IVF Ft. Myers / Cape Coral patient with good questions about PGS

A very nice patient who is also a nurse was seen in our Bonita Springs office today.  She is preparing for IVF in the coming weeks and was seen for her practice embryo transfer and other tests.  We were visiting and discussing the plans.  She indicated that she was interested in doing PGS “in order to increase her chance of pregnancy.”

PGS stands for pre-implantation genetic screening.  It is an added procedure during the IVF treatments.  Our clinic performs the embryo biopsies at the blastocyst stage in order to get more accurate results that when a day 3 biopsy is done.  The PGS gives the physician and the patient information about the genetic makeup of the embryo.  PGS results tell us if the embryo in question is expected to have 23 pairs of chromosomes or if it has an abnormal number of chromosomes like is seen in down’s syndrome where the embryo has an extra chromosome 21.

In the past and in most cases of IVF currently, the embryos are chosen based on their appearance.  Unfortunately, embryos can look completely normal and be genetically abnormal.  Abnormal embryos (with abnormal number of chromosomes) are the most common cause of implantation failure, IVF failure, and miscarriages.

In addressing this particular patient, I explained to her that “more technology is not always better.”  I explained that in her particular case the chance that the PGS information would increase her chance of pregnancy depended on the number of eggs and subsequent embryos that she made. If she were to respond conservatively to the ovarian stimulation and make few eggs, then the PGS would probably not increase her chance of pregnancy over the routine IVF where 2 or three embryos are selected based on their appearance.

If a patient makes fewer eggs, the PGS will just serve to give information and prevent the implantation or transfer of an abnormal embryo that would result in no pregnancy, a miscarriage, or even an abnormal fetus.  Fortunately, mother nature is quite good at preventing abnormal embryos from growing.  Please refer to the maternal age and reproduction web page at www.drpabon.com or www.geneticsandfertility.com

One other confounding issue is that I believe PGS can help in most cases because it can change clinical treatment and outcomes.  This is because when PGS is done at the blastocyst stage, the information is so good that we most often do a single embryo transfer.  This virtually eliminates the risk of twins and higher order pregnancies regardless of age.  So, the chance of pregnancy per transfer is higher, but some patients don’t have a transfer because all the embryos are abnormal by PGS or so abnormal they don’t develop to the biopsy stage.

This very nice patient should understand that it is ok to use technology when the use of the technology matches her goals and that sometimes the added cost of the additional technology may not increase her overall chance of pregnancy unless there is a good number of embryos to sort through.  The big question is: how many embryos is enough?  This question has not been answered yet in regards to blastocyst biopsies.

What we should say is that PGS increases the chance of pregnancy per embryo transferred.

All the Best!!

Julio E. Pabon, M.D., F.A.C.O.G.

copyright J. Pabon collection
copyright J. Pabon collection

Medical and Laboratory Director

Fertility Center and Applied Genetics of Florida

Assistant Clinical  Professor

Florida State Univ. College of Medicine

www.geneticsandfertility.com

Congratulations to A Riverview/Lakeland IVF Family

Hi Dr. Pabon!  I can’t thank you enough for helping to make our dreams come
true!  It was certainly a challenge, but it was all worth it to finally have
our miracle baby in our arms.  :-)  Caroline is such a sweet, precious baby!
Scott and I are so completely in love!

Amazingly enough, my pregnancy was so easy!  I never had any problems, not
even morning sickness in the beginning.  My doctor closely monitored me to
make sure no problems developed.  I had non-stress tests twice a week
starting at 32 weeks, and had ultrasounds at 32 and 36 weeks to check her
growth.  Luckily though, all was fine and there was never any pre-eclampsia
problems, or any other problems.  Definitely counting my blessings!

Thank you so much for all your hard work to get us to this point.  You truly
are a miracle worker!  I will bring Caroline by sometime soon to meet you
and all your amazing staff.

Thank for your kind words, M.M.

Dr. Pabon and staff

copyright J. Pabon collection
copyright J. Pabon collection

Polycystic Ovarian Syndrome: Updated Ultrasound Criteria

Polycystic ovarian syndrome or PCOS is a very common cause of chronic anovulation and infertility.  Unfortunately, there has been  recent confusion among health care providers as to which patients are most likely PCOS.  The confusion has come from studies that have included patients as PCOS based on ultrasound criteria.

The hallmarks of PCOS are oligomenorrhea (infrequent menstrual cycles due to infrequent ovulation) and hyperandrogenism (the presence of physical manifestations of increased male hormone levels).  Sometimes the history and physical signs can be vague.  For that reason, clinicians and researchers have been looking for more sensitive ultrasound findings.  Unfortunately, the bar for the PCOS criteria for ultrasound findings appears to have been set too low.  This has led to over diagnosing many patients as PCOS.

In my clinic, it is common to see a patient that has been told that she has PCOS based on ultrasound criteria only while she reports regular ovulatory cycles.  This is incorrect.  The findings of this study may lead to less incorrect diagnoses.  The authors report on a higher threshold of 26 or more resting follicles per ovary in patients that also have oligomenorrhea and hyperadrogenism.

The analysis showed that a threshold of 26 follicles struck the best compromise between sensitivity (85%) and specificity (94%) when discriminating between women with PCOS and control participants.

“Using newer ultrasound technology and a reliable grid system approach to count follicles, we concluded that a substantially higher threshold of follicle counts throughout the entire ovary (FNPO)—26 versus 12 follicles—is required to distinguish among women with PCOS and healthy women from the general population.”

Reference:  Hum. Reprod. (2013) 28 (5):1361-1368.doi: 10.1093/humrep/det062First published online: March 15, 2013

Julio E. Pabon, M.D., F.A.C.O.G.

copyright J. Pabon collection
copyright J. Pabon collection

 

IVF Babies not at higher risk of birth defects

Babies born by IVF not at higher risk of birth defects: study

The Associated Press

Published  May 7, 2012

Test-tube babies have higher rates of birth defects, and doctors have long wondered: Is it because of certain fertility treatments or infertility itself? A large new study from Australia suggests both may play a role.

Compared to those conceived naturally, babies that resulted from simple IVF, or in vitro fertilization — mixing eggs and sperm in a lab dish — had no greater risk of birth defects once factors such as the mom’s age and smoking were taken into account.

However, birth defects were more common if treatment included injecting a single sperm into an egg, which is done in many cases these days, especially if male infertility is involved. About 10 per cent of babies born this way had birth defects versus 6 per cent of those conceived naturally, the study found.

PHOTOS

Doctors used a technique called preimplantation genetic diagnosis to screen out embryos that would carry either the BRCA-1 or BRCA-2 gene, linked to breast cancer.

Doctors used a technique called preimplantation genetic diagnosis to screen out embryos that would carry either the BRCA-1 or BRCA-2 gene, linked to breast cancer.

It could be that the extra jostling of egg and sperm does damage. Or that other problems lurk in the genes of sperm so defective they must be forced to fertilize an egg.

“I don’t want to scare people,” because the vast majority of babies are born healthy, said the study’s leader, Michael Davies of the University of Adelaide in Australia.

Couples could use simple IVF without sperm injection, freeze the embryos and implant only one or two at a time, he said. All of those can cut the chance of a birth defect.

The study was published online Saturday by the New England Journal of Medicine and presented at a fertility conference in Barcelona, Spain. Health agencies in Australia paid for the research.

More than 3.7 million babies are born each year through assisted reproduction. Methods include everything from drugs to coax the ovaries to make eggs to artificial insemination and IVF. Fertility treatments account for about 4 per cent of births in Australia and as many as 8 per cent of them in Denmark, where costs are widely covered, Davies said.

In the United States, more than 60,000 babies were born in 2009 from 146,000 IVF attempts. About three-quarters of them used ICSI, or intracytoplasmic sperm injection.

ICSI was developed because of male infertility. But half the time, it was not done for that reason but to improve the odds that at least some embryos will be created from an IVF attempt. Many clinics do it in all cases.

IVF costs around $10,000 to $12,000 per attempt and another $2,000 for sperm injection.

The study used records on nearly 303,000 babies conceived naturally and 6,163 conceived with help in Australia from 1986 through 2002, plus records on birth defects detected by age 5. Researchers counted heart, spinal or urinary tract defects, limb abnormalities and problems such as cleft palate or lip, but not minor defects unless they needed treatment or were disfiguring.

They looked at birth defect rates according to type of fertility treatment. They also had three comparison groups of women who conceived naturally, including some with some history of infertility or who previously needed help to get pregnant.

Among fertility treatments, only ICSI, the sperm injection, resulted in higher rates of birth defects once other factors that affect these odds were taken into account.

“They take a sperm that is probably not normal and force it to conceive,” said Dr. Darine El-Chaar, an OB-GYN at Canada’s University of Ottawa. She led a smaller previous study of this and called the new work impressive and “the study that needed to be done” to sort out the source of these risks.

In the study, frozen embryos were less likely to result in birth defects than fresh ones used soon after they were created. Defective ones may be less likely to survive freezing and thawing, so the fittest embryos result in pregnancies, Davies said.

Babies born to women with a history of infertility who ended up conceiving on their own, or who had natural pregnancies after assisted ones, also had higher rates of birth defects. That suggests that infertility itself is playing a role.

Dr. Glenn Schattman, president of the Society for Assisted Reproductive Technologies and a Cornell University fertility specialist, said it was reassuring that ordinary IVF is safe. If ICSI is chosen because male infertility is involved, “parents have to be aware that by having a child with their own genetic material, they might be increasing their risk” of a birth defect, he said.

Dr. Joe Leigh Simpson, a geneticist and research chief at the March of Dimes, said doctors should take this work seriously and discuss it with patients. He said techniques have improved over the last decade and ICSI may be safer now than when this study began.

Even with genetic testing for various diseases, “we always tell our patients that this doesn’t guarantee a perfect baby,” he said.

Dr. Julio E. Pabon, Medical director of Fertility Center and Applied Genetics of Florida and faculty member of Florida State University College of Medicine, agreed with Dr. Simpson’s comments while adding that congenital anomalies seen when ICSI is used to overcome a very severe male factor problem, there may be genetic aberrations present in the father that increase the risk of urogenital anomalies in the male children because the genetic information for the genes that may have caused the infertility may be closely linked to other developmental genes.  The anomalies are uncommon and are usually easily diagnosed and treated.  “Couples do not choose to use a sperm donor to avoid ICSI.”

Naples IVF Patients Have Access To The Highest Technology

IVF Technology advances with Pre-implantation genetic screening, vitrification, and single embryo transfers.

Twin and higher order pregnancies are considered a complication of IVF and super-ovulation.  Twin and Higher order pregnancies can end prematurely in more than 70% of cases.  Pre-term birth is very dangerous for babies.  There can be respiratory, vascular, intestinal, infectious, and brain complications that can lead to a life of disability.

IVF patients have been asking on a weekly basis for twin pregnancies.  Patients say things such as “twins are cute,” or “I only want to go through one pregnancy,” or “I am older and only want to go through one more pregnancy.”  Some patients also focus on the cost of ART treatments and the desire to increase the chance of a live birth by implanting more embryos.  I assure you that the cost of the NICU and the care that a pre-term baby or babies with short term or long term morbidities may require is many, many, many times higher that the cost of many IVF tries.

Up until recently, we have usually transferred one or two embryos into younger patients early in the process.  Sometimes more embryos are transferred in special situations.

Recently, technology has changed.  One such change has been the new freezing technology called Vitrification.  With this technology, the pregnancy chance with a fresh embryo transfer is similar to that of a frozen/thawed embryo transfer.  Therefore, there is not a “fear” of freezing embryos anymore.  In the past, frozen/thawed embryo transfer pregnancy rates were a fraction of a fresh transfer.  Nowadays, the transfer of a frozen/thawed embryo into a “programmed” uterus may result in a higher chance of pregnancy than the transfer of a fresh embryo into a hyper stimulated patient.  That is why many patients hear the “all freeze” protocol information in our consultations.  The better freezing technologies present patients with the choice of transferring one embryo at the time.

Unfortunately, a single embryo transfer carries a lower chance of pregnancy than when 2 or 3 are transferred.  Most younger patients can expect a chance of pregnancy with a single embryo in the range of 35-40%.   So, commonly, patients will ask for two.

Recently there is a whole new technology that is really a game changer.  Pre implantation genetic screening of embryos at the blastocyst stage yields such good data that patients can expect a chance of pregnancy in excess of 80% per transfer per single embryo.  The reason for this huge jump is that the single embryo being transferred has been shown to carry the normal number of chromosomes by very powerful technology.

With pregnancy rates in excess of 80% per “normal” embryo transferred (normal within the limits of the technology), transferring two such tested embryos is essentially a planned twin pregnancy.

I have been trying to counsel our patients to accept single embryos for transfer, but many are still pushing and pushing.  At this time we can manage cases on a one on one basis, but patients should educate themselves of the risks to themselves and their babies. I have discussed this issue with our Maternal Fetal Medicine consultants and they all support the transfer of single embryos after PGS with trophectoderm blastocyst biopsies and 24 chromosome microarray complete genomic hybridization.

I will follow this post with the American Society of Reproductive Medicine document about multiple pregnancies.

Julio E. Pabon, M.D., F.A.C.O.G.

www.geneticsandfertility.com

copyright J. Pabon collection
copyright J. Pabon collection

CEO Fertility Center and Applied Genetics of Florida

Assistant Clinical Professor/Florida State Univ. College of Medicine

 

 

Immediate IVF Is Most Effective for Older Women

Fast Track IVF as reviewed after the ASRM meeting last year by Damian McNamara

Although many physicians first recommend superovulation treatment in a stepwise approach to infertility, a study has shown that immediate in vitro fertilization yields significantly higher pregnancy and live birth rates for couples trying to conceive when the woman is aged 38-43 years.

“Older women have special considerations, including a limited window of opportunity for becoming pregnant,” Dr. Richard H. Reindollar said at the meeting.”

“My recommendation would be when couples come in after 6 months of trying to conceive that they be shown this as an option. If money is not a factor, IVF is the most effective strategy,” said Dr. Reindollar, chair of the department of obstetrics and gynecology, Dartmouth-Hitchcock Medical Center, Lebanon, N.H.

To determine the optimal strategy, researchers randomized 154 older women with unexplained infertility to clomiphene, follicle-stimulating hormone (FSH), or immediate in vitro fertilization (IVF). Participants assigned to clomiphene received 100 mg for 5 days and one intrauterine insemination (IUI) for two cycles. Those in the FSH group received 225 IU for 5 days plus one IUI for two cycles. The rest underwent immediate IVF.

All women were part of couples who had tried to conceive unsuccessfully for at least 6 months.

The primary aim was to compare the effectiveness of these strategies after two treatment cycles. After two cycles, 51 couples underwent a total of 87 clomiphene/IUI cycles; 52 couples underwent 91 FSH/IUI cycles; and 51 couples had 85 immediate IVF cycles.

Immediate IVF is the most effective treatment for couples when the female partner is at the end of her reproductive years, Dr. Reindollar said when presenting these preliminary results of the Forty and Over Infertility Treatment Trial (FORT-T). Cost analysis of the data is planned for the future.

Per cycle, 7% of the women in the clomiphene/IUI group had a clinically recognized pregnancy, compared with 8% in the FSH/IUI arm and 25% in the IVF group.

When the two fertility treatment groups were combined, the live birth rate was 5% (9 of 178 treatment cycles), compared with 15% for women in the IVF group (13 of the 85 treatment cycles).

“The use of FSH/IUI has come under scrutiny in the past few years,” Dr. Reindollar said. Pregnancy rates below 10% and a high rate of multiple births, including triplets and quadruplets, are among the criticisms.

He conducted a previous randomized trial of women younger than 40 years with unexplained infertility (Fertil. Steril. 2010;94:888-99). Dr. Reindollar and his colleagues determined that FSH/IUI provides no added value to a regimen of three cycles of clomiphene and up to six cycles of IVF in terms of cost-effectiveness and time for a pregnancy to lead to a live birth.

For the current study, determination of the overall effectiveness of the three treatment strategies, even beyond the first two cycles, was a secondary aim. After the first two cycles, all couples underwent four cycles of IVF. Follow-up of these couples ended Sept. 15, 2011. Overall, by study end, 46% of the women had achieved pregnancy (71 of the 154 participants).

“There was some catch-up in the clomiphene and FSH arms by the end of the trial,” Dr. Reindollar said. However, despite this catch-up in pregnancy rates, 70% of live births were achieved through IVF. “Beginning treatment with immediate IVF, compared with initial treatments of superovulation and IUI, results in [a] significantly higher number of live-born infants.”

Dr. Reindollar said he plans a future cost analysis of the data and will look at whether any significant differences emerge when patients are stratified by age (38-41 years vs. 42-43 years).

All the women in the study were fertility-treatment naive and had a normal clomiphene challenge test. In addition, participants had no pelvic pathology, had an acceptable ovarian reserve, and reported regular menstrual cycles. The male partners had normal semen analysis findings.

The groups did not differ significantly by demographics. The mean age of women was 40 years in the clomiphene and IVF groups and 41 in the FSH group. Approximately one in five in each group was older than 41 years. The majority of each group reported no prior deliveries: 67% of the clomiphene patients, 79% of the FSH patients, and 69% of IVF patients. In addition, more than 75% of participants were white and more than 80% had a history of oral contraceptive use.

 By: DAMIAN McNAMARA, Ob.Gyn. News Digital Network
From the Annual Meeting of the American Society for Reproductive Medicine

copyright J. Pabon collection
copyright J. Pabon collection

ASRM Mourns Loss of IVF Pioneer Sir Robert Edwards

ASRM Mourns Loss of IVF Pioneer Sir Robert Edwards
ASRM released the following statement this morning, attributable to Linda C. Giudice, MD, PhD, President, American Society for Reproductive Medicine.
“All of us in the American Society for Reproductive Medicine mourn the passing of Sir Robert Edwards.
Dr. Edwards was a great scientist whose stellar scientific work advanced our understanding of human reproduction, human embryonic stem cells, advanced pre-implantation genetic diagnosis and revolutionized the treatment of infertility. We extend our condolences to his family, and his many friends around the world.”
The Nobel Prize-winning scientist worked with Dr. Patrick Steptoe to bring about the birth in 1978 of the first baby conceived through in vitro fertilization.  See  BBC News coverage- “Test-tube baby pioneer Professor Sir Robert Edwards dies” at http://www.bbc.co.uk/news/uk-england-cambridgeshire-22091873.
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Florida Fertility Doctor advice for pregnant patients

Our Pregnant patients often complain of nausea.  The usual recommendation in the USA has been to take Vitamin B6 at doses from 25-75 mg per day.  Physicians don’t usually prescribe anti-nausea medications unless the patients can’t keep fluids down.  In that case, phenergan can be used or the newer Zofran.  Here is a recent FDA approval that may help also.

All the Best!

Julio E. Pabon, M.D

www.drpabon.com

Sarasota / Bonita Springs, Florida

FDA approves morning sickness therapy.The AP (4/9) reports that a Food and Drug Administration announcement Monday, “means a new version” of Bendectin (doxylamine, dicyclomine and pyridoxine), is “set to return to US pharmacies” under the brand name Diclegis (doxylamine succinate and pyridoxine hydrochloride), as a “safe and effective treatment” for morning sickness, or pregnancy-related nausea. At the time when lawsuits involving Bendectin began, the FDA “continued to call the drug safe; appeals courts ruled in favor of Bendectin maker Merrell Dow Pharmaceuticals; and eventually a US Supreme Court decision would render continuing suits unlikely.” But in 1983, Merrell Dow stopped producing Bendectin, citing the high litigation costs as the reason. Diclegis, which is manufactured by the privately held Canadian company Duchesnay Inc., is expected to be available on the US market in the beginning of June.

Reuters (4/9, Clarke, Berkrot) adds that in a statement announcing the FDA approval, the Blainville, Quebec-based drug maker noted that doxylamine is a common ingredient in many antihistamines that are available over-the-counter and pyroxidine is vitamin B6. A generic version of Diclegis – Diclectin (doxylamine 10 mg/pyridoxine 10 mg delayed-release) – has been available in Canada for the past 30 years.

copyright J. Pabon collection
copyright J. Pabon collection

 

IVF and Acupuncture : Unclear Benefits

By Amy Norton

NEW YORK (Reuters Health) Jan 30 – Acupuncture may help some women conceive through in-vitro fertilization (IVF), a new meta-analysis concludes. But the true benefit in the real world, if any, remains unclear.

Ten years ago, a study in Germany was the first clinical trial to report that acupuncture seemed to improve pregnancy rates in women undergoing IVF. But studies since then have had mixed results.

“I counsel women that the literature is not convincing yet that (acupuncture) helps you get pregnant,” said Dr. Frederick Licciardi, who heads the New York University Fertility Center’s mind/body program.

At the center, women can opt for acupuncture sessions, yoga and other “mind/body” services, but the programs are aimed at easing stress and promoting general “wellness” — not at boosting IVF success, said Dr. Licciardi.

For the new meta-analysis, reported online January 12 in Fertility and Sterility, Dr. Cui Hong Zheng and colleagues at Tongji Medical College pooled the results of 24 small clinical trials testing the effects of acupuncture in women undergoing IVF.

The trials varied widely: Many tested needle acupuncture, some electro-acupuncture and some included laser acupuncture in the mix.

There was also no consistency among control groups. In many trials, control groups received no treatment. In others, they received sham treatments – and the sham approaches varied, too.

Dr. Zheng’s team found that overall, women who had acupuncture had a slightly higher pregnancy rate than women who did not have the therapy — but no higher birth rate.

The results looked a little different, though, when the researchers excluded five studies that used blunt needles as a control. When those trials were dropped, women in the remaining studies who received acupuncture fared a little better: 41% became pregnant in the acupuncture groups, vs 37% in the control groups.

Three of those trials also looked at birth rates, which were 35% in the acupuncture groups vs 25% in the control groups.

According to Dr. Zheng’s team, the findings suggest that the blunt-needle acupuncture used in some trials is not a truly “inactive” placebo, and may actually have effects similar to the real thing. That, the researchers say, may explain why those studies failed to find benefits from real acupuncture.

But Dr. Licciardi — who stressed that he is “not anti-acupuncture” — was unconvinced.

One of the big problems with the analysis, he said, is that it combined studies that were all looking at very different things: different types of acupuncture, different controls, and different timing of the acupuncture sessions.

“They’re just too heterogeneous to generalize and draw conclusions,” Dr. Licciardi said.

He was also skeptical of the researchers’ choice to drop certain trials, which then essentially gave them “the results they wanted.”

In the bigger context of acupuncture research, finding a good control has long been a problem.

The bottom line, according to Dr. Licciardi, is that no one yet knows if acupuncture can really make a difference in IVF success. But if a woman wants to try it simply to feel better or de-stress, there would be little harm.

Acupuncture is generally considered safe, with side effects like bruising at the needle site. The cost can vary widely — and may or may not be covered by insurance — but a session would typically start at around $100.

As for why acupuncture would help a woman get pregnant with IVF, no one is sure of that either.

There’s some evidence that needle stimulation may improve blood flow to the uterus. And researchers are looking at whether acupuncture might make the uterine wall more receptive to the embryo.

SOURCE: http://bit.ly/xUSWrV

Fertil Steril 2012.

 

Tampa IVF patient says Dr. Pabon is worth the drive to Sarasota

A Tampa IVF patient says Dr. Pabon is worth the drive to Sarasota.
As posted on Google Reviews, 2012:
“We have 2 beautiful, full term, completely perfect healthy baby boys, thanks to the good Dr. My husband and I were delighted to find Dr.J.Pabon. He and his staff are by far the most wonderful people to work with as we went through our experience trying to get pregnant. He and his staff were amazingly talented and knowledgeable. We highly recommend him over any fertility doctor in Tampa. He is worth the drive. We checked out several in Tampa before deciding on Dr.J.Pabon. They are fairly priced and the one on one attention is great. You do not have to see a dozen different doctors. Just Dr. Pabon. It is very personalized and we received the attention we felt we deserved. Not like the other clinic where you see who ever is on duty.”
Comment by Dr. Pabon:
I am so happy and honored that patients choose our clinic.  Many of you choose to travel long distances.  Thank you for the confidence and the opportunity to be part of your life.
Sincerely,
Julio E. Pabon, M.D., F.A.C.O.G.
IMG_0440 copy
Fertility Center and Applied Genetics of Florida
Sarasota and Bonita Springs, Florida, U.S.A.
www.geneticsandfertility.com  www.drpabon.com