Is there a risk of discarding a tested embryo that could have resulted in a healthy baby?
It is Infertility Awareness Week during the last week of April 2019. I am posting a series of videos between now and April 30th, 2019 which will include lectures, video blogs and interviews with fertility experts including reproductive endocrinologist, reproductive urologist and my point of view as a fertility acupuncturist.
I sat down with reproductive endocrinologist, Dr. Paul Magarelli, to ask about genetic testing of embryos and what men and women can do to optimize their fertility (egg and sperm quality) before their IVF cycle.
Video: How has the IVF technology advanced in the past 10 years to increase success rates and chances of a healthy baby? Is there a risk of discarding a tested embryo that may have actually resulted in a healthy baby?
Dr. Lorne Brown Interviews Dr. Paul Magarelli About Genetic Testing
Dr. Lorne Brown: Hi, my name is Lorne Brown, I'm a doctor of traditional Chinese Medicine. My practice is Acubalance Wellness Center and it's located in Vancouver, British Colombia, Canada. It's called acubalance.ca. And today I'm going to ask a few questions to Doctor Paul Magerelli. He's a reproductive endocrinologist. His practice is in Colorado Springs, Colorado. Dr. Magarelli, I've gotten to know Magarelli over many years, he's spoken at the Integrated Fertility Symposium in Vancouver, he's offered lectures on line and in person to acupuncturists and naturopaths that integrate with reproductive medicine, IVF, et cetera. He travels around the world to lecture. He's got chapters in medical textbooks, and he's done research and continues to do research on integrating acupuncture and other natural modalities into IVF with the hopes of increasing IVF success. So, I thought since it's Infertility Awareness Week, we actually call it Infertility Awareness Month, the month of April here in Canada, that we'd have this discussion with Dr. Magarelli. And actually we're going to keep these videos up because, even though it's because it's Infertility Awareness Week and Month, this information is valuable to any man or woman who are trying to conceive any time of year. So, Doctor Magarelli welcome and thank you for making the time for our discussion today.
Dr Magarelli: My pleasure, Lorne. And yes, it has been a wonderful journey with you and the acupuncture community over the past, I think it's more than 10 years now.
Dr. Lorne Brown: It's crazy, it has been a while. So I want to jump in on kind of where the technology is today and talk about comprehensive chromosomal screening. It's been called pre-genetic screening. Please let us know what the scientific term is today, 'cause I know they've adopted kind of the term and acronym they want today. The question I want to ask you around this as you give us the right terminology, is there's been some news articles about women are throwing away potentially good embryos, but they're coming back that they're not normal. And I kind of want you to kind of give us where this technology is today, and really, which kind of women will benefit from this technology or doing some chromosomal testing and how are you using this in your practice today?
Dr Magarelli: That's a, it is a good question today. There is some controversy about this. The correct term now is PGT-A, which is preimplantation genetic testing for aneuploidy. There's a PTG-M other designations, but that's the one that sort of supplants PTS, supplants CCS. And so the real term is PGT-A. It's goal, first and foremost, is for us to better select embryos that have a greater potential for implantation, and normal embryo development, as well as fetal development, and normal birth. You can't argue with the idea that putting abnormal embryos into the uterus really does no one any favors.
Historically, we never had the tools to be able to determine if embryos were chromosomally normal or not, and therefore, we did the best we could. And to answer your question about it's value, let's go back to when we didn't know about PGT-A, and it's very simple. If you look in the United States, the CDC thought these are organizations that monitor pregnancy rates
based on age and IVF centers. And it's a legal requirement. If you look between the 80's, 90's, 1980's, 1990's, pregnancy rates are right around 30%. 1990's to 2000, around 35 to 40%, and 2000 to 2016, which is the latest dates for the reporting, it has stayed at 40% pregnancy rate in the ideal population, which is less than 30, of course, and then going down from there. So anything that can increase that 10% from 40 to 44%, what we consider significant, since there have been no changes. And part of my research on acupuncture with Diane Cridennda was this idea that we could actually increase pregnancy rates 15% by simply adding acupuncture. So that was revolutionary at the time, and that's over 10 years ago. With the advent of preimplantation genetic testing, we now can 10 fold in treats. Pregnancy rates in women over 40, so they can go from a historic 4% to 40 or 50%.
Now, how do we do it? Simply we determine if the embryos are chromosomally normal before we put them in. How do we do that? Well, the embryo that we put in is a blastocyst, it has two parts, the baby part and the placenta. They all came from the same cell. So the presumption was, and still is, that the chromosomes in the placenta part of the embryo is the same as the chromosomes in the baby part. That's the presumption. So if we take some cells from the placenta part, it should represent the baby part. And low and behold, you see this dramatic increase in pregnancy rates of all ages of women from 20 to 45 at numbers that dwarf what we had done historically.
So where is the problem? It's incomplete, like all medicine. Nothing is perfect, like all medicine. So are there going to be times where the placenta part of the embryo does not reflect the baby part? Absolutely, and visa versa. You may get a placenta that says the embryo's normal, but the baby part is not. You might get the placenta part that says the baby is abnormal and it turns out that they baby part is normal and they self correct. It's a numbers game. We're measuring 10 cells out of thousands of cells. And so there's a bias in the selection of the cells, of which we have no control. So the big issue that worries women now is the one or two criers in the night that, especially out of New York City for some reason, that have explained that yes, sometime you can put in abnormally tested embryos and find a normal baby. That is a rare event, and an expected event. It is nor surprising. If a patient doesn't ever want the risk of not transferring a embryo that is normal, then she should not do PGT-A, because we spend 30 years not doing PGT-A, so please don't spend the money or the time, and simply put the embryos in is my philosophy. As to what ages benefit, well, in terms of aneuploidy, abnormal embryos, and causes of miscarriage, these all accelerate after age 30 to 35, 40, 41, 42, 43, 44, such that many studies have looked at embryos made in women over 45 and 100% are abnormal. So the best woman to advantage this would be those women over 40, who have a very high risk of transferring a truly abnormal embryo. I think I can go on for hours and, but.
Dr. Lorne Brown: Answer the question, and I think I'll add, because we've seen in our clinic, the clinic that we're with in Vancouver, if somebody has a history, they're young, but they're having a history of recurrent pregnancy loss, and they're like, "I can't go through another loss," this is also what you do, as well, for the testing, I assume.
Dr Magarelli: No, actually I do it on everyone. I don't have that limitation. But yes, the first studies that were done with randomized control trials with a type of PGS, which is what it was called, called FISH F-I-S-H, Fluorescent in situ hybridization. Those patients benefited the most, and statistically better outcomes when they did FISH. Today we know that PGT-A can help everyone from age 20 to 45, and the big impediment to the utilization is how some practices, not my practice, how some practices almost double the cost of IVF by simply adding this wonderful test on embryos.
Dr. Lorne Brown: And so in your practice, it's the norm that everybody would have this testing and will talk as later, you've made it more affordable, because I think that's the barrier. Actually, I'm going to, tell me if I'm quoting you, but I think in one of our discussions, you believe that the future is everybody will have this genetic testing, it's just the cost that's keeping it from everybody having it right now.
Dr Magarelli: Well absolutely, and I would love to say that 100% of my patients utilize it. It's about 86%. The nation's at utilization is around 30%. And again, the number one reason folks don't do it is the cost.
Dr. Lorne Brown: Sure. And just the question we get, so to help put some of these men and women at ease, a lot of them are concerned that you're going to hurt their baby. But to clarify, you're taking from the placenta, not from the fetus, and so there is not a real concern of hurting the baby. There's always a risk to any procedure, but this generalization alone, well I want to say my baby's not going to have an arm because you took the cell for the arm idea.
Dr Magarelli: Well, correct, that is a fear. Of course it's science fiction. Every cell, when you first make an embryo is called totipotent. Every cell can make a whole human being. That's how you get identical twins. You don't get identical twins with one right arm, one left arm, one left arm, you know, you don't. Because those cells have the total potential to make a whole human being, and then as we get to the blastocyst stage, we have differentiation of duties. There's the inner cell mass, it's not really a baby yet, but it's going to be the baby. And then you have the trophectoderm, or the outside, which is going to be the placentas. So we wouldn't, right now, I could say never say never, but I don't think anyone would take cells from the inner cell mass where the baby is to do testing. It just, it's counter intuitive. There have not been increased incidences of negative outcomes from chromosomal testing. As a matter of fact, this goes back to my point, we double, triple, and sometimes 10 fold increase the chance for one healthy baby by testing the embryos, not by not testing it. So yes, there's always going to be fears, that's what parents are supposed to do. But believe me, we as reproductive endocrinologists have even more fear.
Dr. Lorne Brown: Doctor Mag, thank you for answering this question. And for those that are interested in more information on PGT-A, again, you can contact the Reproductive Medicine and Fertility Centers in Colorado Springs, Colorado, because they have lots of information on that.