SCIENCE PULSE    Shipping Specimens

Many patients receiving medical care for infertility will use cryopreserved (frozen) sperm, oocytes and/or embryos at some time during their treatment. Here in the PFC laboratory, we routinely cryopreserve sperm and embryos. We also receive specimens from sperm banks nearly every day. All of these specimens are stored on-site in our secure tanks with continuous monitoring. All specimens are stored in liquid nitrogen at -196ºC. Movement in or out of the tanks only happens when specimens are transferred post freezing or retrieved for thawing or shipping. We store sperm and embryos for our patients for an annual fee as long as we are able to maintain yearly contact with them and the annual storage agreement is renewed.

The shipping of tissues that are frozen and stored at such a low temperature is not easily accomplished. The liquid nitrogen in which they are stored is not toxic in any way, but it is extremely dangerous and can cause serious injury and even death if not handled properly.

In attempting to transport tissues that are normally stored in liquid nitrogen, we have to use a device that will keep the tissues in their same deep frozen state. This is accomplished using a “Dewar” which resembles a large thermos. A Dewar is a vacuum insulated container, mostly filled with an absorbent lining that soaks up liquid nitrogen. The Dewar is “charged” prior to use by filling it with liquid nitrogen over successive days until it will absorb no more. Once saturated, the excess liquid is poured off and the Dewar is then ready for use. Specimens are loaded into the hollow core and they are maintained in their frozen state by the cold nitrogen vapor evaporating from the surrounding absorbent layer. The Dewar holds an appropriate temperature for as long as nitrogen remains inside. Loss of nitrogen by evaporation happens continuously. Typically a fully charged Dewar maintains temperature for between 7 and 30 days depending on its size, how often it is opened and how well it was charged before use. With any Dewar however, loss of refrigeration occurs after a certain period of time, unless more nitrogen is added. In addition, dropping the Dewar or otherwise damaging it in any way can crack the container and this will result in instant failure of the vacuum seal with subsequent loss of nitrogen and thawing of the contents.

When we receive a shipment of sperm from a bank, there is always a risk that the Dewar was damaged or that there was a shipping delay that was longer than the life of the liquid nitrogen in the tank. If the specimens have thawed, typically the sperm bank will replace them at no cost. However, their liability is limited to replacing the sperm, and if you just lost the last 3 vials of your favorite donor, you’ll have to choose a new donor.

Shipping of embryos is a much more risky proposition. Embryos can’t be replaced in the same way that a sperm sample can be replaced, if they can be replaced at all. The major shipping companies such as FEDEX, UPS and DHL will not knowingly accept embryos for transport and therefore would not have any liability for loss. At PFC we discourage shipment of embryos due to the risks involved. We will not ship embryos from our laboratory on your behalf, however you can come and collect your embryos in person and ship them yourself. We will ask you to sign papers releasing us of any liability once the embryos leave our office. We cannot accept any liability for embryos that are being shipped in from elsewhere; it is a practice that we discourage.

If you absolutely must ship embryos, we suggest that you contact a company that has the expertise and the experience to make this type of shipment as safe as possible. Locally, we recommend “Swift Stork Courier” (www.swiftstork.com) who will arrange collection and delivery of the embryos and ensure appropriate and safe handling during transport. For long distance shipments, we put patients in contact with “Kynisi Courier Systems” (email: kosta@kynisi.com), a company based in the UK that specializes in shipping embryos. If you want to send your embryos from

San Francisco to Detroit, or Dublin or Dubai, Kynisi is the only company we know that can get embryos on airplanes without being x-rayed in security. They also get advance clearance to make sure that embryos don’t get delayed in customs as they cross international borders. Kynisi can also arrange for an embryologist to travel with your embryos, and they can organize for the embryos to travel in the passenger cabin of the aircraft, as opposed to being thrown in the luggage compartment with the other cargo. This is important, as a Dewar left lying on its side will lose nitrogen more rapidly than when upright. Kynisi’s services aren’t inexpensive, but considering that the embryos are priceless, there really isn’t a good alternative.

For those patients considering moving their frozen tissues to a facility that offers long-term storage at reasonable costs, we recommend “ReproTech” (www.reprot.com) in Reno, NV. ReproTech is experienced and knowledgeable, and gives great customer service. They too can arrange safe movement of your tissue from us to them, and back again with minimal inconvenience. They often take the extra precaution with embryos by splitting them into 2 groups that are then shipped separately. ReproTech shares the PFC philosophy of thinking of embryos as irreplaceable, and they take every known precaution to ensure a safe and efficient shipment. However, despite the good work of ReproTech, Kynisis and others, I recommend that you do not ship your embryos. The risks are too great.

 Joe Conaghan, PhD

Joe Conaghan, PhD, HCLD , PFC's ART Laboratory Director, is internationally recognized for his work with embryos. His background includes involvement in the first PGD on human embryos. His high standards and extensive experience bring national recognition to our laboratory. Additionally, he trains fellow embryologists for licensure and is an inspector for CAP, the licensing body for IVF laboratories in the USA.

PFC Spotlight    From Uzbekistan to America

  I emigrated from Uzbekistan to America with my parents and two daughters (Isabella and Elina) in January of 1996. It was a bittersweet experience to leave behind my home, my friends, and my profession, but I was giving my children the ability to pursue a better future. Adjusting to the change would have been a lot more difficult if it weren’t for the US government organizations that helped my family financially. Also, we were lucky enough to arrive to San Francisco - the best city in the world. We all fell in love with San Francisco at first sight. At the same time we recognized that we have to work hard to be worthy residents of this beautiful city and country.

Though I immensely enjoyed working as a criminal defense lawyer in Uzbekistan, I did not have the time to simultaneously get a U.S. degree in law and support my two children. Therefore, I went to study medical billing and had my first job at Complete Medical Billing. I later accepted a job at a dental office where I honed my medical billing skills further. Several years later, I joined Pacific Fertility Center, which has and continues to be an interesting and enjoyable experience with a friendly environment. Though I am merely a medical biller, I still have a lot of pride working in a company that gives families the gift of life. I have been very vocal about my job because I feel that PFC is an invaluable company and I am grateful to be a part of it.

On a personal note, my daughter Isabella is working as a business analyst and has a four-year-old daughter who I love and of whom I am immensely proud.

Elina has just finished her freshmen year at USF and plans to pursue employment law in the future. After living in America for eleven years, I have not come to regret my move. It has presented my children with opportunities both on a personal and academic level, has made me a stronger person, and has widened my ability to uphold Jewish holidays more openly than I was capable of doing in Uzbekistan.

I look forward to many more years at PFC and appreciate the skills I have learned and the people I have met.

 Asya

               
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ASK THE EXPERTS    Spinning for a Girl

  Pacific Fertility Center Team
Left to Right: Front: Philip Chenette, MD, Isabelle Ryan, MD, Carolyn Givens, MD
Back: Joe Conaghan, PhD, Carl Herbert, MD, Eldon Schriock, MD

Question:

I am an OB/GYN in the bay area and I have a patient that is interested in having a baby girl. She asked about “sperm spinning” as a method of gender selection and whether it would be useful in her situation.

Answer:

Our office receives a lot of questions from patients and members of the public about sex selection. Our location in the very liberal San Francisco may be cause for the increasing demand we see in having a baby of a predetermined gender. People are also well informed about what can be achieved with modern technology, and since sex selection is a reality, there’s definite demand for it.

The procedure that you ask about, “sperm spinning” is better known in the medical and scientific communities as the “Ericsson Method”. The technology was developed by the German scientist Dr. Ronald Ericsson and has been licensed in the US and internationally since the early 1970’s. It takes advantage of the fact that sperm bearing a Y chromosome (that would make a boy) are very slightly lighter than X-chromosome bearing sperm (that would make a girl). The distribution of X and Y bearing sperm in a normal sperm sample is equal, but Ericsson’s method uses gentle centrifugation of sperm through a slightly viscous fluid to segregate the heavier (girl) sperm from the lighter (boy) sperm. Since the difference in the weight of the 2 types is so slight (about a 3% difference in amount of DNA), a perfect separation cannot be achieved. Ericsson’s website (www.childselect.com) claims a 78-85% success rate in couples seeking a boy and a 73-75% success rate for girls. At PFC, we do not endorse or recommend this method of sex selection, nor can we verify the above success rates. As far as we know, couples availing of sperm spinning are not given details of how well purified their samples are prior to using them for insemination.

A more reliable method for separating sperm in our opinion is the “Microsort” technique offered at the Genetics and IVF Institute (www.givf.com) in Fairfax, Virginia. The technique was developed originally by Dr. Lawrence Johnson at the US Department of Agriculture, and was later refined for use in humans in collaboration with GIVF. Microsort also takes advantage of the small difference in DNA content between “boy” and “girl” sperm. The sperm are dyed with a stain that binds to DNA and then an instrument called a flow cytometer can effectively separate populations of sperm based on how much dye they have incorporated. The Microsort scientists test a small aliquot of every separated sample to determine the exact enrichment that they have achieved. According to the latest figures posted on their website (http://microsort.net/index.php) the average enrichment for X-bearing sperm is 88% with 91% (525/574) of babies born being female. The technique is less effective for Y-bearing sperm with an average sample purity of 73% and 76% (127/152) of babies born being male. Bear in mind that the figures for babies born might be distorted since some patients may have terminated pregnancies that were not the gender that they were seeking. You may also have noticed from the GIVF data that there’s more demand for girls than boys. This is likely due at least in part to the fact that X separations work much better and therefore may be used more, but Dr. Ericsson’s website also claims a much stronger female demand even though his technology supposedly works better for boys. We do support the use of Microsort sperm here at PFC but there are limitations on the use of this technology. First, the sperm can only be separated in 2 laboratories in the US, (Fairfax and Huntington Beach in southern California), and the Microsort researchers prefer that you attend in person to give a fresh sperm sample. Second, the technology is currently only offered under an FDA approved clinical trial, and you have to be doing family balancing or trying to avoid a sex-linked disease in your family to be enrolled. For most people, unless you already have a child of a different gender from the one you are seeking, you won’t be able to participate in this FDA study.

Last, but not least is preimplantation genetic screening (PGS) that can be used to tell the sex of embryos created during in vitro fertilization (IVF). We feel that this technology is the most accurate of the sex determining strategies since there’s less than a 3% chance of a misdiagnosis. Embryos generated in an IVF cycle are subject to a biopsy procedure on the third day of growth that allows a single cell from the embryo to be analyzed to see if it has 2 X chromosomes (female) or X and a Y chromosome (male). IVF with PGS is the most accurate method for sex selection, but also the most involved and the most expensive. The Ericsson method is the easiest and the cheapest, but carries a greater risk of being inaccurate.

 Joe Conaghan, PhD

FROM US TO YOU    Flexing Our Power

 Tuesday February 1st was a busy day here at Pacific Fertility Center. The front office was busy with their usual patient appointments, comings and goings for consultations, ultrasound scans and blood draws. In the procedure area and the lab, we were having one of our busier days, with 7 retrievals, 5 fresh embryo transfers and 1 frozen embryo transfer scheduled. It’s rare for us to have so many procedures on a single day, but because the exact date of a patient’s retrieval is uncertain and depends on their response to stimulation drugs, we get a day like this a few times per year. Fortunately, PFC has an exceptionally large and well-equipped laboratory, so we can cope easily with variations in case load. Also, both our nursing and embryology staff schedules are flexible enough to allow us to schedule extra staff when necessary. On that Tuesday for example, we had 8 of our 9 embryologists on duty in the lab

Even though most patient appointments don’t happen before 8 AM, lab and nursing staff are here between 7 and 7:30 in the morning to open up the facility and perform the usual quality control (QC) checks before the work day can begin. In the lab, once all QC and start-up procedures have been completed and documented, we begin looking at embryos that are to be transferred that morning, thawing frozen embryos for transfer, evaluating fertilization for the previous day’s patients, retrieving eggs and processing sperm samples. The nursing staff is busy checking in patients for retrievals, doing all their pre-operation checks and setting up IV bags, and coordinating patients for embryo transfers. Mornings are definitely our busiest time; we do this every day (7 days a week) so we like to think that the work flows smoothly.

At approximately 8:30 AM, right in the middle of the action, the power to our building and to those in a 10-block radius, went out. When a power outage occurs, there’s a split second when everything goes dark, but before you can think about it, emergency power kicks in and we almost seamlessly continue working. However, as part of our procedures for disaster preparedness, we have protocols for working during a power outage, and these immediately become active. First we check our emergency power generator and then all vital equipment to make sure that everything has power and is functioning normally. In the lab, one of our 15 incubators reset itself and went into calibration mode, so we simply moved its contents to a new home. No other problems or incidents occurred that day. We completed all retrievals and transfers in the usual way and our biggest concern was simply wondering why the power had gone out.

On the nursing end, patients were escorted up and down 5 flights of stairs because the elevators shut down, but otherwise their day was uneventful.

Emergency procedures and back-up power are a vital part of our operation. Our emergency generator will run our facility for 36 hours, or longer with the addition of diesel to the tank. The generator gets a 30-minute test run and an inspection every week. It receives a full service a minimum of 4 times a year and immediately after any power outage. After this instance, a service technician checked the generator and refilled the tank.

In the event there is a power failure when no one is present, the system will automatically switch over to back-up power. The alarm system in the lab then proceeds to dial each embryologist in turn on his or her home and cell phones until the call is received and verified with a code. All vital equipment is alarmed which enables us to check the status of the equipment from a remote location. We also have auditory monitoring capability and can listen to the background noise in the lab (such as a fire alarm) at any time. If it is necessary, we are prepared to have an individual physically present in the lab within 30 minutes of getting an alarm call.

Embryos and sperm in freezers don’t actually need power at all, provided that we physically fill the cryo tanks with liquid nitrogen once or twice a week. The computers that usually monitor and automatically fill these tanks do need power of course, but they are not essential to maintain refrigeration.

On February 1st, power was restored after 90 minutes, however we never know the time or duration of a power outage. At Pacific Fertility Center, we remain well rehearsed and prepared, just in case it happens on the busiest morning of the year.

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-- Best regards from all of us at Pacific Fertility Center.