LIFE by Dr. Pat
LIFE by Dr. Pat fertility clinic
Know your IVF clinic: judging treatment with KPIs
Assess your own cycle, one indicator at a time
Author
Dr. Patsama Vichinsartvichai — Thai Board of Obstetrics and Gynaecology; Thai Board of Reproductive Medicine; MClinEmbryol, EFOG-EBCOG, EFRM-ESHRE/EBCOG.
- IVF
- ICSI
- infertility
- trying to conceive
- ovarian stimulation
- KPI
- competency
- benchmark
Most patients who have been through IVF have wondered at some point: how well did that cycle actually go? Was my antral follicle count too low? Was this stimulation drug right for me? How good was the egg collection? Is the clinic's laboratory any good?
Here is how to check for yourself. Start by digging out the records from your previous cycle — everything you have. I will also tell you which numbers are worth knowing, asking for, or writing down.
Three factors matter roughly equally
- The stimulation protocol the doctor chooses — the drug, the dose and the number of days
- The quality of the patient's eggs and sperm, which follows from age and lifestyle
- The quality of the laboratory and the care taken by the embryologists
Which numbers you need
A cycle starts with the antral follicles. Stimulation grows them until they are ready for collection. At egg collection (OPU) you get both mature eggs (MII) and immature ones (MI and GV). After fertilisation there are normally fertilised embryos (2PN) and abnormally fertilised ones (1PN, 3PN); by day 5 some reach the blastocyst stage. The numbers fall at every step.
The figures worth recording are:
- Antral follicle count (AFC), from transvaginal ultrasound before stimulation starts
- Number of follicles at least 12 mm across on the day the trigger is decided
- Number of eggs collected (COC) on the day of collection (Day 0)
- Number of mature eggs (MII) on Day 0
- Number of normally fertilised embryos (2PN) on Day 1
- Number of embryos reaching blastocyst (Day 5–6)
- Number of embryos sent for chromosome testing (Day 5–6)
- Number of chromosomally normal embryos (Day 5–6)
KPI calculator
Use the KPI calculator I wrote. Enter the numbers above, press calculate, and it returns your KPIs with the benchmark in brackets.
1. Follicles responding to stimulation (benchmark ≥ 80%)
Formula: (follicles ≥ 12 mm on the trigger day ÷ antral follicle count) × 100
What this indicator tells you
- Whether stimulation was started on the right day
- Whether the dose and type of stimulation hormone were right
- Whether the follicles had enough hormone receptors
A worked example
At a monitoring scan one follicle is far ahead of the rest — say 16 mm while the others are 8–9 mm. Egg quality at collection is usually poor in this situation.
The cause is starting stimulation too late: a dominant follicle has already been selected for that cycle, so the others do not grow. It is common in women whose cycles are shorter than 28 days.
2. Oocyte retrieval rate (benchmark ≥ 80%)
Formula: (eggs collected ÷ follicles ≥ 12 mm on the trigger day) × 100
What this indicator tells you
- Whether the number of stimulation days was right
- Whether the trigger drug was the right one
- Whether the interval from trigger to collection was right
- Whether the patient administered the trigger injection correctly
A worked example
A patient has 18 large follicles before the trigger and is triggered with a GnRH agonist. On collection day only 5 eggs are retrieved, of which 3 are mature.
The likely cause is that the patient did not mount an LH surge after the GnRH agonist, so final oocyte maturation never happened; the eggs were not released and fewer were retrieved than expected. About 10–15% of patients given a GnRH agonist fail to produce an LH surge.
3. Oocyte maturation rate (benchmark ≥ 80%)
Formula: (mature eggs, MII ÷ eggs collected) × 100
What this indicator tells you
- Whether the trigger drug was the right one
- Whether the interval from trigger to collection was right
- Whether the trigger injection was given correctly
- Whether stimulation ran for an appropriate length of time
A worked example
Plenty of follicles grew and plenty of eggs were collected — but most of them turned out to be immature, and immature eggs make poor embryos.
Causes include giving the trigger at the wrong time, stimulating for too short or too long, or an insufficient type or dose of trigger. In some women the eggs simply mature more slowly than usual: collecting at 34–36 hours after the trigger then yields many immature eggs, and collection needs to be later — some mature only at 40 hours.
4. Normal fertilisation rate (benchmark ≥ 70%)
Formula: (normally fertilised embryos, 2PN ÷ mature eggs, MII) × 100
What this indicator tells you
- Egg quality — whether the chromosomes are normal
- Sperm quality — chromosomes and fertilising ability
- The embryologist's ICSI technique — it must be quick and precise, without damaging the egg
Fertilisation is confirmed by seeing pronuclei — one carrying the egg's chromosomes and one the sperm's, making two pronuclei (2PN). Abnormal fertilisation shows no pronucleus, one (1PN) or three (3PN); 3PN means one extra chromosome set, that is three sets in all. The abnormality can also be total fertilisation failure.
5. Blastocyst development rate (benchmark ≥ 60%)
Formula: (blastocysts on day 5 + day 6 ÷ normally fertilised embryos, 2PN) × 100
What this indicator tells you
- Laboratory conditions — clean air, low oxygen and so on
- The embryologists' skill
- The overall quality of the stimulation protocol
- Egg quality
- Normal gene activity in the embryo
In 10–15% of patients, no embryo reaches blastocyst however it is cultured — because getting there requires the embryo's own genes to switch on and generate nutrients and energy.
6. Euploid blastocyst rate (benchmark ≥ 50%)
Formula: (euploid embryos ÷ embryos tested) × 100
What this indicator tells you
- Egg and sperm quality, and the woman's age
- How eggs and sperm were handled from collection onwards
- Embryo care in the laboratory
- The embryo biopsy technique
The older the woman, the higher the proportion of abnormal eggs. The biopsy technique and the chromosome-testing technology also contribute to abnormal results.
How did yours come out?
If you have worked out your own numbers, bring them in and I will go through them with you, so the next cycle can be fixed where it actually needs fixing. Book online, or watch the explanation on YouTube.
These benchmarks are not mine. They are international standards — for example The Vienna consensus: report of an expert meeting on the development of ART laboratory performance indicators (2017).
References
- ESHRE Special Interest Group of Embryology and Alpha Scientists in Reproductive Medicine. The Vienna consensus: report of an expert meeting on the development of ART laboratory performance indicators. Reprod Biomed Online. 2017 Nov;35(5):494-510. doi:10.1016/j.rbmo.2017.06.015