DEFINITIONS OF TERMINOLOGY

1. Assisted Reproductive Technologies or ART-Collectively the medical procedures that are specialized treatments designed to increase the number of eggs and/or sperm, or bring them closer together, thus improving the likelihood of pregnancy.

2. Anti-sperm Antibodies or ASAB-Antibodies present in either the serum of blood or in semen. The presence of anti-sperm antibodies in the semen causes the sperm to stick to each other, therefore, ICSI is used as the method of insemination.

3. Blastomere(s)- The term used to refer to a single cell of at least a two cell embryo.

4. Gametes- reproductive entities from the male and female. Male gamete= Sperm; and the Female gamete=Oocyte or egg

5. Embryo Biopsy-The micromanipulation procedure whereby a single blastomere is removed from a six to eight cell embryo for the purpose of Pre-implantation genetic diagnosis (PGD) prior to transfer of that embryo to the uterine cavity.

6. hCG-Human chronic gonadotropin-Injection taken 36 hours prior to egg retrieval to mature oocytes within the ovary.

7. Beta hCG-Blood serum hormone measured 11 and 13 days post embryo transfer to determine a chemical pregnancy.

8. Estradiol-Blood serum hormone that increases in response to ovarian stimulation by hormonal medications.

9. Ovarian Stimulation-Hormonal medications are used to produce multiple mature follicles on the ovary, rather than the single egg that normally matures each month.

10. Ovarian Hyperstimulation-Occurs when the ovaries have responded very well to the hormonal stimulation. As a result, higher levels of serum estradiol is present. Usually embryo cryopreservation is performed instead of embryo transfer. If the patient becomes pregnant, there is an increased risk of the patient becoming very ill.

11. Semen Analysis-An assessment of an ejaculate by determining one or more of the following parameters: sperm volume, sperm count(how many sperm there are), sperm motility(percentage of sperm that are moving), sperm motile progression(percentage of sperm that are moving progressively forward, and sperm morphology(the shape of the sperm).

Terminology According To Timeline

DAY 0: Egg Retrieval and Oocyte Insemination

EggRretrieval-Ultra sound guided procedure is performed by the physician whereby oocytes or eggs are harvested from the follicles on the ovary. This procedure is performed under anesthesia administered by a nurse anesthetist. The entire procedure takes on the average of 7-12 minutes.

Mature Oocytes-Eggs that have completed the first stage of maturation which is exhibited by the presence of the Polar Body structure. This egg is ready for insemination.

Immature Oocytes-Eggs that are slightly immature because they have not completed the first stage of maturation. As a result, no Polar Body is present. These eggs do have the capability of maturing while they are in the incubator.

Germinal Vesicle Oocytes-Also referred to as GV's. Very immature eggs that require at least 24 hours to mature in culture. They are not available for insemination and are discarded.

Polar Body-Structure present outside of the cytoplasm of the egg that indicates that the egg has completed its first stage of maturation and is ready to be inseminated or fertilized.

Cleaning of Oocytes-There are two groups of cells that surround the egg. They are the corona radiata (the cells attached to the zona pellucida) and the cumulus oomorphous cells(surround the coronoa radiata). In order for ICSI to be performed, these cells must be cleaned away from the zona pellucida. The cleaning process is accomplished by both a chemical and mechanical means. The eggs are exposed to an enzyme that helps to break down most of the cells. To completely remove the corona radiata cells, the egg must be pipetted in and out of a small bore glass pipet to shear away those tightly attached cells. Once this is done, then the egg is naked, and the maturity status of the egg can be determined by the presence or absence of the polar body. It is possible that the cleaning process can reduce the number of eggs to be ICSIed because not all of the eggs survive the cleaning process. If an egg is fragile, it will probably not survive the cleaning process. Sometimes all of the eggs survive the cleaning, however, it is not uncommon to lose 1-5 eggs.

Vacuoles- Fluid filled sacs located in the cytoplasm of the egg

Capacitation-Process sperm must undergo in order to fertilize and egg. Sperm must be capacitated for standard insemination, but not for ICSI.

Day 1:  Fertilization Assessment: Expect phone call to discuss fertilization results and to receive tentative embryo transfer time for 2 days later if transfer is to take place on day 3

Pronucleus or Pronuclei-The structure or structures that are present within the cytoplasm of the egg that houses the chromosomes from the sperm and the egg. These structures are present 12-18 hours following insemination.

Fertilization-The presence of pronuclei in the cytoplasm of the egg.

Zygote- Term used for a fertilized egg.

2PN-Two pronuclei are present within the cytoplasm of the egg. This represents normal fertilization.

IPN-One pronucleus is present within the cytoplasm of the egg. This represents either parthenogenic fertilization or the coming together of the two pronuclei.

No Evidence of Fertilization or NEF-The egg is not exhibiting any pronuclei. The egg may be unfertilized or the two pronuclei may have gone into syngamy(the coming together and disappearance of the two pronuclei in a normally fertilized egg).

3PN-Three pronuclei are present within the cytoplasm of the egg. This represents abnormal fertilization, and the zygote is discarded today.

Zygote Cryopreservation-Cryopreservation of Zygotes will be performed on this day for either of these two reasons:

1. Patients have at least 20 2PNs. If so, 15 2PNs will remain in culture for embryo transfer, all remaining 2PNS will be cryopreserved.

2. Female patient is exhibiting signs of ovarian hyperstimulation.

Day 2:  Embryo Cleavage or Cell Division (Expected cell division range is 2-4 cells)

Embryo Cleavage or Cell division-Zygote undergoes at least one to two rounds of cell division. Once cell division occurs, the zygote is now referred to as an embryo.

-If there were 4 or more 2PNs, the culture dish is not pulled out of the incubator today, therefore, no phone call.

Day 3: Embryo Development Assessment (Expected cell division range is 6-8 cells) Patients must be available by telephone in the morning

-Assessment of embryos will be performed first thing in the morning. Patients will receive a telephone call to discuss the status of the embryos. Decision as to whether embryo transfer will occur today or in two days will be decided this morning based on the development of the embryos.

Minimum Criteria to Culture to Blastocyst-There must be at least 3 embryos that are 8-cell or greater in order for the patients to become candidates to culture to blastocyst. Usually, if the minimum criteria is met, we recommend that the patients culture to blastocyst. However, there are other factors that could possible affect our recommendation. Some of those factors include:

1. Age of patient-Patients that are 40 years old or older usually have a day 3 embryo transfer. All of our patients that are 42 years of age or older that are using their own eggs, have their embryo transfer on day 3 always.

2. Patients who use surgically extracted sperm for insemination generally do not have good embryo development when embryos are kept in culture beyond day 3. Most of these patients will have a recommendation to have their embryo transfer on day 3.

3. The Number of embryos between 6-8 cells-The fewer the number of embryos that are between 6-8 cells, and the more comfortable the patients with transferring all that they have between 6-8 cells, then they will get the best embryo because they are taking them all. If however there are more embryos between 6-8 cells than what the couple feels comfortable in transferring, then it will be our recommendation to culture to blastocyst.

Embryo Grading-Embryos are graded prior to embryo transfer consult. Our grading system is on a scale of grade I—the best, to grade IV—the poorest. Definition of the grading system is as follows:

1. Grade I-Embryo exhibits equal blastomere size and no fragmentation.

2. Grade II-Embryo exhibits equal blastomere size and 10% or less fragmentation.

3. Grade Ill-Embryo exhibits unequal blastomer size and/or 20% or greater fragmentation. Vacuoles may be present.

4. Grade IV-Embryo exhibits unequal blastomere size and 50% or greater fragmentation. Vacuoles occupy greater than 50% of the embryo. Embryo can also be dark, indicating that it may be beginning to die.

Arrested Development-On day 3, if embryos are less than 6 cells that may have arrested or stopped growing.

Blastocyst culture-Either all or the excess embryos remaining following an embryo transfer are cultured two to three more days to give the embryos an opportunity to develop into blastocyst embryos to be embryo transferred or cryopreserved. If embryo transfer is not performed today, and embryos will be cultured to day 5, you will not come in today. You will receive your appointment time for the day 5 embryo transfer later today.

Blastocyst Development Rate-The average rate of development of an eight cell embryo on day 3 to a blastocyst on day 5 is about 50%. This is an average of all patients. There are patients that have 100% blastocyst development; in other words, for every eight cell embryo they have on day 3, they get a blastocyst embryo to develop by day 5 or day 6.

Zona Pellucida-The proteinous coat that surrounds the cytoplasm of the egg/embryo, and the structure that the sperm bind to in the initial steps of the fertilization process. The zona pellucida should become thinner as the embryo develops.

Assisted Hatching-This micromanipulation procedure is performed on embryos for embryo transfer on day 3, immediately prior to the embryo transfer. A very dilute acid is used to create a small hole within the zona pellucida of the embryo to assist the embryo in hatching out of the zona around day 6. Damage to embryo with this procedure is less than 1%. The following is the criteria for assisted hatching:

Day 5: Blastocyst development and embryo transfer; no phone call, patient arrives at appointment time.

Blastocyst Embryo-Embryo that has been in culture for a minimum of five days. The embryo is now progressed to be greater than one hundred cells. The blastocyst is a cavity that forms within the embryo. The cavity of the blastocyst embryo will be at one of the following stages of development:

Fully Expanded Blastocyst-Can occur by day 5. This embryo is now available for embryo transfer or embryo cryopreservation.

Expanding Blastocyst-The cavity has quite become fully expanded. This embryo is available for embryo transfer. If not one of the embryos selected for embryo transfer, then it will be cultured one more day. If it is a good blastocyst on day 6, it will be cryopreserved.

Early Blastocyst-The cavity is very early in its development, and there has been hardly any expansion observed. This embryo is available for embryo transfer. If it is not one of the embryos selected for embryo transfer, then it will be cultured one more day. If it is a good blastocyst on day 6, it will be cryopreserved.

Hatching or Hatched Blastocyst-Blastocyst embryos will begin to hatch out of the zona pellucida around day 6. These embryos are hardly ever available for embryo transfer, however, they are cryopreserved. Because they are out of the zona pellucida, they do have a tendency to be more vulnerable to the freeze/thaw process. Some of the hatched blastocyst do survive and go on to initiate pregnancies.

Blastocyst Embryo Grading: There are three vital components of the blastocyst embryo. They are:

1. Inner cell mass-Should be visible within the blastocoel cavity. This group of cells will ultimately give rise to the fetus.

2. The Trophectoderm Layer of Cells-Should be proliferative which gives the blastocoel cavity and opaque appearance rather than transparent.

3.  Cells at the periphery of the embryo: Should form "hills and valleys" as opposed to being flat in appearance.

EMBRYO CRYOPRESERVATION

Embryo cryopresrevation is the process whereby water is slowly removed from the zygote or embryo and the water is replaced by a cryoprotectant. The cryopreservation process slowly takes the zygotes or embryos from body temperature to room temperature to -196°C when it is finally plunged into liquid nitrogen. The zygotes or embryos are kept frozen until thawed. In the frozen state, all the embryos physiological processes have ceased, therefore, there is no aging of the embryo occurring. The physiological processes resume upon thawing.

The zygotes and embryos are cryopreserved in straws and are grouped either singly, in pairs, or no more than 3 per straw. At the time the embryos are being cryopreserved, the embryologist will take into account the total number of embryos being frozen to accommodate the best number of be thawed out in the future.

FROZEN EMBRYO TRANSFER (FET)

A frozen embryo transfer cycle can be performed as follows:

1. Natural Cycle-This is an option for patients that have normal menstrual cycles. Patients will be monitoring their LH surge and when they detect the surge which indicates that they are ovulating, then the embryo will be thawed and transferred seven days later. Less expensive than the replacement cycle, however there a some medications to be purchased.

2. Replacement Cycle-The patient will be taking hormonal medication to control her cycle. The timing of the embryo thawing and transfer can be planned out because of the control of the cycle. It is more expensive than the natural cycle FET because of the expense of the medication2.

Embryo Thawing: Reverse process of Embryo Cryopreservation. Cryoprotectant is slowly withdrawn from the embryo and the water moves back into the embryo.

Zygotes: Were frozen at the 2PN stage. These are thawed out 2 days prior to the scheduled embryo transfer. They will be looked at the day following the thaw and you will receive an update phone call. Embryo transfer will be the next day.