A human embryo
In 2007, PFC took the bold step of changing the way we freeze embryos. Traditionally, embryos are frozen using a �slow-freeze� protocol where they are exposed to weak
concentrations of cryoprotectants before being cooled slowly (-0.3 �C/min) for 2-3 hours. This system has worked well over the years, but recent advances in an ultra-rapid
freezing technology showed great promise. PFC began looking at a technology called vitrification in 2006. After seeing wonderful results from in-house trials we were able to
phase vitrification into our practice in March of 2007. By June, we had stopped slowfreezing completely. In late 2008, after our 200th thawing cycle with vitrified embryos, we examined the data.
From our first 2 years of thaws, we recovered 94% (423/448) of embryos vitrified, and 94% (397/423) of these were alive when the thawing process was completed. The total
number viable was 88% (397/44 8). These numbers compare well to those reported in the scientific literature, but we continue to improve the process and strive for even
better results. Vitrification uses tiny straws called �cryotips� to house the embryos during the process, and uses higher concentrations of cryoprotectants than slowfreezing.
These details make the procedure technically challenging, which may sometimes result in the loss of an embryo. The tiny straws can crack or break due to the
extreme physical force that they endure during freezing and thawing. If this happens, the embryo in the straw cannot be recovered. This lack of recovery or survival is a complication
of any freezing procedure. We continue to go to great lengths to minimize these losses, some of which are unavoidable.
Frozen embryos are stored in liquid nitrogen
We have completed 202 thawing cycles to date (A thawing cycle refers to a treatment cycle wherein a patient returns to use vitrified embryos and we thaw and transfer 1 or more
to her uterus at the same time). Ninety-seven of these 202 cycles (48%) resulted in an established clinical pregnancy. The average number of embryos transferred per cycle was
1.9 and the implantation rate (embryos implanting out of embryos transferred) was 31%.
The vitrification procedure and materials continue to evolve. Irvine Scientific, the company that manufactures the cryotips, continues to improve their product. They are
working extremely hard to eliminate defects that may lead to straw failure during cooling and thawing. At the same time, PFC continues to evaluate new ways to improve embryo survival and implantation rates. This
year, we are investigating a process which artificially collapses blastocysts prior to vitrification. We will also be investigating the use of assisted hatching with thawed
embryos. Be sure to watch these pages for exciting updates in the months to come.
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We never planned nor expected to have twins, but we feel exceptionally fortunate
to have the best of both worlds: a boy and a girl. It was a great hand of luck, which,
minus the infertility part, has been our story from the beginning of this journey.
We knew we wanted kiddos, but like many couples wanting kids nowadays, we thought
we had a good reason to postpone starting a family. Our plans were to travel the world,
come back home and then grow kids. We sold everything we owned, bought two
motorcycles and traveled across 30 countries over the span of three years before returning
to San Francisco. Only later did we discover that infertility would be our issue.
We tried to conceive on our own for a year without luck. When we decided to get
preliminary blood work to help solve our mystery, each test came back normal. Our
prognosis wasn't good: unexplained infertility.
I spent the next three weeks researching our fertility options online�looking at doctors
and clinics, and comparing their success rates and patient reviews. During my
research process, I learned how quickly the chances of having a family were dwindling
for a couple of our age. A 40 year old healthy woman has around a 25% chance of a live
birth through IVF. While a woman over 42 years of age, has a 5% or less chance of
conceiving. I was almost 41 years old.
I felt very good about Pacific Fertility Center as
all five of the doctors were researchers in the field of fertility with exceptional resumes.
Furthermore, as practitioners, they seemed more experienced than most, in working with
women past age 40. I chose the first doctor I spoke with, Doctor Ryan, based on her online
profile. She was straightforward, and took the time to explain our treatment to us both
verbally and visually (drawing out diagrams). She has a rare ability to conduct a professional
yet personal relationship. She is genuinely warm, personable, and interested in her
patients. Pierre and I knew after one meeting that we wanted to work with her.
The injections and the medications became a kind of ritual for us. The experience brought
Pierre and I closer. Of the seven eggs collected, four developed into embryos. On the third day,
all four were transferred and we started to wait, hopeful it would "work". Six weeks later,
late in the evening, I began to bleed and was sure I had miscarried. For the first time I
realized what it meant to me to have a child. I wouldn't let myself believe I had miscarried,
but I also recognized the emotional tail-spin I'd go into if I had in fact lost the pregnancy.
We both must have had the saddest night of our lives. Early the next morning, I went
in for an emergency appointment. The image came up on the ultrasound screen and,
within seconds, the doctor turned to me and exclaimed: "You have twins!" Pierre and I
looked at each other elated. Twins! It was the best fortune imaginable.
Max and Emmanuelle are now 9 months old. We barely remember life before them. They
are healthy, incredibly good-natured babies. Pacific Fertility Center was the best choice
for us, but not entirely based on our (and Dr Ryan's!) success. We knew it was a one-shot
deal and the result, a girl and a boy, could not have been better.
For parents thinking about using IVF, I would recommend setting a limit in the number
of attempts before you begin treatment. Knowing we were with the best doctors
allowed us to approach the procedure in a more relaxed way. Knowing our odds,
however, we did feel like this was our last hope. Now we find it more amusing and
gratifying to find ourselves looking for our own characteristics in our kids. We see Max
and Emmanuelle as little individuals who have been placed into our care, two beautiful
and unique little people whose personas are going to blossom in front of our eyes.
We are incredibly grateful to Dr. Ryan and the team at PFC for allowing us to know the
joy of giving birth. However, we are most grateful to be parents. Above all else, it is
this unconditional love that lasts 18 years and beyond, that really defines parenthood. Even
if your fertility issue doesn�t permit the use of your own genes, know that you still will be a
very loving, loved and fulfilled parent.
--Submitted by Merritt Grooms
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In January, Dr. Carolyn Givens and I attended a meeting in Hawaii organized by the American Board of Bioanalysts (ABB). This organization board certifies and licenses
embryologists, andrologists, and a number of other laboratory specialists in the United States. Our meeting was under the direction of the College of Reproductive Biology, a
special interest group within the ABB and for which I am the immediate past Chair.
The meeting was small and intimate, a situation always welcomed among reproductive biology professionals. The location allowed for good interaction with embryologists from
Japan who have always been a great source of ideas and innovation within our specialty.
In fact, the highlight of the meeting was a series of videos shown by Dr. Yasuyuki Mio from the Mio Fertility Clinic in Yonago, Japan. He
was able to take time-lapse cinematography of human embryos in culture, and as a result reported some novel observations on how oocytes fertilize and how embryos develop. The
actual moment of sperm entry into the oocyte was recorded and it was possible to see that human oocytes form a fertilization cone (a membrane that helps bring the sperm into the
oocyte), shortly after sperm entry. The events that follow (2nd polar body extrusion, which is the egg extruding a set of chromosomes, and pronuclear formation, alignment of the
nuclei from the egg and sperm) occurred as expected, but for the first time the male and the female nuclei could be distinguished from each other.
After fertilization, the embryos were seen to change dramatically as they developed. In particular, they appeared more disorganized and untidy immediately after a cell division
event and more symmetrical and organized several hours later. This discovery has implications for those embryos that sometimes may appear poorly. It suggests that they may
look better later in the day when they are clear of the cell division process. Another important observation regarding blastocysts, is that those that develop 2 inner
cell masses (ICM: the precursor cells of the fetus) do so in a predictable way. At PFC, we avoid using embryos with two ICMs whenever possible, as they are likely to lead to the
formation of identical twins. A normal embryo should have only a single ICM. Currently, it is possible that one of the ICMs may be small enough to avoid detection. The observation
was made that the fine cellular bridges within the embryo cavity appear to correlate to the presence of an extra ICM.
Another notable presentation was that of Dr. Tetsunori Mukaida, of Hiroshima HART Clinic, on sperm morphology. He demonstrated that
observing sperm under ultra-high magnification can show structural defects that are not always visible when using standard microscopes. While magnifying sperm thousands
of times has its difficulties, Dr. Mukaida reported that sperm with subtle physical defects have a much lower chance of making an embryo that can become a baby. Sperm that are
close to perfect in size, shape and structure are difficult to find in any sperm sample and it can take hours just to find a few ideal sperm. However, the extra effort may be worthwhile,
especially in patients that have had a previous IVF cycle where the embryos did not develop well or implant after transfer. PFC is currently looking into this technology and we will report
more details in a future issue of Fertility Flash.
Attending meetings like this and keeping up with the latest developments in our field is an important part of the culture at PFC. We share
the load of traveling to educational events and are always excited to bring home ideas and thoughts to share with our colleagues. PFC is committed to implementing the latest technology
and innovations to maximize pregnancy rates for our patients. We will continue to stay updated with all of the research and development in our specialty.
Joe Conaghan, Ph.D., HCLD is PFC�s laboratory director. Dr. Conaghan is internationally recognized for his work
on improving embryo culture conditions. His interests include developing programs for the treatment of severe male factor
infertility; diagnosis of genetic disease in embryos; and improved embryo culture.
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Carolyn Givens, M.D. was the first in San Francisco to successfully initiate a pregnancy using intracytoplasmic sperm injection (ICSI).
She currently co-directs the Bay Area Pre-Implantation Genetic Diagnosis Program (PGD) and is director of PFC�s PGD program.
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Q: I�m 38 years old and have been trying to get pregnant for about a year. All of my lab tests and my husband�s semen analysis have been normal. What do you think is the problem?
A: For women in their late 30s, it is naturally going to take longer to get pregnant.
They are experiencing what I like to call �age-related sub-fertility.� Some may be lucky
and become pregnant right away. However, for the majority of women, as we age fewer
of the eggs we ovulate are chromosomally normal; and therefore fewer ovulations result
in the release of a normal egg. It just may take more ovulations before that normal egg
is released, fertilized, implants, and succeeds in becoming a baby. It is estimated that about
1 in 5 eggs are normal at age 35, about 1 in 10 at age 40, and only 1 in 25 at age 45. So,
at age 38, if about 1 in 8 eggs are normal, you may have only 1 or 2 chances a year for
successful conception. If your intercourse was not well-timed that cycle or there was
some other subtle inefficiency, the chance for conception may be lost.
The catch-22 with age-related sub-fertility is that it takes longer to get pregnant and
meanwhile, you are getting older and your egg quality is also declining. For this reason,
many women seek treatment with fertility medications or IVF as they get older. These
treatments can increase the number of eggs produced and exposed to sperm in a single
month, thus improving the odds that normal eggs will be found.
The good news is that for most women still in their 30s, fertility treatments for age-related
sub-fertility are often successful.
-- Carolyn Givens, M.D.
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Pacific Fertility Center (PFC) is happy to announce the implementation of its Electronic
Medical Records (EMR) system. After a thorough workflow analysis of PFC�s clinical,
administrative, and billing processes, EMR Manager Christian Marquez, and IT Director
Dave Bjorklund have begun the initial phase of EMR implementation.
PFC�s mission has always focused on providing quality infertility care for its patients, and with
the chosen HIPPA-compliant EMR system, eIVF, that mission will be enhanced. HIPPA is the
system of federal guidelines to protect patient confidentiality and eIVF is the software system
from the company Practice Highway, that is designed for fertility and IVF practices.
Once the EMR system is fully implemented, there will be many benefits for PFC patients.
One example would be the increased efficiency of the medical records department. Currently,
as in many medical offices, each patient has a paper medical chart that is approximately 9 x 12
inches in size and about 1-2 inches thick. All medical reports and clinical notes are filed
within designated sections of the chart. The chart must be located for every patient visit or
telephone call. Many times, the chart may not be in the medical records filing room due to
handling by office staff involved in the care of a patients� treatment. As you can imagine, PFC�s
three file clerks often spend a great deal of time locating charts and transporting them to various
locations within the organization.
With an EMR system, all medical reports and notes normally recorded and stored in a medical chart will soon
be entered or scanned into a computerized database for quick and efficient access by any authorized personnel from any
office location. The software system is designed to be convenient to access by authorized PFC
staff but adequately protected from inappropriate viewing or use by any other individuals.
In the near future, patients will be able to access their medical treatment plan or ask questions
through eIVF�s secure online patient portal, accessed through PFC�s website.
In addition, if authorized by the patient, referral physicians may have online access to the
patient�s medical record.
These types of changes will enhance the patient and doctor relationship, and at the same time improve
productivity and efficiency within the PFC organization. We are excited about this transition to a
paperless medical record. We will keep you informed of our progress.
-- Christian Marquez, EMR Manager
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Free Seminar
Overcoming Infertility:
The Next Step to Parenthood
Ask • Meet • Learn
Led by PFC's Infertility Specialists
Dates:
Wednesday, June 17
Wednesday, July 15
Wednesday, August 19
Location:
Pacific Fertility Center
55 Francisco Street, 5th Floor
San Francisco, CA 94133
Contact:
Please call for reservations,
directions and parking information:
888-834-3095
Sign Up Now
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-- Best regards from all of us at Pacific Fertility Center.
Copyright � 2009 Pacific Fertility Center and Its Licensors. All rights reserved.
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