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Archive for September, 2010

Should Doctors Talk About Money?

By David Kreiner, MD

September 29th, 2010 at 7:14 am

One of the most distressing things I face in practice is when I get negative feedback from a referring physician.  Fortunately, it happens rarely but recently I was shocked about the complaint.  Apparently, his patient was offended that I discussed the finances involved with her treatment.  Her Ob Gyn agreed with her that it was inappropriate for me to discuss the cost of her options.  He told me, “I like you and think East Coast Fertility is an excellent program but I never talk about money directly to patients!  It’s not – I don’t know…seemly!”   “Money issues are discussed with the business office, the doctor only discusses the medicine”.

Perhaps it’s unfortunate that fertility doctors have to be so concerned about their patient’s pocket books unlike other fields of medicine that are usually covered by some measure of insurance.  But in the case of infertility with only a handful of states having some kind of mandated coverage – not everybody in the United States -  mandate or no mandate for infertility  -even has health insurance!  Many fertility patients are in some form or another “cash pay” patients.  One of the most popular places that patients visit when they go to any fertility clinic’s website is the finance page.  This is simply a fact of life.

For this reason I have developed many programs that will create access to fertility care for as many people as possible.  But here is the catch! One program does not fit all. These are simply not over sized tee shirts – each of these programs represent a certain course of  medical care – and each individual and couple needs the assistance of a caring doctor to help them choose the right program that will fit their own particular medical history.  In addition to the NY State DOH Grant Program and our own East Coast Fertility Grant Program, we have the Micro-IVF Program, The Money Back Guarantee Program,  and The Single Embryo Transfer Program.  The most effective treatment and the most efficient is always a full stimulation IVF. However, if someone has insurance coverage for IUI and meds but not IVF then they may prefer to do IUI. If they do not have coverage for IUI either then it may be more cost effective to do the Micro-IVF Program or minimal stimulation IVF at 2-3 x the success of IUI with less risk than gonadotropin IUI and less cost per pregnancy. Yet at a price of $3900 it may be more attractive than a full stimulated IVF. There is also The Single Embryo Transfer Program where we reward patients transferring one embryo at a time by making their cryo, embryo storage and unlimited frozen embryo transfers for free.  Others prefer the insurance of The Money Back Guarantee Program where patients are offered six IVF retrievals and frozen embryo transfers for a fixed fee that is refunded if they do not result in a live birth.   In order to inform patients about our success and programs that make IVF more available to them we offer free consultations.

In today’s world of fertility care – a good doctor will help a patient find not only the right treatment but how to access that care.  In order to do that – a doctor may have to do what some may think is unseemly – and that is to talk about money.

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When Will You Be in Menopause? Do You Even Want to Know?

By Pamela Madsen

September 27th, 2010 at 8:22 am

As a peri-menopausal woman – the answer is yes. In fact I would like to know in advance that the period I am getting is my last one – so I can celebrate it. But the way things stand now – I won’t know that I am getting my last period until a year passes.  Kind of takes a lot of the ritual possibilities out of it. My girlfriend has a "Goddess Party" for her daughters when each of the got their first period – why shouldn’t we celebrate the last?

Now a new study released during 26th annual meeting of the European Society of Human Reproduction and Embryology in Rome  states that researchers  have developed an  accurate way to predict the age when women will hit the menopause using a simple blood test.

The average difference between the predicted age and the actual age that the women in their study reached the menopause was only a third of a year, and the maximum margin of error was between three and four years.

The  implications of this test for women and their doctors; if the results of the research are supported by larger studies,  means that women will be able to discover early on in their reproductive life what their expected age at menopause will be, so that they can plan when to start a family.

Knowing you fertility life span – is huge for women. That’s why Dr. David Kreiner at East Coast Fertility and I have been trying to get the word out about "Fertility Evaluations". Right now we can’t predict when a woman will hit menopause but technology does exist right now for women to get a reading on where they are now in their own biological clock.

In this new study – they are taking blood samples from 266 women, aged 20-49, who had been enrolled in the much larger Tehran Lipid and Glucose Study, Dr Ramezani Tehrani and her colleagues were able to measure the concentrations of a hormone that is produced by cells in women’s ovaries – anti-Mullerian Hormone (AMH). AMH controls the development of follicles in the ovaries, from which oocytes (eggs) develop and it has been suggested that AMH could be used for measuring ovarian function. The researchers took two further blood samples at three yearly intervals, and they also collected information on the women’s socioeconomic background and reproductive history. In addition, the women had physical examinations every three years. The Tehran Lipid and Glucose Study is a prospective study that started in 1998 and is still continuing.

Dr Ramezani Tehrani, who is President of the Reproductive Endocrinology Department of the Endocrine Research Centre and a faculty member and Associate Professor of Shahid Beheshti University of Medical Sciences in Tehran, Iran, said: "We developed a statistical model for estimating the age at menopause from a single measurement of AMH concentration in serum from blood samples. Using this model, we estimated mean average ages at menopause for women at different time points in their reproductive life span from varying levels of serum AMH concentration. We were able to show that there was a good level of agreement between ages at menopause estimated by our model and the actual age at menopause for a subgroup of 63 women who reached menopause during the study. The average difference between the predicted age at menopause using our model and the women’s actual age was only a third of a year and the maximum margin of error for our model was only three to four years.

"The results from our study could enable us to make a more realistic assessment of women’s reproductive status many years before they reach menopause. For example, if a 20-year-old woman has a concentration of serum AMH of 2.8 ng/ml [nanograms per millilitre], we estimate that she will become menopausal between 35-38 years old. To the best of our knowledge this is the first prediction of age at menopause that has resulted from a population-based cohort study. We believe that our estimates of ages at menopause based on AMH levels are of sufficient validity to guide medical practitioners in their day-to-day practice, so that they can help women with their family planning."

Dr Ramezani Tehrani was able to use the statistical model to identify AMH levels at different ages that would predict if women were likely to have an early menopause (before the age of 45). She found that, for instance, AMH levels of 4.1 ng/ml or less predicted early menopause in 20-year-olds, AMH levels of 3.3 ng/ml predicted it in 25-year-olds, and AMH levels of 2.4 ng/ml predicted it in 30-year-olds.

In contrast, AMH levels of at least 4.5 ng/ml at the age of 20, 3.8 ngl/ml at 25 and 2.9 ng/ml at 30 all predicted an age at menopause of over 50 years old. The researchers found that the average age at menopause for the women in their study was approximately 52.

Dr Ramezani Tehrani concluded: "Our findings indicate that AMH is capable of specifying a woman’s reproductive status more realistically than chronological age per se. Considering that this is a small study that has looked at women over a period of time, larger studies starting with women in their twenties and following them for several years are needed to validate the accuracy of serum AMH concentration for the prediction of menopause in young women."
Who knows – maybe one day we will be able to celebrate our last period – just as some people celebrate the first.

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Agency, Independent or Clinic Matching: Using a donor? You need an attorney (or two or possibly three)

By Amy Demma, Jd

September 17th, 2010 at 8:40 am

By the time ART patients arrive at collaborative reproduction for  family building the cast of parties involved in the process has grown to include  physicians, nurses, clinical staff, lab professionals, mental health providers, the donor (or donors), perhaps agency representatives and to round it all off, attorneys who specializes in alternative family formation.

Reproductive Attorneys are legal professionals experienced in the area of clinically assisted family building. These highly-specialized attorneys can advise on donor selection but are typically brought in once a match between the recipient and the donor (or donors) has been confirmed. Primarily the role of the reproductive attorney is to draft and negotiate contracts between the parties (in embryo donation it is important that the “donor” actually be viewed as two parties: an egg donor and a sperm donor and that each of those folks have independent counsel) but the attorney may also be called upon to review other legal documents such as agency service contracts and clinic consents. Some attorneys will also oversee escrowed funds deposited by the recipients for the anticipated expenses of the cycle.

If you are anticipating family building with donor gametes (egg, sperm or embryo) going at it without legal counsel puts much at risk. Without a contract in place between the donor and recipient both parties are left vulnerable to parentage challenges, financial disputes and other possible conflicts around issues that can be addressed in a donor agreement. (Clinic consents should not be relied upon in place of independent contracts between the parties…remember, clinic consents were drafted on behalf of the clinic, they are documents of a different nature than an egg or embryo agreement). Rights, responsibilities and obligations owed and expected of each party to the other is detailed in the donor agreement and parentage, a particularly complex judicial matter will be explicitly addressed by clearly stating the intentions of the donor(s) to be recognized only as that, a donor and any other presumption or right of presumption of parentage will be explicitly and clearly relinquished. The recipient parents are acknowledged in the donor agreement as the legal parents.

Other matters that will also be negotiated and then documented by each party’s attorney may include matters of payment, breach, anonymity, future contact as well as control and disposition of excess embryos.

If prospective parents are applying for insurance coverage for clinical expenses, if coverage should be declined, reproductive attorneys may also be able to provide counsel and services related to appealing insurance denials.

It is a good idea to begin considering attorney selection at the time recipients have decided to pursue collaborative family building. Clinics and/or your agencies should be able to recommend attorneys. The American Fertility Association and RESOLVE: The National Infertility Association both have lists of reproductive attorneys available at their websites. The American Bar Association’s Assisted Reproductive Law Section has resources available, as well.

To learn more about Amy Demma, JD, Founder Prospective Families

Please visit http://www.prospectivefamilies.com

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Fertility Over Martinis

By David Kreiner, MD

September 9th, 2010 at 7:41 am

Last week we had an in service on the IVF programs that are offered to patients at East Coast Fertility.  You know – any time you ask even the most devoted employees to stay after school – not everyone is thrilled by this. Especially after a long day of making babies! One staffer asked her friend why they needed to attend, the meeting was after all about something she knew about already; that is what makes ECF a wonderful place for patients to overcome their infertility and besides – it was cutting into "Dancing With The Stars".

"I heard that this restaurant is one of the best", her colleague and friend said.  "Besides, how often do we get to have a drink together".

At this point our fearless marketing director stood up by her easel, marker in hand and proceeded to attempt to elicit from the 18 members of the East Coast Fertility staff what words would they use to describe ECF.  She was aiming to help our staff communicate better with our patients about all of the different programs that ECF had to offer.

One of the nurses – clearly bored by the process sipped her martini and with a disparaging look at Pamela, the  marketing director impatiently blurted that ECF is successfully effective in performing IVF and got up to go to the rest room.  Clearly she felt that she didn’t need to know what she already thought that she knew!

Nurse Rosa proudly stated that ECF is about providing sympathetic care to our patients.  Christina, the popular front desk clerk offered "affordable".  At this point I could not hold back as my drive has been to make IVF safe, effective and accessible.  Our two new physicians, Dr. Eli Rybak, the orthodox rabbi practicing in our Brooklyn office and Dr. Jessica Mann, our South American woman chimed in together proclaiming that ECF accommodates the diversity common to New York and Long Island.

Pamela declared that the ECF’s mission was about delivering safe and effective IVF to as many people of varying ethnic and economic backgrounds.

How do our programs do this?  Are they consistent with our intended message to patients?

The first program discussed was our Micro IVF or Minimal stimulation IVF program.  

At $3900, this program is priced to make IVF affordable.  Since minimal gonadotropin stimulation hormones are used it is expected to have less affect on a woman’s body and be easier in that it requires less monitoring.  Cheaper and less risky appeals to many women who otherwise would not consider IVF as a viable option.  The pregnancy rate we have seen thus far in these cases varies from 20% to 50% depending on the patient with the greatest success experienced by our young PCOS patients and patients with a history of tubal ligation in the past.  I reminded everyone that Helen, a 32 year old patient from South Carolina was 7 weeks pregnant with a singleton pregnancy and she had severe endometriosis.

Our Single Embryo Transfer (SET) program was my attempt to eliminate financial cost as a reason for patients to transfer multiple embryos and thereby increase the likelihood  of causing risky multiple pregnancies.  Patients without insurance or other discounts who transfer one embryo at a time will not have to pay to cryopreserve excess embryos.  Frozen storage as well as frozen embryo transfers are free until a live baby is born or they have used up all their embryos.

This program is available for the MicroIVF and full stimulated IVF cases.  Data since the inception of this ECF SET program in 2007 shows that pregnancy rates for elective single embryo transfer lag fresh elective double embryo transfer by 6% but only 2% if you include the frozen embryo transfers.  These groups were age matched with no significant difference noted between single and double embryo transfers for any age except with regards to the incidence of multiple pregnancy.  There were no twins in the single embryo transfer group but about 30% twins and two cases of triplets in the elective double embryo transfer group.  Essentially, for the good prognosis patient, SET eliminates risky multiple pregnancies without jeopardizing pregnancy rates and without increasing cost.

Our egg freezing study was brought up by Dr. John, Director of embryology.  Half of the eggs retrieved are frozen prior to fertilization.  The other half undergo Insemination in the typical IVF fashion.  These embryos are incubated for 3 to 5 days and then placed in frozen storage.  The frozen eggs are thawed an hour after freezing and are inseminated.  These embryos are transferred 3 days after the study patients have undergone retrieval.  Study patients get free hormone medications, ICSI, coculture, embryo glue, assisted hatching, cryopreservation, frozen storage and free frozen embryo transfers.  The cycle costs them $6900.

He also mentioned our new PGD/PGS program to screen for chromosomal problems in the embryos.  Using a new technique called the Microchip Assay developed by Jacques Cohen at Reprogenetics, ECF is collaborating to offer patients this more accurate assay that tests all 23 pairs of chromosomes in the embryo.  Initial tests suggests that this test may diminish the risk of miscarriage and help select the most viable embryo to transfer.

We completed our discussion with a review of our grant programs.  We were selected by NY state to provide IVF under the DOH grant.  As it is supported by NY state the patient’s cost share is significantly reduced.  Unfortunately, these funds are limited so ECF sponsors it’s own grant program.  The ECF grant like the DOH grant is income based.  Patients pay between $6900 and $9900 for basic IVF.  The cost of medications are reduced and any additional procedures if needed are at half price.

In the end – our staff felt like it was important for all of us to truly understand why we did what we did for our patient community. We always think that we know what our mission is all about – but it was good to be reminded.  

The only remaining question was whether to order the tiramisu or the apple crumb.   

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