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Save donor age

hello and good evening it's good to be back it's monday 8pm uk time so as always it is time to start our live event i am your host caroline and please let me know that you can hear me loud and clear and of course we do have another special guest with us tonight as you can see here already is dr juliana dora feyenova how are you feeling dr liana it's good to have you back okay dr liana can you hear me all right so i guess uh dr liana cannot hear me right now so everyone else i guess you can hear me so please let me know but let me see dr liana hi how are you feeling and i hope you can hear me now hi carolina i can hear you very well i'm happy to be here hello everyone hello all right so i was worried for a second because you didn't hear me but it's all okay you can hear me now so thank you so much for uh confirming that for us as well everything is okay and as i mentioned we will start our live event tonight and as you know this is another stronger together live event and we are here to support you as we know how stressful how difficult it is when it comes to ivf treatment so we want to just simply we want to educate you we want to help you out with your questions and of course we are inviting lots of top fertility experts so that they can help you a bit in those uh well definitely difficult times for everyone right here but i'm glad that we are all here back as dr lyanna it's back with us once again i'm always really happy that you are always brilliant here so thank you so much for joining our stronger together initiative once more and of course as always i want to thank to our ambassadors and partners you can see them right here without their support it would be very hard to simply um bring this stronger together initiative so thank you so much for your support and today definitely we have a topic a difficult topic but on the other hand it's also i would say hopeful topic so it is about iv h limit how old is too old for ivf treatment and when should we keep trying so dr lyanna as always will start with her presentation and afterwards it will be time for your questions so all you will need to do is just type those questions in the chat section so that dr lyanna can help you out a bit of course so you can do that now you can type those questions now or later on of course it's up to you but we will answer all the questions right after uh dr liana's presentation and i just also want to mention that dr liana is ivf specialist director or of international corporations at ivy med fertility center which is located in kiev ukraine and she's also medical director of auvergine egg bank so once again thank you so much for joining us and well are you ready to begin with your presentation good evening everyone dear carolina thank you for such kind introduction i'm happy to be with you once again i really appreciate the work which is done by ivf media donation friends i'm sure that stronger together it's a great initiative for all of our patients for for us even ivf specialist because we may talk to you we may share our knowledges we may develop new strategies in these really complicated times for everyone in the times of the we are talking during the the covet era because the webinar will be reported recorded and i hope that we will just remember these times as something which passed very soon and this is a time when we re-evaluated the most important things and we will be talking about something which is most important the parenthood and age because age this is a crucial factor for every every one of us so what is the limit and how old is too old for the ivf treatment and when should we keep still trying uh once we are talking about the goals of the reproduction and i am talking for my goals and goals of my team the goal the most important of those is to achieve pregnancy as soon as possible to maximize success rates for the first initial cycle for each patient to reduce multiple pregnancies and guarantee safety in ivf and also to help as many patients as possible by reducing the costs and considering the limits especially the legal ones as different kind of the ivf treatments are not available in all countries and patients have a desire to get pregnant and to have babies in every location independently of what the regulations are and the fact is that our biological clock is always running and even right now but if we are spending that time very useful by learning the possibilities of what is still possible and if we are talking about the resource so our resource is the ovarian reserve which we are given since the very beginning of our life and the maximum number of the follicles in our ovaries are during the antenatal growth on the seven months of the development of the of the phytos and then after several apoptotic uh reactions which are happening in our bodies until the poverty we have about 40 000 follicles and during the fertile period which is between 11 to 45 years old we are all having about 400 500 ovulated cycles meaning we are using only uh like only tiny percent of the oocytes which are given during all our life and 99 and nine percent of our oocytes are lost unfortunately because we are talking now together and the possibilities are given for those young patients as the fertility preservation of the oocytes embryos and even ovarian tissue but if you are talking about having babies today those alternatives were not possible several years ago even five ten years ago so we need to talk about opportunities which are given to those patients who are considering of getting pregnant right now and because of the age and because of the fact that we are losing our potential we are having less follicles we are having less quality of the oocytes and this is the fact that more and more patients who is coming initially to get their treatment they are in their older maternity age and we are facing the situation we as a reproductive doctors that once the patient who is over 35 years old is coming to visit us her chances are already lower and they are getting lower and lower with age we have an alternative and this alternative is a high success rate in case of using oside donation or cryopreserved oocytes which were cryopreserved before but again we should consider if this is a treatment which is uh which is recommended or which is the patient is okay with this due to psychological factors or any other or even the the legal issues if this is accessible in the home country of the patient etc and this is another fact that the average aid for a first delivery in the world is increasing and if we will keep the trend and the trend is that every decade the increases per two years so until 2100 the first delivery will take place in 51 and again we as an ivf specialist we need to have a decision how to help those patients how to prevent this how to save the the materials the resources if this is possible and also what to do in order to maximize the chances and the possibilities of getting still pregnant and this is also part that the patients and we all are living longer that's why this is very logical that we are planning our some reproductive plans we are trying to to get them later another thing that the rate of the genetic abnormalities also increases with age and even young patients if we are talking about a quality of the oocyte or the quality of the embryos some percentage of our oocytes and embryos will be aneuploid even if we are talking about egg donation up to 30 percent of young oocytes being producted by donors they will be unemployed and now we can prevent this because we can get this information from and also the older we are the higher percentage of aneuploidy which is also the reason of the unsuccessful treatment cycle how we see our full ivf cycle so we are starting from the ovarian stimulation by selecting the appropriate medication and the treatment protocol and the regime uh once we got optimal number of the oocytes we perform fertilization and this is hard work of the embryology and we should be sure that we have the best conditions in the embryology laboratory and the cultivation protocols and the the work of the embryologist is appropriate in order to maximize the chances of the embryo cultivation then this is the responsibility of the ivf specialist to prepare your endometrium and the whole body to perform all the needed screening tests and the decisions to be made in order to understand that the implantation potential will be the highest and successfully perform the embryo transfer so this is the first opportunity to get pregnant in case we are not pregnant if and if we are lucky to have enough materials we can perform frozen embryo transfer but of course with the additions of the of the different um screenings like immunological treatment or a genetic evaluation or something which was not done and this is our practice like we would never do another embryo transfer until we are not sure what was the fail reason of the failure of the previous one but if we are talking about older patients it's not always that once we perform ovarian stimulation we receive oxides it's not always true that once we we receive even an oocyte we would receive embryos and we will talk about all these opportunities what if we do have oxides but we don't have embryos if we don't have even all sides which are what are the alternatives and the possibilities so what are the predictive factors for the successful osi development this is first is age of course second and these are factors which are confirmed in which we consider as the most important right now this is anti-muller hormone probably every one of you knows already your level of the antimural hormone and doctors consider this somehow and they predicted your outcomes based on these this is also android follicle count and this is something would might be changed during cycle to cycle and probably also you know that during one cycle you you can have two follicles being seen on the ultrasound and another cycle you can see four or five etc and also what is important is even if if you are starting the ivf cycle it should be proper medication and type of the stimulation protocol recommended there are also some additions like the supplements and vitamins and like the testosterone growth factor etc and experience some experimental treatments but their efficiency is not absolutely confirmed but we should keep trying also like we still recommend this to to be used but the the fact is what would be the outcome how confirmed it would be i would like to present you one of the unique techniques which we are using in our center this is the ovarian rejuvenation for the oocytes and endometrium and the we are using platinum to reach plasma injected into the ovaries and endometrium and it works really well for those patients who have very low ovarian reserve but they still have some image and we can still see several follicles or even few follicles the platinum rich plasma gives us the possibility to evake those small android follicles or pre-entered follicles to grow them in the next cycle in order to perform the stimulation for whom we are using this for the patients with primary ovarian insufficiency for advanced maternal age premature ovaleran failure loss of the ovarian functions due to different external reasons and the variant dysfunctions how it is performed there are two steps first we are preparing the prp plasma we will draw about 20 milliliters of blood we will do centrifugation of the plasma and we will separate the red cells and and the plateau the procedure will take about one to two hours uh and about two to one one to two milliliters will be injected into the ovaries um the procedure will be scheduled immediately as soon as the material is ready and the injection will be done the same as we are doing the avarion puncture with the tiny needle under the ultrasound guidance we will inject the prp distributing the materials across the ovary the procedure is done under the anastasia and it's absolutely safe because this is the own blood and there is no risk of the infections of the allergic reactions so this is one of the ex again it's experimental treatment but in ukraine it is allowed and it works as i said absolutely well for those who is not ready for outside the nation yet and would like to increase the chances for the self oocytes to be used but once the or the oocyte is received the very important is to check the genetic status of the materials and we are having the opportunity in our clinic to check the oocyte status we are performing ngs testing of the outside we are the first polar body biopsy and we may check if this oocyte is uploaded because you blow it outside will produce as healthy embryo with the highest potential for the implantation the same we will do or we recommend to do with the embryos so as soon as we developed blastocyst we are doing by the laser tiny hatching like in the zona of the blastocyst we are taking small piece of the material and test for the genetic status this embryo and we are recommended to transfer only genetically euploid and healthy embryos to increase the chances for the success also there are different factors it's not only about having healthy embryo and well prepared in dimitrium like the endometrium should be proper structure and proper thickness but also we need to remember about endocrine status of the patient and this is what we are usually do like our um package of the initial tests is higher is wider than in some other clinics we are checking thyroid function we are recommending to check immunological status as well we are checking potential for the implantation by accessing the window of implantation and many many more different tests based on the medical status and the previous outcomes of the patient we usually and we always analyze all the previous outcomes and we are trying and we are finding the reason why was the the failure for this patient something just few words about ukraine because i'm practicing in ukraine for 13 years already with whole my great team uh the whole ukraine has more than 60 ivf clinics right now uh all are private uh what are the benefits and why ukraine is such a friendly country for international patients to come and this was a absolute practice until the covet break because in ukraine there is legal outside donation and surrogacy and we can also do export of biological materials to different destinations to different countries and also ukrainians were recognized as the best-looking nation in the world in 2019 by by the uk journal and this all bring us to the fact that we have been very active in receiving international patients to be treated on the territory of ukraine and i in my experience i've been treating patients from 32 countries but right now we understand that the practice has been changed to transfer the preserved materials instead of traveling patients and this is the opportunity which is given right now by the outside banks that if you are located in the country where egg donation is possible and you are not able to travel right now due to the restrictions or you would you are you don't want to risk yourself you still can contact us and get the opportunity to receive biological materials into your clinic into your country and we will help you to understand the whole process and to to manage all this by this we are offering frozen donor oocytes sperm samples uh we can even create embryos in ukraine and bring them to your location and we will perform and recommend the cryo shipping possibilities to uh safe and reliable uh transfer your materials into your home country in our own site bank we have extended egg donor catalog sperm donald catalog we are licensed eggbank we are following all recommendations of the european societies of different different countries like fda canada latin america etc donors can be identifiable and anonymous as well and in order to safely transfer the biological materials we are following all international regulations for the transportation of cryo-preserved materials and you need to remember that materials dry preserved materials is your property and you're right every patient has the right to select a clinic where he or she would like to be treated and also in the country if you are talking about conventional outside donation it's a it's the most important and the most effective treatment for the older woman all over the globe and this can be using fresh or vitrified oocytes the success rates are the highest possible using the oversight donation if we have wide variety of old phenotypes you can easily select the donor materials in ukraine all donors are with the proven fertility we implemented genetically tested osi technique this is the only and the first egg bank where we have oocytes being already ngs testing we are the first polar body biopsy so you can be sure that we avoid those 30 percent of unemployed oocytes which potentially can come from the egg donation and it's very easy to schedule if you are coming to ukraine to receive egg donation treatment this can be done during one visit and if you are happy to receive materials into your clinic you are doing this in your home country and this is absolutely appropriate according to all your conditions what is also can be recommended for those older women in the older age once you are creating and you can produce one or two oocytes in order not to lose the possibility to have embryo transfer because probably you have uh in your practical experience the fact that you produced one or two oocytes and you ended up without embryo to be transferred we recommended so-called combined outside donation this is for patients with the low ovarian reserve who are not one hundred percent ready for the outside donation uh and this is almost 100 transfer guarantee meaning you we will use two dishes in one dish we will put all sides your own all sides and in the another dish this would be done or outside both would be fertilized with the sperm of your male partner and on the end on the day of the embryo transfer checking the quality of the materials we will decide together with the patient which materials should be transferred and this also works absolutely well also in ukraine there are possibilities of alternatives for outside donation so-called spindle transfer or nuclear transfer probably you've heard about three parent babies again it's experimental treatment but i should say that ivf in general is just 41 years old and 40 years ago it everything was experimental so we are talking just about the the years of trying this um technique and the fact that this is not considered as a routine yet but probably this is just because this jet is just are the first steps how this works and in order to understand this we will talk just a little bit about mitochondria mitochondria it's like like a battery of the cell 90 of the cellular energy is produced by the mitochondria and also mitochondria has its genome it's about 37 genes and if you are talking about young oocyte we have a lot of mitochondrias and their potential is high but with the increased age of the patient we are decreasing the levels of the mitochondrial's dna mitochondrial is getting morphologically changed increases the dilations and by the fact of this we have adenosine three phosphate which is giving the energy also decreasing and directive of oxygen species increasing which performing the damage of the the cell and reduces its potential so by getting mitochondrial dysfunction we have lower ivf success rates lower fertilization and higher unemployed rates and by the procedure of transferring the mitochondria and the pronuclear we can receive mitochondrias from young oxide and we can use nuclear mitochondria from the mother's oocyte and the phosphorus oxides from the sperm so this is an absolutely unique technique it's done only in few centers in the world it requires really um specific equipment and the knowledge of the embryologist but this might be done and this is done already in order to maximize the chances you can just see how many any other sites are needed in order to achieve high pregnancy rate and the live burst rate and you can see that in order to get about eight eighty percent of success rate we need to receive 30 o sides but if you are talking about reasons for drop out you need to understand that those are psychological burden physical burden age relational burdens etc but the fact that who would decide you when to stop this should be just your decision and just to to show you some examples i've got some publications and would like to share with you this is israeli one and the fact that that country is covering all the ivf treatment by themselves so patients should not pay anything for the ivf treatment it was very interesting for them to evaluate how many patients would get pregnant with unlimited attempts being paid by the government within four years uh the fact here is that this is all ages it's not only older patients but patients of all ages so you can see that 95.5 percent of the couple conceived 89.6 of couples gave birth to a life infant 81 percent achieved the life burst within first four years and 85 with eight treatment cycle so here we can see how many treatment cycles were performed but the results are absolutely great so when to stop if we are talking about medical considerations this could be number of the treatment cycles being performed already for a patient number of follicles or oocytes received imh level and blastocyst formation but again these are only indications for using own oocytes and if you are talking about donor oocytes or experimental treatment still there is something to talk about because until you're having a womp we can by replacement of the cycle regimen we can grow the endometrium and we have the possibilities to create embryos and until you're having your endometrial and we created embryos there is a possibility to carry the pregnancy officially in ukraine by law there is no upper age limit for the ivf treatment but of course we are considering the somatic status of the patient we are considering previous treatment cycles and the outcomes and again just to motivate you this is the uk data of 100 over 150 000 cycles three women and over 257 treatment cycles and you can see that once nine treatment cycles were performed for patients of 40 42 years old with own oocytes the cumulative life birth rate got up to 30 percent it's not really high it's up to 30 percent but these are on our 40 42 years old if we are talking about own oocytes and age up to 40 years old within starting even with six ivf cycles it's over 60 and up to 75 percent and if you're talking about donor oocytes with starting from five treatment cycles it's already over 80 and up to 95 percent so this is something which is saying that you should ask yourself how many treatment cycles you had already how different they were and also i would recommend getting a second opinion from another doctor from another center from another country because probably the um the facts how we are treating and how we are considering infertility are absolutely different but if we are talking about older age like starting already over 43 this is another publication about cumulative pregnancy and life versus rates through ivf for women 44 45 years old and here you can see that with there is no increase after the third attempt so you can try it for the first time you can try for the second time but the cumulative life burst rate would not be higher than seven percent this is something what we need to consider we need to understand and probably think about alternative here another publication saying about donor oocytes here you also can see that who is receiving already over 30 donor oocytes for cumulative clinical pregnancy rate the the figure would be 89 and higher another issue this is the ethical committee decision and i would like to talk about this together with you this is from the icrm and the recommendations are the following that for the purposes of the statement of futility uh it is between zero to less than one percent chance of achieving the life burst and very poor prognosis is between over one percent to about five percent so it should be discussed with your treating physician and the treating physicians should consider what would be the uh the expectation for the success here clinicians may refuse to initiate a treatment option they they regard as futile provided providing they have informed the patient with regard to the option of the futile and clinician may refuse to initiate a treatment option if the prognosis is very very poor but protecting fertility center with their success rate they are not allowed to say no for your treatment and upon requests clinicians may treat patients in cases of futility or very poor prognosis provided the clinicians can success some benefits and inform the patients of the low er odds of success and thorough discussions uh are advisable at the beginning of the patient's physician's interactions when patients have indications of futility or very poor prognosis and programs and clinics should develop policies and to guide decisions about treating for patients with fertile or very poor prognosis and those discussions which we just had above these are those program and the policies about like some more options to be given to patients with the older age and something this is very very important as for this stock publication just for five days ago from october 5th 2020 which say that the older you are in your last birth the longer you will live so this is the association between the maternal age at last birth and the telomer ledge so this data provides us the new insight into the biological relationship between reproductive history and long-term health and another what is very important and what we follow in our clinic the fact that unexplained infertility generally means that the physician failed to find the true cause of the infertility so if you would consider to be treated or you would like us to consider your treatment history we would be happy to try to find the true reason and true cause of your infertility so to conclude different treatment options may be recommended in ivf to achieve a goal of the parenthood second opinion is recommended due to specific limits in the countries the most effective treatment for patients in advanced age is oocyte donation experimental treatments in ivf are available some of them are already effective and may be accepted widely in the future the most effective treatment for patients in advanced age is the osi donation this is just once again and if you are listening in this webinar and you haven't tried all mentioned above you should still keep trying thank you for your attention and i will be really happy to answer your questions you can see my contact details here also contact details of the clinic ivmat fertility center in kiev also for the outside donation the context of the ovogene eggplant and if you need to travel your materials from one destination to another the courier service details thank you so much and i'm ready to your questions and wonderful thank you so much for that very interesting presentation lots of nuances here as well so we had some patients that already wrote that it's very very interesting so huge thanks for that as always you've been brilliant with explaining everything and well now it is time for our questions and as you can see there are plenty of those questions from our patients right here so let's get started okay yeah sure perfect so uh okay the first question it's in regards to i believe the new methods that you have provided what's the what is the cut age cutoff for this so let's go step by step uh i just would like to say once again to under to be understandable that in ukraine there is no upper age limit uh still even there are no recommendations like every clinic would decide by themselves by the by the medical committee what would be the best option for the patient who referred was referred to that clinic of course the very important fact is the semantic status of the patient and the histories of the previous outcomes and we are always in communication with the treating person from the home country and we would never proceed with the treatment if we are not in touch with such a specialist if you are talking about specific treatments like the prp therapy or ovarian rejuvenation until we can see some levels of image like i would say we've been trying even zero 0.1 but uh the question is we should we can try once again and if we are we can see the follicle which is growing we would proceed with the stimulation but in such cases the outcomes are really different sometimes we are not getting follicle grown the best outcomes with the ovarian regeneration we are getting with the level of 0.3 image and higher so i would say that all patients for whom we did prp therapy we have several indications that we we've seen image be being increased fsh being decreased and new follicles being grown and as soon as we have seen this we are starting the stimulation if we are talking about mitochondrial donation or pronuclear transfer the maximum recommended age is 43 but again it's based on each cycle evaluation usually if still we can see some levels of the image and positive uh treatment positive outcomes for the treatments in the past meaning receiving at least one oocyte we would proceed with the treatment because we need to be sure that we are receiving outside in this treatment and if we are talking about egg donation and surrogacy again as i said it based on the somatic status and the general house of the patient and thank you so much for your very first question and of course your thorough answer to that and let's have a look if you could tell us where can we access the catalogs and if you will be able to provide your email uh i will further this to the to the team and they will send you the access but but also on the website it's a aubergine bank.com wonderful thank you so much for this as well all right um next question is i am 42 and i have very low ovarian reserve and for 5 afc what is the best for me to use my own eggs or donated eggs thank you silviana again i would like to get answer into my question if you have been trying ivf before and what were the outcomes in terms of how many oocytes were produced what was the quality of the embryos etc but if you would talk just uh just statistically uh i think still with the four pile under follicles and 42 your chances of receiving two to three oocytes should be quite high but the question would be of uh blasted transformation probably and the euploidity of your embryos uh but again if you and and the second question would be how long you are giving yourself time until you will get pregnant if you would like to get pregnant within several months definitely outside the nation if you are not ready for outside nation and you would like to try the last chances or some chances which definitely would be lower in comparison to the outside donation you should keep trying with with own and wonderful again thank you so much for that advice and actually next question is quite similar as it is i am 44 and have 1.4 image but i still want to use my own x patients uh who have been pcos patients uh in their younger age still in the age of over 40 to 43 they can see uh image level like this uh and the potential to receive uh more oocytes in this age is higher in comparison to let's say even a previous case but still the percentage of aneuploidity unfortunately is the same or would be the same so if you would like to try i would say that you should try like we would not consider we would we would consider you as a low prognosis but still with some prognosis in about three to five percent or up to ten percent if this is something what you would expect and if you would consider so please yes go ahead all right again thank you so much for that advice all right next question also is right here so i'm 40 years old my amh is 1.96 sorry and nanograms per millimeter and afc 8 fsh 7.6 what are my chances using ivf with own eggs how can i improve my egg quality how should i best prepare for ivf thank you so much again if considering just case by case i would say that this case is the most optimistic one because of the level of the image and fsh is absolutely fine until follicle count is great so i would say that your chances would be even between 20 to 30 or even over 30 percent but again to improve the equality we have different recommendations but they are not as a clinically approved these are not something which was given as a recommendation by any society or something this is just from our experience like the complex of the vitamins uh testosterone etc if you would send us a mail we will send you this hymn but and usually we recommend this to improve the oocyte quality and to to take these supplements two to three months before the treatment cycle this is what would i just recommend to do prior to the ivf treatment but also i would like to recommend to start treatment as soon as possible because you know with every month we are just getting older and older and the chances are getting down so to best be prepared just to start the idea and again thank you so much that was excellent and well there is another question of course and within that there are like few questions okay so let's start with i will read it out of course uh we can take it one by one i'm 42 and a half with amh 3.1 pm all and afc of 11 on last count fsh of 9.5 my tsh is 2.9 i understand that tsh for ivf should be below 2. i am currently taking thyroid regulation medication can i start ivf cycle with elevated tsh or first it have negat or it will have a negative effect on success of the procedure what are my realistic chances of successful ivf with such a low amh afc 11. thank you patricia again your all the measurements like the image android follicle count fsh is also absolutely fine this edge is within the range being normal it's just a recommendation to to have it below two and if you already are taking medications to regulate your thyroid function you just should follow the the chain changes but i think that within two to three weeks even the changes will be already there so the most important is the a it's already 42 point something so again i would recommend to start as soon as possible what is recommended what you just need to consider that for all patients over 38 years old we are recommending medications to fsh plus lh just to consider with your doctor and double check because lh is really important for women in the advanced maternal age and this would be the best stimulation regimen if you have no endometriosis if your cycles are still regular it could be short stimulated protocols with antagonist and probably rcg triggering not to avoid freeze all and maximize the the fresh embryo transfers in the end but maybe you should also consider pgs pgd uh for the embryos because if you will get the android follicle count is huge is is really nice if you will get several oocytes it's very important to know which embryos would be you blow it so here are the recommendations and again just start as soon as possible if possible all right once more thank you so much for that another question a little bit longer one as well and dr juliana it appears to me that you have move clinics what is the maximum age of treatment at your new clinic foreign transfer of cryopreserved embryo that i have you have previously mentioned that you have a partner clinic in canada do you know if i can bring in my cryopreserved embryo form from anonymous donor egg into canada what is the maximum age for pro nuclear transfer this can't be done once you have reached reached menopause is that correct thank you dorothy i am happy to hear you yes i moved to kiev and i am as you have seen i am working together with the team of the ivy mad clinic in key right now this is a great clinic a great team of really moving fast and developing embryology with all those potentials of the mitochondrial prenuclear transfers etc and gs testing um so as i said the maximum age for the treatment is considered during the clinical decision of all doctors after we have received the medical documents related to the patient and all the history also we are if the decision is positive or we need to consider something else we are asking the patient to connect through zoom or skype uh and yes we have clinics in canada but due to the changed regulations recently they will not accept absolutely anonymous donation right now and also all materials which are shipped to canada they need to be fda tested very similar how it is for the usa so i think it will not be possible to transfer those materials you are mentioning right now the maximum age for for nuclear transfer recommended age is 43 but again it's case to case considering previous outcomes and age and potential to produce all sides um and if the the menopause is reached already probably it's there is no possibility because we will not be able to get uh follicles um so the probability of getting outside will be really really low i hope i answered all yes of course thank you so much for that and again that was a thorough answer indeed and well there of course thank you uh there is a thank you sorry from our previous patient as well thank you very much from the previous answer and well another thank you from dorothy here yes thank you excellent and let's have a look of course there are plenty more questions coming up so let me go to the next one straight away i'm 43 i had a recent andro follicle count but could only see two follicles on each side i was told that this was the result of c-section 15 years ago my amh is 4.2 pm all is this good the decrease in the follicle count could not be a reason of cesarean section only in case it was laparoscopy and the there was some uh some something was done to the ovaries but usually cesarean section has nothing to do with the ovaries so it's not connected to one to another um 43 and four follicles each side probably you will be able to produce one to two oocytes again the question is have you tried and what is your experience on reacting into the medications um 14.2 pico moles uh it's into our levels it's between like two point something it's still quite good image so i think you should if if the question is to use your own oocytes uh there is a reason to try here um maybe also you can try ovarian rejuvenation if this is uh unfortunately i don't know where you are so i don't know if this is it can be done in your country or you should travel somewhere and the the opportunities to travel right now are really limited but uh if patients would like to travel to ukraine for treatment they are able to do this even during the the quarantine street stricter current in that then now we sent the documents confirming the patients is coming for medical treatment and there was no questions into the in the borders the only issue if still there are flights etc but our international department will be happy to to help you with that and to accommodate and to to help to answer all the questions regarding the flights etc okay and once more thank you so much for that answer to this question and let's have a look at that next one what would your view be for having pgd tested good embers from successful previous donor and transferring them into a surrogate mother who has only given birth 14 months prior with her own baby her bmi is 21 her blood type is b plus and my donor's blood type is 0 plus like mine and my husband's blood type is 8 plus she seems healthy what do you think would she be a good candidate is it normal to use surrogate only for 15 months after birth by the time she will do our transfer it will be 17 months after birth of her own child um a good question angela um actually uh in our clinic we do not recommend for the surrogacy to to have another attempt either surrogacy or having a transfer after the the birth of a baby within two years but if you will postpone a little bit and if the lady again we need to check the status of the surrogate like if she's healthy if the her pregnancy was without complications if she is not breastfeeding if uh you know there is a list of the tests which are need to be done for the surgery mother um after checking that i would be able to confirm or not uh there is like the information which is here i would just only say that i would recommend well um and that's all but in general uh everything looks fine in terms of the of the the blood type it's absolutely fine all right thank you so much for that someone is typing i'm not sure possibly it's a follow-up but let's go to the next question and of course we will always be able to go back oh sorry there's okay yeah there's a follow-up so let me go straight to that so why is it needed to wait in order to comment the pregnancy itself this is the status of um body of every woman independently it's a patient or a surrogate mother that you have on some conditions uh being changed and surrogacy is very important procedure and very responsible one so just from the clinical side we would like to be sure that we have the best conditions and depending again on how was the delivery of that previous pregnancy how was the pregnancy itself what is the the status of the patient of a surrogate mother today we are recommending to have embryo transfers within two years and later after the previous delivery but every every case can be different this is true and we need just to get to have more information in order to confirm this or to say we still need to wait but general information is like this okay thank you for explaining that once again to us as well and let's have a look at the next question that we have and of course there's a thank you from angela for you right here okay next question is so what oh sorry it was just this i have showed so let me sorry go to the next one right here with covet and travel instructions we decided to freeze my partner sperm in case i need to travel by myself i am wondering if using fresh versus frozen sperm has impact on success of the fertilization i would say that this would depend on the quality of the sperm sample but if clinic decided to freeze it and there was no recommendation that the the quality of the material is low or that that could be any risks here like that it's still recommended to to fly and to produce fresh over so it should be absolutely fine so we it's better to understand the the status and the sperm quality uh to answer this properly but in in many many cases we recommend it the same so if patients would like to avoid staying longer in ukraine for example or if the male partner cannot travel we are just recommending to free the sperm somewhere and we are sending the courier and we bring materials over to ukraine so it's any complications for this usually sperm sample has millions metal sperm and even if there is cryotolerance it's in normal sperm samples it's only up to 30 percent that we are losing and we still have enough for the fertilization so it in general it should be fine excellent thank you so much for that and of course there's a thank you from the patient for you right here thank you all right and let's have a look next question is up so do you use ibm if yes what are the results you have cards high margin um not true like we have the technique is in place but because the results were not really high or like the reason why doing ibm usually ibm was done for the oncological patients in order not to stimulate them because of the of the risk of the high level of the estrogens um and by avoiding this we did ibm uh we do not have really many of those patients uh it's not really common but the technique is there and because there was no high numbers i cannot provide you with proper data but i will be able to find out more and will be able to provide more information if needed but also i'm wondering why you are asking what is the reason from your side to do ibm okay understood and just let me remind everyone that of course i have just sent you a link to where you can use and there's a button to to simply contact div met and of course dr lyanna and i'm sure all of them will be more than happy to assist you and provide you more details as well and let me go to the next question so what are the top three supplements you recommend to improve quality for women over age 40. so it would be testosterone coenzyme q10 10 and vitamin i'm sorry we didn't get the last the last supplement could you please repeat that vitamin d okay vitamin e thank you so much for that excellent um all right let's have a look of course there is another question right here for you i am 45 and have i am age of 8.85 and going through a donor egg treatment at egg retrieval i had three follicles but there were no eggs what are my chances with the different treatments you mentioned my image is 8.5 p more yeah the question here is that probably i would wonder what would be the fsh level here but if still there is a possibility to try owen x i would try to perform ovarian rejuvenation but again the probability of getting um we potentially would decrease the fsh and increase the imh a lit a little bit but we need to check if still we will get more follicles to grow i think a donation for your age and the parameters and also previous outcome is the most reliable and the right procedure all right again thank you so much for that advice all right next question of course it's also here i'm 46 amh at 45 was 4.5 considering a donation but still holding out for own x anything you can add martina very similar to the previous patient uh and the the something what is the most negative here unfortunately this is the age uh i think that both of you also can try combined egg donation like um once you are receiving ivf treatment and gonadotropins even if you are ending up with no follicular growth or if you're ending up with the follicular growth but no oocyte this still also can happen anyhow your endometrium is growing and you should not stop treatment you can just proceed with the egg donation starting from the time of your opium and opiu is day zero this is a day when your egg donor also should be punctured or in this case the synchronization sometimes can be complicated because you need to postpone or to get faster someone and this is not always optimal in timing that's why they vitified outside the nation would be recommended because as you are getting materials from the egg bank you should saw them exactly on a date and a day when you are having your oocyte retrieval and the outside vitrification is sowing absolutely is great technique like survival rate is over 95 we are not losing materials fertilization rate and the clinical outcomes are the same so still there is a true that more publication and more beliefs even between the doctors are for fresh outside donation but my experience shows that the vitrified outside the nation has many many more benefits uh in comparison to the press as a fact of no synchronization as a fact that you can predict how many oocytes you need in order to produce um embryos we usually calculating four uh oocyte for one health c blastocyst so uh also in the pressure donation there is a risk or possibility but also it's a risk to create surplus embryos meaning if you are in your older age and you stimulated one donor per patient and you received five to six blastocyst but you need only one or two so you will have additional embryos which will never be used and someone could potentially have been using part of those societies from the donors so so vitrified outside the nation has many many benefits so i would recommend to try combine if if you would consider this as well all right thanks a million for that one as well that's of course next question there are like few questions left we will be shortly finishing but of course let's go to the next so i'm 46 and 47 next year i want to use donor egg with my husband's sperm but would like to have at least three children is it possible to use the same egg donor and freeze the additional eggs blastocyst what would you recommend to have successful ivf and having a family thank you it's a great planning from you and yes absolutely so if you would consider uh oocyte donation um i would recommend like probably for the successful treatment of having two three babies you would need to have either full fresh egg donation or receiving between 12 to 15 or 18 vitrified donor oocytes you should expect with the good quality sperm of getting four to five or even six blastocyst out of this uh and then with the egg donation it's not usually recommended to perform pgs testing but you you can do this as well um and this would be like a full material to be used um in advance like or in the future and also you can order some vitrified osides if you like if still in a bank you have more materials being available let's say you can do a first trial of 12 oocytes warm them fertilize cultivate until blasted says understand how many blastocysts you received and if this is enough for uh three embryo transfers or four embryo transfers and then you can order the materials from the same donor usually donors are donating several times so it's very common thing that you still can contact with the osi bank and get the same donor materials thank you for that question again and of course for your help with that and uh let's have a look so what is the percentage of viewpoint embryos at 40 statistically it's between 15 to 20 percent okay excellent and can you tell us something about how fast does the image level drop at 40 41 42 43 uh it also the question is what is the starting point but if the starting point is already let's say one so the decrease it would be individual but the average is getting mine like um reduction in 50 every year so if we already on the low levels today i am i have one in one year i will have 0.5 in two years i will get up to almost zero so it's quite fast all right thank you for that clarification as well next question is a bit longer i'm 43 i have been trying to get pregnant for four and a half years and i have 0.2 amh i have done an eight iui and five or six ivf i've never get two blastocysts i have had two day three trash transfers and one resulted in pregnancy last year but i miscarried at 10 weeks my husband who is 44 has low count quality and motility dna fragmentation and very says sorry not sure would you recommend we move on to donor egg or donor sperm we haven't wanted to donor which would be a better choice excuse me donor egg or donor sperm and why it's very really great question i think that during all these trials of eight iois and five or six ivfs and such a male factor probably the the reason of failed attempts was more connected to the male factor than to the oocytes but because today is 43 i think that it's already too late to try to honor sperm but maybe it's still reasonable but again we need to consider the fact that we in 43 the um percentage of success would be about 10 if you will use donor sperm here um or double donation but this is something what you are just not considering here um so the options are still um i would say that uh but we have 0.2 image yeah complicated question i think that the donation would be definitely recommended either your ex and the sperm as getting no implantation and miscarriage uh in the previous treatments and this can be connected to the male factor in this situation or double donation all right okay understood again thank you so much for that explanation and your recommendations as well um okay next question is so is there any clinics in sweden that works with you do i have opportunities to get the help of your clinic um yes yes we have clinics in sweden we are working with um if i'm not mistaken i remember one very well it's dean hall's son but um i would like you to get in touch with us on email and we will be happy to provide you more information and contact persons there okay excellent thank you so much for that all right next question is so i wanted to know if ibm can be used to grow immature m i x too mature m two right m one x two mature yeah yes ibm is uh recommended as a technique to grow uh immature or even the the previous moderation rates of the of the uh oocytes and up to m2 oocytes but again it should be clear medical indication for this let's say if the reason of getting m1 oocytes is a and proper stimulation protocol so then we should just change the protocol or understand what is what is not working properly in the stimulation protocol because uh there is no other reason to receive m1 oocytes so if the stimulation is proper it should be m2 if we are puncturing um follicles on a size of between 10 to 12 13 14 millimeters we are we re we are receiving we are expecting to receive immature oocytes um then we can grow them up to m2 in the laboratory conditions but what is the reason not to stimulate a patient up to m2 in the ovaries so then chances in comparison to ibm at least in our experience would be definitely much higher so it should be proper medical indication for ibm and thank you once again for the clarification and explanation to this question all right next question is up as well so what is your view of folate instead of folic acid in the prenatal vitamins probiotics vitamin d fish oils from small fish in clean waters which brand would you recommend that are organic preferably um dear angela there are so many produces of those supplements we are not really recommending any brands because worldwidely they are so so much different uh the folic acid is recommended of course and the the probiotics but it's all should be it's better there is no one recommendation for all like there is something general but again we need to consider different different factors so it's better to have individual recommendations for this and thank you so much for that as i mentioned of course there are like three short questions and we will be finishing so let me just go straight to this one is there a clinic in germany who is collaborate collaborating and also portugal yes in portugal because outside the nation in portugal is uh legal and officially performed we are collaborating with clinics in protocol i will be happy to provide you with some data but germany uh there outside the nation is not allowed so we can only transfer embryos if those are embryos from your oocytes and your sperm partner sperm [Music] so this is the only possibility there that's why the options are really limited from from germany we would recommend to travel somewhere we just close around like poland or even ukraine or something something around there all right thank you so much again for that so portugal yes germany no okay thank you um all right there are like two questions just shown right here so do you think assisted hatching is necessary or helpful for my cryopreserve preserve donor echo emerald grade 2 a a um assisted hatching like we have very positive experience by using this but and we do well assisted hatching for all embryos which were vitrified and warmed uh and also for the embryos created from the vitrified oocytes so i would say yes but once we would prepare this embryo uh for the embryo transfer from 2aa we would grow it until we will give the opportunity for this embryo to grow until three like three a a and then we will see what is the development how fast it is developing and then decide regarding should the hatching be done here or no because like if the development is absolutely proper so maybe we should avoid helping this embryo and just leave it without it's a decision made by the usually by the embryologist together with the doctor and the patient all right again thank you so much for that stan as well and of course there's a thank you here from our patient and so do you recommend coq10 ubiquinol how much um yes the cochu tan is in the list but i need to double check of the dosage sorry i am not able to provide this right now that's perfectly of course okay no problem here so remember that you can use the link i have just sent to you you can contact dr juliana and her team and of course they will help you out with some more details and well it looks like this is our final question for today so let's have a look so what are the main differences between plastos a b or c there are huge differences between those um morphological grading of embryos this is an invasive but very informative um information we can get from the from the embryos you know that there are different machines like the time lapse technologies and some others which are helping using the artificial intelligence to um to say in advance what would be the potential of this embryos to be implanted so by just simply grading embryos between a b and c uh i would say and this is true that a is the great embryo b is the embryo with some morphological disorders which is equal to the medium quality and c is a very low quality embryo with very low potential for implantation and there are many many publications and we also follow this in our practice that the implantation potential for aa or ab which are considered good quality embryo is high bb is already lower and bc is the lowest still we have implantations but but the potential is very low okay excellent thank you so much for that and as i mentioned uh it looks yeah it does seem that this is our last question but of course again let me remind everyone that this is possible for you to simply get some more details from dr jan and her team all you need to do is just click on the link there is an option there and well uh dr liana thank you so much once again for joining us because as you can see there are plenty of things coming up right here i could just show you those uh right here and of course you can see such a great informative session and so someone is going to see you possibly soon so this is the uh message from from our other patient right here for you yeah thank you it was a good time of traveling around you know and i would like to thank you all it's a great pleasure for me to be with you um and i hope it was really helpful and this will motivate you what is the most important to keep trying to keep more options and to use all this statistical data but also believe in in the surprises from from the from god and from everything what we believe in and i would like to wish you all a great house and for all of us to um to get back to the normal lives very very soon and they will be happy to see you in ukraine if this is your desire and i can help you with your dream into the parenthood thank you so much thank you so much for those words it definitely this is an excellent uh finish for that for sure so as you can see doors those are coming up more and more so excellent webinar couldn't agree more really thank you i know this is just one of those webinars with you and so till the till our next webinar i hope pretty soon i mean i'm not the only one here i'm sure so thank you so much everyone for joining for your questions and i am very very happy that you have found it so interesting and so useful and of course remember this is this has been recorded so it will be available tomorrow on our website myibfss.com but also on our youtube channel so just go ahead and subscribe that way you will know when the video is uploaded and of course you know there are more plenty of those events coming up we will be back tomorrow actually tomorrow we have actually two webinars first one is at 1pm uk time because we will be connecting with australia and the second one is in the evenings i just hope to see you there as well thank you so much have a lovely evening thank you all and have a good night bye