Category Archives: What’s New
Zika virus exposure and its complications continue to be an evolving area of patient care and clinical practice. Given this situation, we highly recommend going to the CDC website directly http://www.cdc.gov/zika/ and checking it periodically for the most up to date recommendations and travel restrictions.
Avoiding exposure is best. Since Zika virus can also be transmitted through sexual contact, it is important that both you and your partner protect yourselves from mosquito bites. Thus if you are presently trying to conceive, it is best to avoid traveling to areas of active mosquito-born Zika transmission. If you live in an area of active mosquito-born Zika transmission or are traveling to these areas, then we recommend taking all precautions to avoid mosquito bites. The following protective measures should be practiced, both day and night, including:
- The use of EPA-approved bug spray with at least 25% DEET*, can apply every 8 hours
- Covering exposed skin
- Staying in air-conditioned or screened-in areas
- Treating clothing with permethrin*
* When used as directed on the product label, these products can be used safely during pregnancy. Reapplication of insect repellant should be practiced as directed on the product label.
More information about preventing mosquito bites can be found at the CDC website: http://www.cdc.gov/zika/prevention/prevent-mosquito-bites.html
More information about areas with active mosquito-born Zika transmission can be found at the CDC website: http://www.cdc.gov/zika/geo/index.html
Over the last three years IVIGen Corporation, a reproductive medicine laboratory headquarterd in Valencia, Spain has been researching endometrial receptivity. Their work has led to a major breakthrough in the area of reproductive medicine, i.e., dispelling the notion that all women’s uterine lining respond to hormone replacement therapy the same way. The IVIGen physicians and scientists have studied patients who have had at least three failed IVF transfers of good quality embryos, i.e., individuals who you would expect to have a very high chance of pregnancy. These investigators have identified over 300 genes that are involved in making the uterus receptive. Their data indicate that approximately 26% of these failed patients have endometrial linings that are out of phase, meaning they are either resistant or hyperresponsive to progesterone. When these out of phase individuals are treated with additional or fewer days of progesterone they get pregnant at expected high rates. The status of being resistant or hyperresponsive seems to be consistent for periods up to two years. At the Florida Institute for Reproductive Medicine we are offering endometrial receptivity assay assessment. A mock cycle of estrogen preparation followed by progesterone is given at which time an endometrial biopsy is performed. Results of the biopsy are available approximately ten days later. Biopsies are interpreted as either receptive, meaning no problem with the standard preparation of the lining or non-receptive either resistant or hyperresponsive. Following correction of a non-receptive lining another mock cycle documenting a corrected window is recommended. Cost to perform the endometrial biopsy including IVIGen Lab interpretation and shipment is approximately $1,200. If there are other causes for an abnormal uterine lining, i.e., fluid in the cavity, a thin lining, polyps, fibroids or adhesions these factors need to be corrected prior to performing the assay. At the Florida Institute for Reproductive Medicine we believe an endometrial receptivity assay should be performed on any individual who has had two or more failed transfers of good quality embryos. We believe the endometrial assay is a major step forward in explaining why at least 26% of individuals may not be getting pregnant. If you feel you may be a candidate for endometrial receptivity assessment, please contact one of our physicians to discuss this in detail.
Kevin L. Winslow, M.D.
In an effort to continually improve our IVF program, patients going through IVF were asked following their embryo transfer (prior to their pregnancy test) to grade on a scale of 1-4 (1 strongly disagree, 2 disagree, 3 agree and 4 strongly agree) ten different aspects of their IVF experience. In addition patients were encouraged to make recommendations to improve the program as well as any other comments they wished. Patients were given the choice to participate or not, to sign their name or not and to post their survey on the internet. Patients were left alone in the transfer room to either fill out their survey or to leave. No patient declined to fill out their survey. Nine patients chose not to sign their surveys. One hundred and eleven (63%) patients agreed to post their survey on the internet. Forty-seven (27%) patients did not indicate a preference to post and were not uploaded. Eighteen (10%) patients indicated they preferred their reviews not to be posted. Of the 111 patients who agreed to post their surveys, the average score was 3.9. Of the 47 patients who did not indicate a preference to post, the average score was 3.9. Of the 18 patients who indicated they did not want their survey posted, the average score was 3.8. Actual copies of the surveys are included so that you may review the actual questions as well as all recommendations and comments.
We thank all of our patients for participating in this survey we will continue to make every effort to improve our IVF experience.
Click thumbnails below to enlarge the reviews
Couples going through in vitro fertilization frequently have additional embryos that are cryopreserved. The majority of couples end up using these embryos for a second or third pregnancy. Approximately 10% of couples will not use their cryopreserved embryos. At the Florida Institute for Reproductive Medicine we strongly encourage these couples to consider embryo donation. For many infertile patients embryo donation is the ideal answer to their dreams of becoming parents. It is a relatively simple and inexpensive option. With embryos from over 50 couples the Florida Institute for Reproductive Medicine has one of the largest donor embryo programs in the country. We have embryos from Caucasian, African American and Hispanic couples. Couples interested in embryo donation can make an initial phone consultation with one of our board certified reproductive medicine specialists (904-399-5620 or www.firmjax.com).
The purpose of this consult is to determine whether embryo donation is an appropriate treatment option. Following this consultation couples will have a follow up consultation with our donor embryo IVF nurse coordinator to review donor embryos. The program is totally anonymous, i.e., the donating couple does not know who the adopting couple are and vice versa. The adopting couple may ask anything they wish regarding medical history, age, infectious disease screening of the donating couple to help make their decision. The female partner prior to undergoing embryo transfer will be asked to have a sonohysterosalpingogram to rule out any significant uterine pathology. This study can be done by the patient’s local ob/gyn or a reproductive medicine specialist.
Preparation for donor embryo transfer is relatively simple – the female is treated initially with estrogen either orally or by patch, on day 13 of estrogen she will have an ultrasound to assess uterine thickness (this can be performed by the patient’s local physician). As long as her lining has thickened appropriately she will begin progesterone. Progesterone can be given either vaginally or IM. Transfer will occur 3-5 days later depending on the age of the embryos. The female partner will travel to the Florida Institute for Reproductive Medicine in Jacksonville for embryo transfer (a relatively pain free procedure). Once the transfer is performed the patient can travel back to her home that same day.
A pregnancy test will be checked 11-13 days later. If the patient is pregnant she will continue on estrogen and progesterone through eleven weeks. She will have a pregnancy ultrasound two weeks after her pregnancy test. If the patient is not pregnant she will stop hormone therapy and can expect a period within 3-5 days. Pregnancy rates with the donor embryo program are primarily determined by the age of the mother producing the embryos, as well as the number and quality of day three and day five embryos transferred. With embryos from a female less than 35 years of age with two, day five embryos pregnancy rates of 50-60% are typical. Of those individuals who are pregnant 30-40% will have a twin pregnancy. In general no more than two, day five embryos or three, day three embryos are transferred at any time to minimize the risk of triplets and high order multiples.
The cost for the embryo donation program is typically around $4,000.00. If the adopting couple or treating physician feel additional screening of the donating couple or adopting couple are indicated additional costs may be incurred.
FREEZING EGGS NO LONGER EXPERIMENTAL
63 Babies Born – Florida Institute for Reproductive Medicine
The American Society of Reproductive Medicine recently removed the label “experimental” in describing egg freezing. To date over 4000 babies have been born from frozen eggs, health data on these babies has been extremely reassuring. Pregnancy rates using cryo eggs have continued to improve now approaching those from frozen embryos. Egg freezing offers tremendous advantages to at least three groups of women: those faced with losing their fertility due to cancer treatment or surgery, women who for whatever reason must postpone childbearing late into their 30s or beyond, and patients requiring in vitro fertilization who are ethically opposed to freezing embryos. While ASRM has not endorsed the use of egg freezing for delayed childbearing, we at the Florida Institute for Reproductive Medicine feel it is an appropriate option for those who otherwise would have little chance of having their own genetic children later in life. At the Florida Institute for Reproductive Medicine, Dr. Yang has pioneered the technology of oocyte cryopreservation, we have had one of the largest experiences in the United States with sixty-three babies born, including the first baby born in the world to a cancer patient who froze her eggs. Again our follow up health data on these babies has been reassuring. I do advise couples that the ultimate health testament will be when children born from frozen eggs have had their own healthy children. We hope by lifting the label of experimental, insurance companies will consider covering egg preservation for at least those women faced with sterilizing. The technique of egg freezing involves going through an IVF cycle, costs are almost identical, approximately $10,000.00 to $12,000.00 depending on the amount of medicine used. The Florida Institute for Reproductive Medicine has participated with a national group, Fertile Hope, in providing significantly discounted costs for egg freezing for cancer patients. Ferring pharmaceuticals has been extremely generous in donating medications saving patients as much as $3,500.00. We welcome ASRM’s recent opinion on egg freezing and hope many other women will be able to avail themselves of this remarkable technology.
Don’t be misled by statements reporting we have the largest IVF, donor egg IVF or gestational surrogate IVF program. The truth is that what is often being represented is far from what you’re probably interested in. Ask specific pointed questions, i.e. how many IVF pregnancies have come from your current lab, not another lab or program that you may have participated in the past. Ask what the take-home pregnancy rate is, be careful to also ask how many total IVF cycles have been performed to get an idea of the programs experience. Ask for official CDC pregnancy results in writing (http://www.cdc.gov/art/). Ask who the lab director is, is the director a doctoral level embryologist? Has the director obtained the certification of highly complex lab director? Has the director been involved in any original reproductive medicine research? At the Florida Institute for Reproductive Medicine we have had over 4,000 babies born from our IVF program over the last twenty years. Our pregnancy rates have consistently been in the top ten percentile nationwide. We have accounted for 87% of all IVF pregnancies, 83% of all donor egg IVF pregnancies and 99% of all pregnancies from cryo eggs over the last ten years in the North Florida/South Georgia area. Our embryology team consists of three doctoral and one master’s level embryologists, headed by Dr. Yang. Dr. Yang has over twenty years of embryology experience; he holds the certification of highly complex lab director. Dr. Yang is world renowned for his original research regarding intracytoplasmic sperm injection/IVF, as well as his work on egg freezing.
We are pleased to announce Florida Institute for Reproductive Medicine is now one of a select group of IVF programs in the nation now offering Day 5 Laser Embryo Biopsy. This technology allows for the laser extraction of multiple cells from a day 5 embryo to test for genetic normalcy prior to transfer. Prior day 3 embryo biopsies where only one or two cells were available for testing has been shown not only to be inaccurate, but to compromise implantation rates. Day 5 embryo biopsy has tremendous implications in terms of avoiding multiple births, i.e. with accurate pre-embryo genetic screening ongoing pregnancy rates of 60-70% have been reported with a transfer of a single chromosomally normal embryo. Because the majority of pregnancy losses are due to chromosomally abnormal embryos, this technology is expected to significantly reduce miscarriage rates. The cost for this service will range from $2,500.00 to $3,000.00 depending on the number of embryos biopsied. We expect these costs to be recouped by avoiding freezing and transfer of abnormal embryos. By avoiding multiple births with their inherent risks and costs, we have eliminated the greatest problem associated with IVF. If you are interested in learning more about this technology, please make a consult appointment with one of our physicians.
For women who wish to have a tubal reversal, we offer state of the art Robotic Assisted Microsurgical tubal reversal using the most advanced surgical tools available today, and are able to still do this at a very affordable cost. Without question, having a tubal reversal performed laparoscopically is associated with a much faster recovery, less pain, and less internal scarring, limiting the chance of damaging the fragile fallopian tubes. However few surgeons are can do this procedure laparoscopically, and for those that do, because of the limitation of standard laparoscopy, sacrifices have to be made in the surgical technique compared to the older standard of having an open incision and using a surgical microscope.
By using the da Vinci Robotic system, we are able to provide you with the best of both worlds, performing a true microsurgical tubal reversal technique, while doing this as an outpatient procedure with a fast recovery and less chance of internal scarring that can affect the newly opened tubes.
How is a tubal reversal performed?
There are three methods by which a tubal reversal can be performed. These include the old-fashioned “open” method, standard laparoscopy, and Robotic Assisted Microsurgical techniques. In the past, patients who underwent the “open” method had a 3-4” incision in their lower abdomen to reach the uterus and tubes. Microscopes were then used to open the tubes and sew them back together. This method allowed precise surgery to be performed, but by using an open incision, patients had a much longer recovery, usually requiring a week or more from work. The open incision also inherently causes scar tissue, which we just hoped did not affect the tubes. Through laparoscopy, patient recovery is much faster, and less scarring inside occurs. The drawback of this procedure is that due to limitations in the instruments, even the best surgeons cannot perform as precise of a tube repair as they could previously do under a microscope by hand. This could possibly sacrifice the success of the surgery. With the use of the da Vinci Robotic surgical system, the best of both worlds are combined, allowing a true microsurgical repair to be done, with a quick recovery and low chance of forming internal scar tissue. Typically one small incision in the belly button (10mm wide), and three other small incisions (7mm wide) are made. This procedure is by far the best for the patient, providing several advantages to ensure that you have the best possible outcome
Who is a good candidate for a tubal reversal?
Tubal reversal success is dependent on the method in which the tubal was first performed. The highest success comes with those that have had “clips” or “rings” placed on the tubes. These methods damage the tubes the least. In some cases, a segment of tube is removed, most commonly done right after a delivery. These methods are termed a “Pomeroy” or “Parkland” method, and in most cases are reversible. Tubes that have been “burned” are often overly damaged and may not be reversible, though each case is different. It is helpful to obtain a copy of the surgical operative report to better determine if a tubal reversal could be performed
Fertility is very dependent on the age of the woman. A tubal reversal is most successful if a woman is 35 years of age or less. For women who are over 37 years of age, studies have shown that a tubal reversal may not be the most cost effective therapy for trying to conceive. These patients are better suited to go directly to IVF.
Is a tubal reversal covered by insurance?
In nearly all cases, insurance does not cover reversal of sterilization. Performing a tubal reversal and trying to get insurance to cover the costs is considered insurance fraud and puts the patient and physician at legal risk.
Why don’t you perform this at an outpatient surgery center?
We only perform Robotic Assisted Microsurgical Tubal Reversals at an accredited fully staffed hospital. Freestanding outpatient surgical centers do not offer the use of the advanced da Vinci Robotic Surgical System. We also feel that it is the safest for patients to have surgery in a hospital. The procedures are all very safe, but in the event that any unforeseen complications would arise, a hospital setting offers you the full resources and staff to properly care for you. If complications occur in a surgical center, you must be transferred by an ambulance to a hospital to receive the proper care, possibly wasting valuable time. Having your surgery performed in a hospital is always in your best interest.
Have you thought about in vitro fertilization but are concerned about the investment? The Florida Institute for Reproductive Medicine offers a package of three fresh IVF cycles as well as the transfer of all cryopreserved embryos. This package includes intracytoplasmic sperm injection as well as assisted hatching if indicated, and it includes cryopreservation of embryos if available. Completion of all fresh and cryo IVF cycles must occur within a sixteen month period. Transfer of all cryopreserved embryos must occur before another fresh IVF cycle is begun. Cost for this package is $14,500, not including the cost of fertility medications. Medication costs range from $2,600 to $4,000 depending on patient’s age, weight and ovulatory status. There are no refunds whether pregnancy occurs before three completed fresh cycles or before completion of all cryopreserved embryos.
Although this program is available to anyone, this program is ideal for patients with a lower than optimal probability of success. When one considers the high pregnancy rates at the Florida Institute for Reproductive Medicine for both fresh and frozen embryos (http://www.cdc.gov/art) we believe this package may represent the best IVF values in the country.
Diagnosis and treatment of infertility is expensive. Unfortunately most insurance companies continue to look at infertility as an elective part of health care – frequently not covering diagnostic testing or treatment. Infertility costs for the most common treatment (i.e. ovulation induction with washed intrauterine insemination) ranges between $500 – $600 at the Florida Institute for Reproductive Medicine. Costs for in vitro fertilization, range between $10,000 – $11,000. In general, we want to try the simplest therapy that has a good chance of working, give it a good try; and if it is not successful, move on to more aggressive options.
The Florida Institute for Reproductive Medicine has partnered with a finance company to provide financing of infertility care. Rates as low as 3.99% are available for individuals with good credit. Loans from $2,000-$40,000 are available with payments ranging from 24-84 months. No up-front payments are needed. There are no pre-payment penalties. The Florida Institute for Reproductive Medicine has an assistance program for our IVF patients who have no insurance coverage and who qualify based on income, whereby up to $2,000 worth of medications will be provided. We have a 10% discount for all active military patients.
Some more creative options couples may consider include:
- Joining a drug study: At times, we at the Florida Institute for Reproductive Medicine have been asked to participate in drug studies. As part of the compensation for participation, patients may receive anything from free medications to an entire IVF cycle. Many of these studies have specific requirements for participation. Check with us to see if there are available studies and if you may qualify for them.
- Donating eggs: At the Florida Institute for Reproductive Medicine we have an active donor egg IVF program. Donors are compensated $3,000 for participating in an egg donation cycle. Donors are allowed to donate up to four times, potentially earning $12,000 – enough for their own IVF cycle. Check with our donor egg coordinator to see if you meet donor requirements.
- Shop for money back guarantees: Some programs will offer a money back guarantee for IVF cycles if they are not successful. Typically centers charge a premium for the IVF cycle in return for the guarantee. Generally these programs have specific requirements for participation. For couples who would be out of options if their IVF cycle did not work, this allows them to potentially participate in other treatment options like donor egg IVF or adoption.
Above all, do your homework. At the Florida Institute for Reproductive Medicine we have always strived to offer the best treatment value for all our services. Our pregnancy rates have been consistently amongst the highest in the country. Costs for all our services at the Florida Institute for Reproductive Medicine typically range 25-30% less than national averages.