Practicing medicine for the past 30 years, I have developed an enormous respect for those things that happen to people that are beyond our control.  Sometimes, the issue of preventability is a gray one and defies definitive blame assignment.  Yet, when the dust settles there remain victims who are harmed for whom we are all sympathetic.  It is for this reason that we are compelled to do everything within our power to ensure that tragic errors do not occur.

Elsewhere in society there are potentially devastating outcomes to human error and, like in medicine, it may be difficult to unravel how much fault is from natural calamity and how much we could have avoided with more rigorous human controls.

Just over a week ago, the world was exposed to perhaps the worst of Mother Nature’s natural disasters: a severe earthquake with multiple aftershocks, followed by a massive Tsunami.  Aside from the horrendous devastation that took place in Japan, ongoing danger persists from damage to several nuclear power plants.  

These unintentional, uncontrollable catastrophes occur naturally and are arguably nobody’s fault.  And although some claim that nuclear power is dangerous because of the history of accidents like at Chernobyl and Three Mile Island, nuclear power plants continue to be constructed throughout the world because many perceive that the benefits of this alternate source of energy outweigh the risks.  We are assured by those responsible that these plants are safe even in the face of the worst disasters… until we learn they are not.

 It is our human condition to speculate how to prevent these complications from occurring.  In IVF, perhaps the greatest potential disaster we face is the mixing up of embryos.

 In February, 2009, a case of a mix-up of frozen embryos in a Michigan IVF program occurred to a couple who already had a set of twins as a result of a successful IVF.  Their embryos were mistakenly transferred into the wrong woman, who then carried the pregnancy and after delivery handed the baby back to his biological parents. Reports of the mix-up have triggered calls from some to make IVF illegal.  This sounds like the recent calls to decommission nuclear power plants and stop production of new facilities.

Mixing up gametes and embryos is tragic and society must do everything humanly possible to prevent it… except disallow the practice of IVF. As with other societal advances, accidents are rare but have unfortunately happened in the field of IVF. But, weighed against the benefit of all the babies who otherwise would never have been born, we should strive to improve the safety of IVF, not eliminate it.

Many of the greatest advances have had tragic results, unintended accidents that could sometimes been avoided. Sometimes, like the post-earthquake nuclear disasters in Japan, they are spawned by natural causes.  But other times, there is an element of human error often preventable with the institution of carefully designed safeguards with a system of checks and balances.

Significant risk, including that of injury or death, is part of nearly everything we do in life today. The construction industry has always been plagued with accidental deaths. Not a bridge or a great high rise has been completed without misfortune. Do we stop construction? No, we ensure that all possible regulations that could protect those involved are in place and followed as strictly as possible to prevent further accidents.

Cardiac bypass surgery and other surgeries save lives and relieve suffering but, occasionally, patients intended to benefit are hurt or even killed accidentally. Rules and regulations are instituted to avoid problems such as performing the wrong operation on the wrong patient, using the wrong medication, operating on the wrong limb. Yet situations do occur rarely, usually because of a human slip. Rules are broken and mistakes result. When they do, hospitals review the procedures and protocols to better insure a sufficient system is in place to catch future errors before they effect patient care.

Just as we have safeguards in the operating room, we have them in place for identifying gametes and embryos with checks and balances that should prevent a mix-up such as the one in Michigan.

In our operating room, patients are identified while they are awake by the embryologist, nurse, physician and anesthesiologist by full name and birth date. As soon as the ovaries are aspirated, the eggs are identified and put in dishes with the patient’s full name and birth date on them. When the dishes are changed to replace the media, again matching names are put on the new dishes with a unique case number. A partner’s sperm specimen is labeled by him and processed in tubes labeled to match the partner’s name and the corresponding patient’s name and the case number. This is double-checked with the patient’s record which will also reflect the unique case number. It is reviewed by two embryologists for accuracy prior to fertilization. Finally, when the embryo is loaded in a catheter for transfer, the identity of the dish from the embryo is checked by the physician, embryologist, nurse and the patient herself prior to the transfer being performed.

Every attempt is made to confirm the identity of the gametes and embryos repeatedly throughout the IVF process from retrieval through transfer. A similar system of double checks of patient and embryo identity exists for frozen embryo transfers as well.

In over 25 years of practicing IVF, my program has not mixed up gametes or embryos.

There are approximately 3 million babies born through IVF and only a few rare mix ups reported. Perhaps we don’t hear …or know…about every mix up. I’d estimate that less than 1/100,000 pregnancies from IVF have occurred with some mix up in the embryo or gamete. When it occurs, it is tragic and requires the attention of our field and a refocus on those checks and balances we have in place to prevent such mishaps.

When it comes to institutions whose impact on society is of such great magnitude, it is essential that governing regulatory agencies ensure that all possible checks and balances are in place to ensure the greatest degree of safety.  All involved must work hard to maintain the highest standards and then we can only pray that we have done everything possible so that such disasters never have such devastating consequences.

Two months ago I had my first IVF cycle & it did not work. I was wondering what common reasons there are a body would reject the 2 embryos that seemed to look good on the 3rd day?
A few years ago I had a healthy child that came naturally with out even trying. In the past 2 years I’ve had an ectopic pregnancy resulting in removing a tube as well as a miscarriage. It’s hard to understand why it was so easy to get pregnant naturally a few years back & why everything we have done since that time has not worked. Also, if a fresh embryo transfer didn’t work on day 3, would you recommend trying a frozen transfer or a fresh transfer again.

Still Not Pregnant

Dear Still Not Pregnant,

I often hear patients refer to a failed embryo transfer as an embryo rejection. I suppose it appears to make sense as the embryos that are being transferred appear completely normal. The disconnect between what appears to make sense and the reality of the procedure of IVF is that the creation of life is an enormously complex process truly beyond the level of human understanding.

Great strides have been made in the process resulting in pregnancy rates exceeding 60% for some groups. However, the apparent quality and grade of an embryo predicts the likelihood of a resulting pregnancy. It is far from guaranteeing a pregnancy. New tests for the viability of an embryo are being developed such as metabolomics and proteinomics. These assess an embryo by analyzing products of an embryo in culture. They will further the likelihood of achieving a pregnancy from a transferred embryo.

Remember, that though an embryo may be otherwise viable it may still be abnormal genetically which will diminish pregnancy rates and usually result in miscarriage when implantation does occur. The likelihood of a genetically abnormal embryo developing increases especially as the age of the woman increases as well as with severely decreased sperm counts in the male.

The decision to go forward after a failed fresh transfer with a frozen transfer of sister embryos or a new fresh transfer should be individualized based on the quality and grade of the frozen embryos, the age of the woman, her

insurance coverage and her tolerance for the stimulation and retrieval as well as her motivation and patience. I recommend you have this conversation with your physician who can advise you better about your specific situation.

I wish you the best of luck!

The Joneses had just moved to Norfolk after a forced retirement at Johns Hopkins and hadn’t finished unpacking when the greatest fertility event of all time hit the news. Patrick Steptoe and Robert Edwards had succeeded in Great Britain with creating a new life through a process they called In Vitro Fertilization that the media had termed “test tube babies”.

I had the great fortune to study REI (reproductive endocrinology, infertility) with the Joneses and Zev Rosenwaks in Norfolk from 1985-1988. In 1988, I started IVF on Long Island which was successful then in about 25% of cases. In 1990, I met Dr. Robert Edwards who impressed me with his wit, his charm as well as his great intellect. I told him about my softball team named East Coast IVF that Dr. Edwards found particularly amusing. After all the scientific and political challenges he overcame to successfully achieve a live birth through IVF, he was struck by the irony that IVF had become routine as a commonplace alternative for those with difficulty building their own families.

Today, IVF is now successful 50% of the time. Four million babies have been born who if not for the technology of IVF would not be here today. What a remarkable testimony to his scientific accomplishments. Dr. Edwards truly deserved the Nobel Prize for developing this technology that led to the creation of so many lives.

As someone who owes his career to the man I am forever grateful and to those who have been touched through the birth of one of the 4 million we owe him much more than we can ever give.

The old fertility legend about a couple who had failed fertility treatments, adopts a baby and then all of a sudden gets pregnant is one we have all heard.

In fact, as a practicing reproductive endocrinologist over the past 25 years, I have experienced this with some of my own patients.

Those stories have led us to believe that it takes longer for women with high stress levels to conceive. Unfortunately, there has not been much research on this. Until now, the best evidence for the benefit of stress reduction comes from the wellness center at Boston IVF where they had shown higher IVF success rates for women who were involved in their Mind Body program.

Latest Research on Stress and Fertility

A new study in the current issue of the ASRM journal Fertility and Sterility (the primary research outlet for our national fertility society) lends credence to a link between stress and fertility. In the study, 274 British women, ages 18 to 40 years old, were examined to determine if using fertility-monitoring devices would improve their chances of conception.

They were followed for six menstrual cycles or until they got pregnant, whichever came first. On Day Six of each cycle, saliva samples were collected. Researchers measured their levels of alpha amylase and cortisol, two substances that reflect how the body reacts to stress.

Pregnancy rates were compared in women with the highest concentrations of alpha amylase in their first cycle to women with the lowest levels of the stress hormone marker. It was found that over the six-month period, the group of women with the highest alpha amylase (and hence stress) were 12 percent less likely to conceive than women with the lowest.

Cortisol levels were not associated with the women’s chances of conceiving. The alpha amylase and cortisol reflect two different components of the stress response and don’t necessarily correlate well. Alpha amylase reflects the “fight-or-flight” response to immediate stressors.

To confirm these findings, the research team conducted a larger and longer study of women trying to conceive. Evidence from these trials suggests that stress-reduction techniques can improve pregnancy rates in couples who use in vitro fertilization and related methods.

Applying the Findings

With such findings it appears that patients would benefit if they enroll in various stress reducing programs when trying to conceive. Mind-body programs, support groups, acupuncture and massage apparently offer the greatest benefit.

As a practitioner in the field of infertility for 25 years, I endorse these adjunctive therapies for my patients undergoing treatment, with the goal of reaping the fertility enhancing benefit of stress reduction before we submit them to multiple treatment cycles.

IVF’s Early Years

Practicing reproductive medicine during the ’80s was like having a new love or beginning a new romance — all of it seemed liked a miracle, and everything was about helping patients get pregnant using this new technology and educating the world about what was now possible. This was an exciting time, and the 15 percent pregnancy rate was achieved by transferring six embryos at a time.

But our excitement was often tempered by the consequence we experienced with many high order multiple pregnancies. Unfortunately, these were often complicated and did not always end well. Aside from pregnancy and neonatal complications, many of the marriages also suffered. It was hard to balance a new family’s anticipation and heartfelt joy with the sometimes painful and unforeseen consequences — babies who suffered and families that fell apart.

Sometimes beginnings are like that. They start off so bright, and then they get tempered.

The Middle Years—Safer and Not So Sexy

Thankfully, I am now in the “middle years,” of IVF which is so much more successful and no less a miracle. We can attain pregnancies in greater than 60 percent of retrievals for women under 40. These rates are accomplished while transferring one, two or, at most, three embryos at a time. Cryopreservation, or freezing embryos, has also improved our pregnancy rates per retrieval, giving us multiple opportunities to get a patient to conceive from a single IVF stimulation and retrieval.

The middle years of IVF are not like the beginnings of a romance — this is the wood chopping time. The freshness of the technology has worn off, and the focus on making the treatment affordable, accessible and safe may not seem as sexy. But it is the middle years of any pursuit — whether it is marriage, raising a child or practicing medicine — in which the gold is often mined.

A Time for Reason, Not Headlines

The middle years of my practice mean we are making an effort to encourage safer single-embryo transfer and avoid risky multiple pregnancies. We introduced a program in 2007 at East Coast Fertility for patients who transferred one embryo at a time, offering free cryopreservation, storage and frozen embryo transfers until a live baby was born.

Still, patients don’t commonly choose single-embryo transfer. They haven’t seen what I have seen — they still believe that the technology will some how fail them, that IVF won’t work. But from our experience, similar to others’, there was no significant difference in pregnancy rates between patients who chose to transfer one embryo vs. those who chose to transfer two embryos.

While there was a trend toward higher rates for the two-embryo transfer group, it was practically eliminated when frozen embryo transfers were added. These groups were age-matched with no difference except for a 40 percent twin rate and one triplet in the two-embryo transfer group, compared to the single-embryo transfer group in which no twins were created.

It is hoped that these results will encourage a higher percentage of patients with a good prognosis to transfer a single embryo, which is the safer option.

The middle years of practicing reproductive endocrinology captivate my heart. It is a time for reason — not headlines. And for me that is just perfect.

We are approaching a time that freezing eggs will be a standard option for an IVF program much like Embryo freezing is today.  Despite the fact that hundreds of babies have been born apparently without an increase in defects or abnormalities, the American Society for Reproductive Medicine (ASRM) has proclaimed that Egg freezing is still considered experimental.

This is not just a scientific decision but is a philosophical and political one as well.  In the 1980’s, IVF was being performed likewise on an experimental basis.  Insurance companies denied that it had become standard of care until recently.  In fact, there are insurance providers who in an effort to deny claims continue to call IVF experimental despite the million babies already born without significant increases in abnormalities or defects noted.  However, the ASRM is afraid to push the envelope and take a risk that may make them appear to be promoting a procedure that could theoretically be associated with increased problems with the children created after egg freezing.

But why should we be interested in egg freezing anyway when we have IVF that is successful and known to be relatively safe after 33 years of experience?  The reasons are multiple.  A young woman who develops cancer and will have radiation therapy or chemotherapy that may affect her eggs or have her ovaries removed would with egg freezing have an option to preserve her fertility and still have her cancer treated.  In the past, the loss of a woman’s future ability to bear children was sometimes more emotionally depressing for her than the cancer itself.  The prospect of offering hope to such affected women is spreading throughout the community in part through the efforts of the Lance Armstrong Fund supported group, Fertile Hope.  They are attempting to educate not just affected individuals but oncologists and other physicians who come into contact with patients who may be able to take advantage of new IVF technologies to preserve their fertility while undergoing cancer treatment.

Another great potential use for frozen eggs is in the donor egg program.  Currently, our egg donors go through fresh IVF cycles coordinated in time with the recipients so that the eggs are fertilized fresh when they are retrieved.  This is highly successful in achieving pregnancies in approximately 80% of donations.  However, cycles can be delayed in trying to synchronize patients.   If programs can achieve similar success rates using frozen eggs it will allow recipient patients to choose donor eggs much like they select donor sperm today.

Yet, another benefit of the ability to bank frozen eggs is for women who either because of their career or lack of finding a suitable partner need to put off their childbearing until a time when they would otherwise put their future fertility at significant risk.  This is a more controversial use of this technology but a practical concern for countless women today for whom conceiving before age 35 is unrealistic.

Needless to say, egg freezing will be a great benefit for many when it becomes a safe acceptable IVF standard.  That time for consideration by patients is rapidly approaching and is something that the public needs to be made aware of.

My son is starting his second year residency in obstetrics and gynecology. He, like I was 30 years ago, is turned on by reproductive medicine and enjoys performing gynecologic surgery. When I decided then to specialize in reproductive endocrinology and infertility (REI) I was looking forward to being on the frontier of fertility medicine. The details of Reproductive physiology were being unraveled in real time and IVF had just reported its first successful pregnancies. In those days, microsurgery of the fallopian tubes was commonly performed by REIs as well as endometriosis and fibroid surgery.

During my fellowship, surgery was a huge part of my training. I travelled to Nashville to train with one of the world’s experts in laser laparoscopy. I practiced my tubal microsurgery skills weekly on anesthetized rats in a plastic surgical lab. I assisted on reproductive surgery several cases every week throughout my fellowship.

Myself and other fellows performed research on basic reproductive physiology questions that had yet to be worked out. Personally, my interest was polycystic ovarian disease and its relationship to weight gain. I studied male hormone production in the ovary and the adrenal gland before and after significant weight loss. I discovered that there was an inverse relationship between weight loss and male hormone production and that this was mediated through insulin. These were exciting times. If only we had metformin back then, I would have proven that in addition to weight loss, we could decrease insulin levels and therefore male hormone levels with metformin.

Today, discoveries in reproductive physiology are much more esoteric than it was when I was a fellow. Reproductive surgery, in particular tubal microsurgery and laser laparoscopy for endometriosis and adhesions is usually replaced with in vitro fertilization (IVF) which has become so much more successful, less invasive and therefore a preferable option. Most causes of infertility, if they are not successfully treated with ovulation induction and intrauterine insemination (IUI) can be overcome with IVF.

In the 1980’s when I was a fellow, IVF was grossly inefficient and we had to transfer multiple embryos to achieve a pregnancy. Consequently, triplets and quadruplets were not rare occurrences. In many programs, they constituted over 10% of all pregnancies. Today, we can often transfer one embryo at a time minimizing the risk of multiple pregnancies. We can freeze excess embryos so many patients need go through only one stimulation and retrieval and still have multiple transfers providing them with an excellent chance of conceiving a baby from their efforts.

Today, we get excited about advances in preembryo genetic screening and diagnosis and contemplate the current and future potential of eliminating hereditary medical disorders. This involves highly trained laboratory personnel who perform the latest technologic advances. In 2010, the REI, in general is removed from a hands on involvement with the frontiers of Reproductive Medicine and instead works like a film producer gathering his team including these lab personnel, nurses, etc and directing them as to how to approach his patients’ fertility problems. It used to be that he used the microscope and laser laparoscope to perform the tubal and endometriosis surgery. The IVF retrieval and transfer were new procedures that were still being perfected.

Today, they are the routine cases performed daily by the REI.

My son looks at the REI of today as a doctor who starts his day with 1-2 hours of ultrasound that is part of the daily ovulation monitoring for IUI and IVF. Many REIs no longer perform more surgery than hysteroscopy and occasional laparoscopy or myomectomy in addition to their retrievals. These are all considered routine procedures now. The current frontier in infertility is limited pretty much to the laboratory. Though many of us consider ourselves expert in stimulations, retrievals and transfers and while we know we make a significant difference in our patients’ outcomes our work does not appear or feel as glamorous as it once did. Perhaps, he will decide, as I did, that the pleasure in helping women build their families is sufficient reward. Or perhaps, this Nintendo generation, will seek a more apparently exciting lifestyle. How about that Robotic surgery?

It was fifteen years ago that I sat listening to a lecture about the hazards of multiple pregnancy and how IVF had increased multiples so drastically in the preceding ten years. What a depressing thought. I loved helping women conceive. I was living my dream, practicing the infertility and IVF I had learned ten years earlier at the Jones Institute with Howard and Georgeanna Jones themselves as well as Zev Rosenwaks and other masters of the IVF craft.
I had seen quadruplets created first hand as a result of our IVF efforts. But, that was a necessary side effect of transferring a sufficient number of embryos to offer a patient a reasonable chance for a successful transfer. IVF was very inefficient back then and our pregnancy rate even in 1995 with transferring 3-4 embryos was at best 40%.
The sobering truth is that multiple pregnancies — even with ‘just’ twins — are sometimes dangerous to the health and well-being of mother and babies let alone the triplets that were still occurring in 7-10% of the pregnancies at the time.
Since then, thanks to dedicated research to fine-tune IVF, much has been learned about both clinical practice and laboratory technique. IVF is no longer experimental and is currently much more efficient so that the live birth rate for women under 35 years of age at East Coast Fertility is greater than 60% per retrieval.
One of the most important recent developments — single embryo transfer, or SET — is being consistently backed up by study after study as the optimal IVF method for patients with a good prognosis.
The SET Program
The safest pregnancy with the greatest chances for an optimal outcome — a healthy baby — is a singleton pregnancy. In 2007, East Coast Fertility started leading the field of reproductive medicine by establishing our own SET Program.
Confidence in our high quality embryology laboratory and immensely successful embryo cryopreservation program has afforded ECF the ability to limit the number of embryos transferred, essentially eliminating the risk of triplets or more.
We analyzed our success with elective single embryo transfer and compared it to our success with elective double embryo transfer since the opening of our lab in 2005.
Fresh eSET was less likely to result in pregnancy than eDET 39/75=52% vs. 342/561=61% though this difference was not significant statistically. When frozen embryo transfer pregnancies were added this difference was 64% vs. 68.3%. There were no multiples in the eSET group but a 27.8% twin rate in the eDET group with 2 cases of triplets. So to encourage patients with good prognosis to utilize SET, we offer the following incentive:
For the cost of an IVF cycle, SET Program patients will receive free cryopreservation of their embryos, free storage and free frozen embryo transfers until they have a baby. This represents a savings of up to over $12,000. It also ensures a much better chance of a healthy baby.
Is SET for you?
Each patient’s case is considered individually. Each factor impacting conception and pregnancy is taken into account, such as; the age of a patient, embryo quality, the number of prior failed IVF cycles and embryo quality. Single embryo transfer is appropriate in certain situations where the likelihood of a multiple pregnancy is high, including; women younger than 35 years, women who conceived with first IVF cycle, women with concerns about multiple gestation and donor egg recipients.
Single Embryo Transfer is revolutionizing the practice of reproductive medicine, and the team at East Coast Fertility is committed to their collective pledge to lead the way in creating safe, healthy pregnancies.

The case of a mix-up of frozen embryos in a Michigan IVF program in Feb. 2009 yet again became a media splash with the affected couple appearing on ABC News to promote their new book, “Misconceptions”.  The couple who already had a set of twins as a result of a successful IVF recounts a story about their experience including the fact that the frozen embryos were mistakenly transferred into the wrong woman.  This woman carried the pregnancy and after delivery handed the baby back to his biological parents.  Reports of the mix-up have triggered calls from a few to make IVF illegal.

Mixing up gametes and embryos is tragic and society must do everything humanly possible to prevent such a mix up except disallow the practice of IVF.  As with other societal advances, accidents have rarely and unfortunately happened in the field of IVF but, weighed against the benefit of all the babies who otherwise would never have been born, we should strive to improve the safety of IVF, not eliminate it.

Many of the greatest advances have had tragic results, unintended accidents that should have been avoided. Usually, they are the result of human error often preventable with the institution of carefully designed safeguards with a system of checks and balances.

Significant risk, including that of injury or death, is part of nearly everything we do in life today. The construction industry has always been plagued with accidental deaths. Not a bridge or a great high rise has been completed without misfortune. Do we stop construction? No, we ensure that all possible regulations that could protect those involved are in place and followed as strictly as possible to prevent further accidents.

Nuclear power is controversial because of the fear of accidents. Despite past accidents at Chernobyl and Three Mile Island, nuclear power plants continue to be constructed throughout the world because it is perceived that the possible benefits of this alternate source of energy outweighs the concerns for the risks.

Cardiac bypass surgery and other surgeries save lives and relieve suffering but, occasionally, patients intended to benefit are hurt or even killed accidentally. Rules and regulations are instituted to avoid problems such as performing the wrong operation on the wrong patient, using the wrong medication, operating on the wrong limb. Yet situations rarely occur, usually because of a human slip. Rules are broken and mistakes result.  When they do hospitals review the procedures and protocols and insure a sufficient system is in place to catch errors before they have an effect on patient care.

Just as we have safeguards in the operating room, we have them in place for identifying gametes and embryos with checks and balances that should prevent a mix-up such as the one in this case.

In the operating room, patients are identified while they are awake by the embryologist, nurse, physician and anesthesiologist by full name and birth date. As soon as the ovaries are aspirated, the eggs are identified and put in dishes with the patient’s full name and birth date on them. When the dishes are changed to replace the media, again matching names are put on the new dishes with a unique case number. A partner’s sperm specimen is labeled by him and processed in tubes labeled to match the partner’s name and the corresponding patient’s name and the case number. This is doubly checked with the patient’s record which will also reflect the unique case number. It is reviewed by two embryologists for accuracy prior to fertilization. Finally, when the embryo is loaded in a catheter for transfer, the identity of the dish from the embryo is checked by the physician, embryologist, nurse and the patient herself prior to the transfer being performed.

Every attempt is made to confirm the identity of the gametes and embryos throughout the IVF process prior to transfer. In 25 years of practicing IVF, my program has not mixed up gametes or embryos.

There are approximately 1 million babies born through IVF and only a few rare mix ups reported.

Perhaps we don’t hear about every mix up. I’d estimate that between 1/50,000 and 1/100,000 pregnancies from IVF have occurred with some mix up in the embryo or gamete. When it occurs, it is tragic and requires the attention of our field and a refocus on those checks and balances we have in place to prevent such mishaps.

I work hard and I pray that we do everything possible so that this never happens again. The FDA regulates gamete donation. The New York State Department of Health regulates our labs and our operating rooms. These checks and balances are in place and are included in the monitoring performed by these agencies.

Perhaps, if the other states required as strict a monitoring to ensure their clinics and doctors are adhering to the necessary safeguards as well then the mix-ups would not occur.

Pre-embryo genetic screening (PGS) was developed to help weed out embryos containing inherited metabolic disorders and genetic abnormalities prior to implantation. It was thought that PGS could be used to minimize the risk of miscarriage and perhaps even increase live birth rates in older women IVF undergoing .

We have thus far been disappointed in our results obtained using the FISH technique, the procedure performed for PGS for the past decade and a half. But an alternative new technology that was recently developed makes me very excited about PGS once again: Array Comparative Genomic Hybridization (aCGH).

ACGH is a technique actually applied to detect deficiencies and excesses of genetic material in the chromosomes. DNA from a test sample and a normal reference sample are labeled using colored fluorophores that hybridize to several thousand probes. These probes are created from most of the known genes of the genome and placed on a glass slide.

The differential color of the test compared to the normal sample DNA reflects the amount of DNA in the test specimen. It can pick up monosomies, trisomies or significant deletions on an embryo’s chromosomes.

The first baby born from this procedure was in September 2009 to a 41-year old woman. When aCGH is performed on a Blastocyst biopsy, it is effective in screening out mosaicism (mixed cell lines in the same organism). ACGH is 20 percent more sensitive than the best FISH assays with an error rate of two to four percent. Fifty percent of the embryos tested were normal with pregnancy rates exceeding Blast transfers without aCGH screening.

So, who could benefit from using this new technology?

1. Patients with repeat miscarriages can eliminate up to 90 percent of their miscarriages.

2. Older patients who naturally have a higher percentage of genetically abnormal embryos may now screen for and only transfer their normal embryos.

3. Patients who want to maximize their success with a single embryo transfer.

4. Patients who have experienced repeat implantation failure can be screened for genetically abnormal embryos.

This technology is available for about the same cost as the FISH procedure yet, since it is performed on a Blastocyst, it is safer with less effect on the integrity of the embryo and without significant risk of wrongly identifying abnormal embryos. A concern with FISH is that embryos identified as abnormal can actually result in a normal fetus. This risk is practically eliminated with aCGH and is another reason making it more successful.

I expect PGS will now become a commonly used addition to standard IVF to promote more successful single embryo transfer, improve success in older patients, eliminate miscarriages and treat patients with repeat implantation failure.

We are approaching a new era in IVF. Brace yourselves for a thrilling ride into IVF’s future.