This Chatelaine article delves into new research with regards to timing your egg freezing. The analysis found that women who pursue egg freezing in their early or mid-3os can often retrieve — and preserve — a promising amount of healthy eggs. However, if they start trying to conceive in their late 30s, they’re often able to reproduce without using their frozen eggs — making the cost and labour of egg freezing unnecessary.

On the other hand, the article notes that women who pursue egg freezing in their very late 30s, or early 40s, have a less successful chance of retrieving healthy eggs — which means the expense of egg freezing may not be ultimately worth it.

The study suggests that, in general, the optimal age to freeze your eggs is 37: it’s likely to result in the preservation of healthy eggs, and your odds of actually using those eggs are higher.

However, if you’re considering egg freezing, talk a fertility doctor about whether any individual factors (such as cancer treatments, premature reduction of fertility, etc) should sway that number.

The post When is the optimal age (medically and financially) to freeze my eggs? appeared first on Fertility.ca.

My suspicion is that this comes down to two reasons. Financial, yes, but importantly, emotional: For all of us, the plan was to achieve pregnancy naturally. It is a difficult step to move the act of fertilization into the laboratory.

But, if it has been more than six months of trying naturally together, there are three situations in which IVF may make the most sense:

1. Sperm

Whenever male factor is present, couples may choose to try to maximize sperm quality. This could be done through lifestyle management, through vitamins to maximize sperm quality, through medication such as Clomid to maximize the stimulation of the testes, and through intrauterine insemination to deliver more sperm to the ends of the fallopian tubes.

But none of the above is as effective as doing IVF. This is because with IVF, we can bypass all concerns associated with count, motility, morphology, or obstructions related to previous vasectomy or a congenital absence of the vas. All are treated with a single procedure, by doing intracytoplasmic sperm injection, or ICSI. ICSI places the sperm into the eggs.

It is an extraordinarily effective treatment, as long as the sperm’s DNA can support a healthy embryo.

And so before doing IVF, you might consider getting a karyotype done to confirm normal genetics, and a DNA fragmentation assay of the sperm, if available, to ensure that the DNA being delivered is well packaged and likely to be easily handled by the eggs.

For these reasons, male factor subfertility may often be a serious frustration, but if sperm’s DNA quality can be confirmed, then your expectations for successful IVF can be very high.

2. Tubes

It’s rare that compromised fallopian tubes will be able to be reopened through a cannulation procedure, very rare. The reality is that IVF is a far more successful approach, because it simply bypasses the fallopian tubes. Pregnancy rates can often be superb for a couple facing a situation where eggs and sperm are of good quality, the uterine structure is healthy, and the maternal health is excellent. If it is just a mechanical issue – sperm could not reach the eggs – IVF is a bypass.

As noted, we can try cannulation, or sometimes, if tubes are only partially compromised, we will look to inseminations.

“Partial compromise” can be very difficult to diagnose. Imaging, such as sonohystogram and HSG (hysterosalpingogram) will routinely miss compromised tubes, and the gold standard of investigation – laparoscopy – is highly interventional and invasive. For that reason, we miss fallopian tube compromise with great frequency, and arguably the number one cause for unexplained infertility will prove to be tubal dysfunction. It is for that reason that unexplained infertility is often also well treated through IVF.

A major risk for tubal compromise is low-grade endometriosis, but any source of pelvic scarring, including pelvic inflammatory disease from a previous STD like Chlamydia, a ruptured appendix, or other bowel surgery, all are risk factors for tubal compromise.

3. High quantity of low quality eggs

This situation is more complex. Many couples, particularly when women are over thirty-five years, increasingly worry about egg quality.

On the face of it, IVF would not seem to be all that beneficial; simply placing a sperm inside the egg does not increase its quality. Ninety-three percent of first trimester losses are related to embryo quality, 90% of which come back to egg. So, egg quality is a serious concern in any fertility setting.

The advantage that IVF can provide is this: Numbers. With high-dose fertility drugs, instead of the two to four eggs we will often encourage people to have intercourse or inseminations with, we would be aiming for ten, fifteen or twenty eggs with IVF.

And so it is a numbers game: If egg quality is a concern, and egg quantity is high, then IVF has a superb chance of being more beneficial than any other therapy for the shear advantages that come when ten to twenty eggs are fertilized at a time. It is like one to two years of trying naturally all focused into a single cycle.

And so when is IVF less successful?

Arguably, IVF is less successful when none of the elements above are present: If egg quality is a potential concern, but egg quantity is low, with all other parameters being normal, then IVF is unlikely to be of great benefit. When the issue is related only to uterine structure or implantation, IVF is unlikely to be successful, and if the issue is related to the couple’s overall health, IVF is unlikely to be successful.

IVF, therefore, may be our gold standard of therapy, but it is not for everybody. Still, if any of the three diagnoses above apply to your situation, and it has been a number of months of trying with other means, then IVF may well be considered as a reasonable option.

The post 3 situations where you’ll want to consider IVF appeared first on Fertility.ca.

As physicians, it’s our duty to inform all patients that this is accepted dogma and that there is no minimal dose that is known to be safe and, therefore, no one should use any such substances.

But, speaking to patients who, regardless of the advice above, are going to continue with the lifestyle that they have chosen, we have the following to share.

(And on a personal level, we understand how some people come to those choices. After all, fertility is not something that lasts a couple of weeks, or even a month. It can last six months, twelve months, and longer, and it can be a dramatic and isolating lifestyle change for people to make at a particularly vulnerable time in their lives.)

So, if it comes to harm reduction – if you are looking to minimize stress, knowing that you should really be doing it through going to bed on time, eating better, and exercising in an appropriate fashion – you might also want to have a glass of wine with your friends from time to time.

Please understand we are not talking about excessive drinking or other abuses of alcohol. We all know that alcohol can be used for self-medication purposes. But, it can also be a gentle part of a social lifestyle. Red wine contains resveratrol, part of the antioxidant family that may or may not be beneficial for eggs. So if you are going to have alcohol, perhaps a glass of red wine with friends, as is socially appropriate to your life, would be the best choice.

And what about smoking? It’s true that smoking residues are found in seminal fluid and in the follicular fluid, i.e. the fluid that aids eggs and sperm. What would be an appropriate therapeutic dose? We aren’t sure, but it seems self-evident that if you can minimize smoking as much as possible, you can feel confident that you’ve done all you could at this short time in life to maximize the chances of pregnancy. Once you’re pregnant and delivered, as long as you aren’t smoking around your child, then it’s your decision to make.

We cannot be as calm about marijuana use. It’s very clear that it reduces sperm counts and quality for men, often dramatically. Yes, of course, you all know people who will smoke pot daily and father a pregnancy, but for many men who have average sperm counts, the use of marijuana decreases it substantially.

So, what about eggs? We can’t tell if egg quality changes with the use of marijuana or not. The effects are so profound for sperm that, by extrapolation, we are more worried about pot than cigarettes or alcohol.

And, of course, we cannot advocate for cocaine, MDMA, or other stimulants. We recommend a lifestyle change—perhaps aided by support groups, substance abuse treatment, or therapy, if you’re having a hard time discontinuing use of these substances—if you wish to get pregnant.

The post Smoking, illicit drugs, alcohol and fertility appeared first on Fertility.ca.

Women who are not yet ready to start a family may choose to freeze their eggs to keep the option on the table for longer.

There has been significant promise, but also significant disappointment, with egg freezing to date. The disappointment stems from the relative lack of success rate data. Many more women are freezing eggs than thawing them. And until they are thawed, how do we know how successful the treatment really was?

At first, the data was generally only coming from egg donors, women pre-selected to have eggs that would be expected to succeed. Significantly less data was available for “social” egg freezing, that is, women who are choosing to delay their reproduction and hope to be able to freeze their eggs in time. The majority of our patients were waiting for the latter data sets to come through, as we tried to keep expectations firmly in check.

We are now finally seeing the numbers, and it appears that for most patients egg freezing works as well as embryo freezing, with success rates often in the range of 60% (see this article for more). This published data fit our internal data suggesting clinical pregnancy rates 55-60% per set of eggs for women under 38.

Egg freezing is promising when we have enough good eggs to freeze. If you are under 38 years old (age being a marker for egg quality) and have been told you should be able to freeze 12-20 mature eggs (ie. you have a good ovarian reserve), and are working with a good lab able to offer vitrification, you may anticipate having three or more fertilized egg develop to blastocysts and a reasonable expectation for pregnancy in the future. No, it isn’t perfect – all things being equal frozen eggs do not work as well as fresh eggs – but with good counselling egg freezing may provide some measure of reassurance that had been missing until now.

For a good video that walks you through the process check out this video, or a more detailed scientific review, see this article.

The post New data on non-donor egg freezing success rates! appeared first on Fertility.ca.

The process of assisted hatching refers to procedures done to the zona pellucida. The zona pellucida is the shell that surrounds the egg. Its clearest purpose in nature is to become suddenly hardened once one sperm has entered the egg. This prevents other sperm from entering the egg.

But this hardening of the egg shell can happen at other times too. For some women with egg quality concerns, perhaps women over thirty-seven years, the zona pellucida is hard from the beginning and this otherwise fertile egg will not be able to be fertilized naturally.

Under these circumstances, ICSI (intracytoplasmic sperm injection, the placement of sperm inside the egg) should help. But it still leaves a very hardened zona pellucida behind, and this can cause problems later in development.

By day five of embryo development, there are enough cells within the embryo that it is generally at the “blastocyst” stage, and the embryo attempts to hatch out of the zona pellucida. This generally goes without incident, but if the zona pellucida is too hard and too thick, the hatching may not occur and implantation will be compromised.

Assisted hatching is the process by which, generally on day three of embryo development, the integrity of the zona pellucida is compromised to weaken it to allow for the embryo to hatch more easily later on.

Historically, this was done chemically, but the problem with this approach was that the chemicals could sometimes leach further than the zona pellucida, damaging the embryo itself.

Modern technique is to use a laser, which can be so finely calibrated, that we routinely see no compromise at all. For that reason, assisted hatching can be offered with relative safety, for the downside risks appear to be small. There have been some worries that, even with a laser, there could be some residual damage. What if, for example, the sharpened edges associated with the laser would somehow damage an embryo that is hatching, perhaps severing the embryo in two? Were that to be the case, one would anticipate increased risk of monozygotic twinning (identical twins) associated with assisted hatching. People have looked to this in great detail with no definitive answers.

In our practice, we do see a heightened chance of monozygotic twinning compared to the background rate that might be expected in the general population, but have been unable to ascribe this to assisted hatching (or, in fact, to any particular event that occurs in the lab. It is possible that a subset of fertility patients is simply more at risk of monozygotic twinning than the background population).

It is not just women with egg-quality concerns that it may be beneficial for. For all embryos that are being cryopreserved, the zona pellucida is expected to come out harder than on a fresh embryo. Any couple with these circumstances may benefit from assisted hatching.

Furthermore, assisted hatching is helpful when doing pre-implantation genetic screening; it allows the biopsy catheter to access the cells to be assessed.

Does all of this mean that assisted hatching is right for you? That is a conversation for you and your physician, but assisted hatching is something that we are willing to consider for the majority of our patients at our clinic who are looking to IVF.

The post Assisted Hatching: When is it necessary? appeared first on Fertility.ca.

1. Oocyte (egg) quality

Implantation is more likely to happen when a healthy embryo is present, and the best predictor for a healthy embryo is a healthy egg. Egg quality is based on a number of factors.

2. Sperm quality

We now know that paternally imprinted DNA is disproportionately expressed in developing placental tissue. In other words, sperm quality matters a lot when it comes to implantation. For a successful pregnancy, sperm should have stable, well balanced DNA.

What you can do:

There are many ways that sperm quality can be maximized. Antioxidant vitamins are a popular intervention. We have more on sperm here and here.

3. Embryo quality

Embryo quality is a reflection of both egg and sperm. If you are doing an IVF cycle, embryo quality can be determined by grading systems. The embryos most likely to continue to develop will have 6, 7, or 8 cells by day 3 of development in the lab.

If you are considering a frozen embryo transfer (FET), embryo quality is also a reflection of the laboratory’s freezing-and-thawing success rates. In some labs, FET cycles have a pregnancy rate of one-quarter to one-half that of fresh cycles, but the rates vary by clinic and many of us are now seeing the same (and even higher) success rates with FET. Embryos may be frozen with the traditional slow-freeze protocols, but with the flash-freeze vitrification methods we are seeing better success rates.

Here’s what you can do:

Maximize egg and sperm quality before you start treatments.

Consider a repeat fresh IVF cycle instead of multiple frozen cycles.

4. The number of embryos transferred

There are some suggestions that embryos help each other to implant. In other words, the more embryos that you transfer, the greater the chance that each one will stick.

Be very careful with this one. The movement in our field is away from multiple-embryo-transfer, not towards it, because the risks associated with multiple pregnancy are very real. Some clinics even advocate for elective single embryo transfer. But if there are other impediments to implantation–say, embryo quality is a known concern–then our standard of care is to transfer multiple embryos in the hope that one will take.

We also find we have more success with blastocyst embryos transferred at day 5 rather than morula embryos transferred at day 3.

5. The woman’s overall health

An overall health screen tests many things, and usually includes thyroid function and prolactin levels.

Depending on your situation and family history, you may also be screened for other systemic diseases that can affect implantation. For example, we might look to rule out diabetes, autoimmune conditions such as elevated Natural Killer cells, a pre-disposition to hypercoagulability, markers for celiac disease…and many more.

If you and your immediate family are otherwise healthy, many of these tests are not routinely offered.

Here’s what you can do:

Eat well, exercise moderately, don’t smoke, and continue seeing your family doctor for annual check ups even when under active fertility care. If you have or suspect a specific medical condition, ask your doctor if further testing is warranted.

6. Shape of the uterus and fallopian tubes

Some women have an anterverted uterus, some women have a retroverted uterus. Both are fine: the terms simply refer to which direction your uterus tips. Of more importance, we need to confirm that the uterine cavity is a normal size and shape for implantation to be successful.

To check the structure of your uterine cavity, the gold standard of imaging is a 3-dimensional sonohysterogram. Hysteroscopy (surgery) is used when necessary for things like fundal polyps, impinging or submucosal fibroids, and/or a uterine septum extends 10mm or more.

The shape of your fallopian tubes should be confirmed by ultrasound, a hysterosalpingram, or (less often) surgery. We also screen for chlamydial antibodies, because a history of this infection can affect tubes. We know that dilated tubes (”hydrosalpinges”) may compromise implantation, and sometimes suggest that they’re surgically removed before IVF.

Here’s what you can do:

Make sure that you have all the imaging tests available to you updated before starting your treatments. If your doctor suggests uterine surgery, you may want to get a second opinion. But don’t be too hesitant: the surgery is often a day procedure, and the benefits can be profound.

7. Lining of the uterus

We look at the uterine lining itself, to judge whether or not implantation may be expected. The endometrial lining can be assessed in the following ways:

Appearance on the transvaginal ultrasound

An ideal lining will be at least 7mm thick on day of ovulation trigger (the day your HCG spikes). Ideally, it will also have a “triple line” appearance (an ultrasound finding that shows a good response to estrogen).

After ovulation, the endometrium compresses somewhat, and the triple-line pattern will be less distinct. These are normal findings.

Luteal endometrial biopsy

An endometrial biopsy is not part of every cycle, but it may be done in the luteal phase of a cycle before IVF, in an effort to confirm that the implantation window exists. Various markers for this implantation window have been identified, including histologic appearance and grading, specific findings seen only by electron microscopy, and the staining for various markers that are thought to be associated with implantation.

There are several tests which analyze endometrial biopsy further looking for markers of implantation. This is controversial, as it does not work as well as we would like, but some tests include Harvey Kliman’s Endometrial Function Test, the “E-tegreity Assay” for beta-3 integrin, and sending a biopsy specimen off for culture (this is most useful when intrauterine fluid is collecting and worries about infection persist).

We offer the EFT through our office in partnership with Dr. Kliman.

Here’s what you can do:

When endometrial thickness is low (the lining is never more than 6mm thick), you should talk to your fertility doctor, for management is highly individualized. Many authorities recommend a BMI of >18.5; a healthy lifestyle that involves no smoking and limited caffeine; and ask that you consider red meat to be part of your diet. Supplemental estrogen is regularly used and acupuncture may also be suggested. But again: you should really speak with your doctor.

If you have irregular cycles and a tendency towards a thick lining (>12mm), you might benefit from an endometrial biopsy to rule out hyperplasia.

Even if the EFT is limited, the very act of getting an endometrial biopsy may help with implantation. The proper studies have not yet been done to support this statement, but many smaller ones suggest that implantation may be boosted by as much as 20% in some cases.

8. Embryo transfer technique during IVF

In an IVF cycle, embryo(s) selected for transfer will be collected into about 0.020cc of fluid and inserted into the womb. The process of insertion is highly physician dependent: this means that it matters who does your embryo transfer. The following issues will be considered by your doctor:

(a) Transfer medications like progesterone, antibiotics, and steroids.

(b) Cervical preparation

(c) Use of a tenaculum

(d) Catheter type

(e) Ultrasound guidance

(f) Post transfer instructions

Here’s what you can do:

Work with a doctor and clinic that you really trust. Embryo transfer is very important. Some physicians even suggest doing a mock transfer prior to the IVF cycle itself. It has been our experience that the uterus is lying in a slightly different position every time. In other words, the mock transfer did not help as much as we would have hoped for. We now judge the value of a mock transfer on a case-by-base basis.

9. Luteal Support

We support the luteal (post ovulatory) uterine lining with progesterone whenever we are worried about natural progesterone levels. Progesterone may be taken orally, intramuscularly, vaginally, or rectally. Other medications that you may read about for the luteal phase, and into early pregnancy, include estrogen, ASA, dexamethasone, Fragmin, Lovenox, IVIG, HCG, and others. We are very cautious here: some of these medications have side effects that, in some circumstances, could be of real concern to you or your baby.

Here’s what you can do:

Definitely talk to your doctor. The medications that you take in the luteal phase, and into pregnancy, must be compatible with bringing a healthy child into this world. That said, the ideal balance will keep your endometrial lining stable. If you find that you consistently have your period before the planned pregnancy test day, your luteal support may need to be re-examined.

10. Lifestyle

You need to minimize caffeine, quit smoking, and avoid alcohol. Intercourse during the “two week wait”? We think it’s fine, but I would ask your doctor, as everyone has a different opinion on this subject.

Conclusions

To be successful, your clinic must focus on implantation. Many protocols and techniques are well standardized across fertility clinics, but implantation standards are not. Because of this, there are great differences in implantation success rates across both clinics and doctors. We hope this article will help shed light on some of the complications and what you can do to help achieve a successful implantation.

The post How do I improve my chances for embryo implantation? appeared first on Fertility.ca.

When we retrieve eggs, a lot of them may look good under the microscope, but in fact not be functional. Not every IVF patient is the same but on average it takes four to five eggs to generate one blastocyst.

Blastocysts are the best developed embryos we have in the laboratory and will take five to six days to generate.

Blastocysts are associated with the highest pregnancy rates. Not every blastocyst is genetically balanced.

A blastocyst with the correct number of chromosomes is called “euploid”. For women that are thirty-five, on average 70% of blastocysts will be euploid; for women thirty-six to thirty-eight, it is closer to 50%; and over thirty-eight years, it is closer to 30%. By the time women are over forty-two, it is likely an even lower fraction.

Even euploid embryos may have smaller genetic or other irregularities such that it will be an approximately 80% implantation rate.

Looking at all the numbers above, then, for the average thirty-seven year-old patient, mathematically at least, we can expect pregnancy if there are three blastocysts to be transferred over one to two cycles. To generate three blastocysts, we would like to have generated fifteen eggs.

That is why our goal for IVF is to generate twelve to twenty eggs.

I have seen cases where there were only two eggs, leading to two blastocysts and an ongoing twin pregnancy. If you have a very low ovarian reserve, but every reason to believe you have extraordinarily high-quality eggs, it is reasonable to hope that IVF could work for you.

But for most women, if there are fewer than twelve to twenty eggs being generated through IVF, then there is a lower chance for success based on the math described above.

So why not more than twenty eggs? The answer is that over twenty-two eggs, there may be enough hormonal imbalances that pregnancy rates may start to fall again. With such high numbers, the current community standard is shifting to freezing all embryos and not completing the transfer at all, instead waiting for a future cycle when your hormones are likely to be in better balance.

The post Why do you want 12 to 20 eggs for IVF? Isn’t that a lot? appeared first on Fertility.ca.

It holds great promise for maximizing pregnancy rates. Most IVF failures can be attributed back to embryo quality.

Is PGS right for you? Perhaps, but it’s a highly personal choice. It depends a lot on your circumstances and needs to be explored with your doctor.

PGS is expensive and complicated. Neither of these things are great to hear, of course, but the promise inherent in this level of testing is profound and, for some couples, it can be an extremely beneficial solution.

Why is it so difficult? To understand the science, I recommend starting with www.chromosome-screening.org. The short version is, the process is a part of IVF.

As you know, IVF is when your eggs are retrieved and inside a laboratory introduced to sperm. Some days later, the fertilized eggs are placed back into the womb. Before that happens, PGS can be done.

To do PGS, we remove one or more cells from the embryo. These cells are then analyzed in the laboratory or they’re shipped to an external lab.  We look at the number of chromosomes that those cells carry. The idea is, that the cells accurately represent the embryo about to be implanted.

There are two kinds of lab analysis done on the cells: The laboratory can look for specific and known genetic diseases or can count the number of chromosomes.

Most people choose to count chromosomes. Most people aren’t looking for any specific disease because both partners aren’t predisposed to any diseases that are inheritable. What they’re looking for is to find out if their embryo is going to be of sufficient quality to be consistent with an ongoing pregnancy.

The most common reason that embryos are not healthy is something called aneuploidy – that means the embryo has too many or too few chromosomes. PGS checks to make sure the embryo has the correct number of chromosomes or anything else that would be abnormal or not suitable for transfer.

PGS is not all that new but the techniques involved have been changing over time.

One aspect that has not changed – you will need to do ICSI and assisted hatching as part of the process. ICSI is the placement of the sperm into the eggs, and it is necessary rather than traditional fertilization (where many sperm are placed around the egg), as with traditional fertilization there are going to be extra sperm stuck to the edge of the zona pellucida (egg shell). That means when the biopsy is done, an extra sperm could accidentally come along with the cell and the test will appear to be abnormal when, in fact, the cells were just fine. Doing ICSI, where we place the sperm into the egg, negates that risk.

Assisted hatching is where a laser penetrates the zona pellucida, at least partially in this case, so that the biopsy needle can be placed against the cells for removal.

Before PGS is even started, you are looking at the costs and complications implicit in IVF with ICSI and assisted hatching. But there are other expenses too. Most laboratories will charge a biopsy fee, the lab will also charge a diagnostic fee for the genetic testing and there can be some shipping charges when external labs are used.

Are the added expenses worth it? Well, in select circumstances, absolutely! If the technology can deliver on its promise, I’m willing to guess most of our patients would be more than happy. After all, many couples who have completed IVF without success can become frustrated by the apparent transfer of high-quality embryos into a healthy woman and still no pregnancy.

This happens because many so-called healthy-looking embryos, in fact, are aneuploid. Depending on the age group, only 30%-70% of apparently healthy, day-five embryos are, in fact, normal (and the ratio is even less for day-three embryos). Any technique that allows us to find the best embryo could be highly advantageous.

Historically, we have looked at cell number and the relative fragmentation of embryos to guess at an embryo most likely to be consistent with ongoing pregnancy. In more recent years, many labs strongly favour growing embryos to the blastocyst stage, which is five days of growth in the lab, to further differentiate the best-growing embryos. Finally, some laboratories are using “embryo scopes”, camera systems to allow constant visualization of the developing embryo. Huge amounts of data are being generated with such techniques, though it is difficult to say, of all this data, which of it is actually useful to predict who is going to have a baby.

And there’s the appeal of PGS: It gets right to the heart of the matter as we confirm whether or not there are the right number of chromosomes to be consistent with an ongoing pregnancy.

It is not that a euploid embryo is guaranteed to result in pregnancy, but some labs are reporting pregnancy rates in the range of 80% when euploid embryos are transferred. So, this is not a guarantee, but a far higher pregnancy rate than any other therapeutic approach to date.

But of note, I also mention the technical complications.

The chief amongst the complications are this: The biopsy and embryo manipulation.

Does the biopsy harm embryos? It may: There are some data suggesting embryos biopsied on day three do not fare as well as those biopsied on day five. Like any ongoing scientific processes, there remains debate on this point, but at this time, based on what information is available right now, I believe day-five biopsy makes the most sense. I may have to change my mind again in the future, the subject really is changing that quickly!

Though the day-five biopsy appears to be safe – cells are taken from the outer trophectoderm (cells that will eventually become the placenta) rather than from the inner cell mass (cells that will become the baby) – the challenge is deciding how best to handle the embryo from that point forward. There is going to be, after all, a waiting period while we look to the results of the PGS. This can be as short as twenty-four hours, or up to a week, depending on how the technique is done; but it necessitates for a day-five biopsy, either day six embryo transfer, or a freeze-all technique. Freeze-all meaning the embryos are frozen to be transferred in a future cycle (this will also add to the expense).

So, which is better? A day-six transfer or vitrification and transfer on a future cycle? I favour the latter, but again, this is lab dependent and you can get various opinions depending on which clinicians you speak to and the latest paper on the subject.

Lastly: The results that come from the laboratories regarding PGS are not always as reliable as we would like. There are some reports of embryos being retested and having completely different results than they did the first time around. Could this happen to you? Well, yes, it could and it is partly a limitation of the nature of the process: We are biopsying so few cells. This has to be contrasted with an amniocentesis, for example, done at sixteen weeks of pregnancy when literally hundreds of cells could be tested at a single time. It is much more accurate and you will find that even as PGS purportedly can rule out, for example Down’s Syndrome, you will be asked to have a definitive test later in pregnancy, regardless. PGS cannot be and is not definitive.

I like to write articles that discuss complicated subjects in transparent and easy-to-understand ways. PGS is a topic that is changing, at the information becomes more settled, I will continue to post information that I feel will be useful to a wider population.

At this time, the best I can say is that an educated conversation with your clinician is going to provide you the best sense for whether PGS is going to be helpful to you. That said, if you do not have confidence that you can generate a good number of blastocysts that PGS probably is not going to be helpful. After all, it is a sorting mechanism, and if you only have one or two embryos for transfer, sorting is not required. Careful transfer of your embryos may be all that is necessary.

The post Will pre-implantation genetic screening improve my IVF chances? appeared first on Fertility.ca.

Not everybody needs IVF. Many patients may benefit from intrauterine inseminations.

IUI, where sperm is washed and placed high within the womb, can address a variety of concerns including:

• concerns around cervical mucus or scarring after a LEEP procedure
• erection concerns
• difficulty timing intercourse (perhaps due to work, or irregularity of ovulation)
• unexplained infertility
• donor sperm
• financial: And understanding that IVF may be “better”, but it is also much more expensive and invasive, and a hoped for success through a trial of inseminations

As you can see, there’s a wide variety of reasons why people may choose IUI, so success rates vary greatly from less than 5% to over 20% per cycle. You would really need to speak with your clinical team to understand what the odds of inseminations may be like for you.

It can be difficult to make sense of these wide-ranging numbers. Specific questions of what approach will maximize pregnancy rate can be actually quite tricky to answer. Here are two:

1. Should we always trigger ovulation?

One of the advantages of inseminations is we should be able to get the timing exactly right.

But for the timing to be “exactly right” we want to be able to place the sperm before the egg is released. We say a released egg is viable for twenty-four hours but we know from watching eggs in the lab that they are really optimized in their first six hours upon release.

Sperm, while functional for up to five days, is almost always very functional for the first twenty-four hours. That means we want to place the sperm into the womb before the egg is released, ideally the day before, so that they will be available when the egg is available.

The challenge with placing it the day before, however, is that while we are organizing for the insemination, we don’t actually know if the egg is going to be released on time.

To ensure the egg is ready on time, we often encourage using a “trigger shot”. This is an HCG hormone. It is actually a pregnancy hormone – and after a trigger shot, if you did a home test, it would suggest that you were pregnant. We use HCG because it is almost exactly the same structure as LH, the natural hormone that releases eggs. By taking the HCG shot, you can ensure yourself and us that the timing of the insemination will be ideal.

Different clinics will have different approaches. And it’s important to make note, it hasn’t been proven that HCG shots improve pregnancy rates.

2. Should you do one or two intrauterine inseminations?

The worry is that the timing of the insemination may not have been perfect. For that reason, it may be helpful to do inseminations two days in a row. If one insemination is too early (or the other is too late), at least one of them will be ideally timed. So is it worth doing IUIs two days in a row?

You can discuss this with your clinic. Pregnancy rates that peak at 30% are frustrating: It means that 70% of patients at least won’t succeed with their insemination cycle.

At my clinic, we do the double IUIs as our standard of care, not because we know that it increases pregnancy rates – we can’t know that – but because we are certain that it helps to minimize the stress of all involved. Everybody needs to be able to look back on the IUI and know that it was done in the best possible way.

Having said that, when it comes to donor sperm, which is so much more expensive, we generally encourage a single insemination. Clearly, every clinic is going to have a different opinion on this approach.

As long as you find a clinic and solution that minimizes your stress and maximizes your comfort level, then you have the best approach that fits you.

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There’s been an increase in talk about the role vitamin D plays in our health. Vitamin D has been linked to a variety of autoimmune diseases and cancers (breast and colorectal).

Recent studies suggest that vitamin D may play a role in fertility. It may be important for egg quality or play a role in embryo implantation. Right now, we just don’t know how it impacts fertility and further studies are needed.

Infertility is a common problem affecting 10-15% of Canadian couples. In our study of 173 Canadian IVF patients, we found that women with higher vitamin D levels were more likely to achieve pregnancy following in vitro fertilization.

Vitamin D is a fat-soluble prohormone that your body gets from exposure to sunlight, from foods rich in vitamin D or by taking supplements. People living in countries at higher latitudes, such as the US and Canada, are more prone to vitamin D insufficiency.

Women with higher body mass indexes (BMI), especially a BMI of 40 or higher, were more likely to have deficient levels of vitamin D.

We found a 55% prevalence of vitamin D insufficiency in their reproductive age infertility population. Clearly, women are not getting enough vitamin D from their diet, sunlight exposure or supplementation.

What we do know is that women with sufficient vitamin D levels had significantly higher pregnancy rates per cycle start (52.5%) compared with insufficient or deficient women (35%).

More studies are needed to find out whether vitamin D supplementation can improve pregnancy rates. Women experiencing infertility should speak with their healthcare provider for more information regarding the possible link between vitamin D and infertility.

Making sure you have all the vitamins and nutrients your body needs to function properly is an important part of taking care of your overall health!

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