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Archive for the ‘Single Embryo Transfer’ Category

IVF and Comprehensive Chromosomal Screening (CCS) a/k/a Pre-embryo Genetic Screening (PGS)

By David Kreiner MD

January 20th, 2016 at 1:55 pm

 

credit T. Minella

In 1985, when I started my fellowship training at the Jones Institute, IVF technology was so new that we numbered each baby that was born as a result of IVF and it was still in double digits. People came to us for IVF from all over the world because our success rate was the best — at that time, just 15 percent.

The technology of IVF was so inefficient then, it was routine to transfer six embryos at a time. That’s what it typically took to create a singleton pregnancy. Sometimes the result was multiples. My experience with multiple pregnancies in those early years opened my eyes and heart to the additional struggles that accompanied patients’ tremendous joy at finally being pregnant.

With the discoveries and improvements in both clinical and laboratory procedures and techniques in the early 2000’s, success rates for IVF boomed… allowing for the transfer of a much more limited number of embryos that depended on patient age and embryo quality. Ultimately, the goal was Single Embryo Transfer (SET), the transfer of one high quality embryo to eliminate the additional risks associated with multiple pregnancies.

The challenge has been that, despite the transfer of an embryo that appeared of highest quality, one could not tell by simply looking under the microscope that the embryo was genetically normal. Abnormal embryos were not just less likely to implant, but if they did, would miscarry or result in an abnormal fetus.

Technology to test embryos with CCS to determine if they were chromosomally normal before transferring them into the uterus has been available for over 10 years but previously the test was often inconclusive, occasionally inaccurate, and potentially hazardous to the embryos. In addition, the test cost between $5000 and $7000. Today, CCS (also known as PGS) has improved to the point that it is nearly 100% accurate and rarely inconclusive or damaging to embryos and the cost is generally not significantly more than $3000, depending on the number of embryos tested.

Incorporating CCS/PGS into IVF will increase the ability for a patient to achieve a live birth of a normal healthy baby while minimizing the risk for a miscarriage and to do so in fewer embryo transfers since only normal healthy embryos need be transferred. It is envisioned that the additional cost of PGS will be offset by virtue of going through fewer frozen embryo transfers .

These 30 years, I have seen a number of game changers in IVF.  CCS/PGS may be among the most significant.

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Would you consider using CCS/PGD?

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To Single Embryo Transfer (or Not to)?: That is the Question

By Tracey Minella

February 11th, 2015 at 12:24 pm

 

Credit: stockimages/ freedigitalphotos.net


One of the hardest parts of undergoing in vitro fertilization is the difficult decision of how many embryos to transfer back…because each embryo transferred has the potential to implant and develop into a baby.

In the 1980s when IVF was new and success rates were understandably low, it was common to transfer as many as 6 embryos back. Even then, many women did not conceive. Others conceived multiple pregnancies. Still others conceived only one.

Happily, today the technology has been dramatically fine-tuned, resulting in much higher IVF success rates and, because fewer embryos are being transferred, fewer multiple pregnancies.

Some women can’t or don’t want to have a multiple pregnancy and are interested in a program that virtually eliminates the risk of more than a singleton pregnancy. Some of their reasons include possible health risks for the mother or babies, concerns over the higher costs of raising multiples, or the fear of being placed on bed rest and its potential financial impact.

On the other hand, because IVF can be expensive and often not covered by insurance, and because the couples attempting it may have already been trying to conceive for a long time with and without medical assistance and expense, it’s tempting to want to “put all your eggs in one basket”. These couples want to transfer a higher number of embryos back to maximize their chance of conceiving in that one cycle or because they can’t afford to do more cycles. Many couples think of the possibility of twins as a bonus. Two-for-one. Instant family. Dream come true.

But if the financial burden was lessened, and the odds of a live birth from transferring one embryo were nearly comparable to the odds for transferring more, would that make a difference to you? Would you opt for the statistically safer singleton pregnancy vs. the statistically riskier multiple pregnancy? Would you really prefer a multiple pregnancy or would you rather have a succession of singleton pregnancies, the way you originally planned before infertility entered your life?

Deep, emotionally-charged decision. No right answer. Just the right answer for you.

Some good news that may affect your decision is 20-year study of 92,000 patients from Denmark, Norway, Sweden, and Finland, recently published in the on-line Oxford Journal, Human Reproduction, on January 21, 2015. The Nordic study found that the health of children born from IVF has significantly improved and that the risks of pre-term or severely pre-term births have declined dramatically…and it’s primarily due to transferring just one embryo. In addition, the stillborn and infant death rate for singletons and twins born through IVF has declined. http://bit.ly/1Ejgg1o

For those interested, Long Island IVF has a well-established Elective Single Embryo Transfer Program with success rates comparable to traditional IVF in select patients. If you elect to transfer one embryo in your fresh cycle you get free cryopreservation of your embryos and free storage for six months or until a live birth occurs. As an additional incentive to motivate patients to make safer choices, we offer patients transferring a single embryo during their fresh stimulation cycle up to three frozen embryo transfers, within a year of their retrieval or until a live birth occurs, for the price of one. For more details and information on whether SET may be right for you, visit http://www.longislandivf.com/single_embryo_transfer.cfm or ask your LIIVF physician.

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What did/would you consider when deciding how many embryos to transfer? Is the elective SET program something you did/would consider? Why or why not?

 

 

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Ready, Set, Save On IVF!

By David Kreiner MD

September 3rd, 2014 at 7:46 am

 

credit: stuart miles/free digitalphotos.net


A pharmaceutical company started a new program designed to attract a larger market share by discounting its fertility medications by 50%.  What a novel idea!

Who would not choose to save over a $1000 if given the choice?  It got me thinking…

Do patients know about the many discounts offered by Long Island IVF?  

Here at Long Island IVF, a full stimulation IVF cycle is offered to qualifying patients earning under $100,000 per year at $7,500 and somewhat higher to those earning up to $200,000 per year.  Anesthesia is an additional $525 and medications… including the savings through the new Ferring® rebate program… would range in cost from $1500- $3500 depending on the needs of the patient.  For example, an “average” patient receiving 20 amps of Bravelle® (FSH) and 10 amps of Menopur® would pay about $1,050 for these medications and hundreds more for Novidrel® (hCG)  and Endometrin® (progesterone).  Of course, those requiring more medication would have proportionally higher costs for their medications.

We offer other cost-savings programs at Long Island IVF including up to three frozen embryo transfers for the cost of one and free cryopreservation to patients electively transferring a single embryo in their fresh cycle.  More details on our Single Embryo Transfer (SET) Program and its financial incentives are available here: http://bit.ly/WpzCvv

 

We also offer a minimal stimulation IVF, also known as Micro IVF, at $3900. Because patients using this treatment protocol use less fertility medication to achieve their minimal stimulation than is used in in a full stimulation IVF cycle, there are significant savings on medication costs as well. Patients are encouraged to ask their doctors if they are candidates for Micro-IVF. More details on our Micro IVF Program are available here: http://bit.ly/12ZjvaD

 

Most importantly, these cost savings programs are available with the same high level of service and comparable success that Long Island IVF is famous for where we offer patients as good a chance of achieving a pregnancy as nearly anywhere in the nation.

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Have you researched the many grants and other cost-savings programs available at Long Island IVF?

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National Twins Days

By Tracey Minella

July 30th, 2014 at 10:22 pm

 

image courtesy of david castillo dominici/freedigitlaphotos.net


Twins. Gotta love ‘em.

For the majority of couples struggling with infertility, the idea of having two babies at once…especially in cases of a long, expensive treatment history… is a dream come true. Times two! For some, twins are a “two-fer” that helps “justify” the expense of IVF and IUIs. Twins are also a great way to quickly “catch up” in the total number of children department. After years of having none, suddenly you are the parents of two… instant “standard American family”. In fact, many call it quits after twins.

On the other hand, twins (or triplets) make others nervous. The fact is that a multiple pregnancy can be more complicated than a singleton. Many infertile couples have stressed enough over just getting pregnant and may prefer to avoid the additional worries a high risk multiple pregnancy sometimes presents. This fear, coupled with financial incentives, has driven the popularity of quality Single Embryo Transfer (SET) programs which may offer comparable success rates. For information on Long Island IVF’s SET Program success rates and incentives, click: http://www.longislandivf.com/single_embryo_transfer.cfm

But those lucky enough to have twins will agree that once they arrived safely, it’s mostly two times the pleasure and two times the fun.

This year, August 1-3 is the National Twins Days Festival. http://www.twinsdays.org/, which is billed as the largest annual gathering of twins in the world.

We are inviting all our parents of twins (or more) who are so inclined, to SHOW US YOUR TWINS! Upload your favorite photo to our Facebook page any time between August 1-3. We want to see all those cuties…the ones born this week, the ones who are leaving for college, and the ones in between!

Your success will give others hope. (But those who find viewing baby photos difficult will have advance notice to avoid viewing those posts on the page on those days.)

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If you could control it, would you prefer having twins or one baby at a time?

 

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The Dilemma of Excess Embryos

By Tracey Minella

January 25th, 2014 at 9:32 am

credit: wiki commons public domain

 

There is so much to focus on when beginning IVF. Insurance and financing issues. Learning about all the medications, as well as how to inject many of them. Understanding the processes of daily monitoring and blood work, of retrievals and transfers. Deciding how many embryos to transfer back and whether to cryopreserve the others.

Most people do cryopreserve the embryos which are not transferred back on a fresh IVF cycle. These frozen embryos are often thawed and used in a later cycle, either years later after a successful fresh cycle or sooner if the fresh cycle was unsuccessful.

Sometimes, especially in cases where patients only transfer back one embryo, like patients in Long Island IVF’s Single Embryo Transfer Program http://bit.ly/1jjvr3y patients may obtain enough embryos from their first fresh IVF cycle to satisfy all of their family-building needs through subsequent frozen embryo transfers. They may have one baby, then another a few years later, and then yet another…all from one retrieval. Yes, they are the lucky ones.

I remember… almost casually… signing off on the cryo consent, my primary focus being on all the matters that had an immediate effect on my first fresh cycle. I wanted to be pregnant now. I’d worry about what to do with any leftover frozen embryos… after I had all the children I wanted … later. It took a few cycles before I finally had any embryos left over to freeze, but the moment I did, I set in motion a decision more complicated and emotional than I initially imagined.

What to do with excess embryos is about as personal a decision as there is. If you don’t have too many, do you keep transferring them until they are gone? Do you donate them…full genetic siblings to your other children…to another couple? Do you donate them to research if your state allows? Do you just keep them in storage and pay the fees? Do you discard them?

I was reminded of the difficulty of this decision when I read about New Zealand’s law limiting the amount of time that embryos can remain in storage to ten years. http://bit.ly/1f7uypm . Fortunately, there is no such law in New York. It is stressful enough for patients to decide what to do with excess embryos without the government imposing an arbitrary time limit on them.

There is no single right answer. Just a right answer for you.

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If you cryopreserved embryos, are you comfortable with your initial decision on how they should be handled? Or are you undecided?

 

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The Dream of Motherhood Never Dies

By Tracey Minella

December 15th, 2013 at 8:09 pm

 

image courtesy of David Castillo Dominici/freedigital photos.net


There are women who have babies with ease…they pick the month they’d like the baby to be born, conceive effortlessly, and often enjoy care-free pregnancies and deliveries. Others have unplanned pregnancies and sometimes complain or give up the baby. And some women choose to never have children at all.

And then there is us. The infertile ones.

We began our quest as innocent planners of big families and summertime babies. And as the journey wore on we somehow morphed into women who’d settle for just one healthy baby born on any day of the year. We altered the dream to our reality. And we prayed it would come true.

For many of us with access to quality reproductive medical care, the dream will come true. The statistics for IVF success are rapidly rising as technology improves daily. Single embryo transfers (SETs), already popular at Long Island IVF, are helping to reduce risky multiple pregnancies. And Early Embryo Viability Assessment (EEVA) Testing, which is part of a clinical trial at Long Island IVF, is helping embryologists choose the embryos most likely to result in a pregnancy.

But what about those who don’t have access for financial or other reasons? What about their dreams? If faced with no other options, these women resolve to live child-free. Many end their infertility journeys after having suffered devastating losses or repeated disappointments and are emotionally, physically, and financially exhausted. For most of them, living child-free may not really be a choice, but rather, the only option available.

I don’t think the dream of motherhood ever dies. Certainly not for women who wanted it badly enough to endure the sacrifices and demands of repeated IUIs and IVFs. The journey may end, but the longing remains. Even if the woman stops talking about it. Even if she says she’s okay with living child-free. That’s just self-preservation talking.

This week that theory was validated as a 64 year old woman gave birth after a 41 year infertility journey. She got married six years before the first IVF baby was even born. She tried IVF only once, in 1988, without success and thereafter gave up treatment…for 23 years. But the dream hadn’t died. She went back for another IVF procedure and is finally a mother at 64. Her daughter is named Durga, which means “invincible”. For the full story, clickhttp://bit.ly/INs6ua

This story is offered not to spark debate on how old is too old to become a mother, but as testament to the unwavering power of the dream of motherhood and the miracles capable from modern reproductive medical technology.

What may feel like the impossible dream today may be the invincible dream tomorrow. Dare to dream it.

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photo credit: David Castillo Dominici/free digital photos.net

 

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Infertility Podcast Series: Journey to the Crib: Chapter 32: Octomom

By David Kreiner MD

December 1st, 2013 at 8:26 am

 

Welcome to the Journey to the Crib Podcast.  We will have a blog discussion each week with each chapter.  This podcast covers Chapter Thirty-Two: Octomom. You, the listener, are invited to ask questions and make comments.  You can access the podcast here: http://podcast.longislandivf.com/?p=146


A year ago, the Medical Board of California revoked the license of Dr. Michael Kamrava, finding he “did not exercise sound judgment” in transferring 12 embryos to Nadya Suleman, who already had six children at home. The ruling, while not surprising, was illuminating, and it’s worth reflecting on the five things we learned from Octomom:

 

1.      Know How to Say “No”: There is a point where physicians have to make a judgment call. Pregnancies with triplets – let alone eight infants – put the mother at high risk of serious medical complications and put unborn children at risk for developmental disabilities. Physicians need to rely on their professional expertise and experience to know when to turn down a patient request no matter how vehemently it is made.

 

2.      Beware the Patient with Tunnel Vision: Often when a patient comes to a fertility doctor, unsuccessful pregnancy attempts have made her anxious and determined. She might want to get pregnant regardless of the risks that pregnancy may present.

3.      Less is More: In 1999, 35 percent of all transfers involved four or more embryos. In 2009, only 10 percent had four or more. And those high-number transfers are generally reserved for patients with significant fertility challenges. In contrast, Octomom already underwent multiple successful IVF (in vitro fertilization) procedures and had given birth to six children when she had her 12-embryo transfer.

 

4.      Know When to Deviate: While Dr. Kamrava’s deviation from guidelines was an extreme departure, deviations do occur for specific reasons, such as repeated IVF failure, age-related infertility and poor egg quality. It is important to know when implanting several embryos is appropriate.

5.      “Reduce” Risk: Dr. Kamrava complained that Octomom refused to undergo “selective reduction,” which would have reduced the number of embryos she carried to term. Here, again, is an argument for fewer transfers. Had he transferred fewer embryos, Octomom would not have had to face such a difficult decision.

 

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Was this helpful in answering your questions about what could have been done differently to prevent the Octomom case? How much weight do you give your doctor’s recommendation on the number of embryos to transfer?

Please share your thoughts about this podcast here. And ask any questions and Dr. Kreiner will answer them.

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Infertility and National Prematurity Awareness Month

By Tracey Minella

November 19th, 2013 at 10:53 am

 

photo credit: praisaeng/freedigitalphotos.net

Infertility is a disease. Its course often follows a common progression. It often starts with the abandonment of what turns out to have been unnecessary birth control. It then progresses through a repeated series of monthly disappointments until charts, thermometers, and the “chore-mentality” move into the bedroom. ObGyn intervention becomes an RE referral. A battery of tests and invasive procedures follow. Sometimes there’s Clomid. Maybe even ovulation induction with IUIs. Possibly, there’s IVF.

It’s no wonder that most infertility patients are so caught up in the all-consuming grind of simply trying to get pregnant, that they don’t think past getting that positive pregnancy test. They don’t think that…after all that time and sacrifice…something could threaten that hard-earned pregnancy.

It’s National Prematurity Awareness Month. And there is no better time to focus on what you can do to reduce your chances of having a premature baby than before you become pregnant.

It’s not always known why babies are born prematurely, but according to the Mayo Clinic*, some risk factors can include:

  • Pregnancy with twins, triplets or other multiples
  • Problems with the uterus, cervix or placenta
  • Smoking cigarettes, drinking alcohol or using illicit drugs
  • Poor nutrition
  • Some infections, particularly of the amniotic fluid and lower genital tract
  • Some chronic conditions, such as high blood pressure and diabetes
  • Being underweight or overweight before pregnancy.

 

According to the CDC**, some of the symptoms or warning signs of pre-term labor include:

  • Contractions (the abdomen tightens like a fist) every 10 minutes or more often.
  • Change in vaginal discharge (leaking fluid or bleeding from the vagina).
  • Pelvic pressure—the feeling that the baby is pushing down.
  • Low, dull backache.
  • Cramps that feel like a menstrual period.

If you are doing IVF, one of the things you may want to consider to reduce your chances of prematurity is having a single embryo transfer (“SET”), if your doctor feels you are a good candidate. Doing so virtually eliminates your chance of a multiple pregnancy. In addition to the safety considerations for mother and baby, SET at Long Island IVF offers financial incentives, including free cryopreservation and reduced rates for subsequent frozen embryo transfers. Click here for more information about Long Island IVF’s Single Embryo Transfer Program. http://bit.ly/WpzCvv

As an IVF mom of two preemies myself, let me acknowledge that very often, babies arrive early for reasons beyond our control. Sadly, the outcomes are not always happy. But knowledge is power, so control what you can, watch for the signs, and listen to that little voice if you feel something is amiss. And remember that the vast majority of these hard-earned pregnancies do turn out just fine.

*http://mayocl.in/HWaNGz

** http://1.usa.gov/IdCytZ

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Do you worry about prematurity? If so, would you consider SET to reduce the chance of a multiple pregnancy?

Photo credit: http://www.freedigitalphotos.net/images/agree-terms.php?id=100141619 /praisaeng

 

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Infertility Podcast Series: Journey to the Crib: Chapter 30: The Gift of Life and Its Price

By David Kreiner MD

November 9th, 2013 at 11:56 am

 

Welcome to the Journey to the Crib Podcast.  We will have a blog discussion each week with each chapter.  This podcast covers Chapter Thirty: The Gift of Life and Its Price. You, the listener, are invited to ask questions and make comments.  You can access the podcast here: http://podcast.longislandivf.com/?p=141

The Gift of Life and Its Price

 

IVF has been responsible for over 1 million babies born worldwide who otherwise without the benefit of IVF may never have been.  This gift of life comes with a steep price tag that according to a newspaper article in the New York Times in 2009 was $1 Billion per year for the cost of premature IVF babies.

 

According to the CDC reported in the same NY Times issue, thousands of premature babies would be prevented resulting in a $1.1 Billion savings if elective single embryo transfer (SET) was performed on good prognosis patients. 

 

The argument often given by a patient who wants to transfer multiple embryos is that to do SET would lessen their chances and to go for additional frozen embryo transfers is costly.

 

In fact, if one considers the combined success rate of the fresh and frozen embryo transfers that are available from a single stimulation and retrieval, the success rate is at least as high if not higher in the cases of fresh single embryo transfers. 

 

At Long Island IVF, in an effort to eliminate the financial motivation for multiple embryo transfers, we offer free cryopreservation and embryo storage for a year to our single embryo transfer patients.  In addition, we offer them three (3) frozen embryo transfers for the price of one for up to a year after their retrieval.

 

IVF offered with single embryo transfer is safer, less costly and probably the most effective fertility treatment available for good prognosis patients.                     

 

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Was this helpful in answering your questions about single embryo transfers?

Please share your thoughts about this podcast here. And ask any questions and Dr. Kreiner will answer them.

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Infertility Podcast Series: Journey to the Crib: Chapter 29: Why the Wyden Bill Does Not Support Fertility Patients

By David Kreiner MD

November 3rd, 2013 at 11:20 am

 

Welcome to the Journey to the Crib Podcast.  We will have a blog discussion each week with each chapter.  This podcast covers Chapter Twenty-Nine: Why the Wyden Bill Does Not Support Fertility Patients. You, the listener, are invited to ask questions and make comments.  You can access the podcast here: http://podcast.longislandivf.com/?p=138

Why “The Wyden Bill” Does Not Support Infertility Patients

 

IVF results subjected to government audit were mandated to be reported with the passage of the “Wyden bill”.   The intent of the CDC and national reproductive society (SART) was to assist infertility patients by informing them of the relative success of all IVF programs in the country. 

 

Unfortunately, what sometimes creates the best statistical results is not always in the best interest of the mother, child, family and society.  Now that prospective parents are comparing pregnancy rates between programs there is a competitive pressure on these programs to reports the best possible rates.   Sounds good…unfortunately it doesn’t always work out that way for the following reasons.

 

Patients with diminished ovarian reserve, who are older or for any number of reasons have a reduced chance for success, have a hard time convincing some programs to let them go for a retrieval.  In 2008, we reported our success, 15% with patients who stimulated with three or fewer follicles.  Sounds low and in fact many of these patients were turned away by other IVF programs in our area.  However, for those families created as a result of their IVF, these “miracle” babies are a treasure that they otherwise… if not for our program giving them their chance… would never have been born.

 

Another unfortunate circumstance of featuring live birth rate per transfer as the gold standard for comparison is that it pressures programs to transfer multiple embryos thereby increasing the number of high risk multiple pregnancies created.  This is not just a burden placed on the patient for their own medical and social reasons but these multiple pregnancies add additional financial costs that are covered by society by increasing costs of health insurance as well as the cost of raising an increased number of handicapped children.

 

William Petok, the Chair of the American Fertility Association’s Education Committee reported on the alternative Single-Embryo Transfer (SET) “Single Embryo Transfer:  Why Not Put All of Your Eggs in One Basket?”.  He stated in November 2008, that although multiple rather than single-embryo transfer for IVF is less expensive in the short run, the risk of costly complications is much greater.  Universal adaptation of SET cost patients an extra $100 million to achieve the same pregnancy rates as multiple transfers, but this approach would save a total of $1 billion in healthcare costs.

 

We have offered SET since 2006 with the incentive of free cryopreservation, storage for a year and now a three for one deal for the frozen embryo transfers within the year in an effort to drive patients to the safer SET alternative. 

 

If we are going to report pregnancy rates with IVF as is required by the Wyden Bill, let us put all programs on the same playing field by enforcing the number of embryos to be transferred and even promoting minimal stimulation IVF for good prognosis patients.  The Wyden Bill without the teeth to regulate such things as the number of embryos transferred and reporting success per embryo transfer does more harm than good.  Let us promote safer alternatives and report in terms of live birth rate per stimulation and retrieval, including frozen embryo transfers, so that there is a better understanding of the success of a cycle without increasing risks and costs from multiples.

 

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Was this helpful in answering your questions about the Wyden Bill, IVF success rates and reporting requirements, and SET?

Please share your thoughts about this podcast here. And ask any questions and Dr. Kreiner will answer them.

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