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Speaker 2Hi everyone. One we're back with another episode of fertility docs, uncensored. I'm one of your host Dr. Abby Evelyn from Nashville fertility center. And today I'm joined by my friends, Dr. Susan Hudson from Texas fertility center. Hello and Dr. Kerry ENT from the fertility center of Las Vegas. Hello. Hey guys. So, so we were just talking right before we go. Got started . Since it's close to Halloween, we were kind of talking about funny stories that we had tricks that we had played on people. Carrie , tell me what, tell me about your trick that you played on somebody one time.
Speaker 3So when I was in college, there was , um, there was a group of girls that I was friends with and we had the one token male friend and <laugh> the, I lived on the, the, I say first floor, but it British first floor. So it was actually the second floor and the zero floor or the ground floor I should say, was nicknamed the Virgin vault . And it was, it was the only all female floor on the entire campus. So where'd you get a college carry , uh , Washoe in St . Louis. Oh, wow. So we , um, group of girls were friends. We had our one token male and he would occasionally do things that we did not approve of. Like at one point, the trick that he played on us was he broke into all of our rooms and stole our underwear, hung it up, hung them up in his room, across a clothes line . And , uh , we did not take kindly to this, so we to get him back, we had to get him back. And so for help , an entire thing of tampons and pads and strategically place them in his room, in his clothes, in, in his back pack, in his really everything we could think of. And I still remember his face to this day when we had gone to, he happened to be in a choir and we went to the Christmas concert and he put his hand in his pocket and pulled out a tampon in the middle of the Christmas choir concert. <laugh> um , because of course that's what you do. So I always like it when you like, stick a stick your hand in your pocket and you find a 20, but you don't really wanna find a tamp much less if you're a guy much less, if you're a guy <laugh> . Yeah. So, so that's what we did, which I guess should have been the clue right then that I was going to eventually become a gynecologist if I really thought about it. So there you go.
Speaker 2That was the tip off <laugh> what ,
Speaker 3Um, what sweet and innocent things has your face hidden Abby ? I know that there's a trick in there somewhere. Well, let me just
Speaker 2Say, when we were talking about this, initially, Carrie claimed that she had never played tricks on people and I'm, I'm always known as being the rule follower. I never break the rules, but there are a few times when I did. And my story also was from college. Um, we had a friend of ours who, same thing. She played a trick on us and she was just a hilarious person anyway. And so my roommate and I decided that we were gonna get her back. And so we were sitting there on a Saturday night, in our dorm room with nothing better to do. And so we came up with this idea of popping a bunch of popcorn. So we Bo popped and popped and popped just bags and bags of popcorn <laugh> . And our dorm was the facing of the door was really wide. So the distance between the wall and the door, there was like probably about three inches of depth there. And so what we did, and she went to bed really early at night, so we always to late . So it was a Saturday night. So we kinda went sneaking down the hall. We took paper bags actually, and basically papered the door up to the, to the very top. And so there was just a small opening at the top of the door. So we were trying to be really quiet <laugh> . So we were pouring popcorn, these bags of popcorn down in her door. And so we kept pour . So the door was like full of popcorn . So the next morning we were up early. And so , um, so we went to eat lunch and so we thought, well , we'll just walk by and see if Terry's opened her door yet or anything. So we go by and her door is completely perfect. There's not, not a bit of popcorn anywhere. The door is just completely, you know , she's completely taken everything down. So we thought, well, we'll just knock on her door and just start talking to her. So we knocked on the door and she invited us in and, you know , acted like she had no idea of anything going on. And so we all just started talking and we were just talking about something that was gonna happen in school the next day. And then she brought out this just giant, like walk of popcorn, <laugh> she ? Yeah . Pop some popcorn, but you guys like some this , so anyway, she , she kinda knew it was us . So we all started giggling. So it was kind of funny. <laugh>
Speaker 4That's cute.
Speaker 2That's cute. So, Susan, what about you? Do you have any funny stories?
Speaker 4Um, I, I am usually more the person who gets tricked than the trigger <laugh>
Speaker 2So have you been tricked then?
Speaker 4Like little things? Not anything. I , I can't think of my , um , so I, I am not, I appreciate nature, but when it comes to plants , <laugh> like , I'm, I'm relatively clueless. You know, I, I , I think you're ,
Speaker 2You didn't major biology. I'm guessing then , huh ?
Speaker 4I'm on major in biomedical science , but when it to like keeping plants alive or anything like that , it , you know, I'm the person who like the further away I stay from it, the more likely it is to survive. See
Speaker 2Your kids and your pets are alive still, right?
Speaker 4Yeah . All of my children and pets are still alive.
Speaker 2Yeah . Yeah . My theory is that I love plants and I have plants in my office and at home and I sort of joke about, well, if I couldn't keep my plants alive, you probably wouldn't wanna see me as a physician. So, so, but that didn't apply to you, Susan, just to me , <laugh>
Speaker 4Fortunately my patients talk and I think that's the reason my, my, my dogs and my children still like, are, are surviving. But when I was in medical school, we lived in , um , some duplexes and there were four of us who happened to live really, really close together. And one night , um, three of the girls were studying at one house and I was studying by myself. And , um, so they , um, came up with this letter that they , um, essentially, they, they wrote this letter from the PPS , which was the plant protection. <laugh> essentially like chasing me about like the care of my plants. And I was gonna have these fees and everything like that. I mean , they had like gotten a letter and like they had put a stamp on it. And of course I didn't pay attention. They were like, Hey Susan, we got some mail for you. And I was like, oh , OK . I come over to like chit chat and visit for a little bit. And I didn't notice it didn't have a postmark on it anyway. So I opened it up and I'm like reading this whole thing. And I'm like so confused and finally realized it was a joke, needless to say, I actually held onto that letter as a , because it was , it was so funny. I mean, it was cute. It was fun. You know, I , and , and I recently took a snapshot and sent it to the three girls that were in our little group. And it was , it was a nice memory. And, you know, like I said, I , I admit when it comes to plants, you know, I, I love the house I lived. I live in right now because I came into like a, her yard . So like, it was all done. That's the best thing for me. <laugh>
Speaker 2Well, today we have a very special guest. Um, she has joined us one other time. Her name is Dr . Amy Jones. She officially is a scientific director of ovation fertility. And so specifically she is really our go to person novation for all things genetic. So she knows how to do all that stuff that you read about , uh, in the newspaper and all the really cool, neat things that we can do to help bring about fertilization and to find out if our embryos are normal or not. So, Amy, tell us what you're gonna talk about today. Well ,
Speaker 5I think we wanna talk about how the use of technology specifically as it relates to genetics, can help people get pregnant and have a healthy lab of birth .
Speaker 2Very cool.
Speaker 3So P GTA , pre-implantation genetic testing for Anlody or the abnormal number of chromosomes is probably the most common thing that, that we do when we testing embryos. I mean, there's a whole host of stuff that we can look at embryos for, but that's the most common one. And what's, what is the most common scenario that we would see that for, that you would say it's really helpful for a patient? Um,
Speaker 5Well , I actually prefer the uncommon scenarios, but we'll talk about the common scenarios. You
Speaker 3Gotta dip a toe in before, or you push the whole person in <laugh> mm-hmm
Speaker 5<affirmative> . So let's say you go through IVF and you have , um, four blasts and you just randomly choose one to transfer. Um, and then you become pregnant and you miscarry well, you've wasted that amount of time when you could be, instead of transferring an embryo that we know will not give you a healthy live birth, you could test the embryos, freeze them and come back through for a frozen embryo transfer that will have a better chance of re resulting in a healthy life
Speaker 4Birth . So in this situation, I think what you're saying that you have multiple embryos P GT a can serve as a useful way of figuring out not only which ones, you know, we already know which ones look the best based on what our embryo tells us, but which ones chromosome have the best chance of giving us a baby. Right? That's right. I
Speaker 2Have a question. You have a young, healthy patient, so say I'm 25 and I'm gonna go through IVF. Why would I wanna do genetic testing? I mean, don't 25 year olds have a lot of genetically normal
Speaker 5Embryos. You know, we see rates as high as 50, 60, 70% , um , abnormal and , and younger patients , uh , not all patients, but if you happen to be that patient and it takes you, you know, four or five F E Ts, if you have a lot of embryos before you find your normal one, it's definitely worth the , the time and expense to do P
Speaker 4G T. So sometimes I know people are really concerned. You mentioned the expense of P G T so , so mm-hmm , <affirmative> , um, kind of speaking from your perspective, how much does adding P G T to an IVF cycle run just as a general ballpark, knowing that we have differences across the country and that type of thing.
Speaker 5Right. So three to 5,000.
Speaker 4And how much would you say the average frozen embryo transfer costs ? Oh,
Speaker 5Wow. It's been a while since I've looked at those fees. Uh, <laugh> three, three to 5,000 probably
Speaker 4Also. Yeah. So essentially if we have multiple embryos and say, we have a 50, 50 chance of picking a ch only normal embryo in the 50% chance that we've chosen abnormal, we could have already paid for P G T and then known directly for all of your entire cohort of embryos, which ones are gonna give you your best chances.
Speaker 5Yeah, exactly. And I think the data also supports that pregnancy rates and , uh , live birth rates are better with frozen embryo transfers. Patients do better, embryos do better, and a uterus that's prepared for a transfer as opposed to an egg retrieval.
Speaker 4So why , why do you think that is? Well, you
Speaker 5Could probably explain that piece better than I could. <laugh> so
Speaker 4Why is that Susan <laugh> ? So kind of the , the simplest way to think about it is when everybody going through those IVF retrievals, your hormones are going crazy. And , and those hormones specifically progesterone end up at higher levels than what they are ideal for creating the best environment for implantation. And if we can come back in a frozen embryo transfer and have very tight control over kind of the hormonal environment, we thereby get better chances of success.
Speaker 3So, Amy, you said that you were more interested in the unusual causes and the unusual benefits. What are the are unusual things, besides, besides the obvious of you have a 41 year old woman who's going through and doing P G T because she, she has a higher likelihood of having abnormal embryos and she wants to avoid a down syndrome , um , child or a pregnancy that's going to inevitably end up in miscarriage. So we've got, got the obvious , but what are the less obvious reasons to do P G T?
Speaker 5Yeah. So , um, I mean, it's that conversation that you have with the patient who's coming through? Who knows they wanna have, let's say two or three kids and they are 35 years old , um, younger or older , either one. And if they come through, they produce maybe two, three, or , well , let's say three or four blasts of those two or three are normal. Um , they have a transfer and it's successful. Okay. So they , they carry that birth to term. And now they're a year older, maybe they're ovarian reserve has diminished. And the two embryo they have in storage are abnormal, but they didn't know that on the front end. So they waste more time transferring those embryos. And all of a sudden they're 37 38, and they have a , you know, much higher chance of producing abnormal embryos and ovarian reserve . So I think those are the patients that it's important to reach them. It's important to have that conversation up front , um, and sort of frame it as IVF is such a huge investment. And one cycle might not do it. So you need to be prepared that it could take one or two or three cycles before you have enough to produce the family that you have envisioned your whole life. Um, and so if you don't have that conversation, then the decision will be made downstream and you, you know, you can't reverse that. So
Speaker 3One of the, kind of along that theme , um, the theme in my clinic this week, and I was telling my residents this, cuz I, I was, my patients had been teasing me , me that I've got my little ducklings behind me, cuz I happen to have three residents in my clinic with me this week. But , um , <laugh> the, the theme of my clinic this week has been translocations. And what that means is that instead of having 46 chromosomes, they're paired off nicely, we have the 46 chromosomes that are stuck together in an abnormal way. And these patients didn't happen to know that because their balanced translocation. So they have the total aggregate amount of chromosomes that they need and they are as it's called balanced. But what that means, and in the case of this, this one particular patient, she came to me with the intent of saying, I don't wanna get pregnant right now. I'm 35 years old. We wanna have a baby in the future, but , um, abortion is not okay with me. Like I would absolutely not have terminate a pregnancy for down syndrome, but I really would like to avoid that if at all pop . And so we wanna do IVF with genetic testing. Okay , fine. So we did the IVF. We did the P GT and her embryos came back and the T testing came back as suspicious for a translocation because they both had this really unique set of, of , of missing one chromosome gaining another chromosome. And they were what's called reciprocals. So matching, you know, where there was one, they were missing the other and, and vice versa on the opposite one. And so , um, the brilliant geneticist that at Amy's lab put a lovely little note that says, Hey, pay attention to this for which I am always grateful when I see cuz if they write me a note, I listen , um, and that patient ultimately went on to go do a total of four cycles. She got 10 embryos, but of those 10 embryos, only three were good. Um, the other seven one had down syndrome, the other six all had that translocation. And, and we never would've known own because the embryos themselves are beautiful. Like you look at them and they're textbook gorgeous. But when you look at their genetic testing, they're not, and it would've been, we would've been a couple years down the road before we realized that if, if she hadn't opted to do that testing and I've got another patient with a very similar story, young, healthy, 10 embryos, but in her case, eight of them are bad and we should really
Speaker 5To track , uh , how many we catch because there's, I mean, quite a few of those letters that we send out attached to reports.
Speaker 3Yeah. Well, it's got implications for the kids too. Like the other patient that I saw this week, she, the only reason she came to me , um, was because her grandmother had told her, yeah, there's something in our family. We're more prone to down syndrome. You need to, you need to look into this when you're ready to have babies. And she didn't know any more than that, but that story alone was enough for me to know what testing to order. She's got a Robert so and translocation that makes her extraordinarily prone to down syndrome babies and wow . And so it means that not only can I help her to have a healthy child, but I can tell her exactly, you know, when your kid is of age, this is what you tell them, and this is what they need to be tested for. Because if they carry this translocation, they're gonna need to have, consider doing this testing for their babies too, to avoid passing it along. Yeah.
Speaker 5So I'm curious , um, have you guys seen a shift in, in patients who approach you about this type of testing versus 10 years ago?
Speaker 4In my practice, almost everybody there's, there's a few exceptions, but almost everybody does P GTA in my practice. And I know that varies from practice to practice. There's some practices that don't do hardly any , um, I generally pose it as we are . We are gathering more information and like, like we talked about earlier, I talk about, you know, if we're, if we're wrong one time and we select one embryo that would've been chromosome abnormal, you would've paid four where the T I , I think that, you know, the nice thing is I think T a is one thing that hasn't really increased in price and , um, may have , um, decreased some over the past 10 years. Um, I think the accuracy, I think we trust the data more than ever. Um, now the data we get now now is, can be a little more confusing because as we've gained information, now we add information about those AISM and, and things like that, that I didn't worry about 10 years ago because we , we , we honestly didn't know we needed to pay that much attention to it. Um, but I think there , I , I always consider there's power in know, and, you know, some people choose not to have that knowledge and that's okay. Um , mm-hmm <affirmative> but I , I think that , um, there is , there's definitely some benefit. Um, I, I, I think the hardest conversation I have with patients with P G T are the people who go through and they end up with one embryo on day three, if we're still looking at day three <laugh> and you know, those are the people that are like, I have one embryo, do I test it? Um, I , I know what I say, but, but Amy, what are , what are your thoughts from kind of the lab standpoint of that one embryo on day three, if you you're looking at day three ,
Speaker 5I think it's definitely worth testing because if you don't test it, then you're going to pay for a thaw and a transfer it's abnormal mm-hmm <affirmative>. So I think it's definitely think it's worth testing. So I
Speaker 2Have kind of one other question before we close, cuz we kind of jumped right in and we kind of all know that of the gaits, both sperm and egg that unfortunately for us females, that the egg is kind of usually to blame for Aloy or for the abnormal number of chromosomes. So can you speak a little bit to the physiology of us females and why that's the case and kind of, we alluded to it earlier, but kind of the difference in age, if you're 25 or 35 45 , in terms of your chances for ALO . Yeah.
Speaker 5I actually have , um, the combined ovation stats for different age groups. If you'd like me to go over some of that.
Speaker 4Yes, please. That'd be awesome.
Speaker 5How many que there are a few questions there <laugh> so,
Speaker 2So tell me why being female makes it more likely for you to, or for your egg to be the reason why the chromosome number is imbalanced. Why does it not? Why does the sperm not do that usually? Well, the sperm
Speaker 5Are preproduced every 70 days or so and eggs. We, I mean the theory seems to go back and forth, but right now I think that everyone's somewhat in agreement that we're born with all that we're going to have, regardless the eggs are sitting around in our bodies for longer than sperm are. And , um, and there's pretty complicated mechanisms that contribute to chromosomes getting sticky, but basically they just don't separate, like they should.
Speaker 2So, so let me interrupt. So when I go to ovulate, the egg comes out and all of a sudden correct me if I'm wrong , but it has to get rid of half of its chromosomes. Right. So it can join with a sperm. Yep . That's kind of the issue, right. Doesn't happen so well.
Speaker 5Yeah. Yep . That's um, so when you get that H C shot and you're going through IVF that causes the little communications that are sticking into the egg to pull out, and that tells the egg to extrude its first polar body, which is that extra set. And then it has another extra set to get rid of once it's fertilized. So if
Speaker 2It gets rid of too few or too many and the sperm joins with it, then the embryo itself ends up having too fewer, too many chromosomes. Correct. That's
Speaker 5Right. Amy,
Speaker 4Once in a while I have patients who really want kind of proof. Did , did this happen because of the sperm or because of the egg? Where, where is the technology on that?
Speaker 5Um, so we're getting closer. Uh, we would have to have parental DNA to be able to do , um, investigations. The limitation really is how we amplify the DNA. It's a pretty blunt mechanism for amplification. Um, but I'm, so it makes it harder to fare it out that kind of specific information, but I'm hopeful that this new technology that we're looking at now will enable us to , um, look more closely at a lot of things, including discerning the difference between , uh , balanced and normal translocations , um, potentially looking at epigenetic mechanisms. I mean that's downstream, but , um, there's, you know, as, you know, technology and genetics, you moved quite quickly and there's always exciting things going on in fields that don't have to look at such tiny amounts of DNA. So we have to sort of take that and then scale it way down to the amount of DNA that we have access to. And because we have to amplify the DNA again, it's just a kind of a blunt mechanism that makes the inform not as interesting, but as the technology becomes more precise, we can look more closely at. So
Speaker 4That is something perhaps in the future. That's
Speaker 5Right. Okay. So now that we've interrupted you and asked six other questions in between the first question we asked you, what are the general OID or abnormality rates if you're in your mid twenties , mid thirties, mid forties. So ovation data , um , got already here , is it less than , uh , 35? We're looking at around 60% of your embryos should be , um, normal or Eloy , so not and Eloy , but Eloy . Um, and then when you get around the mid thirties, you know, it's 50%, 38 to 40, 40% over 40, you know, it's just, it starts to trail off 20%, 41 to 42. And then over 42, you know, you have a , a real risk of, and any of these age groups, you have a risk of having no , um, Eloy them . Well , we
Speaker 2Appreciate your time today and to our audience. Thanks for listening and tune in next week for more also be sure to subscribe and leave us review in iTunes. We'd really love to hear from you .
Speaker 3Thank you so much for everyone for listening and thank you so much to Amy for joining us. We appreciate it. We'll see y'all next week. Bye everybody. Bye. Your body .