Dr. Khurram Rehman has been Rated the Top Reproductive Endocrinologist in WA

I have the distinct pleasure of announcing that our very own Dr Khurram Rehman has been rated the Top Reproductive Endocrinologist in Washington State for Winter 2013 by Healthtap! He is also their highest rated expert in the nation for the topics of fertility, infertility, female infertility, and fertility treatment.

For those of you who are not familiar with Healthtap, it is a medical Q&A website that specialized in connecting patients and doctors. It allows patients to ask questions and receive answers from real doctors. Questions are usually best kept brief, and the service is not meant to be a replacement for an office visit, but it allows users to receive professional answers to their questions.

So check out Dr. Rehmans Profile, ask him a question, or just browse some of the community answers about infertility, or any other medical topics. If you do happen to make it over to the site, be sure to vote for Dr. Rehman!

We also have our own FAQs section on our website and with it the ability to ask our doctors fertility related questions. So if you have any questions don’t hesitate to head on over and ask your question!

Curious About Gender Selection?

family balancing

It is now possible to select the gender of your next child. Image from sheknows.com

So you have a pink nursery and are surrounded by dolls and dresses but you really want a boost of testosterone in your house, or maybe you want to break the rough and tumble life and stop having to buy band aids in bulk. OK, so maybe that was a little stereotyped, but you get my point – you want to mix up your kids a little and really don’t want to keep taking the risk that nature might not be on your side.

There have been so many old wives tales over the years about the best way to guarantee the gender of your baby – from diets, to sexual positions to who climaxes first but now we really can help you get the gender that you want to balance out your family if you wish.

The procedure is not easy, and neither is it cheap but for some patients it is definitely the right decision to make. We will be able to help you make that decision during your consultation with the medical staff here.

In order to do family balancing you will need to undergo an IVF cycle and then on day 3 when the embryos are at the 6-8 cell stage we will carry out PGD, where a single cell is removed from each embryo and then that cell is analyzed to see if it came from a male or a female embryo. It is then possible for us to relate that information back to each embryo and thus select the required gender for transfer.

The gender of any particular embryo is determined by the sperm – all normal eggs will contain a single copy of an X chromosome and then a normal sperm will contain either a Y chromosome or an X chromosome. To make a female embryo then the sperm that fertilizes the eggs needs to contain an X chromosome and to make it male it will have a Y chromosome.

Statistically speaking when sperm are created the distribution of X and Y chromosomes is evenly spread and so there should also be an even distribution of male and female embryos created as well. That being said, during an IVF cycle we cannot guarantee that this will be reflected in what we see. A good example of this is the fact that when you toss a coin you will eventually get heads 50% of the time and tails 50% of the time, but it is quite probable to get 10 heads in a row on the way to getting that equal distribution.

There are a lot of hurdles during an IVF cycle for anyone, but when we are doing PGD for family balancing purposes they can be magnified in some cases. In a regular cycle there is always a drop off from the number of follicles recruited to the number of eggs retrieved, fertilized and then making good quality embryos. As far as PGD is concerned there is also the fact that the embryos have to have reached at least the 6 cell stage to be really appropriate for biopsy and then develop all the way to a blastocyst ready for transfer on day 5.

There is also the fact that there is a chance that the embryos that look most appropriate to be transferred are not of the desired gender at all or even that the only embryos that we obtain may be of the opposite gender to that which you are looking for. In these cases you will have to make a decision as to what to do and that decision will have to be made within a matter of hours due to the timing of the transfer.

That all being said we have had many successful cases where the desired gender is obtained and the couple achieves a pregnancy. For more details please make an appointment for a new patient consultation and also check out the other information on the web site regarding IVF and PGD treatments.

Learn More About PGD

Preimplantation Genetic Diagnosis

PGD in action: a single cell is being removed from the embryo so it can be sent off and biopsied


I get a lot of questions from both current and prospective patients about PGD, or Preimplantation Genetic Diagnosis. With good reason too. PGD is a complex procedure that can greatly affect the outcome of a patient’s IVF cycle. In order to potentially answer some of these questions I wanted to write up a more detailed piece about the procedure. So without further ado…

What is PGD again?

It is possible to remove genetic information from embryos during certain phases of their development and carry out testing on that cellular material.  One stage that this can be done is on day 3 when an embryo should be between the 6-8 cell stage, and taking this cell from a  developing embryo during treatment has been shown to be ‘completely safe’, according to the largest study of babies born following this particular technique.  PGD done at this stage is often preferred as it allows for the results to be obtained by day 5 and a fresh transfer to occur.

It is also possible to remove multiple cells from the trophectoderm of a day 5 blastocyst. If the results are going to be back the next day (can vary depending on what we are testing for) we can transfer fresh embryos to the uterus on day 6. If the results are not going to be back in time for a fresh transfer we would then vitrify (a method of freezing) them and possibly transfer them on a subsequent FET (frozen embryo transfer) cycle if the results came back as desired.

PGD can help doctor’s spot diseases, chromosomal abnormalities and even gender before deciding which embryos to transfer during fertility treatment.  However, there have been concerns about the safety of PGD, but recent studies have reassured people in the field.

It has suggested the risks of low birth weight, premature birth, major malformations and the perinatal death rate is the same as for other forms of IVF.  This would suggest that embryo biopsy does not adversely affect the health of newborn PGD children.

So, what can we test for as far as PGD is concerned?  There are a huge number of diseases and conditions that can be tested for, including many forms of translocations and other genetic errors.  To some degree as long as it is a test that can be found by doing any form of post pregnancy testing, such as an amniocentesis, then that same test can be applied to PGD.  It is also possible to build a specific test using cheek swab samples taken from a couple, so total customization is possible.  We currently work with a number of different testing laboratories and if you have concerns about whether the condition you wish to be tested for is available we can direct you to the appropriate genetic counselor to discuss it further with them.

What do I do if I want PGD?

If there is a need to build a probe specific to you then this process can be very involved, and can expect to take at least 12 weeks.  It is important to make sure that the probe can be reliably used to identify the condition and that there are specific markers that can be used to check this.  The best advice is to initiate the probe preparation step as soon as possible and then work on the rest of your IVF work-up.  However, you cannot start your IVF cycle until we have been given the OK by the testing laboratory to make sure that the probe is ready.

There are risks associated with this treatment, as there are with all forms of medical treatment and these will have to be weighed up against the benefits that you might gain.  These are really best done on a case by case basis with the medical staff here and the genetic counselors at the PGD testing laboratory.

The next step after you have met the doctor and made the decision to undergo PGD for any reason is to meet with me to go over the paper work and consent forms that are required.  During that meeting I will be able to go over all the finer details of the treatment that will happen in the laboratory and the time frame for getting results.  Although I won’t be able to answer any medical questions but it will be a good opportunity to discuss any concerns that you might have about the different laboratory procedures that will happen, and also talk about the different stages that the laboratory will be in contact with you.

During the actual laboratory procedures great care is taken to make sure that the embryos themselves are allocated a totally unique number to identify them and that this number is assigned to each cell that is removed from it.  During the biopsy and each and every time that an embryo is moved after the biopsy is taken place this procedure is witnessed by an additional staff member to assure that the integrity of the numbering system is maintained.  That way you can be assured that the PGD results obtained actually relate to the correct embryo.

What else should I know about PGD?

There are limitations to the procedure and various hurdles that have to be gotten over on the way to undertaking a PGD cycle.  We currently recommend that the minimum number of embryos to proceed with the case is 6-8, but this is very case specific and the final decision is left to you.  The reason for having a minimum is the fact that there is a damage rate associated with the biopsy and that as well as getting an appropriate PGD result the associated embryo has got to be suitably developed in order to be used for a transfer.  Taking this into consideration the risk of not having anything to transfer is greater with a lower number of embryos to biopsy.

It is also possible to carry out PGD on embryos that have been previously frozen, whether they were frozen at the 2PN, cleavage or blastocyst stage of development.  The procedures for the biopsy are the same, and the timing of all the different aspects of the treatment are going to be dependant on the stage at which they were frozen.

This is an exciting new field that has a lot of possibilities for improving outcomes for patients, and we are very happy to be keeping at the cutting edge of treatment.  For the latest developments and treatment options relevant to you please contact the clinic directly.

Cheers!

Our New IVF Lab is State of the Art!

embryology-lab

Our new IVF lab, isn’t it pretty!

The ability of a reproductive health practice depends not only on the skill of the clinical team from the doctor and embryologist to the nursing staff and modern pharmaceuticals but also on the IVF lab.   A properly designed and operated IVF laboratory  is a critical factor and has a significant impact on the probability of going home with a healthy child.

Mother is the gold standard for human reproduction. Not only does she generate the eggs but, after fertilization, she has a number of methods to nurture the embryo. Besides providing nutrition and oxygen, she performs other functions. The ability to grow an embryo in the modern IVF lab is a tribute to the robustness of the embryo. Mother also can protect the growing embryo from toxic materials in the environment.

The newly fertilized embryo is just starting to express its genetic information, the cells are rapidly dividing. The mother embryo combination has several mechanisms to protect the embryo. The mother’s liver will detoxify many of these toxic materials.  Her kidneys will excrete the wastes. The lungs can also act as an excretory mechanism. Traditional in vitro fertilization (IVF) labs often lack a control mechanism to protect the embryo. These labs tend to be less productive compared to modern, state of the art facilities.

When we decided to move into a new facility last year it gave us the opportunity to completely redesign our IVF lab from the ground up. This attention to detail allowed us to achieve levels of volatile organic compounds (VOCs) that are remarkably low compared to what would be seen in older practices. How is this done you ask?  We now have the ability to incorporate a detoxification system into modern laboratories that removes many of these potential toxic agents.

The laboratory is designed as an isolated series of rooms. The air supplied is filtered and also passed through a large robust chemical filter using activated carbon and potassium permanganate. The heating and ventilation system is designed and built to a high standard and scrupulously cleaned. The materials in the lab are also carefully selected so they don’t off gas (release) any toxic materials.

One such example is the material found in most homes. You know it as Formica. It is made of particle board which is held together by formaldehyde glue. The formaldehyde is used to preserve medical specimens and embalm bodies. Obviously formaldehyde is highly toxic to the naked embryo. All of the materials in the embryology lab have a very low potential of releasing a contaminant. The lab is positively pressurized. The rooms are sealed so that they are physically isolated reducing the level of organics.

There is a final special feature of this lab. It was rigorously tested and cleaned with special cleaners. As a result, the air in the facility is uniquely clean. The average traditional lab has over 3,000 plus micrograms of potentially toxic materials.  This is based upon the pioneering work of Dr. Jacques Cohen. The contaminants range from formaldehyde, chlorinated hydrocarbon, benzene, styrens and many others, which are potential estrogen disrupters. We dramatically reduce these agents. A recent independent, third party testing of our new lab resulted in no detectable levels of volatile organic compounds!

Our lab is state of the art, and provides a level of cleanliness that is unmatched by any other lab in the area. This is just one example of our commitment to excellence. A commitment to provide all of our patients with the best possible chances of success.

None of this comes cheap. Despite this, we have the best and most affordable financial programs available. Our IVF witness program, a RFID system that electronically tracks all patient samples during IUIs and IVF treatments, is another example where no expense was spared to ensure the utmost peace of mind of our patients. If we positioned ourselves as the cheapest program in the area, none of what you just read would be possible. Remember, small is good, but with cheap… well you get what you pay for.

What Did You Just Say? IVF Vocabulary Explained

IVF vocabulary

Confused about something we said? Learn what some of the common infertility terms mean. Image from essentialbaby.com.au

So you have embarked upon your IVF cycle here with us at Overlake Reproductive Health and you have been bombarded with a lot of different information. You were given a folder full of pieces of paper with news about blood draws, injections, scans and preparation for a full blown assault on your body. In the midst of all that is an online video for you to watch and a consent form for you to read and make an appointment to sign it in the office. The amount of homework you have to do might make you feel like you are back at school, but we are here to help you every step of the way.

Throughout the course of your treatment here there will be a lot of medical terms and acronyms thrown at you. You will have probably heard a few of them before, but just in case I wanted to explain some of the terms we will be using. If you are feeling a little like you are drowning in a medical soup, don’t worry, you should be up and treading water by the time I am done with you. I will be highlighting some of the more important terms and describing where in the process they will be coming up.

First of all there is the biggie – “IVF” or the test tube baby process itself, which I am sure most people have heard of by now. It stands for In Vitro Fertilization – the in vitro part being Latin for ‘in glass’. Now there are not many people that even use glass dishes anymore, but in vitro has become a phrase for any medical or scientific procedure that occurs outside of the body and in the laboratory. The test tube baby phrase itself is also a little of a misnomer as most people probably use dishes rather than tubes these days as well.

IVF not only stands in as a blanket term that covers everything, from blood draws to laboratory work, that are carried out over the course of a few weeks to get you pregnant but also to signify one way in which the eggs can be fertilized after the retrieval. What we mean when we say ‘IVF fertilization’ is that the sperm will be prepared to a specific concentration and then just added to the dish with the eggs and allowed to get on with its job of swimming to the egg and fertilizing it. This is opposed to ‘ICSI’, which stands for Intra Cytoplasmic Sperm Injection which is utilized when there are either a low number of sperm, they are not swimming very well or there have been previous fertilization issues seen. With ICSI we actually isolate and pick up a single sperm which we inject right into the egg to allow for fertilization to take place. Allowing many more couples the chance to conceive their own biological offspring than would be possible with just IVF fertilization alone. Pretty nifty, if you ask us!

Moving on to the egg retrieval day, we take oocytes (eggs) and then add the sperm to fertilize them. We check to see whether they have fertilized the morning after the egg retrieval, which the laboratory refers to as day 1. At this point in time we are looking for the evidence of pronuclei. The pronuclei (or PN) are the nucleuses, the structures that hold the genetic information of both the sperm and the egg, and they signify that fertilization has taken place – they can be seen about 18 hours after insemination. Sperm and eggs are haploid – they only have half of the genetic compliment of chromosomes that are needed to make an embryo so after the appearance of the pronuclei then they will fuse and the embryo (fertilized egg/oocyte) is on its way!

The egg is made up of a few different components, the most important of which you need to know about are the zona and the cytoplasm. The zona is most easily referred to as the shell of the egg – it is the outermost level that keeps the embryo intact until it completes division and hatches or breaks free ready for implantation. The other part is the cytoplasm which is a gel like substance surrounded by a membrane that comprises all the necessary components of the cell including the nucleus.

The next stage for the little embryo(s) is to cleave or divide which happens numerous times over the next few days while they are here in the laboratory with us. The first division is when the contents of embryo split into 2 parts – the chromosomes (cell blueprint) are duplicated and then they are split so that each of the 2 halves has the same number of chromosomes. This division continues as each cell duplicates and then divides. In this way the number of cells continues to double, ending up with 2-4 cells on day 2 and then 6-8 cells on day 3.

Next up, we will bring you into the clinic on day 3 to talk with you about your embryos and try to help you decide how many and when you should transfer. Your embryos will have been graded at this point and so will have been allocated a score based on the way that they have divided. We will have assessed the percentage of fragments in them as well – the less fragmentation the better. I liken fragments to breaking a bread roll and getting crumbs, as in when the cytoplasm divides there can be small parts of it that falls apart. Some fragmentation is OK, so don’t worry if your embryos have this happening.

The next major developmental stage for the embryos is the blastocyst which occurs by day 5 and is the last stage of development that we culture to before either transferring back into the uterus, or freezing for a future FET (frozen embryo transfer). In general a human blastocyst contains about 70-100 cells, and at this stage they have differentiated into 2 distinctly different cell types. There is the inner cell mass which is a tight bunch of cells that actually becomes the embryo. Meaning it becomes all the structures of the actual baby. The other area is the trophectoderm, which is a single layer of cells making up the spherical shape that works to implant the embryo onto the uterus and is integral in forming the placenta.

I hope this was helpful to explain some of the terms we use around here. If you have a term that you are confused about you can check out our glossary or ask in the comments below.

Cheers!

Why the IVF Laboratory is Vital to Patient Success

The embryology laboratory is a huge part of ensuring that the very best chance of success is achieved in any given IVF cycle. What goes on inside the embryology lab is often the overlooked piece of the equation for IVF success.  A superbly designed and run laboratory is a critical component in making sure that there are healthy embryos to put back on transfer day. Unfortunately, most IVF labs have significant design flaws.

A partial list includes of common flaws include:

  • Lack of complete isolation from surroundings
  • Insufficient level of positive pressurization
  • Lack of chemical filtration or a chemical filter with insufficient residence time
  • Inappropriate materials in construction
  • Low ventilation rates
  • Bypassing of particulate or chemical filters
  • Contaminated or compromised source of supply air
  • Designs which render maintenance difficult or impossible
  • Lack of isolation of the fan motor from the air steam.

These flaws can all contribute to greater circulating levels of volatile organic compounds (VOCs), and other contaminants inside an IVF lab. VOCs can be harmful to the growing embryos and have been found to severely reduce success rates.

The IVF laboratory must also provide a microbiologically clean environment to insure that cultures are not contaminated by molds, bacteria, and viruses because the presence of such contaminants has also been linked to significantly reduced success rates. To that end, Overlake Reproductive Health has spared no expense to create a world class laboratory, most assuredly the best in this area of the country. Design specifications included strict attention to the following parameters.

  • Temperature stability
  • Ventilation rate
  • Relative humidity
  • Pressurization
  • Isolation
  • Low VOC levels
  • Low Aldehyde levels
  • Low Particle counts
  • Mold reduction
  • Chemical Filter Residence time
  • Noise Level
  • Lighting Level

By paying strict attention to these details we were able to build, from the ground up, a state of the art IVF laboratory. A laboratory that can ensure the highest levels of success for your embryos. We didn’t stop there. In our pursuit to provide the best possible environment for the developing embryos we also looked at optimizing the culture conditions.

Culture conditions are also important to the development of your embryos. With modern technology we are able to achieve conditions that closely emulate a mother’s uterus, which is the ideal environment for growing embryos. To that end, using a tri-gas culture system that controls oxygen levels is critical.   Use of liquid, highly purified gas is not inexpensive, but also critically important to properly maintain gas levels in the incubators. Finally, an incubator system with individual chambers and drawers for embryos is important to minimize temperature and gas fluctuations which fluctuate dramatically if a large standard incubator system is used. When we moved into our new lab we were able to acquire the best individually chambered low-O2, humidity controlled incubators available in the world.  Much to the delight of our lab director, Shaun Kelly.

ivf incubator

The best darn embryo incubators money can buy. Image from astec-bio.com

None of this comes cheap. Despite this, we have the best and most affordable financial programs available. Our IVF witness program, a RFID system that electronically tracks all patient samples during IUIs and IVF treatments, is another example where no expense was spared to ensure the utmost peace of mind of our patients. If we positioned ourselves as the cheapest program in the area, none of what you just read would be possible. Remember, small is good, but with cheap… well you get what you pay for.