Infertility eNewsletter, Summer 2012
Cleveland Clinic’s IVF Lab Has Its Eye on Embryos With New EmbryoScope
Cleveland Clinic’s IVF lab at the Beachwood Family Health and Surgery Center is now one of only 10 labs in the United States and the only lab in Ohio with the EmbryoScope™ (Unisense ® FertiliTech) used to continuously monitor embryo development from conception to time of transfer. The device will open up a whole new area in understanding embryo development, allowing staff to identify new grading criteria for embryo selection.
This high-tech device allows the incubation of up to 72 embryos at a time—12 from each of six patients. A built-in camera provides automated and continuous time-lapse imaging of fertilized oocytes without disturbing their environment.
Because data suggest that the timing of variables such as pronuclear formation, syngamy, early cleavage, compaction and cavitation are indicators of an embryo’s developmental potential, this device will provide embryologists the ability to evaluate these variables at many more time points. As the IVF lab and physicians gather more information about the early development of the embryos and the resulting pregnancies, they can add to the grading criteria for selecting embryos with the best implantation potential.
A novel benefit for patients is that they can receive a CD showing the cleavage of all their embryos prior to implantation and witness the development of their baby from the very beginning.
The device has already resulted in several successful pregnancies for Cleveland Clinic patients.
Research Offers New Hope for Preserving Fertility in Cancer Patients
Infertility is a significant complication of cancer treatment because many treatments can substantially damage or destroy a young woman’s reproductive system. Understanding that this is often a major concern, Cleveland Clinic has given considerable attention to the long-term reproductive health of women of childbearing age undergoing cancer treatment. In an effort to offer new hope for preserving fertility, Nina Desai, PhD, HCLD, Director of IVF and Clinical Research, and colleagues have developed a mouse model for maturing enzymatically isolated preantral follicles suspended three-dimensionally in a tyramine-based hyaluronan (HA) hydrogel culture system.
Whereas a conventional culture system limits the growth of the follicle, forcing granulosa cells to attach to the surface of the culture and abandon the oocyte, the HA culture system more closely-mimics the follicles’ natural growth conditions without disrupting the complex interactions between somatic cell components and the oocyte that are necessary for cytoplasmic and nuclear maturation.
Dr. Desai and her team tested several encapsulation methods and HA gel concentrations and examined the ability of HA-embedded follicles to mature in vitro and produce mature metaphase II oocytes. The investigators were able to develop mature eggs with apparently normal meiotic spindles, suggesting the eggs could go on to normal fertilization and embryonic development, which will be the second stage of the research.
The study will be published in the journal Reproductive Biology and Endocrinology.
Unique Ob/Gyn Residency Accommodates Tracking Into Subspecialties
Unlike other residency training programs in the nation, Cleveland Clinic’s Ob/Gyn residency training program allows residents the flexibility to design their own program. This new program began recruiting its first class last fall. It is expected that those residents will finish the program in June 2016.
In this “trainee-centered” program, residents have the option to track into a curriculum specifically designed to provide more extensive experience in the gynecologic subspecialties. This flexible training concept also allows residents to spend more time within the chosen subspecialty areas of interest, thereby gaining increased proficiency in advanced procedures and becoming more active in the surgical management of patients and complex decision-making.
Flexibility Leads to Greater Focus
Most obstetrics and gynecology residency programs in the U.S. have a rigid and fixed curriculum that focuses largely on training in obstetrics and less focus on gynecologic training. The major strength of Cleveland Clinic’s program lies in the breadth and depth of exposure to gynecologic surgical training while maintaining core training in obstetrics.
By the end of the first year, residents may choose to concentrate their training in general Ob/Gyn or one of the following subspecialty tracks:
- Gynecologic oncology including breast surgery
- Female pelvic medicine and reconstructive surgery
- Reproductive endocrinology and infertility
The five themes within each obstetrics and gynecology track are:
- Primary and Preventive Ambulatory Health
- Reproductive Endocrinology
- Gynecologic Oncology
There are several rotations within each theme, some of which are core for specified levels of the program. The remainder of rotations contributes to a menu of options from which residents according to their needs.
Twenty resident positions (five per level) are available for this four-year program. In addition to this core training, which residents need to pass their boards, residents also have the opportunity to gain significant experience and a deeper understanding of gynecologic surgical training and issues in women’s health that physicians deal with daily.
Experiences Provided Throughout Cleveland Clinic
Most training will take place at Cleveland Clinic’s main campus. Residents also train at Hillcrest and Fairview hospitals, both of which are Cleveland Clinic health system hospitals that provide obstetrics care. General and subspecialty operative gynecology are also performed in these locations. Additionally:
- Fairview Hospital features a level III perinatal center, a level III NICU and a level II trauma center.
- Hillcrest Hospital features a level III NICU and level II trauma center.
In each year of training, residents rotate through the Hillcrest and Fairview hospitals’ high-risk labor and delivery service and the maternal-fetal medicine clinics.
One morning per week is departmental-protected conference time for faculty and trainees. The first Wednesday of the month is then morbidity and mortality conference, the second Wednesday is journal club, the third and fifth Wednesdays are Grand Rounds, and the fourth Wednesday is administrative time.
Resident-protected education time occurs every Wednesday morning following departmental-protected times. During these sessions, various didactics, small- group activities, simulations and hands-on activities are conducted.
Patient rounds are scheduled at various times depending on the service and clinical volumes. Continuity clinics take place at Cleveland Clinic’s main campus and regional sites, and all are precepted by full-time Ob/Gyn generalist faculty members who have training and interest in outpatient clinical teaching.
Educational activities are monitored through semiannual program reviews, rotation-by-rotation specific feedback, program surveys, and attendance at conferences, rounds and journal clubs. Residents also have other collaborative learning and research opportunities made available to them.
For more information, please contact Pat Wolf, Ob/Gyn Residency Program Manager, at 216.444.4884 or firstname.lastname@example.org.
Applications for Cleveland Clinic’s Ob/Gyn residency are accepted through the Electronic Residency Application Service (ERAS) at https://www.aamc.org/students/medstudents/eras.
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Visit our Group Page often to interact with our physicians, nurses and embryologists as they share the latest information on infertility diagnoses, treatments and procedures. Engage with patients facing the same challenges. Feel free to invite others with an interest in this topic to join the discussion.
Single-Sperm Freezing Results in One Happy Family
In situations where both partners experience fertility issues, special attention and teamwork are necessary to achieve pregnancy. In the case of one couple recently treated at Cleveland Clinic, male fertility issues called for a novel solution to a problem that has challenged investigators for almost 15 years.
With severe male factor infertility, the number of sperm available may be very limited. The laboratory needs to be able to reliably isolate and freeze the few sperm that can be found. One sperm is all that the fertility experts had to work with in the case of Jason and Jennifer Schiraldi, and fortunately for the couple, one sperm is all it took to achieve conception.
This patient’s successful outcome resulted from the collaborative efforts of the In Vitro Fertilization Lab Director Nina Desai, PhD., and Edmund Sabanegh, MD, Director of the Center for Male Fertility at the Glickman Urological & Kidney Institute.
After a standard course of testing to address fertility concerns, it was discovered that this couple was experiencing issues on both sides of the equation: Jason Schiraldi was diagnosed with azoospermia, and Jennifer Schiraldi had a diminished capacity to produce eggs.
Dr. Sabanegh elected to perform a delicate microsurgical testicular biopsy on Jason Schiraldi with the hope of extracting enough sperm for the couple to proceed with an IVF cycle. Dr. Desai’s lab was responsible for assessing the tissue samples for the presence of sperm and ultimately freezing the tissue for Jennifer’s treatment cycle.
Very few sperm were present. The laboratory elected to freeze a single motile sperm that they were able to find and isolate after extensive screening. The hope was that if all the tissue was screened, more viable sperm would be found.
The Single Sperm Freezing process starts with very careful microsurgical biopsy of the testicles by a male reproductive surgeon to identify potential small areas of sperm production. In the IVF laboratory, a sample is screened at 300 times magnification for presence of sperm. Living sperm are identified and picked up with a glass needle. After incubation with a cryoprotectant, sperm are ready to be frozen.
The sperm are moved with a fine glass needle, and the use of the microscope, to the freezing device. The sperm is sequestered in one microliter or less of fluid and then placed on a plastic capillary tube with a preformed gutter. The capillary tube is then placed into another straw and sealed. The straw is then slowly cooled before storage in liquid nitrogen.
On the day of Jennifer’s egg retrieval, after another 3-4 hours of searching, with three technicians, no living sperm could be found. The decision was made to use the single sperm that had been initially found and frozen to inject one oocyte. Jennifer’s remaining eggs had to be frozen due to lack of sperm.
Fortunately for the couple, one sperm was all it took. The egg was successfully fertilized and developed normally. After three days, the embryo was transferred to Jennifer's uterus. Sixteen days later, Jennifer and Jason learned that they were to become parents. Daughter Kenley was born on April 20, 2010, after a normal pregnancy.
To learn more about this procedure, contact Dr. Desai at email@example.com or 216.839.2907.