Susan Hudson (00:01)

You're listening to the Fertility Docs Uncensored podcast, featuring insight on all things fertility from some of the top rated doctors around America. Whether you're struggling to conceive or just planning for your future family, we're here to guide you every step of the way.

Susan Hudson MD (00:22)

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Susan Hudson MD (00:52)

Hello everyone. This is Dr. Susan Hudson from Texas Fertility Center with another episode of Fertility Docs Uncensored. I am here with my boisterous babelicious co-host, Dr. Carrie Bediant from the Fertility Center of Las Vegas.

Carrie Bedient, MD (01:07)

Hello, how are you doing?

Susan Hudson MD (01:09)

Good, good. How's things been going in Vegas Land?

Carrie Bedient, MD (01:12)

It's good. Normal heat, normal summer. I was just looking, so as for our listeners, as we sign on, we're looking at each other because we've got video recordings, so it's how we post to YouTube and things like that. And was just looking at like, I've got Vegas summer skin where all the oil is coming out and it's trying to moisturize desperately in an environment where moisture just does not happen. I use three different moisturizers every day.

That are good quality moisturizers in order to survive. I'm just thinking about all the skin stuff now.

Susan Hudson MD (01:42)

I have a lovely pimple patch on right now. I love this one. Those are like the greatest things ever. I mean, like who ever knew. But I learned that recently, because most of them are just the silicone, but they're silicone with other stuff in them too. That's what I actually got because once in a while I get s these little things under my skin and I'm like, So I'm I'm pretty impressed.

Carrie Bedient, MD (01:54)

Yeah. Yeah.

Have you tried any of the ones that have the micro darts in them? Yeah.

Susan Hudson MD (02:08)

Microdarts. No, this one has some retinol and some tea tree oil and stuff like that. Tell me about microdarts because that actually sounds like it hurts. Okay. Okay.

Carrie Bedient, MD (02:22)

It's got just enough of a little bit of a poke to it that whatever the ingredients are can go a little bit deeper. You wouldn't use that on necessarily a regular pimple, but if you had a dark spot, if you had something that was deeper, that can potentially help. And then the other things that I just found are they have patches that are big enough to go over your nose. And it's not like the little Biore strips that we grew up with. It's a full patch that goes over your your nose area, which is helpful for me because that's where I get a lot of stuff. And it's just the hydrocolloid where it sucks out all the gook and that is a highly technical medical term. But they're they're fabulous. I don't know who invented them, but they're geniuses.

Susan Hudson MD (03:02)

I think it's pretty cool stuff. It's just nice that they have more things available to help those of us who occasionally are in need.

Carrie Bedient, MD (03:07)

Mm. Uh-huh, besides the stupid creams that dry out your skin to high heaven and may or may not actually help.

Susan Hudson MD (03:15)

Exactly. We do have a question.

Carrie Bedient, MD (03:16)

Do you have question today? Don’t know why I always ask you that. I know full well we always have questions because we never run out of questions.

Susan Hudson MD (03:24)

We never run out of them.

Here's our question for today. Hello, been trying to conceive for two and a half years, never pregnant, desire more than one kid. I'm 33, I have Hashimoto's and hypothyroidism. She is taking synthroid, hyperprolactinemia, she's taking cabergoline, endometriosis stage two, excised in May of 25, never smoker, alcohol free, not overweight, AMH is 7.2.

But don't meet PCOS criteria. Now PMOS criteria. On prenatal vitamins, CoQ10, vitamin D, Ovacitol, Semen Analyses are golden, two failed IUI cycles with REI, letrozole with Ovidrel, pausing before the third IUI cycle to reassess. Second opinion doc is concerned about autoimmunity, prescribed low-dose naltrexone, and referred to a reproductive immunologist.

I don't know much about these two things, but I do want to get to the root of any outstanding problems before investing more money, time and energy into IUI or IVF. Thoughts. Thank you.

Carrie Bedient, MD (04:26)

What do you think about that? What do you think of reproimmunology and the naltrexone?

Susan Hudson MD (04:32)

I actually had this conversation with a patient today and I don't like pissing people off, but I would like to venture that realize that we are reproductive endocrinologists. And we went to three extra years of training for REI, reproductive endocrinology and infertility. And I am not actually certain if there's actually training for someone to be a board certified reproductive immunologists. I think most of these people are either REIs with an interest or immunologists with an interest crossing over. I think a lot of it is a whole bunch of voodoo. There's many things that we can address that help people get to where they need to be. And are there deeper layers to fertility challenges than what we understand at this point in time? Absolutely. Do I think that reproductive immunologists hold the holy grail of all things that we should be doing and we don't? No. What do you think, Carrie?

Carrie Bedient, MD (05:34)

There are some fellowships out there, but the big distinction is that most of the OBGYN fellowships go through ABOG, the American Board of Obstetrics and Gynecology. And they're held to all of the standards that are universal across all of our our specialty. There's oncology and there's REI and MFM and Urogynecology, all those things.

Reproductive immunology fellowships aren't a part of that. There's this group of people who have an interest in it, that have their own society kind of within REI. I think they're formalizing it more. But one of the things that I see is that reproductive immunology ebbs and it flows. And there are times when it's a really hot topic, and there are times where it's less so.

The pattern that I seem to see is that there's a bunch of papers come out about it, and none of them are really conclusive enough for us to say, yeah, this works. Unlike letrozole and clomid, for example, which have real clear data that they make an improvement. Things like IVIG and natural killer cells and all the rest of that, there's data out there, but there's so much data in every single direction, it's really hard to say, yeah, this makes a difference.

It's interesting that she says she doesn't want to spend more time and money on IUIs when there's a pretty decent likelihood she's gonna spend a fair amount of time and money on a reproductive immunologist. And I think that there is something to reproductive immunology. Like we know that in endometriosis patients, for example, this was my fellowship research project, the macrophages go crazy. And it's based on the person who has endo, not on the tissue itself.

I think there's something to it. I just don't think we're really great at knowing what that is. I have very mixed feelings. And a lot of the tests they run, there's so many that if you check enough of them, you will get a positive. Because if you check a hundred things, something's gonna show up. Whether or not it makes a difference, meh. 

But that's one of the big things that I worry about is that there's just it's not as conclusive as I would like it to be.

Susan Hudson MD (07:32)

What are your thoughts on low dose Naltrexone? I mean, that's a medicine that we've historically used for other things. And when we're using it for the other things that I'm thinking of, like this is the same medicine we use to help addicts get off of things like heroin. When you look at the risk-benefit profile, it's in favor of using naltrexone. Now

Everything you put in your body while you're pregnant is going to have a plus and it's going to have a minus. Is there conclusive safety data about low dose naltrexone just for autoimmune conditions?

Carrie Bedient, MD (08:10)

In pregnancy, I think there's a couple of layers to what you're asking. The main place that I have heard of low-dose naltrexone as applies to our field is with endometriosis treatment for pain, because I think it does have a beneficial effect there. Now, I do not see pure endo-patients. I'm mostly seeing them in terms of fertility and getting them pregnant. So I am not an expert in treating endo-pain, nor do I pretend to be.

So I have seen patients who come to me with a history of using low-dose naltrexone for pain control, but I haven't seen it in terms of being used as a fertility adjunct and in the immunology space. So there are a lot of meds where we don't know exactly what they're for. A good example is the GLP1s. We know that they've got amazing impact on diabetics and on weight loss.

They're starting to find more and more conclusive data on addiction behaviors and whether that's violence, whether that's other substances. So there's a lot of meds that have multiple impacts. I'm not saying it's not useful. I just don't know that we know what it is yet because I I haven't seen a whole lot in the immunology space.

Susan Hudson MD (09:15)

Yeah, I had somebody who has Hashimoto's today and that was one of their primary treatments is low-dose naltrexone. And I'm like, well, it may have an impact, but this individual had quite a few other things. This is her recurrent pregnancy loss evaluation. She had a lot of other things going on that were potentially confounding variables.

So make sure we're answering the question.

I mean, I think she's a good candidate for more therapy. I just don't know if reproductive immunology is going to add a lot at this moment in time.

Carrie Bedient, MD (09:47)

Mm-hmm. Yeah.

I think I would agree with that. I don't think, for example, low-dose naltrexone is necessarily going to cause any problems. I think talking to a reproductive immunologist is a reasonable thing to do, but the reproductive immunologist needs to be someone who's willing to prescribe you whatever they're giving you, because oftentimes the REI who's looking at the same data will have a different opinion. They may not be willing to prescribe some of those same medications. So I think the reproductive immunologists need to be able to do that and to advise you on it too. Because if there is a pattern of something they want you to start and stop, change doses on, you want them managing it. You don't want your REI managing it when that is not something that they automatically put you on themselves. Because if you're gonna go to a reproductive immunologist, max out their their skill set. I'm excited to see what the field brings. I think that there is a lot to reproductive immunology. I just don't think we know quite how to apply it as definitively as we would like or as maybe is advertised. Yeah. Yeah.

Susan Hudson MD (10:50)

I think that's fair. That's fair. And I did like what you said about make sure your reproductive immunologist is available to actually treat you because a lot of times they're like, well, have your REI do this and have your REI do that and this type of thing. And it's giving infusions and things that we just don't normally handle. And just like I wouldn't send you to your cardiologist and tell them how to manage your heart condition.

They should be helping. I want all of my heart patients to have their cardiologist on board and maximizing their part of it, but they need to actually be maximizing that.

Carrie Bedient, MD (11:26)

Agreed. Agreed.

Susan Hudson MD (11:28)

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Susan Hudson MD (12:35)

Right, so today we are going to take a deep dive into PGT-A. We've had an episode probably about three or four months ago that we talked about all kinds of PGT, and PGT is pre-implantation genetic testing. But today we're really gonna dive deep into the type of testing that we do the most often and the one that generates the most questions.

Carrie Bedient, MD (12:59)

Alright, PGT-A it is. So let's start off with just the basics of PGT-A. What does it stand for and what kind of treatments can we use it with?

Susan Hudson MD (13:10)

Absolutely. So PGT-A, so PGT is pre-implantation genetic testing. The A stands for aneuploidy, which is just a fancy word for abnormal number of chromosomes. And PGT-A is something that we can use in IVF or in vitro fertilization cycles. We cannot use it in things like IUI or inseminations or with timed intercourse.

Because we don't have access to those embryos because those embryos are inside your body at that point in time. PGT-A is something that is performed on embryos once they get to either the day five, six, or seven stage. They generally have to be what we call an expanded blastocyst. So an advanced stage embryo where we can tell what parts can become the baby and what parts can become the placenta.

And that embryo generally has to be a certain grade. Now that grading criteria is going to vary from lab to lab, organization to organization, but there are guidelines because you may have an expanded blastocyst, but if it's really, really bad quality and we know it's not consistent with life, that embryo is generally not going to be biopsied with PGT-A. Carrie, how do we, how do we do the biopsy, what what's involved?

Carrie Bedient, MD (14:33)

To get to the biopsy, the embryologist will take the embryo that they've decided meets all the criteria, and they will sometimes create a small hole with a little laser. It's a little pew pew and they make the tiny little hole. It's very closely calibrated. It's designed to just hit the outside of the zona, which is the thick part around the embryo.

Opens that up and then they go in with a pipette or a little pipel, so mini pipette and they suck out a couple of cells. Depending on the exact type of PGT-A that is being done, what the lab is that's running it, there's some that can get just three or four cells and that's sufficient. There's others where they want five or six. It's taking a relatively small amount of cells out of the embryo.

Especially when you figure most embryos by the time they get to day five, six, seven, are gonna have upwards of a hundred, hundred and fifty or more cells in them. So it's just taking a couple out and we do it on day five because what happens if you were to try and do this to a day three embryo?

Susan Hudson MD (15:36)

Well, if you were trying to take out a cell from a day three embryo, your day three embryo generally is probably going to have between eight to twelve cells. So that's a huge proportion of your cell population. Plus, at the point that we can do a biopsy on day five, six, or seven, we can tell what part's gonna become the baby and what part's gonna become the placenta. And we're only sampling cells that are gonna become the placenta, not the baby, because obviously we wouldn't want to steal from the little baby.

Carrie Bedient, MD (16:05)

So what happens if you were to accidentally get something? Not that this would happen because the embryologists are really good about avoiding the ICM, but what happens if you were to accidentally get a little bit of the inner cell mass? Would that baby be missing an arm or a foot or a nose?

Susan Hudson MD (16:21)

No, no. The embryo would generally correct itself. The embryo does tend to be very forgiving, which is part of the reason why we are able to do this. So no, we would not be missing a foot because of a biopsy of the inner cell mass.

Carrie Bedient, MD (16:37)

Nor would you be missing a chunk of the placenta because you took a little bit out.

Susan Hudson MD (16:40)

Correct, correct. All right. Another important thing to know is that generally what's going to happen is after that biopsy happens, the embryo is cryo-preserved, and then that sample is sent away to a lab to have the PGT-A testing done. So when you are going to your doctor's office, when you're going to your IVF retrieval center, the actual testing for that PGT-A except in very rare circumstances, is not going to be in-house. Back 15 years ago, there were a number of in-house labs and things like that. But what we found is having a lab that can really dedicate itself to this type of testing and having people send in these samples, you're going to have much better turnover and you're going to have much better results and consistency with those results, giving us more reassurance that when we're giving you information about the quality of your embryo as to its chromosomes, we're giving you as accurate a information as possible.

Carrie Bedient, MD (17:41)

What's a chromosome? Just to make sure we're defining what we've been talking about all this time.

Susan Hudson MD (17:45)

Absolutely. Chromosomes are essentially our genetic makeup in our programming. We all have 46 chromosomes, 23 sets. And we want to make sure that those chromosomes haven't multiplied or gone away.

So having missing chromosomes or even missing parts of chromosomes. Now, it's important because sometimes people are like, well, this is gonna tell me if my baby's going to be healthy. Not exactly. So this testing is looking for chromosomally related disorders. Now, realistically, there's only a handful of true whole chromosome-related disorders that can result in live birth. So the most common is Trisomy 21, or what's commonly known as Down syndrome. There's some others like Edwards, Patau, chromosomes 13, 18, those types of things. Those babies are born with severe, severe, severe problems and usually don't live past maybe six months to a couple of years. And there's a whole host of things that can be missing segments of chromosomes.

Now, this is different from genes. If you have your carrier screening done when you go and see your REI at one of your new patient visits, and they're looking for things that hide in the family tree until the right person meets the right person. This is not testing genes. So the way I think about it is your hands are the chromosomes and the genes are your fingers. So we're making sure we have two hands, not necessarily 10 fingers with this testing.

Carrie Bedient, MD (19:14)

Excellent.

Susan Hudson MD (19:15)

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Susan Hudson MD (19:45)

So when we look at using PGT-A, a big reason why we use it is because there's some evidence that it improves outcomes. That's the reason why we do most of what we do in fertility care is we have intentionally chosen to do certain pathways, treatments to help improve the chances of you taking home a baby. When does PGT-A actually improve those outcomes?

Carrie Bedient, MD (20:09)

This is a tricky one to answer because doing PGT-A will not inherently change the embryo. It gives you more information about it. But that embryo, whether it has had PGT-A or not, is going to implant or not implant as it sees fit. And the value of PGT-A comes in identifying which embryos were never going to make it.

And then avoiding using them because fertility is a hugely emotional process. It's very time-consuming, it's very expensive, it is all-consuming in terms of what it does to your brain and how much people focus on it when they are in that particular season of life. One of the things that we have identified, and Susan, you and I talk about this all the time, is we can't help a patient who isn't coming to us anymore because she or they are absolutely fried and utterly done with everything related to fertility. When people come in and let's say they haven't done PGT testing and maybe they're a good candidate and get several embryos, they transfer one and it doesn't work. They transfer the second one and they have a miscarriage. They transfer a third one and it it's maybe a biochemical. And then if they were to get to the fourth one, that was going to be the one that stuck, but they tapped out because they're fried.

When you do PGT-A, you can identify embryos one, two, and three. They weren't ever gonna make it, no matter how perfect everything else was. Skip straight to embryo number four and speed up the time to conception while minimizing the times that it won't work in a place where we can identify it. My statistician and I got into a big discussion when I first joined this clinic of miscarriages are not benign.

Even though it's not cancer, they're not life-threatening in the vast majority of cases. They hugely attack a person's sense of self-worth, their sense of faith in their body, their hope that this can work in the future, and the amount of anxiety and depression and all of the other emotional chaos that they bring, it's not benign. People stop treatment because of these.

And if they stop treatment, there's no amount that I can help if they're not here for me to help. Being able to go straight to an embryo that is much more likely to work, not guaranteed, but more likely, can be really, really valuable.

Susan Hudson MD (22:25)

So, an important thing to understand is that when we look at embryos, most embryos that are chromosomally abnormal are never going to implant. And most that do implant are going to be lost in a first trimester miscarriage, usually relatively early, not always, but usually a first trimester miscarriage. And only a very small proportion would result in a live birth of a chromosomally abnormal person. But when we look at embryos that are being created by younger women, so women in their upper 20s, early 30s, we expect at least, at least half of the embryos to be chromosomally abnormal. So if you're sitting there with four embryos, half the time we're gonna be wrong. Now when you start getting to be 38, 39, 40 and we're looking at 60 to 70 percent, or somebody who's in their mid forties when we're like, ooh, 90 plus percent chances of the embryo being chromosomally abnormal, you don't want to take time, or at least a lot of people don't want to take time transferring embryo after embryo after embryo with embryos that never had the chance. And when people look at the cost of PGT-A, relatively speaking, and this is not going to hold for everywhere, but relatively speaking, the cost of doing PGT-A while you are doing a fresh IVF cycle and you have not frozen your embryos yet is usually going to be about the same cost as doing a frozen embryo transfer. So if we select wrong based on grade and there is no correlation between grade of an embryo and whether it's chromosomally normal, if we select incorrectly one time.

You would have already paid for your PGT-A.

Carrie Bedient, MD (24:12)

Can you just do PGT-A as you go?

Susan Hudson MD (24:15)

That's a good thing to ask. So PGT-A, like, I'm about to transfer this one embryo, so I'm going to thaw biopsy, refreeze. Theoretically, is it possible? Yes, it is physically possible. Is it financially a good decision? Probably not, because usually PGT-A is going to the entire thaw, biopsy, refreeze, and the PGT-A itself, that process is usually based on a grouping, a number of embryos. Whether you test one embryo or four embryos or eight embryos, it's going to be relatively about the same cost. And oftentimes that can get somewhere between six to eight thousand dollars.

When we talk about when is the right time to do PGT-A, sometimes people decide at when they're doing their IVF cycle, whether it's a personal decision or they're guided by their physician. They're like, no, we don't need to do PGT-A at this moment in time. And what we often see in our practices is they've done these transfers that Carrie just talked about. They did transfer one, they did transfer two, they did transfer three. They're one of these individuals who has lots of embryos sitting there. Maybe they have six, seven embryos left. And they're like, do I, do PGT on A on these at this point? Because I don't know if we're transferring good embryos. And that's a very good question. And I think a lot of it has to do with how many embryos you have and what your long term plans are.

I've had people who maybe they only have one or two embryos left, and I'm like, mm, probably not financially the greatest idea, but let's transfer these embryos. And if we do have to do another IVF cycle, let's PGT-A those. If you have a lot of embryos and you're thinking about family size, embryo disposition, like what am I gonna do with all these embryos? And I don't know if they're chromosomally normal or not, those are people that I think sometimes investing in that is better. And really a lot of it is peace of mind, knowing how many embryos do I actually have that have a good chance of resulting in a child. And then also, when you're thinking about embryo disposition, sitting in there and being like, okay, I have these embryos, say I created them when I'm 38, I know there there's probably a 60 to 70% chance that they may be abnormal, but I don't necessarily want discard them if they're chromosomally normal. It can have a lot of implications in in your long-term planning.

Carrie Bedient, MD (26:49)

Patient just recently came back for a second baby, and she had gone through IVF, got a bunch of embryos, did not want to do PGT. We transferred the first one, has a beautiful baby, came back a few years later and went straight into her next transfer, but had a biochemical pregnancy. And she was just shattered by that. And she and her husband decided that they were going to thaw and biopsy, everything. And I just called her today with a positive pregnancy test. And she's ecstatic because when we got those embryos back, fully half of them were abnormal. And we did a study in our clinic that looked at how does morphology or the appearance of the embryo translate when you've got PGT testing versus when you do not? And what we found is that the morphology or grading doesn't seem to matter when you've got a PGT tested embryo. If you know that it's euploid, meaning it's got the correct number of chromosomes, whether it looks the prettiest or the ugliest out of that cohort doesn't necessarily matter. But when you have an untested set of embryos, the beauty contest matters. The one that's the prettiest does tend to have a higher likelihood of sticking. And so it's a valuable piece of information. Now, this doesn't necessarily hold true for every single lab everywhere because grading is very much in the eye of the beholder. But I thought it was really interesting that doing PGT all of a sudden made grading far less useful, provided they made the cut to get frozen and biopsied in the first place.

Susan Hudson MD (28:15)

So what are your thoughts about people who are younger, so maybe less than thirty five, or people who are using donor eggs? What are your thoughts of the risks and benefits of using PGT-A in those populations? Because those are the ones I see most often come to me as a second opinion.

Carrie Bedient, MD (28:35)

There was a study relatively recently that showed that doing PGT-A when using a donor egg may actually be detrimental and be less helpful in terms of getting to your pregnancy. But this has some major asterisks, footnotes,

signs to it that are going to influence the d this decision because many people who are using donor eggs, for example, we have a lot of male couples and they have to use a gestational carrier or GC. That is extraordinarily expensive and time consuming. And you now have brought a third person in who's carrying this pregnancy. So if you transfer an abnormal embryo, you are potentially putting a third person at a risk you could have avoided with having a miscarriage.

You're also putting them at risk of having a pregnancy that you, as the intended parent, may decide you want to terminate because of a chromosomal abnormality, but the GC may feel differently about being willing to go through a termination. And in those cases when a GC is going to carry the pregnancy, there's a very good argument for doing PGT-A because there is more at stake here than just a straight success rate.

When you've got someone else who's, let's say, caring for themselves and using a donor egg where they're under 35, situation is everything because we can have five different patients come to me with the exact same plan, but the story behind it is different. Do you want multiple kids? Yeah, let's do PGT. Because if we get a bunch of embryos, but most of them are bad, we need to do another retrieval cycle to get you the 3.4 kids you want. If you have strong feelings of, I would never get a termination of pregnancy, never in a million years, but I really don't have the ability to handle a special needs child that I could have avoided, then let's do PGT. Maybe you live in a state that's extremely restrictive, and a termination of pregnancy is not an option at all. That makes a lot of difference. Maybe you already have a special needs kid and you're trying to identify a gene or just make it such that your family can still grow but not grow in a way that is so taxing to the resources for everybody. So there's a lot of individual analysis and goal setting that we take into consideration when we do this because we will have some patients who say, look, I don't want you to touch my embryos any more than you absolutely have to. I don't want to spend any extra money more than I absolutely have to. I'm 30 years old, I'm going to take my chances or I want to transfer every single embryo.

In those cases, well, shoot, don't bother the embryo, just transfer them all. Because in many cases, the REI doesn't want to be put in a position where they've got an abnormal embryo that the parents are demanding to be transferred. And there's the potential for a very severe problem in in the child. And I'm talking about the life-threatening ones, the ones that don't make it past a couple months or a couple of years of life that we have seen throughout our careers of these people spend their entire lives in the ICU. And that's a big discussion, big ethical consideration, all of those things. That was a long winded answer.

Susan Hudson MD (31:34)

When we look at patients with recurrent pregnancy loss, I think a lot of us think that PGT-A can give us a strategic advantage. So, first of all, realize that in people who come to see us with recurrent pregnancy loss, 50% of those people are going to have a negative evaluation. Meaning when we test the chromosomes of the couple, we look for acquired blood clotting conditions like antiphospholipid antibody syndrome, we look for DNA fragmentation in the sperm, we check for uterine anomalies. All these things that we look, we do a big evaluation because we don't just test one thing for recurrent pregnancy loss, because in people who have one thing identified, 30% of people have multiple things going on. So it's a very complicated scenario for us to handle.

That in those people who have a negative evaluation, the most likely situation is that some, not necessarily all, but some of those losses were most likely because of chromosomally abnormal embryos implanting and sticking around longer than they do in the average person. By us being able to use IVF with PGT-A and selectively place a chromosomally normal embryo.

We do find that we do have better outcomes. Now, is that the only path we can take? Absolutely not. The great thing about recurrent pregnancy loss is that there are great studies to say that most people with recurrent pregnancy loss are going to be eventually successful if they kept on trying on their own. The problem is if you come to see us and you're on miscarriage three or four.

We can't tell you if that next success successful embryo is gonna be on this next pregnancy or five pregnancies down the road. And like Carrie said, having miscarriages is a tough thing to go through. Besides the fact that it's rips out your heart, it's a loss, and you're grieving in any way, every way, shape, and form as you would with any other loss, it also takes one of those most valuable assets time. If you have a miscarriage, generally, we aren't trying two weeks later. It takes time for your HCG levels, your pregnancy hormone levels to drop down and to get back where they need to be, not including the time that you may mentally, emotionally, physically need to wait to move forward. Though it's not something you have to do with recurrent pregnancy loss, I think it does pose a strategic advantage in a lot of cases.

Carrie Bedient, MD (34:02)

Definitely want to get as much as we can out of that information. Now, will PGT-A identify autism?

Susan Hudson MD (34:09)

No.

Carrie Bedient, MD (34:09)

Can anything identify autism?

Susan Hudson MD (34:11)

Not at this point. We know things that are risk factors, but honestly, a lot of those risk factors are things that are not modifiable, like the age of your male partner. Which I mean, I love my husband. I wouldn't trade him in for that reason. But I mean, that's reality. That's one of the big risks. Having closely spaced pregnancies. We try to minimize that as much as possible within our clinics, but when it comes to autism, it's a big void of a whole lot of not a lot of strong information.

Carrie Bedient, MD (34:41)

And sometimes when we do get the information back, it comes as a no result. And no result can be from a few different reasons. Sometimes it's that we take the embryo's cells and in order to be able to do the PGT-A, we have to amplify them, meaning we get a very small amount of material to work with and we have to run it through the copy machine in order to get enough copies to get the data that we're looking for.

Well, there are cases when you feed the original into the copy machine and the copy machine eats it. It's not that the embryo is bad, it's just that you didn't have the data to work off. Or the copy machine spits out the answer, but everything is blurred and you can't read it. You can't actually tell is this a good embryo or not a good embryo. And the question is whether or not you re-biopsy those. And this goes back to a similar scenario of let's say you already have embryos frozen.

Is it ever a good idea to thaw them and re-biopsy them? Very much depends on the couple. For a couple that had any of those reasons we talked about before of really wanting the information for family planning or avoiding other treatments, then absolutely biopsy them and see what happens. For couples that say, I really want the chance to biopsy this embryo, we just treat it as an untested embryo, which before about 2013, 2014, almost everything that we did was an untested embryo because PGT just wasn't all that common back then. And the reliability of the information was different and how we applied it was different. So there's not a problem in transferring an untested embryo or one that has information that didn't yield enough to make the decision on. So you can biopsy embryos that are no result, but it goes back to the the people who are hoping to build a family out of that and what are their values and how do we move forward.

Susan Hudson MD (36:25)

I think that's definitely something that you sit down and talk to your REI about, really thinking about what is your ideal family size, what do you want to do in the long term. A lot of this has to do with how many chromosomally normal embryos do you have and and what is your risk tolerance. If you rebiopsy an embryo, it probably brings down your success rates by about 10%. It's not a huge amount, but it is a tangible amount and I think you're the only one to be able to decide is that risk a good risk for getting the information. There's some people who want that information for various reasons. And there's other people who are like, let's transfer the other embryos we have that we know are chromosomally normal, and then we'll figure out what to do at a later point in time. Now, one nice thing is if you have an embryo that does not give you a result. In a lot of cases, you can get that re-biopsied and tested, usually with low to no cost, depending on your lab. The one thing to think about is just like all businesses, the lab who did your PGT testing may or may not be around in five years from now. If they're not around, there's not gonna be somebody to be able to give you your discount on getting that rebiopsy. So sometimes thinking about that is important because, your home lab where the embryology lab itself is still going to be there theoretically. But these other companies, not that they're fly by night, but this is a very it is a rapidly evolving space. And with that, companies get bought and sold within that space

Carrie Bedient, MD (37:57)

Rapidly evolving space.

Susan Hudson MD (38:05)

relatively frequently. That is something that does make me a little concerned when people are like, I'm just gonna wait. I may re biopsy at a later point. It may not be at the same cost as if you do it now. Just information for people to think about.

Carrie Bedient, MD (38:18)

Let's talk about mosaics.

Susan Hudson MD (38:20)

Mosaics, yes. Okay, so

Carrie Bedient, MD (38:23)

in Italian cathedrals.

Susan Hudson MD (38:27)

Yes, I actually prefer that type of mosaic to mosaic embryos. so

Carrie Bedient, MD (38:32)

Amen. I hate mosaic embryos with a passion.

Susan Hudson MD (38:36)

Yeah, yeah. So What mosaics mean are we have results that show some of our cells are normal and some of our cells are not. And in reality, if you received the pure result from your PGT-A testing, which you're gonna get the nice result that says chromosomally normal, female, male, that type of thing. Right. If you were to get the this other type of result, realize that everything is actually on a spectrum. So on that spectrum, there's a certain amount of noise that is considered normal. There is a certain amount of noise that is clearly abnormal. And there is a little area in the middle that is confusing. It may be beautiful, but it is confusing.

And so what these results show us is that some of the cells are normal and some of them aren't. Now, embryos can, they do not always correct themselves with these mosaic embryos. When we're looking at should we transfer them or not, number one, you should have genetic counseling, not just with your REI. Now, we are fantastic people.

We have great training, but we are not geneticists. We deal with a lot of genetic stuff, but we are not geneticists. And you deserve to talk to a geneticist about all the implications of if we transfer this embryo and we don't get the two polar results, which are I don't get pregnant, or I get pregnant with a healthy baby. If I have a baby with this specific abnormality, what are the potential what we call phenotype? What do they look like? Do they have mental disability? Do they have facial defects? Do they have abdominal defects? Do they have limb defects? How could this look kind of in worst case scenario? It's what I would consider worst-case scenario. And understanding how many of these are in the literature. So I I have another patient that I actually looked at their genetic counseling report earlier today. And it was like, there was one report for this specific chromosomal abnormality that was very well documented and sparse reports of other things that were not documented well. So chances of this abnormality resulting in a live birth are very, very, very low. We never say never, because just like when we talk about the beautiful things we say never say never about, we also never say never about bad things, too. Having that genetic counseling, so you and your partner, if you have one, can really have those conversations of, do we want to go down this path? There are some different types of mosaicism, depending on what type of platform you have done. And that's something you can talk about with the geneticist as well or your reproductive endocrinologist to understand how that may play a factor in the likelihood of having a child that actually is a true mosaic versus being chromosomally normal or not.

Carrie Bedient, MD (41:40)

Trusting the results of what you get on PGT-A is a question we frequently get of this report says that my embryo is abnormal. Can I transfer it anyway? Because there are reports out there in the literature, on the web, all those places that say I had an abnormal embryo, I transferred it, and now I've got a beautiful kid. The platform, meaning the way that the PGT was done, is very impactful on that. And the specific result is very impactful.

When you are looking at what's called NGS, which is the older technology, the one that really is very widespread, that's pretty much everywhere at this point, has different pros and cons than SNP array, which is what other labs use. And some will use a combination of the both of the two. This is why talking to a geneticist is really important, because there are some of those where if you get a mosaic, yeah, you might be a little bit more inclined to say transfer anyway, versus others where if it says abnormal, you're gonna say, okay, there are no reported live births of abnormal embryos that went on to become a viable pregnancy. Knowing those nuances, your doc should know at least what their lab is, because we all have reasons for why we use our labs. Nothing is perfect.

Nothing is perfect, but it's a decision that we've made based on these are the pros, these are the cons, and this is what I think outweighs it. But we're happy to talk about that with you, but trust that your doc has a reason for why they're sending to the company they send to.

Susan Hudson MD (43:08)

Now, when we're talking about these things being maybe not accurate, realize that for a lot of these platforms, I can't say for every platform, for a lot of these platforms, they're right 98 plus percent of the time. Those are pretty darn good odds. Now, another thing to know, because you know, sometimes we'll have patients who come in and whether they want it for family balancing or just kind of, icing on the cake, I want to choose the gender of my baby.

Realize that gender is the thing that is the most likely thing to be not correctly reported. So although it is a wonderful test and lots of people have used it successfully, there always is a margin of error.

Carrie Bedient, MD (43:49)

Absolutely.

Susan Hudson MD (43:50)

All right. Well, thank you so much for spending your day with us.

Carrie Bedient, MD (43:52)

If you enjoyed this episode, subscribe, leave a review. You have no idea how much those reviews help. And send us your questions at fertilitydocsuncensored.com.

Susan Hudson MD (44:00)

And if you want any more fertility information, pick up a copy of the IVF Blueprint, the practical guide to understanding your fertility treatment, IVF, and the decisions you'll face along the way. And we have a whole chapter designated to PGT.

Carrie Bedient, MD (44:14)

Remember that this podcast is for education and entertainment only.

Susan Hudson MD (44:17)

And while we are fertility doctors, we're not your fertility doctor.

Carrie Bedient, MD (44:21)

Nothing we discussed should replace medical advice from your own physician who knows your individual history and circumstances.

Susan Hudson MD (44:27)

Thank you so much for listening. Bye.

Carrie Bedient, MD (44:29)

Bye.

Susan Hudson MD (44:30)

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