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OBGYN.net EXCLUSIVE interview with Michael Kamrava MD, Reproductive Endocrinologist to Nadya Suleman, mother of the octuplets.
How many embryos should be transplanted is always a hotly debated topic. The question "how many is too many?" has now created global controversy since the recent birth of the octuplets.
At the 58th Annual Meeting of the American Society for Reproduction Medicine Hugo Verhoeven, MD and OBGYN.net Editorial Advisor interviewed Michael Kamrava, MD on his methods.
For recast or transcription reuse information contact Roberta.Speyer@OBGYN.net.
NEW: Our viewers' comments on Dr Kamrava's methods.
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Transcript
Hugo Verhoeven: Good afternoon, my name is Hugo Verhoeven from the Centre for Reproductive Medicine in Dusseldorf. I am at the Editorial Board of the OBGYN.net. I am reporting today from the ASRM meeting in Seattle, and it is a great pleasure for me to be speaking this morning with Michael Kamrava. He is a Medical Director of the West Coast Infertility Medical Clinic in Beverley Hills, California.
He told me before that he prefers to do a hysteroscopic embryo transfer because he was quite frustrated with all other techniques he used. Michael it is a pleasure for me to be talking with you. Maybe you could repeat to our listeners why you switched from the conventional embryo transfer methods to the hysteroscopic methods.
Michael Kamrava: It is my pleasure too, thank you. It was basically just as you said, our frustration with the blind embryo transfers because we can’t quite guide blind plastic tube inside the uterus. Also, scientifically the embryo when we put it in with a blind transfer it has a shell around it that doesn’t allow the embryo to stick to the lining of the uterus right away. So, there is a real chance that that embryo can either get inside the fallopian tube, that’s why sometimes we have a tubal pregnancy from this procedure, or sometimes that embryo just falls out of the uterus right after we put it in. I was thinking about it and in Mother Nature what happens is that that embryo hatches out of that shell by around day five or six and then it actually digs inside the lining of the uterus. That’s how it attaches to the uterus.
So we thought well, why not mimic Mother Nature if we can to actually implant the embryo inside the lining. This way we will eliminate any chance that that embryo is going to move from the place that you put it. We have eliminated tubal pregnancies, and we have increased the pregnancy rates because there is much less chance of that embryo falling out of the uterus after you put it in.
Hugo Verhoeven: A very important point if already actually you are doing a transfer of blastocysts on day five, is that correct.
Michael Kamrava: Yes, correct.
Hugo Verhoeven: Okay, what instruments are you using?
Michael Kamrava: These instruments are two components; one is a combination of rigid/flexible mini hysteroscope, and the other one is the transfer tubing that goes through the hysteroscope to deliver and implant the embryo inside the lining of the uterus.
Hugo Verhoeven: What is the diameter of the device that you are entering into the cervical canal?
Michael Kamrava: Roughly about three millimetres.
Hugo Verhoeven: That’s quite big?
Michael Kamrava: Actually you are right; for some patients that is a little bit big, and that is why we have to make some preparation for the patients. And in all the patients before we actually start the whole procedure, like at least a month or so before, and sometimes more if we have time, we actually dilate the cervix to make sure…
Hugo Verhoeven: For hysteroscopy you dilate the cervix…yes, okay.
Michael Kamrava: …procedure to make sure it stays open.
Hugo Verhoeven: And as a distension medium you probably use CO2?
Michael Kamrava: We use a gas for the distension, right.
Hugo Verhoeven: There is no toxicity of the gas for the embryo?
Michael Kamrava: With this one we use actually Nitrous Oxide for the distension instead of CO2. It’s already being used, it’s an inert gas, that doesn’t affect the embryo.
Hugo Verhoeven: Okay, so what are you doing exactly? You are bringing the hysteroscope, and you told me before, you are imitating the implantation so you do not do a transfer, you do an implantation of the embryo. What are you doing?
Michael Kamrava: Right. Exactly. What we do is, you know, we introduce the hysteroscope; introduce it inside the cervix. You can actually see it on a screen, so you can actually guide the tip of the hysteroscope as you go in. So in difficult transfers it has helped actually quite a bit because you will minimize injury to the lining of the uterus that you are introducing because you can see it on direct visualization.
As you go in you can see the inside cavity of the uterus expand very nicely, so there is very little chance of the instrumentation to damage the inside lining of the uterus because of the expansion, and the narrow diameter of the hysteroscope. Then we go all the way up in the top of the uterus in the fundus. Then the hysteroscope is already loaded with the embryo, and then we advance the tip of the catheter through the hysteroscope and then go just slightly inside the lining of the endometrium of the uterus, and then release the embryo.
Hugo Verhoeven: That means you are really bringing the catheter into the endometrium?
Michael Kamrava: Right, correct. It goes directly inside the endometrium.
Hugo Verhoeven: No bleeding?
Michael Kamrava: There is no bleeding. We have done over 150 patients so far. There has been no bleeding. There have been initially with the first few patients – there was one patient that had a slight scratching of the lining of the uterus. We simply picked another place to implant the embryo. That patient did actually get pregnant. No problems.
Hugo Verhoeven: Do you have an improved pregnancy rate using this technique?
Michael Kamrava: We have looked at that and in our own hands in comparison with the blind procedure we have eliminated tubal pregnancies, that is zero ectopic pregnancies, and the pregnancy rate by itself is about 70 percent higher than what we had with the blind procedure.
Hugo Verhoeven: Seventy percent?
Michael Kamrava: Seventy percent higher. Before we used to run on average, from all the patients, all ages, and all different reasons for doing the in vitro, the average was running about 18 percent to 20 percent. Right now we are running actually about 34 percent to 35 percent.
Hugo Verhoeven: That’s quite interesting data. My final question is: you are certainly trying to improve your technique and to find other possibilities to make the implantation rate higher, what are you thinking about?
Michael Kamrava: I think at this point, having come this far I think this procedure now can be repeated in different hands to give similar results because it is not left to a chance. I think the next step really in our attempts at improving the results, would be to optimize the egg development and the quality of the egg.
Hugo Verhoeven: Well Michael, thank you very much for this very interesting
interview.
