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Archive for the ‘MD’ tag

Long Island IVF Celebrates National Doctor’s Day

By Tracey Minella

March 30th, 2017 at 8:48 pm

 

L-R Drs. Brenner, Pena, Kenigsberg, Kreiner


You’ve trusted them with more than just your medical care. You’ve trusted them with your future…with your dreams of having a family. They are your Long Island IVF doctors. And we celebrate them today on National Doctor’s Day. (Camera shy today are Drs. Zinger and Droesch!)

For almost 30 years, the doctors at Long Island IVF have been helping Long Islanders become parents through advanced assisted reproductive technologies like IUI and IVF. We were responsible for such milestones as Long Island’s first IVF baby, its first Donor Egg baby, and its first IVF baby from a cryopreserved embryo. We are often the first practice in the region to offer the newest technologies and treatments in family-building.

Whether you came to one of our doctors through a trusted recommendation from family or friends whose families we helped to build, or you found us through conducting your own research into Long Island IVF’s history, we are so glad you chose our doctors.

There is a beautiful transition that often happens between a patient and her doctor. What starts out as a queasy mix of hopefulness and fear at an initial consultation—where you lay your story and feelings there at the feet of an expert who is still a stranger—often develops into a partnership in care that leads to that sought-after pregnancy. Not always unfortunately, and that is devastating to both the patient and the doctor. The journey may be short for some, longer for others, and stressful for all.

Your doctors pour over your case and feel enormous responsibility to help you succeed because they know how much is on the line. They don’t really exhale until you are sent back to your ObGyn for pregnancy care with a healthy sono photo in your hand.

And nothing makes them happier than when they get to meet your little ones at the annual LIIVF family reunion– or any time you want to drop in for a visit.

If there is a special doctor at Long Island IVF that has touched your life, feel free to give a “shout-out” right here in the comments to let them know how much they mean to you. It will make their day! (Hey Dr. Kreiner, if you’re listening—thanks for the two miracles!)

Now it’s YOUR turn…

Shout out begins now!

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Who is your favorite LIIVF doctor?

 

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Long Island IVF-WINNER: Best in Vitro Fertility Practice 2015- 2016- 2017

It is with humble yet excited hearts that we announce that Long Island IVF was voted the Best In Vitro Fertility Practice in the Best Of Long Island 2015 and 2016 and 2017 contest…three years in a row!

The doctors, nurses, embryologists, and the rest of the Long Island IVF staff are so proud of this honor and so thankful to every one of you who took the time to vote. From the moms juggling LIIVF babies… to the dads coaching LIIVF teens…to the parents sending LIIVF adults off to college or down the aisles… to the LIIVF patients still on their journeys to parenthood who are confident in the care they’re receiving…we thank you all.

We love what we’ve gotten to do every day more than 29 years…build families. If you are having trouble conceiving, please call us. Many of our nurses and staff were also our patients, so we really do understand what you’re going through. And we’d like to help. 631-752-0606.

 

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Balancing Breast Cancer and Fertility Preservation

By Steven Brenner MD

October 9th, 2016 at 5:22 pm

 

Dr. Steven Brenner


A diagnosis of breast cancer is one of the most challenging health issues a person could face.  This diagnosis is even more devastating to the woman who desires to have children the future.  Treatments for the breast cancer may have harmful effects on the woman’s ability to conceive by adversely affecting the health of her eggs.  In addition, the hormonal treatments frequently used to help an individual conceive have the potential to worsen the breast cancer.

There is often turmoil surrounding the diagnosis of breast cancer.  The individual, her family and physicians are appropriately focused on getting rapid effective treatment and survival.  The issue of fertility may not be thought of until a chemotherapeutic plan is just about to start or has already been initiated.

Since there are fertility preserving options for the individuals facing breast cancer treatment, these options should be considered.  If time allows eggs or embryos may be frozen for future use.  The use of such procedures depends on many factors, primarily, will such treatment have a negative effect on the woman’s disease.  If in the patient’s and oncologist’s judgment fertility preservation is an option it should occur rapidly to allow for the timely treatment of the breast cancer.

The key is for the oncologist and patient to be aware and discuss the potential for fertility conservation treatment prior to the start of chemotherapy.  This opportunity for discussion may be lost in the unrest that surrounds the diagnosis.  Breast cancer awareness month, October, 2016, creates a platform to raise these issues and help both individuals and health care providers come more cognizant of available treatments and the importance of timing these treatments to maximize future fertility.

Long Island IVF offers women facing cancer the fertility preservation options of elective embryo- or egg-freezing prior to undergoing chemotherapy. This enables the woman to safeguard some of her eggs from the adverse effects of chemotherapy by retrieving and freezing them before she begins her cancer treatment. Her frozen eggs or embryos will be there for her use in family-building once her cancer battle is behind her. For more information, please contact our office at 877-838-BABY.

 

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Would you consider fertility preservation or mention the option to a friend facing a cancer diagnosis?

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Long Island IVF Doctors are “Top Docs” Again!

By Tracey Minella

August 9th, 2015 at 8:53 pm

 

(L-R) Dr. Brenner, Dr. Pena, Dr. Kenigsberg, Dr. Kreiner


Long Island IVF is proud to announce that several of its doctors have been included in the Top Doctors on Long Island Guide selected from the 2015 Castle Connolly Guide by Newsday.

Three of its physicians…Daniel Kenigsberg, MD, Steven Brenner, MD, and Joseph Pena, MD… have consistently appeared on the prestigious listing as Reproductive Endocrinologists and were recognized again this year.

All three doctors are consistently humbled by this honor. Doctors do not and cannot pay to appear on this list, but rather are nominated and selected through a peer recognition process, so being named to the Top Docs list is an honor that never gets old for these physicians.

Long Island IVF is proud of all of its physicians, embryologists, nurses and staff for their commitment to its patients and is grateful for the recognition given by Castle Connolly’s Top Doctors Guide honors. But the best reward for a job well done is the satisfaction we get from building families every day and seeing the very real impact our work has on the lives and happiness of our patients.

In an effort to give back to the Long Island community, Long Island IVF sponsors annual infertility fundraisers in which it donates a free IVF cycle as a door prize. Long Island IVF also offers a variety of grants which can provide financial assistance to those seeking infertility treatments, including NYS DOH’s Infertility Demonstration Grant as well as the new Jade Foundation IVF Grant which is exclusively available at Long Island IVF. For more information on grants, patients new to our practice should contact the Long Island New Patient Counselor at (631) 752-0606 and existing patients should speak with their LIIVF Financial Counselor.

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If you could say one thing to your LIIVF doctor OR to someone who was looking for an infertility specialist, what would you say?

 

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Infertility Care: Starting with the Basics

By Steven Brenner MD

October 18th, 2014 at 10:52 am

credit: wpclipart.com

“Thinking the worst” is a very common reaction for individuals experiencing adversity.

This is especially true for people experiencing infertility. Concerns regarding the question of establishing the family someone has dreamed of since they were young is daunting and can leave a person with significant anxiety and doubt regarding her/his future.

In this context it is important to go back to basics regarding fertility and understand that many people suffering from this disorder will be successfully treated with relatively simple techniques and therapies. For the more severe abnormalities, it is comforting to know current available therapies can address these issues with great success.

Establishing a pregnancy without infertility treatment requires a healthy egg, functioning sperm and an anatomic path that allows sperm to ascend the genital tract and an egg to travel into a fallopian tube where fertilization takes place. The anatomic path needs to allow the fertilized egg to travel into the uterine cavity. A receptive uterine lining is then required for the pregnancy to implant and grow. To make things more challenging, sperm and egg have a very small window of time to find each for fertilization to take place.

Many couples have experienced infertility as a result of improperly timed intercourse.  This often results from the couple not being aware of the timing of ovulation and the short duration of egg viability. The “fix” for something like this is very simple, requiring merely an understanding of the basic physiology.  Sexual dysfunction can plague a relationship, but it is often not until fertility is compromised that couples seek treatment. The simple fix for fertility may involve nothing more than inseminations timed to natural ovulation. Much more in depth therapies may be required to overcome the other, additional concerns associated with sexual dysfunction.

Ovulatory dysfunction, while a very complex issue, is often very easily addressed with simple treatments. Weight loss or gain may be all that is needed to establish regular ovulatory cycles. Correction of hormonal abnormalities leading to problems with ovulation can often be treated with medications that do not require the intense monitoring of injectable fertility medications associated with in vitro fertilization procedures.  Sluggish thyroid activity and elevations in a hormone named prolactin are such issues that readily respond to oral medications.

A receptive uterine lining to allow for implantation of an embryo that formed in the fallopian tube is needed to allow a pregnancy to be established in the uterus. Although a scarred endometrium or one that is distorted from fibroids may require surgical repair, other disorders of the lining can be treated with local hormonal supplementation. The endometrium, the uterine lining, may not develop appropriately after ovulation secondary to hormonal abnormalities. This may reflect an abnormality in egg production and the hormones associated with ovulation.

Therapies directed at improving ovulation or directly supporting the lining of the uterus with vaginal application of the hormone progesterone may be all that is needed to correct this problem.

Anatomic problems such as scarring of the fallopian tubes may require surgical correction. However, blocked tubes may be opened by minimally invasive procedures at the time of a hysterosalpingogram (HSG). In such procedures, a tube blocked where it inserts into the uterus is opened with a catheter in a setting that does not require general anesthesia.

Many patients will be successfully treated with simple techniques and procedures that are not associated with the expense and invasiveness of the therapies that most people think they will require.

For each infertile person a plan of evaluation and therapy needs to be developed, beginning with the basics. It does not necessarily lead to those treatments that are more detailed and invasive.

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Did you put off an infertility evaluation out of fear of needing expensive, invasive fertility treatments?

 

Photo credit: http://www.wpclipart.com/phps.php?q=ostrich

 

 

 

 

 

 

 

 

 

 

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A Heart-Stopping Tale: The Old Friend, A Fertility Doc, and The Subway Series

By David Kreiner MD

May 31st, 2013 at 9:05 pm

 

image courtesy of freedigital photos.net

“How do I feel?…The Mets won!” he exclaimed. And with those words exuding from his mouth, Marty’s whole face smiled from ear-to-ear.  “How do I feel?…Weak, but I don’t think I need a fertility doctor.”

Marty was on a roll, his joking relaxed me…his light-hearted mood and focus on his love for the Mets gladdened my heart as I was slowly realizing that Marty was back.

This 76 year-old semi-crippled athlete who loved to play tennis despite his obvious orthopedic infirmities of late struggled to walk, much less compete athletically, but clearly competitive sport was a great love of his.

This is how I knew Marty was back as he joked about his Mets winning the Subway Series.

His wife was now by his side, grasping for rational thought clouded by the sight of seeing her life’s soul mate lying apparently helpless on the floor, having just returned from a temporary state of cardiorespiratory arrest.  She was shaking, yet uncertain about Marty’s fate.

Karina, Dr. Karina I learned… our hero… was a 40-something gastroenterologist who initiated chest compressions moments before I arrived to the lobby of the restaurant but seconds after Marty was seen clutching at his chest, collapsing to the ground. He stopped breathing… his heart stopped beating…and he turned blue.

I confirmed there was no heartbeat nor respirations, as Dr. Karina continued chest compressions.  I looked at Marty and thought about all the fuss he had made over the years regarding road safety in our community…his involvement in tennis and the men’s club, as well attempts to bring others into the fold.

I respected Marty as a role model who I wished to emulate 19 years hence.  He was active, athletic, and responsible for the welfare of the community.

I was determined to breathe life back into this man who in my eyes had plenty more tennis matches to play, Mets games to cheer for, and kids to warn to slow down their cars.  With the will of God I exhaled my life’s breath, filling Marty’s lungs not once but twice.  In response to Dr. Karina’s chest compressions and my breaths, Marty started to perk up with a strong pulse.  His palms were now sweaty and his eyes were beginning to focus.

I dared to ask him, “Marty, do you know who I am”?

“Of course,” Marty said.  “You are the fertility doctor and the one who creates life”.

Later that evening, reflecting on the events at the restaurant, I finally felt that maybe there is some truth that Dr. Karina and I acted as agents of God and indeed did recreate life in the lobby of the restaurant that evening.

Photo credit: Victor Habbick/ http://www.freedigitalphotos.net/images/agree-terms.php?id=100100670

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What Does ECF and Hot, Sexy Firemen Have in Common?

By Tracey Minella

April 7th, 2011 at 12:00 am

Well…….both will have booths at the Long Island Women’s Expo this weekend!

Um, yep. That’s about it.

DISSED! (Oh, c’mon… you didn’t really expect me to call the doc who helped me conceive “hot and sexy”. That’d be like kissing your brother! Besides, we’re friends now…or we were friends…and it’s so much more fun to commit blog- writing career suicide.)

Well, let me get off the hot seat to tell you that you simply can’t miss this event this weekend, April 9th and 10th  at the Suffolk County Community College, Brentwood Campus. It’s still too cold to plant anything, so why not venture out to the Expo where things promise to be HOT, HOT, HOT.

Remember those hot firemen? They’re putting on a fashion show on Saturday for charity! Talk about melting…

But if you really want to get fired up, visit the East Coast Fertility Booth #119. Come over and say “hello”. There are free raffles each day for both Dr. Kreiner’s amazing book, Journey to the Crib, and Jodi Picoult’s new bestseller, Sing You Home. We’ll have representatives from different ECF departments there to answer your questions, or if you prefer not talking in public, you can sign up for our free e-newsletter.

All the info you need about the Expo, including a downloadable coupon for discounted admission, is available at http://www.longislandwomensexpo.com/exhibitors.html .

So grab a girlfriend and head on out for a day that’s all about the things that matter to women.

And to the ECF docs who felt dissed: Remember, any man can handle his hose, but it takes real brilliance and skill to handle a wand. And make magic.

Now, that’s HOT.

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IVF: The Chances of Success

By Dr. David Kreiner

November 19th, 2010 at 10:44 am

What everyone wants to know when they decide to look into invitro ferilization (IVF) as a treatment option is "what is my chance for success?"  It’s a complicated question and the answer varies from  patient to patient. But let me try to break down a little bit for you.

In 2002 about 28% of cycles in the United States in which women underwent IVF and embryo transfer with their own eggs resulted in the live birth of at least one infant. This rate has been improving slowly but steadily over the years.  Patients should be aware, however, that some clinics define "success" as any positive pregnancy test or any pregnancy, even if miscarried or ectopic. These "successes" are irrelevant to patients desiring a baby. To put these figures into perspective, studies have shown that the rate of pregnancy in couples with proven fertility in the past is only about 20% per cycle. Therefore, although a figure of 28% may sound low, it is greater than the chance that a fertile couple will conceive in any given cycle.

Success varies with many factors. The age of the woman is the most important factor, when women are using their own eggs. Success rates decline as women age, and success rates drop off even more dramatically after about age 37. Part of this decline is due to a lower chance of getting pregnant from ART, and part is due to a higher risk of miscarriage with increasing age, especially over age 40. There is, however, no evidence that the risk of birth defects or chromosome abnormalities (such as Down’s syndrome) is any different with ART than with natural conception.

Success rates vary with the number of embryos transferred. However, transferring more embryos at one time not only increases the chance of success with that transfer, but will also increase the risk of a multiple pregnancy, which are much more complicated than a singleton pregnancy. The impact of the number of embryos that are transferred on success rates also varies with the age of the woman.

Pregnancy complications, such as premature birth and low birth weight, tend to be higher with ART pregnancies, primarily because of the much higher rate of multiple pregnancies. Nationally, in 2002-2003 about 30% of ART deliveries were twin deliveries, versus 1-2% of spontaneous pregnancies. The risk of pregnancy containing triplets or more was 6% in 2003.

As women get older, the likelihood of a successful response to ovarian stimulation and progression to egg retrieval decreases. These cycles in older women that have progressed to egg retrieval are also slightly less likely to reach transfer.  The percentage of cycles that progress from transfer to pregnancy significantly decreases as women get older.  As women get older, cycles that have progressed to pregnancy are less likely to result in a live birth because the risk for miscarriage is greater.  This age related decrease in success accelerates after age 35 and even more so after age 40.  Overall, 37% of cycles started in 2003 among women younger than 35 resulted in live births. This percentage decreased to 30% among women 35–37 years of age, 20% among women 38–40, 11% among women 41–42, and 4% among women older than 42.  The proportion of cycles that resulted in singleton live births is even lower for each age group.

The success rates vary in different programs in part because of quality, skill and experience but also based on the above factors of age, number of embryos transferred and patient population.  Patients may also differ by diagnosis and intrinsic fertility which may relate to the number of eggs a patient may be able to stimulate reflected by baseline FSH and antral follicle count as well as the genetics of their gametes.  These differences make it impossible to compare programs.

Another factor often overlooked when considering one’s odds of conceiving and having a healthy baby from an IVF procedure is the success with cryopreserved embryos.

Thus, a program which may have a lower success rate with a fresh transfer but much higher success with a frozen embryo transfer will result in a better chance of conceiving with only a single IVF stimulation and retrieval.  Success with frozen embryos transferred in a subsequent cycle also allows the program to transfer fewer embryos in the fresh cycle minimizing the risk of a riskier multiple pregnancy.  It may be more revealing to examine a program’s success with a combination of the fresh embryo transfer and frozen embryo transfers resulting from a single IVF stimulation and transfer.  For example, at East Coast Fertility, the combined number of fresh and frozen embryo transfers that resulted in pregnancies for women under 35.from January 1, 2002 to December 2008 was 396.  The number of retrievals during that time was 821.  The success rate combining the fresh and frozen pregnancies divided by the number of retrievals was 61%.  The high frozen embryo transfer pregnancy rate allowed us to transfer fewer embryos so that there were 0 triplets from fresh transfers during this time.

What can I do to increase my odds?

Patients often ask if there are any additional procedures we can do in the lab that may improve the odds of conception.  Assisted hatching is the oldest and most commonly added procedure aimed at improving an embryo’s ability to implant.  Embryos must break out or hatch from their shell that has enclosed them since fertilization prior to implanting into the uterine lining.  This can be performed mechanically, chemically and most recently by utilizing a laser microscopically aimed at the zona pellucidum, the shell surrounding the embryo.  Assisted hatching appears to benefit patients who are older than 38 years of age and those with thick zonae.

Recently a protein additive called “Embryo glue” was shown to improve implantation rates in some patients whose embryos were transferred in media containing “Embryo glue”.  Time will tell if the adhesive effect of this supplement is truly increasing success rates and warrants wide scale use in IVF programs.

Embryo co culture is the growth of developing embryos is the same Petri dish as another cell line.  Programs utilize either the woman’s endometrial cells obtained from a previous endometrial biopsy or granulosa cells obtained at the time of the egg retrieval from the same follicles aspirated as the eggs.  Growth factors produced by these endometrial and granulosa cell lines diffuse to the developing embryo and are thought to aid in the growth and development of the embryo.  It appears to help patients who have had previous IVF failures and poor embryo development.

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Understanding Fibroids

By David Kreiner, Md

October 29th, 2010 at 2:11 am

Fertility is dependent upon so many things!

We must have healthy gametes (eggs and sperm) capable of fertilizing and implanting in a uterus with a normal endometrial lining unimpeded by any uterine or endometrial pathology. The sperm need be in sufficient number and capable of swimming up through a cervix which is not inflamed and provides a mucous medium that promotes sperm motility. The eggs need to ovulate and be picked up by normal healthy fimbriated ends (finger like projections) of the fallopian tubes. The tubes need to be covered with normal micro hairs called cilia that help transport the egg one third of the way down the tube where one of the sperm will fertilize it.

The united egg and sperm (the “conceptus”) then needs to undergo cell division, growth and development as it traverses the tube and makes its way to the uterine cavity by the embryo’s fifth day of life at which point it is a blastocyst. The blastocyst hatches out of its shell (“zona pellucidum”) and implants into the endometrial lining requiring adequate blood flow.

And you wonder why getting pregnant is so hard?

All too often patients, in some groups as many as 30% of women, are told that they have fibroids that may be contributing to their infertility. Fibroids or leiomyomata are non malignant smooth muscle tumors of the uterus. They can vary in number, size and location in the uterus including; the outside facing the pelvic cavity (subserosal), the inside facing the uterine cavity (submucosal) and in between inside the uterine wall (intramural). Fortunately, most fibroids have minimal or no effect on fertility and may be ignored.

The subserosal myoma will rarely cause fertility issues. If it were distorting the tubo- ovarian anatomy so that eggs could not get picked up by the fimbria then it can cause infertility. Otherwise, the subserosal fibroid does not cause problems conceiving.

Occasionally, an intramural myoma may obstruct adequate blood flow to the endometrial lining. The likelihood of this being significant increases with the number and size of the fibroids. The more space occupied by the fibroids, the greater the likelihood of intruding on blood vessels traveling to the endometrium. Diminished blood flow to the uterine lining can prevent implantation or increase the risk of miscarriage. Surgery may be recommended when it is feared that the number and size of fibroids is great enough to have such an impact.
However, it is the submucosal myoma, inside the uterine cavity, that can irritate the endometrium and have the greatest effect on the implanting embryo.

To determine if your fertility is being hindered by these growths you may have a hydrosonogram. A hydrosonogram is a procedure where your doctor or a radiologist injects water through your cervix while performing a transvaginal ultrasound of your uterus. On the ultrasound, the water shows up as black against a white endometrial border. A defect in the smooth edges of the uterine cavity caused by an endometrial polyp or fibroid may be easily seen.

Submucosal as well as intramural myomata can also cause abnormal vaginal bleeding and occasionally cramping. Intramural myomata will usually cause heavy but regular menses that can create fairly severe anemias. Submucosal myomata can cause bleeding throughout the cycle.

Though these submucosal fibroids are almost always benign they need to be removed to allow implantation. A submucosal myoma may be removed by hysteroscopy through cutting, chopping or vaporizing the tissue. A hysteroscopy is performed vaginally, while a patient is asleep under anesthesia. A scope is placed through the cervix into the uterus in order to look inside the uterine cavity. This procedure can be performed as an outpatient in an ambulatory or office based surgery unit. The risk of bleeding, infection or injury to the uterus or pelvic organs is small.

Resection of the submucosal myoma can be difficult especially when the fibroid is large and can sometimes take longer than is safe to be performed in a single procedure. It is not uncommon that when the fibroid is large, it will take multiple procedures in order to remove the fibroid in its entirety. It will be necessary to repeat the hydrosonogram after the fibroid resection to make sure the cavity is satisfactory for implantation.

The good news is, when no other causes of infertility are found, removal of a submucosal fibroid is often successful in allowing conception to occur naturally or at least with assisted reproduction.

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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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The Fertility Work Up

By Dr. David Kreiner

August 23rd, 2010 at 12:00 am

I have received an enormous amount of email from patients over the years asking for information about how they should get started with their infertility workup.  Apparently, they are women, men and couples who have experienced difficulty conceiving and now want some direction about how they should proceed.  Building a family was something they had imagined their entire lives to be a natural progression–from student to career, getting married then having a family–and they’re frustrated that their difficulty conceiving has affected their lives.  For many—some of whom have never experienced a health problem– it prevents them from appreciating or even doing anything else.

See an RE for a Fertility Workup

My response to these emails has been to tell the patients to seek assistance from a reproductive endocrinologist, whose specialty and experience is in helping infertility patients conceive.  A reproductive endocrinologist, who has two to three years of additional specialty fellowship training in infertility after completing an OB/GYN residency.

The RE will conduct a history and physical examination during your initial consultation.  This exam typically includes a pelvic ultrasound of a woman’s ovaries and uterus.  He/she can tell if there are any uterine abnormalities that may affect implantation or pregnancy as well as assess ovarian activity and rule out cases of moderate or severe endometriosis.

Pelvic Inflammatory Disease

If he elicits a history of previous abdominal or pelvic surgery, a physician may suspect that scarring may have developed that typically interferes with fallopian tube transport of the egg to the sperm and the conceptus to the uterus.  An infection that develops after a pregnancy may lead to pelvic adhesions affecting the tubes as well as scarring within the uterine cavity itself which can prevent implantation.  Pelvic inflammatory disease, PID, can lead to tubal disease and may be associated with other sexually transmitted diseases including HPV, Herpes and especially Chlamydia.

Semen Analysis

The semen analysis is the simplest test to perform and will reveal a male factor in 50% of cases.  A post coital test performed midcycle around the time of ovulation when the cervical mucus should be optimal can detect a male factor or cervical factor when few motile sperm are detected within hours of intercourse.

Hysterosalpingogram

A hysterosalpingogram, HSG, is a radiograph x-ray of the uterus and fallopian tubes after radio opaque contrast is injected vaginally through the cervix directly into the uterus.  It can detect uterine abnormalities that can affect implantation and pregnancy as well as tubal patency.  Unfortunately, this exam may be painful and in some patients with PID can result in serious infection.  Some physicians will administer antibiotics prophylactically for this reason.

Hydrosonogram

A hydrosonogram is an ultrasound of the uterine cavity performed after injecting water vaginally through the cervix directly into the uterus.  It can also detect uterine abnormalities and shares some of the risks seen with HSG but to a lesser extent and usually with less associated discomfort.

Hysteroscopy

A hysteroscopy is a surgical procedure in which a telescope is placed vaginally through the cervix directly into the uterus.  The physician can visually inspect the cavity to detect uterine abnormalities.  The risks of pain and infection are also seen with hysteroscopy.

Blood Tests

Blood tests may be run to identify if a patient is ovulating with adequate progesterone stimulation of the uterine lining.  Day 3 E2, FSH and LH levels can give information regarding ovarian activity and ovulatory dysfunction.  AntiMullerian Hormone (AMH) levels correlate with ovarian reserve.   That is the number of eggs remaining in the ovaries.  Hormones that can affect fertility such as thyroid and prolactin are also assessed to ensure that extraneous endocrine problems are not the cause of the infertility.

Laparoscopy

Laparoscopy is a surgical procedure in which a telescope is placed abdominally through the navel thereby allowing a physician to inspect the pelvic organs.  He/she can identify endometriosis, cysts, adhesions, infection, fibroids etc. that may be causing the infertility.  Unfortunately, only about 25% of cases in women who have a laparoscopy performed will conceive because of treatment performed at the time of the laparoscopy.

Workup Results and Treatment

Treatment can be directed at the cause such as surgery to correct adhesions or remove endometriosis, uterine polyps or fibroids.  Treatment can also be independent of the cause but improve fertility nonetheless.   Ovulation induction increases the number of eggs and therefore the likelihood that an egg will fertilize.  Gonadotropin injections stimulate many more eggs to develop in a cycle than clomid fertility pills.  IVF with minimal or full stimulation is the most successful treatment for any cause of infertility.  The decision as to what treatment to undertake will depend on numerous factors including your age, duration of infertility, cause of infertility, cost of treatment and success of treatment as well as your insurance coverage for the treatment and your motivation to conceive and willingness to accept the risks associated with the treatment.   Today, there is a highly successful treatment available for nearly all women.


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