The Surrogacy Guide for Embryo Grading and Success Rates

For couples and individuals pursuing surrogacy, understanding the intricacies of embryo development and grading is crucial. This knowledge can significantly impact decision-making throughout the surrogacy journey and ultimately affect success rates. In this comprehensive guide, we’ll explore the fascinating process of embryo development, delve into the concept of blastocysts, examine the widely-used Gardner Embryo Grading System, and discuss how embryo grading relates to success rates in surrogacy.

Embryo Development from Zygote to Blastocyst

The journey of an embryo begins with fertilization, where a sperm cell penetrates an egg, forming a single-celled zygote. This marks the start of a rapid and precisely choreographed process of cell division and differentiation. Let’s break down the key stages of embryo development:

Day 1 (0-24 hours post-fertilization): The fertilized egg, now called a zygote, contains genetic material from both parents. Within hours, the zygote begins its first cell division.

Day 2 (24-48 hours): The embryo typically consists of 2-4 cells. These early cells, called blastomeres, are totipotent, meaning they have the potential to develop into any cell type in the body.

Day 3 (48-72 hours): By this stage, the embryo usually has 6-8 cells. Cell division continues at a rapid pace, and the embryo is still relying on energy stores from the egg.

Day 4 (72-96 hours): The embryo reaches the morula stage, consisting of 16-32 cells. The cells begin to compact, forming a tight ball-like structure.

Day 5-6 (96-144 hours): This is when the embryo typically reaches the blastocyst stage, a critical milestone in development.

What is a Blastocyst?

A blastocyst is an embryo that has developed for 5-6 days after fertilization and has two distinct cell types:

1. Trophectoderm (TE): The outer layer of cells that will eventually form the placenta and other supportive structures.
2. Inner Cell Mass (ICM): A cluster of cells inside the blastocyst that will develop into the fetus.

The blastocyst also contains a fluid-filled cavity called the blastocoel. This structure allows for more accurate assessment of embryo quality and potential, which is why many fertility clinics prefer blastocyst-stage transfers in surrogacy arrangements.

The Gardner Embryo/Blastocyst Grading System

Developed by Dr. William Gardner in the 1990s, this grading system has become the gold standard for assessing blastocyst quality. The system uses a combination of numbers and letters to describe three key aspects of the blastocyst:

1. Expansion and hatching status (1-6)
2. Inner cell mass quality (A, B, or C)
3. Trophectoderm quality (A, B, or C)

Expansion and Hatching Status:

1: Early blastocyst – the blastocoel is less than half the volume of the embryo
2: Blastocyst – the blastocoel is greater than half the volume of the embryo
3: Full blastocyst – the blastocoel completely fills the embryo
4: Expanded blastocyst – the blastocyst has enlarged, and the zona pellucida has thinned
5: Hatching blastocyst – the trophectoderm has started to herniate through the zona
6: Hatched blastocyst – the blastocyst has completely escaped from the zona

Inner Cell Mass (ICM) Quality: A: Tightly packed, many cells B: Loosely grouped, several cells C: Very few cells

Trophectoderm (TE) Quality: A: Many cells forming a cohesive epithelium B: Few cells forming a loose epithelium C: Very few large cells

For example, a blastocyst graded as 4AA would be an expanded blastocyst with high-quality inner cell mass and trophectoderm.

Embryo Grading and Success Rates

The correlation between embryo grading and success rates in surrogacy is a topic of great interest to both intended parents and medical professionals. While grading provides valuable insights, it’s important to note that it’s not a perfect predictor of success. However, several studies have shown a strong association between embryo grade and live birth rates.

A large-scale study published in Fertility and Sterility in 2015 analyzed over 14,000 single blastocyst transfers and found:

• Live birth rates for top-quality blastocysts (3-6AA, AB, or BA) were 54.9%
• Live birth rates for average-quality blastocysts (3-6BB) were 42.5%
• Live birth rates for poor-quality blastocysts (3-6AC, CA, BC, or CB) were 33.3%

These figures demonstrate a clear trend: higher-graded embryos generally lead to higher success rates. However, it’s crucial to remember that even lower-graded embryos can result in healthy pregnancies and live births.

Another study published in the Journal of Assisted Reproduction and Genetics in 2018 focused specifically on frozen-thawed blastocyst transfers in gestational surrogacy cycles. The researchers found:

• Clinical pregnancy rates for high-quality blastocysts (≥3AA) were 65.2%
• Clinical pregnancy rates for good-quality blastocysts (3-6BB, AB, or BA) were 53.8%
• Clinical pregnancy rates for fair-quality blastocysts (3-6BC or CB) were 38.5%

These findings further support the importance of embryo grading in predicting success rates, particularly in the context of surrogacy.

Embryo Early Stage Transfers

While blastocyst transfers have become increasingly common due to improved culture techniques and the ability to better assess embryo quality, some clinics still perform transfers at earlier stages, particularly on Day 3. Let’s explore the considerations for early-stage transfers:

Day 3 Embryos

On Day 3, embryos typically have 6-8 cells. The grading system for Day 3 embryos is different from the Gardner system used for blastocysts. It usually considers:

1. Cell number
2. Fragmentation
3. Symmetry of cell division

A typical grading scale might look like this:

Grade 1: 8 cells, little or no fragmentation, even cell sizes Grade 2: 6-8 cells, minor fragmentation, slightly uneven cell sizes Grade 3: 4-8 cells, moderate fragmentation, uneven cell sizes Grade 4: 4 or fewer cells, severe fragmentation, very uneven cell sizes

The decision to transfer on Day 3 versus culturing to the blastocyst stage is complex and depends on various factors, including:

1. Number of embryos available: If there are few embryos, some clinics prefer Day 3 transfer to avoid the risk of having no viable embryos by Day 5.
2. Patient history: For patients with previous failed IVF cycles or poor embryo development, Day 3 transfer might be recommended.
3. Laboratory conditions: Not all labs have optimal conditions for culturing embryos to the blastocyst stage.
4. Genetic testing: If preimplantation genetic testing is planned, embryos must be cultured to the blastocyst stage.

Success Rates for Day 3 vs. Blastocyst Transfers

The debate between Day 3 and blastocyst transfers has been ongoing in the field of reproductive medicine. While blastocyst transfers have shown higher success rates in many studies, the picture is not always clear-cut.

A meta-analysis published in the Cochrane Database of Systematic Reviews in 2016 found:

• Live birth rates were higher for blastocyst transfers compared to cleavage-stage (Day 2/3) transfers (29% vs. 27%)
• However, the cumulative live birth rate (including fresh and subsequent frozen embryo transfers) was similar for both groups

These findings suggest that while blastocyst transfers may have a slight edge in single transfer cycles, the overall chance of having a baby may be similar when considering all available embryos.

Understanding embryo development, grading systems, and their relationship to success rates is crucial for intended parents navigating the surrogacy journey. While higher-graded embryos generally correlate with better outcomes, it’s important to remember that embryo grading is just one factor in the complex process of achieving a successful pregnancy.

Other factors that can influence success rates include:

• The age and health of the egg donor (if used)
• The quality of the sperm used
• The experience and skill of the embryology lab
• The health and preparation of the surrogate
• Transfer techniques used by the clinic

As surrogacy and assisted reproductive technologies continue to advance, our understanding of embryo development and assessment methods will likely become even more sophisticated. For now, the Gardner Blastocyst Grading System remains a valuable tool for predicting potential outcomes and guiding decision-making in surrogacy arrangements.

Intended parents should work closely with their fertility specialists and surrogacy agencies to understand the grading of their embryos and make informed decisions throughout the process. While the journey may be complex, advancements in embryo culture, assessment, and transfer techniques continue to improve the chances of successful outcomes in surrogacy arrangements.