Spy Elite System

By: John O. Issis, MD with Medical West
As healthcare providers, It is among our goals to consistently look for opportunities to improve our methods of care for our patients. Because of the day and age we live in, we are always exploring, evaluating, acquiring, and implementing the latest technologies. The team at Medical West and I are excited to share with you one of the latest technologies we use to improve the quality and efficiency of care for our patients.

I am proud to be able to say that we at Medical West were the first hospital in the state of Alabama to use the Spy Elite System in our procedures. The Spy Elite System is a real-time in-operating room technique that enhances the visualization of tissue perfusion. This allows our surgeons to see the performance of blood flow during procedures. In short, we can see where blood is flowing, and where it is not.

Particularly useful during procedures such as mastectomies, breast reconstruction, amputations, head and neck reconstruction, and others - the Spy Elite System allows us surgeons to see the real-time blood perfusion in damaged or replacement tissue - we can look inside and spy on where the blood is flowing.

During an operation, if I would like to have perfusion data, the images can be generated quickly - sometimes in as little as one minute.

The information provided by the Spy Elite System complements my in-operation judgment and decision-making. By adding only as much as five minutes time to a procedure, the Spy Elite System gives me and my partner surgeons the information we need in order to reduce complications and reducing your chance of a return to the operating room.

The Spy Elite System has been a great addition to our operations here, and we make our procedural plans with the Spy in mind.

It's another way our team at Medical West Hospital utilizes advancing technologies to improve and provide the best quality care possible.

Best, Dr. Issis -

Osteoarthritis & Viscosupplementation

By Robert Flannery, MD
Lemak Sports Medicine
Primary Care Sports Medicine

I've been asked multiple times by multiple patients if I do, "those chicken injections?" I tell them yes, but we've come a long way from those first injections. The debate over viscosupplementation or Hyaluronic Acid (HA) injections has taken some interesting turns over the last several months.

Hyaluronic Acid is one of the many treatments for osteoarthritis (OA). The exact cause of osteoarthritis is still being researched, but we know the end result is loss of cartilage, "thinner" joint fluid, and the dreaded "bone on bone" X-ray report. There is no way to reverse the process and any "treatments" are only temporary. Most are used as a bridge to a knee replacement. However, for some people, that bridge is all they've got and we'll talk more about that later. Other treatments for OA include lifestyle modifications (rest, avoidance of the irritating activity, etc.), exercise, physical therapy, bracing, medications (NSAIDs, narcotics, etc.), weight loss, and corticosteroid injections. You'll notice that lifestyle modifications and exercise seem to be mutually exclusive. They are not, but it highlights the spectrum of treatments for OA and that there is not a good consensus on treatment.

Here is a little background on HA. Some of the first commercially available products were derived from rooster combs. Some products are still made from an avian source and some are made synthetically from a bacterial culture. Regardless of how it is made, the theory behind HA is two- fold. First, it is to bath the joint in HA in hopes that receptors in the cartilage will "remember" what joint fluid should be and begin making more appropriate joint fluid. Second, it will provide some lubrication to the joint until the medication can take effect. The "gel" is injected directly into the joint (ultrasound guidance can be used, but that is a topic for another blog). This can be done in a single injection or up to 5 weekly injections. Results can be seen immediately, but may take a few weeks to take effect. Maximum benefit is usually seen by 6 weeks and typically lasts around 6 months. The decision as to which product to use and the number of injections is made on an individual basis by the physician and the patient.

Recently, there was a change in the 2013 recommendation guidelines for OA of the knee by the American Academy of Orthopedic Surgeons (AAOS) from inconclusive to strongly against HA injections. The full OA guidelines can be found here (http://www.aaos.org/research/guidelines/TreatmentofOsteoarthritisoftheKneeGuideline.pdf). The recommendation regarding HA is #9. I, along with many in my field of primary care sports medicine, am concerned with these changes. Why is this a concern? It all comes down to reimbursement or the lack there of. There is no denying that the cost of HA injections is high (again a topic for another entry). Insurance companies base their reimbursements on guidelines and recommendation of respected academies and societies, especially when considering an expensive treatment option. We are starting to hear and see some rebuttals to the AAOS. Most notably by the Arthroscopy Association of North America (AANA), American College of Rheumatology (ARC), and Osteoarthritis Research Society International (OARSI), which have returned "uncertain" guidelines. They have all been critical of the methodology used by the AAOS in its meta analysis. A recent article by Dr. Bannuru, a leading expert in meta analysis, pointed out numerous flaws in how AAOS “missed the mark” in developing the recommendations.

The short version of my concerns with this recommendation is as follows. The most glaring is that safety profile is not taken into account, especially when discussing HA vs NSAIDs or Tramadol. HA injections have a very minimal side effect profile and have been routinely found to be safe. NSAIDs, which are currently the gold standard for treatment, or Tramadol, have a well-known side effect profile including bleeding, GI, kidney, and cardiovascular risks. Cost also has to be taken in to consideration when making the argument in HA vs NSAIDS. If you look solely at administration cost, NSAIDs will win out. However, if using NSAIDs as a long term treatment, I believe the cost of complications both monetarily and in quality of living will favor HA. That being said, you can make the argument that NSAIDs should only be used as a bridge to knee replacement. My response would be, "what about the patients that cannot have surgery due to other comorbidities?" This is a patient population that usually already has issues with renal, GI, and cardiovascular disease. A lot of them cannot take NSAIDs, cannot exercise because their joints hurt, and corticosteroids have a worse side effect profile. HA injections can be very useful in this subset of patients. On the other end of the surgery spectrum are young patients with OA. We know that joint replacements will last approximately 15 to 20 years. Ask any orthopedic surgeon and they will tell you that replacing a joint replacement is no fun. If possible, I try to "bridge" patients until their early to mid 60s before having a joint replacement. I cringe at putting a 40 year old on NSAIDs for 20+ years. Yes, the younger patient will do better with weight loss, exercise, and PT, but they usually get better results from HA injections as well.

Second, there are multiple factors to interpret when looking at the effects of HA injections including type of medicine, age, overall health, progression of the disease, and metabolism of the HA. This fact makes it very difficult to make a single overarching statement regarding the utility of viscosupplementation. There are multiple types of HA injection, high, low, and mixed molecular weight preparations. The AAOS guidelines document identified that the efficacy of high molecular weight preparations were significantly better.  However, in the recommendation, AAOS did not differentiate among the products.  In fact, AAOS included some HA preparations that are not approved for use by the FDA. When looking at the remaining variable factors patient selection will cover age, health, progression of the disease, and metabolism of the medication. The AAOS guidelines do not mention patient selection. Three of the four are easily identifiable and obviously the younger, healthier, and less disease a person has, the better they will respond to any intervention. Metabolism is very difficult to predict. Some patients will be "responders" and some will be "non responders". Unfortunately, at this time the only way to identify this is trial and error, but research is being conducted.

In conclusion, I feel that the 2013 AAOS guidelines are flawed. At worst, an "inconclusive" or "uncertain" recommendation could have been made. At best, multiple recommendations for high vs. low molecular weight HA and proper patient selection could be made. Viscosupplementation is a viable treatment option. It has an outstanding safety profile and can be used in conjunction with other conservative measures. It can be used as either a bridge to knee replacement surgery or for long term treatment. Further research needs to be done to address efficacy and metabolism. In the meantime, we need to do what we can for our patients with OA and that should include the option for hyaluronic acid injections.

Pediatric Allergy and Immunology

By: Dr. Prescott Atkinson_ Director of Pediatric Allergy and Immunology at Children’s of Alabama and a Professor of Pediatrics at UAB

 

Twenty or thirty years ago, few medicines other than antihistamines were available to treat allergies. Now, we have a vast and growing array of pills, sprays, inhalers and injections that provide increasingly effective treatment for a wide variety of allergic and immunologic illnesses.

At Children’s of Alabama, physicians in Pediatric Allergy and Immunology see children with allergic diseases ranging from simple hay fever to complex, potentially life-threatening conditions such as asthma and anaphylaxis, a severe reaction that can occur following exposure to stinging insects, foods or drugs such as penicillin. For instance, we treat chronic or acute hives, and we treat swelling disorders, particularly hereditary angioedema, which is marked by terrible, sometimes life-threatening swelling that can cause airway obstruction.

We also treat children with atopic dermatitis (allergic eczema) and we assist in the diagnosis and management of food allergies, which are often seen in children with atopic dermatitis.  Together with our pediatric gastroenterologists at Children’s, we are currently helping diagnose and treat patients with a severe inflammatory condition of the esophagus called eosinophilic esophagitis (EoE) that is associated with atopic dermatitis and food allergy. The condition isn’t as rare as you might think - there are hundreds of these patients in Alabama.  EoE is much like eczema of the esophagus. It is an allergic inflammatory process that causes pain, vomiting and more significantly, scarring of the esophagus so patients develop strictures or narrowing. This can cause food to get impacted in the esophagus and lead to a trip to the emergency room.

There’s much we don’t know about eosinophilic esophagitis. It is clearly related to hyper-sensitivity or allergy, often to foods. When the tissue is put under a microscope, it looks a lot like eczema. It’s not a pure allergic problem, but it has an allergic component. Cow’s milk is often the culprit.

We have many medications and techniques we can use to treat all these allergic illnesses. For example, we can provide immunotherapy shots to reduce a patient’s sensitivity to common aeroallergens such as pollen, house dust mites and animal dander and to insect stings. The treatment of severe insect sting allergy of the type that causes anaphylaxis with immunotherapy has been proven to work in numerous scientific studies, but many people, including those in the local medical community, are not aware of this important treatment option.

We’re getting more knowledgeable about how the immune system works, and many new biologic medical products are now coming onto the market. The first of these biologics to be approved by the FDA, a monoclonal antibody called omalizumab, or Xolair, is used in patients with allergic asthma. It’s moderately effective at blocking the allergic reaction. Unfortunately, it’s costly, so it’s not something to take for conditions like hay fever, but it becomes a cost-effective option for patients who have allergic asthma that is putting them in the hospital every other month.

Often, patients come to us with suspected food allergies, and right now all we can do is provide them with the right diagnostic testing and then give advice on how to best avoid their specific allergens – there aren’t any shots or specific treatments available. Food allergies have proven extremely difficult to treat, but that may be changing. Research is advancing into protocols to desensitize patients with these allergies. These treatment protocols are still being developed but if and when they become approved for use in dedicated centers, I’d certainly like our clinic to be one of those. For example, one of the latest studies shows that patients with severe peanut allergies may never get to the point where they can eat a bag of peanuts, but they may be able to safely eat a single peanut, which is sufficient to keep them from having a severe allergic reaction from an accidental exposure.

Of course, all these new treatments require a high degree of specialized skill. Our specialists are certified by the American Board of Allergy and Immunology. That means spending at least two years in a subspecialty program with a highly defined and monitored training curriculum to learn how to practice clinical allergy and immunology. This rigorous training is capped by a difficult examination. All graduates since 1990 have been required to participate in maintenance of certification to ensure continuing expertise with new medical discoveries.

For more information about our program or allergies in general, visit www.childrensal.org/allergyimmunology. We have excellent content on the site specifically designed for children, teens and parents.

Dr. Prescott Atkinson is Director of Pediatric Allergy and Immunology at Children’s of Alabama and a Professor of Pediatrics at UAB. He is board certified in pediatrics, as well as pediatric allergy and immunology. He received his MD/PhD from Emory University in 1987, completed his pediatric residency at Georgetown University, and completed a fellowship in allergy and immunology at the National Institutes of Health in 1992. He joined the faculty at UAB that year.

Weight Loss Surgery – Standing out from the Crowd

 

By: Sue Bunnell, RN and Clinical Manager of the Princeton Comprehensive Bariatric Center

I came to Princeton Baptist Medical Center in March of 2010.  But it was a homecoming for me.  I had been part of the Baptist family since 1998-2005.  I was asked to help transform our Surgeon’s vision into 4 walls, and this is our story.

 The first thing to understand about us is that we have a mission.  We have a purpose for how we provide care to this specialized patient population. 

TO ACCOMPLISH OUR MISSION, Princeton Baptist Health System’s Bariatric Team will:

• Strive to ensure that each patient is fully informed, fully prepared and their expectations have been met
• Provide a safe and comfortable environment for each and every patient that is cared for within our facility
• Be committed to treating all patients with the utmost respect and dignity
• Offer preoperative and postoperative nutritional and exercise counseling
• Facilitate support group meetings twice per month
• Provide a complete and comprehensive educational experience to patients wishing to learn about the surgical treatment of morbid obesity and out program
• Provide a comprehensive surgical experience for patients who choose to proceed with Roux-en-Y, adjustable gastric banding or sleeve Gastrectomy
• Develop an after-care program to assist the weight loss surgery patient throughout their journey

WE ALSO EMBRACE Baptist Health System Patient Promise:

 

Now, let me tell you about the structure, or what you will see.  We are a 6200 square foot area, custom designed for the person of size.  When you first enter our Center, you will notice, things are different here.  I will echo that, with a hearty, “Yes, they certainly are”. 

As you begin your look around, you will notice the size appropriate chairs.  These are a custom designed product.  The changes from the intended creation were recommendations by our patients to enhance comfort. 

You will also notice randomly spaced seating throughout our facility.  This is from the valet parking area to our auditorium.  We want you to be comfortable in knowing that we understand that you may struggle walking long distances at a time.    The hallways are adequate for a power chair and a care partner to enter together.  We are here for you, and ready to accommodate your needs!

Speaking of hallways, we have one with a special title.  It is the “Because I can” wall.  We ask patients to bring in photos of various things that represent non-scale victories.  Quality of life is so much more than a number on a scale or “high school skinny”.  It is all about moving off of the side lines and into the game.

The next area of interest is our gym.  It provides an intimate area with 6 machines (all weight rated at minimum of 450 pounds), medicine balls, hand weights and kettle bells.  One of our machines can be configured to accommodate a wheel chair.  Our gym area is very private.  All of our pre-operative patients will receive an orientation class to the exercise equipment.  The goal is to help our patients’ feel comfortable enough in the gym environment to transition into a public gym.  We want to help cultivate a lifelong love of exercise.

Toward the back of the facility, we have a wonderful area designed just for socializing.  There are several intimate seating areas for friends to gather.  Public computers are part of this area even though we have free Wi-Fi.  The educational experience is so important to our patients whether they are seeking to learn more about surgical options or connect with other patients.  We want to support them through all steps of their journey. 

The largest area in our facility is the 1700 square foot auditorium.  This room ROCKS!  Literally, as we have surround- sound, LCD projector, big screen, etc.  We are even equipment with an air-conditioning unit specific to this meeting room.  We are fully equipment to educate. We can seat a little over 100 people for meetings.  We conduct seminar for the patient seeking information about surgery, support group, educational classes as well as Zumba, Yoga and Walking class all within these four walls.  A big favorite is the portable cook top that is located in the front of the room.  We have a kitchen on wheels!  We provide a cooking demonstration with lunch the third Friday of each month.  It has been very well received by our surgery patients as well as other visitors to the Center.  Mr. John Naro, Executive Chef, for Princeton hospital is the guest speaker for this event.

We have a bimonthly support group led by our very own Certified Life Coach, Stefanie Dutton.  She works very hard to keep the topics fresh and original.  She has various guest speakers come to share information.  She provides printed educational material for future reference. 

We have just introduced a Recovery Program.  This program has been specifically written for those who have had weight loss surgery and have experience inadequate weight loss, or weight regain.  We provide compassionate care, in a nonjudgemental surrounding.  We help you work through the issues, set goals, and start making changes to find success.  This is also multidisciplinary with monthly classes, use of the gym and a $40.00/month fee. 

OK – I have been speaking in great length about those interested in the surgical weight loss options.  We here at the Comprehensive Bariatric Center understand that surgical intervention is not the choice for everyone.  We also support a medical weight management program.  It is a multidisciplinary approach with monthly meetings, usage of the gym, and support group.  There is a $40.00/month fee attached to this program. 

This same program can be utilized to accommodate the 7 month physician monitored weight loss requirement that is required by some insurance.  We coordinate your care with your primary care physician and the surgeons’ office. 

Moving to a more personal note, I am a weight loss surgery patient.  I had RNY 9 years ago.  My highest weight was 293 pounds.  I was on 13 prescription medications for various health conditions.  Currently I am sporting a 145 pound weight loss, and all of my health conditions are in remission.  So, when I tell you that I know the feelings of anxiety, fear, frustration, hopelessness and pain associated with obesity, please be assured that I really know. 

God Bless,

Sue

For a detailed list of classes, seminars, dates and times, please visit:www.princetonbariatrics.com. 

We offer tours daily and We Are Here for You through your weight loss journey!!

Princeton Comprehensive Center

205-783-7595

Living with Psoriasis

By: Dr. James Krell with Total Skin and Beauty Dermatology Center

 

Psoriasis is a common chronic disease that affects almost 7.5 million Americans. It can range from mild disease (just a few spots on the scalp, elbows or knees) to severe disease covering 30-40% of the total body. It is estimated that 25% of patients with psoriasis have severe disease.

Psoriasis can start at any age, but the most common age of onset is in the mid-20s. The cause of psoriasis is unknown, but about 30% of patients have inherited it from one of their relatives. The most common type of psoriasis is plaque psoriasis, but a frequent type of psoriasis is called guttate psoriasis and occurs in young people (often under the age of 20) as a result of a strep infection.

Psoriasis is frequently associated with itching and can often affect daily life activities such as walking (especially when it is on the feet), standing or sitting for long periods of time, sleeping and even one’s sexual life.

There is also a strong association with depression, and about 30% of patients with psoriasis have a type of arthritis called psoriatic arthritis that is associated with pain and swelling of the feet, fingers, wrists and back. It is also associated with stiffness in the morning.

Recent studies have shown that psoriasis is associated with a higher risk of cardiovascular disease. This data comes from several sources, but the main source is the large database in the United Kingdom.

The cardiovascular risk is highest in patients who are young and have severe psoriasis. Nonetheless, the risk exists in all patients with psoriasis. Dermatologists continue to ask the question as to whether treating the psoriasis reduces the cardiovascular risk in those patients.

A study of 2,400 patients in Denmark published in 2012 begins to answer that question. In the study, the authors found that patients who were treated with biologic medications (Enbrel, Humira, Stelara) and Methotrexate had a lower incidence of stroke, heart attack and death.

We recommend that all patients with psoriasis have a primary care doctor who can look at their cardiovascular health on a regular basis. We suggest reducing cardiovascular risk factors when possible. In particular, we suggest weight loss and that patients not smoke.

At Total Skin & Beauty, we treat psoriasis aggressively in our practice with phototherapy, topical therapy, laser therapy, oral medications and new biologic injectable medications to get most patients’ disease under good control.

Dr. Krell is considered to be a national expert on psoriasis and has lectured extensively in the United States and internationally on this frustrating disease.

info@totalskinandbeauty.com

Glaucoma – the “sneak thief” of sight

 

By: Leo Semes, OD _ Professor, UAB School of Optometry.

 You may have seen recent headlines about glaucoma awareness.  Prevent Blindness America, whose mission is to educate the public about causes of blindness, glaucoma being the second-leading cause in the USA, has this resource.  (http://optometrytimes.modernmedicine.com/optometrytimes/news/prevent-blindness-declares-january-national-glaucoma-awareness-month; accessed January 8, 2014).  Diagnosis of glaucoma often is delayed due to the fact that is typically symptomless for vision loss until significant damage had occurred, hence the awareness campaign

In a larger sense, the World Glaucoma Association is campaigning globally the World Glaucoma Week 2014, “BIG – beat invisible glaucoma.”  Celebrated March 9-15 this year, this clever slogan is a reminder to all that glaucoma is often a symptomless and painless disorder that can lead to blindness.  I should know, my mother was diagnosed early in life with glaucoma, treated and yet lost vision to the disease.  Contemporary management of glaucoma has improved over that past generation and consists of reducing the No. 1 risk factor – elevated intraocular pressure (IOP).   In fact, the FDA has approved a number of very efficacious topically applied drops to lower IOP.  Administration is typically once to three times per day which enhances compliance on the part of the patient as well minimizes side effects. 

A positive family history has been linked to an increased risk of developing glaucoma, along with a number of additional factors.  Studies from the early 1990s indicated that roughly one-half of glaucoma is undiagnosed.  While the prevalence of glaucoma is somewhere in the neighborhood of 4%, the proportion undiagnosed represents a large number at risk for vision loss.  Unfortunately, while diagnostic strategies have advanced to uncover early damage over the past three decades, the undiagnosed percentages remain. 

A comprehensive eye examination includes measurement of IOP.  In addition, suspicion of early damage by observation of characteristic features of damage or vision loss can prompt definitive testing to confirm or rule out a diagnosis.  Definitive testing includes direct observation and digital imaging of the optic nerve and retinal nerve fiber layer as well as a visual field test that measures sensitivity of the retina and can identify early functional loss.  If glaucoma is identified, new treatment options have shown significant progress in reducing the likelihood of blindness over a lifetime.  So, if you have a family member diagnosed with glaucoma, see your eye care professional.  UAB Eye Care (205 975-2020) offers comprehensive eye examinations that include screening for glaucoma as well advanced testing and treatment options if glaucoma is identified. 

Changes to Implementation of Pain Management Provider Registration

 

by: Kelli Robinson (Kelli is a dual member of both the Health Care Law Consulting Group and the Labor & Employment practice at Sirote.)

 On January 17, 2014, the Board announced a modification in its implementation of registration for providers of pain management services.  As reported earlier, pain management services are those medical services that involve the prescription of controlled substances in order to treat chronic non-malignant pain by a physician who treats pain.  The Board defines the provision of pain management services as:

• A physician practice which advertises or holds itself out to the public as a provider of pain management services; OR
• A physician practice which dispenses opioids; OR
• A physician practice with greater than 50% of the patients being provided pain management; OR
• A physician practice in which any of the providers of pain management services are rated in the top 10% of practitioners who prescribe controlled substances in Alabama, as determined by the Alabama Prescription Drug Monitoring Database on an annual basis.

Until further notice, however, the Board is not requiring the top 10% prescribers to register as providers of pain management services.

All other requirements remain in effect; consequently, physicians must still register with the Board if they are engaged in:

• A physician practice which advertises or holds itself out to the public as a provider of pain management services; OR
• A physician practice which dispenses opioids; OR
• A physician practice with greater than 50% of the patients being provided pain management.

The Board also reminds physicians that the requirements for registration are for physicians treating chronic, non-malignant pain, not for physicians who treat acute pain or malignancy-related pain.  Additionally, the Board’s registration requirements do not apply to a licensed hospice program or any physician providing pain management services for that program, or to any facility maintained or operated by the United States government.

To help physicians determine whether registration as a provider of pain management services is required, the Board recently published the following questions on its web site:

1. Do you treat chronic non-malignant pain? If your answer is NO, you do not need to register as a provider of pain management services. If your answer is YES, please proceed to the following question.
2. Do you advertise or hold yourself out as providing treatment for patients with chronic non-malignant pain? If your answer is YES, you should register as a provider of pain management services. If your answer is NO, please proceed to the following question.
3. Does the ultimate user (patient) physically leave your medical practice with an opioid? If your answer is YES, you should register as a provider of pain management services. If your answer is NO, please proceed to the following question.
4. Do you treat more than fifty percent (50%) of your patients for chronic non-malignant pain? If your answer is YES, you should register as a provider of pain management services.

The Application for Alabama Pain Management Registration plus instructions can be found on the Board’s web site.
Email Kelli Robinson or visit her attorney profile.

 

New Technologies in the In Vitro Fertilization (IVF) Lab

By: ART Fertility Program

Fortunately, improvements in Assisted Reproductive Technology for fertility care occur constantly.  In this article we update providers and patients on an important development which offers the ability to screen the embryo for genetic diseases carried by the parents and to screen for chromosomal abnormalities in the embryo. 

This will ultimately decrease the miscarriage rate and increase the chance to have a healthy baby through IVF or Egg Donation.  Additionally, 2 new instruments are presented which allow us to offer improved pregnancy outcomes with IVF and Egg Donor.

Preimplantation Genetic Screening (PGS) and Diagnosis (PGD) – change in biopsy and transfer procedures

 

1.       What is the difference in Preimplantation Genetic Screening and Preimplantation Genetic Diagnosis?

Preimplantation Genetic Screening (PGS) and Diagnosis (PGD) are both used to perform genetic testing on biopsied cells taken from embryos during an IVF cycle. During PGS, embryos are screened for changes in chromosome numbers, whether a translocation/inversion or aneuploidy.  All 23 pairs of chromosomes may be screened at one time. 

 

With PGD, embryos may be tested and diagnosed for a specific disease such as Cystic Fibrosis, Tay-Sachs, or Spinal Muscular Atrophy.  Most genetic diseases that have been identified by a study of the parents for a gene mutation can be tested for with PGD.

 

2.       How has the procedure changed?

Previously a blastomere was biopsied from a 6 – 8 cell cleavage stage embryo on day 3 of culture and the blastomere was sent to a diagnostic lab.  Results were received, and 1 - 2 normal embryo(s) were transferred to the patient’s uterus on day 5 of culture at the blastocyst stage.

 

Currently, several cells are biopsied from the 100 or more cell embryos at the blastocyst stage on day 5 of culture.  The blastocyst is then cryopreserved with vitrification and stored until results are received. 

 

The patient then undergoes a frozen embryo transfer (FET) cycle at her convenience where the normal embryo(s) is warmed and transferred in an attempt at pregnancy.

 

3.       What are the advantages to the new procedure?

Since the blastocyst has many more cells than the cleavage stage embryo, multiple cells are removed and processed as compared to 1, sometimes 2, blastomeres.  A larger amount of cells for diagnosis means more accurate results.

 

Mosaicism is reportedly lower at the blastocyst stage as compared to the cleavage stage embryo, thereby increasing the chance that results are representative of the rest of the blastocyst.

 

Even though each blastomere of a cleavage stage embryo is totipotent, cells biopsied from the blastocyst are trophectoderm cells, which are extra-embryonic  tissue, thus the inner cell mass of the blastocyst is not manipulated – it is this tissue that becomes the baby.

 

A laser is needed to perform the biopsy on the trophectoderm cells and is used to prepare the embryo on day 3 of culture. The laser is much easier to use than the previous methods using mechanical and chemical means.

 

Performing the embryo transfer in a non-stimulated FET cycle may be advantageous as compared to the stimulated IVF cycle.

 

A higher percentage of patients will potentially receive a single embryo transfer leading to fewer high-risk pregnancies.

 

4.       Will PGS or PGD increase a woman’s chances of pregnancy?

The chance for delivery of a healthy baby will be increased with the use of PGD, and will vary with the use of PGS with each unique situation.

 

5.       What does a couple need to know before PGS or PGD is performed?

A couple should make an appointment with their fertility specialist to discuss PGS or PGD.  The process for PGD is more involved than PGS. 

 

With PGD, a formal consultation with a genetics counselor is indicated and a customized genetic marker will be designed by the diagnostic lab prior to the IVF/PGD cycle.  A marker is not required for PGS testing.

 

Should you have questions about PGS or PGD, please call the ART Fertility Program of Alabama’s scheduling department at 205-870-9784 to schedule an appointment with a physician.

New incubator systems

1.       What is an incubator?

The incubator is one of, if not the, most important piece of equipment in the IVF Lab.  The incubator provides a stable environment for the developing embryo during IVF procedures. 

In order to optimize embryo growth and clinical outcome, the incubator functions to control temperature, gas concentrations and humidity, as well as reduce environmental stresses.

 

2.       How does the new G185 differ from a typical incubator?

The G185 is smaller and has individual chambers for each patient.  Water is not required as the incubator functions without humidity.  Gas cylinders are easily connected providing the carbon

dioxide and low oxygen environment desired.  Each chamber contains a stainless steel plate heated to 37⁰ centigrade.  This creates a compartmentalized system.

 

1.       Does the G185 provide a better environment for embryos?

Maintaining the embryos in a more compartmentalized system provides a better environment by limiting exposure of embryos to the room environment when entering the chamber and quicker recovery of temperature, gas concentration and pH.

 

2.       Will Art Fertility’s patients benefit from this G185?

Due to the better temperature and gas stability, along with the compartmentalized, low oxygen environment of the G185, ART Fertility’s patients will benefit from this new technology. 

 

Thus far we have seen an increase in embryo quality leading to more embryos available for transfer and vitrification and a trend towards an increase in pregnancy rates.

 

New Laser – Saturn 5 by Research Instruments

1.       What is a laser?

The Saturn Laser uses a high-powered ablation laser and a visible pilot laser transmitted through fibre optics.  The Saturn has sub-micron accuracy with a computer controlled laser.  An Exclusion Zone^TM ensures safety of the cells by establishing an area of lowest laser pulse near critical areas.

 

2.       What is the laser used for in the IVF Laboratory?

The Saturn Laser is used to introduce an opening in the zona pellucida (ZP), the outside covering of the embryo.  This procedure is referred to as Laser Assisted Hatching or LAH in lab terms. 

 

LAH may be indicated during an IVF cycle for the following: advanced maternal age, recurrent implantation failure, elevated FSH or P4, poor embryo quality including embryos with thick ZP, and frozen-thawed embryos or oocytes. 

 

Spontaneous hatching of the embryo from the ZP is a necessary event prior to implantation of the embryo in the uterus. Creating an opening in the embryo’s ZP is thought to facilitate implantation for those embryos considered to have trouble implanting due to hardening of the ZP or lack of spontaneous hatching.

        Another use of the laser is to collapse the blastocyst, the 5 or 6 day old embryo, prior to cryopreservation by vitrification. The blastocyst is characterized by an inner cell mass, the trophectoderm cells, and the fluid filled blastocoel cavity. By lasering the junction between two trophectoderm cells, the blastocoel cavity will collapse, causing the fluid to leave the cavity. 

 

        Vitrification has been found to be more successful after removal of fluid from the blastocyst.  Research has indicated an increase in blastocyst implantation following laser collapse of the blastocyst prior to vitrification.

 

3.       What benefits have you seen from this new technology?

Results with the Saturn Laser thus far in our program have shown a trend towards a higher implantation and/or ongoing pregnancy rate when LAH and/or collapsing is utilized.

 

4.       How will ART Fertility’s patients benefit from this new laser?

The improvement in implantation and pregnancy results should allow patients a higher chance to have a baby with IVF.

 

At ART Fertility of Alabama, we are excited about these new additions to our laboratory. These new developments in Assisted Reproductive Technology for fertility care will increase the chances to have a healthy baby through IVF or Egg Donation, and we are thrilled to offer this to our patients.