“I Want Twins” ..#IVFTwins..Twin Complications

“I Want Twins” …#IVFTwins… IVF and Twin Complications

Attention all patients looking for IVF Doctor that will help them have twins

“We want IVF Twins” is not an uncommon request.  Here are two recent email enquiries that prompted this commentary:

“My fiance’ and I would like to have two kids, but we would like to have them all at once.  Is this something that you can facilitate at your facility?  We’d like to know if this is a procedure you can assist with prior to us paying the $300.00 consultation.  If so, please send me the necessary documents for us to complete so we can schedule a visit sooner rather than later. Possibly Friday, May 22, 2015 if you have available time slots.”

Another recent enquiry is as follows:

“Hi, my name is _____, I am 40 years old.  I have __ daughters,  I didn’t have any problems with any of my pregnancies.  And me and my husband want twin boys.  I want information on exactly how long and what I should do, and how much this Operation costs.  Thank you.”

And my reply is:

Multiple pregnancies such as twins are the principal complication of assisted reproductive techniques such as IVF.  Twin pregnancies have a much higher risk of complications.  Most are due to the much higher risk of pre-term birth.  Twins deliver pre-term 58% of the time and 56% of twins have low birth weight (CDC 2012). Twins have up to a 6 times higher risk or cerebral palsy and up to a 6 times risk of severe cardiovascular anomalies. Twins are 4 times more likely to die in pregnancy and 7 times more likely to die shortly after birth.

Over the 21 year span of my career, our specialty has strived to improve the success of our treatments.  Unfortunately, this usually required the implantation of more than one embryo.  The most common reason for failure of a fertility treatment is that the embryos are not genetically normal.  The most common reason for the implantation of more than one embryo is lack of good information about the genetics of the embryos.

It is still common practice to transfer 2 embryos when patients are treated with standard IVF procedures.  If that is done, then the risk of a twin pregnancy is 25-30%.   The transfer of two instead of one embryo may increase the chance of a successful treatment from 35% to as high as 50% depending on the age of the patient.  This all applies for embryo transfers based on IVF without genetic testing of the embryos.  The transfer of 2 embryos that have been shown to be “genetically normal” by the embryo biopsy tests can result in a twin pregnancy in more than 80% of cases.  This is an unacceptable high rate of a “complication.”

The newest technologies allow us to test the chromosomal makeup of the embryos on the 5th or 6th day of embryo lab culture. with this information we have been able to establish a preimplantation genetic screening single euploid embryo transfer program.  A euploid embryo is one where the chromosomal makeup of the embryo is known to be 23 pairs of normal chromosomes.

This technology requires the use of a microscopic laser to remove 8-10 cells from the trophectoderm of the blastocyst.  It is a leap in accuracy from the biopsies that we have been performing since 1999 at the six to eight cell stage (third day of embryo growth).  Initial scientific evaluation of the newer technology of blastocyst biopsies in 2012 gave outstanding results with the transfer of single embryos resulting in pregnancy rates in the 60% range regardless of maternal age.

Right away we knew that this method of assessing embryos was good since we were able to transfer single embryos with confidence.  The older technology had limitations as reflected by the fact that we were unable to maintain similar pregnancy rates despite transferring 2-3 embryos routinely during the past decade.  With the newer technology, we have enjoyed pregnancy rates in excess of 70% since 2013 in our pre-implantation genetic screening program where more than 95% of the transfers are of a single euploid embryo.  Results continue to be exceptional.  In the first quarter of 2016 (at the time of this post) 21 of 23 patients have had a positive pregnancy test (91%) in our frozen thaw genetically tested embryo program (PGS) and 19 of the 23 have an ongoing pregnancy (82%).  In one case a patient with a single embryo did not have a transfer as the embryo was not recovered after thaw.  Remarkably, only one of the 23 patients received two embryos while all others received one.

Our Single Euploid Embryo Transfer Program began in 2013.  in 2013 and 2014 the technology for assessing the chromosomes was microarray based that gave as much information as sequencing approximately 3% of the genome of the embryos.  This was enough to tell us that there were 23 pairs of chromosomes.

Since January of 2015, the technology for assessing the chromosomes has improved to what is called “next generation sequencing.”  The information obtained is considered to be about 3 times more and with higher resolution.  Next generation sequencing is like reading about 10% of the genome of the embryo.

Current technology that sequences about 10% of the genome is sufficient because more testing would yield information of uncertain relevance at this time.

Summary response:

Multiple pregnancies are a known “complication of Assisted Reproductive Techniques.”  IVF procedures where the embryos are not tested genetically may lead clinics and patients to accept the transfer of more than one embryo more often.  These are accepted risks based on clinical guidelines.  Transferring or implanting more than one healthy looking and “genetically normal” embryo is not advisable because it leads to an unacceptable high risk of resulting in a complicated pregnancy that endangers the babies.  The complications and potential morbidities can be life changing and permanent.

Please refer to another good resourse for much more information on this subject: www.oneatatime.uk.org

Julio E. Pabon, M.D.IMG_0440

Fertility Center and Applied Genetics of Florida

Sarasota and Bonita Springs, Florida



Tubal Reversal and Obesity Risks

I have a high bmi can the tubal reversal still be done?

Dr. Pabon after surgery 2013

This is a question that we received in an email this weekend.

The answer is yes. Unfortunately, just because I can do something, it does not mean that it should be done.

The question should not be not only about whether a tubal reversal is a difficult or risky procedure for a patient with a high BMI, but should address the subsequent high risk pregnancy that may result.

Please “Google”   “Obesity and Pregnancy Risk”    “Obesity and Surgical Risk”

I spend a significant amount of my time counseling patients about the importance of good health before elective procedures, IVF, and pregnancy. This is only because there is a large amount of scientific data supporting this. It is difficult to tell a lady that her BMI is too high. I try to be sensitive and bring up my own struggles with weight. Nonetheless, some patients don’t listen and some are sometimes offended.

Regarding elective surgery like a microsurgical tubal reversal, it is in the best interest of the patient to help to make the procedure as safe as possible. Obese patients have a higher risk of many surgical complications. It makes sense to try to become more fit for the surgery and the subsequent pregnancy.

Regarding IVF, many studies have shown a lower chance of pregnancy in obese patients and a higher risk of many subsequent complications in the pregnancies that are achieved.

As many of you know, I am a fan of a low carbohydrate lifestyle. I often recommend it. I also inform patients about Weight Watchers programs. I am not a fan of “bariatric surgery.” In may opinion, the main problem leading to the obesity epidemic is our over-indugence in a high energy diet full of sugar, flour, and all forms of Carbs.


Julio E. Pabon, M.D.

Sarasota and Bonita Springs Florida


Please read the attached documents for detailed information about this subject:


Number 549, January 2013

(Replaces Committee Opinion Number 315, September 2005)

Committee on Obstetric Practice

This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.

Obesity in Pregnancy

ABSTRACT: In the United States, more than one third of women are obese, more than one half of pregnant women are overweight or obese, and 8% of reproductive-aged women are extremely obese, putting them at a greater risk of pregnancy complications. Therefore, preconception assessment and counseling are strongly encouraged for obese women and should include the provision of specific information concerning the maternal and fetal risks of obesity in pregnancy, as well as encouragement to undertake a weight-reduction program. At the initial prenatal visit, height and weight should be recorded for all women to allow calculation of body mass index (calculated as weight in kilograms divided by height in meters squared), and recommendations for appropriate weight gain should be reviewed at the initial visit and periodically throughout pregnancy. Nutrition consultation should be offered to all overweight or obese women, and they should be encouraged to follow an exercise program. Pregnant women who have undergone bariatric surgery should be evaluated for nutritional deficiencies and the need for vitamin supplementation when indicated. Obese patients undergoing cesarean delivery may require thromboprophylaxis with pneumatic compression devices and unfractionated heparin or low molecular weight heparin. For all obese patients, anesthesiology consultation early in labor should be considered, and consultation with weight-reduction specialists before attempting another pregnancy should be encouraged.

The prevalence of obesity in the United States has increased dramatically over the past 25 years. The recent National Health and Nutrition Examination Survey found that in the United States, more than one third of women are obese, more than one half of pregnant women are overweight or obese, and 8% of reproductive-aged women are extremely obese (1). The obesity problem is greatest among non-Hispanic black women (50%) compared with Mexican American women (45%) and non-Hispanic white women (33%) (1).

In 2009, the Institute of Medicine (IOM) published revised pregnancy weight gain guidelines that are based on prepregnancy body mass index (BMI) ranges recommended by the World Health Organization. These ranges are independent of age, parity, smoking history, race, and ethnic background (2, 3). The revised IOM recommendations define normal weight as a BMI of 18.5–24.9, overweight as a BMI of 25–29.9, and obesity as a BMI of 30 or greater. The IOM guidelines do not differentiate between Class I obesity (BMI=30–34.9), Class II obesity (BMI=35–39.9), and Class III obesity (BMI≥40) (2).

Pregnancy Complications

Overweight and obese women are at increased risk of several pregnancy complications, including gestational diabetes mellitus, hypertension, preeclampsia, cesarean delivery, and postpartum weight retention (4–8). Similarly, fetuses of pregnant women who are overweight or obese are at increased risk of prematurity, stillbirth, congenital anomalies, macrosomia with possible birth injury, and childhood obesity (9, 10). Additional concerns include potential intrapartum, operative, and postoperative complications and difficulties related to anesthesia management. Obese women are also less likely to initiate and sustain breastfeeding (11).

Maternal Complications

In a prospective multicenter study of more than 16,000 patients, a BMI of 30–39.9 was associated with an increased risk of gestational diabetes mellitus (odds ratio [OR], 2.6 and 4.0), gestational hypertension (OR, 2.5 and 3.2), preeclampsia (OR, 1.6 and 3.3), and fetal macrosomia (OR, 1.7 and 1.9), when compared with a BMI of less than 30 (7). In this same study, the cesarean delivery rate was 20.7% for women with a BMI of 29.9 or less, 33.8% for women with a BMI of 30–34.9, and 47.4% for women with a BMI of 35–39.9. Other studies have consistently reported higher rates of preeclampsia, gestational diabetes mellitus, and cesarean delivery (particularly for arrest of labor) in obese women than in nonobese women (4–6).

At least three cohort studies suggest that obesity is an independent risk factor for spontaneous abortion among women who undergo infertility treatment (12–14). In recognition of this association, it is recommended that health care providers encourage obese women to lose weight before beginning infertility therapy. Data also link obesity with spontaneous abortion among women who conceive naturally (15).

Fetal Complications

When counseling obese women about potential pregnancy complications, it is important to inform them of the associated fetal risks, including prematurity, stillbirth, congenital abnormalities (eg, neural tube defects), macrosomia, and childhood and adolescent obesity. Some studies have reported a higher rate of premature delivery for obese women than for women of normal weight (4, 16). However, in a study of more than 2,900 obese women, prepregnancy obesity was associated with a lower rate of spontaneous preterm birth (17). A large Swedish cohort study reported a greater risk of antepartum stillbirth among obese patients than among women who had a BMI of less than 20 (16).

Obese pregnant women are more likely to give birth to an infant with congenital anomalies (9), and obesity also lowers detection rates of fetal anomalies during prenatal ultrasonography (18). Data establish that the risk of neural tube defects among obese pregnant women is double that of pregnant women of normal weight after correcting for diabetes as a potential confounding factor (19–21). The benefit of the administration of folic acid doses higher than 400 micrograms per day has not been studied in obese pregnant women without diabetes.

Multiple studies have shown that maternal obesity and excessive weight gain during pregnancy are associated with large-for-gestational-age infants (5, 22–24). Furthermore, these large-for-gestational-age infants are at increased risk of childhood and adolescent obesity (6, 25, 26). Although the diagnosis of fetal macrosomia is imprecise, prophylactic cesarean delivery may be considered for suspected fetal macrosomia with estimated fetal weights greater than 5,000 g in women without diabetes and greater than 4,500 g in women with diabetes (27).

Intrapartum Complications

It is important to discuss potential intrapartum complications with obese women, such as the challenges associated with anesthesia management and the increased risk of complicated and emergent cesarean delivery. Other potential problems include difficulty estimating fetal weight (even with ultrasonography) and the inability to obtain interpretable external fetal heart rate and uterine contraction patterns.

Anesthesia Management

If an anesthesiology consultation was not obtained antepartum, it should be conducted early in labor to allow adequate time for the development of an anesthetic plan. The use of epidural or spinal anesthesia is recommended in the obese pregnant patient when anesthesia is needed or elected; however it may be technically difficult or impossible to administer this type of anesthesia because of obscured landmarks, difficult positioning, and excessive layers of adipose tissue. Alternatively, the use of general anesthesia in obese pregnant women also poses several challenges, including difficult endotracheal intubation due to excessive tissue and edema (28) and intraoperative respiratory events from failed or difficult intubation (29).

Cesarean Delivery

Operative and postoperative complications among obese pregnant women include increased rates of excessive blood loss, operative time greater than 2 hours, wound infection, and endometritis (30–32). Sleep apnea occurring in this group of women may further complicate anesthetic management and postoperative care (33).

Obese women who require cesarean delivery have an increased incidence of wound breakdown and infections (31, 34). Antimicrobial prophylaxis is recommended for all cesarean deliveries unless the patient is already receiving appropriate antibiotics (eg, for chorioamnionitis) (35). For obese women who require cesarean delivery, consideration should be given to using a higher dose of preoperative antibiotics for surgical prophylaxis (36). Attempts to decrease the incidence of wound breakdowns and infections that have been studied include closure of the subcutaneous layers and the placement of subcutaneous drains. Investigators have demonstrated that suture closure of the subcutaneous layer after cesarean delivery in obese patients may lead to a significant reduction in the incidence of postoperative wound disruption (37, 38). However, postoperative placement of subcutaneous draining systems has not consistently been shown to be of value in reducing postcesarean delivery morbidity (39, 40).

Because of an increased risk of venous thromboembolism, placement of pneumatic compression devices before cesarean delivery is recommended for all women not already receiving thromboprophylaxis (41). Obese patients, especially those who are hospitalized and immobile, may be at increased risk of thromboembolism. Individual risk assessment will lead some health care providers to plan thromboprophylaxis with pneumatic compression devices and unfractionated heparin or low molecular weight (LMW) heparin in such patients (42). However, cesarean delivery in the emergency setting should not be delayed because of the timing necessary to implement thromboprophylaxis (41). Postpartum unfractionated heparin or LMW heparin prophylaxis has been recommended for patients thought to be at high risk of venous thromboembolism (43, 44); however, data are insufficient to determine whether the benefits of unfractionated heparin or LMW heparin prophylaxis in this group of patients outweigh the risks (45, 46).

Because of the increased likelihood of complicated and emergent cesarean delivery, extremely obese women may require specific resources, such as additional blood products, a large operating table, and extra personnel in the delivery room. Particular attention to the type and placement of the surgical incision is needed (ie, placing the incision above the panniculus adiposus) (34, 47). There are additional logistical challenges to monitoring labor and performing an emergent cesarean delivery in the extremely obese patient. Therefore, these patients should be counseled about these possible complications of an emergent cesarean delivery.

Bariatric Surgery Considerations

The number of obese reproductive-aged women undergoing bariatric surgery is increasing (48). Although maternal gastrointestinal complications, including obstruction and hemorrhage, can occur as a result of this procedure, the incidence is infrequent (49, 50). Furthermore, pregnancies after bariatric surgery are less likely to be complicated by gestational diabetes mellitus, hypertension, preeclampsia, and macrosomia than are pregnancies of obese women who have not undergone such surgery (51, 52).

Pregnant women who have undergone bariatric surgery should be evaluated for nutritional deficiencies and the need for vitamin supplementation when indicated because they are at increased risk of deficiencies in iron, vitamin B12, folate, vitamin D, and calcium. Women with a gastric band should be monitored by their general surgeons during pregnancy because adjustment of the band may be necessary (53). Bariatric surgery is not an independent indication for cesarean delivery (54).


Obese women are at increased risk of several pregnancy complications; therefore, preconception assessment and counseling are strongly encouraged. Obstetricians should provide education about the possible complications and should encourage obese patients to undertake a weight-reduction program, including diet, exercise, and behavior modification, before attempting pregnancy. Specific medical clearance may be indicated for some patients.

At the initial prenatal visit, height and weight should be recorded for all women to allow calculation of BMI, and recommendations for appropriate weight gain should be reviewed both at the initial visit and periodically throughout pregnancy (3). The 2009 IOM guidelines recommend a total weight gain of 15–25 lb (6.8–11.3 kg) for overweight women (BMI=25–29.9) and 11–20 lb (5.0–9.1 kg) for all obese women (BMI ≥ 30). (For an online BMI calculator, see http://www.nhlbisupport.com/bmi). Nutrition consultation should be offered to all overweight or obese women, and they should be encouraged to follow an exercise program. Nutrition and exercise counseling should continue postpartum and before attempting another pregnancy. Because these patients are at increased risk of emergent cesarean delivery and anesthetic complications, anesthesiology consultation early in labor should be considered (22).


Recommendations for obese women who are pregnant or planning a pregnancy include the following:

  • Preconception assessment and counseling are strongly encouraged and should include the provision of specific information concerning the maternal and fetal risks of obesity in pregnancy and encouragement to undertake a weight-reduction program.
  • At the initial prenatal visit, height and weight should be recorded for all women to allow calculation of BMI, and recommendations for appropriate weight gain, guided by IOM recommendations, should be reviewed both at the initial visit and periodically throughout pregnancy.
  • Nutrition consultation should be offered to all overweight or obese women, and they should be encouraged to follow an exercise program. Nutrition and exercise counseling should continue postpartum and before attempting another pregnancy.
  • Women who have undergone bariatric surgery should be evaluated for nutritional deficiencies and the need for vitamin supplementation, when indicated, because they are at increased risk of deficiencies in iron, vitamin B12, folate, vitamin D, and calcium.
  • For patients undergoing cesarean delivery who have additional risk factors for thromboembolism such as obesity, individual risk assessment may require thromboprophylaxis with pneumatic compression devices and unfractionated heparin or LMW heparin.
  • Consideration should be given to using a higher dose of preoperative antibiotics for cesarean delivery prophylaxis.
  • The use of suture closure of the subcutaneous layer after cesarean delivery in obese patients may lead to a significant reduction in the incidence of postoperative wound disruption.
  • Anesthesiology consultation early in labor should be considered.
  • Consultation with a weight-reduction specialist before attempting another pregnancy should be encouraged.


  1. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999–2010. JAMA 2012; 307:491–7. [PubMed] [Full Text]
  2. Institute of Medicine. Weight gain during pregnancy: reexamining the guidelines. Washington, DC: National Academies Press; 2009.
  3. Weight gain during pregnancy. Committee Opinion No. 548. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:210–2. [Obstetrics & Gynecology]
  4. Baeten JM, Bukusi EA, Lambe M. Pregnancy complications and outcomes among overweight and obese nulliparous women. Am J Public Health 2001;91:436–40. [PubMed] [Full Text]
  5. Cedergren MI. Maternal morbid obesity and the risk of adverse pregnancy outcome. Obstet Gynecol 2004;103:219–24. [PubMed] [Obstetrics & Gynecology]
  6. Sebire NJ, Jolly M, Harris JP, Wadsworth J, Joffe M, Beard RW, et al. Maternal obesity and pregnancy outcome: a study of 287,213 pregnancies in London. Int J Obes Relat Metab Disord 2001;25:1175–82. [PubMed] [Full Text]
  7. Weiss JL, Malone FD, Emig D, Ball RH, Nyberg DA, Comstock CH, et al. Obesity, obstetric complications and cesarean delivery rate–a population-based screening study. FASTER Research Consortium. Am J Obstet Gynecol 2004;190:1091–7. [PubMed] [Full Text]
  8. Vesco KK, Dietz PM, Rizzo J, Stevens VJ, Perrin NA, Bachman DJ, et al. Excessive gestational weight gain and postpartum weight retention among obese women. Obstet Gynecol 2009;114:1069–75. [PubMed] [Obstetrics & Gynecology]
  9. Stothard KJ, Tennant PW, Bell R, Rankin J. Maternal overweight and obesity and the risk of congenital anomalies: a systematic review and meta-analysis. JAMA 2009;301:636–50. [PubMed] [Full Text]
  10. Oken E, Taveras EM, Kleinman KP, Rich-Edwards JW, Gillman MW. Gestational weight gain and child adiposity at age 3 years. Am J Obstet Gynecol 2007;196:322.e1–8. [PubMed] [Full Text]
  11. Li R, Jewell S, Grummer-Strawn L. Maternal obesity and breast-feeding practices. Am J Clin Nutr 2003;77:931–6. [PubMed] [Full Text]
  12. Bellver J, Rossal LP, Bosch E, Zuniga A, Corona JT, Melendez F, et al. Obesity and the risk of spontaneous abortion after oocyte donation. Fertil Steril 2003;79:1136–40. [PubMed] [Full Text]
  13. Fedorcsak P, Storeng R, Dale PO, Tanbo T, Abyholm T. Obesity is a risk factor for early pregnancy loss after IVF or ICSI. Acta Obstet Gynecol Scand 2000;79:43–8. [PubMed] [Full Text]
  14. Wang JX, Davies MJ, Norman RJ. Obesity increases the risk of spontaneous abortion during infertility treatment. Obes Res 2002;10:551–4. [PubMed]
  15. Lashen H, Fear K, Sturdee DW. Obesity is associated with increased risk of first trimester and recurrent miscarriage: matched case-control study. Hum Reprod 2004;19:1644–6. [PubMed] [Full Text]
  16. Cnattingius S, Bergstrom R, Lipworth L, Kramer MS. Prepregnancy weight and the risk of adverse pregnancy outcomes. N Engl J Med 1998;338:147–52. [PubMed] [Full Text]
  17. Hendler I, Goldenberg RL, Mercer BM, Iams JD, Meis PJ, Moawad AH, et al. The Preterm Prediction Study: association between maternal body mass index and spontaneous and indicated preterm birth. Am J Obstet Gynecol 2005;192:882–6. [PubMed] [Full Text]
  18. Dashe JS, McIntire DD, Twickler DM. Effect of maternal obesity on the ultrasound detection of anomalous fetuses. Obstet Gynecol 2009;113:1001–7. [PubMed] [Obstetrics & Gynecology]
  19. Shaw GM, Velie EM, Schaffer D. Risk of neural tube defect-affected pregnancies among obese women. JAMA 1996;275:1093–6. [PubMed]
  20. Waller DK, Mills JL, Simpson JL, Cunningham GC, Conley MR, Lassman MR, et al. Are obese women at higher risk for producing malformed offspring? Am J Obstet Gynecol 1994;170:541–8. [PubMed]
  21. Werler MM, Louik C, Shapiro S, Mitchell AA. Prepregnant weight in relation to risk of neural tube defects. JAMA 1996;275:1089–92. [PubMed]
  22. Rode L, Nilas L, Wojdemann K, Tabor A. Obesity-related complications in Danish single cephalic term pregnancies. Obstet Gynecol 2005;105:537–42. [PubMed] [Obstetrics & Gynecology]
  23. Stephansson O, Dickman PW, Johansson A, Cnattingius S. Maternal weight, pregnancy weight gain, and the risk of antepartum stillbirth. Am J Obstet Gynecol 2001;184:463–9. [PubMed] [Full Text]
  24. Watkins ML, Rasmussen SA, Honein MA, Botto LD, Moore CA. Maternal obesity and risk for birth defects. Pediatrics 2003;111:1152–8. [PubMed] [Full Text]
  25. Hediger ML, Overpeck MD, McGlynn A, Kuczmarski RJ, Maurer KR, Davis WW. Growth and fatness at three to six years of age of children born small- or large-for-gestational age. Pediatrics 1999;104:e33. [PubMed] [Full Text]
  26. Salsberry PJ, Reagan PB. Taking the long view: the prenatal environment and early adolescent overweight. Res Nurs Health 2007;30:297–307. [PubMed]
  27. American College of Obstetricians and Gynecologists. Fetal macrosomia. ACOG Practice Bulletin 22. Washington, DC: ACOG; 2000.
  28. Mhyre JM. Anesthetic management for the morbidly obese pregnant woman. Int Anesthesiol Clin 2007;45:51–70. [PubMed]
  29. Hood DD, Dewan DM. Anesthetic and obstetric outcome in morbidly obese parturients. Anesthesiology 1993;79:1210–8. [PubMed]
  30. Kabiru W, Raynor BD. Obstetric outcomes associated with increase in BMI category during pregnancy. Am J Obstet Gynecol 2004;191:928–32. [PubMed] [Full Text]
  31. Myles TD, Gooch J, Santolaya J. Obesity as an independent risk factor for infectious morbidity in patients who undergo cesarean delivery. Obstet Gynecol 2002;100:959–64. [PubMed] [Obstetrics & Gynecology]
  32. Perlow JH, Morgan MA. Massive maternal obesity and perioperative cesarean morbidity. Am J Obstet Gynecol 1994;170:560–5. [PubMed]
  33. Maasilta P, Bachour A, Teramo K, Polo O, Laitinen LA. Sleep-related disordered breathing during pregnancy in obese women. Chest 2001;120:1448–54. [PubMed]
  34. Wall PD, Deucy EE, Glantz JC, Pressman EK. Vertical skin incisions and wound complications in the obese parturient. Obstet Gynecol 2003;102:952–6. [PubMed] [Obstetrics & Gynecology]
  35. Antimicrobial prophylaxis for cesarean delivery: timing of administration. Committee Opinion No. 465. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;116:791–2. [PubMed] [Obstetrics & Gynecology]
  36. Use of prophylactic antibiotics in labor and delivery. Practice Bulletin No. 120. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;117:1472–83. [PubMed] [Obstetrics & Gynecology]
  37. Cetin A, Cetin M. Superficial wound disruption after cesarean delivery: effect of the depth and closure of subcutaneous tissue. Int J Gynaecol Obstet 1997;57:17–21. [PubMed] [Full Text]
  38. Chelmow D, Rodriguez EJ, Sabatini MM. Suture closure of subcutaneous fat and wound disruption after cesarean delivery: a meta-analysis. Obstet Gynecol 2004;103:974–80. [PubMed] [Obstetrics & Gynecology]
  39. Al-Inany H, Youssef G, Abd ElMaguid A, Abdel Hamid M, Naguib A. Value of subcutaneous drainage system in obese females undergoing cesarean section using Pfannenstiel incision. Gynecol Obstet Invest 2002;53:75–8. [PubMed]
  40. Magann EF, Chauhan SP, Rodts-Palenik S, Bufkin L, Martin JN Jr, Morrison JC. Subcutaneous stitch closure versus subcutaneous drain to prevent wound disruption after cesarean delivery: a randomized clinical trial. Am J Obstet Gynecol 2002;186:1119–23. [PubMed] [Full Text]
  41. Thromboembolism in pregnancy. Practice Bulletin No. 123. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:718–29. [PubMed] [Obstetrics & Gynecology]
  42. Bates SM, Greer IA, Hirsh J, Ginsberg JS. Use of antithrombotic agents during pregnancy: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126:627S–44S. [PubMed]
  43. Bates SM, Greer IA, Pabinger I, Sofaer S, Hirsh J. Venous thromboembolism, thrombophilia, antithrombotic therapy, and pregnancy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008;133:844S–86S. [PubMed] [Full Text]
  44. Royal College of Obstetricians and Gynaecologists. Report of the RCOG working party on prophylaxis against thromboembolism in gynaecology and obstetrics. London (UK): RCOG; 1995.
  45. Tooher R, Gates S, Dowswell T, Davis LJ. Prophylaxis for venous thromboembolic disease in pregnancy and the early postnatal period. Cochrane Database of Systematic Reviews 2010, Issue 5. Art. No.: CD001689. DOI: 10.1002/14651858.CD001689.pub2. [PubMed] [Full Text]
  46. Hague WM, North RA, Gallus AS, Walters BN, Orlikowski C, Burrows RF, et al. Anticoagulation in pregnancy and the puerperium. Working Group of the Obstetric Medicine Group of Australasia. Med J Aust 2001;175:258–63. [PubMed] [Full Text]
  47. Houston MC, Raynor BD. Postoperative morbidity in the morbidly obese parturient woman: supraumbilical and low transverse abdominal approaches. Am J Obstet Gynecol 2000;182:1033–5. [PubMed]
  48. Bariatric surgery and pregnancy. ACOG Practice Bulletin No. 105. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113:1405–13. [PubMed] [Obstetrics & Gynecology]
  49. Wax JR, Wolff R, Cobean R, Pinette MG, Blackstone J, Cartin A. Intussusception complicating pregnancy following laparoscopic Roux-en-Y gastric bypass. Obes Surg 2007;17:977–9. [PubMed]
  50. Patel JA, Patel NA, Thomas RL, Nelms JK, Colella JJ. Pregnancy outcomes after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2008;4:39–45. [PubMed]
  51. Sheiner E, Levy A, Silverberg D, Menes TS, Levy I, Katz M, et al. Pregnancy after bariatric surgery is not associated with adverse perinatal outcome. Am J Obstet Gynecol 2004;190:1335–40. [PubMed] [Full Text]
  52. Martin LF, Finigan KM, Nolan TE. Pregnancy after adjustable gastric banding. Obstet Gynecol 2000;95:927–30. [PubMed] [Obstetrics & Gynecology]
  53. Weiss HG, Nehoda H, Labeck B, Hourmont K, Marth C, Aigner F. Pregnancies after adjustable gastric banding. Obes Surg 2001;11:303–6. [PubMed]
  54. Maggard MA, Yermilov I, Li Z, Maglione M, Newberry S, Suttorp M, et al. Pregnancy and fertility following bariatric surgery: a systematic review. JAMA 2008;300:2286–96. [PubMed] [Full Text]

Copyright January 2013 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920. All rights reserved.

ISSN 1074-861X

Obesity in pregnancy. Committee Opinion No. 549. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013:121;213–7

As seen on HealthDay News in 2011:

Obesity May Increase Risk of Surgical Complications

Inflammation, infection much more likely following elective procedures, study shows

FRIDAY, July 8 (HealthDay News) — Obese people who have elective surgery are nearly 12 times more likely to suffer from complications than those of normal weight, new research indicates.

Since data on surgical outcomes are often used by insurance companies, the Johns Hopkins researchers argued that the findings should change how doctors and hospitals are reimbursed for more complex procedures or penalized for higher complication rates.

Operations on obese patients are more demanding because they take longer and the operating fields are deeper, study leader Dr. Marty Makary, an associate professor of surgery, explained in a Hopkins news release. Obese patients who undergo surgery are also at greater risk for surgical site infection and slower healing because of reduced blood flow in fat tissue, Makary noted. Despite these added risks, Makary noted, “payments are based on the complexity of the procedure and are not adjusted for the complexity of the patient.”

The study is published online in the journal Plastic and Reconstructive Surgery.

In conducting the study, researchers examined insurance claims, identifying 2,403 obese patients and 5,597 normal weight patients who underwent elective breast procedures, such as breast lifts, reductions and augmentations, between 2002 and 2006.

Within 30 days of surgery, 18.3 percent of the obese group experienced at least one complication, compared to 2.2 percent of non-obese patients. More specifically, obese patients were 22 times more likely to have inflammation, 13 times more likely to develop infection and 11 times more likely to experience pain.

The findings are significant, given that 34 percent of adults in the United States are estimated to be obese — up from just 15 percent a decade ago. Meanwhile, the number of people having elective plastic surgery is also on the rise. Annual plastic surgery volume increased 725 percent between 1992 and 2005. Despite the trend, the study’s authors concluded the increased risk of complications could deter some surgeons from taking on these higher-risk obese patients.

“It’s more work, and it’s a more complex surgery, as opposed to operating on a thin patient. And the payment is the same,” Makary pointed out. “There are definitely incentives there for surgeons and institutions to select healthier patients. They’re getting reimbursed less per unit of work for obese patients.”

The researchers concluded that more research is needed to determine the role obesity plays in a wider range of surgeries so that new standards can be established to account for any differences, particularly increased risks.

More information

The American Heart Association details some of the cardiac risks associated with surgery in obese patients.


FDA and EPA advice about fish consumption and pregnancy

FDA News Release

FDA and EPA issue draft updated advice for fish consumption for persons trying to conceive, pregnant, or breastfeeding.

For Immediate Release

June 10, 2014

The U.S. Food and Drug Administration and the U.S. Environmental Protection Agency today issued draft updated advice on fish consumption. The two agencies have concluded pregnant and breastfeeding women, those who might become pregnant, and young children should eat more fish that is lower in mercury in order to gain important developmental and health benefits. The draft updated advice is consistent with recommendations in the 2010 Dietary Guidelines for Americans.

Previously, the FDA and the EPA recommended maximum amounts of fish that these population groups should consume, but did not promote a minimum amount. Over the past decade, however, emerging science has underscored the importance of appropriate amounts of fish in the diets of pregnant and breastfeeding women, and young children.

“For years many women have limited or avoided eating fish during pregnancy or feeding fish to their young children,” said Stephen Ostroff, M.D., the FDA’s acting chief scientist. “But emerging science now tells us that limiting or avoiding fish during pregnancy and early childhood can mean missing out on important nutrients that can have a positive impact on growth and development as well as on general health.”

An FDA analysis of seafood consumption data from over 1,000 pregnant women in the United States found that 21 percent of them ate no fish in the previous month, and those who ate fish ate far less than the Dietary Guidelines for Americans recommends—with 50 percent eating fewer than 2 ounces a week, and 75 percent eating fewer than 4 ounces a week. The draft updated advice recommends pregnant women eat at least 8 ounces and up to 12 ounces (2-3 servings) per week of a variety of fish that are lower in mercury to support fetal growth and development.

“Eating fish with lower levels of mercury provides numerous health and dietary benefits,” said Nancy Stoner, the EPA’s acting assistant administrator for the Office of Water. “This updated advice will help pregnant women and mothers make informed decisions about the right amount and right kinds of fish to eat during important times in their lives and their children’s lives.”

The draft updated advice cautions pregnant or breastfeeding women to avoid four types of fish that are associated with high mercury levels: tilefish from the Gulf of Mexico; shark; swordfish; and king mackerel. In addition, the draft updated advice recommends limiting consumption of white (albacore) tuna to 6 ounces a week.

Choices lower in mercury include some of the most commonly eaten fish, such as shrimp, pollock, salmon, canned light tuna, tilapia, catfish and cod.

When eating fish caught from local streams, rivers and lakes, follow fish advisories from local authorities. If advice isn’t available, limit your total intake of such fish to 6 ounces a week and 1-3 ounces for children.

Before issuing final advice, the agencies will consider public comments, and also intend to seek the advice of the FDA’s Risk Communication Advisory Committee and conduct a series of focus groups.

From Dr. Pabon: Please keep up to date by following the final recommendations from the FDA.  My most practical advice is to try to limit the consumption of fish products from fish “higher in the sea food chain” as mercury levels seem to concentrate in the top predators like shark, grouper, and swordfish.

J. Pabon, M.D.

Sarasota and Bonita Springs, Florida

Julio E. Pabon, M.D. 2014
Julio E. Pabon, M.D. 2014

Dr. Pabon’s Best Wishes For Father’s Day

Twins Happen
Twins Happen


My little guy, James (11), has been asking me many questions about my likes and preferences.  I did not catch on that father’s day was close.  My wife finally told me friday morning that he has been planning to make a gift for me.  I told her that all I wanted was time and memories.  Later, my eyes teared as I drove to the office when I thought about my boys and the fact that both of them prefer time and memories over material things.

Holidays have become very materialistic.  Many of us are concerned about the next gift to give or receive.  Instead, it is important to use the dates to center ourselves about our religions, our veterans, our presidents, our heroes, our mothers and fathers.

Remember fathers:

The time we share is the greatest gift.

Father and Son being silly
Father and Son being silly

Best wishes to all.

Most Sincerely,

Julio E. Pabon, M.D.

Sarasota and Bonita Springs, Florida


Julio E. Pabon, M.D. 2014
Julio E. Pabon, M.D. 2014



Florida IVF Doctor Agrees with New Recommendations for IVF

As a Florida IVF Doctor or Reproductive Endocrinologist, I agree with the new recommendations for older infertility patients.  In our Florida IVF clinics in Sarasota and Bonita Springs, I have been discussing the new recommendations for older IVF patients for quite some time.  Richard Reindollar’s team has reported in both the “Fast-track” study and in the “Fort T” studies that patients should made aware of the differential chances of pregnancy associated with different treatments.  He has demonstrated that older patients benefit from more aggressive treatment like IVF sooner rather than later.


As I discuss on a daily basis, older patients have a decreased chance of pregnancy because they make more genetically abnormal embryos.  In the past, many good Ob/Gyns and Reproductive Endocrinologists were hesitant about moving patients quickly to IVF due to the fear of multiple pregnancies and associated severe complications like pre-term birth and a much higher risk of neonatal morbidity, mortality, and congenital anomalies associated with twin and higher order pregnancies.  With current scientific advances, even older patients can be treated with single embryo transfers after pre-implantation genetic screening of blastocysts. The application of PGS for a planned single “Euploid” (and embryo with 23 pairs of chromosomes) transfer allows patients of all ages to have implantation rates with a single embryo that are higher that even implanting 3 or more embryos that have unknown genetic makeup.

Below is a recent Bulletin from the American Society of Reproductive Medicine detailing the results of these studies:

ASRM BulletinIMG_0440 copy

Volume 16, Number 25

May 6, 2014


Highlights from Fertility and Sterility

Older Women Should Move More Quickly to IVF

A new study demonstrates that, for couples of older reproductive age with unexplained infertility, immediate IVF is the most efficient treatment, resulting in fewer treatment cycles and a higher live birth rate.

In an NIH-funded, randomized clinical trial, 154 couples receiving infertility treatment at Boston IVF and Brigham and Women’s Hospital were randomly assigned to one of three groups to receive a specific type of treatment for their first two cycles.  One group was assigned to have IVF.  The other two groups were assigned to have intrauterine inseminations (IUIs) with the female partner receiving either an oral medication to induce ovulation (clomiphene citrate- CC) or injectable ovulation drugs (follicle stimulating hormone-FSH).

If patients in the two insemination groups did not achieve an on-going pregnancy after two cycles, they were switched to IVF for their subsequent cycles.

The participating couples were required to have been trying to conceive for at least six months and to not have previously tried any of the treatments being used in the study.  The female partner had to be between 38 and 42 years old, with regular menstrual cycles, at least one ovary and fallopian tube, acceptable ovarian reserve, no disorders of the reproductive organs and no history of ectopic pregnancy.  The male partner had to have enough motile sperm.

After two cycles of the assigned treatment, differences were observed in pregnancy rates and live births between the groups.   Of patients who went straight to IVF, 49% became pregnant and 31% gave birth.  Of those taking oral medications and having inseminations, 22% became pregnant and 16% gave birth.  For the injectable medication/insemination group, 17% became pregnant and 14% gave birth.

All couples who had not been successful in their first two cycles of any treatment used IVF in their subsequent treatment cycles, but the couples in the immediate IVF group of the study went through 36% fewer total cycles than the couples who began their treatment in either of the ovulation drug/IUI groups.

By the end of the treatment, of all the couples in the study, 71% had conceived a clinical pregnancy and 46% delivered at least one live-born baby.  84% of all live births in the study came about as a result of IVF.  For those couples having a live birth, those who started with IVF took an average of two cycles to conceive, while those who started with ovulation drugs and IUI averaged three to four cycles. Of the 154 couples enrolled, 140 started and 115 completed treatment.

While the major finding of this study  is that immediately starting infertility treatment with IVF in older couples is the most effective treatment, it also showed that, if a couple chooses to try ovulation drugs with insemination first,  oral fertility drugs (clomiphene citrate) are as effective as injectables (FSH).

Richard Reindollar, MD, Executive Director of the American Society for Reproductive medicine (ASRM) was the study’s principal investigator when he was at Dartmouth Hitchcock Medical Center (DHMC), prior to ASRM.  He described how the study came about. “Previously, in the Fast Track and Standard Treatment (FAST-T) trial, we found that for young couples with unexplained infertility, proceeding to IVF after three cycles of clomiphene with IUI was more cost-effective than the standard approach at the time- which required them to go through several additional cycles of injectable ovulation drugs with insemination before allowing them to try IVF.  We suspected that immediate IVF without any prior cycles with IUI would be more effective in an older age group but needed to demonstrate that through a rigorous trial.”  Marlene Goldman, ScD, Professor at DHMC and first author of the paper stated, “While we recognize that not all patients might choose to start treatment with IVF, the results of this trial will give reproductively older patients with unexplained infertility the evidence they need to skip less effective treatments and start their families more quickly if they wish to do so.”

Goldman et al, A randomized clinical trial to determine optimal infertility treatment in older couples:  the Forty and Over Treatment Trial (FORT-T), Fertility and Sterility, in press.


Do fertility drugs increase the risk of ovarian cancer?

Fertility Drugs like Clomid, Menopur, Pergonal, Gonal F, Follistim, and others have been used for many years to induce ovulation in both women who don’t ovulate and those that need to produce more than one egg at the time.  Physicians have tracked whether patients have a higher risk of future ovarian cancers after receiving such drugs.  So far there is no evidence that shows that there is a higher risk of ovarian cancers after using fertility drugs.  What we know is that actually being pregnant or using a birth control pill can lower the risk of future ovarian cancers.  Here is a recent article that reassures us in this regard.  Note that patients that took Clomid and then never became pregnant did have a higher risk of future ovarian cancer.  This implies that the risk may not have been increased by the drug, but because the patients did not conceive and did not use oral contraceptives either.

Julio E. Pabon, M.D., F.A.C.O.G., October 2013IMG_0440 copy


No Increased Risk of Ovarian Cancer Found With Common Fertility Drugs

October 14, 2013


By Lorraine L. Janeczko

NEW YORK (Reuters Health) Oct 14 – Women taking ovulation-inducing drugs are not at increased risk of ovarian cancer, researchers have found.

Writing in Fertility and Sterility, online September 6, Dr. Britton Trabert and colleagues note that the use of fertility treatment has been on the rise. It is biologically plausible, they add, that ovulation-inducing drugs could be associated with ovarian cancer.

But as Dr. Trabert told Reuters Health by email, “we found no evidence that either clomiphene or gonadotropins, the drugs in our study most commonly used to treat infertility, were associated with an increased risk of ovarian cancer.”

Dr. Trabert, from the Division of Cancer Epidemiology and Genetics at the National Cancer Institute in Bethesda, Maryland, and her colleagues analyzed data from women seen for infertility at five large U.S. practices between 1965 and 1988.

Nearly 10,000 women with at least one intact ovary were included in the study. The researchers followed the cohort for a mean of 17.6 years for ovarian cancer cases (n=85) and for a mean of 26.2 years for non-cases.

Overall, they found no association of ovarian cancer risk with ever use of CC (adjusted relative risk 1.34; 95% confidence interval 0.86 to 2.07) or gonadotropins (aRR 1.00; 95% CI 0.48 to 2.08).

However, women who used CC and remained nulligravid at follow-up were at higher risk of developing ovarian cancer than were those who successfully conceived, compared with nonusers (aRR 3.63; 95% CI 1.36 to 9.72 vs. aRR 0.88; 95% CI 0.47 to 1.63, respectively).

Dr. Trabert said it remains unclear whether nulligravid women on anti-ovulation drugs are at higher risk than are nulligravid women without exposure to the medications.

“These findings shouldn’t influence current treatment practices,” she said. “Our study evaluated drugs as they were prescribed mainly in the 1970s and 1980s, and many of the exposures were much higher than those with the drugs used today.”

Dr. Caren M. Stalburg, who wasn’t involved in the study, said the findings are reassuring and consistent with earlier meta-analyses that showed no link between ovulation-inducing drugs and ovarian cancer.

“They may also help identify a subset of individuals who are at increased risk for ovarian cancer long-term, that is, those women who remain nulligravid after the use of clomiphene citrate,” Dr. Stalburg, an ob-gyn at the University of Michigan Medical School in Ann Arbor, told Reuters Health by email.

“Given that we do not have effective mechanisms for ovarian cancer screening, it is unclear how these individuals should be monitored per se,” she added. “Awareness of the risks in this subset of women may be all that is possible for now.”


How Old is Too Old To Become a Parent?

IMG_0440 copy






This is a difficult question.  As Reproductive Endocrinologists, it seems that the boundaries of acceptability are always changing.  In my practice, we do not discriminate on the basis of age.  Older patients are informed of the increased risk of pregnancy complications such as hypertension, diabetes, and pre-term birth that are more common as patients age.  Patients are treated into their late forties and  and early fifties.  We screen patients very thoroughly and require a cardiac stress test for those over 45.  Patients that choose to try to conceive in their mid forties or later are informed that they have to be in optimal health and not have significant “co-morbidities.”  The most common one of these is obesity.  If a patient wishes to try to become pregnant later in life, she needs to demonstrate  that she is not increasing the risk further by being obese.

I try to educate patients about the ethics of advanced age parenting and assess the family structure to make sure kids will be cared for if the older parents become ill.

There was and interesting case a few years ago in Florida when a lady called a Florida IVF clinic and was turned away by the receptionist “because of her age.”  It turns out the patient was in the legal profession and sued that clinic for age discrimination.

The article below comments about a terrible event in Italy and suggests that there should be legal age limits imposed upon patients and clinics.  Who is to decide what is the proper limit.  What about an older man that marries a younger lady or vice versa.  It is best to make these assessments on an individual basis instead of making more rules.  I hope that U.S. Reproductive Endocrinologists will use good judgement on a case by case basis.

Here is the article as reported in the A.P. by A Vasireddy and S. Bewley

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


How Old Is Too Old to Become a Parent?

Tragic Outcome of Post-menopausal Pregnancy: An Obstetric Commentary

Vasireddy A, Bewley S
Reprod Biomed Online. 2013;27:121-124


Initially, in vitro fertilization (IVF) was offered to overcome the problem of tubal disease. As experience has grown with the treatments and as the technology has improved, IVF has become available to a wider patient population, based on more heterogeneous indications. Nowadays, it is offered to treat male factor, tubal, immunologic, hormonal, unexplained, etc. causes of infertility. Over the years, it also became evident that the treatment can be successfully completed with donated gametes (egg, sperm donation) or when the embryo is implanted into a surrogate’s uterus. This has opened up new areas of use. The availability of such “nonclassic” methods also raises legal and ethical questions.

A trend in delaying childbearing can be observed in the past decades. Women in increasing numbers continue their education and seek a professional career. In modern societies, it also seems more difficult to establish stable relationships that could be the base of a family. The result of these changes is that more and more women start thinking about conceiving once they are already over 30.

The ovaries contain a finite number of eggs. Reduced oocyte availability and poorer egg quality are associated with increased reproductive difficulty as women age. While under 30 years of age, only 5%-10% of couples face infertility problems. By the age of 40, the incidence of infertility is over 40%. Over the age of 45, women rarely conceive on their own or with assisted reproductive technology (ART).

Age-related problems in the woman can usually be overcome with the use of donated oocytes. This commentary article discusses the ethical and biological aspects of oocyte donation at an advanced age in relation to a controversial legal case.

Commentary Summary

According to a 2011 report, an Italian court took a 1-year-old child away from a couple as they were considered too old to be fit parents at the female age of 57 and male age of 70. The child was conceived through ART treatment abroad.

The authors discuss that as women age, the proportion of embryos affected by aneuploidy increases, and this is a major limiting factor in achieving pregnancy in the late 30s and early 40s. The uterus also shows some signs of aging, probably related to suboptimal blood supply, but this seems to be less of an issue because the age factor can be overcome by the use of donated oocytes.

It is also known that pregnancies at the extremes of the reproductive years are associated with a higher frequency of medical complications (hypertensive complications, gestational diabetes, preterm delivery, stillbirth, operative delivery). A pregnancy conceived through egg donation in a woman with advanced age is also associated with an increased incidence of medical complications, so the use of “young” eggs does not prevent these complications.

Even if a pregnancy progresses uneventfully and results in the delivery of a healthy child, one has to consider the chronic medical problems and malignancies that affect women in the fourth through sixth decades of life when they need to raise the child. While one tries to help couples whose last resort is gamete donation, the interest of the offspring also needs to be considered. Should the parents become incapable of fulfilling their parental responsibilities, it will become the responsibility of the society to provide care for these children. Therefore, the authors feel that the fertility treatment of women of advanced age or even in menopause should be regulated to avoid future cases like that in Italy.

Age is probably the single most important parameter affecting reproductive success. A woman’s chance to conceive starts to decline at around the age of 30, and over 45 it is very rare to achieve a successful pregnancy. This is due to the reduced number of eggs available for fertilization as well as to their poorer quality that leads to increased aneuploidy rates with age. Women who delay childbearing can expect a longer time to succeed, more need for ART, and smaller family size. ART may compensate for some of the reduced chance but cannot make up for all of it. Pregnancies that are conceived in women over 35 are complicated by higher miscarriage and stillbirth rates; medical complications during pregnancy are more common too.

Women over 40 are more likely to require donor eggs to achieve a pregnancy when compared with younger women. An embryo that is created from a younger woman’s egg will have a high chance to implant, so women even after reaching natural menopause still have a chance to achieve a successful pregnancy. However, they need to be aware that these pregnancies are still complicated by more hypertensive complications, low birth weight, and need for operative delivery.

A child born to older parents may face relationship or emotional problems with his/her parents due to the big age gap. On the other hand, older parents are more likely to be able to provide the financial needs required to raise a child. The availability of social egg freezing is another issue that will likely result in more pregnancies among women of advanced reproductive age. Freezing eggs at a younger age allows women to study and start a job before they interrupt their professional career with a pregnancy and delivery. These women will probably not have big families that may have consequences to society. These women may also be diagnosed with medical problems or may be affected by undiagnosed medical issues by the time they decide to use their eggs, which may complicate the pregnancies and may lead to a higher rate of maternal morbidity/mortality.

Therefore, care providers have to be very careful when counseling women about pregnancies at an older age. Women should be encouraged to try on their own at a young age. Those who for various reasons cannot complete their desired family size early on should undergo a thorough medical evaluation before their own or donated eggs are used. An upper age limit should also be set to avoid problems like the one discussed in the article and to make sure parents will be there for their children until their children at least reach adulthood.


Sex Selection IVF

Sex Selection IVF

Sex selection IVF by Laser blastocyst trophectoderm biopsies and PGS with microarray 24 chromosome complete genomic hybridization techniques in our Florida Clinic is the most accurate method available.  While most clinics that provide sex selection IVF services are still depending on older technology based on the biopsy of a day 3 embryo and FISH (Fluorescent in situ hybridization probes), we have been pioneers in the application of blastocyst biopsies in the Southeastern United States.  The technology is so reliable that the majority of treatments can be completed with a single embryo transfer (fresh or frozen/thawed) with an expectation of pregnancy in more than 60% of patients that receive a single embryo.  We have been offering PGD, PGS, and sex selection IVF services since 1999.  Our first pregnancy with PGS/PGD technology and sex selection IVF was in a treatment completed in late 1999.  At that time and until mid 2012, all of our procedures were based on day 3 embryo biopsies.  Recently, we have brought the capability of blastocyst biopsies to the Southeastern United States.  The decision to lead in this technology was based on emerging science confirming the safety and increased reliability of the results based on the biopsy of the blastocyst.  The results for PGD, PGS and sex selection IVF are so reliable that we have increased our pregnancy rates while reducing the number of embryos transferred from 2 or 3 to only one in most cases.  This allows completion of the treatment without the risk of a complicated multiple (twin or triplet) pregnancy.

Family Balancing & Sex Selection

Technology has advanced significantly in the past several years allowing couples the option of selecting the sex of their next child.  Fertility Center & Applied Genetics of Florida and the offices of Julio E. Pabon, M.D., P.A.  participated in the MicroSort® clinical trial.   Dr. Pabon had a long association with the MicroSort® study team as a study collaborator.

The microsort trial had hoped to reliably sort sperm in order to reliably select a sample rich in Y chromosomes (to lead to a male child) or rich in X chromosomes (to lead to a female child), but the trial failed.  There were never reliable enough results to bring it to clinical fruition.  Research continues in this area of science.  Unfortunately, thus far sperm sorting procedures are not reliable enough for clinical use.  At this time the only reliable method for family balancing or sex selection requires “in vitro” fertilization and pre-implantation genetic diagnosis or screening of pre-embryos prior to implantation.

Pre implantation Genetic Screening (PGS) or Pre implantation Genetic Diagnosis (PGD) for Sex Selection IVF (family balancing)

PGS stands for pre-implantation genetic screening of embryos.  PGD stands for pre-implantation genetic diagnosis of embryos.  PGS or screening is the term for the procedures involved in determining that an embryo or embryos have the correct or incorrect number of chromosomes.  PGD or genetic diagnosis of embryos is the term for the procedures (very similar in the IVF lab) that lead to diagnosing a particular disease or condition in the embryo that has to do with a particular genetic disease.  PGD is usually performed to test embryos when the parents are “carriers” of a particular disease like Cystic fibrosis, spinal muscular atrophy, Fragile X, sickle cell anemia, etc.  For the purposes of screening embryos in order to determine their gender, PGD is carried out to determine the number of chromosomes and which sex chromosomes are present.  PGS also helps to prevent conditions that are caused by genetic errors in the numbers of chromosomes in embryos like the Down’s syndrome (trisomy 21) or other conditions like it where the embryo may have an incorrect number of chromosomes and may be used as part of sex selection IVF.

Humans with a normal complement of chromosomes have 23 pairs of chromosomes.  There are 22 pairs of chromosomes called the autosomes that determine characteristics other than gender.  In addition to these 22 chromosomes, there is a pair of “sex chromosomes” that carry the genetic information that leads to the differentiation of the fetus into a girl or a boy.  The Karyotype of a girl is 46 XX while that of a male is 46 XY.  The presence of the Y chromosome leads to differentiation into a boy.  The figure below is a computer enhanced image of the chromosomes in the nucleus of cell.

Scan 8

The sex of a pre-embryo can be determined three, five, or six days after the fertilization of the egg.  Our center had its first live birth after PGD/PGS sex selection IVF in 2000.  The patient carried a sex-chromosome-linked fatal genetic disease.  In this initial case, we were able to screen three day old pre-embryos for abnormalities in eight key chromosome pairs.  One of the chromosome pairs was the sex chromosomes.  We were able to select XX carrying female pre-embryos to transfer into the mother.  This avoided the severe neurological disease that was carried in the male offspring in this family.  Since then, we have treated numerous patients with PGD or PGS for not only sub-fertility, recurrent pregnancy losses, genetic disorders, as well as patients with a desire to pre-determine the sex of the next child.

Our patients are always counseled that no medical procedure can be 100% guaranteed.  It should be noted however thatsince 2002, we have treated hundreds of patients without one misdiagnosis or surprise regarding the sex of the child.

PGD/PGS technology has become more reliable.  In the first years of PGD/PGS, we relied mostly on the biopsy of day 3 multicellular pre-embryos.  Day 3 multicellular pre-embryos are usually composed of 6-8 cells.  While most pre-embryos are made up of identical cells, 7-10% of them can be mosaics.  Mosaic multicellular pre-embryos can lead to a sampling error that can give erroneous results since the cell sampled may not represent what ultimately becomes the baby.  In addition, in the early years of this technology, we relied mostly on fluorescent “in situ” hybridization techniques in order to identify the chromosomes.  The probes used for “in situ” hybridization were designed to bind to unique regions of chromosomes and relied on binding affinities that varied with each assay.  Nonetheless, we were able to have very reliable results with not a single misdiagnosis even in the early years.

Since 2006, our program evolved to more reliable 24 chromosome microarrays and complete genomic hybridization techniques.  These complex technologies expand the available DNA in a cell and give a reading of the genetics of the cell that is more reliable than the old “FISH” techniques.  Even more recently, as of the Fall of 2012, our program has moved from day 3 multicellular pre-embryo biopsies to the highest current technology.  This is the laser assisted trophectoderm blastocyst biopsy.

Laser assisted trophectoderm blastocyst biopsies raise the bar to the highest possible level because we sample embryos on the fifth or sixth day and we sample more than one cell per pre-embryo.  This increases the reliability and reduces the negative impact of mosaicism.  One can be 98%-99% sure that the results of  the embryo biopsy will represent the ultimate genetics of the fetus and subsequent baby.  Please refer to the PGD/PGS portion of this web page.

Family Balancing/Sex Selection Common Questions

Is Sex Selection ethically appropriate? 
At Fertility Center & Applied Genetics of Florida and the offices of Julio E. Pabon, M.D.,P.A., we treat all pre-embryos with great respect and encourage families to preserve through cryopreservation normal pre-embryos regardless of their sex chromosome status.

The ethics of sex selection are certainly controversial.  There are certainly those who feel that this technology should only be applied to prevent devastating genetic diseases or conditions.  Some feel it should not be an elective procedure used for family balancing.  Family Balancing & Sex Selection is an extremely personal decision.  We are fortunate to have the freedom to make such choices.  Choosing one blastocyst pre-embryo over another certainly is better than choosing further along in the fetal stages of the pregnancy.

Given the safety of the processes involved, it is our opinion that family balancing through sex selection is acceptable.  The processes are carried out on pre-embryos prior to any tissue differentiation or organ system development.  Blastocyst pre-embryos have not yet developed any differentiated tissues such as nerve tissues or cardiac tissues.  The potential for development exists just as in the stem cells in the bone marrow, the dermis of the skin, and even in the menstrual cells shed each month.

What if all the pre-embryos are of the opposite sex that we desire?

Patients must understand that there may not be any normal pre-embryos in any particular treatment cycle.   Very abnormal pre-embryos may arrest or stop growing prior to reaching the blastocyst stage for biopsy.  Also, the results of the genetic tests may not yield a normal chromosome complement of the desired gender.  These results are very disappointing, but are a reality of the biology involved.  Patients must decide whether they wish to freeze normal pre-embryos of the opposite sex desired or if they would accept them for implantation.  Alternatively, the embryos can be placed in an adoption program managed by our offices.   A treatment may be a scientific success while still being disappointing.

What are the procedures like?

Patients will have a thorough consultation that can be in person (local patients) or via SKYPE or on the phone.  Dr. Pabon prefers SKYPE instead of the phone because he can share his desktop with the patients and show tables and images to patients during the remote consultation.  Patients will be prepared for IVF in the usual manner.  They will be required to do some routine labs and pre-tests as described in the IVF patient guide.  Out of town patients can be prepared by their local physicians or clinics and travel to Sarasota at the very end of the ovarian stimulation phase.

Are the procedures safe?

Modern IVF procedures are extremely safe.  There have been recent changes in the ovarian stimulation and the egg maturation trigger that have virtually eliminated the risk of severe ovarian swelling or “ovarian hyperstimulation syndrome.”  In years past, the final trigger was with full dose hCG.  This led to ovarian hyperstimulation in 10-25% of patients depending on their clinic protocols.  Severe hyperstimulation was the most feared complication as it could lead to hospitalization and even severe complications like blood clots.  Recently, we have applied new science in order to trigger most of our higher responding patients with a very gentle “agonist trigger.”  This strategy leads to a very mild ovulation that leads to only mild ovarian enlargement and exceeding low risks of ovarian hyperstimulation. The only down side is that the agonist trigger results in lower implantation rates and therefore these cycles lead to the harvest of the eggs and the IVF and embryo biopsies, but the blastocysts have to be frozen for implantation the following month.

The other common complication that is feared by most specialists is a twin or higher order pregnancy.  Fortunately, this complication is quite rare now that we are able to complete most treatments with a single embryo transfer.

May I have Twins Please?

Dr. Pabon advices against the transfer of more than one “robust” embryo with normal genetic results.  In years past and in patients being treated without PGS testing of their embryos, it was quite common to implant 2 embryos.  The reason for this is that one cannot tell if an embryo is genetically normal based on its appearance.  Implanting 2 embryos without PGS results in average pregnancy rates of 45-50% in good prognosis patients in their early and mid thirties.  Implanting one “robust” embryo with known normal PGS genetic results results in a pregnancy in more that 60% of patients.  Implanting 2 in this situation has resulted in 100% twins in every case robust embryos were transferred (at the time of this writing).  A planned twin pregnancy is not good medicine because these pregnancies are very risky for the babies due to pre-term birth and much higher chances of severe congenital anomalies and cerebral palsy.

Our Medical and Laboratory Director:IMG_0440 copy

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

Florida IVF Doctor with advice for Egg Donors

As a busy IVF Doctor in Florida serving Sarasota, Tampa, Bradenton, Ft. Myers, Naples, and Egg Donor IVF patients from all Florida and abroad, I had a good visit with a young lady that hopes to donate her eggs anonymously to a lovely couple.  During her counseling and education I was reminded of the great gift that our egg donor patients give.  As I do value them as dear patients, their wishes are very important to me.  Their anonymity is important to them as it is to the intended parents.  We had a conversation about her reasons for being interested in egg donation and as I spoke with her, I reminded her that she should be careful with social media and the internet.

Few of us realize that the internet is eroding our privacy gradually and surely.  For example, many people post many photos of themselves in social media sites. Unfortunately (or fortunately depending on your point of view), the technology exists for facial recognition software to search the entire internet to find matching faces.  For that reason, I remind anonymous egg donors to not post straight on face “shots” in their social media pages or in the internet at all if they truly value their privacy.

Also, anonymous egg donors are asked to not join the social marketing networks of the fertility center where they are treated.

Just a reminder from your doctor,
IMG_0440 copy

All the best!!

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

Fertility Center and Applied Genetics of Florida

Sarasota and Bonita Springs, Florida  U.S.A.

Florida IVF Fertility Doctor Reminds You That Babies Are Listening

As a Florida IVF Fertility Doctor, I remind  you that babies are listening.  Here is an article by Meghan Holohan as reported by NBC News. I fully believe that babies are listening.  We need to talk and sing happy songs so the little ones can hear.


Unborn babies are hearing you, loud and clear

Meghan HolohanNBC News 22 hours ago

What unborn babies hear can shape their brains, a new study shows. Here, an infant undergoes an assessment for fetal learning.

Courtesy of Veikko Somerpuro, Un
What unborn babies hear can shape their brains, a new study shows. Here, an infant undergoes an assessment for fetal learning.

Expectant moms who coo and chat to their babies while they’re pregnant may be doing more than stimulating the fetus – they may be shaping their child’s brain, according to research published Monday.

A study in the Proceedings of the National Academy of Sciences reinforces what many people had believed—babies hear what their moms say and their brains recognize these words after birth.

Researchers at the University of Helsinki in Finland looked at 33 moms-to-be, and examined their babies after birth. While pregnant, 17 mothers listened at a loud volume to a CD with two, four minute sequences of made-up words (“tatata” or “tatota”, said several different ways and with different pitches) from week 29 until birth.

The moms and babies heard the nonsense words about 50 to 71 times. Following birth, the researchers tested the all 33 babies for normal hearing and then performed an EEG (electroencephalograph) brain scan to see if the newborns responded differently to the made-up words and different pitches.

Babies who listened to the CD in utero recognized the made-up words and noticed the pitch changes, which the infants who did not hear the CD did not, the researchers found. They could tell because their brain activity picked up when those words were played, while babies who didn’t hear the CD in the womb did not react as much.

“We have known that fetuses can learn certain sounds from their environment during pregnancy,” Eino Partanen, a doctoral student and lead author on the paper, said via email.

“We can now very easily assess the effects of fetal learning on a very detailed level—like in our study, [we] look at the learning effects to very small changes in the middle of a word.”

This paper does more than simply find that babies in utero can hear; it shows that babies can detect subtle changes and process complex information.

“Interestingly, this prenatal exposure also helped the newborns to detect changes which they were not exposed to: the infants who have received additional prenatal stimulation could also detect loudness changes in pseudo words but the unexposed infants could not,” Partanen says.

“However, both groups did have responses to vowel changes (which are very common in Finnish, and which newborns have been many time previously been shown to be capable of).”

These findings build on other research conducted over the past 20 years that looks at how babies respond to sound. Minna Huotilainen, who also worked on the study, published a study in 2005 showing that fetuses can discriminate among sounds. And, in 1988 researchers found that babies who heard soap operas in utero became addicted—at least to the melodies. Babies with moms who watched soaps while they were pregnant responded to the melodic cues in the shows.

Can what your baby hears in the womb really affect learning?

Courtesy of Veikko Somerpuro, Un
Can what your baby hears in the womb really affect learning?

The finding support the idea that an unborn fetus can learn and remember just as well as a newborn, the researchers said. It may be worthwhile to expose babies to more sounds before they are even born.

“The better we know how the fetus’ brain works, the more we’ll know [about] early development of language,” Partanen says. “If we know better how language develops very early, we may one day be able to develop very early interventions [for babies with abnormal development].” 


Posted by:

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


IMG_0440 copy

Fertility Center and Applied Genetics of Florida

Treating patients from Sarasota, Tampa, Bradenton, Ft. Myers, Naples, and Bonita Springs, Florida, U.S.A.

www.geneticsandfertility.com   www.drpabon.com

Translate »