Infertility eNews, Spring 2013

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It’s Twins! Two New Technologies Help Create a Family

New parents Caroline and Ed Marks are doubly thankful. In December 2012, they welcomed identical twin daughters Charlotte and Claire.

At two months, the girls slept through the night and started to smile. They’re in the 50th percentile on growth charts. Mom and Dad couldn’t be prouder.

But it’s another duo that has everyone, including local and national media, talking about the Marks family. Caroline and Ed were the first patients at Cleveland Clinic’s Fertility Center to use two technologies — an enhanced version of preimplantation genetic screening (PGS) and EmbryoScope® time-lapse system — which facilitated the successful pregnancy.

“We would not be where we are now without both of those technologies,” says Caroline.

Preimplantation Genetic Screening

Caroline and Ed had been trying to have a family, and had one round of in vitro fertilization (IVF), without success. Because a genetic test revealed that Ed had a chromosomal defect, the Markses were perfect candidates for PGS, an advanced genetic test to identify embryos that are chromosomally normal. Transferring only normal embryos increases a patient’s odds for pregnancy with a healthy baby.

For a typical genetic test, a single cell is removed from the embryo on Day Three and sent for analysis. But with a new PGS technique known as trophectoderm biopsy, five to seven cells are removed from the embryo on Day Five, at the blastocyst stage. The trophectoderm cells are excised from the blastocyst with a laser. Older versions of PGS involved excision of a single cell, and screening for only nine chromosomes. Trophectoderm biopsy, applied for the first time in the Marks case, screened for 24 chromosomes.

“PGS, especially trophectoderm biopsy, provides a more accurate analysis, especially for patients who need to screen for inherited genetic disorders and chromosomal abnormalities,” says IVF Laboratory Director Nina Desai, PhD, HCLD. “In very early embryos, not every cell is identical, so some abnormalities may be missed.”

Of the Marks’ 12 embryos, five showed some abnormality and were ruled out for implantation. For the rest, there was EmbryoScope, which helped refine the Marks’s selection.

EmbryoScope® Time-Lapse System

EmbryoScope’s high-tech incubator with time-lapse camera allowed Dr. Desai to see more of each embryo’s development than she could before. Traditionally, she would take embryos out of an incubator once a day and look at them under a microscope. She says that method is similar to glimpsing school athletes for a few seconds, once a year, and trying to pick the future basketball stars. With EmbryoScope, she could see a play-by-play of each embryo’s progression.

“Embryos do amazing things when we’re not looking,” she says. “Under a microscope, I might see two embryos that look the same. But with EmbryoScope, I might see that one developed more erratically than the other. EmbryoScope gives us extra information that could provide an edge in choosing the most viable embryos.”

It certainly worked for the Marks family. Of the embryos selected after PGS, Dr. Desai identified two that looked best under EmbryoScope on Day Five. Both were transferred to Caroline. One took — and split into twins.

When EmbryoScope is used for Cleveland Clinic fertility patients, the pregnancy rate of day five transfers for patients under the age of 39 is approximately 70 percent.

“We’re so grateful,” says Caroline. “This technology has made our family possible.”

For more information about these technologies, contact Dr. Nina Desai at 216.839.2907.


Freezing Eggs — The New Standard in Preserving Women’s Fertility

Freezing unfertilized eggs has been an investigational procedure since 2003. Patients needed to sign a consent form acknowledging the procedure was investigational. Last fall, the American Society for Reproductive Medicine declared egg freezing a first-line fertility treatment, clearing the way for more women and couples to pursue it.

Studies have shown that in vitro fertilization (IVF) with frozen eggs produces similar rates of pregnancy and healthy babies as IVF with fresh eggs.

Much of the credit goes to a recent advance in cryobiology called vitrification. Vitrification is a flash-freezing technique that doesn’t cause damaging ice crystals to build up inside egg cells, which was more likely with slower conventional freezing.

Cleveland Clinic's IVF laboratory was a pioneer in using vitrification to freeze 6- to 8-cell embryos and now uses it for freezing all embryos.

Why Freeze Eggs Instead of Embryos?

“The benefit of freezing eggs is that you don’t have to fertilize them,” says Cynthia Austin, MD, Director of Cleveland Clinic’s IVF Program. “That can be appealing to, say, cancer patients who want to preserve their fertility for after their cancer treatments, or women in their early 30s who don’t have a partner and want to delay childbearing.”

Freezing unfertilized eggs also helps patients avoid the ethical dilemma of what to do with embryos they don’t use.

“It’s also easier to donate frozen eggs instead of trying to align the cycle of the donor with the cycle of the recipient at the time the eggs are made,” says Dr. Austin.

Target Age: 32 to 34

Freezing eggs is no guarantee that a woman will be able to get pregnant, however. Eggs don’t have the same potential that embryos do, notes Dr. Austin. Some may not survive the freeze. Some may not fertilize, because not all eggs do. Some may make hardier embryos than others.

“Out of eight eggs, we may only get three or four embryos,” says Dr. Austin.

And when it comes to freezing eggs, the biological clock is still ticking.

According to Dr. Austin, ages 32 to 34 are the best time to freeze eggs. (Younger women typically have no reason to freeze eggs because they still have time to pursue pregnancy without IVF.)

“As women get older, the quantity and quality of their eggs decrease,” says Dr. Austin. “By age 40, IVF doesn’t work as well. By age 43, there’s very little we can do to increase a woman’s fertility.”

Cleveland Clinic fertility specialists also offer other fertility preserving options — particularly for women preparing for cancer treatment. For more information, contact the IVF program at 216.839.3150, and select option five.


Robotic Reconstruction Better for Complex Vasectomy Reversal

Not all vasectomies are alike. Typically, they’re done with scrotal surgery. But sometimes they’re done through the abdomen, during another surgery. And sometimes they’re done unintentionally due to a hernia or damage during hernia repair or other surgery.

It stands to reason, then, that not all reverse vasectomies are alike.

“When vasectomies are done through the scrotum, reversing them is more straightforward,” says Edmund Sabanegh Jr., MD, Chairman, Department of Urology in the Glickman Urological & Kidney Institute. “Those reversals can be done at skin level, using a microscope. But for vasectomies done through the abdomen, it’s more complicated. Usually, the original surgery was very deep so there’s more scar tissue involved. That makes it harder to get magnification to reconstruct the vas deferens.”

But even that procedure isn’t as difficult with Cleveland Clinic’s new da Vinci® surgical robot. Dr. Sabanegh and other specialists in Cleveland Clinic’s Center for Male Fertility now use the robot to laparoscopically reverse patients’ abdominal vasectomies.

During the minimally invasive procedure, the surgeon places laparoscopes into the patient’s abdomen, identifies the site of the vasectomy and connects healthy areas of the vas deferens to bypass any obstruction.

“The robot provides a high level of magnification and a 3-D view of the site that we never had before,” says Dr. Sabanegh. “And it allows us to manipulate the scopes in ways a human hand can’t do. The robot’s precision and dexterity make this complex procedure easier.”

That’s good news for the delicate procedure that requires utmost precision. Even with the robot, the surgery takes up to five hours. Recovery usually takes just a couple of days.

Cleveland Clinic is one of the first health systems in the Midwest to do robotic vasal reconstruction for vasectomies performed inside the abdomen.

The procedure may also be beneficial for men with azoospermia who have had hernia repairs on both sides of the abdomen or hernia repairs as children.

“With pediatric hernia repairs, because the structures are so small, there can be inadvertent damage to the vas deferens,” explains Dr. Sabanegh.

That’s why men who had pediatric hernia repairs may experience fertility issues later in life.

Specialists at Cleveland Clinic’s Center for Male Fertility are dedicated to understanding and treating men who are unable to initiate a pregnancy. For more about the variety of surgical and nonsurgical treatments now available, contact the Center for Male Fertility at 216.444.5600.


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Cleveland Clinic’s Harboring Hope Fund Gives Prospective Parents a Second Chance

The reality of In Vitro Fertilization (IVF) is both hopeful and discouraging for many patients. Although the process often successfully brings joyful couples the family they’ve hoped for, it is also expensive for many patients. This is especially true for couples whose first round of IVF has failed.

The cost of IVF, usually greater than $15,000, is often too high for prospective parents, especially because only 20 percent of patients have insurance coverage for this treatment. For the 1 in 6 couples who requires medical intervention to conceive a child, the costs related to IVF can be prohibitive and heartbreaking.

But there’s hope.

Cleveland Clinic’s Harboring Hope Fund offers qualifying couples grants, based on select financial and clinical criteria, to proceed with a second cycle of IVF. The goal of the fund is to provide as many grants as possible to qualified couples needing a second round of IVF. Couples may also reapply for the grants if they are not selected initially. The fund coordinates care with referring obstetricians to ensure the provision of the best full-service care.

For more information on Cleveland Clinic’s Harboring Hope Fund grants or to learn how to donate, please contact Margie Clapp at 216.839.3100 or clappm@ccf.org. To learn more about the program, call 216.839.2929.

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