PGD and Recurrent Pregnancy Loss

January 23, 2007 - Tuesday
1:03 PM to (EST)
Guest Speakers: Serena Chen, MD
Institute for Reproductive Medicine and Science of St. Barnabas

Categories
IUI • IVF • PGD • Pregnancy • Pregnancy Loss

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Corey_Whelan	Welcome to tonight's AFA Chat. I am Corey Whelan, The AFA's Director of Development and your moderator this evening. Tonight's topic is Recurrent Pregnancy Loss: Is PGD the Answer? We are very fortunate to have as our guest speaker this evening Dr. Serena Chen, the Director of the Division of Reproductive Endocrinology in the Dept. of Ob/Gyn at Saint Barnabas Medical Center. Dr. Chen is also Director of the Ovum Donation Program there. Saint Barnabas is located in New Jersey. Dr. Chen will be on hand to answer all of your questions on pgd. We welcome her, and all of you!
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Suzi	Has the chat started yet? Hi Dr. Chen, I would like to ask a question. I have a cousin with cystic fibrosis, a first cousin on my mom's side. Is this something I should be concerned about? I am ttc for one year and am starting to consider seeing a specialist anyway. Thanks!!
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Corey_Whelan	Welcome everyone. The chat has not officially begun as of yet, and Dr. Chen will be here in around five minutes. Please have patience and thanks to all of you for being here!
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Corey_Whelan	Welcome Dr. Chen!
jgwiggs	hello dr.chen
Corey_Whelan	I see we already have one question in the chat room. Dr. Chen, if you need to see it, press the action key and it will come up.
barnes	Do testicular sperm increase the chances of RPL? I’ve had 2 miscarriages following IVF, one following a day 6 transfer that resulted in a pregnancy with 2 empty sacs and a second miscarriage with trisomy 15. We’re wondering if testicular sperm could cause these problems, even though I know many doctors seem to think it’s due to age – I’m 35. Would PGD be helpful in identifying chromosomal abnormalities for us?
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staceylynne39	Hello, Dr. Chen.... can you comment on timing of transfer after IVF/PGD
Corey_Whelan	I think Dr. Chen may be having some technical problems guys. Let's give her two secs to catch her breath.
staceylynne39	ok....
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Serena_Chen_MD	hello - yes - some technical issues. I think I lost the first question.
Corey_Whelan	Let's move on. It was from Suzi, she can re-post it. Thanks, Suzi
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ahoos	I am 31 years old with 2 early miscarriages. I have a borderline FSH of 8-10 on Day 3. I have one failed IUI and am waiting for a cyst to clear up. My doctor wants to do one more IUI and then move to IVF with PGD. What are your thoughts on using PGD for women with FSH issues?
barnes	It seems like there are some studies that suggest that PGD isn’t helpful for PGD because of mosaicism that exists with day 3 embryos. Is technology really at a point where PGD makes sense for chromosomal abnormalities? My biggest concern is false negatives – especially if PGD results indicate I have with no normal embryos to transfer.
Serena_Chen_MD	Dear Staceytynne39 - At IRMS at Saint Barnabas, we prefer to transfer the embryos on day 4. This seems to work better (at least for us) than day 3 or day 5 or 6. Pregnancy rates are higher and less embryos are lost to arrest.
staceylynne39	ok thanks
JenD	Hi Dr. Chen - I am 30 years old, have had 3 early pregnancy losses, all occurring between weeks 4 and 5, no successful pregnancies. Working with specialist but have no explanation for cause of RPL. Am not being treated with anything yet, is PGD something I should ask my Dr. about?
staceylynne39	If a patient has done two cycles of IVF/PGD, and found no normal embryos in either cycle... it is fruitless to keep trying?
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Serena_Chen_MD	Dear ahoos; At this point, we have no data on FSH levels of 8 to 10. In our program, pgd might be indicated due to your 2 miscarriages. You should have testing for recurrent pregnancy loss to see if a cause for your losses can be identified. One of the most important tests is a karyotype for you and your partner.
ahoos	Thanks, we are both negative for karotype and my 2nd loss was Trisomy 13
cj	Hi Dr Chen - During PGD, what happens to any abnormal embryos?
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Serena_Chen_MD	Dear barnes: The answer to your question is complex. Each patient must be treated as an individual. PGD may make sense for some and not for others. You must take into consideration the program statistics, individual patient characteristics, etc. A false negative means that by PGD the embryo is considered normal, when some of the cells are abnormal. A false positive is when an embryo is considered abnormal when some of the cells are normal - in reality, these are not true false positives - if an embryo has at least one abnormal cell, it is abnormal. The rate of false negatives in our laboratory is about 2 to 3% - this rate differs from lab to lab. This is why PGD cannot be considered a substitute for Amniocentesis or CVS.
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barnes	Thanks - those error rates are smaller than I thought. Do testicular sperm increase the chances of RPL? I’ve had 2 miscarriages following IVF, one following a day 6 transfer that resulted in a pregnancy with 2 empty sacs and a second miscarriage with trisomy 15. We’re wondering if testicular sperm could cause these problems, even though I know many doctors seem to think it’s due to age – I’m 35. Would PGD be helpful in identifying chromosomal abnormalities for us? (sorry if this is a double post - I'm not sure if my first question got lost)
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Serena_Chen_MD	Dear JenD: PGD may be a reasonable option. Yes you should speak with your doctor about PGD. Also please take a look at www.serenachen.yourmd.com and www.sbivf.com for more detailed information about PGD for recurrent pregnancy loss.
moondreams	Hi Dr. Chen, I did IVF with good quality 5 day blasts and had a miscarriage at 8 weeks from fresh and a chemical pregnancy from frozen. Is PDF something I should look into before starting my next frozen cycle, or is that something that has to be done before the freeze? Anything else that should be looked into? Not sure what else I can do to maximize my chances of a successful pregnancy.
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Serena_Chen_MD	Dear staceyt: This depends upon the particular patient, her diagnosis, the embryo quality, response to drugs, etc. We do not have a lot of data on 2 cycles with no normal embryos. We have had patients who had babies after 2 cycles with no transfer. However, this must be an individualized decision. For patients doing PGD for age or miscarriage, after 1 cycle with no normal embryos, there is an 80% chance that she will have at least one PGD-normal embryo for transfer the next cycle. For patients with a balanced translocation, the chance is 65%
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Serena_Chen_MD	Dear ahoos: It would be reasonable for you to consider PGD. You should speak with your doctor.
staceylynne39	thanks Dr. Chen...
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ahoos	thanks
Serena_Chen_MD	Dear barnes: Yes testicular sperm does increase the rate of abnormalities. Your husband should have a karyotype done as the risk of him having a balanced translocation may be increased depending upon the reason for the lack of sperm. Age of the female is also a factor. Trisomy 15 is usually an egg factor.
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joank	Hi Dr. Chen, I am 35 and over the past 2 years I have done 5 IUI's which only resluted in 1 Pregnancy which ended around 5-6 weeks . I then did an IVF cycle and I got pregnant and unfortunately miscarried at 11 weeks- testing showed Turner's. Do u think I should look into PGD?? - Joan
barnes	Thanks very much.
Serena_Chen_MD	Dear moondreams: At this time, it is best to perform pGD on fresh day 3 embryos. There is very little data or experience with frozen embryos and even less with blasts, still less with frozen blasts.
staceylynne39	When doing IVF repeatedly, are a patient's response levels likely to change? (i.e. less responsive to protocols.)
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moondreams	Thanks.
michele	dr.chen, i have had two early pregnancy losses , the first was a chemical pregnancy , the second one was a miscarriage at 9 weeks , following th d&c it was found the fetus had an extra chromosome,. i am presently 7 weeks pregnant but the pregnancy is not progressing properly (empty sac) the doctor says it is probably chromosomal, will lose pregnancy. i am 38 years old and have been conceiving naturally. do you think i should look into pgd.?
cj	Hi Dr Chen, what generally happens to any embryos that are not considered "normal" or of good quality? Say 2 are good and 2 are not - what happens to the 2 that are "not"?
Serena_Chen_MD	Dear joank: You should have a complete evaluation for recurrent pregnancy loss by a reproductive endocrinologist. It would be reasonable to consider PGD for a balanced translocation or for unexplained recurrent first trimester loss. We think that the vast majority of these losses are due to chromosomal aneuploidy. Many women may have more than one risk factor for miscarriage. All factors should be treated.
Serena_Chen_MD	Dear staceylynne39: As a patient ages, response tends to decline. There is very little data on the effect of repetitive cycles. This does not really seem to occur.
staceylynne39	ok thanks...
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birgit	Hi Dr. Chen- How does PGD help (if it does) for advanced maternal age issues? I have had two cycles of stimulation/IUI with 3 eggd each time, but no pregnancies. RE believes sperm are fertilizing the eggs but they are not implanting because of AMA (I'm 44). RE recommends against proceeding to IVF because increased cost will not result in significant increase in possibility of success. Can PGD help?
Serena_Chen_MD	Dear michele: Yes, recurrent first trimester loss is usually due to aneuploidy. Therefore, PGD for aneuploidy should theoretically be beneficial. However, you should still have a full evaluation for recurrent miscarriage. Also, whether or not PGD is beneficial is very program dependant.
m_lachner	Hi Dr. Chen, I am 31 years old and have had three miscarriages all conceived through IVF. The first two at weeks 8 and 9 after heartbeats were confirmed via ultrasound, but babies were measuring small. The third miscarriage was with a frozen at 5 weeks. RPL workup came out normal. I do have a borderline FSH 11. Could the miscarriages be due to chromosomal anomalies due to egg quality? Is PGD indicated in my case? Thanks.
maddie1702	Hi Dr. Chen, I just turned 40. At 39 my 1st ivf misscarried at 8wks trisomy 10. no pgd. 2nd ivf with pgd 3 normal embryos ,did not stick beautiful 5 day blasts. 3rd ivf new pgd extended panel od 12,2 normal embryos transfered ,did not stick again great5 day blast. everything blood work ,genetics we test normal ! 4th ivf this past Nov before I turned 40. 13 eggs tested extended panel of 12. nothing normal to transfer in. All 13 were still blasting on day 5. So this time Doc. said I could try my own again. I said no thanks I am trying my sisiters eggs . She has two beautiful children and she is 30 yrs, Should I test her eggs with pgd if she has alot ? Thank you Maddie
staceylynne39	Dr. Chen... is there any research to indicate what causes poor egg quality... age is obviously a big factor...but why do you hear of some people in their 20's or 30's ?
Serena_Chen_MD	Dear cj: That depends upon the circumstances. If the embryos are abnormal by PGD they are not transferred. On the other hand if they are not tested, and the patient is of an age where it is appropriate to transfer more than 2 embryos, those embryos may be transferred. Again, the decision depends upon multiple factors.
Serena_Chen_MD	Dear birgit:
Serena_Chen_MD	Dear Birgit: At age 44 most eggs are chromosomally abnormal (aneuploid), so that PGD could be beneficial if you made enough embryos to perform embryo selection. If you only produce 3 eggs to maximal stimulation, the chance for pregnancy is very low, because there are so few eggs. In many ways, PGD helps you play the numbers game, if the numbers are poor, PGD may not be helpful. At age 44, donor egg is usually a much better option than IVF using your own eggs in terms of success rates.
michele	thanks
Serena_Chen_MD	Dear m_lachner - Women with a borderline FSH seem to have a greater miscarriage risk and a greater risk for aneploidy. Theoretically, PGD should be helpful. However, many women with an elevated FSH may not produce enough eggs for PGD to be beneficial. Also success rates are very program dependant. At age 31, with an FSH of 11, we would recommend PGD, but this may not be true of all programs.
Serena_Chen_MD	Dear maddie: Although young women can still make abnormal embryos, our data do not demonstrate a benefit to testing a young, fertile donor. If a patient requests PGD, we will do it, but it does not seem to improve the pregnancy rate in this particular situation.
cj	Dr Chen, To continue with my question, if the embryos are abnormal by PGD and they are not transferred...then what happens to them? Are they left to die, do they die on their own because they're abnormal? Is there any possibility of them living? If so, could they then be frozen for later consideration?
Serena_Chen_MD	Dear stacey; Poor egg quality is a very vague term that can mean many things and it is still quite a big mystery, even to the leading scientists. We believe that age can be a big factor, but you are correct, there are many young women who make very poor quality eggs. Most of the time we do not have a good explanation, although some risk factors are ovarian surgery, smoking, fragile x, balanced translocation, chemotherapy, radiation, severe endometriosis, etc. Most women with poor ovarian function are unexplained or due to age.
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staceylynne39	Thanks Dr. Chen.... poor egg quality is def frustrating to hear.... by the time you get that diagnosis, its too late to do anything about it.
staceylynne39	Dr. Chen, do most clinics that do IVF also do PGD? I heard St. Barnabas does some PGD for other clinic for example.
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ahoos	Dr. Chen, For egg quality issues, what is the pregnancy rate of IVF with PDG vs. just IVF?
Serena_Chen_MD	Dear Stacey: More and more programs are doing PGD every day. The number of programs that have facilities and staff extensive enough to do PGD "in house" is in the minority. We perform PGD in house and our PGD director, Dr Santiago Munne, also performs PGD for numerous programs across the country and around the world. However, statistics for PGD performed "out of house" in this way cannot be applied to "in house" statistics since there are numerous factors that impact upon the pregnancy rate and PGD is only one factor.
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Serena_Chen_MD	Dear ahoos: This depends upon why the PGD is being performed and the age and individual circumstances of the patient. In general, implantation rates can increase by 40% or more.
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m_lachner	Dr. Chen,
Ginachka	hello
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staceylynne39	If a patient has been preg but miscarried before trying IVF with PGD.... does this indicate a better likelihood of implantation?
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m_lachner	Dr. Chen, how can you tell whether a clinic has a good PGD program? If they don't what risks exist for the embryos if they are sent "out of house" for PGD?
cammyvu	Hi Dr. Chen. It seems that many doctors don't take m/cs seriously until you've had a few. I finally got pg with my second IVF cycle in Nov, but it unfortunately ended in m/c at 8 weeks (lost the heartbeat). I don't want to wait for subsequent m/cs to try to figure out what's wrong. I've requested my RE do genetic testing from my D&C, and I'm still waiting for the results. But is there anything else I can be doing to proactively prevent a 2nd m/c from happening next time? Is PGD beneficial after just one m/c or is it only done after recurring m/cs? I will be turning 35 in a fw months.
Ginachka	Dr. Chen if i had 1st IVF and it ended up in chemical pg does that mean that I should consider PGD
staceylynne39	In my case, I've had two miscarriages.... one IVF/PGD with no ET due to abnormal embryos... I keep wondering if my history of pregnancy (albeit failed), means something positive.
Serena_Chen_MD	Dear Stacey: In general, yes.
staceylynne39	Glad to hear that! ::smile
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Ginachka	Dr. Chen my doctor said that PGD decreases chances of implantation and unless there is a genetic disorder I should not do it
Serena_Chen_MD	Dear M_Lachner: The best programs perform PGD "in house". This means the program is seeing a large volume of PGD patients, has experience in performing the embryo microsurgery that is required and experience in reading the slides and culturing biopsied embryos. It also means that results can be obtained more quickly to allow for day 4, instead of blast transfer. This lowers the risk of embryo arrest after PGD.
bheit	Dr. Chen- What is the value of doing PGD if you've already done it 2x with results demonstrating Aneuploidy? We have not had a sucessful transfer.
Serena_Chen_MD	Dear cammy: This depends. PGD, like any other medical treatment, is not one size fits all. For some patients it may be beneficial after no miscarriages for some patients, it may make sense to wait until you have had 3. You should make sure you have a thorough evaluation for all identifiable causes for miscarriage before considering PGD.
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ch	Hi Dr. Chen,
cj	Dr Chen, if an embryo is determined abnormal through PGD and is determined not to be transferred, then what happens to it? Is it left to die, does it normally die on its own because its abnormal? Is there any chance of it living? If so, could it be frozen for future use?
Corey_Whelan	Folks, I want to give you a five minute warning. The chat ends at 9 p.m.
Serena_Chen_MD	Dear Ginachka: Not necessarily. For some patients this can be a good prognostic sign - a sign that you have a good chance of being successful with the next cycle. The chemical pregnancy can mean different things in different circumstances. Please sit down and discuss your concerns with your RE.
ch	I just did a pgd cycle and found out of 25 retrieved and 10 biopsied only 2 were normal. I am 41 and had a son via IVF no pgd 2 years ago. Do you think I could possibly have any normals left??
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staceylynne39	thanks for your time Dr. Chen.....
bella	Dr. Hello, I had a failed pgd report two weeks and ago and am trying to gear up for a cycle in Feb . I did not get a transfer. I am 39, have two daughters conceived naturally , male factor and 12 eggs ((9 fertilized) . The center that did the pgd only does 20 a month. We are so confused and distraught. It was my first ivf. We want to try again. Please help
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Corey_Whelan	Folks, we don't have time for any new questions, sorry.
cammyvu	Thanks Dr. Chen. I really love my RE and my clinic, but they don't do PGD in-house. If it's determined that I could benefit from PGD, would it be better for me to stay with the RE and clinic that I'm comfortable with and have them send the embryos out for testing (as long as they send it to a good, reputable PGD clinic), or would it be better to go ahead and switch to a clinic that does the PGD in-house? Any stats on which ones produce the best success rates?
Corey_Whelan	Please let Dr. Chen catch up with the questions on the board and we need to say good night. Dr. Chen, I want to thank you so much for taking your time to help us all here this evening.
bheit	OK,. Will Dr. Chen be able to answer mine?
marie	hi Dr.Chen. I've had pgd testing for 2 ivf cycles . . . 2transferred on 2nd cycle and 4 transferred on 3rd crycle. . . sadly no pregnancy. they tell me it's a protein defficiency in my uterus . . is there hope?
Corey_Whelan	I learned so much! Thanks to all of you as well.
m_lachner	Dr. Chen, Thanks for your time...
Serena_Chen_MD	Dear Ginachka: In some labs, this is true. When we first started performing PGD in the mid 1990's, we were worried about this. With time, improvements in technique, culture systems, patient selection, technology and experience, we have been able to significantly improve implantation rates in many, many patients. However, this is not true of all programs. At IRMS at Saint Barnabas, we are lucky enough to have a large embryology staff, highly skilled and experienced at embryo microsurgery and we do a very large volume of PGD each year. Still, even here at Saint Barnabas, we do not recommend PGD for all patients. There are many patients who will not benefit from PGD. This must be a careful and individualized decision.
cammyvu	Thank you so much for your time, Dr. Chen!
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Corey_Whelan	I want to thank you all for asking your questions - you teach us all when you ask. Our chat is officially over and I wish you all the BEST OF LUCK!!!!
ahoos	thanks!
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bheit	I didn't get a response.
Serena_Chen_MD	Dear bheit: It would not be fair to answer this online. This is a one on one recommendation made after a careful assessment of your previous history and review of your medical records. If you want to have a consult, we can do one in person or by phone. Check out www.sbivf.com for more information.
bheit	Thank you. That's what I figured. Do you see a value in doing IVF without doing PGD?
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bella	Please respond . Bella. We can afford three more tries at ivf.
Serena_Chen_MD	Everyone - Thanks so much for having me here tonight. You all asked some excellent questions. Sorry I will not be able to answer all of them. We do answer questions on our message board at www.sbivf.com, so please visit us when you have a chance. Take care and best wishes to all of you!
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cammyvu	thanks Dr. Chen
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cj	Thanks Dr Chen
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Siamak_Bashar	HI, Every Body
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PGD and Recurrent Pregnancy Loss

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