Articles

The following is part one from an extensive discussion with Dr. Gil N. Mileikowsky by Martha Densmore,RN, L.Ac., editor of the RGLA newsletter, on the topic of PGD. A second part will appear in 2005.

Q: What is PGD?
A: PGD stands for Preimplantation Genetic Diagnosis. That's the analysis of the chromosomes of the embryos, following In-Vitro Fertilization, before we transfer them into the patient's uterus. Such analysis is not possible for patients where the fertilization occurs in their own body, i.e. In-Vivo.

Q: Should all patients who undergo IVF do PGD?
A: No, but too few patients take advantage of this wonderful capability because of the additional cost, about $2,500, and a very deep rooted fear that if we touch in any way the embryo, their baby will be missing an arm, an eye, a kidney, a leg. That's not possible because the embryologist only removes one cell out of eight, and each one of these eight cells have the potential of becoming a full human being!

Q: Who do you consider to be the prime candidates for PGD?
A: 1. Couples who suffer from severe history of hereditary disease.
2. When both partners are over 35 years old.
3. When we have a significant number of embryos (over five), because just by looking at the embryos we can not determine which ones to choose to transfer. That's important because pregnancy rates with live embryos are significantly higher than frozen embryos.
4. When the couple wants to balance their family. For example, if they have five daughters and wish to have a son or vice versa.

Q: How long ago was PGD developed?
A: Over many years but its availability was restricted to the most tragic cases. One of the first couples to benefit from PGD lived in Georgia. They had two sons who died at a very young age from a severe form of muscular dystrophy expressed solely in males but not in females, as the defective gene is on the "x" chromosome. As you know, a boy has only one "x" chromosome, while a female offspring has two "x" chromosomes so one of them will have the normal gene. Thus, a girl will not suffer that tragic outcome, but she can transmit it to her male offspring. The only way for such a couple to avoid this problem is by selecting the female embryos and only transferring those into the womb. That was the first such clinical application in the U.S.

Q: Why was PGD availability restricted for such a long time?
A: Because it was considered "experimental" i.e. risky. At the time it required an embryo biopsy that could destroy the viability of the embryo (at four cells stage). Thus the risk of suffering from a chromosomal/ genetic disease had to be much higher than the risk of destroying an embryo. Today such a risk is considered low enough to allow the expansions of the indications and availability of PGD.

Q: Is it 100 percent safe?
A: Unfortunately nothing in medicine is 100 percent safe. The highest percentage of damage to embryos by PGD reported today is below 10 percent. Thank God, none of my patients’ embryos were ever damaged by PGD thanks to the wonderful skills of Dr. Hall, Ph.D. and Dr. Evsikov, Ph.D.

Q: Can you tell us about any psychological impact of PGD?
A: Patients do not realize that half of spontaneous miscarriages are due to chromosomal anomaly. So they often blame themselves for provoking their pregnancy loss, such as the day they lifted the heavy load at the supermarket, the day when they fell, or maybe the fact that they had to slam on the brakes of the car to avoid an accident. They think these events caused their miscarriage. I shall never forget the couple that cried and blamed themselves for the death of their fetus in utero. We saw a heartbeat at eight weeks gestation and at 10 weeks the heart of that fetus stopped beating. I removed it and sent it for genetic analysis. You would not imagine their relief when I told them that they lost that pregnancy due to a severe chromosomal anomaly. Ultimately, she delivered twins after we transferred frozen embryos resulting from her previous IVF procedure. Had we been able to provide this couple PGD, in 1990, most probably we could have avoided these horrible feelings of guilt.

Q: Does PGD have any impact on the "take home" rate?
A: Absolutely. The take home rate is the percentage of successful patients who actually delivered a baby following their IVF cycle, to distinguish from those who got pregnant but lost their conception. PGD allows us to identify those healthy embryos prior to transfer in utero and thus increase our patients’ fertility rate and the actual delivery of a healthy baby. Look at this interesting couple who requested egg donation. We had 12 embryos following the IVF procedure, yet we can not transfer more than five embryos at one time because of the unacceptable rate of multiple pregnancy (triplets, quadruplets ...) if we transferred more than five embryos at once. How am I going to determine which embryos to choose? It's amazing, after PGD was performed for this couple we were left with only five normal embryos. We transferred them and she is now past her eighth week of pregnancy. This was not her first attempt, but PGD was not performed in her previous egg donors IVF cycles and she failed to achieve any pregnancy before.

Q: It sounds like PGD could stand for “Pretty Good use of Dollars.” Is that right?
A: Certainly, if we look at how PGD increases your rate of return on your investment. After all you may get three babies for the price of one!

Q: Are you concerned about the possibility of "designer babies" where people could choose to have their kids with blue eyes and blond hair?
A: That's not possible to predict. It reminds me when Marilyn Monroe met Einstein. She was so excited to see him that she asked him, “Wouldn't it be great if we had kids? They would be as smart as you and as pretty as me.” He reflected and then asked, “'What if they were pretty like me and smart like you?” You see we do not control Mother Nature. We only assist where nature has difficulties. The outcome of our work depends on genetic probabilities. I am only an "assistant producer."

Q: What else would you like to share about PGD?
A: We don't talk enough about the fact that the sperm of an older man can cause chromosomal abnormalities. Patients always hear that it is the age of the woman that determines the capacity and adaptability of the embryo. It's not only the woman. It's also the man.

Q: Does a patient still need to do amniocentesis if they do PGD?
A: Yes. There are complexities, such as mosaicism, that do not show up at the early eight cell stage embryo. Amniocentesis is performed at three or four months gestation by checking the amniotic fluid and the fetal cells floating in it.

Q: Is PGD expensive?
A: When you are already spending thousands of dollars it is well worth it to spend an extra $2,000 or $3,000 to really maximize your chances. This is a basic check up that covers most disorders. If you want to check for additional disorders the cost is more.

Q: Are you charged per embryo tested?
A: No. It is a fixed price, around $2,500 for however many fertilized embryos there are in a cycle. Here is a story for you. Years ago I was associated with a foremost embryologist here in town. At the time we had no PGD available. So it was a guess based on "appearance" only. As we know "appearance" can be deceiving. He would decide which ones looked best to him, to his eye.

Q: Some look better than others, right?
A: Exactly. My embryologist said, “Gil, please tell the patient I don't think this is going to work.” So the day I did the embryo transfer I already told them, “You know, even though we did the embryo transfer, just consider that this is just an exercise so we will learn and have a better chance for next time.” Basically they left the hospital with the clear impression that we failed. Guess what. They had triplets.

Q: Well that tells us something, doesn't it!
A: It tells us that the way embryos appear does not really tell us about their future

Q: That is new information to me. How many women did I see walk out the doctor's door crying because they were told the embryos were not good quality based on the visual appearance. I remember a patient I treated with fertility acupuncture in our center being turned away on her transfer day, because at the last minute it was decided the pictures of her two embryos did not look good. It was so sad for all of us.
A: That's not the right thing to do. Let's remember, essentially there's not much to lose. There's no sense throwing away those embryos. Doing an embryo transfer is not painful. It's not risky. Worst case scenario, they're not pregnant. But they're already not pregnant so what have you got to lose?

Q: Money, no?
A: Well what is it? Very little. In our office we have an all-inclusive flat fee. We do not charge for the embryo transfer. The embryo transfer is like an insemination. I like to use the analogy of the ugly duckling. The ugly duckling can turn out to be a beautiful swan. And this is why PGD is so important. It can help us find the future "beautiful swan."

Dr. Gil Mileikowsy is a Reproductive Endocrinologist. He can be reached at 310-858-1888 and 818-981-1888

Today, fertility procedures are common and while the different approaches may perform more or less equally, the success rate of each of the techniques depends on choosing the appropriate procedure for each patient, as well as the experience of both the doctor and the laboratory.

A close partnership between the doctor and the couple is another key to success. Educating each patient, helping them understand the differences among the various procedures, pointing out the procedure's limitations and implications is especially beneficial. Generally this has a calming effect on each patient and, as a result, helps control their stress levels.

In the U.S., 2 to 3 million couples - 15 to 20% of the couples in the country - can't have a child with more traditional methods. Fortunately, due to the variety of procedures available, many of these infertile couples have a chance of a lifetime in becoming parents - regardless of whether infertility is due to the male (30%), the female (30%),both (30%), or is unknown (10%).

The following procedures are some of the most common high tech treatment options for infertility.

The Assisted Reproductive Technologies Procedures

1) IVF ("test-tube" procedures)

A) IVF -with micro-operative techniques
Twenty years ago, the pioneering response to infertility was "in vitro" fertilization. This procedure especially counteracted blocked fallopian tubes, one of the main sources of female infertility. Infection and endometriosis are generally the causes of blocked or severely damaged fallopian tubes. Since, in the natural environment, the sperm and the egg meet half way in the fallopian tubes, fertilization does not occur in blocked tubes. The natural site of fertilization being unavailable, the main challenge was to create a new environment for the gametes to meet, and the answer was "in vitro" in the laboratory ("in vitro", from the Latin, meaning "glass").

As in most fertility treatments, IVF is a four-step procedure that includes:
1) ovarian stimulation
2) retrieving the egg
3) introducing it to the sperm (the ultimate "blind date") and
4) replacing the fertilized egg in the woman's womb.
The retrieval of the ripe egg by ultrasound through the vagina only demands a mild sedation. Once retrieved, the egg is prepared to meet with the sperm, placed in an incubator and carried to the laboratory. A few hours later, the gametes will be introduced to each other in a plexiglass dish and hopefully, fusion will occur. Generally, after three days, the fertilized egg is transferred back into the woman's uterine cavity by simple insemination (it requires no sedation). This IVF procedure is a cost effective method for the right candidates.

B) IVF -with micro-operative techniques

B1) ICSI -IntraCytoplasmic Sperm Injection
Developed in Belgium in 1993, the latest technical breakthrough in the field of assisted fertilization consists of a single sperm injection into the egg's cytoplasm during the "in vitro" fertilization process. When the sperm cannot penetrate the egg, it needs the assistance of this wonderful technique. With a syringe, containing a maximum of one sperm, the doctor pierces the egg's two coats, first penetrating the zona pellucida, then the elastic egg membrane, and finally releases the precious sperm in the core of the egg, close to the nucleus.

This state-of-the-art technology is a direct answer to male infertility (low sperm count, low motility or no motility) which represents roughly 30% of all infertility cases. The selected sperm have been chosen by the embryologist for their vigor and therefore for their chances to successfully fertilize the egg, but even non-motile sperm can achieve fertilization and a full pregnancy. Direct injection into the egg allows, beyond a doubt, a greater rate of fertilization. To assure a superior success rate, the fertilized egg is generally allowed to mature in the laboratory's incubator for three days. After 72 hours, the embryo - now a ball of cells - is then transferred into the uterine cavity, where hopefully it will soon nestle into the well-prepared uterine lining.

B2) Embryo - Assisted Hatching
This most recent technique consists of making a small incision in the hard outer shell of the embryo. Performed just before the transfer procedure, this microscopic surgery helps the growing embryo, now a ball of cells, once placed back into the woman's womb, to successfully move out of its original protective coat, "hatching" like a baby chick out of its shell. A few days later, the free embryo will then attach itself to the uterine cavity and grow into a baby.

2) ZIFT (Zygote Intrafallopian Transfer)
The ZIFT procedure was discovered in Belgium in 1988. In this case, the egg is fertilized outside the womb, "in vitro", to avoid any problems with fertilization. Instead of reinserting it into the uterus it is planted higher up in the fallopian tube where fertilization would naturally occur. This way, the 4 to 6 days it takes for the egg to travel, gives the uterus optimum time to prepare for implantation. The ZIFT procedure more closely mimics what happens naturally in the woman's reproductive tract than do other "test-tube" procedures and is often more effective. It allows the fallopian tube to nourish the hours old, developing eggs in ways that cannot be duplicated in laboratories today. A perfect candidate for ZIFT is a woman who has never had tubal surgery nor any problems with tubes or severe cervical disease scarring. Cases of unexplained infertility and failed IVF can also lead to a beautiful ZIFT baby. The odds of pregnancy through ZIFT are higher than through intra-uterine transfers. The procedure is expensive because it requires two surgeries. First the doctor retrieves the eggs by ultrasound, then 24 hours later, performs a laparoscopy under general anesthesia to place the zygotes in the fallopian tubes.

3) TET (Tubal Embryo Transfer)
In this ZIFT related procedure, the fertilized eggs are reinserted into the uterus 48 hours after retrieval (instead of 24 hours in the ZIFT procedure).

4) GIFT (Gamete Intrafallopian Transfer)
Unlike other assisted reproductive technologies, GIFT is a two-step procedure (retrieval and transfer only) versus the three-step process (retrieval, "in vitro" fertilization and transfer). Here, the sperm and the egg -the gametes - separated by a bubble of air are placed directly into the woman's tube. The sperm seeks out the egg in its natural environment and fertilization occurs in the patient's own tube. A single laparoscopy is performed to retrieve the egg and transfer the gametes. Both are done the same day under the same general anesthesia. Drawn up from its ovarian follicle, the ripe egg is put directly into a tube kept at body temperature. Later on, the egg and the sperm will be transferred into the woman's fallopian tube, where fertilization will occur "in vivo.”

Laparoscopy, which was invented in the 50s by three European Professors (Dr. Semm, Dr. Palmer and Dr. Steptoe), consists of making a very small incision in the bellybutton area. The inside of the abdomen and the pelvic organs can then be viewed with a small instrument called a laparoscope. In the retrieval process, the mature egg is withdrawn from its protecting follicle. This approach is done through the abdomen.

What are the next frontiers?
Fertilization procedures and assisted techniques continue to improve. The possibilities for the future are unlimited. One technique that is in development is the extraction of eggs by women when they are in their peak fertile years, around the age of 24. The eggs are then frozen for use in the future, whenever the women decide to attempt pregnancy. They, in effect, become their own egg-donors from their own "egg-bank,” giving them an excellent opportunity to become pregnant, even if they are past optimum child-bearing age.

Dr. Mileikowsky is Assistant Clinical Professor of Obstetrics-Gynecology at UCLA; Board Certified by the American Board of Obstetrics-Gynecology; Board eligible by the American Board of Reproductive Endocrinology; a member of the Society of Assisted Reproductive Technology (SART); a member of the American Society for Reproductive Medicine; a member of the LA County Medical Association and a Fellow of the American College of Obstetricians-Gynecologists.

GLOSSARY OF TERMS

• Cytoplasm: Fluid surrounding the egg
• Embryo: A fertilized egg that has begun cellular division.
• Fallopian Tubes: A pair of tubes that provide communication between the ovary and the uterus, where sperm and egg meet in normal conception. "In vivo."
• Gamete: The male or female cell, a sperm or an egg, that fulfills a reproductive function.
• In Utero: Inside the uterus.
• In Vitro: Inside the laboratory; in Latin, it literally means "in glass".
• Laparoscopy: A surgical procedure that allows viewing of the fallopian tubes, the uterus, ovaries and other abdominal organs. A small lighted instrument with a telescopic lens is inserted through a small incision below the naval.
• Zygote: A fertilized egg before cell division begins.

Les nouvelles frontières technologiques
en matière de reproduction
d’après notre interview de Gil Mileikowsky, MD

La génération des bébés miracles, de la “IVF” à “l’ICSI”. Vingt cinq ans après la naissance de Louise Brown, le premier bébé né grace à la ferlilisation “in Vitro”, et les milliers de bébés qui ont suivis la voie tracée, le monde entier reste encore ébahi par les bébés éprouvettes. Les spécialistes de l’infertilité et les embryologistes mondiaux ont été, quant à eux, très occupés ! Encouragés par les premiers succès, ils ont fait, les unes après les autres, de remarquables nouvelles découvertes, dans un domaine qui interesse plus que jamais chacun de nous.

Aujourd’hui, les procédures pour la fertilité sont courantes, et bien que différentes méthodes puissent donner des résultats plus ou moins identiques, le succès dépend de la méthode appropriée, choisie suivant le cas de la patiente, ainsi que de l’expérience du docteur et du laboratoire.

Une étroite collaboration entre le docteur et le couple est l’autre clef du succès. Eduquer le couple, l’aider a comprendre les différences, ainsi que les limites et implications des procédures existantes, est très bénéfique. Généralement tout ceci a un effet calmant sur le couple et aide a réduire et controller le niveau du stress de la patiente et de son partenaire.

Aux Etats-Unis, 2 à 3 millions de couples (soit 15 à 20 % des couples) ne peuvent pas avoir d’enfants de manière traditionnelle. Désormais grace aux diverses procédures disponibles, beaucoup de ces couples infertliles ont la chance de pouvoir devenir parents, peu importe que l’infertilité soit dûe à l’homme (30%), à la femme (30%), aux deux (30%) ou pour une raison inconnue (10%).

Les procédures suivantes, sont les plus communes des options hautes technologies, disponibles à ce jour pour l’infertilité.

Les procédures de reproduction à l’aide de hautes technologies

1) IVF (“test-tube” procedures). FIV (procédure “In-Vitro” en éprouvette)
A) IVF - with micro-operative techniques. FIV - avec la technique d’une micro-chirurgie.

Il y a 25 ans la réponse à l’infertilité était la récente découverte : la fertilisation “in-vitro”. Cette procédure éliminait le problème des trompes de Fallope, l’une des causes majeures de l’infertilité de la femme. Les infections et les endomitrioses sont généralement la cause des trompes bloquées ou sévérement endommagées. Comme dans un environnement naturel le sperme et l’ovule se rencontre a mi-chemin dans les trompes, la fertilisation ne peut se produire dans des trompes bouchées. Le site naturel n’étant pas disponible, le principal challenge était de créer un nouvel environnement pour que le sperme et l’ovule se rencontrent et la réponse était “in-vitro” (“in-vitro” en latin veut dire “dans le verre”). Comme la plupart des traitements pour la fertilité, la FIV comprend quatre étapes : 1) stimuler l’ovaire, 2) prélever les ovules parvenues à maturité, 3) les introduire au sperme en laboratoire, 4) placer les ovules fertilisées dans l’utérus.

La récupération des ovules à maturité pour le sperme, se fait par le vagin, guidée par la technique ultrason et nécessite seulement une sédation moyenne. Une fois récupérées les ovules sont préparées pour rencontrer le sperme, placées dans un incubateur et transportées au laboratoire. Quelques heures plus tard, la rencontre s’effectuera dans un récipient en plexiglass, et avec un peu de chance la fusion se fera. Généralement après 3 jours, les ovules fertilisées sont réintroduites dans l’utérus de la femme par une simple insémination (pas besoin de sédation). Cette procédure FIV ou “IVF” en anglais, est une méthode relativement peu onéreuse pour les bonnes candidates.

B) IVF - with micro-operative techniques. FIV - avec la technique d’une micro-chirurgie
B1) ICSI - IntraCystoplasmic sperm Injection. Injection du sperme IntraCystoplasmique.

Développée en Belgique en 1993, la dernière découverte technologique dans le domaine de l’assistance à la fertilité, consiste à un unique sperme injecté dans le cystoplasme de l’ovule (liquide entourant l’ovule) durant la procédure de fertilisation “in-vitro”. En effet quand le sperme ne peut pas pénétrer l’ovule, il a besoin de l’assistance de cette merveilleuse technique. A l’aide d’une seringue contenant au maximum un sperme, le docteur perce les 2 épaisseurs de la membrane de l’ovule, et dépose le précieux sperme au cœur de l’ovule.

Cette technologie d’une grande précision, est la solution dans une grande partie des cas ou l’infertilité de l’homme est en cause (peu de sperme, lente mobilité du sperme ou pas de mobilité) ce qui représente en gros 30% des cas d’infertilité. Le sperme sélectionné est choisi par l’embryologiste pour sa vigueur et par conséquent pour sa chance de fertiliser l’ovule, mais même un sperme non mobile peu fertiliser un ovule et conduire à la grossesse. L’injection directe dans l’ovule permet sans l’ombre d’un doute un pourcentage de fertilisations réussies bien plus élevé. Pour multiplier les chances l’ovule fertilisée, est généralement gardée dans son incubateur pour 3 jours, lui permettant ainsi de se développer. Après 72 heures l’embryon, (maintenant une pelote de cellules) est transferré dans l’utérus, où avec un peu de chance il s’attachera sur la paroi de l’utérus qui a été bien préparée par les traitements précédent l’intervention.

B2) Embryo - Assisted Hatching. Eclosion assistée de l’Embryon.

Cette plus récente technique, complémentaire de la précédente, consiste à faire une mini incision sur la membrane dure extérieure de l’embryon. Exécutée juste avant le transfert dans l’utérus, cette chirurgie microscopique aide l’embryon, maintenant une pelote de cellules, a sortir de sa membrane protectrice (“éclore”) comme un poussin de sa coquille. Quelques jours plus tard, l’embryon libéré de sa membrane se fixera sur la paroi de l’utérus, et grossira pour devenir un bébé.

2) ZIFT (Zygote Intrafallopian Transfer) Transfert de zygotes (les ovules fertilisées avant que la division des cellules commence) dans la trompe de Fallope.

La procédure ZIFT a été découverte en Belgique en 1988. Dans ce cas, les ovules sont fertilisées “in-vitro” pour ne rencontrer aucun problème de fertilisation ( 2 à 3 ovules fertilisées sont implantées pour multiplier les chances d’une implantation). Mais au lieu de les réintroduire dans l’utérus, elles seront placées plus haut dans la trompe de Fallope où normalement la fertilisation se fait. Durant les 4 à 6 jours où les ovules voyagent pour arriver à leur destination, l’utérus disposera d’un maximum de temps pour se préparer à une implantation. La procédure ZIFT, mimique ce qui arrive naturellement dans le système reproductif de la femme et ce beaucoup mieux que les autres procédures éprouvettes, et est souvent beaucoup plus effective. Cela permet à la trompe de Fallope de nourrir les ovules fertilisées depuis quelques heures, de façon qui ne peut être reproduite, à ce jour, dans aucun laboratoire.

La parfaite candidate pour cette procédure est une femme qui n’a jamais eu de problème avec ses trompes de Fallope, ni de chirurgie, ainsi qu’aucune maladie du cervix qui aurait risqué de laisser des cicatrices. Dans les cas d’infertilité non expliquée et où la procédure IVF n’a pa réussi, la procédure ZIFT peut mener a un beau bébé. Les chances de grossesses avec ZIFT sont plus importantes, qu’avec une procédure de transfert intra-utérine. Parce que cette procédure nécessite 2 interventions chirurgicales, le coût en est élevé. Premièrement le docteur prélève les ovules guidé par l’ultrason, et 24 heures après performe une laparoscopie sous anesthésie générale pour déposer les Zygotes dans la trompe de Fallope.

3) TET (Tubal Embryo Tranfer) Transfert de l’embryon dans la trompe.

Dans cette procédure aparentée à la procédure ZIFT, les ovules fertilisées sont réintroduites dans la trompe de Fallope, 48 heures après avoir été prélevées, au lieu de 24 heures dans le cas du ZIFT.

4) GIFT (Gamete Intrafallopian Transfer) Gamete (cellule masculine ou feminine, un sperme ou une ovule, qui assume une fonction reproductrice) transféré dans une trompe de Fallope.

La procédure GIFT, contrairement aux autres procédures ne nécessite que 2 étapes (prélèvement et transfert) au lieu des 3 étapes habituelles (prélèvement, fertilisation et transfert). dans ce cas Le sperme et l’ovule - les gametes - sont séparées par une bulle d’air et placés directement dans la trompe de Fallope de la patiente. Le sperme cherche l’ovule dans son environnement naturel et la fertilisation intervient dans la trompe de la patiente. Une seule laparoscopie est effectuée pour prélever l’ovule et transferrer les gametes. Les 2 procédures ont lieu le même jour sous la même anesthésie générale. Prélevé directement de son ovaire l’ovule qui est a maturité est déposé dans un tube à la température du corps. Plus tard l’ovule et le sperme seront transférrés dans la trompe de la patiente où la fertilisation interviendra “In-Vivo”.

La laparoscopie, qui a été inventée dans les années 50 par 3 Professeurs Européens (les docteurs Semm, Palmer et Steptoe) consiste a faire une très petite incision au niveau du nombril. L’intérieur de l’abdomen et les organes de la reproduction peuvent être vus par un petit instrument appelé laparoscope. Pour retirer l’ovule à maturité, il suffit de la retirer de son enveloppe protectrice (follicule). Cette intervention est faite par l’abdomen.

Quelles sont les nouvelles fontières?

Les procédures de fertilisation et les techniques assistées continuent de s’améliorer. Les possibilités pour le futur sont illimitées. Une technique qui est en cours de développement et d’amélioration est l’extraction d’ovules à maturité, par des femmes au pic de leurs années fertiles(autour de l’age de 24 ans). Les ovules sont congelées pour pouvoir les utiliser dans le futur, lorsque la femme décidera d’essayer de devenir enceinte. Elles sont par le fait, leur propre donneur d’ovules, par leur propre banque d’ovules, leur laissant une excellente opportunité d’obtenir une grossesse, même si elles ont passé l’age optimum de devenir enceinte.

Le tout nouveau “PGD” (Pre-implantation Genetic Desorder).

Tout récemment, outre toutes les plus nouvelles et différentes techniques qui peuvent être employée pour la fertilisation, une spécialité vient de s’ajouter : le “PGD” ( “Pre-implantation Genetic Desorder”), dont les particularités sont décrites ci-dessous :

Le “PGD” est conseillé aux femmes qui ont essayé de concevoir sans succès - à celles au dessus de 35 ans - celles qui ont (dû par association à leur race ou ethnie) une maladie génétique - celles qui ont une maladie génétique héréditaire ou qui ont eu des miscariages à répétition.

Effectué par un laboratoire hautement spécialisé, le “PGD”permet à la patiente qui a un sérieux problème génétique (elle ou son mari), d’éliminer le risque de le passer à leur enfant. Pour faire ce test, il faut bien sûr, que ce soit une des nombreuses maladies dont le géne a été identifié à ce jour.

Le “PGD” est une technique utilisée durant une fertilisation “in-vitro” . Cette technique permet de tester et de définir, si les embryons qui vont être implantés ont le problème génétique ou non, et par conséquent de n’implanter que les embryons qui sont sains. De plus parce que les tests sont effectuées avant l’implantation des embryons, le “PDG” élimine le choix douloureux de terminer une grossesse, après des analyses qui déterminent que le futur bébé a une grave maladie génétique.

En outre, ce test qui détermine à 100%, le sexe de l’embryon, permet par exemple, d’éviter l’hémophilie qui n’est transmise qu’aux garçons, en implantant uniquement des embryons féminins, ou tout simplement de déterminer le sexe de votre futur bébé..”

Le test “PGD” peut être d’un grand secours dans beaucoup de cas, qu’il serait trop long d’énumérer ici, seul un spécialiste comme le docteur Mileikowsky, toujours à la pointe du progrès, peut déterminer si vous en avez besoin ou non.

But a third pregnancy did not readily come. The next five years the couple underwent tests and unsuccessful outcomes, including a miscarriage after a GIFT (Gamete Intra-Fallopian Transfer) procedure. They began to lose hope of finding a cause or a treatment.

"The causes of infertility are sometimes difficult to pinpoint," says infertility specialist Gil N. Mileikowsky, M.D., who eventually helped the couple conceive again. "Interestingly, about 1/3 of all cases are attributed to a problem with the wife, 1/3 to problems related to the husband and 1/3 to problems of both partners. In this case we suspect that an anatomical problem in Emily's reproductive tract was interfering with the sperm’s ability to reach the egg."

The family was referred to Dr. Mileikowsky when they moved to California. Dr. Mileikowsky was born in New York, lived 5 years in Israel, and was raised in Belgium. He came to the U.S. for his internship at Cook County Hospital in Chicago. He moved to Houston, Texas for his residency training in OB/GYN at Baylor College of Medicine and completed his Clinical Research Fellowship at USC in LA. Dr. Mileikowsky recommended a new procedure, Zygote Intrafallopian Transfer (ZIFT).

"The ZIFT procedure more closely mimics what happens naturally in the woman's reproductive tract than do other 'test tube' procedures (IVF, In Vitro Fertilization) and is twice as effective. It allows the fallopian tubes to nourish the hours-old, developing eggs while the uterus has the optimum time needed to prepare for its arrival. It also provides more control over the number of fertilized eggs reintroduced into the mother."

Put very simply, ZIFT involves removing the eggs from the woman's ovaries through the vagina in an Ultra-sound guided procedure. In a laboratory, the egg is identified, isolated and fertilized with the father's sperm. Using the laparoscope, Dr. Mileikowsky places the fertilized eggs in the fallopian tubes, where they would have traveled in a normal pregnancy.

In a related procedure, Tubal Embryo Transfer (TET), the eggs are allowed to mature in the lab for an additional 24 hours in order to see which are most likely to develop. During this time the zygotes divide and become embryos. As in ZIFT, the embryos are then placed in the fallopian tubes.

"Procedures which place the fertilized egg in the uterus rather than the fallopian tubes miss this important first step," explains Dr. Mileikowsky. "The tubes themselves were designed to nourish the egg during the first few days. The uterus needs time to undergo changes vital to successfully carry a baby to full term. Of course, if a woman's tubes are blocked, ZIFT or TET cannot be used."

Like most infertility treatments, the ZIFT procedure requires dedication by both partners and the support of the doctor. "Fertility drugs were injected daily for about a month and a half before the procedure began," says Emily. "My mood swings were somewhat unpredictable and I had to schedule my injections for the same time every day. Fortunately, Dr. Mileikowsky was as committed to the procedure as we were and was a source of comfort throughout the entire term. We were also concerned about multiple births. Dr. Mileikowsky explained that the chances of having more than one baby was very remote."

After one ZIFT procedure, Emily and Bill successfully conceived and delivered twins, Isabelle and Elizabeth.

If you would like more information about ZIFT or other fertility treatments, contact Dr. Mileikowsky at 5363 Balboa Blvd., in Encino, phone (818) 981-1888 or 436 N. Bedford Dr., in Beverly Hills, phone (310) 858-1888.

Dr. Mileikowsky is certified by The American Board of Obstetrics-Gynecology and an Active Member of the American Board of Reproductive Endocrinology, the IVF Group of The American Fertility Society, The American Society of Reproductive Surgeons and the LA County Medical Association.