Prioritizing Embryos — PGT vs Morphology

When you have more than one embryo ready for transfer, you must decide which embryo goes first. Two major tools guide this decision:

• PGT (genetic information): chromosomal normality, mosaicism, translocations, single-gene status
• Morphology (how the embryo looks): grade of inner cell mass, trophectoderm, expansion stage

Where it fits:

• You use embryo prioritization after retrieval, not during stimulation.
• Prioritization affects transfer order, chance of success per transfer, and how many cycles you may need.

What it changes:

• PGT can dramatically shift the order of embryos, because genetic normality usually predicts the highest success.
• Morphology adds detail within groups (euploid vs mosaic vs untested).
• The right strategy reduces failed transfers, miscarriage risks, and time to pregnancy.

Upstream decisions that influence prioritization:

• Day 5/6 development
• Lab performance and biopsy technique
• PGT type (PGT-A, PGT-M, PGT-SR)
• Patient age and ovarian response (affects proportion of euploids)

Who It Helps

Signals Prioritizing by PGT Is a Good Fit

• You have multiple embryos and want to maximize success per transfer.
• You want to reduce miscarriage risk.
• You’re older than 35 or have a history of recurrent pregnancy loss.
• You’ve had previous failed transfers without clear cause.
• PGT results show clear differences (euploid vs mosaic vs aneuploid).

When Morphology Becomes More Important

• You have untested embryos (no PGT).
• You have multiple euploid embryos and need tie-breakers.
• PGT is not affordable or not medically indicated.
• You prefer a transfer sooner without waiting for PGT turnaround.
• You have embryos from different cycles or labs with differing visual grades.

When a Mixed Approach Works Best

• You have a mix of euploid + mosaic embryos.
• You have euploid embryos with varying morphology.
• You have embryos where morphology and genetics disagree (e.g., beautiful mosaic vs mediocre euploid).

Step-by-Step

A simple sequence with checkpoints to reduce stress and protect embryo quality:

1. Sort by Genetic Category

   • First: Euploid

   • Then: Low-level mosaics

   • Then: High-level mosaics (case-dependent)

   • Last: Aneuploid (not transferable except rare exceptions)

2. Refine Within the Category Using Morphology
   Prioritize based on:

   • Trophectoderm quality (important for implantation)

   • Inner cell mass (future fetus)

   • Blastocyst expansion stage

3. Cross-Check With Clinical Factors

   • Uterine readiness

   • Previous transfer outcomes

   • Age and medical history

   • Implants-per-transfer strategy (single embryo vs multiple cycles)

4. Decide Transfer Order + Confirm Plan
   Make a final list, e.g.:

   1. Euploid 5AA

   2. Euploid 5AB

   3. Low-level mosaic 4BB

   4. High-level mosaic 3BC

5. Review Costs & Timeline Before Scheduling Transfer
   Ensures you avoid surprise billing and understand add-on prenatal testing if mosaics are used.

Pros & Cons

Pros of Prioritizing PGT First

• Highest live birth rate per transfer
• Lowest miscarriage rate
• Prevents unnecessary failed cycles
• Reduces emotional roller-coasters
• Minimizes long-term cost by avoiding repeated transfers

Cons of Relying Mainly on PGT

• Requires biopsy + lab processing (time + cost)
• Mosaic results can create confusion
• Small risk of embryo biopsy harm (rare but real)

Pros of Prioritizing Morphology First

• Works well when PGT is not performed
• No added biopsy or testing cost
• Immediate transfer possible

Cons of Relying Only on Morphology

• “Beautiful” embryos can still be genetically abnormal
• Higher miscarriage risk
• May require more transfers and more medication costs

Costs & Logistics

Typical Line Items

• PGT-A / PGT-M / PGT-SR fees
• Embryo biopsy
• Freezing + storage
• Transfer cycle costs
• Prenatal testing (if mosaic transfer)

Insurance & Prior Authorization

• Some plans cover PGT only for medical indications (e.g., translocations).
• Biopsy often billed separately.
• Prenatal follow-up costs (NIPT, amnio) vary widely.

Cash-Flow Scenarios

• Choosing by PGT first may cost more upfront but less overall.
• Morphology-first may avoid biopsy costs but increases risk of multiple transfers.
• Ask for written quotes for:

• • PGT

  • Biopsy

  • Freezing

  • Transfer cycle

  • Prenatal testing (if applicable)

Tracking Tips

Use a simple 1-page bill tracker:

• Test type
• Clinic charges
• Lab charges
• Insurance status
• Date submitted
• Date paid

What Improves Outcomes

High-Impact Actions

• Prioritize euploid embryos first
• Use clear transfer order categories
• Optimize uterine lining and hormonal timing
• Choose a lab with strong biopsy + PGT accuracy
• Keep stimulation protocols consistent across cycles (reduces variability in morphology)

Low-Impact Actions

• Embryo photos alone without grades
• Supplements not prescribed for a medical reason
• Overemphasizing day-5 vs day-6 embryos when genetics is available
• Obsessing over tiny morphology differences (AA vs AB rarely changes outcomes significantly)

Case Study

A 34-year-old patient had:

• 3 euploid embryos
• 2 mosaics
• 1 untested embryo from a previous clinic

Initially, she wanted to transfer the “best-looking” 5AA embryo—even though another embryo had the same morphology but slightly better genetic profile.

After applying the prioritization framework:

Final order:

1. Euploid #2 (stable profile, strong morphology)
2. Euploid #1
3. Euploid #3
4. Mosaic embryo with low-level abnormality
5. Mosaic high-level
6. Untested embryo

Outcome:

• First transfer led to live birth.
• She retained embryos for a second pregnancy with clear expectations and no additional retrieval.

Mistakes to Avoid

• Treating morphology as more important than PGT for euploid embryos
• Ignoring mosaic detail and chromosome type
• Rushing to transfer before results are fully explained
• Prioritizing day-5 embryos when day-6 euploids perform similarly
• Stacking too many factors—keep the order simple
• Not writing down your transfer sequence ahead of time

FAQs

Q. Is PGT more important than morphology?

Ans : For most people, yes. Genetics predicts success better than appearance.

Q. Can a gorgeous embryo be abnormal?

Ans : Absolutely—morphology alone can be misleading.

Q. Should I always transfer the best-looking euploid first?

Ans : Usually yes, but the genetic result matters more than small grade differences.

Q. What if I have only mosaics?

Ans : You can still prioritize: low-level → specific favorable chromosomes → high-level.

Q. Do day-6 embryos perform worse?

Ans : Not when they are euploid—day-6 euploids have similar live birth rates.

Q. Should untested embryos ever go before mosaics?

Ans : It depends on age, history, and morphology—but generally mosaics go first because they at least carry genetic information.

Next Steps

• Free 15-min nurse consult
• Upload your labs
• Get a personalized cost breakdown for your case

Related Links

• Genetic testing carrier
• Intended Parents
• Become a Surrogate
• Fixed‑Cost Packages
• SART
• CDC ART
• ASRM