Embryo Development, Grading and Selection Copy —
Training activity: 1

Details

Perform and record morphological embryo grading at both the cleavage and blastocyst stages

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Considerations

• The effect of embryo quality on cycle outcome
• Internal and external quality assurance
• National grading scheme
• Benefits and limitations of embryo morphology grading systems

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

What does success look like?

• Identify what is expected of you in relation to performing and recording morphological grading at both the cleavage and blastocyst stages.
• Consider how the learning outcomes apply, specifically in relation to evaluating embryo quality and development to inform clinical decisions.
• Discuss with your Training Officer to gain clarity of what is expected of you in relation to the expected grading standards and recording methods.

What is your prior experience of this activity?

• Think about what you already know about morphological grading criteria for cleavage and blastocyst stage embryos from academic content or previous observations.
• Consider possible challenges you might face during the activity, such as subtle morphological variations, assessing timing, or using the grading system.
• Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice from your Training Officer when required, for example, if assessing ambiguous or borderline embryo quality.
• Acknowledge how you feel about embarking on this training activity, particularly regarding the responsibility of assessing embryo quality.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as identifying and applying morphological grading criteria.
• Identify the specific insights you hope to gain into the correlation between morphology and developmental potential.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of attempts or feedback on embryo assessment.
• Identify important information you need to consider before embarking on the activity, such as the specific grading system used in the clinic, reference images, or SOPs.
• Use of external quality assessment schemes to aid understanding, particularly where your clinic does not routinely use time-lapse or grade at the cleavage stage.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst assessing the morphology of cleavage or blastocyst stage embryos?
• Are you encountering situations such as:
  • Fragmentation level making accurate grading difficult.
  • All embryos developing at a slower rate.
  • Technical difficulty arises with the microscopy visualisation during an assessment.

How are you reacting to the unexpected development?

• How is this impacting your actions? For example, are you responding to the situation appropriately? Can you adapt or change your approach to grading criteria application or documentation?
• Consider the steps you are taking in the moment, such as adjusting the microscope settings to ensure optimal visualisation.
• How are you feeling in that moment? For instance, are you finding it difficult to maintain grading consistency? Is it affecting your confidence in assigning the final grade?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully assigning a consistent grade by referencing SOPs? Or are you needing support because the ambiguity of the morphology requires senior verification before documenting the final grade?
• What are you learning as a result of the unexpected development? For example, are you mastering a more effective technique for differentiating between minor artifacts and true morphological abnormalities?

On action

What happened?

• Begin by summarising the key steps you took when performing and recording morphological embryo grading at both the cleavage and blastocyst stages.
• Consider specific events, actions, or interactions which felt important, such as how you applied the morphological criteria (e.g., assessing fragmentation, blastocoel expansion, or ICM quality) or how you ensured accuracy in documentation.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately consulting the grading atlas when faced with borderline blastocyst morphology.
• How did you feel during this experience, e.g., focused on achieving consistent grading accuracy or stressed by the subjectivity of certain criteria?

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding applying standardised grading criteria and assessing developmental potential. What strengths did you demonstrate, e.g., meticulous adherence to the specified grading system and documentation?
• What skills and/or knowledge gaps were evident, e.g., difficulty quickly differentiating between subtle variations in trophectoderm quality?
• Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in evaluating embryo quality to inform clinical decisions?
• Identify any challenges you experienced, such as technical difficulty with microscopic visualisation (e.g. due to a bubble), and how you reacted to this. This might include needing to seek advice or clarification on scope of practice regarding assigning a final grade when morphology was ambiguous, and how you reacted to this.

What will you take from the experience moving forward?

• Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to improving the speed and consistency of your morphological grading.
• What will you do differently next time you approach morphological grading, for instance, by proactively establishing a peer-review system for borderline cases?
• Do you need to practise any aspect of the activity further, such as differentiating between cells and large fragments or key learning outcomes related to critically appraising techniques for embryo morphological assessments?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences of embryo development monitoring or performing advanced morphokinetic assessment since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, a subsequent case involving ambiguous grades forced you to re-evaluate the rigidity of criteria application and potential subjectivity during your first attempt at this training activity.
• Considering what you understand about advanced morphokinetic predictors and static morphological grading now, were the actions or considerations you identified after your initial reflection on this training activity sufficient? How have you since implemented or adapted improvements in your systematic grading documentation or reliance on time-lapse data based on further learning and experiences? For example, how you proactively integrated a mandatory cross-reference check with time-lapse data into your standard morphological review documentation.
• Has discussing inter-observer variability in grading or the impact of borderline grading on clinical outcomes with colleagues, peers, or supervisors changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior colleague about a discrepancy in grading a blastocyst refined your understanding of the importance of consistent application of standard criteria.

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent morphokinetic assessment and quality assurance experiences, contributed to your overall confidence and ability in accurate and consistent embryo evaluation, particularly in preparing for assessments like DOPS or OCEs? For example, how your accumulated precision in morphological grading and differentiation of subtle abnormalities now enables you to confidently and efficiently grade and record embryo quality at different stages of development during a DOPS assessment.
• How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to applying morphological criteria and generating predictive quality assessments? How does this evolved understanding help you identify when something is beyond your scope of practice or requires escalation? For example, how your evolved approach means you now routinely escalate cases where grading ambiguity persists despite standardized morphokinetic input, recognising this requires senior verification to inform clinical decisions.
• Looking holistically at your training journey, how has this initial embryo grading experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to evaluating embryo quality and development to inform clinical decisions? For example, how this foundational experience has supported your development in critically appraising techniques for embryo morphological assessments.

Relevant learning outcomes

#	Outcome
# 1	Outcome Evaluate embryo quality and development to inform clinical decision.