Archive for August, 2011
By Tracey Minella
August 31st, 2011 at 12:00 am
Hey Guys! It’s the last day of the month, so this one’s for all of you manly men.
I was thinking about you when another baseball history-making moment occurred this month. You don’t have to be a Yankees fan to appreciate the accomplishment of a team having three Grand Slams in a single game. One is rare, but do-able enough. Two is ridiculous. But three?
Until the Yankees just did it.
Did any of you think they’d have a third one after the second one? It’s never been done in baseball history. Yet, there’s that Yankees magic that strikes at moments like these.
So what does this have to do with infertility, you ask?
Well, think of all the disappointing times you’ve faced along the journey to parenthood and the times it seems like conceiving a baby is a dream that is simply out of reach. Do you say to yourself that it’s never going to happen? Of course you probably have.
And then there’s the whole “working as a team” aspect of the Yankees’ accomplishment…its how they made a miracle happen. Well you have the ECF team working with you. And I like to think of the ECF team as the New York Yankees of Reproductive Medicine!
So maybe, when the goal seems like you’d need a miracle to make it happen, all you really need is to stay the course, come together as a team, and keep believing that magic happens.
The Yankees make miracles on the field. We make miracles in the lab.
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At what point did you believe the Yankees were going to get the third grand slam? Right after the second one, or at some later point?
Do you think the level of faith you had in the Yankees’ ability to pull off such a miracle is lower or higher than the level of faith you have in your RE to get your partner pregnant?
Remember, ECF is the first Long Island IVF center to offer a men’s only support group! If you’d like more info on coming down two Tuesday nights each month to vent with like-minded guys, contact Bina Benisch, M.S., R.N at firstname.lastname@example.org.
By David Kreiner MD
August 30th, 2011 at 10:54 am
Tagged with be your own egg donor, cancer and infertility, East Coast Fertility, egg banking, Egg Donor, egg freezing, egg preservation, fertile hope, infertility information, IVF, oocyte freezing, vitrification
We are approaching a time that freezing eggs will be a standard option for an IVF program much like Embryo freezing is today. Despite the fact that hundreds of babies have been born apparently without an increase in defects or abnormalities, the American Society for Reproductive Medicine (ASRM) has proclaimed that Egg freezing is still considered experimental.
This is not just a scientific decision but is a philosophical and political one as well. In the 1980’s, IVF was being performed likewise on an experimental basis. Insurance companies denied that it had become standard of care until recently. In fact, there are insurance providers who in an effort to deny claims continue to call IVF experimental despite the million babies already born without significant increases in abnormalities or defects noted. However, the ASRM is afraid to push the envelope and take a risk that may make them appear to be promoting a procedure that could theoretically be associated with increased problems with the children created after egg freezing.
But why should we be interested in egg freezing anyway when we have IVF that is successful and known to be relatively safe after 33 years of experience? The reasons are multiple.
A young woman who develops cancer and will have radiation therapy or chemotherapy that may affect her eggs or have her ovaries removed would with egg freezing have an option to preserve her fertility and still have her cancer treated.
In the past, the loss of a woman’s future ability to bear children was sometimes more emotionally depressing for her than the cancer itself. The prospect of offering hope to such affected women is spreading throughout the community in part through the efforts of the Lance Armstrong Fund supported group, Fertile Hope. They are attempting to educate not just affected individuals but oncologists and other physicians who come into contact with patients who may be able to take advantage of new IVF technologies to preserve their fertility while undergoing cancer treatment.
Another great potential use for frozen eggs is in the donor egg program. Currently, our egg donors go through fresh IVF cycles coordinated in time with the recipients so that the eggs are fertilized fresh when they are retrieved. This is highly successful in achieving pregnancies in approximately 80% of donations. However, cycles can be delayed in trying to synchronize patients. If programs can achieve similar success rates using frozen eggs it will allow recipient patients to choose donor eggs much like they select donor sperm today.
Yet, another benefit of the ability to bank frozen eggs is for women who either because of their career or lack of finding a suitable partner need to put off their childbearing until a time when they would otherwise put their future fertility at significant risk. This is a more controversial use of this technology but a practical concern for countless women today for whom conceiving before age 35 is unrealistic.
Needless to say, egg freezing will be a great benefit for many when it becomes a safe acceptable IVF standard. That time for consideration by patients is rapidly approaching and is something that the public needs to be made aware of.
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If faced with one of the above situations, and a clinic who would offer it, would you choose egg-freezing even though the ASRM considers it experimental? Why or why not?
By Tracey Minella
August 29th, 2011 at 1:40 pm
Mother Nature can be a real b*tch.
Right on the heels of a ridiculously rare earthquake this week came the almost as rare hurricane on Long Island this weekend. What’s next? Locusts?
And while you guys snickered at my earthquake post (yes, I heard you), the impending hurricane actually did get your attention. At least one patient used our social media platforms to ask if the embryos are safe in a hurricane. And I’m sure many others wondered in silence.
Now to get the full effect here, you need to imagine me in a raincoat beside the shoreline, being pelted by gusting winds and rain, like any good storm reporter. Ready?
“Hello folks, this is Tracey Minella with East Coast Fertility News, reporting live from Plainview, New York, where throngs of infertility patients awaiting Hurricane Irene’s arrival are wondering if their embryos will be safe from the storm.
Despite the Governor’s declaration of a state of emergency and evacuation orders, I’m standing here in a puddle up to my waist in the ECF parking lot. Right behind me is the Long Island Expressway which is totally dark and deserted except for a scattering of disabled cars.
That blaring beacon of light in the distance is coming from the ECF facility that houses the embryology lab down on Old Country Road… obviously glowing from its back up generator automatically kicking in. [Crowd erupts in applause] Now back to you in the studio.”
As we learn from the casualties in every natural disaster that even the best back-up plans don’t offer guaranteed immunity from harm due to Acts of God, you can take comfort that ECF has plans and procedures in effect designed to safeguard and offer heightened protection to your precious cargo in such precarious circumstances.
In a coincidental strike of stress-reducing good timing, the IVF lab is on a scheduled break from retrievals and transfers until September 7th. But in the event this hurricane (or any yet to come) caused major and prolonged power outages in ECF offices, patients needing an IUI or other time-sensitive or essential medical services could be accommodated in ECF’s generator-powered facility on Old Country Road.
In other words, ECF’s got your back.
There has been no disruption to services at ECF from Hurricane Irene and all offices are open for their regular business hours and services.
In the event of another hurricane, feel free to call the ECF office or service for further instructions and/or information from the medical and support staff. They will be happy to help you. Not just this week, not just this hurricane season, but always.
And check the website, blog and facebook for updates as well. We will post them so long as cable/internet service is not interrupted. Better yet, why not "Like" us on facebook right now, so you can receive and access important weather-related or other updates even faster?
Hope you all are safe and did not have much damage from Irene.
Be sure to check back this Thursday when we post the three lucky winners of the video contest!!!! Then again next Tuesday when the free micro-IVF cycle winner is announced!
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Feel free to share your storm experience with us here.
I’ll start things off: I have a huge tree on my den roof and believe the effects of no internet or facebook access for two days will haunt me for years after that tree is removed.
How about you?
By Tracey Minella and David Kreiner MD
August 26th, 2011 at 12:00 am
Tagged with Dr. David Kreiner, East Coast Fertility, Fertility, FET, free cryopreservation, free FET, infertility information, IVF, IVF pregnancy rates, Jones Institute, multiple pregnancies, selective fetal reduction, SET, Single Embryo Transfer
Single embryo transfers. What a concept!
Back when I was doing IVF in the mid-90’s, transferring FOUR embryos was the norm! Sometimes even more, depending on the patient’s history! After a few failed IVFs, I did a GIFT/ET in 1994 with 4 eggs for the GIFT plus a 3ET. Technically, I could have been the “Septomom”, though prior history didn’t make that seem possible. I did get pregnant that cycle but later miscarried that twin pregnancy.
Also back then, my best friend was doing IVF at a clinic upstate. She had elected on medical advice to reduce a triplet pregnancy to a twin pregnancy, but miscarried after the selective reduction. A few years later, she got pregnant with triplets again. She did not reduce and, despite many complications, has healthy 12 year old triplets now.
It’s refreshing to see that technology at some of the finest fertility clinics now enables couples to choose single embryo transfers (SETs) and avoid the expense and potential complications a high order, high risk multiple pregnancy brings.
Dr. Kreiner of East Coast Fertility believes so strongly in the success rates and safety of SETs that his practice offers an amazing financial incentive to patients undergoing traditional IVF. Read on for details:
I entered the field of IVF in 1985 when the pregnancy rate at the Jones Institute, the most successful program in the country, was 15 percent. This rate was achieved by transferring six embryos at a time. As a consequence, we experienced many high order multiple pregnancies. Unfortunately, these were often complicated and did not always end well. Aside from pregnancy and neonatal complications, many of the marriages also suffered.
Thankfully, today IVF is so much more successful and we can attain pregnancies in greater than 60 percent of retrievals for women under 40. These rates are accomplished while transferring one, two, or at most three embryos at a time. Cryopreservation, or freezing embryos, has also improved our pregnancy rates per retrieval giving us multiple opportunities to get a patient to conceive from a single IVF stimulation and retrieval.
In an effort to encourage safer single embryo transfer and avoid risky multiple pregnancies, we introduced a program in 2007 at East Coast Fertility for patients who transferred one embryo at a time. For these patients we offered free cryopreservation, storage and frozen embryo transfers until a live baby was born.
Still, patients don’t commonly choose single embryo transfer.
From our experience, similar to others’, there was no significant difference in pregnancy rates between patients who chose to transfer one embryo vs. those who chose to transfer two embryos. There was a trend, however, towards higher rates for the two-embryo transfer group that was practically eliminated when frozen embryo transfers were added. These groups were age matched with no difference except for a 40 percent twin rate and one triplet in the two-embryo transfer group compared to the single-embryo transfer group in which no twins were created.
It is hoped that these results will encourage a higher percentage of good prognosis patients to transfer a single embryo, which is the safer option.
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Would incentives and stats like those above make you consider SET for yourself? Why or why not?
By Tracey Minella and Melissa H
August 25th, 2011 at 12:00 am
Tagged with coping with infertility, Dr. David Kreiner, East Coast Fertility, Extreme Family-Building Makeover contest, Fertility, Free IVF, Free Micro IVF Contest, infertility help, IVF, IVF Long island, IVF video contest, TTC
The Georgia woman who won a free Micro-IVF cycle from East Coast Fertility on Long Island, New York, last summer dropped Dr. Kreiner an email in May to update him on her beautiful 6 week old miracle baby. She has consented to our sharing her note with you, but we have removed her last name for privacy reasons.
I’ve been saving this note since then to use at just the right time. And the time is now.
She took the time last summer to write an essay. She tucks a little boy in at night now.
What more motivation do you need to try to win this year’s free micro-IVF cycle?
This current contest requires a short video. What better keepsake of your infertility journey could you have, even if you did not win the romantic dinner or the free micro-IVF? The link to the rules is below. You have until this Sunday, August 28th to submit your entry.
Here’s Melissa’s Note:
“On Mon, May 16, 2011 at 1:36 PM, Melissa XXXX <melissaXXXXX@gmail.com> wrote:
Hello Dr. Kreiner!
I just wanted to give you an update on our baby which we conceived from the free MicroIVF cycle you gave us last summer! Leo Sebastien H. will be 6 weeks old tomorrow, and he is doing fantastic! He was born at 39 weeks and was 8 pounds 11 ounces, 21 inches long! He’s already gained more than three pounds and three inches since then. I’m attaching a few photos of him at 2 weeks and one taken in the OR just after he was born. He’s the best baby ever–he’s so alert and easy going. Everyone who meets him is very impressed by him. I just can’t believe our trip to Long Island last summer resulted in such a gorgeous, wonderful baby boy! I can’t thank you enough for your generosity or your expertise in performing the procedure. Thank you so much! David and I are soooo happy.
P.S. I recall you saying that I had the best response to the Clomid/MicroIVF protocol you all had ever seen (I produced several eggs, though we could only retrieve from one ovary. We got 3 eggs from that ovary, but only 1 fertilized–it only took one, luckily!). I was just turning 36 years old at the time. If we were to try for another baby in a year, say summer of 2012, I would be 37 years old going on 38. If my eggs are still good quality then, do you think I might be a suitable candidate for another MicroIVF ? I would really like to come back to you for the procedure, too, since I had such a positive experience at your clinic (as a paying client next time, of course)…”
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Someone…somewhere in the world… is going to be the lucky winner of a free Micro-IVF cycle. Others will win dinner gift certificates. Go charge that camcorder. Now.
Here’s the link to the August 1, 2011 rules post: http://www.eastcoastfertility.com/about/blog/blog-entry/archive/2011/august/article/ecfs-extreme-family-building-makeover-video-contest/?tx_ttnews%5Bday%5D=01&cHash=a6f7a8f9f3d38be671d74bd524251f81
Your baby could be only a 3 minute video away. Enter today.
By Tracey Minella
August 24th, 2011 at 12:00 am
Tagged with earthquake long island, East Coast Fertility, embryo safety, Extreme Family Buiding Makeover Contest, fertility doctor, Free Micro IVF Contest, infertility information, IVF, IVF Long island, TTC
Long Island’s earthquake yesterday came as quite a shock. Of course, technically speaking it was really Virginia’s earthquake, but it shook our little island …and that makes it our quake, too.
Most of us probably haven’t had the ground fall out from under our feet since our infertility diagnoses were delivered. And frankly, that’s all the earth –shaking news anyone should ever have to bear.
Those of us who have kids may have panicked a bit if they weren’t with us when the quake hit. I admit to making a phone call to my daughter’s camp, sorta casually inquiring if the building was still standing. My son was safe with me away from the spinning chandelier.
But what about the embryos???
Images of embryologists John, Maria, and Sharlene diving over Petri dishes, firing up generators, hugging incubators, and throwing their bodies in front of freezers like the secret service agents protecting the president…flashed before my eyes. (Yep, I can be overdramatic.)
So I called the office just to check on the damages… for you guys, of course.
Dr. Kreiner assured me that there were no ill effects from the earthquake. “All eggs, embryos, incubators, freezers and generators are secure”. Then he rolled his eyes and laughed at me. Of course I didn’t actually see him do it, but I know he did.
So I am happy to report that your embryos and eggs are officially earthquake-proofed in the secure hands of East Coast Fertility. Just one more reason to sleep soundly tonight. At least until the after shocks…
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So, where were you when it happened? Did you realize it? Did you think we were under attack like some people in Washington and NYC did? What did you do?
And have you entered our contest to win a romantic dinner or a free micro-IVF cycle yet? You have til 8/28! See the August 1st post for details!
By David Kreiner MD
August 23rd, 2011 at 12:00 am
Tagged with advanced maternal age, David Kreiner MD, diminished ovarian reserve, donor egg, Donor Sperm, East Coast Fertility, Fertility, Infertility, infertility information, IVF, IVF Long island, IVF Over 40, IVF when single, TTC
No knight in shining armor? No Mr. Right? Biological clock pounding in your ear?
Dr. Kreiner of East Coast Fertility helps the single ladies out there who’ve found themselves at a “reproductive crossroads”:
Last week a patient presented to my office with a question that made me feel like I was responding to a Dear Abby letter requesting help to make some crucial life decisions that were related to her reproductive health. As I pondered her query that I had heard so many times before I wondered how terribly nerve racking it must feel like for this woman.
Dear Fertility Doc,
“I am 39 years old, single and I enjoy my career. However, I always dreamed I would have children. Unfortunately, I have not yet met a man that I would feel comfortable with to marry and with whom to have a baby. What should I do?”
At Reproductive Crossroads
The issues that this woman brings up are universal in my practice. She basically has to weigh her desire to have children now rather than delay, using her own eggs or potentially with an egg donor or to adopt. She needs to consider the ramifications of taking time off from her career as well as creating a child with donor sperm. She expressed concern to me that if she were to meet Mister Right how will he respond to this child? Are there any tests that I can perform that can help this woman make a decision?
First of all, it is imperative in cases like this to do a full fertility screen so that we understand from a fertility perspective how much time she has left and how urgent this patient needs to make a decision.
To assess her fertility I do a Day 3 serum Estradiol and FSH, an AntiMullerian Hormone and a sonographic antral follicle count. The FSH is regulated by negative feedback from serum Estradiol and inhibin both of which are produced by the granulosa cells of the ovarian follicles. With diminishing ovarian activity there are fewer follicles, less estradiol and inhibin so with less feedback, the FSH level is high. Occasionally, in patients with low ovarian activity, often called reserve, a patient may have an ovarian cyst that produces estradiol. This will lower the FSH level to otherwise normal activity levels even when there is minimal ovarian activity and inhibin. One would misinterpret the low normal FSH in the presence of higher estradiol which is why this must be measured concurrent with FSH.
AntiMullerian Hormone is also produced by the granulosa cells and low levels therefore indicate depleted ovaries. Likewise, few antral follicles seen on ultrasound typically performed during the early follicular phase of the cycle will indicate low ovarian reserve.
Once we know a patient’s relative fertility through this screen we need to decide whether she is prepared to delay her career for pregnancy and motherhood or should she do IVF and freeze her embryos thereby freezing her fertility potential at the current state.
Since she is single without a participating partner we would be using the sperm from an anonymous donor. The specimens are obtained from sperm banks that are certified by New York State by virtue of their screening and testing for infectious and hereditary diseases. Patients may review what is available from the sperm banks. They can review on the internet the donor’s demographic information, physical attributes, educational and occupational histories, etc for the offered specimens.
If a woman does not have any infertility issues I would attempt donor insemination. However, due to her advanced age, I would progress to more aggressive therapies if we were not successful after a few cycles.
A common concern for women in this circumstance is that they may meet their soul mate in the future and he may not be comfortable with a child produced with someone else’s sperm. This is an issue that is very individual and I can only offer to support the patients as they decide what is best for them.
As she prolongs the decision her fertility is diminishing, and thereby risks not being able to have a child using her own eggs. If conceiving with one’s own eggs is crucial then she must weigh the downside of conceiving a child from an anonymous donor and if she does so, the potential problems associated with finding a man in the future who she may want to have a family with.
It is enormously stressful making these decisions at these reproductive crossroads.
I discuss these issues with my patients and help them arrive at the decision that is right for them.
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Do you go forward with single motherhood, figuring the true Mr. Right would accept this child from your egg and donor sperm? Or do you wait, remain childless, and hope to find Mr. Right only to give up your ability to use your own eggs, having to use donor eggs and his sperm? What would you do?
By Tracey Minella
August 22nd, 2011 at 10:14 am
Tagged with David Kreiner MD, East Coast Fertility, embryo transfer, Fertility, ICLW, infertility contest, infertility information, infertility poetry challenge, IVF, IVF Long island, Reproductive Endocrinologist, starbucks, Tracey Minella, TTC
In honor of National Poet’s Day, East Coast Fertility offers a fun little challenge to everyone stopping by today, whether from ICLW or our regular bloggers…and a fun little reward for your efforts. [Plus don't forget to enter our video contest before 8/28...maybe you will win a romantic dinner OR the free Micro-IVF cycle grand prize! See August 1st post for details! Click here: http://www.eastcoastfertility.com/about/blog/blog-entry/archive/2011/august/article/ecfs-extreme-family-building-makeover-video-contest/?tx_ttnews%5Bday%5D=01&cHash=a6f7a8f9f3d38be671d74bd524251f81]
Infertility can bring out a wide range of emotions in those who suffer from it…mostly frustration and sadness, but sometimes humor. Poetry is the perfect outlet for some of these emotions. We need to vent. We need to laugh.
This poem comes to you on Poet’s Day,
With a challenge and reward coming your way.
Since infertility is close to my heart,
I will give the poem a start.
Continue with four new lines (or even just two);
Or an original poem written by only by you.
You’ve got until Friday, just so you know it,
So don’t even waste a minute.
A Starbucks card for the first ten poets–
But you’ve got to be in it to win it!
Ode to an Embryo
After all the water I had to drink
I felt that my bladder would burst
Now I just lay here, waiting and think
Will it quench my motherhood thirst?
Lying here with legs akimbo
In a welcoming state of mind
Did you stick– or are you in limbo?
Will the fertility gods be kind?
Phew, that’s the heavy, emotional stuff. Or, there’s always the more light-hearted and fun kind of poem. Something like:
Roses are red
Violets are blue
Stick embryos stick
We paid for the glue!
Or something personal directed at your favorite nurse or doctor, like maybe:
I went to a doctor named Kreiner
‘Cause I heard there was nobody finer.
Getting pregnant took years
And a bucket of tears
Then two babies came from my vagi-ner.
Spit out your coffee, did you? Well, okay, maybe that was a tad out there. I’m a blogger, not a poet.
The point is to vent or have a laugh…and earn a Starbucks card. No need to be Emily Dickinson or Robert Frost.
Go on. Post something. You know you have something to say.
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If you are one of the first ten to post a poem, please email your name and address to email@example.com on or before Monday August 29, 2011 in order to claim your gift card.
By Tracey Minella
August 19th, 2011 at 12:00 am
Nearly everyone TTC or doing IVF has heard of their biological clock running out. That phrase refers to the woman’s advancing age, diminished supply and questionable quality of eggs, the rapid approach of menopause, the potential increase in miscarriage and fetal abnormality rates, and the eventual cliff-dive in IVF success stats.
But this week I was reminded of the “other” clock. The more silent clock. Sometimes, the ticking is almost a whisper.
I’m going to call this other clock the “Generational” clock.
The Generational clock is the one that makes you worry that your parents are not going to live long enough to see you have your children. Or maybe not live long enough to become grandparents at all… if you having a baby is their only hope. Or they may have fewer years with your kids because of the infertility delays.
Like the biological clock, the generational clock is tied to your life and your infertility journey, but the generational clock is also tied to your parents’ and in-laws’ lives. That makes it twice as worrisome…twice as likely to blow up in your face.
Mine blew up in 1994 and again in 1996. My parents never became grandparents as I was an only child. My IVF babies were born in 1998 and 2002. Fortunately, my kids have had my wonderful in-laws. They easily give enough love and attention to cover for two sets of grandparents.
This week, my husband’s generational clock exploded with the passing of his dad. I am sad and angry over many aspects of this loss, but mostly that my young children have been deprived of the love of the world’s best grandfather.
He lived long enough to see his other grandchildren graduate college, saw some marry and have children. My oldest would have been 20, not 13, if not for infertility. It’s just not right.
Only one precious grandmother left.
I should stop typing now, so I can plug my ears and drown out the deafening whisper of that ticking…
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Have you feared the loss… or actually experienced the loss… of a parent during the infertility journey? How do you cope?
By David Kreiner, MD
August 18th, 2011 at 12:52 am
Pre-embryo genetic screening (PGS) was developed to help weed out embryos containing inherited metabolic disorders and genetic abnormalities prior to implantation. It was thought that PGS could be used to minimize the risk of miscarriage and perhaps even increase live birth rates in older women IVF undergoing .
We have thus far been disappointed in our results obtained using the FISH technique, the procedure performed for PGS for the past decade and a half. But an alternative new technology that was recently developed makes me very excited about PGS once again: Array Comparative Genomic Hybridization (aCGH).
ACGH is a technique actually applied to detect deficiencies and excesses of genetic material in the chromosomes. DNA from a test sample and a normal reference sample are labeled using colored fluorophores that hybridize to several thousand probes. These probes are created from most of the known genes of the genome and placed on a glass slide.
The differential color of the test compared to the normal sample DNA reflects the amount of DNA in the test specimen. It can pick up monosomies, trisomies or significant deletions on an embryo’s chromosomes.
The first baby born from this procedure was in September 2009 to a 41-year old woman. When aCGH is performed on a Blastocyst biopsy, it is effective in screening out mosaicism (mixed cell lines in the same organism). ACGH is 20 percent more sensitive than the best FISH assays with an error rate of two to four percent. Fifty percent of the embryos tested were normal with pregnancy rates exceeding Blast transfers without aCGH screening.
So, who could benefit from using this new technology?
1. Patients with repeat miscarriages can eliminate up to 90 percent of their miscarriages.
2. Older patients who naturally have a higher percentage of genetically abnormal embryos may now screen for and only transfer their normal embryos.
3. Patients who want to maximize their success with a single embryo transfer.
4. Patients who have experienced repeat implantation failure can be screened for genetically abnormal embryos.
This technology is available for about the same cost as the FISH procedure yet, since it is performed on a Blastocyst, it is safer with less effect on the integrity of the embryo and without significant risk of wrongly identifying abnormal embryos. A concern with FISH is that embryos identified as abnormal can actually result in a normal fetus. This risk is practically eliminated with aCGH and is another reason making it more successful.
I expect PGS will now become a commonly used addition to standard IVF to promote more successful single embryo transfer, improve success in older patients, eliminate miscarriages and treat patients with repeat implantation failure.
We are approaching a new era in IVF. Brace yourselves for a thrilling ride into IVF’s future.