Improve your chance of IVF success with Victoria Wigley, Embryologist

Victoria Wigley , Embryologist tells us everything you need to know to improve your chance of success with IVF. We discuss: 

- What it means to have ‘good egg quality’ 

 - Embryo grading & PGT-A testing

 - What factors will affect how many blastocysts you could get

 - How important the lab is when choosing an IVF clinic and what should be the basic requirements 

 - The importance of improving sperm health before an IVF cycle

 - Top tips to improve your chance of getting good quality embryos

Victoria runs independent IVF advice service 'All About Embryology' and has previously worked at New Life clinic, CRGH and The London Fertility Centre. 

Transcript

Unknown: 0:01

Hi, I'm Rachel Sherriff, and welcome to the fertility suite podcast. Our aim is to educate and empower couples who are struggling with all aspects of fertility. By giving you the information to make informed decisions along the way. We've had a little rebrand since the last one we were formerly the fertility method podcast. But in this second series, rest assured, we still have the same high standard of fertility experts coming to share their knowledge and support you. So if you are struggling with fertility, miscarriage or you just want to arm yourself with the facts, then this podcast is for you. Alright, everybody, and welcome back to another episode of the fertility suite podcast. So joining us this week, we have Victoria wiggly, and Victoria runs an independent embryology and IVF advice service called all about embryology. She used to work at the London Fertility Centre and the CRG h and then most recently at New Life. So welcome, Victoria. Hello, there. Hi. Thank you for having me on. No, thanks for joining us. Do you want to just let listeners know a little bit more about yourself? Just sort of elaborate on the the intro I've given you? I'm sure you can do a better one yourself? No, of course. Thank you. So yes, I've been an embryologist for over 15 years now. And as I say those are the clinics that I worked out for. I then decided about two years ago that I wanted to come a little bit more away from the clinical side, because I started to notice that there was quite a gap in the patient care. And I was finding that patients didn't really understand the embryology side of the treatment. And because of this, they were finding the treatment quite stressful. And they weren't really getting the advice they needed. The mock there was a minefield about all the add ons and everything like that. So I decided that actually I could offer patients a consultation style service, which will actually help guide them through the process. So that's when I decided to launch all about embryology, which was mid 2022. I launched that. That's amazing. That is such a well needed much needed rather like service. So many of the clients that we work with, whether that's in the clinic or online, say that they didn't have access to the embryologist and they were having IVF or they're asking us quite in depth questions about embryology. So to have someone that they can go to independently and ask questions to, you know, IVF is a minefield, isn't it? Like it's such an awesome, it really is. And unfortunately, because the embryologist clinical load is so huge, we are behind the lab door so much at that time, we have to do our patient calls so quickly that I wanted just to actually spend time with patients individually, explain results to them, explain all the terminology helped guide them with their decisions, so helped make them you know, really make an informed choice themselves and not feel pressurised into anything you they've really got to understand it. And unfortunately, having a very quick chat to an embryologist or a short consultation with a doctor sometimes doesn't give them given that help. So yeah, I feel like it is it is a needed service. And often the need actually comes sadly after an unsuccessful cycle. And often the only time you get to speak to the embryologist is sort of within that five day window when you've had your eggs collected, you know, and you're waiting about your blastocyst. So I think to have the opportunity to speak to someone for a decent length of time, perhaps after an unsuccessful cycle is where you can really sort of come into your own and offer some advice. Yeah, and review their cycles to see all the details that perhaps the doctor might not not pick up on. So yeah, is something that can actually really help patients and then help them with a sort of what next, you know, side of things as well, you know, what other treatments can they look at? And, you know, is it worth tweaking something for a future cycle? So yeah, I can really spend the time with them to do that. So today, I think we just want to bust some myths, really, and talk about some really common things that come up certainly, in our clinic, and I'm sure in yours as well, and really sort of get the answers to things that people might not know. So I think we're going to start with perhaps probably the biggest question and the thing that comes up, like the most is like what does it mean to have good egg quality? Like that phrase, good egg quality is bandied around on, ya know, people will talk about oh, all my eggs good quality, how do I how do I have better egg quality? What does that actually mean? Ya know, it's a it's definitely a tricky one. And often it's one that people get muddled with. So there's your egg number, so your ovarian reserve and your egg quality. So often, people get confused with this. So they'll do the testing, you know, they'll look at their Hmh levels and things like that. That's actually determining what your egg number is your ovarian reserve. But the egg quality is something that we don't usually know about until we get those eggs into the lab. So when we're talking about good egg quality, we're looking at how All the eggs appear so that they've got the sub cytoplasm in the middle. And so you wanted to look to see if there's any abnormal inclusions in that if there's any vacuoles, if it's granular, or if it's nice and clear, the shell that surrounds the outside of the egg is that normal in shape and thickness, or things like this, the polar body, which tells us it's the mature egg, you want it to be a nice round polar body, you don't want it to be fragmented, or things like that, what we look at to see if it's a good egg quality, that that, as I say, is something that's different from your ovarian reserve, which is how many eggs you have left in the bank. So that's sometimes what patients get getting bit muddled about. And what are the factors that affect good egg quality. So we know that age and genetics play a part but anything else, I mean that yeah, they're the main ones, you do generally see a decline as we get older, in your egg quality as well as your ovarian reserve. And that's the biggest, biggest factor really, having said that, you can have some patients who are young, and they've got a good ovarian reserve, but they might have a poor air quality. So sometimes, a typical one is where a patient is, has polycystic ovarian syndrome. So she has multiple follicles. And so then reserve will be very high. But actually, sometimes the quality is slightly poorer, because the hormones are all all slightly out of sync. So there are different factors that can affect the quality. And as you touched on as well, genetics, you know, sometimes it is, you know, a predisposed thing. But it is something that, generally age is the biggest driving force that we tend to see. Which is why obviously, you know, as patients get older, the chances of, of miscarriage and implantation failure will will increase. So age and genetics are kind of like the two that we can't really do anything about sadly. And then they're the sort of biggest components. But it's good to know that actually, your hormone balance does play a part in egg policies. When you're having IVF, you were talking about small margins a lot of the time with IVF, right? Like it's the small changes or the small, you know, you don't need big changes and things to have a better outcome. Small changes might get you a couple of more good quality embryos and maybe a couple more good quality embryos is only need lewdly hormonal component is quite small. But actually, if your hormones are well balanced, then that might be enough to get you better quality embryos accurately. It's just about optimising every angle. And the more we can optimise, you know, things like certain supplements that can now be the driving force for the mitochondria, which is sort of the energy hub of the the egg, things like that. People don't realise, but actually, that is so important as well to support. So as much as some of it is predisposed, that we can't control. There are things that we can do to optimise to ensure that really were, you know, have the patients in the best possible position before they start. Yeah. And would you agree that like a three month prep time is key given that we know that follicular recruitment kind of takes roughly around that time? What are your thoughts on that? Yeah, I mean, it's, it's the same with men and women really, for both of them, it would be ideal if you could have that prep time in advance of having any treatment. So that you can get everything balanced. You know, for instance, with the men, they they even more so than the women, they have this sort of proper cycle, where the sperm will completely be a whole new batch for the next ones. And if there are any environmental issues, you can correct those by sort of adapting lifestyle, etc. However, it's a tricky one. Because if a patient comes to me, and she's early 40s, the risk of delaying her starting could be almost worse than giving her the time to prep. So really, it's something that in an ideal situation, especially if patients are younger, yes, having that prep time is really important. But it's a balancing act, you've got to work out what the other factors are before obviously making that decision. And obviously, the best thing to do would be for them to be doing that whilst they're trying to conceive before they even consider the IVF route. So that they're in the right position and maybe things aren't quite working but they're not at the point of wanting to seek out you know, any, any professional help yet to start having all of this advice out there. You guys doing these podcasts, things like that, so people can get themselves in that position, making sure that they they're doing all the right things in preparation so that if they do need to go down to treatment, they're already there with their OPT memorization. I think that that is that is key. Really. Yeah. And you've kind of just hit the nail on the head with really what, like the best approach to IVF should always be like a tailored individualised approach because for example, you know, if you know you have low Hmh, for example, then actually, yes, you might go into a cycle quicker, but also, it's really important that the sperm health is as good as possible. Because if you've got low MH, we need to, you know, we need to make sure the other side of the of the picture is doing, or to help produce good quality embryos, really, really does need an approach that's quite individualised. IVF genuinely, really does. When it comes to embryo grading. So, like how subjective or how important you could say is embryo grading to a cycle outcome? Because I think patients are led to believe when they have their eggs collected, and you're in that five day wait window, like you're waiting to hear what grade they are, and then you're, you're going over in your mind like, oh, well, I've only got so many of that grade, or they will all grade and I'm saying that in inverted commas, like, how important is this? And how is the grading done? Yeah, so it's, it is something that I see a lot of patients put so much weight on, and they really get themselves in a bit of a pickle about it, which I try to take them away from, especially those gradings. In those first two, you know, two or three days, they aren't the be all and end all. Obviously, we're looking for a whole number of things, we're looking for the cell cell numbers, so how the rate of the developments or how fast the Ember is growing, we don't want it to go too fast. But we don't want it to grow too slowly. There are strict checkpoints in the development. So we're looking at that to make our decisions, were looking to see how much fragmentation there is. So when a cell divides, it should divide nicely into two. And this should be nice, even division, what can sometimes happen is you can have little pockets of fragments that come away from the cells. And obviously, that then makes it a poor quality embryo in terms of our grading. So they're the kind of things that we look at when we're in the early stages of development. Up until day three, then when they form a blastocyst, that's when our grading completely changes, because the embryo looks so different. So we're looking at the outer cells being nice, and even in a good number, we're looking at how expanded it is. And then a tight ball of cells in the middle, which is the inner cell mass. And we're looking to see if that if you know, there's a good cell number in there that they're all nicely compact together. So the grading is very different. At that point. The biggest factor I would say to patients is rather than getting fixated on the actual grades, especially in those early days, what we're really wanting to look at is your blastocyst development rate. Now, this is something that scares a lot of patients, but we only expect about half of your day three embryos to go on to get to the blastocyst stage. And that is completely normal. And that's a message that I constantly try and drive home to patients not to worry that then they haven't all made it. And once they form blastocysts, obviously, the blastocyst quality is a little bit more important at this stage. Because you do need strong cell lines, especially the outer cells, which people don't often think because they're not actually the cells from the baby. But they're the cells that make that initial connection with the uterus. So you want good strong cells at that point, to be able to start the process of implantation? Um, so yes, good morphology is genuinely linked to having a higher chance of a conception. But it's not to say it's not the be all and end all. And certainly day three, we can see some beautiful day three embryos that then don't make it to the blastocyst stage. And we can see some that we would have normally wanted to write off at the early stages, but actually, they're the ones that go on to form Lassis. So I do whilst we do tell the patients this information, I do say to them, you know, don't don't get too fixated on it. Because it isn't necessarily the most important thing at this point. And if you have lesser graded embryos, that doesn't necessarily mean that they won't work, right. Like I have patients all the time who have like less than what they're worrying about the grading, they have a transfer with an embryo or blastocyst that maybe wasn't great as high as they wanted it to be. And they still go on to have success, right? Absolutely. Absolutely. And we wouldn't do transfers or freezing on blastocyst that have say for instance, A B C grade, which patients say oh, that's awful. We wouldn't be freezing them or transferring them if they didn't have a chance of success. Obviously, an AE will generally speaking and average AAA over BC we'll have a chance. But there are so many other factors that are involved in conception that it isn't, you know, isn't something that patients should should worry about. If the embryologist and the doctor are happy that it is suitable for transfer, ie it's not arrested. So it's still showing signs of development. And it's not showing any signs of degeneration. Though the two big ones, the doctor and the embryologists are happy with that, then the patient has the chance of a pregnancy. Am I right in thinking over the last sort of 510 years, we've become much more stringent about what we consider suitable for freezing and transfer. In terms of I mean, different different clinics have different policies. Really, the number one thing is, most clinics now will freeze at the blastocyst stage, unless the patient's doing, for instance, a package where they freeze all at day three, and then grow all of them up. If you freeze at the blastocyst stage, the most important thing, as I mentioned, is that it's formed a blastocyst. So you don't want to be on day six, freezing a Morula, which is what it should be on day four. That's the most important thing. In terms of the actual qualities, generally speaking, as long as you can distinguish between seeing in a cell mast cells, and effective themselves, the outer cells that generally speaking is suitable for freezing. But you have to So most clinics will have a BC cut off. So if it's a CC, the C is the inner cell mass. And that means you can't see clear in a cell mass cells. Generally speaking, that's what most clinics will go by, that's the grading system that they use. At the same time, you don't want to free something that is very important, even if the blastocyst because you're then giving the patients false hope that embryo is more likely to not survive. But also, you don't want to risk the patient having too many embryos that then give them all this hope that actually these embryos are very poor quality. So that's where you get the discretion that comes in with the embryologist and we do we ask each other opinions, they'll sometimes be a borderline embryo that I would call a colleague and say, Would you freeze this? I'm not sure. So it is something that you know, we even we don't always know whether it is worth it or not. But yeah, it especially if a patient gets there only once and we'd be more likely to say, let's give you a chance with this rather than discarding it. I think that five day wait is like the hardest part of IVF? For sure. And the one other really hard thing with fertility issues and fertility treatment is there's so many grey areas, right? And we don't know it or we don't have all the answers. And actually, the way most people's brains work is we want definitive answers. No one likes a grey area, right. And that five day window is such a grey area, things can change. And, you know, we've talked about the things that can affect egg quality, so age genetic hormones, but like there's lots of things that will affect how many blastocysts you will get on top of that. So, you know, the sperm house right is really important at that point like is carries, you know, carries your genetics to the egg. Basically, it's 50% of the embryo development. So that is another big factor in how many classes potentially going to get right. Definitely. And actually, patients don't often realise it. But if we see good embryo development up until day three, which even though the sperm is there, the development is actually governed by the eggs DNA up until day three, it's only on day three, that the sperm really kicks in, and it becomes sort of an embryo in itself with both the sperm and the eggs. So if we see a high arrest rate, which is, as I mentioned before, is 50% is the norm and that's what we expect, if we're only seeing a 20 25% conversion rate or less. Actually, alarm bells, alarm bells will ring on the sperm side as well. And that's something that 1020 years ago, no one would think about at all. As long as the man had a good semen analysis, tick, everything else must be down to the woman. We're realising that is not true now. And there is a lot more emphasis on it things like looking at not just looking at the sperm counts and the motility looking at sort of the more of the the integrity of sperm looking at the DNA fragmentation levels, things like that are really important and optimising them the man as well before the for the cyclists is something that we never used to do and now is becoming a lot more sort of advisable. Yeah, absolutely. For anyone listening to this episode. By the time you listen to this, the two previous episodes will have been published and they were actually with Claire Mooney, who is also an embryologist, but also she works in a specialist fertility urologist clinic, she runs a clinic and she really knows a lot about sperm and we talk a lot about DNA fragmentation infection And then the episode before that was with Olivia, who runs the male fertility clinic. So if you're listening and what Victoria has said, has just maybe made you think about something that happened in your own cycle and you want a bit more information about the male side of things, you can go back and listen to the previous two episodes, which will be very helpful. So Victoria then how important is the lab when choosing an IVF? clinic? Like, we've talked about this five day window and actually watching your embryos growing in the blastocyst development? Like what should be like the basic requirement in a lab other than our labs different depending on where you go? When patients are choosing an IVF? clinic? Should they be asking questions about the lab services? Like how important is this in the process? Yeah, no, it obviously it's an embryologist I will say is important. The good thing about being in the UK, is we are one of the most tightly regulated clinics, clinical settings that you can get worldwide, much more so than in a lot of other countries. So we are governed by the hfpa. And they come around and they do regular inspections on clinics. And they will be making sure that the clinic level, including the laboratory is up to standard. And obviously, they have a power to close the clinic down if they if they were concerned. And obviously, that doesn't necessarily apply overseas for anyone if they were listening overseas. But that is a good thing in the UK. Having said that, there are going to be differences between clinics. And those differences can be as a result of differences in the laboratory. So it is very important. And I think patients have the right to ask their clinic before they decide to commit to treatment. Questions about you know, what the KPIs or key performance indicators are? You know, they want to be asking what the laboratories Lassis rate is, what their utilisation rate is, do they monitor their practitioner xe rates, for instance, because, you know, some, some practitioners might have a better fertilisation rate, some might have a lower degeneration rate all these things, if they are monitored, you can see standard sleeping. And you can't afford to have standard sleeping in a laboratory. And most embryologist are incredibly meticulous, real perfectionist top of the game, but it needs to be monitored, because there are going to be people coming into the labour lab that might not be following the the SOPs as well or, you know, they might not have quite as good a practice. And that needs to make sure it's checked. And so by doing practitioner KPIs, you're picking up on that. And then the general performance of the lab, that's when you're going to see things like the blastocyst rates and, and the fertilisation rates. And that's something that a patient can ask for. And any good lab will have that, you know, if it's a smaller lab, they might do it quarterly. If it's a larger lab, they might do it monthly, but they should have up to date results. So that's something that you can look at, when you're when you're choosing a clinic, because it can then show you that you can be confident in that lab and that they'll look after your your eggs and embryos and sperm as well as they can. You could argue that the blastocyst rate is perhaps more important than the life birth rate when they're looking at a clinic, right? Because you're not going to get a life birth unless you've got the blastocyst in the first place. So that's interesting, and not something that I ever would have thought of actually. So that's really good to know that, you know, if you're looking at IVF, clinics, you should be asking about blastocyst rates, as well as looking at the the life birth rates, I think we will get a bit hung up on stats with clinics. And actually, there's so many variables. And also, you know, for clinic does a lot of resource cycles, for instance, they're going to be producing embryos in the lab, but those embryos won't ever be part of your fresh results. So what patients tend to look at what gets published, and that's the fresh embryo results. Frozen ones have a lot of other factors that patients don't tend to look at those. So there is variability in statistics as well. Obviously, you know, you can't deny it, you can present results per embryo transfer as opposed to per recollection. You there's different ways of making the clinic stats look better. But if you get into the nitty gritty with a lab and say to them, I want to know your internal KPIs about all the embryos that you're growing in the lab, how many of the eggs are fertilising? How many of the embryos are forming glasses, all of that will give you a much better overall picture of how the lab is performing compared to what they're putting on their website, as to their results. That's little nugget of gold that little bit. Thank you. So let's go back and talk a little bit more about the male side of things. And XE. So we're going to talk about add on shortly. But you could classic see as an add on, right, but some for some people, it's like what we call a necessary add on. Obviously it does add on to the cost of IVF. But in certain scenarios, it will get you a high fertilisation rate, I'm assuming so like, when would you use XE? And what doesn't xe address? And then, like, what should people consider if they're being offered? xe, sometimes xe isn't so much offers, you're more most told, aren't you? We're going to use Excel, how does that process work? So IXI is for anyone that doesn't know the terminology X is where we physically pick up the sperm and inject it directly into the egg. So that's different is a different method of insemination to conventional IVF. So often, everyone talks about IVF, as is the process. But actually, conventional IVF is one main way of doing insemination and x is the other way. So with conventional IVF, you're mixing the sperm and the eggs together in the dish. Now that is usually the first method that we will consider using and less the patient has got a couple of different factors. So the biggest one is poor sperm parameters. So if the sperm concentration is low, or there's not many sperm moving, so then motility is low, or we're seeing a high level of abnormal forms in the sperm. If we try and mix the sperm the egg together and the dish, chances are they aren't going to get good fertilisation, because there aren't going to be enough sperm that to fertilise, we try and mix about 100,000 motile sperm in the dish per each well. So you need those numbers to be able to get good fertilisation. So in those cases, obviously picking up individual sperm and injecting it will help the patient's chance of fertilisation. Other factors are if they've had IVF, before conventional IVF. And they've had a poor fertilisation, so the sperm might be good. And then might the X might appear normal. But the sperm and the eggs are just not working together, you might not be getting good sperm binding on the outside of the egg, things like that. It could be that there's a hardening or or something or a problem in the sperm head. So we want to overcome that by putting the sperm directly into the egg. Now that's an effect that many people but it can happen. And we certainly do see it happening in a small number of cases. And then they have another cycle with XE and it's successful. And now another thing that we've touched on before is the high DNA fragmentation levels. So even if all the results on paper look normal in terms of the counter motility and everything, if they've got a high DNA fragmentation level, XE is a way of us selecting the sperm that are more likely not to have the high DNA fragmentation levels. So xe can help us in choosing the better sperm for for the insemination. So that's really the main cohorts of people that will need xe if we are looking at the downsides to xe, so some people might say, Well, surely you would just do xe for everyone then and risk, you know, the chance that the patient might have poor binding or something like that. And to those people, I'd say actually, no, I wouldn't advise it for everyone. And the reasons for this is, number one, it's invasive. So with conventional IVF, you're letting the sperm swim around the eggs and we're letting them fertilise naturally overnight. With Dixie we're having to get the needle and put it into the egg. So five to 10% of eggs may not survive this process because you're you're puncturing the membrane and then the membrane might not. So reform back together again in the cell, the egg and might then die. So that's the first reason. The second reason is we can only inject mature eggs. So sometimes after you had your egg collection, the doctor collects as many eggs as they can do. If they come from smaller follicles, sometimes those eggs aren't mature, but they can on occasion mature on in the lab. With xe we can only inject them at the time if they're mature. But it could be that two hours later, after you've done the XE, the immature egg may well have matured on now with IVF. We're leaving them surrounded by sperm overnight. So if they matured overnight, they've still got a chance to go on and fertilise whereas with xe we discard them if we aren't able to inject them. So that's the second reason. The third reason is as much as embryologist are wonderful we cannot guarantee that the sperm that we're picking up and selecting is a normal sperm. Obviously, we look at it with a morphology. You know, we look at it on a higher level with the sperm vacuoles in the head, but we cannot say it's a normal sperm. Whereas with IVF, there's almost a level of natural selection that goes on obviously, an utmost normal spend may well still fertilise, but you're allowing the 100,000 motile sperm to be in a very close proximity to the egg. So there is going to be some level of natural selection, where it was the embryologist is the one choosing. And then my fourth and final reason is it will add quite a significant cost on to the collection. So most clicks it will be over 1000 pounds extra. And obviously if you're already spending that huge rack of money, another 1000 pounds on top when you might not need it isn't worth it. And we see comparable fertilisation results between IVF and XE. So it's not that x is going to give you a better chance of fertilisation just because you're putting the sperm in there. It's only for those people that the IVF may not work for that it isn't needed. Yeah. Okay. And so you what you're saying is you could still be selecting sperm that had high DNA fragmentation and like abnormal, and then perhaps then the embryo doesn't go on to develop genetically as it should. So it's possible because we can't see, we can look at the indicators that are linked with poor sperm. And obviously, we would always deselect against those. But we cannot guarantee the sperm we're picking up is going to achieve fertilisation or go on and be able to result in a healthy baby goes back to about like the three months prep and making sure that sperm is Tip Top as good as it can be before you go into a cycle. Like let's talk about a little bit more in depth about add ons, then because there's loads of add ons right out there. So let's talk about add ons that are perhaps worth considering and add ons where the evidence base is not quite there yet. Add Ons is a really, really tricky area. Because in my mind, as a scientist, a lot of stuff will start off its journey, not necessarily having strong evidence based results. And that will be something that over time when you have more and more data, it may well be that it goes on and you know, it may be something that then becomes the norm. So I don't never want to rule off things. And if a patient comes to me, and they've had three failed IVF cycles and the clinic are just saying just keep doing the same thing again and again. And again, I get that you want to maybe tweak a few things to see if we can improve. Now, having said that, unfortunately, I used to always believe that you know, when the Daily Mail and newspapers used to go to town on saying how awful fertility clinics where I used to find it really upsetting to read, because I was never in a position where micro clinics I worked at would do that. Having now spent 18 months doing my independent work, I'm working with a lot of patients from different clinics in the UK and overseas. And I am realising that add ons are being unnecessarily put on patients. And this is something that may well jeopardise the safety of the patient's embryos. And it may be something that is giving them false hope when there is very little evidence. And it is going to hugely increase the cost of their cycles unnecessarily. So this is something that I am very passionate about. Because whilst I do think that there are some add ons that have a place and the hfpa do list the add ons on their website, and they've given them a grading system as to what the evidence is like. I do think that it's something that patients really need a lot more information about before they make that decision. Because if they're about to leave a consultation with a doctor, or you know, they see a receptionist who's totting up their bills, and someone says to Oh, do you want to have this in your cycle? Yeah, this was briefly mentioned to you. And the patient says, Oh, well, what does it you know, mean? Should I have it? Will it help? Well, it can help you know, we've had some patients that's helpful. And, you know, if you want to give everything, give yourself the best chance and yeah, do it. How many patients are going to walk away and say, I'm not going to do it? Because they'll suddenly say, Well, if I don't do it Am I the one to blame for it not working. And putting that pressure on patients is awful. And it's something that I am seeing does happen. And we really, really, really have to come away from that because it is not fair IVF patients are so vulnerable as it is. And something that I think the more people like yourself, and either independent, I won't get anything from my patients choosing to do an add on or not choosing to do an add on. You know, it's I have no financial gain, I have no gain in whether they get pregnant or not. I am there to tell my patients, what the evidence is, what the pros and cons are, what the risks are, what the costs potentially are. And I then want them to make the informed decision and for them to then turn around and say, if they do it, and it works, what they do, and it doesn't work, at least they've gone into it with an informed decision. And I think we need more and more of that when it comes to add ons. Yeah, absolutely. And it comes back to that tailored approach again, right? Like, yes, a specific add on might be right for one couple, because of what their clinical picture looks like or what's happened in any previous cycles or anything diagnosed that we know about. That could be completely different for another couple. And I'll be like what you said, just really hit home a little bit. And that like that puts the pressure on the patient when you're giving, dumping all that information on them. And just sort of saying, well, it might help. Like you said, of course, people are gonna then pay extra money for that. It's not like, no one ever wants to come out of a cycle that's been unsuccessful going, Oh, well, if only I'd spent the money on that maybe I would have had success. And that's the impression we're giving people when add ons are being sold wires nowadays. And it's yeah, it's a worry. So what's your advice to people considering add ons? You know, if they can't access people like us to get independent advice? Is there somewhere they can go to find more information about the add ons? Like what what sort of perhaps Yeah, but yeah, I mean, that's what I go back to saying about the hfpa website. So in the UK, and even if you're, you know, an overseas patient, you can still access this online, they do break it down into sort of what the evidence is, which patients it may be applicable to. And you know, what you know, that they also deem it is whether it's something that is worth considering for certain cohorts. And I think that's exactly what we go back to saying. There are things, for instance, PDGA, I'm very, very passionate about it not being a blanket thing that is offered to patients when they don't need it. And certainly I've seen some patients being offered it where it almost makes me angry, they're being offered it because they don't need it. Having said that, I think it is a very good tool. For certain patients. I had a patient who transferred her embryos to my clinic, because her clinic didn't offer PDGA. And she had over 10 embryos in storage. And she'd had seven miscarriages back to back and read, they've screened for everything else there was there was no apparent reason why she was having these miscarriages. Is that lady going to carry on doing 10 More transfers with these glasses and risking having 10 More miscarriages. She was broken at that point. And so yes, for her screening, and we screened them, I think about three or four came back as normal. The first one unfortunately didn't work. It was just a failed implantation. But the second one, she had a healthy baby. And so in her situation, yes, that was right for her to do. Yes, she should have spent the money. And yes, I vouch for being involved in her treatment for saying that that was right for her applying it to a first time patient who was 36 years old, just to get them that best one straightaway. No. So it's it's something that patients can have access to, you know, advice, like the HFA has to really see which patients are the ones that it should be advised to and who were the ones that you know, don't don't need it. EDTA testing is very expensive, right? We're talking like 1500 pounds, and then 500 pounds per embryo. Is that like, I mean? Yeah, different clinics have different different rates. But yeah, it will add on a good old black and on top of that, it will automatically add freezing to your cycle because you can't do a fresh transfer. So then it will also then add a frozen thaw cycle onto your cycle. So if patients see the cost of it, again, they're not necessarily given the right information because they've been given the cost of the testing of the boxing. They need to then consider that if they'd had a fresh transfer. They wouldn't have necessarily needed freezing obviously if they had separate glasses then yes, it would. But all of these things aren't often included them vacations for frozen for cycle as well. And all of these extras, the extra testings, you know, for all the steps along the way that is not just the cost of the actual biopsy and testing that they need to consider. So whilst Yes, I do believe it has its place. It's something that patients have to be be wary of if they're offered it when they don't think they need it. Yeah, and it's something else that's important to mention, I think with PGT pgti testing is that if you're going to spend all that money on testing, you need to make sure that the other more basic things have been checked, you know, is the uterus environment healthy? There's no point transferring very expensively PGT, a tested euploid embryo into an environment that's not conducive to implantation, right. So I think sometimes people think PG TA is a fix all solution. And you're, you know, like you said, it's a good tool for some patients used in the right scenario. So again, it's like looking at that individual couple and seeing what's for them. I just wanted to touch before we sort of finish up about, like AI Artificial Intelligence, because I have read a little bit online about how they're now using AI, in embryology and I always say to people like fertility, such a fast moving area of medicine. So I had my son by IVF. He's going to be 11 this year. And in that time, I look back so much has changed. Like it's so fast moving and I can't believe we're now talking about using AI in embryology like, what about this? I know, maybe there's probably but there's definitely probably still lots of grey areas? No, it certainly is a fast moving field, as you mentioned, and one that we don't know yet. It's worth, there is certainly, you know, patients who have embryos growing in the time lapse incubator, that's where it's genuinely used, because you have the camera that sits above the embryos. So AI can do a lot of the embryologist work in terms of looking at the timings of division and things that we might be laboriously going through video reels working out. What they're doing is they're often using this information to put algorithms together. And this is something that lots of clinics have been doing already. But different companies are all trying their own own methods, even things like looking at some things in the egg movement patterns and things like that, that we wouldn't necessarily pick up on their show using AI to try and detect now, I'm absolutely all for anything that can improve our selection process. But it's something that at the moment until the data is there, you know, you've got to sort of have a slight air of caution on it, because you don't want to risk saying to a patient, right, you will definitely be putting back that embryo, even though it's a very, very poor blastocyst over top quality one, which we've known for years would be our selection. If, if you see technology at where it helps us select between a couple of embryos that looking very similar, then yes, this technology is very helpful. Obviously, we've been using the time lapse now for a while, and we're already doing our own sieve analysis on it. So I think it's just a step up from what we're doing. But it's exciting to see, you know, anything in the field that, you know, has advances as long as it doesn't completely get rid of us embryologist. And into robots. Yeah. I mean, that's, it'd be interesting to see where that goes. Right. Yeah, just AI. So how can people get in touch with you? Victoria, I know, probably what you've said, it's going to resonate with a lot of people. And, you know, there's certainly gonna be people that want to get in touch with you. So what's the best way? No, of course. So I've got a website that they can go and have a look at. So that's WWW dot all about embryology.co.uk. And then I also run social media channels. So I've got Facebook, Instagram, and Tiktok. And actually, I've just set up a YouTube one where I try and put all my videos in there. So all of those are with the handle at all about embryology. So if you want to just get a little bit of sort of guidance, as you're going through just looking at stuff, I've got some videos from inside the lab and things. So best place to do with that is to go onto the social media. I also you can drop me an email, which you can find on my website, if you just want to ask a little bit more about what I can offer. Or you can put the consultations directly on the website. And there'll be one on one consultations, either over the phone or over a video call, whichever the preference is where I can help guide you through whether you're a first time patient or whether you're a few cycles in either way I can I can help you through Ray and for anyone listening. I'm going to put all those details in the Episode Notes as well so you'll be able to find links to Victoria's website in the Episode Notes. So thank you so much for coming on. That's been fascinating as always, I have learnt a lot again. That's my impatience. So thank you so much Victoria. It was lovely to meet you. Oh, my pleasure. Thank you for having me on.