid nitrogen tank. also storage details.
- Pictures of the frozen embryos should be kept for records and emailed to the patient .
- Proper record of embryos frozen should be maintained.
- The liquid nitrogen containers should be regularly checked for the level of.liquid nitrogen and topped up.
- When the storage period for which patients have paid has expired, they should be informed , so they can decide whether they want to extend the cryostorage of their frozen embryos , or if they want to discard or donate them.
- The embryologist should ensure that all equipment is regularly serviced to avoid malfunctioning.
- He should regularly check the temperature of CO2 incubators, stage warmers of stereozoom microscope, laminar flow hood workstation, micromanipulator. It's not good enough to rely only on the digital display of the instruments !
- The CO2 level of incubator should be checked every alternate day and should be calibrated in case of any discrepancy.
- The pH of culture medium should be checked once in a week and the CO2 % of the incubator should be adjusted accordingly to achieve a ph of 7.3.
- Keep a track of shelf life of culture medium and disposables; and ensure you have enough inventory to manage your workload. Culture medium is expensive - so don't over order - but make sure you do not run out of supplies either !
- Proper records should be maintained for all the procedures performed.
- A log book should be maintained for regular check of temperature, CO 2% and ph of culture medium.
- Having an EMR ( electronic medical record) can simplify your life considerably !
Communicating with patients
This can be the highlight of my day , especially when the embryos are growing well. It gives me great pleasure to see the joy on the patient's face when they see their embryos - and it's a matter of great personal pride that I have played a key role in their IVF success story !
Sometimes I do need to give patients bad news as well ( for example, when there is total failure of fertilization). It's best to be factual and accurate , and I never try to hide the truth, even if it is bitter. If there is a problem, be upfront with the patient - and we discuss possible solutions for the future.
Communicating with the doctor
IVF is a team effort, and I talk to the clinicians ( doctors and nurses) daily. I review the status of the embryos; and also discuss future cases, so I am prepared for challenging patients. I share interesting articles and research with Dr Malpani , to improve his knowledgebase about embryology ! I do my best to make sure I know a lot about each patient who is taking treatment at our clinic.
Being an embryologist has made my life very rewarding. I am not just an embryo handler - I am helping infertile couples achieve their dreams ! This is a very fulfilling career, and I love and enjoy what I do !