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Money-Back Fertility Treatment Payment Plans

Money-Back Payment Plans

Money-back fertility treatment payment plans or shared risk plans are payment plans that offer unsuccessful patients a portion of their money back. They usually include two or three fresh IVF cycles followed by the transfer of resulting frozen embryos. Money – back fertility plans commonly include fertility financing programs, fertility medication program and some re-arrange or restrict benefits through employer (sponsor) or insurance plan. All together called the bundle.

Who Qualifies for Money-Back Fertility Treatment Payment Plans?

IVF programs that offer money back plans usually require certain age limits and normal to excellent ovarian reserve markers. Older women and those with low egg reserve usually do not qualify for such plans. Programs also place contingencies on ovarian reserve and transferring more embryos. Hence they exclude women interested in a single embryo transfer.

Some of the money – back fertility enterprise do not operate clinical IVF programs. They offer the financial scheme for payment and in some instances fertility drugs. They refer patients to clinics but do not conduct the treatment. The specifics of the couple may not coincide with the contingencies for money – back arrangement. The result is either you are alert to dismiss the plan or follow the plan and take your chances with the success rate. This is the most disturbing aspect of money-back fertility plans.

The delivery rates after fresh IVF in women commonly included in money back plans is close to 40% with single embryo transfer, 50% with two embryo transfer. Use of frozen embryos add approximately 30% chance for delivery after transfer of frozen embryos from the first fresh IVF cycle. In other words they are the least likely to require multiple cycles in the IVF population. Moreover, they are the most likely to get pregnant with multiple babies. The cost for money back fertility treatment plan is maybe higher than a single fresh IVF cycle and a transfer of frozen embryos. Interest is associated with monthly payment plans. Medicine and multiple treatment cycles are also sometimes bundled. In addition cost can escalate due to obstetric care for multiple pregnancy.

At New York City IVF we educate women and recommend single embryo transfer up to age 38.

One opinion about money back fertility treatment plans is New York State Department of Health Task Force Report: Executive Summary on ART

Payment plans that offer unsuccessful patients a portion of their money back create significant ethical concerns.

Physicians whose payment depends on the success of treatment have an incentive to accept only those patients with a strong chance of success (perhaps patients who do not qualify as infertile under generally accepted standards) and to turn away needy patients whose outcome may be less certain. In addition, when payment is linked to outcome, physicians may encourage patients to accept aggressive treatments that increase the chance of success without due regard for the risk those treatments may entail.

Nonetheless, while the Task Force members are deeply troubled by the risks created by money-back payment plans, they do not believe that these plans are inherently unethical in all cases. Programs that offer money-back payment plans should clearly inform patients of all essential terms of the plan. No plan should require patients to provide a blanket consent to all treatments and procedures recommended by their physician.

Patients enrolled in money-back payment plans should receive a prorated refund if they withdraw from treatment before they have completed all of the cycles covered under the plan. The most appropriate definition of “success” in the context of money-back payment plans is a live birth. The condition of the child should never be a factor in the definition of success

IVF programs can address this ethical question using different arrangement. Reducing fees for the second cycle as opposed to selling multiple cycles together would be one suggestion.

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Male Factor Infertility: Azospermia

Male Factor Infertility: Azospermia

Male Factor Infertility: Azospermia

Male Factor Infertility: Azospermia means no sperm are found in the ejaculate. Azospermia requires careful evaluation and treatment so that the couple has the best chance to conceive with IVF. The evaluation should be methodical and compassionate to guide the couple through such a multifaceted process to pregnancy and delivery of a healthy child.

Four Things Have to Happen at Initial Evaluation for Azospermia

a. Is it truly azospermia? sometimes repeat sperm analysis together with spinning of the ejaculate multiple times may yield few sperm. This has to be performed by a diligent andrologist and in a facility that can freeze sperm immediately if found. In some azospermic men, repeat analysis and freezing can avoid a surgical procedure to retrieve sperm.

b. A genetic cause for azospermia should be excluded. Specifically three known genetic problems should be excluded because they can be passed to offspring and because they can predict the success of surgical sperm retrieval. A chromosome analysis should be done to exclude sex chromosome abnormalities e.g klinefelter Syndrome (47XXY). Y chromosome microdeletion study should be conducted to exclude a deletion of the part of Y chromosome related to sperm production. Cystic fibrosis carrier screening should also be run to detect defect in the CF gene that may be associated with absence of the ducts conducting the sperm outside of the testes.

c. Evaluation of Ovarian Reserve for Female Partner. If ovarian reserve evident by day 3 FSH, AMH levels and antral follicle count seen on vaginal ultrasound is not diminished, this predicts reasonable chance for success with IVF-ICSI if sperm are found. Extremely low ovarian reserve or advanced female age may preclude surgical sperm retrieval, unless an donor eggs are acceptable.

d. Urological evaluation. This has to be the last step in evaluation. Male urologists are the physicians specializing in evaluating the chance for successful sperm retrieval (TESE) as well perform these procedures. Before referral by a reproductive endocrinologist and infertility specialist, there should be every reason to think that if sperm were obtained there is a reasonable chance for conception after IVF-ICSI. The urologist should be a specialist in male reproduction and well versed in the techniques of sperm retrieval. You actually need to ask your urologist two questions: what are my personalized chance for finding sperm when surgery (TESE) is performed? What the technique used to obtain sperm? Authorities generally agree that the technique for TESE markedly affect the chance for finding sperm.

Moreover, every workup should end with an important question; would you accept donor sperm if no sperm were obtained after surgery?

 How is TESE Performed?

Testes and ducts

Testes and ducts

Testicular sperm extraction is a surgical procedure that entails sampling of multiple areas of the testes aiming at finding sperm to be used for IVF-ICSI. The tested is delivered outside the scrotum, bisected and multiple biopsies obtained from several areas of the testes. The tissue is examined for the presence of sperm. If no sperm were found, more biopsies are obtained till sperm are found. There are generally two types of azospermia: obstructive azospermia (due to obstruction of the ducts of the testes while sperm production is intact). Sperm is obtained in close to 100% of these cases. Non-obstructive azospermia (NOA) where is a defect in sperm production, approximately 60 to 70% of the procedures yield sperm.

Blind biopsy from one area of the testes has no place in modern treatment of azospermia. Asking your urologist about the technique of TESE is of paramount importance. The first surgical attempt carries the highest chance for success.

Recently, Doppler ultrasound mapping of the testes can help localize the areas of that should be biopsies because they yield a higher chance for finding sperm.

Why is IVF-ICSI Required after Sperm Retrieval?

The number of sperm obtained after TESE is small in the magnitude of tens to hundreds of sperm, too small to use the sperm for IUI. ICSI is absolutely required for all cases of surgical retrieval of sperm. The sperm can be used in one of two ways

a. Frozen TESE sperm: The sperm are frozen to be thawed at a later date, on the day of egg retrieval for the female partner. This method saves the cost of IVF if no sperm were retrieved and donor sperm use is unacceptable.

b. Fresh TESE sperm: Ovarian stimulation is started and TESE is performed on the day of egg retrieval or the day before. Fresh sperm are used for ICSI. Donor sperm (if acceptable) is obtained as a backup. Though suggested, there no concrete evidence that fresh TESE sperm is superior to frozen TESE sperm.

In addition in some caes with associated genetic problems, preimplantation genetic diagnosis (PGD) can be performed followed by the transfer of normal embryos.

Can the Chance for Pregnancy be predicted in Male Factor Infertility: Azospermia ?

There are several predictive factors for pregnancy in female partners of men with azospermia. These can be categorized into:

i. Successful sperm retrieval is related to whether the procedure is the first one or a repeat procedure, the volume of the testes, medical treatment before surgery, the technique used and the cause for azospermia. Some causes are associated to minimal chance for obtaining sperm.

ii. Pregnancy after sperm retrieval is related to the female partner age and her ovarian reserve. Younger women have a very good chance of conceiving if sperm are obtained. This is the most important factor once sperm are retrieved.

iii. Obstructive azospermia has a higher chance for sperm retrieval than non-obstructive azospermia.

iv. Moving sperm at the time of ICSI has a higher chance to yield a pregnancy than non moving sperm

v. Men with higher testosterone levels and lower LH levels has higher chance of sperm retrieval

vi. The effect of using of frozen TESE sperm is controversial. Some authorities think that using a fresh TESE sperm is better than frozen sperm.

vii. Use of Doppler: recent work indicates that the use of Doppler study of the testes before the procedure may help localize the areas that should be biopsies and yield a higher chance for sperm harvest.

Male Factor Infertility: Azospermia requires a multidisciplinary approach; first consultation with a reproductive endocrinologist (female age is still the most important factor) followed by a consultation with a reproductive urologist for the TESE procedure for successful sperm harvest and pregnancy

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Endometriosis will not Lower IVF Success

Endometriosis will not Lower IVF Success

Endometriosis will not Lower IVF Success

Effects of endometriosis on fertility treatment success has always been a controversy. When a woman is diagnosed with endometriosis, she receives multiple contradicting advises from multiple sources. It is very difficult for women to sort through these recommendations and pick the one that are suitable for her symptoms and reproductive plans. Indeed reproductive plans and symptoms are by far more important than the nature of the problem, anatomically, as well as what one reproductive surgeon or a fertility specialist think you should do.

Reproductive Plans in women diagnosed with endometriosis

Simply do you want to fave a baby or did you complete your family?. If you want to have a baby, then an initial infertility evaluation is required: testing for ovulation, ovarian reserve, male factor and Fallopian tube patency is required. Sometimes other forms of pelvic imaging e.g MRI is needed to test for ovarian cysts or endometriomas…Endometriosis itself may require laparoscopy and biopsy for accurate diagnosis.

Women are then categorized according to findings: endometriosis only, endometriosis with other factor or endometriosis with low egg reserve. That will facilitate further advice.

One very important indicator that you are not talking to the right person if he or she did not complete the evaluation for male factor and egg reserve. These are essential tenets of fertility and failure to test them will have impact on success. It would be absurd to do surgery for endometriosis for example to discover later that you have a severe male factor that require IVF -ICSI.

If you desire future fertility, reproductive endocrinologists should taylor their advice to preserve reproductive tissues and minimize surgery. There is a strong evidence that surgery in the ovary reduces ovarian reserve, irrespective of technique used.

Pain in women diagnosed with endometriosis

If the main symptom is pain, in different forms, then medical or surgical treatment can be employed. in women who completed their families. Medical treatment e.g non cyclic oral contraceptive pills of GnRH agonists (depot lupron) prevent pregnancy. From a practical stand point, surgery im many cases may not promote pregnancy in women with with mild and severe endometriosis.

Women diagnosed with endometriosis and report pelvic pain should focus on getting pregnant. Pregnancy can suppress endometriosis for a long time after delivery

Fertility Treatment in Women Diagnosed with Endometriosis

Absolutely avoid doing surgery in the ovaries in women interested in pregnancy. This is crucial. Opening endometriomas and tripping their walls leads to significant loss of egg reserve. The only indication to remove endometriomas if they are complicated e.g rupture or suspicion of malignancy. There are many reports of finding eggs in the wall of endometriomas after removal and reduction in egg reserve markers after surgery. Bilateral surgery for endometioma can lead to menopause, irrespective of the skill of the surgeon.

In minimal and mild endometriosis with reasonable egg reserve, normal sperm analysis and open fallopian tubes, ovarian stimulation and IUI can be entertained in young women (38 years).

In women with moderate or severe endometriosis e.g endometriomas, blocked tubes.. or those with associated male factor infertility or low egg reserve, IVF yields a much higher pregnancy rate.

IVF Success in Women with Endometriosis

Recent analysis of IVF cycles performed in women with endometriosis with or without other factors (tubal, male, unexplained infertility) indicates that

Isolated endometriosis is associated with similar IVF success and live birth to other infertility factors, though the number of eggs retrieved may be smaller.

Endometriosis when associated with other factors e.g male or tubal factor may have lower success rates. The live birth rate is still excellent 35 to 45% per cycle.

Endometriosis-and-IVF

Treatment of Endometriosis related pain

Both medical treatment and surgery are effective for treatment of pain. Endometriomas do not respond to medical treatment. Endometriosis on the peitoneum and and other organs respond to medical and surgical treatment. Adenomyosis (endometriosis of the uterus) is a surgical disease and respond only to surgery.

In general medical treatment is successful but requires patience and can be used for a longer period of time with add back therapy.

If you are diagnosed with endometriosis there is wide range of treatment options. Treatment should be  personalized to your reproductive goals and symptoms not to physician expertise and bias. There is really little controversy about what need to be done in each situation. Women just need to be specific about what they want: get rid of pain or have another baby. IVF success is not impaired in women with endometriosis.

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Hepatitis B: what do you need to know if trying to conceive

Hepatitis B: what do you need to know if trying to conceive

Hepatitis B: what do you need to know if trying to conceive

Hepatitis B is relatively common in the US and worldwide. There are approximately one million individuals living in the US with chronic hepatitis B. According to the CDC, the highest rate of infection occurs among those 20 to 49 years old. Approximately 5% to 10% of adults and children older than age 5 with hepatitis B infection go on to develop chronic infection. Globally, 350 million individuals live with chronic hepatitis B infection, according to WHO and other sources. One third of those infected reside in China (乙型肝炎). It is more common in Asia, Saharan Africa and some areas in South America. Migration and medical tourism may increase the magnitude of hepatitis B problem in the US. In Asian countries the prevalence is slightly higher in men and is about 10% of adult population. Universal vaccination of all infants at birth and vaccination of at risk individuals e.g type I and II diabetes, sex partners of hepatitis B infected individuals, men who have sex with men, travelers to high risk areas, can prevent transmission of hepatitis B.

Reproductive endocrinologists and fertility specialists are responsible for detection of hepatitis B in partners and prevent the transmission of hepatitis to non infected partner and newborn. Women and men are tested for hepatitis B at the time of initial fertility consultation. Abnormal results are interpreted and measures are taken to avoid transmission to others, during natural conception and with the use of assisted reproduction (IVF).

Hepatitis B Discordant Couples Discovered Prior to Fertility Treatment

One of the major means of transmission of hepatitis B is sexual intercourse. At initial consultation if one partner is hepatitis B Surface antigen positive (HBsAg) indicating chronic infection, vaccination of the other partner will most likely prevent the transmission of hepatitis B during attempts of natural conception and fertility treatment. The vaccine is administered three times at 0, one month and 6 months. High levels of Hepatitis B surface antibody (anti-HBs) indicates immunity.

During fertility treatment, when the male partner is infected and female partner is not, modification of sperm washing techniques minimize the risk of hepatitis B transmission. These include separation of sperm from seminal fluid and then testing of the sperm for hepatitis B before use IUI or intracytoplasmic sperm injection (ICSI). The use of ICSI may reduce but not eliminate the transmission of hepatitis B virus (controversial).

Prevention of Hepatitis B transmission from Egg Donors

Egg donors are initially screened through careful history to exclude those exposed to risk factors, then a complete physical examination. They are also initially screened for viral infections including hepatitis B. Within one month of egg retrieval, donors are retested using conventional labs as well as DNA based testing for hepatitis B (and hepatitis C and HIV) to further minimize the risk of transmission.

Prevention of Hepatitis B transmission from Sperm Donors

Sperm donors undergo a careful questionnaire related to risk factor, followed by examination and laboratory screening. Sperm is obtained and frozen and quarantined. Donors are then retested using FDA approved laboratories to further minimize the risk of transmission of infectious diseases including hepatitis B.

Prevention of Hepatitis B transmission to Gestational Carriers

Male and female partners (intended parents) are tested in a manner similar to sperm and egg donors. If testing was not possible, the carrier is carefully counseled that FDA mandated testing is not followed. In case of a hepatitis B carrier partner, the carrier is vaccinated prior to transfer of embryos.

Low Temperature Storage of Cells & Tissue from a Hepatitis B infected individual

There were few reported cases of transmission of hapatitis B from frozen tissue. Those cases did not involve sperm, eggs or embryos. As a precaution, reproductive cells from infected individuals are frozen in separate tanks than those not infected. More recently, the use of closed systems that do not allow cells to touch liquid nitrogen in the tank, the use of nitrogen vapor instead of liquid and the sterilization of nitrogen using ultraviolet rays can further minimize the risk of transmission.

Hepatitis B Discovered During Pregnancy

A hepatitis B infected mother have a small risk of transmission of the virus to the fetus during pregnancy. The risk of transmission, however, is significant at the time of delivery.Sometimes medical treatment of mothers is indicated with anti-viral medications to minimize this risk after consultation with a maternal and fetal medicine specialist.

All newborn to a hepatitis B infected mother should receive at birth

i. Hepatitis B immune globulin (HBIG) to neutralize a virus acquired from the mother and ii. Hepatitis B Vaccine to produce long term immunity.

Careful screening of intimate partners, egg and sperm donors can markedly reduce the chance of hepatitis B transmission during natural conception and IVF.

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Congenital Anomalies of the Uterus: septum

Congenital Anomalies of the Uterus: septum

Congenital Anomalies of the Uterus: septum

Congenital Anomalies of the Uterus: septum: A uterine septum is a vertical separation in the middle of the uterus dividing the cavity into two: right and left. The septum may be partial or could extend all the way through the cervix or even to a varying distance into the vagina.

Uterine Septum and congenital uterine anomalies

Uterine Septum and congenital uterine anomalies

Many of these separations are unnoticed. Septa may be discovered accidentally e.g during a hysterosalpingogram (HSG) done to investigate infertility. The role of a reproductive endocrinologist is to a. confirm the diagnosis of a septum and differentiate it from other conditions that make the uterus appear as double; bicornuate uterus and uterus didelphys and b. to counsel the couple about the possible effects of the septum on reproduction and indication for corrective surgery of the uterus

Diagnosis of Uterine Spetum

After clinical exam to inspect the cervix, HSG can visualize the duplication of the uterus but cannot accurately differentiate a septum from two separate uterine horns. MRI and 3D ultrasound can accurately characterize the abnormality.

Effects of Uterine Septum on Reproduction

A septum is not a proven cause for infertility. In fact the majority of women with uterine septum are without symptoms. Some women with a septum manifest with recurrent first trimester pregnancy loss or less commonly late (second trimester) pregnancy loss and preterm labor.

It is unpredictable who will carry a pregnancy to term and who will have a pregnancy loss. Because the outcome cannot be predicted, the majority of reproductive endocrinologists

recommend resection of the septum to unify the uterine cavity. This is especially the case after this

Hysteroscopic Resection of Uterine Septum Completed

Hysteroscopic Resection of Uterine Septum Completed

surgery can be accomplished with minimal access hysteroscopic surgery. An operative hysteroscope is introduced into the uterus and a micro scissors or an electric loop is used to cut the septum.

There is some evidence that resection of a septum may reduce the chance for pregnancy loss.

 

Accurate diagnosis of uterine septum is essential before discussing the possible reproductive consequences and method of correction.

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Ovarian stimulation protocols for Low Responders prior to IVF

Ovarian stimulation protocols for Low Responders prior to IVF

 

Ovarian stimulation protocols for Low Responders prior to IVF

Flare lupron protocol with luteal priming (synchronization) for Low Responders prior to IVF

 

Ovarian Stimulation Protocols for Low Responders prior to IVF

Low response to controlled ovarian stimulation represent a significant fraction of IVF population presenting for fertility treatment. Low responders may represent 30% or more of women seeking IVF. The proportion may be larger in some areas due to delay in childbearing as a lifestyle choice. Low response to ovarian stimulation is commonly defined as producing 5 eggs or less after stimulation. While may factors may contribute to low response e.g smoking, prior surgery of the ovary, exposure to chemotherapy, the vast majority of are age related. Sometimes low response happens in younger women e.g 30 year old. Young low responders has a better chance of conceiving because their eggs, though few, are healthier (chromosomally normal) than older e.g >38 low responders.

Few strategies can increase egg yield and possibly egg quality in low responders,  usually employing one or a combination of

i. increasing the dose of gonadotropins,

ii. avoiding long lupron suppression before start of stimulation,

iii. adding an oral agent (clomid or letrozole),

iv. synchronizing follicles prior to start injections,

v. using androgen prior to cycle start and sometimes

vi. adding growth hormone.

There is no clear evidence to one protocol over the other. Increasing the dose above a total of 450 units per day does not seem to further increase egg yield in low responders. Some patients respond to one ovarian stimulation protocol over another. One example of low responder protocol is illustrated above. Estradiol and antagonist are used to synchronize the follicles before menses so that they are uniform in growth when stimulation starts. Short lupron is used (flare or microflare) to induce the release of internal gonadotropins. This is followed two days later by high dose of fertility medication (total 450 units per day).

There is some evidence that pre-treatment with androgens (testosterone) may improve egg yield. The evidence for the use of DHEA (dehydroepiandrosterone) is limited. There is also week evidence that the use of growth hormone may improve egg quality.

Embryological procedures are also sometimes suggested as ICSI of all available eggs to maximize fertilization and assisted hatching of the egg shell (zona pellucida). Pre-implantation genetic screening is unlikely to be helpful as few embryos are available for testing.

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Fertility Treatments You Should Avoid

Fertility Treatments You Should Avoid

Which Fertility Treatments You Should Avoid?

Infertility is defined as inability to conceive after one year (6 months in women >35 years) of regular unprotected intercourse (no contraception) and in the absence of any known cause for infertility. Earlier referral is recommended in

  1. older women 35 years or more,
  2. unable to have intercourse (e.g erectile dysfunction..),
  3. genetic (e.g cystic fibrosis carrier), medical or pregnancy related risk factor (e.g systemic lupus, hepatitis C, HIV, hepatitis B… ),
  4. if a fertility factor is suspected (no ovulation,PCOS, hypothalamic amenorrhea, male factor, endometriosis, tubal disease..) or
  5. if fertility preservation is desired following cancer diagnosis.

Evidence is accumulating of the most effective fertility treatments after fertility assessment. Many fertility treatments are offered indiscriminately, they have little chance of succeeding or are risky (ovarian hyperstimulation syndrome, multiple pregnancy). In general simple logic does not determine if a treatment is effective or not. It is only through well conducted studies we can prove the efficacy of such a treatment. Moreover, considering the final outcome- a live healthy newborn- should be the one to look for in such a study.

The following is not a medical advice, but a review of recent evidence related to fertility treatment options. You should discuss treatment with your fertility specialist. It is possible that sometimes these treatments are indicated for fertility treatment in special circumstances. Fertility treatments you should avoid may include:

You should not time your ovulation

If you have access to intercourse with a male partner every other day, timing ovulation using any method, does not increase your chance for natural conception. If you have intercourse twice or more a week you have excellent chance of conceiving within one year. Studies evaluating timed intercourse using basal body temperature charts, urine LH kits, cervical mucus, failed to show improvement in pregnancy rate beyond intercourse every other day. No evidence that fertility apps improve the chance for conception.

Age category (years) Pregnant after 1 year (12 cycles) (%) Pregnant after 2 years (24 cycles) (%)
19–26 92 98
27–29 87 95
30–34 86 94
35–39 82 90

Use letrozole instead of clomid for ovulation induction in PCOS

There is high quality evidence that letrozole (aromatase inhibitor) is superior to clomid for induction of ovulation in women with PCOS and yeilds higher pregnancy rates. 750 infertile women with a diagnosis of PCOS, aged of 18-39 years, were enrolled: 376 patients were assigned to receive clomiphene 50 mg/day and 374 were assigned to receive letrozole 2.5 mg/day in doses escalating to 7.5 mg/day for a total of 5 days per cycle for up to five cycles. The drugs were provided in identical capsules over the same schedule. Ovulation rates with letrozole were significantly superior to clomiphene. Monthly chance for pregnancy and for a live birth was 30% higher in the letrozole group.

Avoid undergoing clomid or letrozole cycles without ultrasound monitoring

Although twins and higher order multiple pregnancies are not as common as in gonadotropin (injection medications) use [8% versus 30%] clomid is probably responsible for more twins than any other treatment because of its widespread use. Do not undergo ovulation induction without ultrasound monitoring to evaluate response and the number of follicles developing. Consider cycle cancellation if many follicles appear in the ovary.

Metformin alone is inferior to clomid in induction of ovulation and improving fertility

There is strong evidence that clomid is superior to metformin in ovulation induction in women diagnosed with PCOS. Letrozole or clomid are the medications of choice for induction of ovulation, not metformin. There is also no strong evidence that metformin reduces the chance for miscarriage.

Do not use oral medications for unexplained infertility

Unexplained (idiopathic) infertility is diagnosed in women who failed to conceive with regular ovulation, patent fallopian tubes and near normal patent sperm analysis. Women with unexplained infertility, mild male factor or minimal endometriosis do not conceive mostly because of chromosomal abnormalities of the egg. Ovarian stimulation using oral medications usually yields one or two eggs (close to natural cycles) while using injection medications can produce more eggs thus increasing the chance that one of them is healthy. There is no evidence that oral medications increase the odds of pregnancy in women with UEI.

Avoid gonadotropins-IUI and proceed directly to IVF

In women receiving oral medications (clomid)-IUI proceeding directly to IVF or proceeding immediately to IVF as first line treatment and avoiding injection medication-IUI is more successful in achieving pregnancy, is faster and minimizes the risk of multiple pregnancy.

The FASTT trial randomized 247 couples to receive three cycles of clomiphene citrate (CC)/IUI then three cycles of FSH/IUI and then up to six cycles of IVF versus 256 couples to an accelerated treatment, that omitted the three cycles of FSH/IUI. An increased rate of pregnancy was observed in the accelerated arm and pregnancy was achieved 3 months faster. Per cycle pregnancy rates for CC/IUI, FSH/IUI, and IVF were 7.6%, 9.8%, and 30.7%, respectively. The observed incremental difference was a savings of $2,624 per couple for accelerated treatment. The study demonstrated that FSH/IUI treatment was of no added value.

The FORT-T  trial randomized couples with ≥6 months of unexplained infertility with female partner aged 38-42 years to treatment with two cycles of clomiphene citrate (CC) and intrauterine insemination (IUI), follicle stimulating hormone (FSH)/IUI, or immediate IVF, followed by IVF if not pregnant. The cumulative clinical pregnancy rates per couple after the first two cycles of CC-IUI, FSH-IUI, or immediate IVF were 21.6%, 17.3%, and 49.0%, respectively. The majority (84%) of live-born infants resulting from treatment were achieved via IVF. Immediate IVF demonstrated superior pregnancy rates with fewer treatment cycles in the immediate IVF group.

Avoid using DHEA, GH or aspirin as adjuvants to IVF

There is no conclusive evidence that pretreatment, prior to IVF, with dehydroepiandrosterone (DHEA), growth hormone (GH) or other medications improves the pregnancy rate r live birth rates.

Avoid transferring two or more embryos when feasible

Multiple pregnancy carries an higher risk to the mother and to the health and neurological functions of the newborn. Outcomes in twins are definitely inferior to singleton babies. Women <38 years with a good quality embryo in there first or second IVF cycles should consider single embryo transfer. In the third cycle consider double embryo transfer.

Avoid routine use of pre-implantation genetic screening to improve the pregnancy rate after IVF

Chromosome analysis of embryos is available. There is no conclusive evidence that PGD will increase the chance for a live newborn. PGD will definitely not make the embryos healthy. If accurate, it will just enable finding the healthy embryo faster but the total number of healthy embryos, if any, will remain the same per completed IVF cycle. The accuracy of the test is no 100%, it is costly and require taking one or few cells from each embryo. Young women with good ovarian reserve have excellent pregnancy rate even with single embryo transfer. Moreover embryo freeze-thaw cycles yield comparable outcomes to fresh IVF cycles. Older women and women with low egg reserve produce a small number of embryos, which means that testing is not an efficient approach. PGD may have some role in older women e.g.>40 years producing a large number of embryos e.g >6 embryos. These women are the outliers.

Avoid using a physician with no experience in managing fertility problems

This will likely cause delay, reduce success and may increase complications. If you seek a specialist care, avoid any treatment that you do not understand its rationale. The choices are usually expectant treatment (regular intercourse), ovarian stimulation-IUI or IVF. Know the expected success rate and multiple pregnancy rate for each option offered to you by a reproductive endocrinologist.

Fertility Treatment Men Should Avoid

  1. Avoid treating abnormal sperm parameters with oral or injection medications or supplements. No such treatment was demonstrated to improve the chance for a live born in female partner.
  2. Avoid surgery for varicocele even if sperm parameters are abnormal. Surgery for varicocele is a treatment that was not proven to increase the odds of live born in female partner.

 

To lean more about fertility treatments please visit nycivf.org

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How to Avoid Conceiving a Baby with Cystic Fibrosis

How to Avoid Conceiving a Baby with Cystic Fibrosis

Cystic Fibrosis is a recessive genetic disease that affects a child mostly because he or she inherited two abnormal copies of the gene, one from the father and one from the mother. If both the mother and father are carriers, there are 1 in 4 chances for the baby to be affected. The odds of carrying a mutation are variable and are approximately 1 in 29 in Caucasian populations.

Autosomal Recessive Inheritance

Autosomal Recessive Inheritance

Prior to conceiving a baby, one of the partners can be tested for common cystic fibrosis mutation, using a simple blood test. If one partner is a carrier the other partner is tested. One partner does not carry CF gene mutation: no need to test the other partner and the risk of CF transmission to the baby is very low.

Both partners carry CF gene mutation: the risk of CF transmission to the baby is 25%. In this case the couple can consider IVF with preimplantation genetic diagnosis (PGD) for the specific mutation. Embryos that do not carry the mutation are transferred to the uterus, avoiding the disease.

Consulting with a reproductive endocrinologist can identify the risk and prevent the transmission of cystic fibrosis to your baby.It is a recessive genetic disease that affects a child mostly because he or she inherited two abnormal copies of the gene, one from the father and one from the mother. If both the mother and father are carriers, there are 1 in 4 chances for the baby to be affected. The odds of carrying a mutation are variable and are approximately 1 in 29 in Caucasian populations.

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