The final critical step in the IVF process is the embryo transfer. Trans-vaginal embryo transfer, often combined with abdominal ultrasound guidance, returns embryos to the woman’s uterus with the goal of implanting into the uterine wall and creating a pregnancy leading to live birth. Successful embryo transfer depends on the protocols of the clinic, development of the embryos in culture, and optimized preparation of the uterine lining. Embryos can be fresh or frozen–thawed, with or without biopsy for genetic testing, at time of transfer. Good embryo transfer technique is required from both the clinician and the embryologist. In all cases, a fine sterile flexible plastic catheter designed for embryo transfer is loaded with the embryos by the embryologist and handed off to the clinician for insertion into the patient’s uterus. Methods of catheter loading and hand-off to the clinician will be discussed, as well as troubleshooting notes.

Pre-implantation genetic testing for aneuploidies (PGT-A) of embryos involves confirming the chromosomal status of the embryo through assessment of biopsied cells. Most miscarriages and failed implantations are believed to be due to abnormal chromosomal status. Possessing the correct chromosome complement increases the ability of an embryo to implant and result in a live birth. Historically, biopsies occurred at the cleavage stage. However, with more cells being able to be biopsied at the blastocyst stage, representing a smaller proportion of the embryo, blastocyst biopsy is currently regarded as a safer procedure with increased sensitivity for detecting mosaics. Therefore, as the benefits of blastocyst biopsy became more evident, blastocyst biopsy has gradually become the method of choice in most in vitro fertilization (IVF) laboratories. As a technical procedure, lack of blastocyst biopsy skills has been an obstacle for some clinics to adopt this practice. This chapter outlines a structured methodology to train a biopsy practitioner to acquire the competency to confidently perform this procedure in a consistent manner that is safe for the embryos whilst maximizing the chance of pregnancy.

From a practical point of view, the culmination of excellent work in the IVF laboratory is the perfect transfer of the right embryos to the right part of the uterine cavity, aseptically and safely. As with all other tasks in the IVF laboratory, embryologists need to gain experience with embryo transfer (ET) techniques. Embryo loading in the different types of ET catheters, compared to ICSI or embryo biopsy, seems a fairly straightforward procedure but involves a great deal of responsibility. Excellent communication with doctors during ET, good embryo loading technique, training and proper traceability are key elements that will provide the quality needed for this simple but important step in assisted reproductive treatments.

Scientists working in IVF laboratories come from varied backgrounds with a myriad of different educational experiences. Rarely are there local or national requirements which dictate the education or training needed; however, at a minimum, any aspiring embryologist will have an undergraduate degree with emphasis in biology and chemistry. A degree in laboratory sciences may offer many desirable, general laboratory skills, while an advanced degree, Masters or PhD in clinical embryology or reproductive sciences will give the scientist a stronger theoretical background. Laboratory directors and managers responsible for hiring scientists must take numerous factors into consideration when selecting candidates. Clinics with low cycle volumes will require embryologists with broader skill sets as they are likely to be responsible for all aspects of the laboratory, whereas clinics performing thousands of cycles per year may employ receptionists and technicians to manage the administrative laboratory duties so that scientists can focus on the embryology work.

The zona pellucida surrounding human embryos may be breached to facilitate the process of hatching following in vitro culture, either to promote implantation or in preparation for removal of cells for pre-implantation genetic testing (PGT). This technique is referred to as ‘assisted hatching’ (AH). Since publication of the first studies on AH in the 1990s aimed at improving implantation and pregnancy rates, in which a chemical method was used to breach the zona, multiple variations of the technique have been attempted by practitioners. Application of AH prior to fresh embryo transfer in young, good-prognosis patients has been repeatedly shown to be ineffective. The method continues to be successfully applied to fresh embryos for embryo biopsy and outcome data support application in frozen–thawed (vitrified–warmed) embryos and oocytes prior to transfer. Proper training, patient selection and methodology are important to the clinical success of AH as any other micromanipulation technique. Complete removal of the zona pellucida to avoid trapping has been proposed as an alternative to partial breach but studies are scarce.

Oocyte pick-up is the process whereby oocytes are microscopically identified and pipetted from follicular fluid aspirates and placed into a culture environment prior to in vitro fertilization (IVF). This chapter sets out the laboratory operating procedure for oocyte pick-up and considers practical training methods and competency assessment. From the outset, it is important for embryologists or technicians to be aware that changes in the wider environment of a gamete or embryo can affect its immediate culture environment. The external environment includes not only the space in which the pick-up is performed – the flow hood, which much provide stable temperature and pH maintenance for the oocytes – but also the consumables and culture media used. Task-based training leading to competency should follow a robust pathway. Oocyte pick-up is a critical process and, as such, should be performed effectively and reproducibly by the embryologists within the team.