A. PGD = Pre-implantation genetic diagnosis. This test is used to determine if a particular mutation that can lead to a specific disease (e.g. cystic fibrosis) is present in the embryo. This is a diagnostic test designed to detect for a specific disease based on patient's family history.
PGS= Pre-implantation genetic screening. This test is used to screen forgenetic abnormalities found all chromosomes.
PGS 5 test checks for chromosome abnormalities on chromosomes #13, #18, #21, X and Y only. This is recommended for couples who are under 35 years of age or couples that are interested in gender selection.
Disorders related to PGS5 testing can lead to live births with lifelong diseases. This test does not check for abnormalities on other chromosomes. If abnormalities are present on other chromosomes, that embryo has the increased risk of miscarriage/ failure after transfer. An embryo transfer with normal PGS5 result has a pregnancy rate of about 49%.
PGS24 test can detect genetic abnormalities on all autosomes (22) and sex chromosomes (X or Y). This is strongly recommended for any patient who is over the age of 35 with the increased risk of genetic abnormalities in her embryos. It is also considered by many with a history of recurrent pregnancy loss. Any embryo with abnormal PGS 24 test result should not be transferred because it carries high risk of miscarriage and/or fetal abnormalities. An embryo transfer with normal PGS24 test result has > 70% pregnancy rate.
PGS testing has an accuracy rate of 95-98%. We advise patients that even with a normal PGS result there is a small risk of error due to embryo mosaicism. When there is mosaicism, the cells taken from the embryo for chromosome testing may not represent the genetic makeup of the remaining cells in that embryo (either normal or abnormal). In other words, one cell taken from a day 3 8-cell embryo may have genetic abnormalities while the remaining 7 cells are chromosomally normal.
Both PGS-5 and PGS-24 tests are offered in our facilities for $4500 each and each test includes testing for up to 4 embryos.
|Q.||My embryo passed PGS 5 test and Dr. Yelian said my hormone levels and lining were good that cycle, why was I still not able to achieve a pregnancy?|
A. PGS 5 test only checks 5 pairs of chromosomes, not the other 18 pairs, for abnormalities and therefore other untested chromosomes may carry significant genetic abnormalities and may lead to a failed pregnancy or miscarriage. To avoid such a possibility, we recommend nowadays PGS 24 test for future embryos before embryo transfer.
A. Double trigger refers to the use of either two Lupron injections separated by one hour or the combined use of Lupron and HCG injections to trigger the final oocyte maturation process.
Lupron is a synthetic form of GnRH,( gonadotropin releasing hormone), which is produced in the hypothalamus to stimulate anterior pituitary gland to release FSH and LH. In this way, Lupron acts on the pituitary gland to release large amounts of FSH and LH, ensures the final maturation of eggs and triggers the release of eggs. Lupron has a very short half life, lasting only a few hours. HCG is human chorionic gonadotropin and has a chemical structure similar to LH. HCG is normally produced during pregnancy. HCG is comprised of alpha and beta subunits and the beta subunit has a structure similar to that of LH which leads to egg maturation and ovulation. HCG has a much longer half life lasting approximately 3-5 days. Because higher HCG doses are needed for ovulation, HCG carries the risk of cyst formation when used as a triggering agent during an egg retrieval cycle. Dr. Yelian recommends that all patients using HCG as part of double trigger must take the next cycle off due to cyst development. It is also recommended that patients use birth control pills to complete that cycle to reduce the risk of OHSS or cyst formation. If a patient insists on stimulation for the next cycle, she MUST be monitored on CD2 and can only proceed with stimulation if no cysts are found.
A. Typically Estrace is given to improve the lining during the transfer cycle and ideally endometrial lining should be more than 8mm on the day of transfer. However, some women have scar tissues inside the uterus due to prior damage from repeated D&C or fibroid removal. Their lining does not grow properly. In this case, a surrogate may be considered to carry the pregnancy.
On the other hand, endometrial lining that is thickened (more than 15mm) has not been found to be detrimental to pregnancy.
In terms of Estrace use, there are two types of Estrace applications either orally or vaginally. When using one tablet of oral Estrace, the serum estradiol should increase by 150pg/ml. Each additional oral Estrace tablet will further increase estradiol by 100-150 pg/ml. Each vaginal Estrace suppository usually increases serum estradiol by 500pg/ml.
A. Endometrial lining pattern can be homogeneous or trilaminar.
Trilaminar pattern carries a higher chance of pregnancy. Homogeneous pattern has a lower chance of pregnancy, but does not mean pregnancy will not take place.
Typically during the follicular phase, the pattern of the endometrium should not change. However, after ovulation, there is an increase in progesterone level and it is possible for a trilaminar pattern to change into a homogeneous pattern. For this reason, Dr. Yelian strongly recommends patients stop using any herbal supplements during a transfer cycle since supplements may contain small amounts of progestin leading to a homogeneous lining pattern. If progesterone level is above 1.5ng/ml before starting progesterone administration, the transfer cycle must be cancelled.
A. In terms of early cycle monitoring, regardless of ER or ET, CD2 or CD3 monitoring is required in order to determine baseline hormone levels and to formulate medication regimens for the rest of the cycle. Ultimately, our office attempts to minimize monitoring in order to help reduce patient stress levels and costs. Patients are often asked to be monitored on CD 8, 9 or 10 in order to determine which day would be best for the trigger shot. When to trigger a patient is determined based on cycle length and the potential risk of premature ovulation. For example, a patient with short cycle or with diminished ovarian reserve has higher risk of ovulation and thus needs an earlier trigger date.
If a trigger shot is not given, the LH surge is unpredictable and ovulation timing is also unknown, making ovulation easy to miss. We urge patients to be monitored on the recommended dates provided by Dr. Yelian.
A. In general, triggering occurs when the follicle size is at least 15-18mm or when LH has yet to surge. Nevertheless, follicle size is less critical since Lupron will allow the follicle to continue to grow as it releases both FSH and LH.
A. In order for a baby to reach full term delivery, there are numerous steps that have to take place. First, the follicle must grow correctly, with the optimal amounts of hormones to stimulate the follicle into maturation. Ovulation must occur correctly, where the egg is released from the follicle and expelled into the fallopian tube through muscle contraction and eruption of the follicle. The egg is naturally captured by the fallopian tube.
In IVF, the embryos are cultured in medium that mimics the environment of the fallopian tube and this allows the embryos to grow in a healthy, nutrient rich environment. In order to culture to Day 5, typically, the embryo must be free of genetic abnormalities which can halt development or can cause the embryo to die before reaching day 5.
|Q.||Why do IVF patients have such a high rate of subchorionic hemorrhage (SCH) when compared to that of natural pregnancy? What should I do if it does not go away?|
A. There are no published data indicating that IVF pregnancies result in a higher SCH rate than that of traditional conceptions. However, IVF pregnancy requires earlier monitoring than that is in natural conception (week 5 vs. week 10-12), therefore, SCH may have already resolved before the first ultrasound in a natural pregnancy. Most SCHs seen in early OB ultrasound are called echolucent areas that could be either blood or fluid and the majority of SCHs eventually resolve on their own.
In patients with SCH, it is recommended to avoid sexual intercourse as it could cause uterine contractions and increase the size of the hemorrhage. Also, the patient should avoid all strenuous activities and if SCH continues to increase in size, she should be placed on bed rest. If the size of SCH becomes too large, it can lift the placenta off its implantation site and block the communication and transfer of nutrients between the fetus and mother, leading to miscarriage or demise.
Note: If a patient with SCH is taking any medication to reduce or prevent clotting, such as heparin, lovenox or aspirin, she SHOULD STOP taking these medications.
A. Femera is an aromatase inhibitor. It works by blocking the enzyme aromatase which helps convert testosterone to estrogen. By blocking this conversion, it reduces estrogen production. It was originally developed as combination therapy for patients with estrogen receptor positive breast cancers with chemotherapy. When used in IVF or transfer cycles, this is an "off-label" use, meaning it was not developed or approved by FDA for this purposes. In IVF, it can be helpful in reducing the estrogen production, thus stimulates the hypothalamus to produce more GnRH, to stimulate the release of FSH from the pituitary gland.
It is only given for a short period of time to prevent over stimulation or to avoid prolonged non-conversion of estrogen.
In any cycle, if FSH is more than 20-30 IU/L, Femera is usually NOT be used.
A. Life IVF Center recommends and emphasizes single embryo transfer since the human uterus is designed for single gestation. When there is more than one fetus inside, it creates added stress to the uterus, and higher demand for the mother. The uterus can only hold a specific volume; therefore, multiple fetuses will typically be born at an earlier date (preterm labor) and with lower weights (3.5 to 4 pounds or 1600 to 1800 grams). There is also an increased risk of pre-eclampsia or gestational diabetes with multiple gestations.
If multiple embryos are transferred and established, there is a procedure that can be used to reduce the number of gestations in patients with multiple gestations. This is called “selective reduction.” This procedure places ALL fetuses at risk for miscarriage.
A. The endometrial lining should be 8mm or greater on the day of trigger.
A. Life IVF Center would prefer to transfer a Day 5 embryo since this is an early indication of good embryo quality with better chance of survival. Some facilities may believe it is better to culture to day 2 or day 3 and then transfer the embryo with the expectation that embryo will grow better in the uterus. However, this practice is controversial and with limited evidence of pregnancy success. Therefore, we routinely grow the embryo to day 5 utilizing incubators and culture media similar to the best natural environment. Day 2 or Day 3 culture and transfer occurs due to low embryo survivability over several cycles.
1st number represents staging = 3-6
3 – Partially Expanded Cavity
4 – Fully Expanded Cavity
5 – Hatching Embryo
6 – Fully Hatched Embryo
A - Good Fetus Component
B - Fair on Fetus Component
C - Poor of Fetus Component
A – Good on Placenta Component
B – Fair on Placenta Component
C – Poor on Placenta Component
Grading does not detect genetic abnormality. If embryo development is too slow (e.g. a Day 7 embryo resembles a Day 5 embryo in terms of growth and development) then the chance of that embryo survival is reduced and with reduced pregnancy rate. Embryo with delayed growth would not be ideal for a fresh transfer since the embryo and uterus/endometrial lining are not synchronized.
|Q.||Is it better to transfer a day 2 embryo or to thaw it and grow to day 5 blastocyst and then transfer?|
A. If this embryo was from another facility or previously frozen at an earlier date at Life IVF, then the embryo can be evaluated by culturing to day 5 before transferring. If the embryo was cultured originally in another lab or before some of the current revisions in staff and techniques at LIC, the embryo can potentially be cultured to day 5. Our practice has significantly improved on laboratory quality and embryologist working knowledge on embryo development and fragility, therefore, previously frozen D2 embryos could be re-cultured to day 5.
However, if the embryo was already unstable and was frozen at day 2 due to limited viability, then it may not be possible to thaw and culture to day 5; instead the embryo would be transferred on Day 2.
|Q.||This is my 3rd ER cycle. My CD2/3 FSH is always <15, why does Dr. Yelian not prescribe FSH injection and only give me Femera or Clomid?|
It depends on ovarian function and age of the patient. For patients with diminished ovarian reserve (DOR) and less baseline follicles, using Femera or Clomid is a better option for mini stimulation.
A. Tamoxifen is similar to Clomid in function as they both work as selective estrogen receptor modulator. By blocking the estrogen receptors within the body, they stimulate the body to produce more follicles which result in higher circulating estrogen levels. The difference between Clomid and Tamoxifen is the location where estrogen is blocked. It is believed that Tamoxifen may not interfere with the development of the endometrial lining, but research in this area is limited. On occasion, Tamoxifen can be used in a natural cycle and it is typically used late in the cycle (starting CD8 or CD10).
It can also be used during a transfer cycle. However, it is not recommended for longer than 5 days and is used early in the cycle due to potential effects it may have on the embryo after transfer.
A. Limited research suggests that low LH levels during the follicular phase of the cycle could lead to poorer quality embryos when compared to those with normal range LH levels during the follicular growth phase.
In a patient with DOR, it is possible to have a mature follicle by CD2 or CD3 since the FSH level has not dropped during the luteal phase of the previous cycle and continues to stimulate follicular growth. If the patient has very few follicles left, an ER can be attempted. However, frequently those follicles do not contain good quality eggs due to prolonged stimulation.
A. Necon 1/35 = 1mg progestin with 35 ug ethinyl estradiol in each tablet.
Lo Lo Estrin = 10 ug Ethinyl estradiol in each tablet.
Estrace = 2mg estradiol in each tablet.
By supplying the body with exogenous estrogen, it suppresses the hypothalamic production of GnRH and reduces the production of LH and FSH (via negative feed-back). The best combinations of medications to reduce or suppress LH and FSH are those using both progestins and estrogens (e.g. Necon 1/35), which works better than using estradiol alone (e.g. Estrace). However, estradiol alone works better than progestin alone (e.g. provera) to suppress GnRH production. If a patient has FSH>50, it is significantly better to use birth control pills such as Necon, rather than estradiol medication alone in order to most effectively reduce the FSH level.
|Q.||When can a surrogate or regular patient have sexual intercourse after transfer? Does orgasm affect my pregnancy?|
A. The recommendation for sexual intercourse following a transfer for regular patients is to abstain until first pregnancy test. For the first 3-5 days following a transfer, the embryo has not yet implanted into the endometrial lining/uterine wall. During sexual intercourse, uterine contractions can occur and can cause expulsion or the loss of a non-implanted embryo. After the first pregnancy test, it may be necessary to use condoms during sexual intercourse to avoid uterine contractions caused by prostaglandin found in the semen. In general, sexual intercourse is safer after the fetal heart beat is observed on ultrasound.
For a surrogate, it is recommended to abstain from sexual intercourse until after the 10 week graduation date.
For any patient with SCH, sexual intercourse is not allowed until SCH resolves. The uterine contractions induced by intercourse can make SCH worse and increase the risk of miscarriage or fetal demise.
A. No. Sexual intercourse during an egg retrieval cycle will not affect the outcome of the procedure since the egg is captured before ovulation. But if you have many follicles, intercourse might lead to torsion of an already unstable ovary and become a surgical emergency.
A. There is no specific amount of time necessary to wait before traveling. However, it is recommended that patients following transfer to not lift anything heavier than 10 pounds, so assistance will be necessary for any luggage. In terms of flying, for any woman who is pregnant or may become pregnant, the added hormones that are produced by the body can increase the risk of developing deep vein thrombosis (DVT) and it is encouraged that these patients take extra precautions to stretch and walk around during a flight or car ride to prevent this problem. A simple stretch could be to flex the feet, or pointing your toes, and then draw then back towards the shin, and these calf pumps will help prevent DVTs during a long flight.
A. PCOS – Polycystic ovarian syndrome – is often characterized by obesity, increased pigmentation especially in areas such as the neck, armpit, groin and breasts, male like symptoms including deeper voice and increased facial hair or male pattern baldness, and irregular periods. Typically, patients with PCOS have increased testosterone activities and the production of FSH and LH are often reversed during a cycle. Due to hormone irregularity, these patients have irregular or infrequent periods, are hyperandrogenic, and have increased number of follicles in each ovary (>12 follicle in each ovary). There is an increased risk for diabetes mellitus (DM) and the development of endometrial cancer. All patients with PCOS should be tested for DM prior to treatment unless they already have the diagnosis of DM. If a patient does NOT have DM, then metformin is prescribed to help decrease the risk of developing DM, but it does not decrease the risk of miscarriage. If a patient already has DM, then metformin will not be used. Most patients with PCOS will use clomid or Femera in an ER cycle in order to help regulate the length of the period and hormone production. However, Clomid may not be used in an ET cycle due to the side effect of thinning the endometrial lining. Patients with PCOS have an increased risk of ovarian hyperstimulation syndrome (OHSS) and should be monitored closely after triggering.
Unfortunately, PCOS patients also have more eggs due to the lack of regular ovulation. However, the egg quality is diminished since the eggs remain in the ovary for an extended period of time and are considered to be "old eggs".
A small percentage of PCOS patients do not respond to the medication, specifically, Clomid, and the follicle will not develop. In these patients, egg donors might be more appropriate. The reason for the non-response is unknown and cannot be predicted in any patient.
A. In a traditional pregnancy, it would not be expected that you rest for any period of time after conception. Therefore we do not have any requirement for bed rest after the transfer procedure. We encourage you to resume normal activities or even return to work. Please keep in mind that activity should be limited to light exercise and not to lift more than ten pounds. The intent is to minimize uterine contractions during this time. Thus, no sexual intercourse is allowed and patient should avoid any abdominal straining, also known as Valsalva maneuvers. In some patients, the progesterone medication used during the transfer may cause constipation. Dr. Yelian recommends to increase light activity such as walking, drinking more water (8-ounce glass, 6-8 times a day), and drinking plum juice. If a patient still has difficulty with constipation, she may take Colace, a stool softener medication.
A. Although we recommend patients return to normal activities, we would suggest only light exercise such as walking, shopping. It is NOT recommended to lift weights (limit lifting to 10 pounds or less), run, jog or participate in any other strenuous activities which may place additional stress or strain on the abdominal cavity or cause uterine contractions.
A. Have fun! The only restriction on alcohol consumption during a cycle is the embryo transfer cycle. We recommend that alcohol not be consumed beginning on the night of the trigger shot and especially not after the transfer and during pregnancy.
Note: For adult women, moderate drinking is considered to be 1 drink per day or no more than 7 drinks in a week.
A. If Clomid is used during an IVF cycle, the medication can reduce the endometrial lining and create a lighter menses following the cycle.
If a patient is planning to do a transfer cycle following an IVF cycle that utilize clomid, it is recommended that the patient wait one cycle before continuing to a transfer cycle. However, if the patient is planning on another IVF egg retrieval cycle, then there is no need to take one cycle off.
In general, the Clomid dose is based on BMI and personal response. Dr. Yelian believes that less medication is better so most patients will take 25mg or one half tablet of Clomid, unless they have previous poor responses to low doses of Clomid.
A. A patient who does not respond to Clomid and has pre-mature ovulation is typically given a GnRH antagonist medication, either Ganirelix or Cetrotide.
|Q.||Why do I need to take Provera this cycle; Dr. Yelian has never asked me to take that for the previous cycles?|
A. Provera is an exogenous form of progestin and is used in the luteal phase for patients who have infrequent periods in order to mimic the body's natural cycles. Typically, it is prescribed for 10 days following an egg retrieval to help induce menses and to increase regularity. On occasion, it may be used to help suppress ovulation or reduce elevated LH levels during follicular phase.
A. Both HSG and SIS evaluate uterine abnormalities which may prevent successful embryo attachment or pregnancy. HSG must be done by a radiologist and must use radiation and contrast dye to visualize the uterus and fallopian tubes. However, SIS utilizes saline and ultrasound and does not require radiation exposure. SIS is also a procedure that can be performed in our office with immediate results with minimal risk. Therefore, SIS is preferred to HSG and only one is required before a transfer cycle.
|Q.||If the patient is doing oocyte preservation, what is the likelihood of fertilization after oocyte thawing?|
A. With current newer freezing method, there is no known detrimental effect on the fertilization rate after oocyte preservation. Since our freezing method quickly freezes the oocyte, it greatly diminishes the risk of oocyte damage which can occur with slow freezing processes. Our current fertilization rate is 97% with all thawed oocytes.
A. No. If cramping is more intense, it could have something to do with catheter placement during the transfer. If so, it is recommended that in the next transfer cycle, a mock transfer be performed to determine optimal catheter placement. One other reason could be due to increased endometrial thickness during a transfer cycle as this could potentially cause more intense uterine contractions.
|Q.||My ultrasonographer said I have a cyst in my ovary. Should I be concerned? Is it going to affect my ER procedure?|
A. If the cyst is non-functional, meaning it does not produce hormones, such as estrogen, then the cyst will not affect egg retrieval and may not need to be removed. On some occasions, cyst may appear and disappear within the same cycle without any effect on the cycle. However, if the cyst is functional and is producing estrogen, then it may be necessary to trigger ovulation, to rupture the cyst, and then take Lo Loestrin to prevent re-formation of the cyst. The patient can start a new cycle as long as the cyst does not return. If the cyst returns, the doctor may discuss the option of cyst removal in order to help prevent recurrence.
|Q.||I am planning to do an embryo transfer this cycle, but I have fluid in my endometrial lining. How does this affect the transfer? Do I need to cancel this cycle? How do I prevent this in the future?|
A. The actual source or cause of this phenomenon is unknown. However, it is believed that one of the following may be involved: excessive or increased exposure to estrogen, backflow of cervical mucus produced during the cycle, the fluid originating in the fallopian tubes and draining into the uterus, or a disruption in the balance between uterine fluid production and absorption. If the fluid does not dissipate, then the transfer cycle must be cancelled. At this time, it is unclear if this can be a recurrent problem.
A. This problem typically occurs more frequently in younger patients who have multiple follicles and have used large amounts of recombinant FSH, such as Follistin or Gonal-F and HCG used as the trigger agent. This syndrome occurs more frequently in conventional IVF treatments, but is seen rarely in natural cycle IVFs or minimal stimulation IVFs. At our office, we seldom use HCG to trigger a patient; instead, we use Lupron which does not have the same risk as HCG does. Also, we do not use large doses of either FSH or Menopur in our cycles.
OHSS is characterized by abdominal bloating and/or weight gain (more than 10 pounds in 3-5 days), mild/moderate abdominal pain, and in rare cases, decreased urination. If a patient has these symptoms, they should immediately contact the office for diagnosis and management.
A. Cycle day 1, or CD1, is considered the first full flow day of the menses. If the full flow begins before 6PM on that day, then that day is CD1. If it begins after 6PM, then the next day is considered CD1.
A. Sperm sorting is the technique used to enrich sperm gender based on the amount of DNA found in the sperm, assuming that female sperm has more DNA than male sperm. This method of gender selection is not FDA approved and has limited improvement in gender selection rate, which is naturally at 50%. This method will only increase the ability to select gender to 65-70%. However, PGS testing is 97-100% accurate at determine gender. There is a small margin of error in PGS testing due to embryo mosaicism.
A. Generally, a chemical pregnancy is when the pregnancy hormone level (HCG) increases and then suddenly drops. Typically pregnancy hormone levels increase but are much lower than expected, and eventually drop by about week 4 or 5 of gestation. This can happen when the embryo implants into the endometrial lining but does not grow after that, which is typically due to chromosomal abnormalities. Hypothetically, the body can have an immunologic rejection of the embryo, where the body perceives the embryo as a foreign threat and attacks the embryo as a way to rid the body of the threat.
A. More and more evidence suggests that frozen transfer may be more successful in terms of pregnancy rate than that of fresh transfer. The reason could be that it is easier to synchronize the age of the embryo with the timing in the uterus during the cycle with a frozen embryo transfer, especially when embryo development could be faster or slower than normal.
A. ICSI (Intra-Cytoplasmic Sperm Injection) is a process where one single sperm is selected and injected directly into the egg to complete in fertilization. This method greatly increases the rate of fertilization but has been shown, in some studies, that it may slightly increase the risk of congenital anomalies such as polydactyl (extra digits) or heart defects. In terms of birth defect, there is a 0.6% difference in anomaly rate between natural pregnancy and ICSI pregnancy (3.6% vs. 4.2%, respectively). According to this data, the risk of congenital anomaly is minimal when compared to the benefit of significant increase in fertilization rate.