Академический Документы
Профессиональный Документы
Культура Документы
1 9, 2016
doi:10.1093/humrep/dew016
ESHRE PAGES
IVI Valencia, Valencia, Spain 2Fertilitetscentrum Stockholm, Stockholm, Sweden 3Biogenesi, Reproductive Medicine Centre, Monza, Italy
Leuven University Hospital, Leuven, Belgium 5Sahlgrenska University Hospital, Goteborg, Sweden 6Inst. Histology and Developmental Biology,
Faculty of Medicine of Lisbon, Lisbon, Portugal 7Hospital HM Monteprncipe, Madrid, Spain 8Genera c/o Clinica Valle Giulia, Roma, Italy
9
UZ Brussels, Brussels, Belgium 10IVF Consultancy Services, Leicester, UK 11European Society of Human Reproduction and Embryology,
Grimbergen, Belgium
4
Submitted on December 18, 2015; resubmitted on December 18, 2015; accepted on January 11, 2016
study question: Which recommendations can be provided by the European Society of Human Reproduction and Embryology Special
Interest Group (ESHRE SIG) Embryology to support laboratory specialists in the organization and management of IVF laboratories and the
optimization of IVF patient care?
summary answer: Structured in 13 sections, the guideline development group formulated recommendations for good practice in the
organization and management of IVF laboratories, and for good practice of the specic procedures performed within the IVF laboratory.
what is known already: NA.
study design, size, duration: The guideline was produced by a group of 10 embryologists representing different European countries, settings and levels of expertise. The group evaluated the document of 2008, and based on this assessment, each group member rewrote one
or more sections. Two 2-day meetings were organized during which each of the recommendations was discussed and rewritten until consensus
within the guideline group was reached. After nalizing the draft, the members of the ESHRE SIG embryology were invited to review the guideline.
limitations, reasons for caution: Evidence on most of the issues described is scarce, and therefore it was decided not
to perform a formal search for and assessment of scientic evidence. However, recommendations published in the European Union Tissues
and Cells Directive and relevant and recent documents, manuals and consensus papers were taken into account when formulating the
recommendations.
wider implications of the findings: Despite the limitations, the guideline group is condent that this document will be helpful to
directors and managers involved in the management and organization of IVF laboratories, but also to embryologists and laboratory technicians
performing daily tasks.
study funding/competing interest(s): The guideline was developed and funded by ESHRE, covering expenses associated
with the guideline meetings. The guideline group members did not receive payment. Dr Coticchio reports speakers fees from IBSA and
ESHRE pages content is not externally peer reviewed. The manuscript has been approved by the Executive Committee of ESHRE.
& The Author 2016. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved.
For Permissions, please email: journals.permissions@oup.com
Cook, outside the submitted work; Dr Lundin reports grants from Vitrolife, personal fees from Merck Serono, non-nancial support from Unisense, outside the submitted work; Dr Rienzi reports personal fees from Merck Serono, personal fees from MSD, grants from GFI, outside the
submitted work; the other authors had nothing to disclose.
Introduction
In line with the scope of the European Society of Human Reproduction
and Embryology (ESHRE), this document represents an updated
version of the guidelines for good practice in IVF laboratories published
in 2008 (Magli et al., 2008). The aim is to provide a wider coverage of key
aspects of the IVF laboratory, to give continuous support to laboratory
specialists and consequently contribute to improving IVF patient care.
2 Quality management
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
2.10
2.11
2.12
2.13
2.14
3 Laboratory safety
3.1 Laboratory design
The IVF laboratory must have adequate functionalities to minimize any
damaging effects upon reproductive cells, and ensure good laboratory
practice. The laboratory should be adjacent to the operating room
where clinical procedures are performed.
When commissioning the IVF laboratory, the most recent developments in facilities, equipment and procedures should be considered. Attention should be given to operator comfort to provide a safe working
environment that minimizes the risk of distraction, fatigue and thereby
making a mistake. Taking into account local, national and European occupational health and safety requirements, considerations should include
bench height, adjustable chairs, adequate work space per person,
microscope eye height, efcient use of space and surfaces, sufcient environmental lighting and air-conditioning with controlled humidity and
temperature.
More specically:
3.1.1 Materials used in laboratory construction, painting, ooring and furniture should be appropriate for clean room standards, minimizing
Volatile Organic Compounds (VOC) release and embryo toxicity.
3.1.2 Laboratory design should ensure optimal workow over minimal
distances while handling reproductive cells during all treatment
phases.
3.1.3 Laboratory access should be restricted to authorized personnel.
3.1.4 A system for clean access of personnel and materials to the
laboratory is highly recommended.
3.1.5 Rooms for changing clothes should be separate from the
laboratory.
3.1.6 Hand-washing facilities should be placed outside the laboratory.
4
3.1.7 Separate ofce space for administrative work should be available
outside the laboratory.
3.1.8 A separate laboratory with a safety fume hood should be provided
for analyses using xatives and other toxic reagents.
3.1.9 The area for cleaning and sterilization of materials, if present, should
be separate from the laboratory.
Vaccination of all personnel against hepatitis B or other viral diseases, for which a vaccine is available, is recommended.
Patients must be screened for infectious diseases according to national and international regulations.
Staff must be informed when a viral-positive patient is to be
treated and be aware of the risks of handling infected biological
material.
SOPs should be in place to manage eventualities where infection
might take place, e.g. needle-stick injuries.
3.5.2 To ensure adequate safety measures, the treatment of viralpositive patients should be only performed in IVF laboratories with
dedicated areas and equipment. Alternatively, such patient treatments could be allocated to specic time slots provided processing
of their biological materials is followed by a thorough disinfection of
the allocated areas and equipment.
3.5.3 Whenever biological material is imported into the IVF laboratory
from another clinic, full screening results should be obtained in
advance. If any transported material is viral-positive, a dedicated
dry shipper may be needed, depending on European and national
regulations.
(or donors) and their tissues and cells, together with relevant data
regarding products and materials coming into contact with them, are
available at all times.
4.1 Proper training in traceability procedures for all laboratory staff is
mandatory.
4.2 Before commencing any procedure, the laboratory must be provided with each patients unique identication code which has to
clearly and easily refer to the patients documentation. Each treatment cycle must be assigned a unique code.
4.3 Corresponding consent forms, clinical data and serological examinations undertaken by patients/donors prior to admission to
the treatment should be available to the laboratory staff.
4.4 Rules concerning the correct identication and processing of reproductive cells must be established in the laboratory by a
system of codes and checks including:
4.5
5 Consumables
Specications of critical reagents and materials should be in compliance
with European and/or national regulations.
5.1 All consumables and media should be t for their purpose, of
embryo culture grade quality and preferably CE-marked. Use of
quality controlled media, oil and disposables is recommended. If
appropriate quality control testing for IVF purposes is not provided, this must be performed by the laboratory itself or by a designated company. In addition, packaging integrity and appropriate
delivery conditions should be checked. Documentation of quality
control testing must be supplied for any commercial media and
this must correspond with the delivered batch.
5.2 Sterile single-use disposable consumables should be used.
5.3 Reagents, media and consumables should always be used prior to
the manufacturers expiry date.
5.4 Size of the bottles and other packaging must be appropriate to minimize openings and time between rst and last use.
5.5 Appropriate refrigeration facilities must be available for storage of
media and reagents. The correct temperature during their shipment
to the clinic should be veried. Repeated shifts of temperature
should be avoided while handling in the laboratory.
5.6 Patient or donor serum and follicular uid should not be used
as a protein supplement. Commercial suppliers of human serum
albumin or media containing a serum-derived protein source
should provide evidence of screening according to European
and/or national regulations.
5.7 An appropriate stock management system for media, oil and consumables, including the batch number, date of entry and expiration
date should be available.
7 Oocyte retrieval
Oocyte retrieval is a particularly sensitive procedure and special attention should be given to temperature and pH as well as efcient and
quick handling.
7.1 An identity check before the oocyte retrieval is mandatory.
7.2 The time between oocyte retrieval and culture of washed oocytes
should be minimal. Prolonged oocyte exposure to follicular uid is
not recommended.
7.3 Appropriate equipment must be in place to maintain oocytes close
to 378C. Flushing medium, collection tubes and dishes for identifying oocytes should be pre-warmed.
7.4 Follicular aspirates should be checked for the presence of oocytes
using a stereomicroscope and heated stage, usually at 860 magnication. Exposure of oocytes to light should be minimized.
7.5 Timing of retrieval, number of collected oocytes and the operator
should be documented.
8 Sperm preparation
Before starting a treatment cycle, at least one diagnostic semen analysis
should be performed according to the protocols described in the World
Health Organization (WHO) manual (World Health Organization,
2010). In addition, a test sperm preparation may be advisable in order
to propose the most adequate insemination technique (IVF/ICSI).
Patients should be given clear instructions regarding the collection of
the sperm sample (hygiene, sexual abstinence, timing etc.). A frozen
back-up sample should be requested if sperm collection difculty on
the day of oocyte retrieval is anticipated.
Sperm preparation aims to:
9 Insemination of oocytes
Oocytes can be inseminated by conventional IVF or by ICSI. The insemination/injection time should be decided based on the number of hours
elapsed from ovulation trigger and/or oocyte retrieval, also keeping in
mind that fertilization will need to be checked 1618 h later.
Viscous substances such as polyvinylpyrrolidone (PVP) can be used to facilitate sperm manipulation.
In case of only immotile sperm cells, a non-invasive vitality test can be
used to select viable sperm for injection. After injection, oocytes should
be washed prior to culture.
10.1
10.2
10.3
11.9
12 Cryopreservation
Cryopreservation can be performed for gametes, embryos and tissues.
12.1
12.2
12.2.1 For sperm, slow freezing is still the method of choice, but rapid
cooling is a possible alternative.
12.2.2 For oocytes, vitrication has been reported to be highly successful and is recommended.
12.2.3 For cleavage-stage embryos and blastocysts, high success rates
have been reported when using vitrication. However, for pronuclear and cleavage-stage embryos, good results can also be
obtained using slow-freezing methods.
12.2.4 For tissues, the method of choice is slow freezing, but vitrication of ovarian tissue is an option.
12.3 In order to minimize any risk of transmission of infection via LN2:
12.3.1 Contamination of the external surface of cryo-devices should
be avoided when loading them with samples.
12.3.2 Safety issues have been raised regarding direct contact of the
biological material with the LN2; however, at this point closed
devices cannot be favoured over open devices. Laboratories
should make decisions based upon their results, risk analysis and
regulations in place.
12.3.3 Specimens from sero-positive patients should be stored in
high-security closed devices. Dedicated vapour phase tanks are
recommended.
12.4 At cryopreservation, documentation on biological material
should include:
Labelling of devices.
Cryopreservation method.
Date and time of cryopreservation.
Operator.
Embryo quality and stage of development.
Number of oocytes or embryos per device.
Number of devices stored per patient.
Location of stored samples (tank, canister).
Cryo-devices must be clearly and permanently labelled with reference to patient details, treatment number and/or a unique
identication code.
A periodic inventory of the contents of the cryobank is recommended, including cross-referencing contents with storage
records.
At thawing, documentation on biological material should include:
Thawing method.
Date and time of thawing.
Operator.
Post-thawing sample quality.
A double-check of patient identity is recommended in the following steps: transfer of samples into labelled cryo-dish, loading of the
12.5
12.6
12.7
12.8
12.9
Funding
The guideline was developed and funded by ESHRE, covering expenses
associated with the guideline meetings. The guideline group members
did not receive payment.
13 Emergency plan
Conict of interest
G.C. reports speakers fees from IBSA and Cook, outside the submitted
work; K.L. reports grants from Vitrolife, personal fees from Merck
Serono, non-nancial support from Unisense, outside the submitted
work; L.R. reports personal fees from Merck Serono, personal fees
from MSD, grants from GFI, outside the submitted work; the other
authors had nothing to disclose.
References
Supplementary data
Supplementary data are available at http://humrep.oxfordjournals.org/.
Authors roles
M.J.d.l.S. chaired the guideline development group and hence fullled a
leading role in writing the manuscript and dealing with reviewer comments. N.V. provided methodological support. All other authors,
listed in alphabetical order, as guideline group members, contributed
equally to the manuscript, by drafting the sections, and discussing recommendations until consensus within the group was reached.