Ongoing Quality Assessment/Improvement in Clinical IVF

Abstract

The main objective of any in vitro fertilization (IVF) program is to provide the highest quality care for the patients being treated. Although “quality” in this context can be interpreted in several ways, it is generally perceived as achieving a high rate of healthy live birth per cycle. Critical to achieving this goal is a comprehensive, effective, and active quality management program that monitors and assures standards are maintained and improvements introduced, both regarding the clinical management and treatment of the patients and the performance of the IVF laboratory. This chapter focuses on management of the laboratory, with specific attention given to quality control, quality assurance, and quality improvement in order to provide the highest standards and greatest reproducibility of laboratory services. Four areas of quality management within an IVF laboratory are defined: patient and tissue identification, supply management, equipment maintenance, and monitoring of clinical outcomes. Each of the quality management sections are accompanied by the most salient regulations defined by the College of American Pathologists (CAP) as well as helpful tools for performing active quality control and for monitoring laboratory performance through quality assurance analyses. The designs of trials for quality improvement are described in order to provide a working framework for implementation of improvements in laboratory performance. In addition, a detailed discussion of a comprehensive quality management program for the IVF laboratory is provided.

Appendices

Appendix 1: Requirements for Supply Management in the IVF Laboratory

• 1. Maintenance of records of the batch or lot number, date of receipt and date placed in use of all reagents and media.

• 2. Reagents and solutions are properly labeled, as applicable and appropriate, with the following elements [12].

  • (a) Content and quantity, concentration of titer

  • (b) Storage requirements

  • (c) Date of prepared or reconstituted by laboratory

  • (d) Expiration date

• 3. All reagents are used within their indicated expiration date [12].

• 4. Explicit procedures for media preparation and modification are documented [12].

• 5. For each batch of culture media prepared in-house, the quality of the media, including pH, osmolarity and culture suitability using an appropriate bioassay system should be confirmed [24].

• 6. Media storage and expiration requirements are documented [12].

• 7. The laboratory has a documented method for quality control of media [12].

  • (a) Culture media must be able to support the viability of gametes and/or the growth of embryos. Media must be evaluated using a bioassay system such as the one or two cell mouse embryo culture assay or a sperm motility assay. If culture media or protein supplement is modified or prepared in-house, there must be documentation that it has been tested on site. Commercial media must be used within the labeled expiration period. Documentation of quality control testing using an appropriate bioassay system must always be supplied by the manufacturer and retained for quality control records. The media quality control process must include steps to document the acceptability of the receiving conditions for transported commercial media [12, 25].

• 8. The laboratory tests and documents the quality of the contact material using a bioassay [12]. Materials pretested by the manufacturer with an appropriate bioassay system do not require further in-house testing. Documentation of testing performed by the manufacturer must be retained as part of the quality control records [12].

Appendix 2: One-Cell Mouse Bioassay Protocol

Super ovulation: Inject 4 to 6-week-old virgin females with 5–10 i.u. pregnant mare serum (PMS), followed 48 h later with 5–10 i.u. human chorionic gonadotropin (hCG). Place females with males immediately following the hCG injection; mating is assessed the following morning by the presence of a vaginal plug.

Embryo collection: Sacrifice females around 10 AM on the day of plug, excise the oviducts and place in warm collecting medium in a Petri dish. After tearing open the ampullary region of the oviduct close to the cumulus mass cluster, the cluster is expelled under positive pressure into the medium containing hyaluronidase (1 mg/ml). The cumulus masses are disaggregated after about 1 min, leaving denuded zygotes. Wash the embryos in collecting medium then and then once in the culture medium before placing them into culture. Embryos from each female should be allocated equally to each treatment group in order to overcome any donor variation.

Embryo culture: Place embryos into protein-free culture media that was pre-equilibrated overnight in a 6% CO₂ atmosphere. Culture embryos in groups of 10 in 20 μl drops of medium under an oil overlay at 37°C for 96 h.

MEA assessment: Assess embryo development in the afternoon of Day 4 and record the stage of development to determine the % of embryos that formed blastocysts. Ideally, culture the embryos for an additional 24 h to obtain the number of hatched blastocysts; in addition, obtain the total blastocyst cell count for each blastocyst using an inverted microscope.

Below is an example of acceptable criteria for using a 1-cell assay:

• 1. There must be 20 1-cell embryos in each treatment.

• 2. When evaluated at 96 h, the controls must yield ≥70% expanded blastocysts to pass:

  • (a) Expanded blastocysts  ÷  1  −  cell embryos  =  % expanded blastocysts

• 3. The average total expanded blastocyst cell count must be ≥80 cells.

• 4. Items whose treatments pass the mouse assay are suitable for use in human embryo culture.

• 5. Those treatments that fail are tested again; if a treatment fails the assay twice, it is not considered further for use in the IVF laboratory.

Adapted from [46]

Appendix 3: Questions to Ask When Selecting an Incubator for Your Laboratory

• (a) What size incubator do you need?

• • How large is your lab space?

• − Do you have room for stackable incubators?

• − Do you have room for benchtop incubators?

• (b) What is the patient volume for your lab?

• • How many patients will you place in one incubator at a time? −

  • How many patients will you place on a shelf?

• • What about any program growth?

• (c) Do you need additional space for more advanced technologies?

• • Time lapse video recording?

• • Microfluidic embryo culture?

• • Real-time bioanalyses of embryos?

What Is the Set Up and Flow for Your Culture System?

• What size are your dishes?

  • Do you place them within a larger dish or on a platform during culture?

• Do you perform all steps of IVF in one incubator?

• Do you euse the same incubator for both dish equilibration and culture?

• How many oocytes/embryos do you place in a dish?

  • For IVM?

  • For IVF/ICSI?

  • For Embryo Culture?

• How often do you change dishes for embryo culture?

  • No media changes?

  • Daily?

  • Every 2 days?

  • After 3 days?

What Kind of Atmosphere Do You Plan to Use for Your Culture System?

• What will be the O₂ Tension (atmospheric or low O₂)?

• What will be the N₂ source?

• N₂ Generator?

• N₂ Cylinders?

• Liquid N₂ Vapor?

• Mixed gas tanks?

How Do You Plan to Regulate the Incubator Atmosphere?

• What is your preference for measuring CO₂?

  • Infrared (IR) sensor?

  • Thermal Conductivity (TC) sensor?

• How do you want your incubator insulated?

  • Air jacketed?

  • Water jacketed?

• Do you want internal doors for your incubator?

  • How many?

• How is the access to the water pan?

What Level of External Monitoring Do You Require?

• (a) What readings are on the digital display?

  • CO₂?

  • O₂?

  • Temperature?

  • Humidity?

• (b) Can each of these parameters be adjusted?

• (c) Can you set your own critical limits for each parameter being measured?

  • How sensitive can you establish these limits?

    • ±1.0° or 0.1°?

    • ±1.0% or 0.1%?

• (d) How is the access to sampling ports?

• (e) Can this incubator be integrated with your external alarm system?

• (f) Can this incubator be placed on a back-up generator?

  • What happens to the internal atmosphere when the incubator switches to a generator?

    • Does the incubator also need to be placed on a UPS machine?

What Is Required for the Maintenance of the Incubator?

• How often do you need to clean the incubator?

  • Can the incubator easily be taken apart and cleaned?

• How often do probes need to be replaced?

• How often do filters need to be replaced?

How much Does the Incubator Cost?

• How much does it cost for preventative maintenance?

• What type of warranty does the incubator come with?

• What’s the proximity of the distributer?

  • How fast can I have a problem addressed by a technician?

  • How much are technical fees?

What Are Other Considerations for Purchasing an Incubator?

• Have other successful IVF programs used this incubator for embryo culture?

  • Have you contacted these programs for references?

  • How are their statistics?

• How user-friendly is the incubator?

Appendix 4: College of American Pathologist Guidelines for the Maintenance and Quality Control of Equipment

Following installation and validation of your equipment, it is imperative that there is continuous monitoring while in clinical use. Close ­monitoring of equipment helps to ensure its performance is maintained and that problems are detected as they occur. The 2010 Reproductive Laboratory CAP Checklist [12] lists the following requirements for maintaining general lab equipment and incubators:

• 1. There is documentation of monthly evaluation of instrument maintenance and function, including temperatures of refrigerators/freezers in which reagents or patient specimens are kept.

• 2. There is a schedule or system available at the instrument for the regular checking of the critical operating characteristics for all instruments in use.

  • (a) This must include, but is not limited to electronic, mechanical, and operational checks. The procedure and schedule must be as thorough and as frequent as specified by the manufacturer. There must be a routine plan or schedule available at the instrument for the regular checking of the critical operating characteristics of all the instruments in use. The laboratory should have an organized system for monitoring and maintaining all instruments. Function checks should be designed to check the critical operating characteristics to detect drift, instability, or malfunction, before the problem is allowed to affect test results. All servicing and repairs should be documented.

• 3. There is documentation of checks of incubator function each day of use using an independent measuring device for the following.

  • (a) Temperature of incubators

  • (b) Gas concentrations in incubators

    • In lieu of measuring daily gas concentrations, the laboratory may verify acceptable incubator culture conditions by monitoring and documenting daily checks for pH. Alternatively, laboratories using premixed gas may retain the manufacturer’s certificate of analysis as documentation of acceptable QC records instead of performing independent measurements

• 4. Acceptable limits of temperature, humidity, gas content, and/or pH are defined.

• 5. The laboratory has a method to detect and prevent incubator gas failure.

• 6. The laboratory’s incubator for embryos and gametes has emergency backup power, and it is tested at least quarterly.

• 7. All critical incubator, storage, refrigeration, and freezing units are monitored and checked each day of use.

• 8. The laboratory’s incubator for embryos and gametes has emergency backup power, and it is tested at least quarterly.

• 9. Incubator alarms are monitored 24 h/day (either remote or in the laboratory).

  • (a) Alarm systems, if used, must be checked at least annually. Audible alarms are only effective if someone is able to respond to the difficulty and is trained to follow the appropriate methodology to correct the problem or take alternative measures.