Hatching a Plan

Hello and good evening, good day,

wherever you may be.

My name is Simon.

Yours is worse than Instagram Live.

Pleased to meet you.

My name is Simon Tomes.

I am Emma the Embryologist's husband.

So this is exciting stuff, right?

Our first one.

Yeah.

Yeah.

Yeah.

Yeah.

It's quite clever, isn't it?

It's great.

So I can see this is the

first time we're using this tool.

And we can see we've got

seven people joining us today.

Thank you very much for joining us.

If you want to post... Nine.

Oh, nine.

It keeps going up.

Hey, good stuff.

We'll hit double figures in a bit.

Sorry,

this will get really serious in a minute.

But any of you that know me

know that this is just my edge way in.

But this is wonderful.

So we have Kelly from Rochester and Kent.

Hannah, we can hear you.

Thank you very much.

And Cheryl and Emma.

Hi from Lincolnshire.

Well,

hello from Teddington in Greater London.

We are not in a clinic.

We are not in a laboratory.

We are not in scrubs.

We are in our lounge.

We are in our lounge.

So just to say that my background,

I am in tech and community,

so I am not a medical person at all.

This is all about Emma.

My role here is to host

today and to ensure that

your questions can come in.

and that I can ask them to

Emma and we can have a

conversation to help out

you know this is about

education and I guess yeah

maybe just before we jump

into the topic yeah Emma

like for those that might

not know you could you

briefly give a summary of

who you are and also why

we're here like take a step

back from this particular

topic but why you do what you do

Okay,

so I think most people will have a

clue of who I am.

I'm Emma.

I am an embryologist with 20

years experience,

currently working as the

lab director of the Evewell

Fertility Clinic,

which basically means I

oversee both sites on the

laboratory basis,

look after all the embryologists.

I have a team of about 15 on two sites.

Why are we here?

We are here because

throughout our journey to parenthood,

and throughout my time in

the last 20 years of doing this job,

I think that it is time

that the patients have an

opportunity to know

everything that they need

to know to make informed decisions.

I have spent many years in

an incredibly large clinic

and it wasn't until I

stepped away from that that

I realised that actually

the face-to-face patient

care made me realise that

people really don't

understand this and that

made me really sad.

I don't want our children to

grow up in a world where

they don't have access to

what they need to make

informed decisions about

their lives whether that be

from day to day and I'm a

fertility expert so I

figured that if I'm going

to do this I should do it

and if anyone's ever heard

me speak before I use the

term stay in your lane

quite a lot so that's why

we're here because I think

that the more I get into

this the more I realize

that people really don't

have the you don't know what

you don't know so my idea

is to be able to give you

what you know so that you

can make the right

questions and conversations

around what you need to know

Absolutely.

And Emma, so I, you know,

Emma lives and breathes this right.

And I'm here to advocate for her, you know,

living with someone who's

so passionate about the

world of fertility and like

just straight up cares so

much to make the life of

her patients and even, you know,

people that she's never met

before through her Instagram account,

Emma the embryologist,

if you're not following.

just helping people out like

I think like your your

reason you're on this

planet I mean there's loads

of other reasons why you're

on this planet but that's

certainly one of them so

yeah it's a real privilege

to kind of Emma is so

passionate about this right

so it was really uh hey

let's just go for it let's

start start doing webinars

let's start doing a podcast and this is

essentially the first one

isn't it and we'd like to

welcome you to our

experiment because none of

we didn't actually know if

it's going to work so

anyway let's go yeah let's

do it so this is recorded

um so if you do want to

come back to it another

time please do um we'll put

out links to it through

emma's instagram account um

yeah come back to it whenever

I think it'll stay up for as

long as we say it can stay up for.

And yeah, spread the word.

Please share this with

others who you feel will

benefit from learning about

the Vienna Consensus and

what it means for selecting a clinic.

Yeah, it's an important topic, right?

So should we dive in?

So the way this is going to work,

we get to a point where we

will ask you to ask your

questions and you can do

that in the comments.

But before we do that, I was thinking,

like, let's start super high level.

So Emma,

what is the Vienna Consensus and

why does it matter?

So the Vienna Consensus was

created in 2017 by,

basically they shoved a

load of us in a room at an

ESHRA conference.

I'd say us, I wasn't there.

So ESHRA for the audience

who doesn't know what that means.

ESHRA is the European

Society of Human

Reproduction Education and Embryology.

can I remember what that

last d I should know this

anyway I think it's

embryology anyway it's a

conference that happens

it's it's a very very

massive european conference

that we all um fight over

going to because it's it's

actually an amazing

conference this year it's

in amsterdam they put a

load of people in a room

and they basically said

right enough's enough um

you guys need to come up

with standards you need to

come up with standards

about laboratory practice

you need to have

And those standards have to be set from,

you have to encompass all demographics,

you have to encompass all the people,

you have to encompass all

different warps of

fertility and everything.

And obviously they are averages.

Not everyone will fall in them.

Some people will go lower,

some people will go higher,

but ultimately the reason

they set these standards

was so that we had what we

call key performance

indicators that we could

then all work towards.

And we set our own key

performance indicators within those

figures that if we fall below,

we are legally bound to

start raising an incident

report with the HFEA.

The HFEA uses the Vienna

Consensus to monitor clinics.

And just to jump in there, HFEA,

for those who are unfamiliar?

It's the Human Fertilization

and Embryology Authority.

I do know what that stands for.

Okay,

and that is for our international

listeners who,

because we're based in the UK,

That's the UK regulator, is that right?

Yeah, it's a bit like the FDA in America.

It's a bit like, there's lots of different,

but our regulator is the HVA.

It's an incredibly tight

entity that gives clinics

licenses and allows them to practice.

We're also regularly inspected.

And on one of those things

that we're inspected on is

key performance indicators

that we have to set out as a clinic.

And that all came from the

Vienna consensus.

The Vienna consensus broke

down every part of

laboratory practice into

things that have that you

can as a clinic affect how

many eggs a patient gets.

We can affect that because

we've got to have certain

stimulation protocols and

the skill of our doctors

and the understanding of

your own personal reproductive health.

is what affects that.

So you have those standards,

which comes from probably

the medicine side of things.

But once it gets to eggs collected,

number mature, number fertilized,

number usable, number frozen,

number surviving,

all of those things are

essentially handled by the

embryology team.

And so the Vienna consensus

was developed so that all

embryology teams had a standard to meet.

But I find it astounding that first of all,

it's called the Vienna Consensus.

And I guarantee half of the

people who watch this won't

even heard of it until last week.

And actually,

it 100% correlates with your

potential outcome of having

a baby in a clinic.

And so I personally, instead of,

we'll probably get there

with all the questions in a minute,

hopefully,

but I would like to see it

regulated heavily.

It is regulated to a certain extent.

But my question, as always,

is why is it not open

freedom information?

why don't people know this

why don't they know what

anyway let's carry on

because I could just talk

no that's cool that's cool

so hopefully folks that

that's kind of a good

introduction to it and that

yeah that makes sense um so

yeah so this is your

opportunity to to get your

questions in we're gonna

try uh I was gonna try our

very best to go for it we

have up until the end of the hour

So let's see how we get on.

So yeah, if you're feeling brave,

and you've got some questions,

like just absolutely go for

it on the comments.

I'll bring the question up on screen.

So that's there for reference.

And then we get started.

So yeah,

please have a think if you've got

a question for Emma related

to the Vienna consensus and kind of,

you know,

why that is important in your

choices when it comes to

selecting a clinic, please do go ahead.

yeah I mean we've I could

got some more questions to

to keep us going there m

but uh yeah let's let's see

if we get a few more in

from the audience I'm just

going to check to see if

anything's coming through

not at this stage but

that's fine okay well let

me let me ask a question then

So this is something that,

so you keep banging on

about live birth rates and

your view that they

shouldn't be the only thing

people focus on.

So live birth rates,

they shouldn't be the only

thing that people focus on.

Why is that so?

Because the only opportunity

that you have of having a

live birth rate in any

clinic is if you have an embryo

in the first instance and

when you walk into a clinic

and ask a clinic what your

live birth rates are even

if you give them an age

group which is great like

live birth rate is

absolutely important I'm

not saying it's not

important it's part of the

vienna consensus but you

have to get an embryo

before you get the

opportunity to have a live

birth so the questions we

all should be asking really

is what are my chances of

getting an embryo and then

If I get an embryo in your setting,

how likely is that to lead

to a live birth?

You've got some questions now.

Yeah, yeah, yeah.

You got more on that?

No,

because I think actually the questions

I can see coming in are

quite linked to where I'm going to go.

This is wonderful.

So Archna, thank you so much.

Can you run through the

funnel stats briefly again?

Sorry, I missed the beginning of this.

No worries at all for

missing the beginning.

All good.

So let's get that one up on screen.

So if anyone's following my Instagram,

you'll know that I talk

quite heavily about the funnel.

So everyone everywhere going

through any type of fertility treatment,

whatever that looks like,

even if you're trying to

conceive naturally,

there is essentially a

natural funnel or a funnel.

You have a group of eggs.

So many of those eggs will fertilize.

So many of those eggs will

make competent embryos.

So many of those embryos

will be genetically viable.

And at the end,

you get your pool of usable

embryos from each cycle of treatment.

So you get 12 eggs.

Depending on how narrow your funnel is,

you could either end up

with one or two blastocysts,

which is the stage that

embryos need to reach to

make you pregnant.

Or you may be really lucky

and end up with six or seven.

Now,

a lot of that is going to be governed

by your own inherent demographic.

Why are you sat in a clinic

in the first place?

What is your reason for being there?

What is what is your age?

What's the cause of infertility?

And a lot of that governs

how that that funnel looks.

But also a lot of it's

governed by the Vienna consensus,

because if a laboratory is

performing at what we talk

about as a benchmark value,

you're definitely going to

be better off with the

start of that funnel,

knowing that regardless of

your demographic, remember,

all clinics see all these demographics.

So averages do mean something.

No one is absolutely going

to fall into those averages, definitely.

And there's always going to be outliers.

But ultimately,

if your starting point is a

good benchmark clinic,

then your funnel will

hopefully not be as narrow

as in a clinic that's

underperforming or competent.

As we say,

underperforming is probably a

bit unreasonable.

Competent values are very good,

but it's important to understand that.

you know,

12 eggs in one clinic might only

lead to eight mature eggs,

and that's all gonna be

governed by how well you're

looked after through your

stimulation phase.

12 eggs in another clinic

might mean you get 11

mature eggs because maybe

you were better monitored

in a different clinic.

That, essentially,

your start of your funnel

already is bigger.

And then you've got culture

conditions in lab and stuff like that,

so.

So if I'm going into a clinic,

what sort of questions

should I ask that are

related to the funnel?

Like, do you say, you know,

what does your funnel look like?

Or is it like... This is really tricky.

And I think that's what

Cheryl's asked here is,

I think the next question,

you can probably put that on the screen.

So I think that's really

important because I think

this is where... Thank you, Archana,

for your question.

This is where we are going

to... This is where we

struggle because...

If you were to ask this.

So Cheryl's question is,

how should we use this to

assess a clinic?

Should we be asking clinics

to tell us if they fail at

any of their KPIs?

Great question.

So yeah, actually,

it's a really good question.

And it's really hard because

you will get this really cagey response.

If you walked into my clinic

and asked me this,

I can give you everything,

like literally on a page of

everything I've got.

do them quarterly most

clinics do them quarterly

and then we have to do them

annually regardless and

they have to be broken down

into ICSI for IVF

fertilization embryo

development all the things

I've outlined on the Vienna

consensus I have to do

every quarter for every and

I actually break it up into

age because I think what

the Vienna consensus misses

quite a lot is an age

reference the only age

reference they give you in

the Vienna consensus is to

do with implantation rate

which I get that because

they don't talk too much about PGTA

But ultimately,

it has to be said that your

funnel as you get older gets narrower.

So I don't think it's 100%

fair that every clinic is

expected to eat a benchmark

60% blastocyst formation if

the patient is 43,

because they're not going to.

You know,

you will get a narrower funnel in

the higher age group.

So I think the Vienna

consensus misses that.

But ultimately, your answer is yes,

the data should be there.

Whether or not they will

share it with you is, I would,

but I find it,

it's a difficult question to ask.

And I appreciate, but it is there.

They have to have it because

it's part of our code of practice.

It's part of our legislation.

And just quickly for our audience,

you mentioned the word PGTA.

What does that mean?

PGTA is pre-implantation

genetic testing for aneuploidies,

which we can get onto if

anyone wants to talk about that later.

But that's just another tool

that we use to iron out

that bottom of that funnel

to see how many of the

embryos are usable.

Definitely in women over 37, 38,

we start to use that quite a lot more.

Got it.

Great.

Hopefully, Cheryl,

that helps answer your question for now.

But yeah, keep them coming.

If there's more questions

off the back of what Emma's sharing,

keep them coming.

Okay, so we have Jennifer J. Thank you,

Jennifer.

Will all fertility clinics

have this data available?

I guess... Yeah, they must have.

They must have.

And the problem is they

absolutely must have.

We have...

Like, so imagine your life.

So my life birth data, for example,

I've got everything up to mid 23,

because you're still

waiting for babies to be

born in the latter part of 23.

But I've got all my clinical birth data,

which is heartbeats from

embryos transferred right

up to March of this year.

So that sort of data is

something we're monitoring

I mean,

I'm doing it weekly or every other week.

That's part of my role as a

director of two clinics is

I have to keep an eye on all of this.

But every quarter we will do

fertilization rates and stuff like that.

And I think it's really important to, yeah,

we have it.

So like I said,

but whether or not they'll

share it is another matter.

So there's no like, what is it?

Sort of the GDPR kind of

data requests where people

can actually say, no,

you have this information.

um I guess it's not on it's

not the patient's

information it's just

information you've you've

collected through your

treatment so so a data

request they can't make

their requests because it's

not on so what's really

interesting is about all of

this the hfea have it all

because every time we make

an embryo every time we

collect an egg every time

we make an embryo every

time we transfer an embryo

a form goes off to the hfea

it's called a treatment form and um they

have all the information

from every single clinic.

So why can't they release it?

Because they can't pull data

together properly.

I didn't say that.

Okay, that's an unofficial line from Emma.

Maybe we can get on to the

HPA and data a little bit later.

But that's a good one to dig into.

Thank you, Jennifer, for your question.

So comment from Hannah.

Thank you.

We've not heard of this until last week.

We've been going through

fertility treatment on offer nine years.

We have gathered so much

information since following you.

Thank you.

You're very welcome.

And that makes me really sad,

but thank you.

And that's why, I mean,

it's comments like that

that make me realise how

needed this all is.

You shouldn't be going

through fertility treatment

for nine years without actually, I mean,

someone that's been going

through fertility treatment

for nine years can probably

tell me I have to do my job because it's,

you know, you've done it so much,

you understand,

but I think it's the real

nuances of how that then

equates into how many

embryos anyone ends up with

and I think it's it's

trying to change that

mindset that we are not all

created equal the skill set

is different and I get it

not everyone gets to choose

a clinic and I think that's

really important that we do

touch on that I get it we

debate this a lot about

that yeah but you still

have a right to know what

your particular chances of

conception are and what

challenges you're going to

face regardless um and I

think that data should be

readily available I mean things like

Maybe you should,

because I'm just going to

keep talking otherwise.

No, no, no.

Go for it.

We've got another 40 minutes.

We're all good.

So, yeah.

So I think it's,

I'm not saying any of what

I'm presenting to you is easy,

but I do think it's

relevant to understanding

what goes on behind that lab door.

And KPIs have the effect of

changing people's outcomes.

And there are always going

to be dependent on,

let's talk about NHS clinics.

They are,

the NHS is chronically underfunded.

Um, and I feel desperately sad about that,

but it does mean that their

ability to monitor patients

through stimulation is not

as good as say someone like ours,

where we've got a mixture

of consultants and we've

got access to more care and

we've got access to the

bigger and better

incubators and all of that.

So, and yes,

it pisses me off that that's

the way the NHS is,

but that's the reality.

So I think if you are in a

place to choose your clinic

and you're actually delving

into that private fertility world, then.

you should know this yeah

absolutely yeah just more

transparency and I think

that you know your whole

point about education it's

just because there's a you

often talk about how

overwhelming it is for your

patients or potential

patients it's horrible

And like, yeah,

you go on Google and you

get scared and you're

like... Don't go on Google.

Don't go on Google.

Please don't go.

That's why I do it.

Please don't go on Google.

There's a really awful

grading chart on Google

that I want ripped down and

I can't seem to get it

taken down because it's so awful.

Oh, really?

Yeah.

It's so awful and people

keep quoting it and it

makes me so sad because

it's not even an acceptable publication.

But it's like if you type in

embryo grading,

it's the first thing that comes up.

Please don't.

Please don't.

Maybe we could do a post on that.

I've done one before and I

will do it again because it's really bad.

Anyway.

So do not trust this data.

Well, I mean, that's the thing, right?

If these things get

attention and the search

engines start surfacing them,

then we've got to find a

way to counter that by

sending out information

that's actually correct.

Got it.

Okay, so thank you for that, Hannah.

So Adele Johnson, from what you said,

does that mean that the

results are not available to the public?

Yeah.

Yeah.

Could the public get access to this data?

Okay, let's bring up on screen.

Great question.

Thank you.

I mean, great question.

The answer is you can't, the

The HFA are five years

behind on their live birth

and clinical pregnancy rate data.

They are in a bit of a

pickle is a very polite way

of putting it at the moment.

What's happened to give you

some background is in the

last five or six years,

they have changed their

data submission platform to

encompass all the different

electronic or medical

record systems we are using.

Now, when I started embryology, which was

in ancient times 2002 we

used to have to fill out

for every single patient

imagine the transcription

errors if you can like

imagine just for a minute

they were these forms that

came as triploid we used to

carbon copies we used to

have to fill out every

single patient cycle

on these like hfea forms and

it would be name patient

number how many eggs you

collected how many

fertilized how many embryos

were so manually

handwritten manually

handwritten and this is all

about like but basically

you've got to track every

embryo that we make because

then we've got to talk

about how many fertilized

embryos were discarded

because they didn't grow x y and z

We used to do that manually

and one carbon copy would go in the notes,

one carbon copy would go in

the archive and one would

go in a sealed recorded

envelope that went to the HFVA.

So over the years what's

happened is finally clinics

are starting using

electronic medical records.

We use Meditex,

there's something called Ideas,

there's something called Baby Sentry,

there's another one called

MB App and all of this.

And what's happened is

because we're all on

different platforms but

we're all collating the same data,

The HFVA have had to change

their data submission platform.

So what we should be able to

do is put all your data

into our electronic records,

which is what we do under

your name as your patient record.

And then we should be able

to press a button that says

send and it should go off

to the to the HFVA and they

should be able to collect that data.

Now,

what we have to send them is when you

start treatment,

we have to tell them that you go back.

We have to tell them that

you've registered with us as a clinic.

Oh, really?

We have to upload all your CD forms,

consent of disclosure.

We then have to tell them

that you've started treatment.

We then have to tell them if

that treatment went ahead

with an egg collection or

an IUI if it's with donor sperm,

for example.

The reason I say that is IUI

husband partner isn't licensed treatment,

so that's not reportable.

IUI?

What does that stand for?

IUI, intrauterine insemination.

It's only reportable if it's donor sperm.

because you're using a donor

gamete by the by.

So you have to tell them

when you've had treatment,

you then have to tell them

what that treatment happened.

So how many eggs, how many were mature,

how many fertilized, how many embryos,

how many frozen, how many discarded?

Did you biopsy them?

Were they normal?

All of that goes into the

form that goes off.

And then if there is an embryo transfer,

we then have to do what's

called an early outcome form,

which is positive negative test.

And then if there's a clinical heartbeat,

it then generates a

treatment outcome form that

we're then expected to fill

in within 52 weeks to tell

them whether a baby was born or not.

Okay, does that make sense?

So there are like eight forms.

So what's happening,

we're all working on these

different medical systems

and the HFEA are a

government entity who are, again,

chronically underfunded.

I'm not blaming anyone in HFEA by this,

by the way.

They're actually wonderful humans.

but it's the it's the

practice that's just really

badly managed and what's

happened is the data

submission isn't going off

as supposedly streamlined

as it should and from what

I've been told we are going

to be nearly six years

behind before you as

patients get any published

data now I think the aim

from what I've heard is to

make all of this quite

transparent I think it's

what we all want we want you to know that

like I actually would like things really,

really highlighted about

multiple birth rates in clinics,

because some clinics are

over inflating their stats

by putting more embryos back.

So they look like they're

getting higher life birth rates.

But when you actually click

in the right place,

and see that 30% of those are multiples,

you then need to question

whether you want to be in a

clinic that's ethically not

practicing in my mind correctly.

So the risks of multiple is massive.

Yeah, yeah.

So that's what I think is happening.

That's what I know is

happening to the data submission.

But whether or not this will

ever catch up in a place

where we can answer your question,

Adele that says,

will it be available to the public?

I think that is aspirational

at the moment.

I really hope we get there.

Because they've got it all.

They've got every we have to

tell them what happens to

every single egg that is collected.

wonder it makes you think

like how as as the general

public we can lobby this

stuff like and I know you

know you have respect for

hfea and they're

understaffed underfunded

like many many institutions

out there but I wonder if

you know through our local

mps or through another body

we could all lobby and just

keep saying come on like

give us an update on we do

that quite a lot well yeah

but of course clinics do of

course you do but as the general public

you know come at it from

both sides and just kind of

push to say look how you

know what is the roadmap

for your you're getting

your data up today and just

keep on asking like what is

the roadmap give me at

least some sort of idea

yeah I've been told it's

this year but I also know

that there's so many

problems I don't think it

will be this year

Yeah.

Good question there, Adele.

Thank you.

Right.

Let's jump on to the next one.

So Kelly HP.

Here we go.

So if we had 18 follicles,

but only seven eggs,

what could the reason be?

Would that be considered low

by the standards set?

31 year old.

So this is a KPI.

So the KPI for this which

you're talking about is

part of the Vienna

consensus is eggs collected

from follicle seen of over

a certain diameter.

And I think, off the top of my head,

it's 12mm.

So, again,

you've got so many reasons that

you are...

not getting eggs from

follicles right so there's

this is what I said about

close monitoring so you've

got 18 follicles there that

will hopefully grow

together in a pattern um

but we sorry I'm just

reading down simon show me

you've said something yeah

I'll lead on to that that's fine so what

The follicles can actually,

if you're not closely

monitored or your body just doesn't do,

I mean, I'm not, like I said,

this isn't me sat here

saying no one's doing their job properly.

That's not what I'm saying at all.

There are reasons that if you do not have,

I think you should have

four or five scans during an IVF cycle.

There are some clinics that

will do two and don't even do any bloods.

I think that that is the

scale where things can be

quite detrimental.

What's the reason for that number?

Why four to five?

So because you would have a baseline.

You then have one at day six.

You have one at day eight, ten, eleven,

maybe even one at day twelve.

Anyone that's done stim, stimulation here.

I don't expect you to understand it.

We'll understand that that's

why I was watching your

follicles and trying to

tweak your drugs to make

sure the group of 18 that

Kelly's got are growing together.

If you don't monitor carefully,

what you end up with is

pools of follicles, some up here,

some down there,

and these do not ever mature.

So Kelly,

what might have happened is you

had a group of seven or

eight good ones and they

got those out and then

unfortunately the others were just not.

I see.

grown enough or they

couldn't access them I

don't know whether that's

ever been discussed if you

can't access an ovary that

does happen again this is

something that should be

discussed before you go to

egg collection um I don't

believe in empty follicle

syndrome there's not enough

evidence for it there

you'll definitely have the

odd one or two that doesn't

have anything in it but no

so my my thought would be

that just maybe the

hormones that they were giving you were

didn't grow them together in

the right diameter.

But this is a KPI.

So one of the KPIs we have

is percentage of follicles

collected and eggs retrieved.

That is one of the first

Vienna consensus KPIs.

And I think in a competent clinic,

it's 80%.

And I know in ours, it's over 90.

I think it's 94.

So yes, Kelly, I think it's low,

but I think there's too

many questions in my head as to why.

However,

what you've gone on to said is

that six fertilized,

which is an exceptionally

good fertilization rate.

but they haven't worked,

which I'm really sorry about.

So it'd be interesting to

know how many embryos you

ended up with because the

grade of your best one looks fine.

And if you've heard me talk before,

it's all about day five, day six.

Anyway, we won't go on to that.

What questions could Kelly ask?

um their clinic at this

stage exactly that why did

you only get seven eggs

from 18 follicles I was I

was straight up just be

really really really frank

get them to show you the

images or the that we use

normally we use like a plot

a plot on a chart to show

where the follicles are

what was your oestrogen on

the day that they triggered

you was it you know if you

had seven eggs for me it

would have been around

eight thousand if it was

higher than that then there

should have been more eggs

there all of these questions ask them

Why did I only get seven eggs?

What is your understanding of that?

If you did this again,

what would you do differently?

So ask how many scans you had.

Was it two?

Was it three?

Should there have been more?

Challenge it.

But not, I mean,

this isn't about anyone doing, like,

this isn't about people saying,

I'm telling you everyone's

doing their job wrong.

I'm not at all.

We're working our hearts out

to try and make this work.

But you have a right to say,

is that comparable to what

I would have got somewhere else?

Yeah.

Yeah.

I could imagine those are

tough questions to ask,

but everyone should have

the right to ask them.

And the good clinics out

there would be like, okay, yeah,

let's show you the data.

Let's show you the comparables.

Yeah, that makes sense.

Hopefully that helps, Kelly.

So Adele, follow up question.

Thank you, Adele.

Are there any KPIs set too

low in your view?

Good question.

It's a great question.

It is a great question.

Oh,

now you're going to get my Emma

opinionated head out,

which is always a little

bit touchy and a bit in no filter.

I think that the competent

damage rate for ICSI is...

is way too high.

So it's a damage rate.

Give me a minute.

Seriously, don't work with animals,

children, or your husband.

So when we do ICSI,

a certain number of eggs

unfortunately will not

tolerate that procedure.

Now, there's many, many reasons for that.

The first one is bad stim.

So bad stimulation protocols

will give you poor quality eggs,

which then link into the

lab of what we can and can't do them.

And once we put a needle into them,

they can degenerate and

they can become damaged.

Eggs within ICSI should...

And if you look at some of

my videos on my Instagram,

it's actually incredibly

straightforward after

you've been doing it, obviously,

for as many years as I have.

But they should tolerate it.

It's not...

It's not this massively,

what everyone thinks is

massively invasive procedure.

It takes about 28 seconds.

It's very quick and they

should tolerate it.

They should have a membrane

is bouncy enough to tolerate it.

You are always going to get

the odd patient that has

just drastically poor quality eggs.

Okay.

And I'm not,

they are a different demographic.

You have to move them aside.

But again,

I go back to averages are

averages because we're all

seeing the same demographic of patient,

right?

So eggs that are damaged,

for me should be less than

5% in any setting.

And if it's not, why not?

Is it the stimulation that's

causing the eggs to be poor?

Is it the practitioner skill?

So the embryology skill

that's not trained enough to manage it?

Is there something wrong

with the equipment in the lab?

All of these little things

can add up to eggs becoming damaged.

And I think if you're

running at a clinic with

over 10% of damage,

I don't think that's okay.

Because that means every

patient with 10 eggs is

losing one or two just to damage.

I think that's way too high.

I think what Adele meant,

is there any other KPIs

that I don't think are fit for practice?

That one I would like to see tightened up.

And how do you get that tightened up?

Training.

for everyone for the clinics

of course but if you went

to the hva and you said

look we need to make a

change how do you lobby for

a change to the vm consent

so I'd have to go yeah it

would just be one of those

conversations so that was

2017 yeah so they're going

to do it when's the next

update 2025 okay so what's

that eight eight years uh

yeah something like eight

years okay why do you think

it takes so long because

it's taken that long for us

to get new standards of

practice so things like

We've obviously moved into

the realm of what we talked about earlier,

PGTA.

We've now moved into the

realm of the time-lapse incubators.

And I think because of the

integration of artificial intelligence,

I think we are going to

have to all sit down and

make some new competent

benchmark values that

encompass the new

technologies that we're all using.

we didn't have a time lapse wasn't around.

It was but it wasn't used in

the way it is now.

Yeah.

You speak highly of time lapse.

Yeah.

So that's that one.

What other ones do I think

are set too low.

So I actually think the

implantation rate with

cleavage stage embryos is quite low.

I think 25% is I think that's quite low.

Again,

I don't really like that stat

because I don't think it

gives you any wiggle room for age.

But I think if you go for

gold standard patients,

we always use gold standard

patients as under 35,

which is what the Vienna

consensus is leaning

towards without telling us that.

I think that's too low.

But again, that's my opinion.

So the Vienna consensus,

I think you mentioned this earlier,

it doesn't take into account age?

It doesn't adjust for age.

It talks about gold standard patients,

which is patients under 35.

Okay, okay.

But we talk often about age

and the impact that can have.

So why is it just because

they just wanted to start

off with the consensus and go, right,

let's see.

OK, OK.

So eventually the new

version you think in 2025

will bring in ages.

It has to.

Yeah.

OK.

That makes sense.

Right,

hopefully that helps answer your question,

Adele.

Okay, next up.

So we have John.

Thank you very much, John.

I'm helping a relative look

into egg freezing.

How lovely of you.

Yeah, very cool.

In terms of Vienna consensus,

what statistics should we

be asking clinics to help

compare how good a clinic

is at not only freezing eggs, but how?

But how?

Oh, I love that question.

And I love that you're doing

that for someone.

So the really important

statistics for egg freezing

is the one in the Vienna

consensus that is eggs

retrieved from follicles.

So are the eggs and the

follicles mimicking the

numbers that you're getting?

So what you see on scan, are they?

At the end of the day,

egg freezing is all about

getting as much out of a

patient in one cycle,

so that you don't have to

put people through multiple

cycles to achieve

the end outcome,

which is enough eggs in

storage to protect your

reproductive future.

So if one clinic can give you 15,

20 follicles and get all of

those eggs and get them into the lab,

and then they're all mature,

In egg freezing,

we can only freeze mature eggs.

Immature eggs do not tolerate it.

Maybe the mid range ones do,

but most of the time they don't.

So we don't generally as a rule in the UK,

don't freeze immature eggs.

So I would say your best

stats for clinics is your

relative needs to be asking

what potential number of

eggs are you gonna get in

my demographic with my,

how does it look before

with her hormones and her situation?

And then what percentage of

your eggs overall are

coming through as being mature.

Now that again is a Vienna consensus.

And I think competent is, oh God,

I should know this off the

top of my head.

I think 75%.

Well, my maturity rate is 89.

So it's massively broad.

So if seven,

like that's the difference

between 15 eggs making 11

or 12 mature eggs and 15

eggs being 14 mature eggs.

Yeah.

Yeah.

Yeah.

so and then obviously the

other question I'd be

asking is most clinics now

I actually don't know of a

clinic that's not doing

this now is vitrifying

which is the process that

we use for freezing

vitrification um I'd also

want to know how many of

their own eggs that they

have frozen are they

thawing out remember that

we do thaw out eggs a lot

of the time that have come

in from other clinics yeah

and it's the free it's not the thawing

that very rarely has an

impact on the outcome of the eggs.

It's the freezing process

they were done with.

So freezing eggs at the

moment is really hard

because we're only just

getting the data from eggs

frozen five or six years ago,

because it takes people

five or six years to come back.

So I actually think egg

freezing is really good.

And if I was to freeze and

thaw eggs now at work in a

trial run or a practice run

with maybe some donated

eggs that have been discarded,

for example,

I am getting much better

success rates now than we

used to get six or seven years ago,

because everything's really tight.

But the only data we've got

is from the people using it

five or six years ago.

But what you'd like to ask

your clinic is how many of

your own eggs have you

thought out the ones that

are frozen in your clinic

in your setting?

Because that is her.

That's her statistic.

I frozen out loads of eggs

that haven't come from my clinic.

But that's not my statistic.

That's the other clinic.

Does that make sense?

I hope that makes sense.

Yeah, it makes sense to me.

Then it must make sense.

It must make sense to the audience.

Great question there, John.

Thank you.

Yeah,

a nice one for doing that research

for your relative.

That's very cool.

Okay, Archna, here we go.

So question from Archna.

Do clinics that are

underperforming get closed down?

Yes.

Oh, this is really hard because...

Why is it hard to answer this question?

Because the question of,

I suppose it comes down to

what we consider as

underperforming and what

the HFEA consider as underperforming.

So straight up question.

Do you know of any clinics

that have shut down due

to... So the Homotons

closed at the moment and

that's to do with an

incident in freezing

embryos where a particular

individual was not competency assessed.

and was performing the procedure wrong.

It has affected a huge,

it's incredibly sad.

But because that again is,

so that's not my,

that's not really a KPI.

That's more to do with, we have,

we have rules and

regulations about how new

staff are inducted and how

we have to make sure

everyone's working to our,

our KPIs and that hadn't happened.

So actually by that not happening,

they've broken the code of

practice and they've been

closed down because they are in breach.

So I suppose that is underperforming.

But the clinics that have been shut down,

it's always unfortunately really,

really serious when it happens.

And it's probably too late, in my opinion,

and it probably should have

been picked up.

earlier.

And I wonder whether that

that will come in the

future with us all being

held access to these stats.

Yeah, pick up on that stuff earlier.

Absolutely.

So yes, yeah,

the answer is we there is

there is definitely

closures that have gone on.

There's been a couple of

London hospitals shut down

over the years.

There was one in Nottingham

shut down in 2001 for,

I can't remember now.

But yes, if you look into the,

so you can actually see,

if you ever go on the HVA website,

what they're really,

really good at doing is

actually showing you all

the incidences that have

gone on and what has been

reported and what the

changes are and stuff like that.

and they do have,

if they shut a clinic down, like Cometon,

there will be a 70-page

dossier about what's

happened there and what the

investigation was and what

the next steps are and stuff.

So they're actually really

good at documenting all of

that because ultimately

they are a regulatory body,

so they're very good at regulating,

if that makes sense.

And not so good at data presentation.

Well, yeah,

so I guess it feels like the

way you described that, like,

Their primary goal is to take action.

Their primary goal is your patient safety.

Which will supersede

anything related to data or

analysis or analytics or

any of that stuff.

So their main focus is

always regulation and

tightness and witnessing

and us and our practices

and stuff like that.

So I get it.

So do you think there should

be a separate body for the

data analysis stuff and

then them being on the safety thing?

So there is now,

and that's where we're

struggling because there's

this new data set up is a

separate entity.

Oh, so it's not partly HFEA?

The HFEA are, yeah, yeah, yeah.

So it's a partner of the HFEA.

So it is,

they are trying to set out the data,

which is why I think it will come.

Well, then, you know,

that separation of concern

could lead to them going a

little bit faster, perhaps.

Yeah.

So, yeah.

Is that got a name?

Prism.

It's called Prism.

Is that a project name or an

actual entity?

No, that's our data submission platform.

Okay.

Curious.

Okay, good question there.

So we're going to bring up a

question from Kelly H.

Where can we view clinics statistics?

So most clinics will have

statistics on their website

that you may have to scurry

around to try and break down.

I would be very wary about

clinics that aren't

publishing anything up to 2021 2022.

We've all got it.

So I think

I think that would always

ring alarm bells with me if

you've got a statistics and

a really good entity with a

website up with 2018 data on it,

whereas the last four years gone.

But they should have them on

their website.

It's a funny old thing, actually.

We are allowed to publish

statistics on our website,

but we have to be adhering

to the code of practice

with how we publish that.

So we can't publish anything

outside of what would be

considered HFEA data.

We are meant to publish

under 38 and over 38,

which I think is really

cruel because that means

you're grouping a

38-year-old with the

44-year-old women and their

outcomes are completely different.

But that's how the HFEA want

us to present it.

So you have to present it

that way and then you're

allowed to break it down

into different age groups.

We break it down.

Yes, I know we talked about that before.

But what, you know,

I'll be a skeptic here or

play devil's advocate.

Like how,

how can I trust the data that a

clinic puts on their site?

Like, is it, you know,

like you go on a website

and they say all this.

No, they can get shut down.

Okay.

So literally it will be checked.

They would be threatened

with it being checked.

Yeah.

Yeah.

Okay.

They could be shut down for that.

But can they manipulate the data or like,

you know,

some marketing person can go on

it and this is no

disrespect to marketing people,

but they could like go, right,

show this because it's great.

Don't show that because it's not so good.

Maybe I'm a bit naughty

asking that question,

but I think clinics can

manipulate data because

they can choose not to

treat a poor demographic of patients.

So one of the biggest

questions I would always

ask a clinic when you're

going into them is if you

know that you fall into a

particularly poor demographic,

like if you have a very low AMH.

mh means amh is

anti-malarian hormone it's

a hormone that we all have

tested before we have

treatment um I would be

asking them if they would

treat you with that hormone

level and if they say no we

don't then what do you say

then that is a reason to

not go to that clinic

because they have a they're

they're trying to make sure

they're more successful

through selecting their

patients is that what you're saying

Okay.

I'm asking the direct questions here.

Hopefully that helps you folks.

I'm just going to do a quick time check.

So let's just get that

question off screen.

Thank you, Kelly, for that question.

So how are we doing?

We've got about 15 minutes

to get us to the hour and

we have a good number of stuff.

So at this point,

we will just say thank you

so much for all of these questions.

This is amazing.

And we do hope this is helpful.

If we don't get to answer,

or if Emma doesn't get to

answer all of these questions,

we'll try and spin up

another webinar and maybe

we'll take these questions

and then... I can post them.

And you can post them.

So, Em, do you want to pick something,

and I know this is hard having to pick,

No,

we're going to do a bit of speed dating.

Let's do it.

Go for it.

John.

Rapid fire.

Rapid fire.

How good is the clinic at

not only freezing, how usable then?

Again,

this is a really important question.

So again,

I can tell you from my own clinic

how many eggs I've frozen

that I've then gone on to

use and thaw and how they

have performed in the funnel.

So frozen eggs do not

perform as well as any

other embryo in a funnel.

They tend to fall off a bit more.

So you get eggs collected, eggs frozen,

eggs surviving,

eggs fertilized and then you

get the narrowing to the

blastocysts that form.

Have you done that diagram?

No, not yet.

Not with egg freezing

because it's really hard to

do because it's all age

related and numbers of eggs.

And I also have a full time

job and I don't have time.

But John,

it's a really good question and

you should be able to get

that information as well.

I could certainly provide it to you.

I can tell you it's slightly lower,

but actually our eggs tend

to fall into our funnels quite nicely,

like all patients,

depending on when they were frozen.

Okay, Cheryl, so every clinic,

if a clinic has a funnel average,

then a funnel that needs to

share is simply implied.

No, I don't think it's, so that's really,

really interesting what you say there.

I don't think it's a lesser

skilled embryology team.

I think you need to put, like I always say,

I think it has to be about context.

So I think if you were,

underperforming in a clinic

based on their own particular statistics,

I think we'd need to look

overall before we pulled any conclusions,

there will always be people

that do not create as many

embryos as we're expecting them to.

And actually,

sometimes it can give us a

really good indicator as to

what else might be going on.

If that happens,

I think instead of it being a blame thing,

I think it needs to be an opportunity

To look at the reasons why I

think if it if that's not done,

then that would be my

problem is why are we not

trying to look at what we

can do to make this better.

Well,

I always find it fascinating in

Emma's industry that, you know, you know,

loads of embryologists

around the world and in

particular in the UK.

And you're just helping each other out,

even though you work for, put it bluntly,

competitors.

You know, you're like, well,

why would we not help each other out?

And you do.

You educate each other.

You, you know, you help other, you know,

you help other clinics by helping.

sharing advice and that and

I think that's amazing

right it's not it's not

you're not trying to blame

no no no no no I don't

think it's about that I

think it's about you having

the again this is all about

you just getting the

information sorry the above

should say if they had a

clinic that on average was

worse than the funnel you

shared um yeah so that

There's your differences,

and that's what we talk

about all the time with

Vienna Consensus and

Competent and Benchmark Clinics,

is that you will get a

difference in outcome

because of that funnel.

I have no idea what drives

that funnel in other clinics.

I know exactly what my funnel is,

but obviously I'm only just

highlighting it can be different.

Adele's good good follow-up

question there from Adele

Adele's yeah is there any

getting stronger on

interested in where you're

focusing your efforts hope

that's not commercial I'll

probably um although they

can refuse on the grounds

of the work in progress and

intent to publish are there

any KPIs that I would love

I mean honestly my biggest

thing and what we strive to

do is our fertilization

rate now is over 86 percent so

I'm pretty,

and a lot of that comes from

the key of the doctors and

their performance as clinicians.

I think they're incredible

and they're really,

really bespoke in patient treatment.

I would love to get a position,

get to a position where we

were getting 70% blastocyst formation.

We sit at around 60, 55, 60,

which is still massive.

I still, that's still my big,

like what else?

And this is what the world's working on.

Why?

And we know that a lot of

embryos don't grow because

of abnormalities in the

embryo and we can't fight that.

But there's still embryos that I feel.

why don't they grow?

And is there anything that I

could be doing in the

environment to make that better?

And are your suppliers working on that?

Yeah,

so there's new culture medias that

come out all the time and

that's definitely a work in

progress because that's

something that everyone

gets frustrated with is we

do feel that there is definitely an edge.

I don't think there's many

edges left in IVF.

I think the highest

functioning clinics are

When you say edge, what do you mean?

Edge is as in gains, as in any more gains.

I don't think... Unless

there's a completely new

technology you should use.

Like ICSI, when that came out,

that was groundbreaking.

Oh, massive.

Yeah, yeah.

Because everyone got

fertilisation when they weren't.

So... Yeah.

Let me do... I had IVF, got two eggs.

One was put back.

I've been trying to decide

to try again with eggs or double donor.

I'm doing it to say to my mum,

I'm thinking of going to

try my own eggs once more.

Any advice?

Delia, I'm really sorry.

That must be really, really hard.

I would get a second opinion.

check your hormones and your

age and everything and I

think what someone needs to

do is be really realistic

about your chances with

your own eggs if you go

forward and once you know

those chances you can make

an informed decision and

that's all we can do you

can't you can't over

inflate it there's it's

mean to keep putting people

through treatment for

minimal percentage chances

unless that's what you want

to do um but I would want

you to have a chat with

someone and see if that is

if two eggs is your full

potential or if it's if we

could do better

This one is,

what should I be thinking

about deciding and how many

embryos to stockpile before

transfers just to M42?

So if you're having genetic screening,

we know that in our setting,

a euploid embryo,

which is a normally

genetically tested embryo,

gives you about a 58% chance,

near a 60% of having a baby.

70% of patients get pregnant

with normal embryos,

60% around that take home a baby,

a live birth.

So given that,

if you wanted to have two children,

I always say to people to

try and ascertain

aspirational sometimes to

get four normal embryos to

try and give yourself a

really good chance of

having two children.

Five would be thrilling.

But at the age of 42,

you're looking at about a

20 percent chance of each

blastocyst being normal.

So it really depends on what

egg numbers are at the top

of your funnel to whether that's.

even possible and then

you've got all the

financial and emotional

implications of that so

those would be the numbers

and I think that comes with

a very big caveat that that

is not me belittling how

emotional this journey is

it's very much about me

being realistic about what

the percentages mean um

thank you for that question

uh adele has said thank you

for both giving up your

sunday evening oh you're

very welcome um absolutely

and do more of this

last 38 five eggs before

mature one fertilized

transferred on day two

straight after a collection

has always been

disappointed with the

number of eggs especially

having a high amh

So I'm pleased to see that

you're starting very soon with us.

I think if you've got a high

AMH and you're getting five eggs,

something's not going quite right there.

That doesn't tally up.

I'd be very interested to

see if your antral follicle

count is matching your AMH.

That would be interesting.

I'm not a clinician, so again,

I'm going to stay in my lane.

But I have been doing this

long enough to know that

doesn't marry up.

I don't transfer embryos on day two.

I think it's, to be honest,

I think if they're in a

really good culture

incubator and environment,

the only reason,

I still don't really

understand now why clinics

transfer on day two,

because we are now bound by success rates,

which are pregnancy rate

per embryo transferred.

So, and I think the idea was that,

that we would only then be

transferring viable embryos.

You don't know the viability.

You're literally two steps

down the funnel.

You're not at the bottom.

You have no idea whether

that embryo was gonna go

straight down and not make it,

or whether it was gonna end

up being in that pool at the bottom.

that were viable,

you've got no more information.

And actually for you, Hannah,

we now don't know why that

embryo didn't work.

Did it not grow?

That's one thing.

Or did it not implant?

And those are two very separate things.

So I think actually

blastocyst culture doing a

transfer on day two is

without sounding crass is is to make

clinics not have to give bad

news really yeah because I

don't see the reasons for

it there's unless their

culture conditions are a

suboptimal I I'm not

worried about keeping my

embryos in incubators until

day five six seven they

they're fine so yeah okay um

Right,

I think we're going to go with...

I've had two rounds, two day,

two transfers due to one

egg remaining both times.

My clinic are pushing us not

to culture a same situation.

What's your thought on this?

I think considering Pixie Clinic,

but they're saying lack of evidence.

I don't have any... I

haven't got a load of

evidence on Pixie unless you are... Like,

I think with all these add-ons,

and I'm going to state it very clearly,

I do think that all these

add-ons are coming from a point of...

I think that they're being

developed by people that

genuinely believe they're

going to help people.

But I think they work in a

certain demographic.

And if we start using them on everyone,

we're never going to work

out what that demographic is.

So I think people push these

things on as we don't know

what else to do.

There is no evidence at the

moment that Pixie does

anything apart from a very,

very small particular case

of male infertility.

with HBA antigen loss,

which is something that, again,

that's a very unique demographic.

If your clinic are not

pushing you to go to day five,

then they must feel not

confident doing that.

And I can't comment on that

because that's not my culture setting.

I feel very confident about

patients going to day five.

All my patients with one

embryo go to day five.

I hope that helps, Emma C.

Okay, next up, Sara.

Is it possible to collect

eggs in a different country

and transport it here?

Yes, it is.

It depends on which country.

So again,

this comes back to the HFEA code

of practice regulation.

We are again, very,

very tightly bound by what

countries we can import and export to.

And that is to do with the

legalities of how we treat

eggs and embryos in this country.

If we cannot prove that the

eggs coming in or the eggs

going out will be treated

in the same manner that

they would have been under

the HFVA code of practice, go with me,

we are legally bound not to transfer.

It seems mad because these are your eggs.

I get it.

But that's right.

Especially coming in, for example,

if the eggs weren't stored

in what we call

virology screened tanks we

then can't bring them in

because they could cross

contaminate our tanks I get

that a little bit the whole

going out I actually don't

I find that really hard so

if someone said to me I

want to take my embryos to

the US for gender selection

I'm then not allowed to

facilitate that because

it's illegal in the UK so

all I would say is if you

ever want to do take anything out and you

Oh, yeah, this is live now.

I'm just don't tell anyone.

But yes, you can collect it.

So there are very few.

So there are countries that

we really struggle to work

with places in Africa, India,

and it's all to do with their regulation.

Europe's a fairly safe bet

as long as they're not

anonymous donation.

The US is fine.

Australia is fine.

But any more than that,

you do get into so out.

It's definitely the African continents.

India is a country is very

difficult to import in from.

Okay, next up.

With time-lapse imaging,

should your clinic be able

to provide information

about embryo development?

If so, how would this be provided?

So, yeah, they should.

So I'm a real big believer

in... I'm a huge time-lapse advocate,

and you'll know that from me.

But I...

I don't like sharing videos

too much because I think

they can become quite

overwhelming for a patient to see.

I think it's far nicer to do,

I would actually like to do,

if someone wants to break

down their embryos,

I'll do a Teams call and

share my screen and then I

can go through the embryos development.

And if they can't provide you with that,

they should be able to give

you some sort of written

report of what they have

seen in that time lapse

that is either normal or abnormal.

And they should be able to

break that down because we

are watching them grow.

So we know when they do

certain time divisions and stuff.

So I would...

I would push them on that.

Equally,

if you were then to go to another

clinic and the clinic requested it,

I can request time lapse

from other clinics if I want to see them.

And they should share them

with us with your consent.

It has to come with your consent,

obviously.

And sorry, Kelly,

you're getting ghosted

there from your clinic.

That's unfortunate.

John,

how many eggs need to be banked to

get one usable blastocyst?

Now,

I've got a really good spreadsheet on

this that I've been a bit

too scared to share.

How come?

Because it's horrible.

Because it basically shows

that a woman of 44 needs

about 150 eggs to get one usable embryo.

And it's hard to hear that.

And I don't want to upset anyone.

I don't want to.

So, John, it's a great question,

but it really depends on

the age of the woman coming to this.

So if she was under 35...

we normally say they need

between 15 and 20 eggs.

If she's between 35 and 37, we say 20-ish,

25.

And if they're above 38,

we start to get towards 25, 30 eggs.

So before you'll end up with

what we would consider the

possibility of one normal embryo.

I know that seems like a lot.

And some women,

I had one woman that had 12

eggs and ended up with five

normal embryos.

So it's subjective.

Again,

these are all numbers and funneling

standards.

But to that point, I mean,

we can go over time.

It's fine if folks are good

to go over by a few minutes.

Just that around the sort of

fear of putting out that data.

She's 39.

Yeah, about 30 eggs, I would say.

But it's quite hard to put

that data out because again,

it's my data.

So it's not universal data

and I don't want to mislead anyone.

So that seems something that

I keep in the clinic.

Okay,

so you wouldn't put that out because

it's like contextual to your clinic.

Okay, I understand.

Sarah has written,

is Iran one of those countries?

Iran is one of those countries.

I have definitely got stuff in.

I've seen stuff coming from Iran.

That's going to be really

clinic dependent because

it's to do with whether the

clinic are working under

the guidelines or not.

We can look into it,

but it is a tricky country.

um there you go this is uh

thank you both love touchy

um amazing oh good stuff

and yeah thank you for your

feedback thanks for that

sarah um and and louise I

really appreciate that feedback

Wonderful.

Well, folks,

we've come to the end of the hour,

just gone over by a minute or so,

but hopefully that's been OK.

You know,

thanks so much for your time and

for being part of this webinar.

Very grateful for your questions.

And, yeah, you know,

stay stay connected with Emma as well.

Hopefully you will be.

For those unfamiliar,

Emma the Embryologist is

your handle on Instagram.

Yep.

You post as and when you can.

You know, Emma, full-time job, family.

We've got a lot of stuff going on.

So this is a real passion for Emma.

You know, I really want to reiterate that,

as I shared at the start.

it is about education you

know we have to do this um

so let's keep it let's keep

it going and I really

appreciate that you were

part of this with us our

experiment that looks like

it works well fingers

crossed we can yeah so we

are hopeful that the

recording has worked and it

will still be available so

I think if you come back to

the same link you should

get access to watch it again um

but yeah come back and watch

it we're gonna do more uh

spread the word uh if

there's anyone else out

there who you feel would

value following emma and

the information that she's

sharing then then please do

share that with others um

and we'll do some more

we'll do probably a few

more live well I say a few

more hopefully lots more

live q a's on very specific

topics um so if you do have

any other specific topic

areas where you're like I

want to learn more about

this or I'm unsure about this

Just send Emma a message.

Absolutely.

And we're also start this as

a podcast where we don't take questions,

but we use questions that

you get all the time and

kind of repurpose some of

the educational stuff that

you put out where you

either do a video or you

put some diagrams together.

We have conversations about stuff as well.

So, yeah, more to come.

Thank you so much, folks.

Do take care and all the best.

Bye for now.