From its humble beginnings in a small cottage hospital in Oldham (UK) to its acceptance in mainstream medicine and everyday life, the in vitro fertilisation (IVF) industry has evolved continuously, and is increasingly applicable not only with the treatment of a growing variety of fertility issues but also with challenges of today’s society and lifestyle choices.
Globally, infertility affects seven million people: one in six couples have a problem in conceiving. Last year we celebrated the 40th anniversary of the first “test-tube baby”, Louise Brown, and in doing so the birth of clinical embryology as a profession.
Over the years, IVF success rates have increased. The introduction of hormonal stimulation produced more oocytes than the early natural cycle attempts leading to a more streamlined and controlled treatment cycle leading to a better choice of embryos to transfer, and the need to cryopreserve remaining embryos.
Originally designed for patients with tubal damage—when the oocyte could not journey from the oviduct to the uterus to implant—the application of this science has been developed to include all forms of infertility, from hormonal disorders to severe male infertility. The shift has seen the opening of new possibilities that have been both morally, spiritual and socially questioned, such as the use of donor sperm and oocytes, sex selection, genetic screening and posthumous use.
These processes are manual manipulations in laminar flow hood with heated work surfaces, cultured in special low volume incubators
Embryologists working in the lab mimic nature, closely maintaining optimum conditions of temperature, pH and osmolarity; monitoring the development of embryos, and selecting the best embryo for transfer. These processes are manual manipulations in laminar flow hood with heated work surfaces, cultured in special low volume incubators.
Culturing outside the body close to physiological conditions has paved the way for new techniques, such as intracytoplasmic sperm injection (ICSI) and preimplantation diagnosis via embryo biopsy coupled with the ever-evolving science of molecular genetics.
Recent advances in cryobiology have also meant that frozen embryos have now succeeded in producing a viable pregnancy as fresh embryos (Thomson, 2019).
Embryos are routinely cultured now to five- or six-day post insemination before being transferred to the intended mother when the embryo has reached the blastocyst stage. This ready-to-implant embryonic stage (previously difficult to achieve with suboptimal culture media) now has a success rate of 54%, according to London Women’s Clinic data.
Giles Palmer, Senior Embryologist
Inside the IVF laboratory
The IVF lab is almost always adjacent to an operating theatre where procedures such as egg collection (by follicle aspiration) under sedation and embryo transfer are performed. The eggs and embryos are transferred hand-to-hand, literally, by a hatch (a passthrough you might say in the cleanroom industry) that must remain open for lengths of time up to 30 minutes.
Positive pressure and HEPA filters are commonplace in IVF laboratories, but industry standards are somewhat elusive: there is no consensus on what constitutes an IVF laboratory, and guidelines may differ greatly from country to country.
Only about 15% of IVF clinics are housed within a hospital, and currently may be designed within a medical centre, doctors’ offices and general buildings.
The IVF process also requires auxiliary rooms. An andrology laboratory (preferably in a separate room but not globally mandatory) is used to process the non-aseptic semen. A cryobiology room is then used to store the frozen samples. Plus, a medical gas room is also required.
Apart from gases used by the anaesthetists, mixtures of medical-grade gasses are required to produce the correct environment within the incubators for the developing embryo; typically 6% CO2 with low O2 tension.
Air quality and IVF
The IVF industry might not manufacture a product, as many industries using cleanrooms, but it seems appropriate to measure success by an endpoint of the birth of a healthy child. Development and normal growth, however, can be limited in adverse air conditions. The entire IVF process is governed by the biology of sperm, egg and embryo, and we must optimise conditions to protect the “product” against exposure to adverse external factors. The problem lies in the lack of agreement of these conditions.
The human embryo is sensitive to light, temperature and other environmental conditions. Pollutants can settle on workspaces, and although embryos bathed in their culture media overlaid with a layer of light paraffin oil, attention has to be paid to the risk of toxins infiltrating the barrier because embryos lack an immune system to stave off harmful environmental contaminants.
It should be noted that disposables and new equipment can introduce hazards in the laboratory, too
Urban air can contain high levels of pollutants, such as carbon monoxide, nitrous oxide, sulphur dioxide and heavy metals. Indoor construction materials, such as MDF, PVC flooring, paints and adhesives, constitute the major source of volatile organic compounds (VOCs).
Once only anecdotal in the early days of IVF, studies emerged, showing the negative effect of poor air quality and ultimately, pregnancy outcome (Cohen 1997, Hall 1998, Mayer 1999, Boone 1999). It was shown that compressed gases that fed the incubators had high levels of VOCs (namely benzene, isopropanol and pentane) and it was not uncommon for the laboratory environment to have higher VOC concentrations than indoor air.
Particle monitors and VOC counters have also emerged in the IVF marketplace
The industry took notice and has produced ingenious ways to protect the embryos, from closed laminar flow hoods to improvements to filters systems with “in-line gas filters” and standalone portable air filtration units. Particle monitors and VOC counters have also emerged in the IVF marketplace (Forman, 2004).
It should be noted that disposables and new equipment can introduce hazards in the laboratory, too. Sterile plastic test tubes and dishes in packages need off-gassing. The polystyrene-based plastics can emit styrene (Sing, 2015), and it is good practice to open the consumables well before use and leave in a laminar flow hood. New equipment must also be burnt in (to release residual VOCs from the manufacturing process) in a separate room before use.
GMP guidelines
While health and safety authorities have safe limits for VOC exposure for humans, there is nothing documented for developing embryos. Industry guidelines were (and still are) vague, but both the European Society of Human Reproduction and Embryology and the American Society for Reproductive Medicine recognise air quality is a key factor to success (ASRM 2014, ESHRE 2004) yet without specific details.
In 2004, the IVF landscape changed in Europe with the announcement of the European Union Tissue and Cell Directive, which specified precise quality and safety requirements for the donations, procurement, testing coding and storing. A key point in this policy was clean air (EUCTD, 2004). It was meant to bring cell and tissue use on par with blood and organ handling.
The inclusion of the IVF was both unexpected and fiercely debated (Mortimer 2005, Saunders and Pope 2005) because the original specifications would have been detrimental to in vitro embryo development.
The Directive stated: “Where tissues or cells are exposed to the environment (...) an air quality of Grade A, as defined in the current European Guide to Good Manufacturing Practice, is required. The background must be demonstrated to guarantee the maintenance of Grade A in the tissue/cell manipulation while in use and unmanned”. The document highlighted areas of improvements; there was little or no air management before this draft.
Where tissues or cells are exposed to the environment (...) an air quality of Grade A, as defined in the current European Guide to Good Manufacturing Practice, is required
It was argued that risk of infection is low and that the “product” cannot be sterilised. Equally, the cooling effects of maintaining airflow of a Grade A environment would have been detrimental to embryo culture and introduce vibrations not conducive to fine accurate manipulation needed in many techniques.
A second draft of the Directive stated a less stringent environment if Grade A was either detrimental or technically impossible, but did not define a level of air quality other than close to A.
In the UK, the Human Fertilisation and Embryology Authority (HFEA), a government watchdog, supported a Grade C working environment with a background of Grade D. From 2007, all manipulations must be within a Class II laminar flow hood. This regulation meant IVF labs at the very least had to make some adjustments to facilities and “standard operating procedure”. In the design of a laboratory, great care should be placed on location and adjacent rooms, so to avoid proximity to laundry, canteen or pathology labs emitting possible air contaminants. In a hospital environment, however, limited available space is always a problem.
Design and build requirements
The same deal of attention should be paid during and after laboratory renovation or build. The wrong materials can be the difference between a triumphant inauguration with great IVF success rates or failure with long-lasting effects.
Construction should involve using furniture free of VOCs, preferably stainless steel and low VOC materials and adhesives.
Lab improvements can help increase IVF success by implementing cleanroom standards
In a study following the VOC measurements during a renovation of a laboratory, I was able to show key VOC emissions, such as ethyl alcohol, acetone, hexane and toluene, at various point of construction phases, and ways to alleviate and eliminate the VOCs upon completion of the work (Palmer, 2010). This may be common knowledge to the cleanroom aficionados, but was something quite new a decade or so ago.
Other papers on air quality improvements followed, illustrating how lab improvements can help increase IVF success by implementing cleanroom standards.
Heitmann et al. in 2015, for example, described how a former lab with an unreliable HVAC system was transformed. The project used the strategy of pre-filter, photocatalytic irradiation and chemical filtration, by means of activated carbon, potassium permanganate, and finally HEPA filters. Implantation rates were drastically increased, and clinical pregnancy rate increased by 10%.
Still, as IVF resides predominately in the private healthcare sector, a great variety of different types of facilities exist, from renovated listed buildings of grandeur to purpose-built installations.
The need for consensus
There was a clear need for clarity within the existing guidelines on optimal laboratory conditions, but in a recently published article, a survey of 36 clinics using an IVF quality control app globally, little conformity could be found (Palmer, 2019).
Laboratory temperatures varied from 17oC to 35oC, and humidity from 5% to 80%; only four laboratories measured air quality; and only two measured VOCs.
The implementation of stricter guidelines is not always welcome. The mere mention of my talk on this subject at Cleanzone Middle East on social media raised a quiet storm doubting the merits of cleanroom technologies. Those raising an eyebrow pointed to costs, increase in staff required and questioned the necessity. Needless to say, the feedback was from old school scientists who had clearly not read or approved of the recent “Cairo consensus” published in 2018.
The Cairo meeting of experts was set out in the wake of growing evidence for recommending technical and operational requirements, control of particulates, aspirational benchmarks, and help in laboratory commissioning in the future.
The mere mention of my talk on this subject at Cleanzone Middle East on social media raised a quiet storm doubting the merits of cleanroom technologies
The meeting listed the most common agents of contamination and compared a large number of older facilities with laboratories using cleanroom concepts:
- The mean total VOC levels were considerably lower with cleanroom philosophy (340 μg/m3 vs 1323 μg/m3).
- A call to monitor individual VOCs was proposed (e.g. Aldehydes <5 μg/m3), while a limit of total VOC levels should be less than 500 μg/m3.
- Air quality particulate levels should be comparable to ISO Class 6/GMP B-C.
- The air changes per hour (ACH) in high-level cleanrooms was deemed excessive; it suggested to be aimed at 10-15/hr. The room should be over pressured to an ideal 50 Pa.
- The permitted background of Grade D under the European Union Tissue and Cells Directives (EUTCD) was considered insufficient. ISO Class 7/GMP Grade B in operation/C at rest was the target.
In all, there were over 50 consensus points, and it was concluded that cleanroom design should be implemented in any new IVF laboratory builds.
The IVF Industry 2.0
The global fertility rate continues to decline. Main culprits of this trend are the increase in obesity, environmental factors and lifestyle as well as psychographic changes.
Based on 2019 figures, there are over 3,000 clinics worldwide, and the need for IVF is ever-growing. In the US, 1.5% of all children born are a result of assisted reproduction, while the number is 4% in Australia and Israel, and in Denmark 6.4%.
Several economic sources have valued the market to be approximately US$16 billion, with a compound annual growth rate (CAGR) of almost 10%. If this growth holds strong for the next five years, it would mean an industry worth nearly $40 billion by 2025.
Growth is similar in all areas of the globe and large corporations, backed by venture capitalists, are consolidating chains of clinics. Once a reserve of private consultants or small groups of doctors, IVF clinics have now gone big, resulting in chains of IVF clinics.
The success of freezing produces an ever-increasing inventory of cryo-stored embryos, and estimates from IVF tech company TMRW forecast 21 million people will have stored samples by 2025
The IVF industry has to invest in new facilities equipped with state-of-the-art technology to keep up with this demand and produce high and reproducible standards. The success of freezing produces an ever-increasing inventory of cryo-stored embryos, and estimates from IVF tech company TMRW forecast 21 million people will have stored samples by 2025. This is a huge capacity that will need significant infrastructure to back it up.
Driven by technological advances, especially in the field of fertility preservation, we will see IVF clinics even more widespread and frequently used than they are today.
Consulting on various projects, in the UK and abroad, I have seen a huge lack in understanding of what is required to construct and maintain a successful IVF facility. I welcome the introduction of cleanroom companies into the IVF industry, as many aspects of your work and products are applicable to our industry today.
The modular cleanroom initiatives, such as the Shellbe system, are particularly appealing for their capacity to produce a zero VOC laboratory customised to the clients’ needs.
I welcome the introduction of cleanroom companies into the IVF industry, as many aspects of your work and products are applicable to our industry today
Fickle and demanding, we embryologists may be about the conditions and the design of the IVF clinic, but I am often hampered by lack of local expertise (or material) in various places of the world. As real estate costs and availability become so prohibitive in many cities, the portable, adaptable modular lab can be designed, shipped and constructed like Lego and fit suitably in spaces that were previously unutilised.
With so much evidence and interest in our field, now is the time for the IVF industry to enter the biotechnology arena and be ready for cleanroom technology.
N.B. This article is featured in the December 2019 issue of Cleanroom Technology. Subscribe today and get your print copy!
The latest digital edition is available online.