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Archive for the ‘East Coast Fertility’ tag

Infertility Patient Information Seminar! Come on Down!

By Tracey Minella

December 5th, 2011 at 7:38 pm


Oh, this weather! One night it’s freezing. The next day it’s 60 degrees!

And let’s not even get into the holiday shopping frenzy and those long Christmas wish lists from kids on the nasty list! Aren’t you tired of the mall? Bet your wallet is. Oh, and those blasted cookie exchanges…

So how about a change of plans for a Tuesday night?

Instead of standing on a long line to buy a Starbucks card for someone else, why not grab a friend* and come down to ECF and WE’LL give YOU a Starbucks card for yourself?

Can’t get your friends to leave the mall for a night? Well, in that case we’ll still give you riveting, cutting edge fertility information from one of the most respected doctors (and staff) in the reproductive medicine business.

And cookies. That’s right. We’ll give you cookies to snack on… and you don’t even have to bake 8 dozen of your own to get them!

Plus, after you’ve learned everything there is to know about IVF, you can have all your personal questions answered privately right after the speakers wrap up their quick presentations. And the best part is that you don’t even have to be a current patient to come! Just come in off the street. Have an early dinner and come over afterwards. Or swing by after work.

Have you been trying to conceive without success? Maybe suffered one or more miscarriages? Is your day 3 FSH in the stratosphere? Have other programs told you to give up?  Have they said you’re too fat to conceive? Do you need info on grant programs and financing? Would you like to hear of contests where you could win great prizes like restaurant certificates and free or discounted infertility services? If so, you really need to come down and meet the ECF professional team.

Don’t you owe it to yourself to just check it out? When was the last time you could corner a RE and ask all your questions without them politely dashing out? For free.

Come on. We’re waiting for you. And your legitimately interested friend*…who, by the way, can’t be a spouse, partner, parent, child, pregnant neighbor, octogenarian, or octomom. (That would be cheating!)

Seminar begins Tuesday  December 6th at 6:30 pm at:

East Coast Fertility, 245 Newtown Rd., Suite 300, Plainview, New York 11803

We’ll be there ‘til the last question is asked and answered…or we run out of cookies…whichever comes first ;-) Can’t wait to see you.

And to the Long Island IVF patients…what better time to get to know some of us as our practices merge? Come on down!

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Nearly Wordless Wednesday Photo Caption Contest

By Tracey Minella

November 30th, 2011 at 12:00 am


What a dilemma! I always do a “Just for Guys” post on the last blogging day of the month…but I also do Nearly Wordless Wednesday contests on Wednesdays. So today I had to choose between the guys and the photo contest.

Sorry guys. But if you check back tomorrow, I will have a great post just for you men.

Now, on to Nearly Wordless Wednesday.

The winner of last week’s photo caption contest is KittyLili! Congrats!

Remember the Native American Dog and Pilgrim Cat?  KittyLili’s  caption: “Sometimes, two parties need to overlook their differences and come together for the good of the cause…getting table scraps at Thanksgiving!” was purrrfect!

KittyLili, please email your address and the words “11-22-11 Thanksgiving Dog/Cat caption” to Lindsay at lmontello@eastcoastfertility.com to claim your Starbucks gift card.

Ready for this week’s challenge?

Give this photo a caption either below on this blog or on our Facebook page.

Best entry winner gets Starbucks on us! It’s a fast, fun and free contest open to anyone, whether infertile or not, and whether a patient of our practice or not.

Either provide your email address with your entry or check back to see if you won and we’ll tell you how to email us so we can mail you your gift card.

Plus, if you “LIKE” us on Facebook at https://www.facebook.com/ecfertility#!/ecfertility, we may be able to send you the prize as a Starbuck’s Card e-gift right through Facebook, so you could be sipping your winnings as early as on the day we choose the winner! (And as much as we’d love you to like us on Facebook, it is absolutely not required to either enter or win our contests!)

Enter today! Or at least before next Tuesday!

Photo credit: http://www.killmydaynow.com/2011/03/funny-pictures-of-bad-parenting-part-3-58-pics.html/

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We Have a Winner…

By Tracey Minella

November 29th, 2011 at 12:00 am

Sometimes it’s hard to feel thankful when you’re trying to conceive, especially during the holidays.  

Whether you’re suffering from primary or secondary infertility, it hurts when you don’t have the family you dreamed of. Many people fall into depression over the emotional, physical, and financial stress of their family-building situation. And the holidays make it worse. 

So we realize it was hard to ask you to dig deep inside to discover what you are thankful for as a result of your infertility journey. But we’re thankful to those of you who did it…and who shared those feelings with us. We hope you came out of it with a renewed sense of gratitude for something you didn’t have (or didn’t realize you had) before you embarked on your journey.

The winner of the Thankfulness Contest and a $100 Scotto’s Restaurant gift certificate is Jessica for the following entry:

At a baby shower…in the bathroom, praying that no one would hear me cry,
    I was held by a stranger and told I would be prayed for
 
During the moments that I was CERTAIN I was alone, that no one could possibly understand what I was going though….
    I found myself thrust into a community where it was IMPOSSIBLE to go through this alone.
 
On the days that I fell down, and shattered into a thousand jagged pieces…
    I learned a thousand new ways to change the subject.
 
At an appointment where I was sure we’d be told there was “very little hope”,…
    I was assured he would, “do his very best”.
 
After yet another negative pregnancy test, I was convinced that, “it was me…this is MY fault”.
    I was reminded and promised that I would never have to go through this alone.
 
In a time when I felt truly “undeserving”…
    I was shown what it mean to be loved “unconditionally”.
 
Whether you wish for her when you drop a penny into a fountain, or you are singing him a special lullaby each night…..
      It IS good to have an end to journey towards, but it IS the journey that matters in the end.
 
The bumps in our road….the good…the bad… the ugly…- they all proved to me, not only what I am capable of, but what my soul mate, my family, my friends and perfect strangers are capable of.  For that, I am thankful!

Congratulations, Jessica! Please email Lindsay at lmontello@eastcoastfertility.com to collect your prize.

There are more great contests with different prizes coming up soon. And don’t forget our weekly Nearly Wordless Wednesday photo caption contests! Have you entered last week’s NWW photo caption contest yet? You have until tomorrow to do it! Go on and check it out.

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Happy Birthday, Dr. Kreiner!

By Tracey Minella and David Kreiner MD

November 28th, 2011 at 12:00 am

Today is Dr. Kreiner’s birthday. I always remember this day, not because he is my boss, not because he is my friend, but because he was my doctor.

Where would I be if he had not been born?

I might have had children, but they would not have been the exact ones I have now. They would not be the same ages or have come into my life in exactly the same way.

My journey was what it was because Dr. Kreiner was born. He decided to be an RE and to pioneer IVF on Long Island, precisely at the time that I needed him to be there. And there are hundreds, maybe thousands, of other couples who feel like me.

So, in honor of Dr. Kreiner’s birthday, I’m sharing one of his posts about a tender moment Grandpa Kreiner shared with his grandson about the wonderful work he does:

Last night I tucked my grandson Jayden into bed. “Saba,” which is Hebrew for grandfather, Jayden said, “What do you do at work?” I thought back to when I first talked to his dad, my son Dan, about the birds and the bees. Well, I thought, I help those in need make babies but how do I explain this to a three year old?

I need to explain that my patients are suffering, some so severely that it affects their marriage, their jobs and often their health. I’m responsible for alleviating their suffering. I share my compassion for their troubles, hoping I may start to develop a bond with them.

I meet with each couple to try to evaluate the presence of any relationship problems. Sometimes these problems are sexual in nature, often related to difficulties with communication and, unfortunately, sometimes include violent behavior on the part of one or both spouses. Working with a program that employs a highly-trained mental health professional and a mind-body team approach helps alleviate stress, works on relationships and helps improve the health of my patients through nutrition, acupuncture and massage, as well as support groups. A healthier, less stressed patient with proper flow of Qi is more likely to conceive with my most advanced scientific infertility treatments available to man.

So I say to Jayden, “Saba is a doctor who helps people become mommies and daddies.” Jayden was not sure he was satisfied. His face frowned. He shrugged his shoulders and raised his arms, palms turned up. “How Saba?” he asked.

“With G-d’s help and the help of all those good dedicated men and women who work with me in the office,” I replied. With that, I looked at my grandson with all the joy and love a grandparent can feel for his grandchild, to which Jayden added, “Can we play another game of Wii?”

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BE SURE TO CHECK IN TOMORROW FOR THE WINNER OF THE THANKFULNESS CONTEST!

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Thanksgiving Infertility Patient “Open Venting” Session

By Tracey Minella

November 24th, 2011 at 12:00 am

It’s Turkey Day. And today I am giving you permission to vent. (Actually, you can vent anytime in here, but today you are formally invited to let loose if you need to, as the stressful holiday season has commenced.)

Is it early in the day and you’re checking in for your Fertility Daily “fix” before bravely facing the holiday and all the relatives and their nosy questions, unwanted advice, and insensitive comments? (C’mon, humor me!) If so, why not tell me what you’re dreading about today? Who is the big mouth that could wind up with a fork in her neck if she so much as looks at you funny?

Or is it after the festivities and you are emotionally wiped out by, well, all the relatives and their nosy questions, unwanted advice, and insensitive comments? How about sharing whatever upset you? It’ll make you feel better to vent. And besides, who doesn’t love a good fork-in-the-neck story?

Sometimes it’s hard to feel thankful. Especially when you don’t have the family you expected to have by now.

Truth be told, I had my doubts about the response we’d get for our Thankfulness Contest. I remember feeling very depressed and resentful during the holidays when I was doing my seven IVF cycles. Year after miserable year.

I was pretty bitter and completely overlooked anything good in my life…unable to focus on anything at all other than my infertility struggle. My mind was jam-packed with cycle info, drug inventories, numbers of follicles or embryos, hormone levels, and the ever present mental calculation of “if I get pregnant this cycle, the baby will be born in [insert month] and I will be [insert age]”. There was nothing else that mattered. Nothing.

I was concerned that those of you still on your journeys would be unable to look past your own own anger or sadness…your emptiness…and be able to focus on something positive that came out of your infertility journey. I totally understand that feeling. But if you can look deep inside and find something positive among the negative, please enter the contest for a chance to win a romantic dinner.

And if you’re not feeling thankful, then how about sharing right now what it is that you are feeling? Go on. Vent. You will feel better. And everyone here understands.

Photo credit: http://www.publicdomainpictures.net/view-image.php?image=15403&picture=woman-on-fire

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Nearly Wordless Wednesday Photo Caption Contest

By Tracey Minella

November 23rd, 2011 at 12:00 am

In honor of the day before Thanksgiving, we have a Thanksgiving-themed photo for you to caption! But first we have to name last week’s winner.

The winner of last week’s photo caption contest is Lisa Mogel! Congrats!

Remember the Walmart Shopper in a scooter cart, dragging a child along the ground behind her?  Lisa made us laugh with her comment “So glad I snagged the last Cabbage Patch doll!”. A Starbucks gift card will be on its way to you, Lisa. Just please email your address and the words “11-15-11 Walmart Shoppper caption” to Lindsay at lmontello@eastcoastfertility.com to claim your gift card.

Ready for this week’s challenge?

Give this photo a caption either below on this blog or on our Facebook page.

Best entry winner gets Starbucks on us! It’s a fast, fun and free contest open to anyone, whether infertile or not, and whether a patient of our practice or not.

Either provide your email address with your entry or check back to see if you won and we’ll tell you how to email us so we can mail you your gift card.

Plus, if you “LIKE” us on Facebook at https://www.facebook.com/ecfertility#!/ecfertility, we can send you the prize as a Starbuck’s Card e-gift right through Facebook, so you could be sipping your winnings as early as on the day we choose the winner! (And as much as we’d love you to like us on Facebook, it is absolutely not required to either enter or win our contests!)

Enter today!

Photo credit: http://www.coolholidaygraphics.com/thanksgiving/myspace-funny-pictures.php

Plus if you’re in the mood to win, consider entering our Thankfulness Contest. You have until Sunday, November 27, 2011 to enter to win a free $100 restaurant gift certificate! Get the details here: http://www.eastcoastfertility.com/about/blog/blog-entry/archive/2011/november/article/thankfulness-contest-kicks-off-today/?tx_ttnews%5Bday%5D=07&cHash=70e74b10d49a039bfdb5b684dcde9084

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Washing Your Sheets May Help You Conceive

By Tracey Minella and David Kreiner MD

November 22nd, 2011 at 4:26 pm


No, not the laundry, silly. I’m talking about your sheets of cumulus cells. If you want to improve your chances for pregnancy, washing and separating these sheets of cells at the time of your IVF retrieval, and placing them in the dish with your embryos, may be just what the doctor ordered to get your pee stick to come back positive.

This revolutionary procedure is known as co-culture. Unfortunately, many IVF programs do not offer this pregnancy rate-boosting option. Fortunately for you, Long Island IVF and East Coast Fertility do offer co-culture.

Dr. David Kreiner explains the benefits of this exciting and promising weapon in the IVF arsenal:

Successful IVF is dependent on many factors.  The quality of the egg and embryo, the placement of the embryo into the uterus and the environment surrounding implantation are all paramount to the ultimate goal of creating a pregnancy that leads to a live baby.

Typically, patients present with their own gametes so the genetics and pregnancy potential of the eggs and sperm is usually predetermined when patients first present to an IVF program.  As a specialist in REI and IVF, I have dedicated my career to optimizing those other factors that we may influence.

In the late 1990’s I recorded data on all my embryo transfers including distance the catheter tip was placed into the uterine cavity, number of cells and grade of the embryos, difficulty of the transfer, use of tenaculum etc.  I presented my results at the ASRM in 2000 that highlighted the two step transfer to the middle of the uterine cavity and replaced the tenaculum with a cervical suture when needed and this radically improved pregnancy rates.

The uterine environment has been optimized through screening for anatomic issues in the uterine cavity with a hydrosonogram to identify polyps, fibroids and scar tissue that may impede implantation.  Hormonally, we have supplemented patient’s cycles with progesterone through both vaginal and parenteral (intramuscular) administration as well as estrogen that we monitor closely after embryo transfer and make adjustments when deemed helpful.

The greatest improvement in pregnancy rates for the past several years however has been due to a “Culture Revolution” in IVF that is the media environment bathing and feeding the embryos.  All these advances have had a great impact on IVF success rates to the point that 50% of retrievals will result in a pregnancy.  Unfortunately, older patients and some younger ones have yet to share in this success.

Many IVF programs have reintroduced the concept of utilizing a co-culture medium to improve the quality and implantation of embryos. Co-culture is a procedure whereby “helper” cells are grown along with the developing embryo. Today, the most popular cell lines include endometrial cells (from the endometrium, or uterine lining) and cumulus cells from women’s ovaries.  Both cell lines are derived from the patient, thereby eliminating any concerns regarding transmission of viruses. Endometrial cells are much more difficult to obtain and process, while cumulus cells are routinely removed along with the oocytes during IVF retrieval.

Cumulus cells play an important role in the maturation and development of oocytes.  After ovulation cumulus cells normally produce a chemical called Hyaluronan.   Hyaluronan is secreted by many cells of the body and is involved in regulating cell adhesion, growth and development. Recent evidence has shown that Hyaluronan is found normally in the uterus at the time of implantation.

Co-culture of cumulus cells provides an opportunity to detoxify the culture medium that the embryos are growing in and produce growth factors important for cell development.  This may explain why some human embryos can experience improved development with the use of co-culture.

Preparation of co-culture cells starts with separation of the cumulus cells from the oocytes after aspiration of the follicles. These sheets of cells are washed thoroughly and then placed in a solution that permits the sheets to separate into individual cells.  The cells are then washed again and transferred to a culture dish with medium and incubated overnight. During this time individual cells will attach to the culture dish and create junctions between adjoining cells. This communication is important for normal development. The following morning, cells are washed again and all normally fertilized oocytes (embryos) are added to the dish. Embryos are grown with the cumulus cells for a period of three days to achieve maximum benefit.

Performing co-culture of embryos has improved implantation and pregnancy rates above and beyond those seen with the IVF advances previously described. More importantly, it promises to offer advantages for those patients whose previous IVF cycles were unsuccessful.

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Have you tried this yet?

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How Do You Define “Family”?

By Tracey Minella

November 21st, 2011 at 11:05 am

Since we build families every day, it feels right to note that today marks the beginning of National Family Week. It is fittingly placed right around the holiday most closely associated with family…Thanksgiving.

I love Thanksgiving. I love that it is about food, family, and friends. Football featuring the Cowboys and Lions. The Macy’s parade. March of the Wooden Soldiers. No presents or commercialization. No overcrowded places of worship.

Did I mention food and family?

But what is a "family"?

Now I don’t want to give the impression that my holiday is like a Norman Rockwell painting or that my family is like the Cunninghams from Happy Days. We have good times and laughter. And arguments around the table…sometimes started by an insensitive remark by a blow-hard to a hormonal infertile woman.

Every family has a big mouth.

I remember one gathering when we were knowingly TTC and had failed at IVF, and a cousin walked in with her new IVF twins. “The Mouth” remarked: “I’d NEVER spend $10,000.00 to have a baby!” Way to offend two couples at once, loser! She is always good for a jaw dropper. Spending Thanksgiving…or any holiday… with her is as enjoyable as sitting with a wishbone wedged in your throat all night.

I also remember feeling like we weren’t really a “family” because we didn’t have children yet. We were a “couple”. I made a distinction when I shouldn’t have. And in retrospect, that feeling made Thanksgiving harder each year.

I wish someone pointed out to me back then that a couple is a family. I may have rolled my eyes at them, but if they persisted I may have felt better.

So I am telling you now that when a couple comes together to fight infertility, they get a benefit they don’t usually recognize until after their infertility journey is over. They find they’ve built a rock solid foundation upon which to build… as their family grows from a couple to something larger than that. Trust me on that one.

 

Please enter our Thankfulness Contest. Take some time to reflect on what you have to be thankful for as a result of taking this infertility journey…even if you are still waiting. What have you discovered about yourself, your spouse, your inner strength? We’d love to send you and your spouse out for a $100.00 romantic dinner at Scotto’s Restaurant.

Just you two…no big mouths.

Enter today right here: http://www.eastcoastfertility.com/about/blog/blog-entry/archive/2011/november/article/thankfulness-contest-kicks-off-today/?tx_ttnews%5Bday%5D=07&cHash=70e74b10d49a039bfdb5b684dcde9084

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So how do you define “family”?

Photo credit: http://www.publicdomainpictures.net/view-image.php?image=9638&picture=late-19th-century-family

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7 Survival Tips for Holiday Shopping for Others’ Kids

By Tracey Minella

November 18th, 2011 at 2:57 pm

Well, the stores are already decorated for the holidays, it’s only days before we carve the turkeys, and we’re moments away from the annual onslaught of 24/7 Christmas music on the radio.

Do you see visions of sugar plums? Or are you a Bah-Freakin Humbug kind of person? Maybe a little of both?

There’s no right answer to that one, by the way.

The infertility years were so hard for us.  It took real effort sometimes to be the favorite aunt and uncle. But seriously, Christmas lists for the nieces and nephews brought an almost bi-polar response.

On the one hand, we were like two kids ourselves, tackling Toys R Us with reckless abandon… excited to buy these adorable kids the biggest and most wanted toys on their lists. Then the next hormonal minute, I’d dissolve into tears, cursing the long-listed, greedy brats and reaching for whatever toy had the most pieces and would take the longest time to assemble…as if to punish their fertile parents. Talk about Scrooge.

I’d keep telling myself our day would come to buy toys for our own kids as my heart broke over the Easy Bake Oven and Lego set that would not be under our tree. Again.

Here’s Seven Tips to get through the shopping:

  1. Order toys through online shopping sources instead of going into the stores. Most offer free shipping and some even gift wrap for a fee.

  1. Consider a gift card to a favorite store if the child is older and would appreciate one.

  1. If it’s okay with the parent, and would be enjoyable for the child, consider a gift that involves an outing instead of a toy. Maybe you and the child could share a day at a concert, movie, play, circus, or other event? It may be just the “parenting fix” your heart needs. (Of course, if the kid’s a brat, let the mom take him!)

  1. If you are not superstitious, buy a little something to put away for your future baby. Maybe a small stuffed animal, basic baby toy or rattle, or a book. No one says you have to wait until it gets here to start to spoil it. It may make you feel better.

  1. Buy yourself (or your spouse) a little gift. Reward yourself for braving the toy store crowd with your heavy heart. Try a massage for the added benefit of stress reduction.

  1. Donate a toy to a needy child. Toys for Tots and similar programs are all over during the holiday season. Or check with your local place of worship for suggestions.

  1. Blow off the shopping and enter one or more of our contests!!! (Okay, that was cheap of me, but you really should enter our Thankfulness Contest at   http://www.eastcoastfertility.com/about/blog/blog-entry/archive/2011/november/article/thankfulness-contest-kicks-off-today/?tx_ttnews%5Bday%5D=07&cHash=70e74b10d49a039bfdb5b684dcde9084 OR our Nearly Wordless Wednesday photo caption Contest at  http://www.eastcoastfertility.com/about/blog/blog-entry/archive/2011/november/article/nearly-wordless-wednesday-photo-caption-contest-3/?tx_ttnews%5Bday%5D=16&cHash=36a40ab5dbe8a79061d473968ec1dbbe

And remember, and believe, that your day will come. Here’s hoping that Easy Bake Oven will be under the tree in 2012.

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How do you get through it? Do you have any tips for holiday shopping for other people’s children? Will you try any of the above tips this year?

Photo credit: http://www.publicdomainpictures.net/view-image.php?image=10175&picture=christmas-bag

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Embryo Screening for Genetic Defects is Available

By Tracey Minella and David Kreiner MD

November 17th, 2011 at 4:15 pm

When IVF first hit the news with the birth of the first “test tube baby” in 1978, people were amazed, but also skeptical, and even a bit frightened. Conservatives and religious objectors went nuts over the idea of creating life outside the womb.

Today, IVF is almost as common as root canal. It’s not science fiction anymore. In fact, at least 4 of the 29 kids in my daughter’s class are IVF babies. There are still opponents, for sure, but the “shock value” of plain ol’ IVF has passed to a great extent.

Yet, scientific advances in the field of reproductive endocrinology and genetics have brought technology and tools to the table that continues to amaze, and sometimes frighten the general public.

Now, pre-implantation screening exists that may dramatically improve IVF success rates in several different patient scenarios.

Dr. David Kreiner, of Long Island IVF and East Coast Fertility, describes this latest amazing development and how it may help IVF success rates soar. And it is now available to Long Island IVF and ECF’s IVF patients! Read on to see if it could benefit you!

As Dr. Kreiner explains:

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 undergoing IVF .

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 transfers, 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.

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What do you think about PGS?

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