Laurence A. Jacobs, M.D. - Blog

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Tubal Ligation Reversal ???

 So you think you may want to reverse your tubal ligation?   There are many issues to consider before making a decision to go forward with reversal surgery or to undergo in vitro fertilization (IVF) instead. This discussion will give you the information you need to make an informed decision regarding surgery versus IVF.    Reversibility:  Many tubal ligations are reversible, but only if one area of the fallopian tube is occluded or destroyed by clip or burn techniques. If multiple areas have been treated, tubal ligation reversal is not a surgical option.   Type of tubal ligation:  It is very important for you to get the operative report to see which type of surgery was performed and the extent of tubal damage. For example, Fallope ring or Pomeroy tubal ligations can often be reversed if only one area of the tube has been treated.   Insurance:  Even if you have an insurance policy that “covers infertility”, the vast majority will not cover tubal ligation reversal. However, if you have the surgery and it fails, after one year you may often have insurance coverage for in vitro fertilization.   Costs:  IVF with Dr Laurence Jacobs at Fertility Centers of Illinois (both Chicago area IVF centers - Highland Park & River North) is approximately $10,000. However, several IVF centers charge as much as $12,000-$20,000 per attempt.   Laparotomy (regular incision) will cost approximately $25,000-$30,000 because it includes 2-3 days of hospitalization as well as the surgical and anesthesia bills. Laparoscopic tubal ligation reversal, which can be accomplished by a handful of skilled surgeons, generally will run $10,000-$13,000 since it can be performed as an out-patient procedure.  Age of the female patient:   Women under 35 (usually with good egg/oocyte quality) can do either tubal ligation reversal surgery or in vitro fertilization (IVF) and expect a good outcome. However, women over 35 (with fair to poor egg/oocyte quality) may do better with IVF so that the best appearing and healthiest eggs can be chosen. The “ovarian reserve” of eggs can easily be assessed at any of our Fertility Centers of Illinois Chicago area fertility offices by doing a single blood test and an ultrasound on day 2, 3 or 4 of the menstrual cycle. (see the ‘ovarian reserve’ article on Dr. Laurence Jacobs’ website). http://www.infertilitydoc.net/pdf/OvarianReserveExplained.pdf  Male factor:  A thorough semen analysis (SA) including ‘strict morphology’ should be done before a decision is made regarding surgery reversal versus IVF. If there is any significant male factor problem, IVF is the best choice since the best sperm can be utilized with IVF/ICSI (intracytoplasmic sperm injection) at both of our fertility IVF centers in Illinois in order to overcome male factor. (see the ‘strict morphology’ article on Dr. Laurence Jacobs’ website) http://www.infertilitydoc.net/html/male.html#function  Surgical treatment:  Most true infertility specialists (reproductive endocrinologists) in the Chicago area will do an exploratory laparotomy with a large incision to do reversal surgery. This  involves  three to four hours of surgery and two to three days of hospitalization.   A few Chicago area reproductive endocrinologists can do tubal ligation reversal surgery by laparoscopy as an out-patient, usually costing far less and taking less time.   Will you need fertility therapy after a tubal ligation reversal?  If you are young and there is no male factor problem, trying on your own for six months to a year is reasonable. If, however, you are over 35, or there is mild male factor, ovulation induction with IUI may still be necessary in order to get pregnant.            (see article on ‘Clomid and IUI’ on Dr. Laurence Jacobs’ website)  http://www.infertilitydoc.net/pdf/CLOMID_IUI.pdf Call Fertility Centers of Illinois (847 215 8899 x 21502)  for information and/or to set up a consultation with Dr. Laurence Jacobs.  

Posted on 07/19/2009 02:39:00

Gender Selection/Sex Selection for Genetic Diseases and/or “Family Balancing”

Normal 0 false false false MicrosoftInternetExplorer4 st1\:*{behavior:url(#ieooui) } PGD Gender Selection If you want to be sure that your next child will be the gender you need or desire, be aware that no other gender selection method comes close to the success or reliability of IVF with PGD (greater than 99.9%). Available sperm separation methods, such as Erickson (60-75% successful gender selection) or MicroSort sperm selection (65-85% success) cant come close to the PGD gender selection methods. Using IVF and preimplantation genetic diagnosis (PGD) for gender selection, male and female embryos are identified and only embryos of the desired sex are transferred to the uterus. At our Chicago area IVF clinics, this is the method of sex selection we recommend. Whether doing PGD gender selection for prevention of sex-linked genetic diseases or for ‘family balancing’, the embryos can also be screened by our genetics team for ‘aneuploidy’ (see above). The aneuploidy (abnormal chromosome count) screening process, employed at the time of PGD gender determination, allows for the detection of various genetic count abnormalities, such as Down's syndrome (one "extra" chromosome 21). Comparative Genomic Hybridization-CGH is also available to screen all 23 chromosome pairs for genetic abnormalities and determine gender at the same time. PGD for gender selection IVF pregnancy success rates are similar to regular in vitro fertilization success rates and sex selection rates approach 100%.    

Posted on 06/18/2009 22:36:00

Comparative Genomic Hybridization (CGH)

Normal 0 false false false MicrosoftInternetExplorer4 st1\:*{behavior:url(#ieooui) } /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:"Times New Roman"; mso-ansi-language:#0400; mso-fareast-language:#0400; mso-bidi-language:#0400;} Comparative Genomic Hybridization (CGH) Preimplantation Genetics of all 23 chromosomes !! Preimplantation Genetic Screening/Diagnosis (PGS & PGD) consists of the biopsy of a single cell per embryo, followed by its genetic diagnosis through different techniques, and the subsequent replacement to the patient or freezing, of only those embryos classified by genetic diagnosis as normal. Since the early 1990s, the standard preimplantation genetics testing methods, using PGS/PGD techniques, have only allowed for the evaluation of 9 to 12 chromosomes out of a total of 23 chromosome pairs in the human embryo cell.  CGH solves this problem by evaluating all 23 chromosome pairs, allowing completely screened normal embryos to be identified and transferred or frozen. The field of Preimplantation Genetics has been recently revitalized with the appearance of this new CGH technology. The future of Preimplantation Genetic testing is now available at both our Fertility Centers of Illinois (FCI) Chicago area IVF clinics - FCI Highland Park IVF and FCI River North IVF! Due to our long-standing relationship with ReproGenetics (www.Reprogenetics.com ) and our excellent day 5 blastocyst culture methods and embryo freezing (vitrification) techniques, FCI is one of only a handful of IVF programs world-wide able to offer this major breakthrough. Preimplantation Genetic Diagnosis Background As women get older, many of their eggs become genetically abnormal, causing infertility but also significantly increasing the risks for miscarriages and genetic birth defects. In vitro Fertilization (IVF) is the best fertility option so egg quality as well as embryo quality can be evaluated visually and then a few of the healthiest appearing embryos can be transferred to the uterus. Furthermore, assessing some of the chromosomes of each normally developing embryo, for structural abnormalities (deletions) or abnormal numbers of chromosomes (aneuploidy), by Preimplantation Genetic Screening- PGS, has been available since the early 1990s. PGS can reduce the risk of miscarriage as well as the risk of many genetic birth defects with the subsequent transfer to the patient of those embryos classified by genetic diagnosis as normal. The technique involves the microscopic removal of generally a single cell from a day 3 developing embryo. Most normal embryos on day 3 have 5-8 cells, so removal of one cell usually does not disrupt the embryo. Once a single cell (a blastomere) is removed, the cell is fixed on a glass slide for chromosomal analysis… analyzed using a technique called fluorescence in situ hybridization (FISH) Two days later, one or two of the genetically normal embryos are transferred to the uterus on day 5. Several recent studies have confirmed that the biopsy methods employed during PGS are critical for providing accurate results without harming the embryos being tested. Day 3 embryo biopsy, combined with PGS, can improve IVF success rates if biopsy methods and PGS analysis are each done by experienced embryologists and geneticists, but may produce negative results if either of these processes is performed in a suboptimal manner by inexperienced hands. The 9 to12 chromosomes chosen for testing (usually Chromosomes # 13 14 15 16 17 18 21 22 X and Y) account for over 90% of the genetic miscarriages and birth defects.  For example, Down’s syndrome is caused by an extra # 21 chromosome (Trisomy 21). Aneuploidy (any abnormal number of chromosomes….missing or extra) increases dramatically as women age. The most common situations for recommending PGS include: Women age 39 or older (although some women 35-38 ask for the procedure) Severe male factor (especially when testicular biopsy is needed to obtain sperm) Miscarriages (2 or more genetic or unexplained losses) IVF failures ( 2 or more failures, despite normal appearing quality embryos) PGS methods utilizing the day 3 biopsy of a single cell (usually representing all cells of the 5-8 cell embryo) are associated with an error rate of 5%, with almost all errors attributable to mosaicism (the presence of one or more chromosomally different cell lines within the same embryo). No method based upon screening of a single cell on day 3 can avoid a small error rate due to mosaicism. In addition, there are numerous genetic diseases secondary to ‘single gene disorders’ that result from mutations affecting individual genes on a chromosome. Preimplantation Genetic Diagnosis, or PGD, involves assessing a given chromosome for these single gene abnormalities by doing a day 3 embryo biopsy of a single cell. Using polymerase chain reaction (PCR), fluorescent PCR and DNA sequencing, the geneticists in the PGD laboratory can examine each developing embryo to identify the absence or presence of these specific genetic disorders. The most common indications for recommending PGD include: Previous birth of a child with a single gene disorder (examples - Cystic Fibrosis, Tay Sachs, Muscular Dystrophy, Hemophilia, Thalassemia, fragile X  or Sickle cell, to name a few) Both partners are ‘carriers’ for a single gene disorder, based on screening tests and therefore at risk for passing on inherited genetic disease to their offspring   Comparative Genomic Hybridization (CGH) Complete karyotype chromosome analysis (all 23 pairs) of day 5 blastocyst-stage embryos is now clinically available using CGH. This innovative technology uses whole genomic amplification of the DNA from the embryo biopsy, followed by fluorescent green labeling of the sample DNA, then hybridization with normal DNA, fluorescently labeled red. Images are collected by specialized software which compares intensities between red and green for each chromosome, generating a molecular karyotype. Thus, CGH can identify an ‘imbalance’ in chromosomal material and detect all trisomies and monosomies (aneuploidy) and some large structural translocation imbalances. Advantages of CGH on day 5 blastocyst-stage embryos: Multiple cells are analyzed leading to highly accurate results Trophectoderm cells (future placenta) are tested…not cells involved in the formation of the fetus. This may reduce any potential damage from the embryo biopsy. All 23 chromosome pairs are tested resulting in a complete chromosome analysis. Complete elimination of diagnostic errors associated with mosaicism. CGH is performed on several cells from day 5 blastocyst embryos compared to one cell biopsy with PGD on day 3 embryos.   After day 5 blastocyst biopsies are performed at FCI, the embryos need to be frozen (vitrified) to allow for the lengthy CGH chromosome analysis at Reprogenetics. Transferring the thawed embryos takes place in a subsequent cycle, at the time of optimal endometrial receptivity.  Utilization of this approach requires a significant level of expertise in numerous procedures - day 5 blastocyst cultures, new vitrification (fast freeze) techniques and embryo transfer in a subsequent cycle… and will not be suitable for all IVF centers.      

Posted on 06/12/2009 23:09:00