Kim Kardashian & Understanding Embryo Grading

Dr. Amber Klimczak and Dr. Beverly Reed discuss how Kim Kardashian chose which embryo to use. They also discuss the concept of embryo grading. They discuss common grading systems, what they mean, and questions to ask your doctor about grading.

Transcript

Speaker: 0:06

Hi, I am Dr. Beverly Reed,

Speaker 2: 0:08

and I'm Dr. Amber Klemczak, and we are Two Peas in a Pod. Welcome back, everybody! Alright, Dr. K, I've got a celebrity story for you. Gosh, I hope I know them. This is an older one. It's a Kardashian. You know I love my Kardashians. True. And there's so many of them. There's a lot of them. But admittedly, it's one of the older ones. Fertility stories, but this is about Kim Kardashian. Okay. And a long time ago, she did end up end up undergoing IVF. And from what she shared, I think it's I'm actually not even She got to the point where they needed to figure out which embryo they were going to put in. She had multiple to choose from. Yes. She's in a good position to be in. Yes. And this is always a hard decision for patients just in general. Very. Which embryo should we put in? And ultimately, she did choose the highest graded embryo and I would say that's probably what most people choose, right? I'll talk about some exceptions to that. And so I thought maybe we could talk about embryo grading overall. We did actually have a special request this week to talk about embryo grading, and I do feel like this is probably one of the things that stresses my patients out the most, embryo I think it's something that it's feels black and white, but they really grasp on to, and I think from our side of things, it's really not black and white. It's something that can be very subjective. And so it's hard for me sometimes to relate it properly, I think to my patients because, and we'll talk more about it, it seems really straightforward when you hear an embryo grade, like your letter grade at school, you're like Yeah. Yeah. And it's just not quite that simple. And I think even the concept of giving an embryo a grade is a funny concept if you think about it. We don't really grade people. Okay. And even, for example, in a pathology lab, when somebody sends tissue, we don't grade tissue overall. And, so it's odd that we would grade embryos to start with. But I do want to explain just to our general audience. What we're specifically talking about is patients that are undergoing IVF, in vitro fertilization. We stimulate the eggs to grow in our patient. We pull the eggs out. We add their partner's sperm to grow embryos. And then the embryologist looks at each embryo and assigns a grade. And I think number one, there's so many different ways to grade, right? Yes. Yes, definitely. There's different systems that are used by different labs, even maybe different embryologists within the lab can use different systems. And we can talk about a few of those, but I think there's more widely accepted ones that are probably more people have heard of and probably can relate to, but sometimes even if you ask your friend, if they're going through IVF at the same time as you, hey, what was your embryo grade? They might tell you something and you're like, I don't understand. That doesn't sound anything like my embryo grade. Yeah. And can I tell you too? Sometimes if a patient has done IVF elsewhere, and I'm asking them and I'm looking at their records, sometimes I'm even looking at their grading and I'm saying, wait a second this doesn't look like a traditional grading system, and even I have to look into it as a fertility specialist sometimes to figure out what system they're using. Okay, let's talk about probably one of the more common ones. And I would say most people use the Gardner scale to grade embryos. And I would say I usually see a couple of modifications on that. So we can talk about it, but maybe we can just start with kind of each component of it. So for most people, they're going to get something that has. Three things. A number to start with, and then two letters. And so maybe we'll talk about the number first. So do you want to talk about what does that number mean for grading? Yeah. So an embryo is round, if you can imagine. It's a sphere, but when we look at it under the microscope, it just looks like a circle because we're seeing it to be plain. And so when we look at the size of the embryo and how it's shaped, And the size or the expansion can change as it starts to actually hatch out through what we call the shell of it through the Zoda, right? It will start to hatch and then sometimes it can completely hatch out. So the number that's given to it really depends on how big is it getting and how much has it hatched out of its shell or even completely hatched out. Yes. And one of the common questions that I'll get about this part of the Emory Grading Score is what is considered a good number? And this is interesting because you would think maybe the highest on the scale might be the best number, but that's a little bit controversial I've seen. And the reason for that is a six, that's the highest. A 6 means the embryo has completely hatched out of itself. And that's great, it means that embryo is growing and advancing and everything, but here's the thing, sometimes those can be a little bit more difficult to actually transfer. Because without that protective shell sometimes it's even harder to survive the freeze in the fall. But then even in the embryo transfer catheter, because they don't have their shell, they're so sticky that you want to make sure they didn't stick behind on the catheter as you were doing the transfer. And that's something we routinely check for. Anyways, every single time we do a transfer, we talk to the embryologist, look into the microscope at the catheter and say, did the embryo stay in the catheter or did it actually go in the patient? We go check those things. But I think that's why Maybe more people would say an ideal score would be like a 4 or 5. What do you think? Yeah. I love 6s. Oh, you do? Because it turns into a true beauty contest. If you needed to post a picture of an embryo. Oh, that's true. A 6 is just so gorgeous. They're so beautiful. Because they're like completely out of their shell. Yeah. Like they're hatched. They're just like perfect little embryos. But I agree. This is actually something that's changed as I've moved to different IVF centers because I think it's an embryologist. Really, in terms of whether they prefer to freeze an embryo with a partial shell around it or not. I used to transfer I feel like a lot more sixes and I know that our embryologist prefers for them to have a little protective shell. So I hardly ever see sixes now in our lab. Do you feel similar? Yeah, I think that's, I'm saying we throw out the ones that don't have a shell. I think your favorite stage is six. I would say my favorite really cool when it's frozen. I just, I'm like, that's a picture perfect embryo there. But, I would say this too, does that mean any of the lower grades aren't good? I wouldn't say that at all. I'd say a 3 is good, a 4 is good. I don't really see 1's or 2's very often, because usually if they're small, we'll try to get them to do their own, right? Yeah, a 1 or a 2 will typically, during the process of development, the embryologist might mark that If they're checking an embryo early, let's say on day 5 it's not quite ready, they may mark it as not as expanded, but they're not going to get biopsied or freeze it, it might be marked as that, but I feel like for the most part they're going to wait for a 4, freeze it. Yeah. Okay. Let's move on to that kind of middle digit there. So the next part of the embryo breeding score is a letter. And this is a little tricky because it depends on if you're following that actual Gardner scale versus if your lab has made a modification, because the letter may be. A to C or A to D. And I do think that's important for interpretation when patients get these results. And sometimes they go Googling and because maybe they're misunderstanding the scale that's used, sometimes they may attach a different significance to their grading results than what would actually be the case. But that middle digit is specifically grading the part that is the inner cell mass. Which is the part that would eventually become the baby if the patient is pregnant. And can you tell me because, and here's the thing, Dr. K actually has special experience in this. She has worked in an embryology lab and she got to great embryos. So can you tell us what would make an embryo or an inner cell mass an A versus a C or D? Yeah, so the inner cell mass, if you can imagine, it's almost like a ball of a bunch of stuff. Okay. Okay, and that ball can maybe have not so many cells and be really asymmetric and maybe even have some pieces breaking off, fragmenting off of it and not look so good. Or it can be a nice, tight little ball of cells with tons of cells when they pull in and out of the microscope and look at it in a 3D field and it looks really good. very symmetric, right? And so typically we assign the pareidias the most symmetric and cellular intercell mass when we have an A. And then maybe if it's not so symmetric and has slightly fewer cells, a B, and then C would have even maybe more fragmentation, or not as much symmetry, not as many cells, right? But still to the point that the embryologist feels. This is an embryo that is able to be frozen and has reproductive potential. Awesome. Okay, so then we've got our last part of the grading, so this one's going to be another letter which can go from either A to C or A to D, and this next part is grading the part of the embryo that will ultimately make the placenta. We call this the trophoblastic cell. And so can you tell us a little bit about what could distinguish between that as well? Yeah. The embryo we talked about the inner cell mass, and then you have the trophectoderm, which is actually just almost like a little line of cells all lined up around in a circle around the inner cell mass, and these cells can look interesting. I would say with the higher graded trophectoderms, They're really nice and plump cells. There's a lot of them. Very symmetric, right? Look nice and circular. And to the embryologists, especially if they're going to take a small sample of them, a biopsy is enough for testing. They want it to be nice and juicy, right? And have a lot there. But sometimes it can look shabby, right? It might not have a lot of cells, really flat. And, flat trophectoderm cells maybe fragmentation, little pieces breaking off around. So that would be more so like a lower grade in C. So you can see it's just like a spectrum for them. They look at it, they see how many cells are present, what do those cells look like. And so now that we've talked about each individual component, when somebody gets their breathing back, it could be, for example, anywhere from a 5 or 6 AA, an amazing looking embryo, or it could be something like a 1DD or 1CC and then anywhere in between. And I do think this is so hard because I actually bring this up when I'm talking to people about ID. IVF to start with. And I say, look, when you're sitting in this chair, you and your partner are thinking of course, ours are going to be AAs, right? Why would they be AAs? Mine weren't, and, that's how, and I love the positive thinking, right? But really, what's most common, what would be more an average kind of grading is going to be lower than that, right? And so I think it's good first to just set expectations that these 5 6 AA's are pretty rare, and that the average person is going probably going to have lower grade important embryos. Yeah, definitely. And just like in general setting expectations that your embryo is going to get a grade of all. Yeah, that's true. Yeah. It's just shocking when someone calls you and they're like, Oh, your embryos are these. You're like, these? I'm on A's. Okay. But then this is a really important point. I almost wish I had my slide that I usually show patients. Okay. is what can embryo breeding actually tell us? Okay, so number one, and this is probably the most important, is embryo breeding cannot tell us if an embryo is genetically normal or abnormal. And it still even surprises me, even though I've been doing this so many years, I've seen a beautiful AA embryo be completely abnormal, and one that we knew we shouldn't even use. And then I've seen a CD embryo be genetically normal. Grading tells you nothing about genetics, right? Yeah, definitely. I actually participated in a study that I think is relevant here when I was in fellowship. I will say, remember, the person assigning the grade of your embryo was an embryologist. And in general, embryologists are actually very good. Okay. Great. at choosing normal genetic embryos without realizing it. If your embryos are not going to be genetically tested, and they're just going to choose based on which one of your embryos in your group, or cohort of embryos, is the prettiest or highest graded, that is more likely to be a normal genetic embryo. We actually have the data to back that up. So I think that's important also to understand because that's where a lot of confusion comes about the difference between tested embryos and not tested embryos. Because even if an embryo is not tested, it is having a selection process that the embryologist is going through. It's not just a random selection. Sure. And I think since you brought up breeding too in terms of the embryologist. It's so hard because you'll see strict graders and easy graders. Just like we've all had teachers growing up in school, some teachers will just dole out the A's, and other teachers are so strict, and I will say, my opinion is, our embryologist is very strict, don't you think? Absolutely. She's one of the strictest. Yeah. It's called strict. Yeah, she gave my embryo back to me! Oh my god! You could never have a really great embryo! Oh my god! My husband was like, what? But yeah, another interesting study. My mentor actually looked at this thing, which shows slides of pictures of embryos, to a neurologist. Clinics and have them graded and then actually show the same ones without realizing it to an embryologist. Ah! There is of course inter and intra observer variation in grading, so you can show the same picture to an embryologist on a Monday and the next day and they might grade it differently. Yeah, before and after lunch. Just like everything with humans, we feel differently about things. Highly subjective. Really depends on who's grading and who you think are grading them. Okay then I'm interested because I know you used to grade embryos. Were you a strict grader, or were you I feel like I was right in the

Speaker: 14:31

middle.

Speaker 2: 14:31

Because I was so fearful that the embryologist would do something else wrong. So you really hedge for whoever you're working with, right? That was like the story of me being left. You know when I would be right. Oh, beautiful. Yeah, I would be like, it's okay, we'll interview you. You can do it. In my eyes, you're an AA. Even if you're female. Yeah. I would be too nice of a boy. Yeah. Probably good to just have that as my background. Okay, here's a common situation I would end up in, and you have to tell me if you have the same thing. I call my patient and give them the embryo update and say, okay, great. Then they call back a couple hours later. They googled. Yes. Okay, and in particular Anna, their embryo has the letter C in it anywhere. They googled, they're panicking, they're calling Do you see that happen? Yes but I try and maybe squash some of it on the phone call, but it doesn't always work. But yes, I agree because I think people just have concerns, especially because The letter C in an embryo, like we just said, can mean all sorts of different things to different people out there reading. But the question that you really want to ask your doctor is, in your lab, what is the reproductive potential of embryos that have a C in it? In our lab, it's very good. And I really give my patients that reassurance, especially if maybe that's the only embryo that they're working with. And I think, number one, too is that there's very limited educational information out there about C3 embryos, and in fact, now we can actually refer them to this podcast, too, and, hey, here's your green again, you should listen to our podcast. And here's why. So I will say there are many labs across the U. S. that if they see an embryo with a C in it, they actually do not use those embryos. And because of that lab may not know the potential of an embryo with a C. And in fact, there's not very many studies, and I understand why some studies don't include those embryos. They want to make those studies applicable for maybe the average IVF cycle, but because we have that lack of data, that lack of information, I think it's really hard for patients to really understand what is going on. But a hundred percent what you said about it depends on the lab. It's so important to ask them, what are, what's your data showing for your lab? Because I've been other places before and I've looked at the numbers where having a C in the embryo really did lower the reproductive potential. So lower implantation rate and even higher miscarriage rate. However, even in those cases. I'm going to say give them a chance because some of them still work too. Maybe it didn't work as well as an AA, but why would you not want to at least have the chance to use an embryo, even if it's not at higher chances as some of the other embryos available too. Yeah, and some of the data that I'd like to see is obstetrical outcomes even with differences in the grading for the trophectoderm. And then there's some math, like something that I was curious about is if you have a lower score for your triovective arm, which ultimately becomes the placenta, is that associated with any obstetrical outcomes? Like any placentation disorders? I've been very curious to see that. I'm surprised no one's looked at that before. And again, it's so variable, right? It's based on lab. But I think it's something that we've even in our patient population. Yeah, absolutely. But one thing that I do think is helpful when we're in particular looking at that trophoblastic tissue is if you have a lower graded trophoblastic tissue, sometimes we will talk with the patient to think about whether we still want to do genetic testing. Like maybe we could plant pain in the beginning. Now I could say this is probably not common elsewhere, because this actually does take a lifetime, because in that moment, once you know the grade, that's when sometimes you may consider your decision to genetic testing based on direct advice from the embryologist. But even let's say the embryologist grades an embryo as a seat, she made graded as a C and you like, hey, there's still plenty self from me to sample versus she may give it a three and say, You know what? Part of the reason I gave it a C is these cells look really fragile, or they don't look like there are many of them. I'm just worried if I do take a little sample of these cells, could there be the potential that this could impact the reproductive potential of the embryo, even if it is genetic? Yeah, and that's a rare thing. Yeah, most of the time we don't have that concern with embryos that are grown all the way out. day 7, which are called blastocyst embryos. But yeah, occasionally remember the trophactoderm, that outside part, that's what we're trying to rely on to implant, right? To attach inside the uterus. And so you worry if you take away too many of the cells and it already wasn't so good, maybe you're even impacting its ability to stick on plants. But the hard part is there's not really much data on that because we know if you have a highly graded embryo, A's or B's, there is clear data showing that doing genetic testing does not harm the embryo in any way. What we don't really know is what about a lower graded embryo because remember some people don't even use those at all. So it's a bit of an area that really needs to be studied further. But, back to our labs of data, we've been following our data very closely, and if an embryo has a C in it, it is performing as well as that use of the Bs2. And so that's why we can confidently tell our patients in that situation, hey, based on our data that we have so far, which we've only been open a little bit over a year, we've actually been seeing really positive results. Now that may go back to the fact that maybe Dr. Yang is a really strict creator to start with, right? Yeah. Somebody else's C, maybe somebody else's B, for example. And again, that's what makes it study. But one topic of interest that I think, which I know you'll love, because you love AI and ChatGP and things like that, is the potential for AI to help us with embryo breeding. Have you seen anything about this recently? Yeah, tons. It's all over the conferences, all the medical conferences. They're really trying to figure out how can we use a computer, examining these embryos for symmetry, for cellularity, and all that kind of stuff. And maybe taking out a little bit of that subjective nature of grading but again, we, I, everyone just wants to know what are the outcomes is it actually going to predict? Because even with grading, it doesn't necessarily predict the ability of an embryo to make a life long baby. Okay, we're getting better at grading, but are we getting better at getting people pregnant? Yeah. The disconnect. Exactly. And ultimately, I've seen AA's not work, and I've seen CD's not work. Yes. And once you know that, that's where it creates a lot of stress for patients. Because really, sometimes I ask, should, and I know we have to dispose greatly, right? But I feel like it's almost hurtful to people in so many ways. I think it would probably be psychologically beneficial to just say, You've got three embryos. Yeah, let's try to use them. Yeah, but I, and sometimes I talk to patients about this and they're like, yes, grading causes me pain, but also I have to know, I can't not know. Yeah, I have these all the time. I actually have a patient that we called today that has a positive pregnancy test, did transfer first embryo, highly graded embryo, did not implant at all. Second embryo transfer. Slightly lower graded, and then I was worried. Yeah, we already used our good one. Yeah, I'm not gonna work. Yeah, this is oh Yeah, frustrating feeling. Yes Yeah, just don't have the ability to predict it. I look awesome. Okay, so I wanted to also just talk about now So we've got our grading back. We're about to do our transfer and we always ask our patients Which embryo do you want to put in? And a lot of times people are wanting to choose based on gender, but if they're not wanting to choose based on gender, you would assume most people would want to pick that, right? Yes. Yeah. So have you ever had somebody who purposely didn't want to do that? Yes. You have! Okay, I thought it was the only one. No, I have a few. I have this situation. It actually sometimes is like a special situation. Maybe when people are pregnant. I don't like the way their transfer cycle is going for one reason or another. And maybe they're like, oh, my lining looks so much thicker. Yeah. This other time. Yeah. But I don't want to waste this cycle. It's just got a bad ending. Yes. Yes. Yes. Yep. Yes. I see. I still remember one of my patients. I think she actually listens to the podcast, so she'll know that I'm talking about her. She really surprised me because she did her IVF cycle, she got genetically affected normal embryos. Some were highly graded, some were lower graded. Her lowest graded embryo was a CC embryo. And so we're getting ready to do the transfer. I say, Hey, I'm assuming you want to put the best one in. She said, No, I want to put the worst one in. Why would you wanna do that and this great, why would you wanna put the worst one in and poor things? She had been through losses before, miscarriages and everything. Her brain had been through a lot of trauma at point, and she said, if I did a transfer of my most highly graded embryo and it didn't stick, it would psychologically crush me. And so she said, look. If I put the worst one in, and it didn't stick, I'd feel like, hey, that was the worst one. I still got a lot of other chances. And so I said I don't know that I agree with this, but, and she was in the medical field too. I'm like, I know you know what you're talking about. It sounds like this is a very informed decision. Let's do it. And then, sure enough, her little cc And she got pregnant. She had her baby. Her baby is adorable, and she has been really helpful because she was one of the people who had Googled her grades and after googling she had called and said should we just disperse these embryos? Are they not good embryos? And ultimately getting to see baby really just feels like this is her way of helping other people, and so she's even let me share the photo of the baby and show people this is what a CC baby could look like. She's so cute. She's so healthy. There's nothing about the grading that would make us have concerns. Like sometimes people say could a poorly graded embryo have birth defects or problems like that? No, there's no correlation between that. It's sometimes just something we. More so just judge, could this embryo have difficulty surviving a freeze and a thaw? Or could it have some, lower reproductive potential? But again, can depend on the lab. But anyways, just going through that with her, I saw, again, you've got to give every embryo a chance. Yeah. It gives me chills. Yeah. Oh

Speaker: 24:50

my gosh. Good for

Speaker 2: 24:51

her. And then, okay, I have another funny story, though. This one. So this is one of my friends. We had been friends even before I was a fertility doctor. She had done IVF and she, of course, transferred her most highly graded embryo first, an AA. She got pregnant, had a baby, and then she kept doing transfers, so she has four girls. But she tells her girls, she's yep, you were my AA. You were my CC. And then I thought, this is awkward. You are a fourth grader, every now and then. But the point was, is you would see a photo of all her girls, they're beautiful, healthy girls. It's just amazing. just doesn't matter. And so I think to me, that's one of the biggest messages that I will tell people. It just doesn't matter that much, aside from maybe just using it to decide which embryo we're going to put in, it ultimately will have, amazing chances of having a healthy baby. Totally. Okay. Do you think we covered all the embryo grading questions and everything? Okay, good. We will wrap it up for the week and this was a special request. See how we, respond right away. If you guys have any other special requests, please let us know, and if you would be so kind and potentially leave us a review on our practice website, Keep Fertility, or on our podcast website, or on our YouTube, we would so appreciate the encouragement as we record these podcasts, and we will see you guys next week! Bye! Bye!