Episode 25: Chrissy Teigen & Embryo Testing (PGT)

Dr. K and Dr. Reed discuss how celebrities like Chrissy Teigen, the Kardashians, and Paris Hilton used embryo testing (PGT) during their fertility journey. They talk about what PGT is, who it is recommended for and what the recent studies are showing. 

Transcript

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Hi, I am Dr. Beverly Reed and I'm Dr. Amber Klimczak. And we are Two Peaks in a Pod. Well, guess what today is? I have no idea. It's our one year anniversary! Oh! That's when we opened! I didn't even realize! We did it! Happy anniversary! I'm the partner! We forgot anniversary! I was like, oh no, I don't even know what the date is! Yes! Well, if you remember last year, you kind of got a little bit of a head start. You started seeing some pictures virtually in January. But my first day was February 1st. Yes, that is really exciting. It's not like it's been a year. You know, and I was looking back at photos and everything and one year ago, you could see, you know, no floors here in the building, dust everywhere, cabinets just bleed about. And it just showed me, I'm like, wow, look how much has happened in one year. But also on our patient side of things, it just made me think, what can happen in one year's time for our patients? I know. Maybe next year, our patient's going to be holding their baby. It's really fun. Just recently we've had some people message in labor. Yes! One of your patients messaged in labor, like, shouldn't you be delivering your baby? But she was so excited to tell you that she's delivering. We have, and I just got a baby picture last week. Yeah! From one of our first babies. Oh my gosh. So rewarding. So we've been open like just enough time to see our first pink babies. Yes. Oh, it's just been the best. So congratulations and happy anniversary. And then hopefully we'll have many more to come. I'll mark the calendar next year. Yes, that's right. Make sure I have a card ready. I know. Well, actually. Actually, it's really funny because I was looking up because I wanted to be cute and like get you a gift, but it didn't happen because we're so busy. But I was like, I think what we should do, I think I'll get you a late gift, um, is like every year it's, you know, like when you're married, it's like a certain thing. Oh, yeah. Paper. The first year is paper. Yes. Yeah, yeah. I was like, what can I get for paper really fast? I'll get you a delayed gift. I thought you were going to say that one year ago we still looked the exact same as we do now. I'm feeling much more stressed now. Not that our building looked different. I thought you were going to say we look just as youthful as last year this time. Yes, that's right. You know, I've been shooting myself up with slow talk. I probably look better. No, I'm just kidding. Okay, so who are some of your favorite celebrities? Oh gosh. Okay, you know, this is a hard question because there's some that I am entertained by, but it's not like I'm, you know, look up to them necessarily. That's true. I feel like that's a tricky question. That is true. You like T Swift a lot. I do. I love Taylor. Actually, I just posted on my Instagram. Did you see my? Yes. I'm trying to get Taylor and Trav to come free some embryos with us. Here's the thing. They're in love, but they got a lot going on. And I just think they don't have time for babies right now. Right? Definitely. I can't wait to see their babies. I think she's probably frozen eggs. She's very savvy. Probably, yeah. She's very savvy. So I think it would be good to put some embryos on ice and I was even going to come up with a schedule for her around her tour dates. But I don't know, she didn't reply. Rude, right? That's very rude. We'll reach out again. Maybe direct message her. Yeah. But I do, some of my favorite celebrities are ones that talk a lot about fertility and I appreciate that so much. so much because they really normalize it for our patients. That makes our patients not feel very alone. So ones that have been really open about IVF, for example, are Chrissy Teigen and the Kardashians, multiple Kardashians. Yes. Paris Hilton. These are all ones that I think, um, have been really helpful to just talk through it and share their experiences with patients, which I think is great. Yes. Well, I find Chrissy Teigen, especially entertaining mainly because. I, like, I like to follow her on Instagram, like, I just think she's entertaining, she posts funny things, you know, and she just lives, like, a traditional celebrity life, she's always doing, like, really cool things that I'm jealous of. Um, but, Chrissy Teigen, like you were saying, she's also struggled with fertility and has been down quite a bit. Quite a road. Yeah. I think with just pregnancy in general and fertility. Um, but one of the things that she was open about is that with her, I think it was actually more so with her second round of IVF. Mm-Hmm. She did choose the gender.'cause she had a girl first. Mm-Hmm. And then I think prob, my guess is they probably wanted a boy. So they did elect. to choose the gender of the embryo. And so I thought we could talk a little bit about how you do that. What is genetic testing? Is it really for that or is there more of a purpose behind it and why we do that? Um, so this kind of testing is called pre implantation genetic testing for aneuploidy. Um, so do you want to talk about what we. Actually do it for Yes. Well, and actually first I would even say too, because apparently our field loves to confuse patients. the name of this has changed throughout the years. that's true. Um, even just a couple years ago, we had different terms for it, but the updated terminology is we use an acronym called PGT. dash a. So that's kind of really what we're going to be focusing on. Now there are other, are other types of genetic testing too. And that's going to go beyond the scope of today's podcast. And maybe we'll talk about that on a different podcast, but today we're just taking, doing PGTA. And so what that means is whenever you have an embryo, there's different parts of the embryo. There's the part that's going to become the baby. There's the part that's going to become the placenta, which supports the pregnancy and current technology does allow the embryologist to take a very small sample of those cells that are going to become the placenta and we can send them off to a lab somewhere else. And that lab is able to do screening to see how many chromosomes does each embryo have. So for example, we all have 46 chromosomes where we got half from our mom and half from our dad. But when the egg and the sperm come together, sometimes nature makes a mistake and it gives the embryo too many chromosomes or not enough. And so that's what we typically would call an abnormal embryo. And that is what PGTA can screen. Right, I think that's such an important designation to know that really what are we attempting to do is we're trying to look for abnormal genetics in the embryo, in the whole genetic code, not just the the gender, right? Of course as a byproduct we're able to see because where do you get your gender from? Either two X chromosomes or an X and a Y chromosomes, we are able to tell what gender these embryos are going to be and sort of gender selection from IVF has become a byproduct of what we were really doing to test for healthy pregnancies ahead of time. Yeah, and I think there's a couple things that I always like to just tell my patients about because sometimes when we talk about genetics, it can feel so confusing. One of the things that patients will ask me is, okay, If I have a normal embryo, does that guarantee me my baby's going to be normal? And I say, well, no, because we're only checking the chromosomes, the number of chromosomes, but each chromosome has thousands of genes on it. And our technology is not to the point where we are routinely checking. every single gene on every single chromosome. But that's why we like to offer genetic carrier screening to our patients kind of when they first see us. Because if we do know that our patient and the partner, the sperm source, if they both carry the same gene, for example, cystic fibrosis, our technology does allow us to go in and Pinpoint a single gene, but it's really something you have to know ahead of time and, and also plan for. Um, I will say though, I used to say the technology wasn't available to check all the genes, but guess what? I don't know if you saw this, but in the news I saw the technology is available, it's just not widely used, right. Um, and it's expensive. Um, the technology does check all the genes, but it is$2,500 per embryo to do the testing and. The problem is we don't even know what to do with all this, this information, right? Remember, our field is young. In medicine, we don't even know what all the genes do, So sometimes your embryo could come back with some sort of abnormal gene. We may say, well, it's abnormal. We don't, we don't really know. Does this cause a medical problem or not? We don't know. And so. A lot of people are rather resistant to even doing all of that testing because they don't want to stress you out if they don't even know if certain mutations may cause an issue. Right. The way I compare it for my patients to really make it easy is I say, okay, this type of genetic testing for your embryo is like looking to make sure that the whole street is there or not. And you can imagine your chromosome is like the street and then the genes are like the houses on the street. So we only know that the street is there. We don't know that, you know, house number 10 is present or absent. We don't know. We just know that the street is there, but we're not really sure about the houses on the block basically. Yeah, that's a great way of putting it for sure. And then there are other things too that can go wrong with a baby or pregnancy. You know, for example, um, you know, sometimes just in during pregnancy. The baby may, um, have some sort of problem because, you know, the mom's, the baby's placenta didn't grow properly. It's not nourishing the baby correctly or things like that. And maybe that doesn't have anything to do with genetics in that case. Um, so it is just important to know that although we use screening to try to give you a better chance of having a healthy baby, it's never guaranteed and never a guarantee because other things can happen too. Right. Yeah. And we've talked about this a little bit, but what does PGT really help us to do in the setting of IVF? There's been pretty good studies to show this. It's never going to make your embryo better than what it was there. It's just showing us whether it has a normal set of genetics or not. So what the studies really show is decreased rate of miscarriage, which makes perfect sense. We've talked about how The number one cause of miscarriage is abnormal genetics of the baby or the fetus. And the number two, it's a faster time to pregnancy because it kind of tells us ahead of time, Hey, this embryo is very likely to implant and make a life healthy baby. So it allows us to select the embryos in the proper order. So faster time to pregnancy. lower miscarriage rates are definitely the utility in using genetic testing. Yeah. Um, so I wanted to know, who do you offer PGT A to? Um, and what is your recommendation for patients who say, should I do PGT A? Yeah. I actually offer it to all my patients. Um, I don't withhold it from patients and I explain to them what it means because I really think that the patient should have the option to do it if they want. they're interested in it. And every once in a while, it kind of triggers patients to tell me more information about themselves that they, you know, Oh, I have, you know, this and my family or something. I hear, I hear a lot more about their genetics when I tell them about it. So I always think it's helpful to offer. Um, and really who, who do I strongly encourage to do it for my older patients? So really 35 and older, that's sort of that age where we start to worry that your eggs are more likely to make genetic disorders, make have abnormal number of chromosomes when they're starting to pull apart and split more likely to have an embryo than that has an abnormal set of chromosomes. So those are my patients that I really recommend it for, but I really would allow any age patient to do it. And I do have younger patients that do it as well. Yeah. Yeah. Well, and here's the thing. We know that as we get older, the proportion of embryos that we make that are abnormal increase. So let's take me as an example. I'm 44 years old. If I did IVF right now, we would expect over 90% of the embryos that I make to be abnormal. So surely if somebody like me was gonna do IVF, you'd really wanna do embryo testing so that you make sure you're putting in an embryo that has a normal set of chromosomes. But to be extreme, let's take say we take somebody way younger. Let's say somebody who's 30 years old, okay? Proportion of embryos that we can expect to be abnormal would probably be about 30%. So way better than mine, 90%, okay? But here's the thing, I and really other people are often surprised, wow, when you're 30, 30 percent of your embryos are abnormal? That seems so much higher than you would think. And of course you have to wonder, if it's that high, why are we not seeing people with abnormal babies or, or things like that? And really, here's the reason why. If we were to put an abnormal embryo into the uterus, the vast majority of the time, it doesn't stick. You just don't get pregnant, or even if you do get pregnant, it will miscarry. Only rarely is it able to make it all the way to term, but if it does, that could be cases like Down syndrome or Turner syndrome or things like that. And so I think people are always kind of surprised when they see, even in a younger population though, The proportion of embryos that we make that are our normal is still pretty high, a third. Mm hmm. And what happens sometimes for my younger patients is they make a lot of embryos. Right? And so then it is like, you know, a selection technique. They want to get pregnant quickly. And there is still, like I said, a 30 percent chance that we don't. Pick the right embryo. So sometimes they're just like, yeah, I wanna get pregnant quickly. I don't wanna have a miscarriage. So it makes sense for them to do genetic testing. Absolutely. And so, um, I would say in general, when you talk to a fertility doctor, most of us, if you are 35 and above, are going to recommend you do genetic testing. There are some people who don't follow that, but that would say most of us. Um, I would say most less than 35 will actually say you may not need it. But similar to Dr. K, I offered to all my patients too. And actually over time I've been encouraging it. And here's why I actually looked at my own data, all of the embryo transfers I had ever done for years and years and years. And I looked to see what happened and what I found matched the studies out there. Patients where I did an embryo transfer. with a genetically tested normal embryo had a much lower chance of miscarriage. And when I really kind of thought about the patients that had used, used untested embryos and about just the pain of that journey, it was heartbreaking because I really am so empathetic. I go through that journey. You know this too. We both do. We go through that journey with our patients. It is awful. And I really thought, gosh, if I could prevent my own heartache and my patient's heartache by doing embryo testing, like, why would you not want to do that? You know? And. Um, and what I've really found too is whenever I'm doing fertility treatment, it's really for two reasons. It's of course to help my patient get pregnant, but it's also to help us figure out why she's not getting pregnant on her own. And let's say I have a patient who, you know, let's say she's 30 years old. She responds great to Clomid. We did IU eyes, her lining was great. She grew multiple eggs. She's not getting pregnant. Her IVF cycle went great. Of course, I'm sitting here wondering, where is the problem, right? And so I do think it's important in those cases to do genetic testing because maybe the problem is you're making a higher proportion of abnormal embryos compared to other women that might be more average to your age. And I think it's really important, too, because when we get to the part where we're actually putting an embryo in, we're doing the embryo transfer part, What if it's not working, right? And so then the first thing if you have untested embryos is if it's not working, I'm going to say maybe it was an abnormal embryo and we just don't know it. And so when you're using a normal embryo, that really takes out a large part of that factor. Not to say that a normal embryo can't have other things wrong with it, but It really takes out kind of the number one factor that can contribute to implantation failure in that scenario, and I think that's so helpful with, um, troubleshooting it. Yeah, definitely. I think there's one particular scenario that I do encounter every once in a while that I counsel the patient a little bit differently, and that is when my patient makes one embryo. Mm hmm. Mm hmm. Um, so a lot of times if my patient ends up with one embryo, I may encourage them in general to cycle again and try and bank up more embryos so we have a chance. You know, a chance at success with Mm-Hmm. one of the other embryos as well. Mm-Hmm. Right. But not everyone can do that. IVF is expensive and sometimes it's people's one shot. Mm-Hmm. And if you just make one embryo, that's when I really do talk to them again about how we're not gonna make your embryo better. Yeah. By testing it. Mm-Hmm. Okay. Um, and so what. What should we really do in that circumstance? And I do counsel them, Hey, if this is an abnormal genetic embryo, most likely it's not gonna stick. Or you could have a miscarriage. Mm-Hmm, which again, really can be traumatic. Or worse, you have an ongoing pregnancy with abnormal genetics, so there are risks involved to it, but sometimes those patients opt to not test it, like it's my one embryo, I just want to go for it. Um, and the question that they always ask is, is it going to harm my embryo to test it? You know, like I definitely don't want to do it if it's my one, if it's going to hurt it, right? Um, and so I think it is important that we talk about a really nice study that was done on this, um, that demonstrated that The embryos that we test now, they've been growing in the lab for about a week. So we actually grow embryos a little bit longer than we used to. And once they get to that stage, just like what Dr. Reed was saying, we're actually testing the portion of the embryo that's going to become the placenta, not the portion that's going to become the baby. That's what we're actually taking a few cells away from. Really good studies to show that it does not harm the reproductive potential ultimately of the baby that's created from those embryos.'cause I think that's a really big worry and I can see the concern Yeah. Behind it. And I think it's so valid too, based on the history. Mm-Hmm.'cause some people call modern day PGTA. PGT 2. 0. Okay. Because the older version of PGT was on embryos that were younger. They were day three embryos. And on day three, the embryos are smaller and they haven't differentiated into the part that's making the parts of the placenta. So they were just sampling some of these cells. And what they did find is indeed that was harmful to an embryo to sample it that early in the process. Um, and so that's something that, um, everybody learned about quite a bit in our field. That's why it wasn't really routinely done in the past. In the past, the technology wasn't really good enough to be able to grow embryos out until they were old enough to see that, um, differentiation between the baby and the placenta. Um, so that's kind of all they had, but these days with just better technology and knowing more, um, I think it's really not as much of a current concern as it used to be. That being said though, I agree. I don't think doing embryo testing is harmful to most embryos. But I, and I love big studies, but every now and then, you know, some people are just going to be a little bit different than others. Right. And I can understand logically, maybe every now and then you have a patient with very fragile embryos or something like that. Right. And so that's why it's always a discussion with. your doctor and sometimes we go to talk to the embryologist to get a really good sense of, hey, you know, are we on track for this plan or do you have any concerns? Could, should we consider a different plan in this patient's case? We're always just really wanting to customize it for each patient. And I think that's sort of what makes peak fertility different. So some of you out there listening may have done IVF and probably had an experience more like a really high volume center and you felt like there was a lot of patients going through IVF at the same time. Sometimes people kind of feel like it's a factory a little bit and our practice that was really important that we didn't do that for our patients because we do feel like it makes a difference for us to have that. specialty that we go in. We're looking, we're examining the embryo with the embryologist and she knows your history. A lot of times there's that disconnect. So it really does help to know ahead of time if you're suspecting something like that and we can really tailor it to the patient. It's nice. Yeah. I just love to, I mean, you and I are always in the lab trying to, you know, I'm her embryologist. Like if you're the embryologist, we're like, what you're doing and we can't wait for the results. I'm like all day. I'm like, okay, how many embryos we have, you know? Um, but I think it's important for us to be as invested as possible, of course, um, in the process so that we can really benefit, um, along with the patient too. So, um, okay. I always make it a point to explain to my patient about all the possible results that we can get. So of course we know your results can be normal. or abnormal, but there are two other results that can happen sometimes. So I thought maybe we could talk about mosaic embryos and sometimes when we get an inconclusive or no result. Um, so let's talk about mosaicism first. So, an embryo can be all, all normal or all abnormal or it can be a mixture of both normal and abnormal cells. And that makes it pretty confusing because, What do we do with that? Okay. So years ago, if we got the results back that there was a mosaic embryo, we recommended not using it because we didn't really know what would happen. Okay. However, in more recent years, it has changed quite a bit. We have learned a lot about mosaic embryos, and you will even see some different practice patterns amongst doctors. So we can kind of talk about. Um, Dr. K and I's differences on this too, but what really blew me away, and I want to say this is now maybe, I don't know, six years ago or something, there was a case series published in the New England Journal of Medicine that was a very brave group of women who had mosaic embryos. That was all they had. They didn't have any normal embryos to use. They didn't want to cycle again. And so they said, what happens if we use a mosaic embryo? And shockingly, about half of the time, they had a totally normal baby from a mosaic embryo. And so that really blew everybody away. And so what we think and know at this point is number one, Maybe we need to reevaluate the accuracy of the genetic testing in cases of mosaism, mosaicism, and number two, for mosaic embryos, if they truly are mosaic, maybe some of them have the ability to self correct into a normal embryo. And I still remember when I saw that study for the first time, I thought, that is amazing. So, so because of that, you'll see some differences on how, um, doctors, really even want mosaicism, uh, reported to them and what they do with those results. So, do you want to kind of talk about your take on mosaicism and then I'll kind of compare just, uh, what I do too. Yeah, um, yeah, so exactly like Dr. Reed said, what a lot of people found was that these embryos have reproductive potential and probably something, something's happening between the time that we test them at about a week old to the time even that they're an early pregnancy because they would do more genetic testing in the early pregnancy and most of the mosaicism was gone by even that point, right? So something's happening. And No one really knows. There's a lot of research in that time period going on and we just don't know what's happening to sort of rid these cell lines of mosaicism. Um, and so, you know, we have to figure out if we get a mosaic result, how do we address it? And I think what you really have to ask is what kind of studies should be done to figure out. What should we do with them? And so I think the nicest studies are prospective blinded studies, right? So that means you're going to transfer an embryo without knowing the genetic testing results and follow the outcome out and see what happens to those embryos. If you reveal it early, there could be bias, all of this, right? So you need really nice clinical studies. And so, the genetic testing company that I use did a great study for about a year and a half, where they completely blinded their mosaic results. And they transferred them. In line, just as they did with normal genetic embryos that we call Euclid, where the whole cell line was normal and what they found were that mosaic embryos had a similar implantation and live birth rate at the end of the pregnancy to normal genetic embryos. So this, of course, is based on this specific genetic testing platform that I use, and I really like their data on that. And what it meant for my patients was we had way more usable embryos, right? Available to them. And they had great reproductive outcomes and not, not a lot of risk for them. And so what I do with my genetic testing results then is we don't reveal if they're mosaic, if they come back mosaic. And it should be said that these, the genetic testing company that I use, they hand read the results. They have a. certain threshold for what they call abnormal versus mosaic versus euploid. And so I really trust that they have followed their own data and figured out what is the outcome with these embryos. And so that's what I do for my patients. Um, and I think it really leads to nice results because sometimes patients may not have had a usable embryo. Um, if you know, you don't consider it was a usable, right? Right. Um, So I'm a little bit different from Dr. K in that. And I do, um, think that I've just appreciated it over the years. They increased potential for mosaic embryos to really just turn into a nice normal baby. Um, but I'm just one of those people that feel like I need to know all the information. And so I do actually have the option turned on my genetic testing company to know. Um, are, are any of the embryos mosaic? And if so, is it low mosaicism or high mosaicism and everything? And it's not that it's ultimately going to necessarily change anything at all. We may still use those same embryos, just like Dr. K's patient is going to use those same embryos. But I guess kind of in my mind, I'm just sorting, sort of trying to triage which of the embryos I'm going to use first. So if it's a group of embryos, I'll still just want to use the one that's normal and maybe save the most extra last. Although in Dr. P's, her point could be to that too. Well, it doesn't matter, right? They're all the same changes. Um, so I don't know. We'll have to see over time. Maybe I'll kind of switch over to that side too. But, but for now, I do still have the option to, um, have that turned on. Um, and and certainly sometimes we use different genetic testing platforms, so that's that really these studies and what's important to us. Sometimes patients just don't know to ask is like what genetic testing platform are you using? Because then you can see what data they've done because it matters. They use different thresholds to say what a mosaic is. So it really is. It just kind of depends on what you're using. Yeah, but you know, one of the things that I really felt bad about is because of this uncertainty that has happened with mosaic embryos over time. Understandably, on the patient side of things, it has sometimes created a distrust on clearly normal or clearly abnormal results. And, you know, not too long ago, I remember seeing headlines. It was all over the media saying abnormal embryos turn into normal babies. And I thought, what, even I was like, wait, what? And so of course I look at the study. And what I really don't like about this study is when you look at the details of the study, they were really talking about mosaic embryos. And just like we already knew the mosaic embryos could go on to be a normal baby, that wasn't new news at that point. And when he looked at the abnormal embryos, they were not turning into normal, healthy babies, but they just kind of lumped them all together and grouped them all together and stuck that headline on there. And I just didn't like how that happened. I thought that was actually pretty deceitful. You know, the way of somebody baiting patients, you know, they call it clickbait, it's clickbait, um, and it's not true. And I said, really, somebody could have renamed the study and the study could have said, as we already know, mosaic embryos can be normal babies. And this also reassures us that an abnormal embryo, I wouldn't say it's impossible to have a normal live baby from it, but it's 1 percent less, uh, 1 percent or less chance of having a normal baby from, um, an abnormal embryo. And so knowing that sometimes I'll get people who, you know, ask me, would I be willing to, you know, transfer a mosaic embryo? Absolutely. Would I be willing to transfer an abnormal embryo? You know, I don't feel comfortable doing so. I just have ethical issues with it. I don't want to put somebody through a transfer for a 1 percent or less chance of having a normal, healthy baby. And I do think there's risk because what if an abnormal embryo sticks and you have a miscarriage or you, you know, have a baby with a lot of different problems and everything, and you didn't realize that that could be the case. And so and say, look, if you want to use an abnormal embryo, of course, I'm going to support my patient, but this would be experimental. And then I would just guide you to a study that is being done at Stanford right now. It's called the snake team study in which you can enroll and have them transfer your app embryo and see what happens. Yeah, that is, it is interesting for sure. Um, and again, just have to see those perspective blinded. Applied studies, whatever technology you're using to test your embryos. Um, what if a patient asks you to do genetic testing just because they have three boys? And they want a girl or maybe they have two girls and one boy, like some of us here. You know, I think it would be a good thing to first just give a trigger warning to patients. For some patients that have really struggled with fertility problems and miscarriage for a long time, this can be a triggering topic because they often just feel like, you know what, we would just be so happy to get a baby. It doesn't matter. So this would be a good time to turn it off. Um, but if you're okay with listening, um, I actually do, uh, support the patients, um, you know, request in order to be able to balance their family. Um, so if somebody has all kids of one gender and they want to have a child of another gender, Um, I do think that is a reasonable, um, thing to offer and to do as well. What about you? I, I do support my patients in this too. Yeah. And actually I offer to all my patients, even my patients who have struggled with fertility going through IVF, we're just so happy to have made maybe a couple embryos. I asked them if they have a gender preference on which embryo we choose, because sometimes, I mean, the way I experienced infertility is I'm a control freak. Yeah. We all are, right? Yeah. I'm a control freak, and you're completely out of control of your body, of your timeline. You have this timeline of like everything you've picked out and, you know, for your life. And you were supposed to have a baby by this time, so it'll be delivered by this time. And it, for some reason it was, you know, it kind of makes you feel good that you're like, I have this one thing that I have control over, like I can choose what gender I want. No one wants to do IVF, but it is kind of nice if you're like, I always imagined I was Boy first. And it's like really nice that my patients can have that option to have control. So I do support them in that. And they don't, they, lots of times my patients just want the best quality, you know, the prettiest embryo basically, uh, to look to be transferred first. And that's fantastic. But I do give them the option of doing gender selection. Right. Right. And I mean, I think too, um, I've, I've been surprised because there's been other places I've been before that will not like we should use. They force them to use the best quality embryo. And I think sometimes it's for ethical reasons. Maybe the doctor ethically feels like it's It's not appropriate to choose gender or sometimes, honestly, it's probably for the lab to just have higher statistics on their end, you know, they don't want to choose a lower graded embryo if that's what would be needed, um, for the preferred gender. And I think again, that's where we get the say in this. This is where we get to really customize things according to our patient, what's most important to us. is our patient, not just this outside view of, okay, here's our stats. You know, of course we are always going to work so hard to, you know, get the highest quality IVF, um, for our patients, but we're also not going to let factors like that influence our patient decisions as well. So definitely. Okay. Dr. Pace. So if your patient is pregnant, with a genetically tested normal embryo. You're graduating her. She's going to her OB GYN. She tells her OB GYN, Don't worry, this is a genetic, genetically tested embryo. You don't have to do any special testing on me. How do you feel about that? I completely disagree. So, We recommend all first trimester screening for our patients, regardless of how you conceived and whether or not your embryo was genetically tested before it was transferred. Um, and interestingly, I wrote a paper about this, not to toot my own horn, but we did, we did look at discoordinates. rates with the basically everyone knows about this test now, right? You get pregnant you can get the blood test early around 10 weeks, find out a screening test for genetics. I looked at whether the result of that was the same as the result of the embryos genetic testing, and a very small amount of the time, there can be discoordinates. For example, a mosaic was maybe not picked up on when we biopsied the embryo or something like that. Um, and so actually the case though, we had to believe it was a Turner, um, that it was a Turner mosaic that had been missed, uh, essentially on the genetic. testing of the embryo and then was picked up later on the NIPT, the non invasive prenatal test. I got a bullet, I should probably know my own data better than this, but there is a chance for discordance. It's very rare, but you want to be certain. You've gotten all the way to that point. so much testing already. You should definitely opt for the first trimester screening. You also can find out other things from first trimester screening that aren't just related to the genetics that we didn't test your baby for. For example, neural tube defects. are part of the screen with first trimester blood test. And so we don't test for that when we test the genetics of the baby, you can't test for that. So there's a lot of reasons that you should still stick to the standard screening. Yeah. And I will say too, just to give you guys a reason for that with PGTA, remember we're trying to be very delicate to the embryo. So we're only sampling maybe like three to five cells from the embryo. That's it, right? But when you are pregnant, you're further along and they're doing the blood test, they're going to be able to get many more cells even just from your blood than that. And so in the very rare case where you're getting discordant results, it's probably because there's a lot more. sample that you can use with that first trimester screening. Um, so I agree with Dr. K. Um, I also recommend at least offering it to, I mean, it should never be required, I don't think, but I think it should be at least offered to a patient even if we know we put a genetically tested normal embryo in there just to confirm and make sure that there's no surprise results early. Yeah. Okay, good. Well, should we wrap it up for the week? Okay, good. Everyone have a good week. Alright, thanks guys