--------------------------------------------------------------------------------------------------------------------------------
News from ICRM's Embryology Lab!
     The laboratory at the Idaho Center for Reproductive Medicine has increased our number of incubators. We are excited to bring this new technology into our lab! In the past, incubators have had a very large culture chamber. The culture area in the new Minc incubators is very small. This small area for culturing adds some very big benefits to the quality of embryos grown. 
     The warmed gas mixture is constantly flowing through the humidification flask and into the chambers. This leads to a very quick return to the desired culture environment after the lid has been opened and closed. Equilibration is said to occur in one minute. The older style incubators took more than 30 minutes to bring the temperature, humidity, and gas concentrations back to desired levels.
     The Minc incubators offer a heated base and lid to ensure that temperatures stabilize quickly. There are impressions in the metal of the base which fit the three main types of dishes used for culture. These impressions allow for the heated base to be in direct contact with the bottom of the dish.
     The culture environment will now be one of reduced oxygen tension. What does that mean? That means the embryos will be exposed to less oxygen. In the presence of high (atmospheric) levels of oxygen, production of reactive oxygen species is possible. These reactive oxygen species, or free radicals, can lead to poor development of the embryos.
     The older style incubators received a known concentration of CO2 in the chamber, which was mixed with room air. The Minc incubators require a triple gas mixture (CO2, O2, and Nitrogen) that flows into the culture chamber. The final concentration of oxygen in this culture system drops from just over 20% down to 5%. This will greatly reduce the potential for free radical production in the culture media.
     These new Minc incubators have been thoroughly checked and quality controlled. We are very excited to use them for our November 2011 IVF cycle!
---------------------------------------------------------------------------------------------------------------------------------There's an App For That!
Attain Fertility® Centers has announced the launch of the Attain Fertility Predictor, a free iPhone app designed for women that will help them determine their chances of becoming pregnant on their own. And for women who are unable to get pregnant on their own and need assisted reproductive technology (ART), the predictor then shows her chances of having a baby through in vitro fertilization (IVF). The first of its kind, the Attain Fertility Predictor is filled with vital information, from when to see a specialist, to how many IVF cycles may provide her the best chance of becoming a parent.
Based on a woman’s age and how long she’s been trying to get pregnant without fertility assistance, the Attain Fertility Predictor helps a woman understand her options, including when she may want to consider seeing a fertility specialist. The Attain Fertility Predictor includes other interactive features and information, including:

- Fertility Center Finder: Helps locate the nearest clinic that’s a part of the Attain Fertility network, request an appointment and get directions.
-  BMI calculator: Suggests whether or not a woman is at her optimal weight.
-  Fertility loan calculator: Calculates payments for fertility loans that can make paying for treatment more manageable and can be used for programs like Attain IVF.
-  Fertility information: Users can learn about causes of infertility, different treatment options, IVF costs and information about the Attain IVF Programs.

The Attain Fertility Predictor is now available at Apple’s iTunes App Store and can be used with iPhones and iPads.
--------------------------------------------------------------------------------------------------------------------------------
IUI Explained
     Intrauterine insemination (IUI) is the placing of sperm into a woman's uterus when she is ovulating. This procedure is used for couples with unexplained infertility, minimal male factor infertility, and women with cervical mucus problems. IUI is often done in conjunction with ovulation-stimulating drugs. IUI can be performed using the husband's sperm or donor sperm. Before IUI, the woman should be evaluated for any hormonal imbalance, infection or any structural problems.
     Insemination is performed at the time of ovulation, usually within 24-36 hours after the LH surge is detected, or after the "trigger" injection of hCG is administered. Ovulation is predicted by a urine test kit or blood test and ultrasound.
     In the case of husband inseminination, the male partner produces a specimen, at home or at the clinic or doctor’s office. The sperm is then prepared for IUI. Sperm from the male partner or third-party donor are "washed" or separated. Separation selects out motile sperm from the man’s ejaculate and concentrates them into a small volume. Sperm washing cleanses the sperm of potentially toxic chemicals which may cause adverse reactions in the uterus. The doctor uses a soft catheter that is passed through a speculum directly into the woman's uterus to deposit the semen at the time of ovulation.
     IUI may be used in conjunction with ovulatory medications, such as clomophine citrate, gonadotropins, or urofollitropins. If injectable ovulation stimulating drugs are used in an IUI cycle, careful monitoring is essential. Monitoring includes periodic blood tests and ultrasounds beginning around day 6 of the woman's cycle. Results of these tests will indicate when eggs are mature, prompting the hCG shot.
     IUI is also used with specially prepared donor sperm. The sperm bank sends the doctor's office sperm that is already prepared for IUI.
     IUI is a relatively quick procedure and is performed in the doctor's office without any anesthesia. It should not be painful, although some women report mild discomfort.
(From www.Resolve.org)
--------------------------------------------------------------------------------------------------------------------------------Clinical Success Rates -- Just a Part of the Whole Puzzle
     Before you begin treatment, it's a good idea to be informed and comfortable about the clinic that will be directing your care. In addition to discussiongs with your healthcare provider, you can do research on the success rates and policies of individual clinics. The website for the CDC is a good resource. You can find reports on past success rates for individual clinics, as well as information on patient diagnoses, average number of embryos transferred per cycle, and other factors.
      Success rates for a facility can help you understand what to expect from ART (assisted reproductive technology), but the CDC cautions against using statistic to compare one clinic to another. This is because a clinic’s patient selection process and treatment procedures can significantly affect its success rates. For instance, a clinic that refuses or discourages patients with challenging cases may appear to have a high success rate, while one that accepts these patients may appear to have a lower success rate when, in fact, its success with challenging cases is relatively high. In other cases, a clinic may achieve a promising success rate by transferring a high number of embryos per cycle but, in doing so, may create a high risk for multiple births.
      A good strategy for selecting a clinic is to look for one that treats a high number of patients who have the same diagnosis you have. And of course, it always makes sense to talk to a physician or nurse directly to ask about a clinic's policies and make sure you are comfortable with the people who will be treating you.
-----------------------------------------------------------------------------------------------------------------------------------
Fertility Preservation for Cancer Patients = HOPE
     Due to recent advances in oncology, the diagnosis and treatment of several types of cancer have drastically improved, leading to increases in survival rates through the years. With these advances, more patients are living longer, more productive lives with cancer, and are oftentimes in remission. Although the prognosis for patients with cancer is positive, physicians currently face new challenges in treating younger patients with cancer who wish to maintain the ability to have children later in life.
     Until now, not much thought had been given to being able to have children once cancer treatment is completed and the cancer is in remission. For example, in female patients with cancer, freezing a woman's eggs, or embryos created with sperm from her partner or an anonymous donor allows her the chance to have a genetic child in the future. For male patients, sperm banking and cryopreservation is a highly successful option.
     Physicians making a cancer diagnosis are beginning to offer their patients fertility preservation options through subspecialty, board certified reproductive and infertility (REI) specialists, such as the Idaho Center for Reproductive Medicine.
-------------------------------------------------------------------------------------------------------------------------------
All About AMH
Anti-Mullarian Hormone (AMH) is a hormone to test ovarian reserve.  AMH is produced by cells of developing ovarian follicles.  Until recently, test available to determine ovarian reserve have only been able to show when the egg supply is almost depleted.  At that point, it may be too late.  Research suggests that results from measuring AMH levels may provide an earlier marker of a woman's reproductive potential.

AMH can be drawn any day of the month.  This makes this blood draw very convenient to do.   Other traditional methods in measuring ovarian reserve include measuring ovarian resting follicle numbers via ultrasound and cycle day 3 follicle stimulating hormone levels (FSH).

-------------------------------------------------------------------------------------------------------------------------------
                                                 Improving Mother Nature’s Fertility Curve

Age and experience can be of benefit in life, but when it comes to the vitality of an egg, these 2 attributes do not improve the chances of an egg to be fertilized and achieve a live born child.  Current fertility treatments try to overcome the decreased statistics of monthly fertility with advanced age of the egg.  A woman is born with all the eggs she will have, and each month a chosen follicle becomes the dominant follicle that releases an egg (if the hormone signal pathways from the brain to the ovary are functioning properly). 

The ovary seems to have a different time clock than the rest of a woman’s organs.  Whereas a woman’s heart and lungs can function properly into their eighth decade, the average age of menopause is 51.  The age range in which a person has the most energy is from 17-30 years of age.  Just as a person can’t run as fast at age 40 when compared to age 20, the egg of a 40 year old woman does not have the same energy as the egg of a 20 year old woman.  It takes quite a bit of energy for an egg to perform its functions.  First, the egg has to extrude ½ of its genetic material after the sperm delivers its package of genetic material.  Then, the egg has to orchestrate the lining up of all 23 sets of chromosomes and 3 billion base pairs of genes to facilitate the cross-over of genetic material to make the new genetic code of this potential life. The egg has a battery pack called the mitochondria that provides energy for this process. The fertilized egg then travels down the fallopian tube for 5 days. 

After this 5 day journey, it enters the uterine cavity and within the next 2 days, it will hopefully find the right uterine receptor and start implanting into the uterine lining to establish a blood supply with its mother.  It is via this blood supply that glucose, oxygen, and the essential amino acids and energy are provided to the embryo and the embryo’s energy pack (the mitochondria) is no longer necessary.  If the energy pack is low, an embryo may not complete this process due to insufficient fuel. With IVF, we try to decrease the demands on the embryo.  For example, the embryo does not have to make this long journey down the fallopian tube and essential nutrients are provided to the embryo in the culture media the embryo is bathed in.

Fertility technology can improve some functioning deficits that need to occur to achieve pregnancy.  For the woman who doesn’t ovulate because the follicle stimulating signal is inadequate, exogenous follicle stimulating hormone can be given to cause ovulation (and even super-ovulation) to occur.  For men who have extremely low sperm counts, thus decreasing the probability that a sperm will make it to the upper reproductive tract to fertilize the mature egg, ICSI (intracytoplasmic sperm injection) technology is available.  This makes successful fertilization possible even if a man has only a single sperm, whereas with natural intercourse, a man ideally needs 20 million motile sperm in his ejaculate to statistically feel comfortable about the chances of achieving successful fertilization. 

If the uterine cavity has an organic lesion such as a polyp or fibroid or scar tissue, surgical removal of these lesions can be done.  Removing these lesions will improve implantation rates and blood supply to the potential fetus.

For couples who have all of the components to achieve pregnancy and have unexplained infertility, fertility treatment can increase the number of potential eggs in order to increase the chance of pregnancy on any particular month.  Increasing the number of eggs available also potentially shortens the time to achieve a pregnancy. 

Recent technological developments such as Pregenetic Diagnosis (PGD), provides objective data to help identify which embryos are chromosomally competent to implant.  As of very recent, the technology is now available to evaluate all 23 sets of the human genome.  Embryo chromosomal abnormalities are the most probable reason for unsuccessful implantation.  Mother Nature has a very good screening mechanism, which rarely allows chromosomally abnormal embryos to implant.  When chromosomally abnormal embryos do implant, there is also a higher likelihood of miscarriage.  While this technology is helpful, it is not 100% foolproof.  There are limitations to this technology due to embryo mosaicism (the 1 cell of the embryo that is biopsied may not be an exact representation of the genetic blueprint of the embryo’s other cells).  However, it does provide information that can increase the confidence level that the embryo being placed into the uterine cavity is genetically competent to successfully implant. 

All in all, Mother Nature does do a very efficient job when it comes to reproduction.  Our technology aims to improve Mother Nature’s deficits and increase the odds of achieving a successful, healthy pregnancy in a shorter time period than without the use of this technology. 

Cristin C. Slater, MD

                                                        ************************