Embryo Identification, Step by Step with Lab Director of Top Fertility Program

Top Fertility Program Lab Director Answers Questions on Embryo Identification

We know that there are questions that you want to ask when you work with a fertility program. And we know that you are comfortable enough to ask a lot of them. Maybe even most of them. There are a few, though, that you either don't think to ask or just aren't sure how to bring up. None of us want to be that patient. The nutty one. The paranoid one. Rest assured, all of us want to know certain things. 

 

 

We all want to know how we are getting the embryos that were so painstakingly created. We all want to know that we are getting our own embryos. How do we know for sure? Dawn Kelk, PhD, Laboratory Director of Reproductive Medicine Associates answers those questions, today, on PathtoFertility. 

 

The Embryo Question: What We All Want to Know

Here's the question you don't want to ask:  How can I be sure/do I know that these embryos are mine?

 

This question is asked of me not infrequently and don't worry, I don't take offense to it.  I can assure you at RMACT we have multiple, double, triple and even quadruple checks at every stage in our laboratory process.  We pride ourselves on going well beyond the standard of care when handling eggs, sperm and embryos.

 

 

In fact frequently, the lab staff pay closer attention to patient details than the patients themselves.  We ask that you verify and initial a sticker with details of you and your partner's names, last 4 digits of social security number and date of birth. Women are asked to initial a label right before their egg retrieval and men are asked to initial an identical label at the time they produce a fresh semen sample.  Occasionally there may be typos or clerical data entry errors in our computer system when you first register with our program. This may be due to errors communicated from your referring physician or inconsistencies in information on your care card and drivers license.  It is however, very important for the lab to verify and correct your data before we receive your eggs and sperm. 

 

 

We have double checks at every step of the way...

• 1) The woman verifies and initials a label with both her name and partner's name, last 4 digits of SSN and date of birth at time of egg retrieval.
• 2) The partner verifies and initials an identical label when producing a fresh semen sample.
• 3) When the sperm is washed, a second embryologist verifies the sample.
• 4) When the eggs are inseminated, a second embryologist witnesses, verifies and signs off on the eggs and sperm.
• 5) When embryos are frozen, a second embryologist witnesses the culture dish and cryovials, verifies and signs off on the paperwork.
• 6) When embryos are thawed, a second embryologist verifies the cryo vials or straws. The vials are kept until the embryo transfer so that the physician and patient may also verify.
• 7) At the embryo transfer, the patient is asked by the embryologist to identify themselves. The couple can then see the culture dish through a live video link to the microscope in the embryology lab. They verify the label on the culture dish and they can see the embryos being loaded in to the embryo transfer catheter.

 

 

Occasionally we do catch a clerical error at the time of the embryo transfer when we ask the patient to state their name, last 4 digits of social security number and date of birth. That means that one or both partners did not properly verify their information at the beginning of the cycle. When we ask you to verify your information, please check it carefully as it ensures that no mistake is made. Rest assured though, even if there is a clerical mistake, it can be caught and you will not receive the incorrect embryos. That is why we have so many checks in the system, not to be repetitive, but to be completely thorough.

 

 

We need a patient who is using donor sperm to know her donor sperm number. We understand that this is all a lot to remember, but again it ensures complete safety.  Believe me, when you can't or don't verify completely, the laboratory staff does stress out about it and lose sleep.

 

 

If you have questions, we are available to answer them. Standard protocol demands that the lab identify the patient before egg retrieval and embryo transfer. At RMACT, we choose to go beyond through a live video link to the lab; you will identify your name and information on the embryo culture dish and we will give you a close-up look at your actual embryo(s) for transfer. You will see your embryo(s) being loaded into the catheter for your transfer and we will provide you with a photograph of the embryo(s) that we transfer.

 

 

What else would you like to know about the lab? Are there concerns that you have that have not been addressed here?  Feel free to ask and we will do our best to explain and clarify.

 

 

Dawn Kelk, PhD
Laboratory Director 
Reproductive Medicine Associates of Connecticut

 

 

Reproductive Medicine Associates of CT have the following credentials:

Licensed as a Surgery Center by the State of Connecticut

CLIA (Clinical Laboratory Improvements Amendments) accredited

CAP (College of American Pathologists) accredited

AAAHC (Accreditation Association of Ambulatory Healthcare) accredited

AIUM (American Institute for Ultrasound in Medicine)

We are members of SART (Society for Assisted Reproductive Technology), and also submit data to SART and the CDC (Centers for Disease Control)

 

 

 

 

 

 

 

 

The Frozen Embryo Dilemma - What to Do? Let Us Know Your Opinion

What Is Your Opinion on the Frozen Embryo Dilemma?

Infertility often leads to fertility treatment.

 

Fertility treatment leads to stimulating ovaries to creating more eggs (ovum).

 

More successfully retrieved ovum can mean more embryos created. 

 

That's certainly the expectation, even the hope, with fertility treatment. 

 

Here's the next hope and expectation, we get pregnant. That happens a lot. That is the whole point of treatment. That is the best outcome, that a pregnancy has been created.

How Cryopreservation Works

Very often, there are extra embryos and almost always, they are frozen (cryopreserved). This is a method that suspends the growth and division of the embryo. Typically, a woman, prospective parent, or couple will decide that they would like a second and even third or fourth child and those embryos can then be thawed (removed from cryopreservation, warmed gradually and start to grow and divide again) and, with a high level of success, another successful pregnancy can occur. 

 

This is a scenario that happens all over the United States, as well as in many other countries all over the world.

 

I used the word dilemma in the title of today's blog.

 

Here's the dilemma. 

 

When family building is done, what do we do about the frozen embryos?

 

Why is it a dilemma?

 

For some people, it's not. I haven't met too many of those people in over 24 years of being in the field of infertility. 

 

Most of us struggle with what to do with what can be full genetic siblings to our children.

 

There are limited choices. As best I understand them, here they are: 

 

1. Keep them frozen (there are costs associated with this, but there are cases of embryos frozen for over a decade or more)
2. Allow them to thaw and discard them
3. Donate them to another person experiencing infertiilty
4. Donate them for scientific research

 

Those choices seem stark to me. Maybe it's because they are in a numbered list and the number four doesn't seem very high.

 

There really aren't a lot of choices. Four is not a lot of choices. Especially since, for most of us, the choices aren't all that great. Maybe I should say the choices aren't all that comfortable. 

 

Often, choice number one is used because it's a type of non-decision. It's literally freezing time until another decision is made. It's possible to keep embryos frozen forever if you're willing to pay the costs associated. But then what? Someone, at some time, will need to make a decision about what to do about the embryos.

 

That's the dilemma. 

 

What to do about the embryos.

 

It's a very personal choice. Let's start there.

Making Powerful Choices During Fertility Treatment

One of the problems is that while we're in the middle of fertility treatment, there are so many powerful things that we need to consider. Compromises, life changing decisions that we need to make. While the emphasis is on the pregnancy and the baby, what to do with extra embryos often becomes almost always an afterthought. It's not the point. And often, in the middle of fertility treatment, almost everything except becoming pregnant is not the point.

 

And then we become pregnant, maybe more than once. Our families are built. 

 

Hence the frozen embryo dilemma.

 

So, please, share with us. Anonymously if you like. 

 

What are your feelings about frozen embryos? 

 

What would you do?

 

What have you done?

 

What do you wish you had known to ask or consider or think about?

 

 

Egg to Embryo: Path to Fertility

Todays blog is all about what we need. Seeing it, identifying it, holding it close in our hearts, breath, and our dreams. Seeing it clearly and knowing that it's what's necessary, appropriate and even reasonable.

First, let's review the egg to embryo process. An embryo is a multicellular diploid eukaryote in its earliest stage of development, from the time of first cell division until birth, hatching, or germination. In humans, it is called an embryo until about eight weeks after fertilization (i.e. ten weeks LMP), and from then it is instead called a fetus.  The development of the embryo is called embryogenesis. In organisms that reproduce sexually, once a sperm fertilizes an egg cell, the result is a cell called the zygote that has half of the DNA of each of two parents. In plants, animals, and some protists, the zygote will begin to divide by mitosis to produce a multicellular organism. The result of this process is an embryo.
 
So, back to the egg.  One good egg. That's all you need. One. You don't even need a whole good fertility treatment cycle. You just need one viable egg. For that matter, you don't even need one good egg. Just one viable egg to make one viable embryo. Our IVF Lab Director, Dr. Dawn Kelk, will even tell you that they don't always look good even when it turns out that they are good. A day three embryo will sometimes look much better on day four or five.
 
Same thing with dating or buying a house, getting into the right college or finding the right job. You don't expect or need to have eight perfect husbands or homes, etc. You expect and hope for one. The right one. That's all that you need is one. In fact, more is unnecessary and  can even be confusing.
 
So let's go with the one embryo that is viable. That embryo needs to have cells that divide and multiply and therefore grow. It needs to implant in the uterus, find the nourishment that it needs and that is provided there,  and it needs to continue to grow and divide and multiply. Seeing, in the mind's eye, that the uterus is a warm, nourishing organ. A healthy organ, one that is capable and able. Letting your finger tips rest lightly on the lower belly and allow this to be true. Breathing into lower belly and letting the inhale bring in new blood, fresh oxygen and energy, expanding your vision of healthy, capable and able.
 
Healthy capable and able. And with every breath in, you are nourishing and providing for your body in a way that sustains life. Every breath providing just what is needed, perfectly balanced. Every exhale releasing what is not needed and what your body is done with. Our mantra, often in Fertile Yoga, is "Inhale, nourishment, exhale, gratitude". Nourishment with breath is for everything that the breath provides. Gratitude on the exhale for having provided for the body perfectly and lovingly. Inhale, exhale. Nourishment, gratitude.
 
Starting the week off with breath, mindfulness and gratitude. Happy Monday.

Higher Pregnancy Rates with Preimplantation Genetic Screening @ RMA

Higher Pregnancy Rates with Preimplantation Genetic Diagnosis

Reproductive Medicine Associates of Connecticut (RMACT) is among a select group of fertility centers throughout the USA offering this new genetic screening resulting in higher pregnancy rates.

Affiliated doctors at Reproductive Medicine Associates of New Jersey and the Robert Wood Johnson Medical School offered IVF patients under the age of 43 who had had less than one failed prior cycle the opportunity to participate in the randomized trial.  Twenty-eight patients participated in the trial and all received routine IVF care through embryo culture to day five of embryo development.  At that point, patients were randomized with  13 enrolled for PGD with aneuploidy screening (AS) and 15 enrolled as controls.   There was no difference in maternal age between the study patients and the controls.

Prospective Randomized Controlled Trial Demonstrates Preimplantation Genetic Diagnosis with Aneuploidy Screening Increases Pregnancy Rates

The AS patients’ embryos underwent four-hour trophectoderm screening for 24 chromosomes so that only chromosomally normal embryos would be transferred, while control patients had embryo transfer without further intervention.  Clinical pregnancy rates following transfer were significantly higher for AS patients than for controls (92% vs. 60%) and sustained implantation rates for AS patients were also higher than for controls (75% vs. 56%).

Preliminary results suggest that blastocyst biopsy with 24 chromosome aneuploidy screening and fresh embryo transfer may optimize embryo selection and eventually facilitate single embryo transfer.  The researchers are continuing the current study in order to determine whether there are specific groups of patients who may or may not benefit from this technique.

R.T. Scott
O-05  A Prospective Randomized Controlled Trial Demonstrating Significantly Increased Clinical Pregnancy Rates

Read more in the next week or so to learn what this may mean for you on your path to fertility.  

Infertility and the Price of Egg Donation and Embryos- Beyond Money

  This week I'll be offering up different points of view from professionals in the infertility field regarding egg donation. To be very clear, egg donationis not the only controversial issue when it comes to infertility. Far from it, I believe that every step that the medical and scientific community has taken in advancing medical treatment has been met with reactions that vary from awe to horror. Unlike other medical treatments for other diseases, infertility advancement is often met with a lot of resistance.

Unlike other medical treatments, in the business of infertility, we make embryos. Human embryos. And unlike blood, tissue, plasma or a kidney, a human embryo has the possibility of a human life. I believe that is really the crux of the issue. That how we manipulate a cell or a group of cells is relatively uncharged emotionally and ethically. Once, however, those cells hold the possibility of life, it's a whole other story. You all know that there are all sorts of religious arguments against infertility treatment and conception. And yes, the Catholic Church is front and center on that opposition. The Catholic Church does not stand alone, not by any means, however. Many other Christians, Jews, Muslims, Buddhists, and other religions have one objection or another. Some of these objections have nothing to do with the embryo, but how one gets there. That there is intervention at all. Some objections have to do with the interruption of the "natural" process that occurs in conception.

It seems a natural progression, given that I was and will be talking about egg donation, to talk about embryos. In fact the conversation takes a dramatic and more highly charged turn when we discuss embryos. What we currently can do to ensure that embryos are healthy is a landscape that is changing as we speak. How we can manipulate embryos, what the long term outcomes of manipulation are, what to do with embryos that we don't choose to use, and these are all only the most obvious questions.

I know that this is another slippery slope; I seem to be finding them a lot these days. This bears thinking about so that we can make informed decisions. So that we can look ahead before we create embryos to see a final outcome. Given the amount of legislature and proposed legislature out there, it is imperative that we understand our ethical, religious, legal rights and stances. This is not a place to go without thinking deeply. Deciding about embryos is also about listening to your heart and having respect for underlying responses and emotions.

Stay tuned for more this week about these issues, as layers of understanding are uncovered. These are issues that concern all of us, whether you are trying to conceive or not, as they are part of how society sees itself. What we deem to be responsible or moral. I'd like to hear what you have to think, always.

Infertility Laboratory Director Talks About Embryo Safety and ID

Here's the question you don't want to ask:  How can I be sure/do I know that these embryos are mine?

This question is asked of me not infrequently and don't worry, I don't take offense to it.  I can assure you at RMACT we have multiple, double, triple and even quadruple checks at every stage in our laboratory process.  We pride ourselves on going well beyond the standard of care when handling eggs, sperm and embryos.

In fact frequently, the lab staff pay closer attention to patient details than the patients themselves.  We ask that you verify and initial a sticker with details of you and your partner's names, last 4 digits of social security number and date of birth. Women are asked to initial a label right before their egg retrieval and men are asked to initial an identical label at the time they produce a fresh semen sample.  Occasionally there may be typos or clerical data entry errors in our computer system when you first register with our program. This may be due to errors communicated from your referring physician or inconsistencies in information on your care card and drivers license.  It is however, very important for the lab to verify and correct your data before we receive your eggs and sperm. 

We have double checks at every step of the way....

• 1) The woman verifies and initials a label with both her name and partner's name, last 4 digits of SSN and date of birth at time of egg retrieval.
• 2) The partner verifies and initials an identical label when producing a fresh semen sample.
• 3) When the sperm is washed, a second embryologist verifies the sample.
• 4) When the eggs are inseminated, a second embryologist witnesses, verifies and signs off on the eggs and sperm.
• 5) When embryos are frozen, a second embryologist witnesses the culture dish and cryovials, verifies and signs off on the paperwork.
• 6) When embryos are thawed, a second embryologist verifies the cryo vials or straws. The vials are kept until the embryo transfer so that the physician and patient may also verify.
• 7) At the embryo transfer, the patient is asked by the embryologist to identify themselves. The couple can then see the culture dish through a live video link to the microscope in the embryology lab. They verify the label on the culture dish and they can see the embryos being loaded in to the embryo transfer catheter.

Occasionally we do catch a clerical error at the time of the embryo transfer when we ask the patient to state their name, last 4 digits of social security number and date of birth.  That means that one or both partners did not properly verify their information at the beginning of the cycle.  When we ask you to verify your information, please check it carefully as it ensures that no mistake is made. Rest assured though, even if there is a clerical mistake, it can and is caught and you will not receive the incorrect embryos. That is why we have so many checks in the system, not to be repetitive, but to be completely thorough.

We need a patient who is using donor sperm to know her donor sperm number. We understand that this is all a lot to remember, but again it ensures complete safety.  Believe me, when you can't or don't verify completely, the laboratory staff does stress out about it and lose sleep. 

If you have questions, we are available to answer them. Standard protocol demands that the lab identify the patient before egg retrieval and embryo transfer. At RMACT, we choose to go beyond and through live video link to the lab, you will identify your name and information on the embryo culture dish and we will give you a close-up look at your actual embryo(s) for transfer.  You will see your embryo(s) being loaded into the catheter for your transfer and we will provide you with a photograph of the embryo(s) that we transfer.  What else would you like to know about the lab? Are there concerns that you have that have not been addressed here?   Feel free to ask and we will do our best to explain and clarify.

Dawn Kelk, PhD
Laboratory Director
Reproductive Medicine Associates of Connecticut

 

Reproductive Medicine Associates of CT have the following credentials:

Licensed as a Surgery Center by the State of Connecticut

CLIA (Clinical Laboratory Improvements Amendments) accredited

CAP (College of American Pathologists) accredited

AAAHC (Accreditation Association of Ambulatory Healthcare) accredited

AIUM (American Institute for Ultrasound in Medicine)

We are members of SART (Society for Assisted Reproductive Technology), and also submit data to SART and the CDC (Centers for Disease Control)

 

 

 

Fertility Lab Director Has Protocols that Let Her Sleep at Night

  Our laboratory director, at RMACT,  Dawn Kelk, PhD, sometimes tosses and turns at night. How come? Because as tight as her protocols are in the lab, she is always concerned about clerical error, patient error or any other type of error.

I have to tell you, that is my kind of lab director. Relaxed is a really good state of being in a lot of places. The person handling my embryos doesn't need to be that relaxed. She needs to be really, really diligent. And even more than that, she needs to have procedures and protocols in place to catch anyone when for a moment they are not being diligent. That's right, the yoga teacher's into procedures and protocols. Me, I should be relaxed when I teach you, guide you through gentle poses and guided meditation. Dawn, we want diligent. Tomorrow, you will get to hear first hand from her what the procedures are that are followed, every single time.  

Some of us feel like the lab is a big, black hole where our sperm and eggs disappear, someone waves a magic wand and they reappear as embryos. I think while a lot of us understand how the actual procedures work; some of it is an enigma. Lab culture, co-culture, how is an embryo graded, what does the grading mean, how are the embryo's stored. Dr. Kelk is going to start a conversation with you, tomorrow, with the basics of lag procedure. I love it because it's a great way for you to relax, to know that she is on top of how her lab is run, how things are checked, rechecked, triple checked, quadruple checked, and even then sometimes tosses and turns at night, worrying about you.

Great time to ask questions as well, as this is a conversation. We want you to feel comfortable, and yes, relaxed about how your embryos are being handled. So ask away!

Infertility, when it's not about conceiving, but about carrying a baby

Infertility is not always about not being able to get pregnant. Sometimes it's also about not being able to maintain the pregnancy long enough to deliver a baby. Miscarriages are devestating when you are trying to create your family. When more than one miscarriage occurs, we refer to that as "recurrent pregnancy loss". Please read below for further information. Tomorrow's blog will focus on the other, less medical aspects of recurrent pregnancy loss, including the specific ways that you can manage this type of infertility.

Recurrent Pregnancy Loss 

In all women, 15-25% of all clinically-diagnosed pregnancies end in spontaneous miscarriage and recurrent pregnancy loss (RPL) affects 2-4% of reproductive-aged women. The definitions for the diagnosis of RPL are:

• Two consecutive first trimester or early second trimester miscarriages with fetal heartbeats
• One or more second or third trimester miscarriages that are not explained by an obvious correctable source

Recurrent pregnancy loss causes anxiety and fear in couples seeking to build their families after several miscarriages. It is important to note that successful outcomes will occur for more than two-thirds of all couples with RPL, regardless of their reproductive histories.

RPL has many possible causes, but in up to 50% of cases no specific medical cause can be detected. This is termed idiopathic or unexplained RPL. Your physician at RMACT will thoroughly investigate all possible etiologies, including genetic, hormonal, anatomic, immunologic, microbiologic and thrombophillic (blood clotting disorders) causes. These will be explained below.

Unexplained RPL can lead to intense emotions such as frustration, anger, guilt and depression. Often patients blame themselves inappropriately. It is important to keep in mind that these feelings are normal, and there are many resources available in our office to support you personally and emotionally. Patients should be reassured that exercise, sexual intercourse or eating unhealthy foods do not cause miscarriages.

Treatment plans vary by the diagnosis made. Any correctable conditions should be aggressively treated. In those cases where no specific diagnosis can be made, studies have shown that weekly monitoring and support of early pregnancy supplementation of progesterone and estrogen if indicated, can improve the miscarriage rate and empower patients.

Causes of Recurrent Pregnancy Loss

1. Parental genetic causes: In the general population, approximately 1% of people have stable structural abnormalities of their chromosomes. This group of conditions likely does not impact the health of that individual but can lead to the production of abnormal sperm and eggs. These types of abnormalities typically involve having a piece of one chromosome break off and reattach itself to the wrong chromosome and are called translocations.
   
   Studies on couples with translocations have shown a high number of miscarriages. Treatment options for RPL include genetic counseling, early amniocentesis or chrorionic villi sampling (CVS) or the use of donor sperm or eggs. Recent studies have shown that patients with recurrent loss due to genetic factors may benefit from an advanced treatment option called pre-implantation genetic diagnosis (PGD), which involves the biopsy of an embryo derived from IVF (using your own sperm and eggs) to study the chromosomes of that embryo and find the chromosmally normal one. Using this technique, we can select the normal embryos for transfer and increase the implantation rates while decreasing the miscarriage rate.
2. Embryo genetic causes: This is the mostly likely reason for pregnancy loss which is secondary to improper development of the early embryo. This occurs when the normal complement of 46 chromosomes is not present and therefore a healthy child cannot develop. For couples with RPL, chromosomal analysis of the miscarriage itself can provide useful information.
3. Hormonal or systemic causes: Approximately 10% of RPL patients will have a hormonal disorder associated with their losses. This includes untreated hypothyroidism (and possibly hyperthyroidism). Patients with known thyroid disease will need to have their TSH levels followed closely and will likely need to have their doses adjusted during pregnancy. Unrecognized or poorly controlled diabetes, and even pre-diabetes, increases the miscarriage rate. This rate is reduced to a normal level once sugar and insulin control is normalized. Lastly, deficiencies of progesterone, the hormone that supports early pregnancies, can lead to miscarriages. This is sometimes termed luteal phase deficiency. Treatment involves supplementing with progesterone during the first trimester.
4. Anatomic causes: Developmental anomalies of the uterus are called mullerian anomalies. The most common abnormality associated with RPL is the septate uterus, where a fibrous ridge of tissue protrudes into the endometrial cavity, or womb. Removal of this uterine septum by minimally invasive surgery called hysteroscopy has been shown to improve delivery rates. Other mullerian anomalies, such as bicornuate and unicornuate uterus, are associated more with later-trimester losses or preterm birth and are much less amenable to surgical repair.
5. Auto-immune causes: Anti-phospholipid syndrome is a very specific diagnosis with strict diagnostic criteria. It involves your immune system attacking the placenta or placental blood vessels that can lead to miscarriages and poor pregnancy outcomes. Treatment includes blood-thinning injections and low doses of aspirin. Historical treatments with steroids or with infusions of immunoglobulins to treat a suspected or theoretical immune system problem do not have any benefit and have been shown to worsen maternal and fetal outcomes in pregnancy.
6. Infectious causes: There have been some studies in the past that have implicated asymptomatic infections of the uterus with RPL. These may include mycoplasma, ureaplasma, Chlamydia and others, but current data does not support these associations to be a strong cause of RPL.
7. Thrombophillic causes: This class of blood-clotting disorders is called thrombophillias, meaning "love of clotting" in Latin. It is associated with RPL by causing small clots to form in placental blood vessels that impair the full implantation and function of the placenta. Thrombophillias can also cause blood clots anywhere in your body and may have serious health consequences. Blood tests will help your physician diagnose these conditions and formulate a treatment plan.
8. Lifestyle causes: Tobacco use has a detrimental effect on pregnancy outcomes and increases the rate of miscarriage. Smoking greater than 15 cigarettes per day increases the miscarriage rate approximately 1.5 times. Alcohol consumption beyond 10 drinks per week may increase the miscarriage rate by a factor of 2 compared to non-drinkers. Smoking and drinking to excess may worsen the effects of each alone. In addition Obesity has been associated with markedly higher miscarriage rates and poor pregnancy outcomes.

www.asrm.org/Patients/FactSheets/recurrent_preg_loss.pdf

 

Infertility specialists with research data on embryos

 

Keeping up to date with infertility treatment and research news on the internet, I came across several references to research about rocking mice to improve implantation rates.

" (HealthDay News) - Scientists say they boosted the success of in vitro fertilization in mice by gently rocking embryos before implanting them into the womb. "

I know I'm a bit of a nut when it comes to language so it doesn't surprise me when it bothers me when a writer gets it wrong. As in, "implanting them into the womb".

If you have been trying to conceive, been involved in IVF or IUI's at a fertility clinic or involved with a infertility specialist, you know that we transfer embryos, we don't implant them. We wish we could implant them; however this is not something we have control over. At this point, embryologists and physicians can transfer embryos and then support them in every way in implanting. (One day soon, I will write a blog ranting about the language of infertility and how it drives me crazy. I solemnly promise that I will give fair warning about it in case that's a blog you would prefer to miss.)

So getting back to the rocking of mice embryos, evidently the rocking mimics the journey that an embryo experiences moving through the fallopian tube. This is not a huge study, nor a particularly conclusive study; however it is being discussed in many papers and journals as a way to consider boosting pregnancy rates for human beings.

"One of our goals for years now has been to modify how we grow embryos in the lab to be more like how they grow in the human body, because we know that the human body grows them most efficiently," said Gary Smith, associate professor of Obstetrics and Gynecology at the University of Michigan, Ann Arbor. Smith sees this research as a way of looking at boosting implantation rates in human beings, at further encouraging cells to "feel at home".

Anything that we can do to improve implantation rates, an area where many feel that we have the least amount of control is something to look at as seriously as possible. The following is the most important data I read about this particular study:About 77 percent of the rocked mouse embryos led to ongoing pregnancies, compared with 55 percent of the statically-grown embryos and 83 percent of mouse embryos conceived naturally and grown within the oviduct.

So research marches on and we all keep up to date. Sometimes as a patient it feels empowering to read what is going on in research and we feel heartened by the progress and the very close examination of each and every step with infertility. Sometimes it just feels overwhelming.

Nice thing is that you get to choose how much to read, what to read, when and so on. Use that decision making power wisely. When you start to feel overwhelmed, give yourself permission to stop reading. When trying to conceive, breathing deeply is as important as any other fertility technique you will try. And it feels good. 

Pregnancy test positive? Fertility specialist gives advice- A to Z

Once you are pregnant after a period of infertility, I hope you take some time to relax and enjoy.  Oftentimes patients don't give themselves that space and start worrying about what can go wrong in the pregnancy.  It is natural and normal to still feel nervous and worried at this point. You and your Doctor can handle any problems that arise. You will be monitored closely in early pregnancy to make sure everything is progressing.

When you first discover you are pregnant you will have probably done a home urine test.  These tests are very sensitive and accurate turning either positive or negative.  Anyone with infertility knows these sticks too well.  You will be thrilled that you finally got a positive.  This test will be followed up by a quantitative b-hCG (beta sub-unit of the human chorionic gonadotropin protein) blood test.  HCG is produced by cells from the embryo which will become the placenta beginning 10 to 12 days after conception. Maintenance of the embryo in the first trimester of pregnancy requires the production of hCG, which binds to the corpus luteum (cyst of pregnancy) of the ovary. This stimulates the ovary to produce progesterone.  Progesterone is required to maintain the uterine lining in which the embryo grows and develops.  The b-hCG level rises dramatically in early pregnancy.  Your Doctor will get two levels two days apart.  The expected rise between the two days is about 50-60%.  Patients usually have heard that the level should double in two days, but recent literature says that there are plenty of healthy pregnancies that do not increase at that rate.  Your first level which is usually done 14 days after ovulation should be above 30.  If it went up to 60 in two days that is great if it only went up to 45 that can be fine too.  Try not to worry; it is not something you have control of.

Once you get your two levels and a good rise is documented you can breathe a little easier.  In general I tell patients not to tell the "whole" world until you are past 10 weeks, this positive pregnancy test with a good HCG rise is a happy little secret between you and your partner.  Your estrogen and progesterone levels will also be checked along with the hCG level to make sure that it is adequate to support your pregnancy. If it is not adequate enough, your Doctor may order supplementation or increase your dosage of these hormones if you are not already on them.  If your rise was not adequate, your Doctor may get a third level to further follow the early pregnancy.  Remember on the day of your first pregnancy test you are 2 weeks pregnant (embryonic age), but by standard dating criteria (based on the date of your last menstrual period) you are considered to be 4 weeks pregnant (gestational age) at that time. 

The earliest you and your doctor can look for pregnancy on ultrasound is at about 5-6 weeks (gestational age or 3-4 weeks embryonic age).  At that first ultrasound your Doctor will be looking for a gestational sac.  The gestational sac represents a fluid filled area which is usually about 1-2 centimeters in diameter.  It is where the early embryo develops.  Depending on when the scan is done you and your Doctor may see a structure in the gestational sac called the yolk sac.  The yolk sac is visible before the embryo and it represents early embryonic development.  The yolk sac is a small circle seen on ultrasound within the gestational sac.  The yolk sac provides nourishment for the developing embryo.  The presence of a gestational sac confirms that the pregnancy is in your uterus.  In addition the presence of one or two gestational sacs can document implantation of one or two embryos (twins).  Pregnancies which are not in the uterus are called ectopic pregnancies and can be dangerous. We will talk about these below.

One to two weeks later you will have another ultrasound to document the presence of the embryo in the gestational sac.  The embryo will be measured. This measurement is called the crown-rump-length (CRL).   It is hoped that this measurement is within 2-3 days or your expected gestational age (6-8 weeks).  It is at this time when you can see the first sign of a heartbeat.  It is usually just a flicker, but it represents the development of the embryonic heart.  The heart rate is calculated by the ultrasound machine. Heart rates range between 100-140 beats per minute.  This is an amazing thing to see and can be emotional.  It is also very reassuring, as less than 15% of pregnancies that have progressed to this point will end in miscarriage. 

An additional ultrasound is often done one to two weeks later at 8-10 weeks of pregnancy (gestational age).  At this point in time the embryo has usually more than doubled in size and this growth is charted to document proper growth of the embryo.  By this point, the heartbeat can easily be seen and its rate is usually greater than 140 beats per minute.  After this ultrasound, which documents good interval growth, and a normal heart rate, you are usually discharged to your Obstetrician.  Your Obstetrician will usually see you between 10-12 weeks for an intake visit and set up blood tests and an additional ultrasound to screen the embryo for chromosomal disorders such as Down's syndrome. You are usually off all progesterone and estrogen supplementation at ten weeks because the embryo-placental unit now makes enough of these hormones to keep the pregnancy progressing.  Once you get discharged to your Obstetrician you can relax and think positive that this will be a successful pregnancy.

Now we will address some issues and concerns in early pregnancy:

Do you need hormonal supplementation during this part of my pregnancy?

Many patients who get pregnant after fertility treatments are on progesterone and/or estrogen during the early portion of their pregnancy. If you are not on progesterone (or estrogen) it is because it has been determined by blood tests that you do not need it. The progesterone and estrogen that your Doctor gives you are meant to help support your early pregnancy.  They are usually identical formulations made pharmaceutically to supplement a woman's own secretion of progesterone and estrogen.  Progesterone can be given by intramuscular injection, vaginal suppository, gel, or capsule. Estrogen can be given orally, vaginally, or via a patch.  The Food and Drug Administration (FDA) has placed warnings on all reproductive hormones that they should not be used in pregnancy.  The package insert of your medication will say do not take in pregnancy, but this does not apply to you in this early stage of pregnancy.  Some hormones have been associated with complications and birth defects and the pharmaceutical companies have not chosen to obtain FDA approvals.  You should always feel free to talk to your Doctor about any concerns.  No harmful effects to the mother or the fetus are presently known from the prescription of progesterone or estrogen (estradiol) in the first trimester.   By 10-12 weeks of gestational age, embryo-placental unit hormonal supplementation is no longer necessary.

 What if you see bleeding?

If you notice vaginal bleeding, do not panic. About 25-30% of women will experience an episode of spotting or bleeding during the first trimester.  A small amount of staining is not uncommon and even moderate bleeding can be okay.  Most of the time the bleeding is due to the implantation of the embryo and not the sign of an impending miscarriage. As the embryo's blood supply is being established, it is not uncommon to see some bleeding or staining due to the growth of the placenta into the uterine tissue (the placental cells try to find a blood supply for the growing embryo). Sometimes there is enough bleeding that it can even be seen on ultrasound and is called a sub-chorionic hemorrhage.  This means there is bleeding between the chorion (early placenta) and the uterine lining.  If you notice bleeding you should call your Doctors office, lie down, and try to remain calm.  You will probably be instructed to go to your Doctor's office that day or the next for an ultrasound.  Hopefully your Doctor will document that everything is fine.  You may be placed on limited activity to encourage the bleeding to stop.

What are the chances of miscarriage? What happens if my numbers do not increase normally?

Miscarriages are the loss of an early intrauterine pregnancy.  They represent about 15-25% of all initiated pregnancies. There is an increased pregnancy loss rate with increasing age.  Most of these early losses are due to abnormalities of the embryo's chromosomes. Failure of growth of an early gestational sac or embryo or even loss of fetal heart activity after it had been previously documented is considered a clinical pregnancy loss or miscarriage.  Treatments includes D&C (dilation and curettage of the uterus), medication to make the uterus contract and release the pregnancy, or allowing the pregnancy to pass naturally. In general, for women 35 or younger, about 15-20% of pregnancies will end in miscarriage. For women 35-40, about 20-25%, and for women over 40, the risk is greater than 30%.  That still means that 70% of all pregnancies do NOT end in miscarriage. 

During the first few weeks of pregnancy, about 80% of normal pregnancies will show doubling of the hCG levels each 48 hours. If your numbers do not increase normally, there are 3 possibilities: you could have a normal pregnancy that is in the "slowest" 20^th percentile of normal; the pregnancy could be abnormal and in the uterus (a biochemical pregnancy); the pregnancy could be in the fallopian tube (an ectopic pregnancy).

Please review the American college of Obstetricians and Gynecologists (ACOG) pamphlet on this for more information:

http://www.acog.org/publications/patient_education/bp090.cfm

Biochemical pregnancies are pregnancies that implant in the uterus, but do not progress to be seen on ultrasound.  Often these are defined by a very slow rise and eventual decline in the hCG level.  When this occurs it is emotionally traumatic, but there is nothing you or your Doctor can do to change the fate of the pregnancy.   While emotionally traumatic these usually are not dangerous to your health.

Ectopic pregnancies are pregnancies that implant outside the uterus. About 95-97% of them occur in the fallopian tubes. Ectopic pregnancies represent 2-5% of the pregnancies.  Ectopic pregnancies can be treated medically or surgically, depending upon the situation.  If untreated, they can rupture and become a life-threatening condition. Close monitoring by your Doctor of your blood hCG levels and ultrasound is designed to make the diagnosis of an ectopic early to avoid any significant complications.

What should I eat/not eat?

You should eat a well-balanced diet supplemented with the Pre-Natal vitamins prescribed by your physician.  Sensible eating habits, combined with your prenatal vitamins, are sufficient to maintain your pregnancy. The average weight gain during the first trimester is 3-5 lbs. However some women gain more and some women lose weight. The body stores of fat for even most slim women are adequate to sustain an early pregnancy.

Avoid all beverages containing caffeine or alcohol as well as all herbal remedies and/or supplements except those approved by your Doctor. You should also avoid foods made with unpasteurized milk products or raw shellfish.  Sugar substitutes should be avoided as well.

Because of the risk of mercury contamination which can affect the developing fetal nervous system the FDA suggest pregnant women avoid swordfish, tilefish, shark, and mackerel. You should also limit your consumption of other fish including tuna to less than 12 oz per week. Because of the risk of hepatitis or parasitic infection, any uncooked seafood should be avoided including oysters, clams and raw sushi or sashimi.

Please review the ACOG pamphlet on this for more information:

http://www.acog.org/publications/patient_education/bp001.cfm

What about pregnancy symptoms?

First of all everyone is different.  The most common symptom is fatigue.  In addition many women complain of breast tenderness, and nausea.  Contrary to popular belief not everyone has nausea.  If you are experiencing nausea with or without vomiting, remember it is important to stay hydrated by drinking small amounts frequently and to eat small frequent meals. Nausea tends to be worse when you are quite hungry or full and you will need to experiment to see which foods are best tolerated. For many women, bland starchy foods such as crackers, noodles, soup, etc are well tolerated. It may also be helpful to try an acupressure band - these are commonly sold in drug stores for treatment of sea sickness. Some women find ginger (in ginger ale or sold as ginger capsules) to be helpful.  Many women find prenatal vitamins hard to swallow due to the nausea of early pregnancy. In this case, it is acceptable to break the tablets and take part of one at each meal or to switch to a chewable tablet.  If your nausea and/or vomiting are frequent you should talk to your Doctor about the many medications available which help with this problem. 

Please review the ACOG pamphlet on this for more information:

 http://www.acog.org/publications/patient_education/bp126.cfm

 

What about exercise?

I advise refraining from any strenuous physical exercise such as high-impact aerobic, and road running.  The following guidelines for exercise in pregnancy are provided by the American College of Obstetricians and Gynecologists:

• 1. Regular exercise (at least 3 times per week) is preferable to sporadic activity. Competitive activities should be avoided.
• 2. Vigorous exercise should not be performed in hot, humid weather or during illness.
• 3. Strenuous exercise should not exceed 15 minutes. Additionally, exercise should be preceded by a 5 minute muscle warm-up and followed with a cool down period.
• 4. Activities that require jumping or rapid changes in direction should be avoided because of joint instability. Swimming, biking and walking are ideal during pregnancy.
• 5. A pregnant woman's heart rate should not exceed 120 beasts per minute.
• 6. Women should drink fluids before, during and after exercise to prevent dehydration.
• 7. High impact activities should be avoided.
• 8. Activities such as sitting in a hot tub or sauna should be avoided.

Women who have a history of miscarriage, premature labor, multiple pregnancies, vaginal bleeding or heart disease should consult with their physician about exercise during pregnancy.  A woman with a sedentary lifestyle should not begin a fitness program during pregnancy.  If a woman is physically fit, she may be able to tolerate the same level of exercise during pregnancy with only minor modifications.  Talk to your Doctor.

Please review the ACOG pamphlet on this for more information:

http://www.acog.org/publications/patient_education/bp119.cfm

Are there other concerns or recommendations?

You should avoid very long, hot baths or Jacuzzis as there is a theoretical risk of slightly increasing the chance of neural tube defects with prolonged elevations of the core body temperature.

Most of the development of the major organ symptoms occurs during the first trimester. For this reason, we suggest that you avoid hair coloring, or exposure to pesticides or chemicals if possible.

Airline travel is safe; however, if you should experience complications, it may be difficult to arrange for medical care. If you are experiencing pregnancy complications and you must travel, please check with your physician first. Whether driving or flying, it is advisable to walk around every few hours to avoid the formation of clots in the legs.  You may also want to carry extra fluids and foods for snacks.

Toxoplasmosis, a bacterial infection associated with eating undercooked meat and exposure to cat feces, can cause birth defects if acquired during the first 12 weeks of pregnancy.  If you are pregnant, you should not change your cat's litter box.  Food should be handled carefully and always cooked appropriately.  Gardening chores should be performed with gloves.

Many medications are safe in pregnancy, just be sure to tell your pharmacist that your are pregnant and consult with your Doctor prior to taking any over the counter and prescription medications.

In general diagnostic x-rays are safe if your abdomen is shielded.  Lead aprons shield your uterus and your embryo effectively from any significant radiation.  Determining the safety of other types of x-rays during pregnancy is more complicated, but it is clear that diagnostic x-rays rarely pose a threat to the embryo or fetus.  It is usually recommended that elective x-rays be postponed until after delivery.

Some chemical insecticides have been linked to birth defects.  Whenever possible, take the natural approach to pest control.  If your neighborhood is being sprayed, avoid being outdoors as much as possible until the odor has dissipated-about 2 to 3 days

It has been reported that latex paints contain unsafe amounts of mercury.  Federal regulations now require that paints be reformulated so they don't contain mercury.  But because you don't know what hazard may turn up in paint next, painting should be avoided during pregnancy.  While painting is being done, try to arrange to be out of the house.  Make sure there is adequate ventilation.  Completely avoid exposure to paint removers.

Remember that most pregnancies end up healthy and successful.  Don't let your history of infertility ruin the joy of finally being pregnant.  Talk to your Doctor and the Nursing staff at your center and avoid casual advice.  Most of all stay positive and hopeful, and all the best and good luck on your journey.

Mark P. Leondires, MD; Medical Director of Reproductive Medicine Associates of CT