Remote IVF: a clinical and laboratory guide to performing remote oocyte retrievals

Abstract

The aim of this guide is to describe different scenarios when remote IVF would be needed, considerations around how to plan for the procedure, proper equipment in the procedure room, and proper transportation of oocytes from the procedure room. There are two different scenarios for remote IVF: (1) IVF clinics designed knowing the embryology laboratory is nonadjacent and (2) IVF clinics that routinely provide care to patients in their clinic and want to provide care to those who are ineligible for a retrieval under anesthesia in an outpatient facility. This guide will focus on both scenarios. Much of the advice can be used for IVF clinics that routinely perform oocyte retrievals nonadjacent to their embryology laboratories. Special considerations are needed when patients with complex comorbidities require high-level of care and hospital-level monitoring while under anesthesia and/or post-oocyte retrieval, and are thus unable to be treated in the standard facility. For these reasons we have created a comprehensive guide to nonadjacent, or off-site, oocyte retrievals for reproductive endocrinology and infertility (REI) physicians, nurses, and embryologists to use when planning care for IVF patients. Going forward, we will refer to both these scenarios as remote IVF.

Background

Traditionally, oocyte retrievals are performed in in vitro fertilization (IVF) programs where the embryology laboratory is adjacent to the retrieval procedure room. Today, however, it is not uncommon for the IVF laboratory to be situated nonadjacent to the procedure room, for example, when oocytes are collected in an outpatient surgical center or in a hospital operating room (OR) that is remote to the embryology laboratory. In these cases, new ways to handle quality control, new protocols, and transportation must be modified and performed differently.

Remote IVF is not a new concept. It was first reported by a group in France in 1984 (as described in [1]) and was initially geared towards allowing patients from a broader geographical area to reap the benefits of the nascent technology, which was localized to university-based IVF laboratories and assisted reproduction centers.

The initial manuscripts reported on fairly crude transport techniques. Jansen et al. reported on their patients’ husbands transporting oocytes in their own follicular fluid kept at body temperature over 30–60 min to the laboratory at the University of Rotterdam after oocyte retrieval at a peripheral hospital. Surprisingly, they found no decrease in fertilization rates for these 32 patients compared to 73 patients who underwent oocyte retrieval at the university center (45% vs 46%, respectively) [2].

Other early reports discussed the male partner transporting test tubes containing follicular aspirates in an incubator that could be plugged into the car cigarette lighter to maintain temperature at 37 ± 0.2 °C; of note, these were kept at simply the normal atmospheric gas environment [3–5]. A similar method was described to transport oocytes in their own follicular fluid in an insulated box with a pre-heated block of aluminum that could maintain a temperature of 35 ± 0.3 °C for up to an hour [6–8].

The technique continued to evolve over time. In 1998, Alfonsín et al. described a technique where after oocyte retrieval, the follicular aspirates were immediately examined in a portable modified neonatal incubator maintained at a humidified 37 °C and 6% CO₂. The cumulus-oocyte complexes were then transferred to a tube containing 2mL of medium without HEPES containing 10% maternal serum equilibrated with 6% CO₂. The tube was then wrapped in aluminum foil and placed in a modified heater set at 37 °C inside a Styrofoam box, with temperature maintained via a 12-V battery [1].

More ambitiously, Buckett et al. reported on the first air transport IVF in 1999. Using a heated block within a transportable incubator that could be kept at 37 °C using a car cigarette lighter, wall plug, or rechargeable 6-hr battery. Follicular aspirates in capped tubes were transported by the patients’ husbands via airplane from a hospital 500 km north of Montreal to the McGill Reproductive Center laboratory. The oocytes arrived at the laboratory approximately 225 min after the beginning of the egg retrieval; in both cases, the patients conceived after embryo transfer, although one resulted in an early miscarriage [9].

In all of the above reports, remote IVF was done for the purpose of expanding access to care for a variety of reasons. Specifically, it allowed for clinics not equipped with IVF laboratories to offer and provide high-quality reproductive care to their patients, while alleviating the physical, psychological, logistical, and monetary burden of having to travel to a centralized location for care [10]. These examples present the first scenario for remote IVF—a situation in which an IVF clinic or program is designed in such a way that the embryology laboratory is nonadjacent to the procedure/retrieval room due to logistical or structural facility concerns. In this scenario, the patients are otherwise routine fertility patients who require IVF.

The second scenario for remote IVF would be in situations where an established IVF program wants to expand care to medically complex patients who are ineligible for a retrieval in their existing outpatient facility due to patient-safety concerns and facility licensing. Most IVF clinics are in stand-alone outpatient facilities that are licensed only to provide care to patients who are level I (normal healthy patient) or level II (patient with mild systemic disease) on the American Society of Anesthesiologists (ASA) Physical Classification System [11]. This precludes a variety of patients from being able to access crucial fertility care and their right to reproductive health. Two of the authors of this manuscript (DB and SS), with others, established a remote IVF program at the University of Pennsylvania to care for patients who are ASA Level III (patient with severe systemic disease). In 2020, this group published on successful IVF in women with complex cardiac physiology who had their oocyte retrievals performed in a hospital operating room, which is about a mile away from the IVF laboratory; in that manuscript, the authors demonstrated that we can safely perform IVF for patients who require a high level of care and are otherwise unable to be treated in a lower-acuity outpatient surgical facility [12]. Since then, we have safely managed patients who desired oocyte banking for fertility preservation and/or IVF for autologous or gestational carrier use who were at increased risk of bleeding (pelvic vasculature malformations, severe chronic thrombocytopenia) or had increased anesthetic risks (myotonic dystrophy, prior anesthesia complications, family history of malignant hyperthermia, complex regional pain syndrome, mast cell activation syndrome, and seizure disorder).

In both scenarios, subsequent embryo transfers (if applicable) can usually be done in rooms adjacent to the embryology laboratory as they do not require the infrastructure of a procedure/operating suite, nor are they done under anesthesia.

Here, we have created a comprehensive guide to nonadjacent/off-site oocyte retrievals for reproductive endocrinology and infertility (REI) physicians, nurses, and embryologists to use when planning care for IVF patients. Going forward we will refer to both these scenarios as remote IVF.

Equipment

Creating a remote IVF set-up requires having the appropriate equipment in the right place at the right time. A suggested list of this equipment can be found in Appendix 1. This list assumes the OR suite has all other equipment necessary for a gynecologic procedure (i.e., saline, stirrups, drapes, etc.). Items on the list can either be transported to the OR where the oocyte retrieval will take place, or items can be stored near the location of the procedure.

For the first scenario in which an IVF program is designed to have retrievals performed remote from the IVF laboratory (different floor or nearby building), the procedure room or surgical center should have a dedicated, secure space where equipment for remote IVF can be kept permanently for routine oocyte retrievals. This equipment would include the following: isolette containing a stereo microscope and heated stage, warmer with blocks, transport incubator, and ultrasound machine with transvaginal probe.

For the second scenario, in which retrievals will be performed in a hospital OR only for medically complicated patients, there may be absolutely no equipment in the OR for the embryologist or the retrieval team. Ideally, an isolette containing a stereo microscope and heated stage, a warmer with blocks, and the ultrasound machine with transvaginal probe will be stored in a secure space (e.g., clean equipment room) in close proximity to the OR. At a minimum, a transport incubator that holds temperature and a tube warmer should be manually brought to the OR in these situations.

Isolette containing stereo microscope and heated stage

The isolette must be kept in working condition and plugged into a generator-backed wall outlet at all times (or as early as possible prior to starting a retrieval for scenario #2). It is important to be aware of the strengths and weaknesses of each isolette. For example, many older isolettes mix carbon dioxide with room air to provide the appropriate CO₂ concentration. If this isolette uses a thermal conductivity meter, as opposed to an infrared meter to measure CO₂ concentration, the concentration may be inaccurate depending on the changing humidity of the isolette chamber. If possible, use an infrared CO₂ meter to ensure that the proper CO₂ concentration is maintained throughout the times the incubator is accessed. Temperature must also be validated in the isolette. Older isolettes were poor at maintaining proper temperature. The stereo microscope light source should be checked prior to case start and a replacement bulb should be available. A certified thermometer should be used on the day of the retrieval to ensure optimal temperature within acceptable limits on the heated stage. All quality control (QC) should be documented each day of use and reviewed as part of the standard QC program in the laboratory.

Warmer plus blocks

The warmer plus blocks must be kept in working condition and plugged into a generator-backed wall outlet at all times (or as early as possible prior to starting a retrieval for scenario #2 to allow them time come to temperature). A certified thermometer should be used on the day of retrieval to ensure optimal temperature within acceptable limits. Temperature levels should be documented each day of use and reviewed as part of the standard quality control program in the laboratory. For precise temperature control, it is important that the tubes are the correct size for the block and nothing (i.e., sterile drape) should be placed between the block and heating element. Particular attention should be placed to ensure that the temperature does not overshoot too much and cause warm spots in the blocks or tubes.

Transport incubator

The transport incubator is kept in the embryology laboratory and brought over by the embryologist on the day of retrieval. Transport incubators should maintain specific temperature and gas levels, if possible. Temperature and gas levels (if applicable) should be measured using a calibrated thermometer (and gas analyzer) and documented each day of use and reviewed as part of the standard QC program in the laboratory. For transport incubators with a battery, the power source should be checked to ensure it will function for the maximum potential transport time.

Transport tubes

How the oocytes will be transported is important. Dishes are not ideal containers for oocytes that must be moved and may be subjected to bumps and jarring motion. Some type of tube with either a screw-on or snap-cap will prevent accidents. These tubes can be filled with a few milliliters of either media buffered with HEPES or MOPs (modified media) plus protein or carbon dioxide buffered medium plus protein. Media should be equilibrated overnight. If non-modified media is used, triple mix gas or even 5–8% carbon dioxide (depending on what is used in the lab) can be used to top-off the tubes prior to leaving for the laboratory. To top off tubes with gas, attach a sterile Pasteur pipette to a gas line and swirl in the air pocket of the tube. Since the media has been equilibrated overnight it is not necessary to insert the tip of the pipette into the media. Oil should be avoided in the tube used for transport. It is important that embryologists practice with removing the cumulus-oocyte complexes from the tube prior to the first retrieval occurring.

Ultrasound machine

The ultrasound machine and transvaginal ultrasound probe necessary for oocyte retrievals should be kept in working order and undergo routine maintenance per manufacturer recommendations and hospital policy. It is recommended to always have a second ultrasound probe available for back-up or in case a transabdominal retrieval needs to be performed. It is important that the correct needle guide is paired with the correct probe.

Media, reagents, and disposable plasticware

All reagents and media used in remote IVF are brought from the embryology laboratory on the day of the retrieval. Clean, warmed modified media and warmed gassed bicarbonate media can be transported in tubes within the transport incubator in preparation for the retrieval. The media, reagents, and disposable plasticware used must follow the standard quality control testing schedule and approvals within the embryology laboratory including lot-to-lot review of certificates of analysis.

Environmental considerations

It is important to be aware of the environment (temperature and pH) of the media that the oocytes are exposed to during the retrieval, as well as during travel. Monitoring and evaluation of culture media is one of the key variables to consider when designing the protocol for transporting oocytes from off-site to the embryology laboratory.

If all appropriate equipment is available, especially an isolette, oocytes can be retrieved and searched for in the OR using protein-supplemented bicarbonate media in dishes (under oil). Cumulus cells can be trimmed, but not stripped, of any large complexes and blood clots, but this is not mandatory as the oocytes can also be trimmed immediately upon arrival to the laboratory. Large blood clots should not be added to the transport tube, if possible, to avoid exposure to reactive oxygen species. The oocyte-cumulus complexes should then be placed into the transport tubes as described above (without oil), placed into the transport incubator, and transported to the embryology lab for further processing.

If an isolette is not available, follicular aspirates should be collected into snap-cap tubes containing clean, warmed, and modified media, and tightly capped. These are loaded into the 37 °C transport incubator and transported to the embryology laboratory. The oocyte search then occurs back in the laboratory under controlled temperature and gas conditions, as is standard. Oocytes should have minimal exposure to hospital operating room air due to high levels of volatile organic compounds (VOCs). For times when there is a long window between the oocyte retrieval procedure and when the oocytes will be isolated from the follicular fluid in the embryology lab, consider rinsing and dissecting the cumulus cells away from the oocytes prior to transporting. This becomes especially necessary if the follicular fluid is bloody or coagulating.

Preparation for retrieval

The day before the retrieval you need to prepare labels, charts, media, and charge the travel incubator (if needed). Confirm if you need to bring retrieval dishes, glass pipettes, needles, to the retrieval, or if these supplies will already be at the location. Depending on the supplies in the location of the retrievals, a gas analyzer, thermometer, and corresponding QC sheet to check the isolette may be needed. If the isolette requires filtered water and CO₂, make sure those are available. If no isolette or microscope will be available, 1 mL of modified media in tubes can be warmed overnight and used to collect oocytes and follicular fluid.

Transportation

Have a transport team available. This entails a person separate from the oocyte retrieval procedure to be available to drive the embryologist(s) to and from the off-site location. It may be necessary for two or three trips in each direction, given nursing may also need to transport equipment and staff. In one possible scenario, the embryology and nursing teams go over together, but embryology returns immediately with the oocytes while nursing stays behind to rehouse the supplies and assist the physician with final patient care needs. In this scenario, a second trip with nursing and supplies back to the IVF clinic would be necessary.

When choosing a transportation team, keep in mind liability issues that could arise should there be an accident during transport. Consider having a legal team review the transport process. It is not recommended to have IVF staff drive personal vehicles with oocytes or equipment. It is also not recommended to hand-off oocytes to a courier; an embryologist should be with the oocytes at all times to ensure chain of custody and safe handling of the specimen. Some options for transportation could include hospital security or a non-emergency medical transportation service.

Quality control

Detailed guidance for laboratory QC and quality assurance are published elsewhere [13]. Laboratory staff are encouraged to develop a robust QC program for all laboratory functions, and equipment and media needed for remote IVF may require additional QC. All equipment for remote IVF must be scheduled for calibration and certification similarly to the equipment within the IVF laboratory. All equipment should be considered part of the embryology laboratory equipment inventory.

Protocols should be developed and shared with all stakeholders, including the clinical team, prior to implementation. Standard “time out” protocols will apply, including patient identification using two (2) unique identifiers.

It is strongly recommended that low VOC cleaning supplies be used where retrievals are being performed. For retrievals in main hospital ORs where high VOC cleaning supplies are typically used, use of an isolette will help provide a gassed (if applicable) and heated environment for short-term oocyte manipulation outside the laboratory. Universal and standard precautions should be used as much as possible.

Specific patient characteristics can be monitored as suggested in Table 1. These patient characteristics can be compared between remote IVF and non-remote IVF patients to evaluate the two populations and their outcomes, and to help with quality improvement when necessary.

Table 1.

Patient characteristics monitored for remote IVF

Patient age

Patient AMH

Patient BMI

Indication for treatment

Time of follicle puncture vs. time of oocyte check

Blastocyst utilization rate

Ongoing pregnancy rate

Key performance indicators

The successful workflow of remote IVF oocyte retrievals can be evaluated using key performance indicators (KPIs). The following table summarizes the standard laboratory KPIs used to assess whether quality assurance and QC are being maintained, and that remote retrieval and transport of oocytes followed by standard embryo culture are occurring in a tightly-controlled environment with minimal protocol drift (Table 2) [14]. The goal should be to achieve each competency value at a minimum and each benchmark value ideally. Some patients will have remote retrievals for oocyte cryopreservation rather than embryo culture, in which case the KPIs related to embryo culture will not apply.

Table 2.

Key performance indicator (KPI) competency and benchmark values [13]

KPI	Competency	Benchmark
Rate of oocytes retrieved/follicle	x	80–95%
Rate of mature oocytes retrieved	x	75–90%
Rate of mature oocytes fertilized (2PN)	> 65%	> 80%
Blastulation rate	> 40%	> 60%
Blastocyst warming survival rate	> 90%	> 99%
Blastocyst implantation rate	> 35%	> 60%

An average competency per KPI can be calculated for all patients. If applicable, average KPI values for remote IVF (study group) should be compared to average KPI values for oocyte retrievals that are performed adjacent to the embryology laboratory (control group), to ensure standards are being maintained with no significant differences between the two groups that may be associated with the transport aspect of the retrieval. It should be noted that if remote IVF is performed only for medically complex patients, this may confound comparison of KPIs between the two groups. In addition, the total number of patients in this group may be small and need to be reviewed per case. These are benchmark suggestions to be used as a starting point. Outcomes should be monitored to ensure that the system is in control.

Patient care

In scenario #2, the reason for remote IVF in a hospital setting is due to a patient’s complex medical history precluding safe retrieval in a low-risk outpatient surgical facility or procedure room. Care for these patients is inherently multidisciplinary and should at minimum include the REI specialist, members of the team managing the patient’s primary comorbidities, and anesthesiology. For patients who are considering carrying their own pregnancy, consultation with a maternal fetal medicine specialist is also highly recommended.

As most of these cases will be done on an elective basis, preparation starts well in advance of the patient presenting for baseline ultrasound and bloodwork. After initial consultation with the REI physician, a conversation should occur with the other specialists that ensures adequate recent testing (e.g., echocardiogram or pulmonary function tests) and that medications are adjusted appropriately, particularly if a patient plans on carrying the pregnancy. A management plan should be documented in the patient’s chart. Patients should be medically optimized before proceeding with oocyte retrieval without unnecessarily delaying family building plans. For urgent situations, such as fertility preservation before initiation of gonadotoxic chemotherapy, providers should ensure that the patient is stable enough for ovarian stimulation and oocyte retrieval prior to proceeding. Finally, the other specialists should be aware of the potential for significant fluid shifts after ovarian stimulation and retrieval and should be ready to help a patient adjust their medications as needed in the days following the retrieval.

For patients requiring retrieval in a hospital setting due to complex cardiac physiology, consideration should be given to have a cardiac anesthesia team be available in the event of a cardiovascular emergency. If a patient is anticoagulated for any reason during stimulation, particularly at therapeutic dosing, blood should be readily available in the event of a bleeding complication.

In all of these cases, patients must be carefully counseled on the additional risks posed to them by both ovarian stimulation and the oocyte retrieval procedure; informed consent should be documented thoroughly and appropriately in the patient’s medical record. If the standard IVF consent form is appropriately written, separate consent forms should not be necessary; review with a legal team would be prudent.

From a logistics perspective, additional stakeholders in a hospital retrieval program include the OR teams. OR suite directors and managers must be involved in the planning process of establishing a hospital retrieval program given the resources required. As oocyte retrievals are time-sensitive and can at most be scheduled only 2 days ahead of time, these cases often “bump” other scheduled surgeries, which can be logistically challenging. It is of utmost importance to ensure that the procedure starts on time and that the pre-op and intra-op nursing and anesthesia teams are aware that minutes can matter; we would recommend these cases are scheduled as a first-start case. Consider allowing for extra time prior to retrieval beginning, i.e., add an extra 15–30 min to trigger time to account for staff that is not familiar with the retrieval set up and procedure. A nursing team familiar with the hospital OR suite and procedures should be present, along with a nursing team from REI that is familiar with the instrument setup and oocyte retrieval procedure.

Another important consideration is logistics for sperm collection. If the plan is to use fresh sperm, the workflow could be as follows: the partner drops off the patient in pre-op, goes to the location of the embryology laboratory to produce a sample (which can then be processed), and then returns to the hospital to await the patient in recovery. Frozen back-up sperm should also be available.

Finally, a workflow should be in place for patients to receive appropriate peri-operative instructions from REI nurses who are familiar with them, rather than expecting general nurses in the post-operative care unit to give specific instructions. One example is for patients to receive the instructions on the day they come in for post-trigger labs (e.g., how and when to start progesterone injections if planning a fresh transfer).

Best practices

Before the first retrieval is performed, laboratory personnel and clinical team should conduct a trial run of the standard processes that will be done to address any issues that might be site specific. Pay specific attention to retrieval pump, heat blocks, etc. Equipment validation should be performed to ensure proper temperatures and gas concentrations can be maintained for the amount of time it would take to complete a retrieval and travel with the oocytes. The trial run can be accomplished at the clinic but the more detailed and exacting the better. One example of a successfully trial run would include going through the entire procedure with a dummy patient, all OR surgical supplies, embryology supplies, nursing, physicians and lab staff, and the transport driver(s). During this time, equipment placement for optimal flow during the retrieval to reduce mistakes/accidents is reviewed.

On the day of the retrieval make sure to charge the transport incubator, if needed, and check the temperature. Have extra patient labels and any staff identification necessary to enter the OR. Confirm the physician performing the oocyte retrieval has privileges at the location.

Troubleshooting

Both clinical and laboratory components must be operational and optimized to perform remote IVF. It is best practice to perform and document QC assessments at least one day prior to a retrieval; this provides ample time to address any issues that arose since the previous retrieval. Have a backup protocol in place in case there are issues with the travel incubator, microscope in the OR or CO₂ source in the OR. For example, bring a bottle of a modified culture medium should an issue arise where it is not possible to gas the isolette or transport incubator. Also have a backup system should your transportation be held up; starting the retrieval on time and returning expediently with the oocytes at 37 °C are important parts of the remote IVF protocol.

Potential issues and solutions

Many OR teams will be unaware that overhead lights should remain off until the final oocyte count is complete, and the oocytes are placed in the transport incubator. Consider reviewing with the OR team before the retrieval begins that it is preferred for the lights to remain off immediately after follicle aspiration is complete until the embryology team states it is okay to turn them on.

Unfortunately, it is likely the embryology team will have little control over cleaners used in this space. Be mindful that VOC exposure may be very different than what is at the IVF clinic. Keep an eye on KPIs as a result.

If the embryology and nursing team are relying on transportation from a hospital or security crew, and staffing allows for it, consider having a backup plan where a separate individual can drive the team to the location of the procedure. This will likely not be needed, but a backup transportation vehicle and driver are ideal. Emergencies or unexpected transportation delays can occur and the timing of the oocyte retrieval and returning to the embryology laboratory need to be prioritized.

Remote IVF can put additional strain on embryology, nursing, and physician staffing. Having enough employees to run two procedures at the same time may be needed. Alternatively, retrievals can be staggered to ensure staff has time to travel to and return from one location to the other. Do not underestimate the amount of time it will take to maneuver from a remote procedure back to the home base laboratory.

Alternative suggestions

If it is not possible to have an isolette with a microscope, embryologists can look for oocytes during the retrieval with a microscope in modified media. The microscope will need to have a heated stage and oocytes kept at 37 °C. Work quickly and be mindful when identifying eggs and trimming the cumulus. Oocytes can be transported without CO₂ as well if in modified media as opposed to bicarbonate media. If no microscope is available, all follicular fluid can be collected and transported at 36–38 °C. Identification of oocytes will occur in the embryology laboratory. This method may be more difficult to identify oocytes if there is blood introduced to the retrieval tubes as clotting may occur during the time between follicular fluid collection and searching back in the laboratory. Heparin can be added to modified medium for transport; however, there is controversy in the industry regarding oocyte exposure to heparin and additives during retrieval.

Conclusion

In this manuscript, we present a guide to establishing a program for remote IVF retrievals. In situations where on-site retrievals are not an option, whether based on existing infrastructure or due to patient comorbidities, remote IVF is a viable alternative. It is important to recognize, though, that these are usually less than ideal due to the inability to control the external environment. The most important aspect of remote IVF is to keep the oocytes at 37 °C throughout the process, including transport. With due care, remote IVF can be as effective as on-site retrievals if planned meticulously by performing a dry run and measuring the temperature and CO₂ concentrations/pH at each step prior to implementation of the plan.

There are several ways to perform this procedure off-site, including collection and transport of the follicular aspirates or collection and transport of cumulus complexes that have been isolated from the aspirates. Transport can be accomplished in modified media or in media buffered with just CO₂. In order to get the processed cumulus complexes into the routine environment of the home laboratory, aim to have as short as possible time outside of the on-site incubators. This may necessitate having extra personnel available to take care of equipment once the procedure is over, while a transport team takes the tissue to the home laboratory.

It is important in planning to be ready for unforeseen problems like equipment failure or shortages of media due to accidents. The team must come prepared to solve these problems at the off-site OR by bringing replacement parts and extra supplies. One of the most difficult issues to deal with in these remote retrievals is the uncertainty of when the OR suite will be available. Retrievals are timed in relationship to the hCG trigger, but often hospital OR start times depend on factors outside of REI’s control.

In summary, if planned meticulously, remote retrievals can be a viable alternative for those situations or specific patients where retrievals adjacent to the embryology laboratory are not possible.

Appendix

Appendix 1. Sample checklist for equipment and supplies

Remote IVF checklist
Large equipment
Isolette with microscope and heated stage*
Medical grade CO2 source
Portable CO2 incubator**
Extension cord (sometimes outlets not available at best for location for microscope/isolette/ultrasound)
Distilled H2O for isolette, if needed
QC sheet for isolette temperature and CO2
Arm cover replacements for isolette arm holes
G-100 gas analyzer
Ultrasound machine
Retrieval (clinical supplies)
Transvaginal ultrasound probe x2
Needle guide x2
Retrieval needles x2–3
Suction pump
Test tubes for retrieval follicular fluid
Tubing x2
Probe cover x2
Media x2
Thermometer for warming block
Warmer
Warming blocks x2–3
Gloves for retrieval
Spinal needle x2
Sterile ultrasound gel x2
IVF retrieval paperwork
Retrieval (lab supplies)
Kim wipes
6% hydrogen peroxide
Equilibrated media: 2 blue cap falcon tubes of 10 mL culture media plus protein
Pen/marker
Post-it notes
Parafilm
Labels for dishes and tubes
Equilibrated oil
Organ well—1 sleeve
Egg search dish—2 sleeves
Sterile collection cups—3
Retrieval tube with 2mL of culture media plus protein for transporting eggs back
Test tube rack
Test tubes
Polished glass pipets x2, flame may or may not be allowed in OR
Insulin needles for trimming cumulus and clots x3
Thermometer for isolette
Thermometer for carrier
Pulled glass pipette
Rubber bulbs x3 for glass pipettes
CO2 analyzer
Glass pipettes
Blue pipettes

*Isolette (SmartStation, Astec or Cell-Tek 3000, Tek Event) with microscope (Olympus SZX16) onsite is preferred; if not an option, an acceptable alternative is to isolate the oocytes in follicular fluid and transport back in a 37 °C incubator

**CO₂ transport carrier (Cellbox, Planer or Cell-Trans 4016, Labotect) is preferred; if not an option, ooctyes can also be transported in pH stable media

Appendix 2. Protocol used at the University of Pennsylvania

Day before remote IVF

Confirm there is transportation for embryologists to the OR

• With the IVF nurses, bring supplies to the OR

Confirm there is transportation for embryologists back to embryology laboratory

• To transport the oocytes back to the lab

At the time of retrieval, bring the isolette from storage room (bring code or key, if needed)

1. Confirm the isolette is plugged in, battery charged

2. Confirm arm covers are on and replacements are available

3. Confirm there is medical grade CO₂. If less than 300 PSI, contact the OR and request a replacement.

4. Turn isolette on (using on/off switch) and confirm temperature rises appropriately.

5. Turn CO₂ on (using wrench) and confirm CO₂ level in isolette reaches 5.0-6.0 CO₂. PSI should = 7. Set point on regulator box should be 5.5%.

6. Confirm thermometer is in the incubator and the temperature set point is set to 36.5 °C.

7. Confirm microscope bulb functions

8. Confirm all supplies

9. In lab, make media and equilibrate in incubator overnight

   • 5 Retrieval tubes with 5 mL of culture media + 10% protein
   • 5 Retrieval tubes with 5 mL oil
   • 2 retrieval tubes with 5 mL mHTF + 10% protein

Paperwork

IVF lab cycle paperwork and labels

Day of remote IVF

1. The portable transport incubator is charged (temperature and CO₂)

2. All equipment and supplies, listed above, are gathered

3. Two embryologists will travel to OR via security vehicle

4. Isolette will be QC tested in the operating room for proper temperature and CO₂ level (5.0-6.0 CO₂)

5. Retrieval tube warmer will be QC tested for 37 °C

6. Retrieval will be carried out as per SOP

7. Oocytes transferred to round bottom tube with culture media+10% protein

8. Embryologists and oocytes will be transported back to embryology laboratory

9. A staff member will take the isolette back to storage room

   1. The isolette will be plugged into the wall, but remain turned off
   2. CO₂ will be turned off (using wrench)
   3. Cover isolette with plastic
   4. Make sure emergency number (lab director’s cell phone number) is visible

10. Oocytes will be transferred to a culture dish and cumulus will be trimmed in lab

11. Insemination and culture will be performed at the main embryology laboratory

12. Oocytes will not be left unattended at any time

Declarations

Conflict of interest

The authors declare no competing interests.