Genetics and Reproduction: IVF and ICSI with PGD

Based on Reproductive genetics understanding, therapies are developed and used to maximize outcomes.

Specifically, increased pregnancy rates,decreased incidence of obstetric complications and miscarriage, and the avoidance of fetuses affected by birth defects or other deficiencies are the stated goal of much of the current research in reproductive medicine. The role of genetic testing to guide medical decision making in this regard is sizable and will likely continue to grow in the future.

Genetic evaluations within reproductive medicine may be subdivided into 4 main categories:

1. Preconception genetic testing: The genetic evaluation of prospective parents before pregnancy.

2. Antenatal genetic testing: The genetic evaluation of women who are currently pregnant to determine  the genetic makeup of the developing fetus.

3. Preimplantation genetic testing ( PGD and PGS): The genetic evaluation of an embryo, before uterine transfer, via an embryo biopsy during an in-vitro fertilization (IVF) procedure.

4. Genetic analysis following fetal demise: The genetic evaluation  of the product of conception following a failed pregnancy.

 

IVF and Endometriosis

Endometriosis is a common gynecological condition that affect approximately 10-15% of the female population.

Endometriostic ovarian cysts may be present in up to 20-40% of women with endometriosis scheduled for IVF and on both sides in 19-28% of the cases.

The best medical approach to treat endometriotic ovarian cysts is controversial, as it may delay the fertility, the lady desires.

Should we remove the endometriosis by surgery is matter of debate.

With surgery , there are great chances that it may affect the ovarian reserve and impairs the responsiveness to treatment, and also does not offer any additional benefit in terms of fertility outcomes.

In addition, surgery is great risk to women, as it is mostly a complicated surgery.

The laparoscopic removal of bilateral endometriomas prior to IVF should be limited to those cases with normal ovarian reserve, presence of pain symptoms, rapid growth or sonographic features of malignancy.

Conversely., in the absence of the above-mentioned features, patients with bilateral endometriomas should be encouraged to proceed directly to IVF to reduce time to pregnancy, to avoid potential surgical complications and to limit costs.

The retreival of oocytes may be less in endometriotic cases, compared to normal, but the quality of oocytes may be same and pregnancy rates may be comparable, if lady goes for IVF as early as possible, when all conservative approaches are exhausted

Blastocyst transfer may help in repeated IVF failure cases

Recurrent implantation failure may identified after three failed IVF cycles or after transfer of 10 high grade embryos. There are many different factors which may contribute for this recurrent IVF failure, such as parental chromosomal translocations, abnormal uterine anatomy , hydrosalpinx, or inadequate  culture conditions or embryo transfer techniques.

Failure may be due to factors with the “Seed,Soil or the Cultivator”

Some studies have suggested that local injury of the endometrium by means of a catheter or hysteroscopy can induce an inflammatory response that may facilitate the preparation for implantation.

Artificial rupture of the covering of the embryo ( Zona pellucida) may improve implantation: Assisted Hatching, but is still not proved.

Pre-implantation genetic screening of the embryos is now a day used to get and select best embryos. But this strategy did not show any improvement in patient outcome  and did not show any significant difference on clinical pregnancy rates.

A few studies have reported that congenital and acquired prothromotic conditions are more prevalent in women with recurrent implantation failure. Therefore use of low molecular weight heparin (LMWH) and mini dosage of aspirin on patients with thrombophilia and recurrent implantation failure has been discussed, but large studies are required to prove them .

Finally, another possible strategy is to extend embryo culture to blastocyst stage, aiming to improve embryo selection and uterine receptivity

Bed rest after Embryo transfer in In-vitro fertilization

Bed rest after Embryo transfer in In-vitro Fertilization treatment

Few common questions and concerns after Embryo Transfer.

* What will happen when I stand up?

* For How long I should be in bed ?

* Can I go for a pee , my embryos may come out .?

* That center asked my “friend” to be in bed after embryo transfer for 15 days, and she got the child.

Is there any evidence that : Bed rest after embryo transfer increases implantation or live birth rate?

In Fact : there is no evidence that it does.

There should not be any guilt that, ” If I could have taken an absolute bed rest , may I become pregnant”

It has been shown that: Women, a few minutes after embryo transfer, can stand , empty bladder and return home with no apparant risk to the process of implantation. No restriction of the routine activity or the patients need be advised after the transfer.

The UK National institute of clinical excellence (NICE) in 2004 issued the NICE Clinical Guidelines 001 for Fertility (2), which included the following recommendation:

1.11.9.4 Women should be informed that bed rest of more than 20 minutes duration following embryo transfer does not improve the outcome of in vitro fertilization treatment.

Better take your embryo for a walk. moderate exercise and intercourse around embryo transfer has shown to improve implantation and pregnancy rates.

Cost cutting in IVF ICSI treatment.

Cost cutting can be done by multiple ways in IVF treatment.

One of the most important aspect is Drugs used in IVF treatment.

Low cost IVF can be done if we use Urinary derived gonadotropins.

Now a days, may be because of market pressure or because of misinformation, many IVF centers started using Recombinant Gonadotropins in place of age old urinary gonadotropins.

Do you know that Urinary products, esp Human Menopausal Gonadotropin(HMG) gives better results that Recombinant(Rec FSH) ones ( Ref: Cinics Review Articles in ObGy clinic of north america March 2015).

HMG is one third of the cost of Rec FSH. Hence we made our cost structure IVF may be one fifth to one sixth of many IVF Centers in world.

We use mostly HMG  and it gives very good Blastocysts. Very good IVF success rates, some times the implantation rate goes up to 80-85%. But over all implantation rate is 60-65%

 

Child born from Frozen, Vitrified embryo, after 2 and half years of storage

This lady undergone IVF treatment, she conceived with twin pregnancy,. The pregnancy went well till 6th month. But she started bleeding and aborted both the baby one after another. The second baby was alive for one month ,but died due to prematurity in nursery. We vitrified her extra embryos and transferred two of them after she recovered completely from that episode. One embryo implanted and she had a full term live baby. Now baby is grown so beautiful and intelligent.

Luteal Phase support in IVF treatment, can we make it little comfortable for female partner

When  IVF  is performed, in many centers, after egg retrieval, they start injection Progesterone daily for at least 15-20 days till the day of pregnancy confirmation. It is really a painful phase of fertility treatment. Injections of progesterone are usually  oil based and they dissolve slowly. When you inject it , it makes a small lump in the muscle, either in buttock or arm. It is very painful experience for the female partner.

Can we make this luteal phase little pain free, or can we make Fertility treatment little bit more comfortable.

Female partner suffers the most in IVF treatment, even if the fault may be in male partner, She has to receive injections for the growth of the eggs , undergo egg retrieval, and then injections for luteal phase support. And if she achieves pregnancy, then she might have to receive this injection may be for three months.

Here at Ideal Fertility center , we use vaginal progesterone and we usually or mostly do not use injections of progesterone for luteal support, and our pregnancy rate is at par with the best centers in world performing infertility treatment.

We try to make the IVF treatment comfortable as far as possible for the female partner. We try to make it more user friendly. Minimum visits, minimum blood tests, minimum injections, without compromising the outcome

Can fertility be preserved by Cryopreservation technology

Cryopreservation technology can be applied to Sperm, Embryo and Oocytes

The advantage of Sperm preservation is , easy to obtain in most patients, It has excellent results, and having a long track record of good success, but he bad part is , it is only for the male.

On the other hand , Embryo cryopreservation or freezing advantages are , excellent results in young patients and again a long good an successful track record. But the disadvantages are , it requires in vitro fertilization to obtain eggs, and may be financially costly and requires female patients to choose sperm donor before cryopreservation.

In Oocyte freezing or cryopreservation, the advantages are very good result in young patients and it does not require female patients to choose sperm donor before cryopreservaion, but bad part is, again it requires IVF to obtain eggs, it may be financially costly and relatively short track record.

Even ovarian cryopreservation is on its way, thin slices are stored  and frozen.

Freezing or cryopreservation is now a days are done by rapid freezing, a procedure called ” Vitrification” 

In our center, Ideal Fertility  Center , we are doing vitrification of embryos since long with very good result of “Blastocyst Freezing” with almost 100% recovery for transfer.

Sperms are stored long and before actual IVF procedure, so that if the male partner is not able to provide semen on the oocyte recovery day, we can use the frozen ones successfully.

We have started oocyte vitrification, and achieved one pregnancy too, but we are at a beginning , in future , soon we are starting our ” Egg Banking” services for those females, who because of their carrier demand can not reproduce in younger age and they can have their own child in later part of life.

what is my ovarian status, asks one lady after two IVF failure

Mostly , IVF fails due to ” either defect in soil or the seed”, It is very difficult to accept for a couple when we say , that your embryos are not good and we cancel the embryo transfer.

The problem may be in Sperms or in Eggs. But most of the time , if sperm count is good , the eggs are responsible. ( here I should say that, we might also be responsible if our lab conditions are not appropriate, but at our center, we usually do quality control every day, and moreover, if there are two or three cases in one day, and others are appropriate, then we might feel, that we are not at fault).

Most of the time , couple asks a question: What went wrong, why my test is negative, Even they might ask , who is responsible for this failure?

We always do a egg quality  and egg number estimation before commencing the treatment, esp, in little older females.

It is done by Day 2 , transvaginal sonography and a blood test called AMH, that i anti mullerian hormone. It can be done in any day of the menstrual cycle

Prenatal procedure for Beta thalassemia

Prenatal diagnosis of Beta-Thalassemia is one of the procedure, by which we can reduce the load of thallasemic babies, and help the couple to get or select a baby with thalassemia free or atleast carrier babies. Beta thalassemia is one the common genetic hemoglobinopathy .