One of the hardest things I do is say goodbye to patients. Even when they are pregnant and heading off to their obstetricians because we have been successful, it's still hard. So here are some the things I wish I could say and do:
I am not just acting thrilled that you are pregnant, I AM thrilled that you are pregnant. I am honored that you asked me to help, and I am so excited for you that we were successful.
I will think of you for at least a year after you are gone. I know that's odd, but I've spent a lot of time with you. I've been there for the ups and downs, and I've really gotten to know and like you. If you are pregnant, I will wonder whether the baby has been born yet. I will wonder who he or she looks like, you or your partner.
Please always feel free to call or visit me. If you have a question, I am still your doctor too and would be happy to try to help. If you want to come show me your big pregnant belly, you will make my day! Bring the baby in too, my whole staff will want to see him or her!
If you did not conceive, I take it personally. Even if the odds were against us, I really wanted you to be the one to beat the odds. I wish I could get everyone pregnant.
I wish I could give you a hug goodbye, but I don't know how you will take it.
Send me a baby picture--don't forget. I know that life with a newborn is all encompasing, but even if he or she is now 2 years old and you haven't had time until now, send me a picture. I love babies!
If you thought we gave you good care, tell your gynecologist and your friends. If you didn't, tell me--I absolutely want to know!
If you want to give me a hug, it's OK to do it.
If you see me in public, I will not acknowledge you until you acknowledge me. This is for your privacy. I don't know if you want to admit knowing me, especially if I have family or friends around who know what I do for a living, but I will be happy to admit knowing you. So feel free to talk to me, and please don't feel slighted if I don't approach you.
If there were times during this process where you weren't at your best, I understand. I have gone through this too, and I know how stressful and emotional it is. I have already forgotten what you did or said, and you should too. This office is like Las Vegas: what ever happens here, stays here.
Most of all know that I am terrible at saying goodbye. So if I don't convey all these things to you, it's because I don't know how to put into words how wonderful it is to have been a part of this process. I wish you all the best and hope that we meet again somewhere down the road. Even if it's just in the supermarket, where you are pushing your little one around in a cart, I will be happy to see you.
Sincerely,
Susan Trout, MD
Thursday, July 7, 2011
Friday, July 1, 2011
Surrogates and Gestational Carriers
"Doctor, do you think I need a surrogate?" I get this question a lot, and the answer is almost always "No, a surrogate is not necessary".
Let's start with a few definitions: a traditional surrogate is a woman who provides the eggs and carries the baby. In other words, sperm is deposited into her uterus on the day of her ovulation and hopefully she conceives and then carries the baby to term. The most famous, or infamous, surrogate was Mary Beth Whitehead. She gave birth to a little girl, who was called Baby M in the court proceedings. She refused to give up custody of the baby, claiming that the baby was her biologic child and so she had a right to keep her. After a huge, very public court battle; custody was awarded to the intended parents with Mary Beth retaining visitation rights. Because of this very ugly incident, many states (such as New Jersey where the court battle took place) have laws banning traditional surrogacy. Even in states where it is not specifically banned, many fertility centers will not provide services for traditional surrogacy because of the risk of the surrogate becoming too attached to the child and the murky legal status of the baby, even when there are contracts in place ahead of time (there was a surrogacy contract in the Baby M case).
A gestational carrier is a woman who carries a baby to term, but does not provide the eggs. She is just the "incubator". In this case, eggs from another woman (often the intended parent) and sperm are mixed in the lab to create embryos. These embryos are then placed into the gestational carrier's uterus to hopefully implant and grow. Because the carrier has no genetic relationship to the child, it is believed that the carrier will have an easier time handing over the child and less legal standing in custody battles. The courts, as long as there is a good legal contract, have mainly agreed. Difficulties have arisen when the eggs come from an anonymous donor, as then the intended parent is not the biological mother. When there has been a well written contract, custody usually goes to the intended parent anyway.
So as you can see, this is not something to take lightly. There are definitely very good reasons to use a gestational carrier, but, for most women, it is not the best option. Carriers or surrogates are obviously necessary when the intended female parent does not have a uterus or has a uterus that cannot carry a baby. This does not usually include, however, multiple miscarriages. Please see my previous blog on the subject, but the vast majority of cases of multiple miscarriages have nothing to do with the uterus. Another reason for using a carrier might be a medical condition that would make pregnancy unsafe for mom or baby. Severe lupus with kidney involvement would be an example of a condition that could cause major complications (even death) during a pregnancy. This is something that needs to be decided between you and your doctors. Older age is not a good reason, although it's the one I get asked about the most. Fertility declines and miscarriage and chromosome abnormality rates climb as women get older. This is due to the age of the egg, however, and not the age of the uterus. Therefore putting the same eggs in a younger uterus, will not chance the outcome. Putting younger eggs into the older uterus will, however, improve all of the above (see blog on age and donor eggs). This is why you sometimes hear about mothers carrying babies for their grown daughters. It's the daughter's eggs, which are young, that makes these cycles successful. The age of the mom's uterus really doesn't matter. Carriers or surrogates are also used when there is no female intended parent, such as single men or same sex male couples.
If you do need a gestational carrier or a surrogate, there are some things to consider in picking one. First, has she ever carried a baby before? If not, she may not be the best choice. She has no idea how attached you can get to an unborn child that you carry around for 9 months. It may be very difficult for her to let go once the baby is born. If she has had children, how did the pregnancies go? Were there any complications? How is her health? Does she have any habits or conditions that put her at risk for infectious diseases? (e.g., gets tattoos, needs blood transfusions or blood products, has a partner who uses drugs, etc.) Has she had all of her vaccinations (many disease we vaccinate against, like German Measles, can cause birth defects when contracted during pregnancy, and many American and even more foreign-born woman have not had their full compliment of vaccinations.) What is her nutrition like? (vegitarians and vegans, for instance, often have a very hard time getting enough protein and calcium in their diets to support a pregnancy well.) Does she take any medications? Use drugs? Smoke? Drink alcohol? Is she willing to give up caffeine? What is her mental status like? Did she have any problems with postpartum depression with her previous pregnancies? Why is she doing this? Is she reliable? Does she have any religous beliefs that are going to be a problem with any part of the process? Your fertility center will help you with these questions. The fertility center will usually get and review her previous medical records, go through her medical history with her, and order a psychological screening. They will do a physical exam and test for infectious diseases. They will also do special studies to look at the uterus and make sure it's normal. If there is any question as to her vaccination status, they may order test to make sure that she is immune to things like German Measles.
If you find someone whom you like, the next step is to talk to them about some "what ifs"'. The first one is "what if it turns out she has twins or triplets?" Would she be willing to carry more than one baby, even if it means being put on bedrest? If she is put on bedrest, will she want more compensation for lost wages? If she ends up with quadruplets or more (which really should be a very remote possibility in this day and age, if the guidelines for how many embryos are transferred are followed), will she be willing to reduce the pregnancy to twins? Will she demand it be reduced to twins, even if you do not want it? Next, what happens if the baby is abnormal in some way? You need to be very frank about whether you would want her to have an abortion or not. There are some abnormalities that are lethal at birth. Would you want her to carry the baby to term anyway? Would she be willing to do that? Another discussion point will be your involvement in her pregnancy. Will you want to go to all her doctor's visits? Will you and your partner want to be at the birth? Will that be OK with her? Then, of course, there is the money. You need to find out what compensation she wants, who will pay for maternity clothes, and whether her health insurance will cover the pregnancy and delivery (many insurances now specifically exclude maternity care when the insured is a surrogate or gestational carrier).
Once you get through that discussion, it's time to get a lawyer involved. You will need someone to write up a contract between you and your carrier. She should have her own lawyer review it (someone who is looking out for her interests). The laws vary state to state, so you need someone familiar with your state. There is an association called the American Academy of Assisted Reproduction Technology Lawyers, who can help you find a lawyer familar with these situations. Do not try to get around this part. It needs to be done right. There was a case of a couple who downloaded a contract off the internet instead of paying a lawyer, and it turned out that the contract gave custody to the gestational carrier. Not good!
After that, you should be good to go. Your fertility center will tell you more about the "getting pregnant" part. They can also help you find a gestational carrier, if you do not have anyone that you feel comfortable asking to do it.
Let's start with a few definitions: a traditional surrogate is a woman who provides the eggs and carries the baby. In other words, sperm is deposited into her uterus on the day of her ovulation and hopefully she conceives and then carries the baby to term. The most famous, or infamous, surrogate was Mary Beth Whitehead. She gave birth to a little girl, who was called Baby M in the court proceedings. She refused to give up custody of the baby, claiming that the baby was her biologic child and so she had a right to keep her. After a huge, very public court battle; custody was awarded to the intended parents with Mary Beth retaining visitation rights. Because of this very ugly incident, many states (such as New Jersey where the court battle took place) have laws banning traditional surrogacy. Even in states where it is not specifically banned, many fertility centers will not provide services for traditional surrogacy because of the risk of the surrogate becoming too attached to the child and the murky legal status of the baby, even when there are contracts in place ahead of time (there was a surrogacy contract in the Baby M case).
A gestational carrier is a woman who carries a baby to term, but does not provide the eggs. She is just the "incubator". In this case, eggs from another woman (often the intended parent) and sperm are mixed in the lab to create embryos. These embryos are then placed into the gestational carrier's uterus to hopefully implant and grow. Because the carrier has no genetic relationship to the child, it is believed that the carrier will have an easier time handing over the child and less legal standing in custody battles. The courts, as long as there is a good legal contract, have mainly agreed. Difficulties have arisen when the eggs come from an anonymous donor, as then the intended parent is not the biological mother. When there has been a well written contract, custody usually goes to the intended parent anyway.
So as you can see, this is not something to take lightly. There are definitely very good reasons to use a gestational carrier, but, for most women, it is not the best option. Carriers or surrogates are obviously necessary when the intended female parent does not have a uterus or has a uterus that cannot carry a baby. This does not usually include, however, multiple miscarriages. Please see my previous blog on the subject, but the vast majority of cases of multiple miscarriages have nothing to do with the uterus. Another reason for using a carrier might be a medical condition that would make pregnancy unsafe for mom or baby. Severe lupus with kidney involvement would be an example of a condition that could cause major complications (even death) during a pregnancy. This is something that needs to be decided between you and your doctors. Older age is not a good reason, although it's the one I get asked about the most. Fertility declines and miscarriage and chromosome abnormality rates climb as women get older. This is due to the age of the egg, however, and not the age of the uterus. Therefore putting the same eggs in a younger uterus, will not chance the outcome. Putting younger eggs into the older uterus will, however, improve all of the above (see blog on age and donor eggs). This is why you sometimes hear about mothers carrying babies for their grown daughters. It's the daughter's eggs, which are young, that makes these cycles successful. The age of the mom's uterus really doesn't matter. Carriers or surrogates are also used when there is no female intended parent, such as single men or same sex male couples.
If you do need a gestational carrier or a surrogate, there are some things to consider in picking one. First, has she ever carried a baby before? If not, she may not be the best choice. She has no idea how attached you can get to an unborn child that you carry around for 9 months. It may be very difficult for her to let go once the baby is born. If she has had children, how did the pregnancies go? Were there any complications? How is her health? Does she have any habits or conditions that put her at risk for infectious diseases? (e.g., gets tattoos, needs blood transfusions or blood products, has a partner who uses drugs, etc.) Has she had all of her vaccinations (many disease we vaccinate against, like German Measles, can cause birth defects when contracted during pregnancy, and many American and even more foreign-born woman have not had their full compliment of vaccinations.) What is her nutrition like? (vegitarians and vegans, for instance, often have a very hard time getting enough protein and calcium in their diets to support a pregnancy well.) Does she take any medications? Use drugs? Smoke? Drink alcohol? Is she willing to give up caffeine? What is her mental status like? Did she have any problems with postpartum depression with her previous pregnancies? Why is she doing this? Is she reliable? Does she have any religous beliefs that are going to be a problem with any part of the process? Your fertility center will help you with these questions. The fertility center will usually get and review her previous medical records, go through her medical history with her, and order a psychological screening. They will do a physical exam and test for infectious diseases. They will also do special studies to look at the uterus and make sure it's normal. If there is any question as to her vaccination status, they may order test to make sure that she is immune to things like German Measles.
If you find someone whom you like, the next step is to talk to them about some "what ifs"'. The first one is "what if it turns out she has twins or triplets?" Would she be willing to carry more than one baby, even if it means being put on bedrest? If she is put on bedrest, will she want more compensation for lost wages? If she ends up with quadruplets or more (which really should be a very remote possibility in this day and age, if the guidelines for how many embryos are transferred are followed), will she be willing to reduce the pregnancy to twins? Will she demand it be reduced to twins, even if you do not want it? Next, what happens if the baby is abnormal in some way? You need to be very frank about whether you would want her to have an abortion or not. There are some abnormalities that are lethal at birth. Would you want her to carry the baby to term anyway? Would she be willing to do that? Another discussion point will be your involvement in her pregnancy. Will you want to go to all her doctor's visits? Will you and your partner want to be at the birth? Will that be OK with her? Then, of course, there is the money. You need to find out what compensation she wants, who will pay for maternity clothes, and whether her health insurance will cover the pregnancy and delivery (many insurances now specifically exclude maternity care when the insured is a surrogate or gestational carrier).
Once you get through that discussion, it's time to get a lawyer involved. You will need someone to write up a contract between you and your carrier. She should have her own lawyer review it (someone who is looking out for her interests). The laws vary state to state, so you need someone familiar with your state. There is an association called the American Academy of Assisted Reproduction Technology Lawyers, who can help you find a lawyer familar with these situations. Do not try to get around this part. It needs to be done right. There was a case of a couple who downloaded a contract off the internet instead of paying a lawyer, and it turned out that the contract gave custody to the gestational carrier. Not good!
After that, you should be good to go. Your fertility center will tell you more about the "getting pregnant" part. They can also help you find a gestational carrier, if you do not have anyone that you feel comfortable asking to do it.
Monday, May 23, 2011
IUI (Intrauterine inseminations)
Intra-uterine inseminations may sound like a scary and invasive procedure, when you doctor first mentions it, but it really isn't. It is a procedure to put sperm into the uterus and maximize the amount of sperm that gets to the egg, and it is very similar to a PAP smear in procedure and discomfort levels. IUI is often one of the first-line fertility treatment options. With intercourse, 99.9% of the sperm never makes it into the uterus; it gets stuck in the mucus in the cervix or dies in the vagina before even entering the cervix. By bypassing the vagina and cervical mucus, millions more sperm can be delivered to the egg. Even when the male partner has normal sperm counts, this can help with achieving a pregnancy. Medications like Clomid can make the cervical mucus even more impenetrable than usual, and so IUI is often used when Clomid is prescribed as well.
An IUI consists of two steps. The first step is "washing" the sperm. This is necessary because the fluid around the sperm contains substances called prostaglandins that will make the uterus cramp, if you put the fluid directly inside the uterus. Washing the sperm can be done several different ways. Basically, though, the sperm are spun in a centrifuge to bring them to the bottom. The sperm are then removed and put in fluid designed to help them survive (media), or the fluid is removed and replaced with the media and the sperm are allowed to swim back up into the media. No matter how it is done, the sperm are only put in a small amount of fluid (0.5 ml or so). The helps keep the fluid and sperm from running back out the cervix after the insemination.
After the sperm are washed, they are placed into the uterus: A speculum is placed into the vagina, and the cervix (opening to the uterus) is located. A small flexible tube (only a millimeter or two in width) is threaded through the canal in the cervix and up to the top of the uterus. The sperm is then deposited at the top, and the tube is withdrawn. This feels similar to a PAP smear, and so should not cause much discomfort. The speculum is removed, and the procedure is done at this point. Many doctors will ask you to stay lying down for a few minutes afterwards, and, at our clinic, we actually prop your bottom up in the air a little to let gravity help. Studies show that the sperm gets into the fallopian tube, which is where it meets and fertilizes the egg, within seconds to a minute. So you do not need to stay lying down for very long. After you leave the doctor's office, you may resume your normal activities. It won't fall out!
The risks to an IUI are pretty minimal. It can cause a little spotting or light bleeding, just like a PAP smear can, but this should only last a day or so. There is a theoretical risk of bacteria from the vagina getting pushed up into the uterus with the catheter and causing an infection. In practice, however, this is extremely rare. If your cervix is very curvy or scarred from procedures like D&C's, then it can be a little more uncomfortable too. To have a reasonable chance of success with IUI, you need 10 million moving sperm, so severe sperm problems may not be amenable to IUI. In those cases, IVF may be a better option (see previous blogs on IVF and on male factor infertility). Many couples worry that IUI will cause triplets or quadruplets and such. This is not the case. It is the number of eggs ovulating, rather than the number of sperm, that determines the risks of a multiple pregnancy. So if your doctor is recommending IUI, it is something to seriously consider. It will increase the amount of sperm getting to the eggs and improve your chances of pregnancy!
An IUI consists of two steps. The first step is "washing" the sperm. This is necessary because the fluid around the sperm contains substances called prostaglandins that will make the uterus cramp, if you put the fluid directly inside the uterus. Washing the sperm can be done several different ways. Basically, though, the sperm are spun in a centrifuge to bring them to the bottom. The sperm are then removed and put in fluid designed to help them survive (media), or the fluid is removed and replaced with the media and the sperm are allowed to swim back up into the media. No matter how it is done, the sperm are only put in a small amount of fluid (0.5 ml or so). The helps keep the fluid and sperm from running back out the cervix after the insemination.
After the sperm are washed, they are placed into the uterus: A speculum is placed into the vagina, and the cervix (opening to the uterus) is located. A small flexible tube (only a millimeter or two in width) is threaded through the canal in the cervix and up to the top of the uterus. The sperm is then deposited at the top, and the tube is withdrawn. This feels similar to a PAP smear, and so should not cause much discomfort. The speculum is removed, and the procedure is done at this point. Many doctors will ask you to stay lying down for a few minutes afterwards, and, at our clinic, we actually prop your bottom up in the air a little to let gravity help. Studies show that the sperm gets into the fallopian tube, which is where it meets and fertilizes the egg, within seconds to a minute. So you do not need to stay lying down for very long. After you leave the doctor's office, you may resume your normal activities. It won't fall out!
The risks to an IUI are pretty minimal. It can cause a little spotting or light bleeding, just like a PAP smear can, but this should only last a day or so. There is a theoretical risk of bacteria from the vagina getting pushed up into the uterus with the catheter and causing an infection. In practice, however, this is extremely rare. If your cervix is very curvy or scarred from procedures like D&C's, then it can be a little more uncomfortable too. To have a reasonable chance of success with IUI, you need 10 million moving sperm, so severe sperm problems may not be amenable to IUI. In those cases, IVF may be a better option (see previous blogs on IVF and on male factor infertility). Many couples worry that IUI will cause triplets or quadruplets and such. This is not the case. It is the number of eggs ovulating, rather than the number of sperm, that determines the risks of a multiple pregnancy. So if your doctor is recommending IUI, it is something to seriously consider. It will increase the amount of sperm getting to the eggs and improve your chances of pregnancy!
Friday, April 22, 2011
Smoking and Fertility
We all know that smoking can cause lung cancer, heart disease, and strokes; but many of us still smoke. "You have to die of something" is what I hear a lot from my patients. I am not going to debate the wisdom of that statement here, but let me explain smoking's impact on both male and female fertility.
Female smokers take longer to conceive and have a higher chance of not being able to have children than non-smokers. The toxins in cigarettes can be found in the fluid filled sacs containing the eggs (follicles) in a smokers' ovaries. The eggs are bathed in these toxins, and they literally kill a woman's eggs. One study looking at ovaries of smokers and non-smokers under a microscope found that smokers had about half the number of eggs as non-smokers. The toxins may cause the eggs to be more prone to genetic abnormalities as well. This can also lead to a higher rate of miscarriages. Pregnant smokers are more likely to have low birth weight babies and premature births. Babies who have a parent that smokes are more likely to die of SIDS (sudden infant death syndrome), develop asthma, or be hospitalized for respiratory illness too. Male offspring of mothers that smoked have poorer sperm and more infertility themselves. When going through IVF (in vitro fertilization or the test tube baby procedure), smokers have about half the chance of success as non-smokers. They require more medication and produce fewer eggs with more cancelled cycles. Female smokers go through menopause earlier too.
Men who smoke are not immune either. They have lower sperm counts and the sperm do not move as well. There are more abnormally-shaped sperm too. The DNA inside the sperm of a smoker has more abnormalities. All of this can affect fertility. Male smokers have more erectile dysfunction too, especially as they get older. Their passive smoke affects their female partner's fertility too, even when she doesn't smoke.
So now you have even more reasons to quit. I know it's hard, but this is very important. It's not just for you, but for your whole family. And yes, even though you have to die of something, it doesn't have to be from a stroke at age 50. You want to be around long enough to see your kids graduate from college and get married and to enjoy your grandkids, don't you? So how do you quit? There are many different ways. Many states, such as Colorado, have programs set up with the money won from the tobacco company to help you quit. In Colorado, it's called the Colorado QuitLine. You can call 1-800-Quit Now (1-800-784-8669) or go to http://www.coquitline.org/ for help. They have resources to give you free nicotine replacement gum or patches, coaching, etc. You may want to talk to your doctor about Chantix and whether it is right for you. Pick a partner and quit together, or you may want to try the carrot and stick method. Make a bet with a friend or family member--you will quit smoking by a certain date or _____ will happen. Pick something you really don't want to happen (e.g. you will have to clean out the garage and the basement, you will have to donate $100 to a political candidate you don't like, you will give up TV for 3 months, etc--make it as horrible as you can). If you do quit, the carrot happens--you will give yourself a get away weekend, your friend will buy you a steak dinner, your spouse will allow you to pick the TV shows for a month, or something like that. If you ask for help and try hard, you can quit. As Nike says, just do it!
Female smokers take longer to conceive and have a higher chance of not being able to have children than non-smokers. The toxins in cigarettes can be found in the fluid filled sacs containing the eggs (follicles) in a smokers' ovaries. The eggs are bathed in these toxins, and they literally kill a woman's eggs. One study looking at ovaries of smokers and non-smokers under a microscope found that smokers had about half the number of eggs as non-smokers. The toxins may cause the eggs to be more prone to genetic abnormalities as well. This can also lead to a higher rate of miscarriages. Pregnant smokers are more likely to have low birth weight babies and premature births. Babies who have a parent that smokes are more likely to die of SIDS (sudden infant death syndrome), develop asthma, or be hospitalized for respiratory illness too. Male offspring of mothers that smoked have poorer sperm and more infertility themselves. When going through IVF (in vitro fertilization or the test tube baby procedure), smokers have about half the chance of success as non-smokers. They require more medication and produce fewer eggs with more cancelled cycles. Female smokers go through menopause earlier too.
Men who smoke are not immune either. They have lower sperm counts and the sperm do not move as well. There are more abnormally-shaped sperm too. The DNA inside the sperm of a smoker has more abnormalities. All of this can affect fertility. Male smokers have more erectile dysfunction too, especially as they get older. Their passive smoke affects their female partner's fertility too, even when she doesn't smoke.
So now you have even more reasons to quit. I know it's hard, but this is very important. It's not just for you, but for your whole family. And yes, even though you have to die of something, it doesn't have to be from a stroke at age 50. You want to be around long enough to see your kids graduate from college and get married and to enjoy your grandkids, don't you? So how do you quit? There are many different ways. Many states, such as Colorado, have programs set up with the money won from the tobacco company to help you quit. In Colorado, it's called the Colorado QuitLine. You can call 1-800-Quit Now (1-800-784-8669) or go to http://www.coquitline.org/ for help. They have resources to give you free nicotine replacement gum or patches, coaching, etc. You may want to talk to your doctor about Chantix and whether it is right for you. Pick a partner and quit together, or you may want to try the carrot and stick method. Make a bet with a friend or family member--you will quit smoking by a certain date or _____ will happen. Pick something you really don't want to happen (e.g. you will have to clean out the garage and the basement, you will have to donate $100 to a political candidate you don't like, you will give up TV for 3 months, etc--make it as horrible as you can). If you do quit, the carrot happens--you will give yourself a get away weekend, your friend will buy you a steak dinner, your spouse will allow you to pick the TV shows for a month, or something like that. If you ask for help and try hard, you can quit. As Nike says, just do it!
Thursday, April 21, 2011
Trying to conceive when sex isn't safe
There are many couples in the U.S. who can't conceive the old fashion way. It isn't safe. This is because one or the other of them has an infectious disease like Hepatitis or HIV that could be transmitted to their partner. For these couples, having a child of their own seems completely out of reach. They would love to have a family but do not want to risk infecting their partner. That's where we come in. We can help.
If it is the female who has the infectious disease, then she first needs treatment to bring down the level of virus in her system to an undetectable level. This will help prevent transmission to the child. In the case of HIV, for instance, a c-section is also usually recommended to help prevent transmission to the baby. She will undergo counseling with an infectious disease expert so she understands exactly what the risks are to her and her child. We can then put sperm directly into her uterus on the day she is ovulating (intra-uterine insemination). This is a simple, quick procedure that feels a lot like a PAP smear. It will prevent her partner from being infected through intercourse.
Things get a little more complicated when it is the male who has the infectious disease. HIV and Hepatitis B & C can be found in the semen, even when the blood tests show no virus in the bloodstream. The female can be vaccinated against Hepatitis B, but there is no vaccine for Hepatitis C or HIV. Therefore the patient's partner is at risk. In these cases, we get the male on the best treatment available for his disease. We can then wash the sperm multiple times with a special protocol developed in Europe to remove the virus. A small sample of the sperm is then tested in the lab to make sure there is no detectable virus, and an insemination is done with the rest of the sample. About 4,000 inseminations using this method for HIV have been reported in the literature, and there are no reported infections of the female from it. We have had similar success and have several babies born now to couples who used this method to conceive.
Medications have made it possible to live a long and productive life with HIV. It is no longer the death sentence that it used to be. Couples living with this disease are now looking to the future. They want a family, just like other couples. These procedures allow them to have that family without putting their partners and children at undo risk.
If it is the female who has the infectious disease, then she first needs treatment to bring down the level of virus in her system to an undetectable level. This will help prevent transmission to the child. In the case of HIV, for instance, a c-section is also usually recommended to help prevent transmission to the baby. She will undergo counseling with an infectious disease expert so she understands exactly what the risks are to her and her child. We can then put sperm directly into her uterus on the day she is ovulating (intra-uterine insemination). This is a simple, quick procedure that feels a lot like a PAP smear. It will prevent her partner from being infected through intercourse.
Things get a little more complicated when it is the male who has the infectious disease. HIV and Hepatitis B & C can be found in the semen, even when the blood tests show no virus in the bloodstream. The female can be vaccinated against Hepatitis B, but there is no vaccine for Hepatitis C or HIV. Therefore the patient's partner is at risk. In these cases, we get the male on the best treatment available for his disease. We can then wash the sperm multiple times with a special protocol developed in Europe to remove the virus. A small sample of the sperm is then tested in the lab to make sure there is no detectable virus, and an insemination is done with the rest of the sample. About 4,000 inseminations using this method for HIV have been reported in the literature, and there are no reported infections of the female from it. We have had similar success and have several babies born now to couples who used this method to conceive.
Medications have made it possible to live a long and productive life with HIV. It is no longer the death sentence that it used to be. Couples living with this disease are now looking to the future. They want a family, just like other couples. These procedures allow them to have that family without putting their partners and children at undo risk.
Monday, April 18, 2011
I don't want to be an Octomom!
Having more than one baby at a time (multiple gestations--twins, triplets, etc) is the fear and desire of many couple struggling with infertility. When scientist look at why couple don't pursue fertility treatments, fear of multiple gestations is one of the leading reasons (the other is fear of the cost--see my previous blog on the cost of fertility treatments). However, I get asked on a daily basis whether it is possible to use a treatment or dosage that will give a patient twins rather than just one baby. "If we could have twins, then we would be done!" is what I hear a lot.
We have all heard about the Octomom, but just how likely is a multiple birth with fertility treatment? Well, it depends on the treatment. Clomid or clomiphene citrate (see previous blog on Clomid) is a mild fertility treatment that is often the first treatment recommended for couples struggling with infertility. It has about an 8-10% chance of causing twins and a less than 1% chance of higher-order multiples (triplets, quadruplets, etc). Many facilities, such as ours, will monitor Clomid cycles with an ultrasound done a day or two before ovulation. By measuring the follicles (the sacs containing the eggs that are developing that cycle), we can predict how many eggs are likely to ovulate. The goal is usually 1 to 3 eggs ovulating, depending on the woman's age. If a woman looks like she is going to have five eggs ovulating instead, let's say, we would recommend canceling the cycle and starting over at a lower dose. This practice has really all but eliminated higher order multiple pregnancies from Clomid in our office.
The Octomom did IVF, but that isn't usually associated with a high risk of a multiple pregnancy, especially a high-order multiple pregnancy like octuplets. This is because the doctor and patient control how many embryos are placed into the uterus at one time. The American Society for Reproductive Medicine (ASRM) guidelines say that a woman who is 37 years old or less should have no more than 2 embryos transferred, a 38-40 year old should have no more than 3 embryos transferred, and a 41-42 year old should have no more than 5 embryos transferred (these are guidelines for good quality embryos and may be modified if the embryo quality is poorer). If these guidelines are followed, the chance of triplets or more should be less than 1%. Obviously, these guidelines were not followed with the Octomom. However, most doctors do follow the guidelines. You should definitely have a discussion with your doctor as to how many embryos they recommend transferring and what their clinic's multiple rates are, if you are considering IVF.
The treatment regimen with the highest multiple rate is using injectable medication (gonadotropins, see previous blog on the subject) with insemination. This will often get 3-5 eggs ovulating, which can sometimes be the goal. Every once in a while, though, 4 eggs ovulate, all 4 take, and you end up with quadruplets. Therefore, this treatment regimen should be treated with caution and respect. Very careful monitoring is necessary to avoid having too many eggs ovulate. Cycles should be cancelled, if it looks like the risk of triplets or more is too high. Younger women, especially those with PCOS (polycystic ovarian syndrome, see my previous blog on this topic), should be started on very low doses and watched carefully. Even given careful cautious monitoring, it is still possible to end up with a multiple gestation. Younger women may therefore want to avoid this regimen and go right to IVF. The risk, in our hands, is less than 1%. So even here you are not at tremendous risk for triplets or more.
What happens if you do end up with twins or triplets? What exactly are the risks? Well, let's start with twins. The most common type of twin pregnancy produced by fertility medication is fraternal or non-identical twins. This is a twin pregnancy from 2 separate eggs. Identical twins are not more likely to happen with fertility medication. The risk of miscarriage of twins in the first trimester is similar to single babies and depends more on the mother's age and therefore quality of eggs. However, twins usually deliver before their due date. The average delivery date for fraternal twins is 5 weeks before they are due. This can lead to premature babies with medical complications. Overall, however, most twins do well.
Triplet pregnancies are significantly more risky than twins. 90% of triplets are born prematurely. This makes them much more likely to suffer problems like cerebral palsy (a condition with the inability to coordinate movements, learning problems, speech problems, etc), blindness, breathing problems, and problems with their intestines. One study looking at triplet and higher order pregnancies found a 32% rate of minor neurologic problems and a 6% rate of major neurological problems. The risks of death in the first month of life for triplets is ten to twenty times higher than with one baby. All of these statistics get even worse for quadruplets or more, with the risk of losing all the babies before they are mature enough to survive becoming a major factor. There are risks to you in a multiple pregnancy as well. The chances of ending up with high blood pressure, diabetes, and anemia of pregnancy are higher. Morning sickness tends to be even worse. Bedrest for months is often needed, especially with triplets or more. You are more likely to need a c-section and more likely to hemorrhage at delivery with multiples too.
As you can see, multiple gestations are not with risk. The risks increase substantially as you go from twins to triplets, and beyond. Most fertility centers, however, have worked very hard at reducing their rates of multiples as much as possible. Not that you understand the risks, hopefully your desire for more than one baby at a time has also diminished. If reducing the chance of multiples does not seem to be a goal of your fertility center, you may want to seek a second opinion. With careful monitoring and by following the ASRM guidelines for the number of embryos transferred, your risk of being an octomom should almost non-existent!
We have all heard about the Octomom, but just how likely is a multiple birth with fertility treatment? Well, it depends on the treatment. Clomid or clomiphene citrate (see previous blog on Clomid) is a mild fertility treatment that is often the first treatment recommended for couples struggling with infertility. It has about an 8-10% chance of causing twins and a less than 1% chance of higher-order multiples (triplets, quadruplets, etc). Many facilities, such as ours, will monitor Clomid cycles with an ultrasound done a day or two before ovulation. By measuring the follicles (the sacs containing the eggs that are developing that cycle), we can predict how many eggs are likely to ovulate. The goal is usually 1 to 3 eggs ovulating, depending on the woman's age. If a woman looks like she is going to have five eggs ovulating instead, let's say, we would recommend canceling the cycle and starting over at a lower dose. This practice has really all but eliminated higher order multiple pregnancies from Clomid in our office.
The Octomom did IVF, but that isn't usually associated with a high risk of a multiple pregnancy, especially a high-order multiple pregnancy like octuplets. This is because the doctor and patient control how many embryos are placed into the uterus at one time. The American Society for Reproductive Medicine (ASRM) guidelines say that a woman who is 37 years old or less should have no more than 2 embryos transferred, a 38-40 year old should have no more than 3 embryos transferred, and a 41-42 year old should have no more than 5 embryos transferred (these are guidelines for good quality embryos and may be modified if the embryo quality is poorer). If these guidelines are followed, the chance of triplets or more should be less than 1%. Obviously, these guidelines were not followed with the Octomom. However, most doctors do follow the guidelines. You should definitely have a discussion with your doctor as to how many embryos they recommend transferring and what their clinic's multiple rates are, if you are considering IVF.
The treatment regimen with the highest multiple rate is using injectable medication (gonadotropins, see previous blog on the subject) with insemination. This will often get 3-5 eggs ovulating, which can sometimes be the goal. Every once in a while, though, 4 eggs ovulate, all 4 take, and you end up with quadruplets. Therefore, this treatment regimen should be treated with caution and respect. Very careful monitoring is necessary to avoid having too many eggs ovulate. Cycles should be cancelled, if it looks like the risk of triplets or more is too high. Younger women, especially those with PCOS (polycystic ovarian syndrome, see my previous blog on this topic), should be started on very low doses and watched carefully. Even given careful cautious monitoring, it is still possible to end up with a multiple gestation. Younger women may therefore want to avoid this regimen and go right to IVF. The risk, in our hands, is less than 1%. So even here you are not at tremendous risk for triplets or more.
What happens if you do end up with twins or triplets? What exactly are the risks? Well, let's start with twins. The most common type of twin pregnancy produced by fertility medication is fraternal or non-identical twins. This is a twin pregnancy from 2 separate eggs. Identical twins are not more likely to happen with fertility medication. The risk of miscarriage of twins in the first trimester is similar to single babies and depends more on the mother's age and therefore quality of eggs. However, twins usually deliver before their due date. The average delivery date for fraternal twins is 5 weeks before they are due. This can lead to premature babies with medical complications. Overall, however, most twins do well.
Triplet pregnancies are significantly more risky than twins. 90% of triplets are born prematurely. This makes them much more likely to suffer problems like cerebral palsy (a condition with the inability to coordinate movements, learning problems, speech problems, etc), blindness, breathing problems, and problems with their intestines. One study looking at triplet and higher order pregnancies found a 32% rate of minor neurologic problems and a 6% rate of major neurological problems. The risks of death in the first month of life for triplets is ten to twenty times higher than with one baby. All of these statistics get even worse for quadruplets or more, with the risk of losing all the babies before they are mature enough to survive becoming a major factor. There are risks to you in a multiple pregnancy as well. The chances of ending up with high blood pressure, diabetes, and anemia of pregnancy are higher. Morning sickness tends to be even worse. Bedrest for months is often needed, especially with triplets or more. You are more likely to need a c-section and more likely to hemorrhage at delivery with multiples too.
As you can see, multiple gestations are not with risk. The risks increase substantially as you go from twins to triplets, and beyond. Most fertility centers, however, have worked very hard at reducing their rates of multiples as much as possible. Not that you understand the risks, hopefully your desire for more than one baby at a time has also diminished. If reducing the chance of multiples does not seem to be a goal of your fertility center, you may want to seek a second opinion. With careful monitoring and by following the ASRM guidelines for the number of embryos transferred, your risk of being an octomom should almost non-existent!
Tuesday, April 12, 2011
What is the cost of infertility treatment?
When researchers study why couple don't seek help for their infertility, they find that fear of the cost is one of the top 2 reasons (the other reason is fear of having multiple babies at once) for not going to see a reproduction specialist. Many couples believe it will take tens of thousands of dollars to get them pregnant. They have heard horror stories of friends of friends who spent $50,000 on fertility treatments. While infertility treatment can get expensive, it doesn't always have to do so. I am going to try to give you a realistic idea of what you may be in for, if you do decide to seek help.
If you are considering going to see a fertility specialist (Reproductive Endocrinologist), one of the first things you should do is check with your insurance company. You may be surprised to find out that you do have coverage. Several states, for instance, have laws that mandate insurance coverage for infertility diagnosis and treatment for all but the smallest of companies. These states include: Arkansas, California, Connecticut, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, Texas, and West Virginia. Ask your insurance company whether infertility diagnosis testing and/or treatment is covered. If you do have coverage for treatment, find out the details. Many plans will cover some treatments, but not others. They may have requirements before you can start a specific treatment, or you may need to sign up for a special program within your insurance company (Aetna often makes you do this). Do you have a deductible or maximum amount they will pay out? Ask if the doctor you are planning on seeing is in their network or not. Be an advocate for yourself and learn as much as you can about your coverage. Your doctor's office may be able to help, but you are ultimately responsible for knowing your insurance coverage.
There is one more question you should ask, but this one is of your doctor. Even if your doctor is in your insurance network, sometimes they have a lab or IVF center that is not. This is unusual, but it does happen. This could mean that your insurance pays for you to see the doctor, but not your testing and treatment. Ask your doctor's office whether they will send your lab tests to a lab that your insurance covers and whether procedures such as IVF will be done through a center that is covered by your insurance. This will help you avoid unpleasant surprises when you open up your bills. If you are wondering, the answer to both questions for our office is yes.
Usually the first step a Reproductive Endocrinologist will want to take is to do some testing to see why you are not conceiving. This is often covered by insurance. Even if you do not have coverage for fertility testing, some of the tests may get billed out with another diagnosis such as ovulation dysfunction, pelvic pain, etc. This may increase the chance that insurance covers it. Many fertility centers, such as ours, also have special deals with laboratories such as Quest or LabCorp to get very good pricing on the common fertility blood tests for couples who do end up having to pay out of pocket. For instance, the common blood tests we do will only cost $50-$60, if you have no insurance coverage. A semen analysis to look at the sperm may also be needed. If your partner has different insurance, don't forget to check and see what his will cover. A semen analysis, if it is not covered, is usually about $75-$100.
There is one test that usually does get billed out as fertility testing and therefore may be denied by your insurance company, if you don't have coverage for fertility testing. That is the hysterosalpinogram or HSG. This is a test to see whether the fallopian tubes are blocked (see previous blog on blocked fallopian tubes for more on the subject). Not all women will need this test; so if your insurance does not cover fertility testing, ask your doctor whether you need the test done or not. If you have no risk factors for blocked tubes like pelvic surgeries or infections, then he or she may be willing to forego the HSG or order a blood test for Chlamydia antibodies instead. Chlamydia is a silent cause of blocked tubes, and a negative test lessens the chances that you have blocked tubes. You may also want to ask about a FemVue procedure (see same blog as above) instead, which may be less expensive. Many hospitals, such as our hospital, also have special deals for couples who pay up front rather than wait to be billed. At Rose Medical Center, an HSG ends up being about $800, though. So even with the discount, it is on the expensive side.
Fertility treatment varies tremendously in cost. The simplest treatment is Clomid or clomiphene citrate (see previous blog on Clomid for more about this medication). Clomid is one of Walmart, Sam's Club, Target, and Kings Sooper's $9 per month prescriptions. If you don't have one of those stores near your, call around. Your local grocery store or pharmacy may have a similar deal. Clomid is sometimes combined with intra-uterine inseminations (IUI). This is a procedure that deposits sperm at the top of the uterus to get get it closer to the egg. An IUI usually costs about $400, depending on the center. An ultrasound may also be used to monitor the ovaries response to the Clomid, and that will probably cost about $200. Oftentimes insurance will pay for the ultrasound. We get about a third of our patients pregnant with Clomid, so many patients never need to go on to more expensive treatments.
Beyond Clomid, things get more expensive. Injectable medication (see blog on injectables) can be as little as $600 a cycle and as much as $4,000 a cycle depending on the dose and how long you end up having to take it. When using injectable medication with IUI, a typical cycle would run about $1,000 - $1,500 in medication. Several of the manufacturers of injectable medications have samples or programs for couples struggling with the cost of medication. Therefore you may be able to get free or at least reduced price medication for a cycle or two. There are ultrasounds and blood tests needed, and the cost will vary depending on how many are necessary. Again, insurance will often cover these as testing. A good estimate would be $1,000 in blood tests and ultrasounds, if insurace does not pay a thing. When using injectables with IVF, the costs are going to be more in the $3,000 to $4,000 range. An entire IVF cycle will typically cost about $14,000 - $16,000 with the medication. The most expensive options involve egg donors or gestational carriers. If another woman's eggs or uterus is needed, then the costs are probably more in the $30,000 (for egg donors) to $100,000 (to hire someone to carry the baby for nine months) range.
So, again, infertility treatment can range from $9 for Clomid to $100,000 for an IVF cycle with a gestational carrier. Many more couples will end up in the few hundred dollar range than in the hundred thousand dollar range, so don't panic. Do a little homework first to see what insurance coverage you have, but then at least go talk to a specialist. You may find that you have a condition that's easy and inexpensive to treat, and, in any case, you will at least get some answers. Don't be afraid to talk to you doctor about any concerns about costs. We understand how expensive certain treatments can be. We will work with you to try to keep the costs down. If your doctor is not receptive to these discussions or seems to be trying to "sell" you an expensive treatment, you may want a second opinion. There are lots of great doctors out there, and we would love a chance to help you get pregnant!
If you are considering going to see a fertility specialist (Reproductive Endocrinologist), one of the first things you should do is check with your insurance company. You may be surprised to find out that you do have coverage. Several states, for instance, have laws that mandate insurance coverage for infertility diagnosis and treatment for all but the smallest of companies. These states include: Arkansas, California, Connecticut, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, Texas, and West Virginia. Ask your insurance company whether infertility diagnosis testing and/or treatment is covered. If you do have coverage for treatment, find out the details. Many plans will cover some treatments, but not others. They may have requirements before you can start a specific treatment, or you may need to sign up for a special program within your insurance company (Aetna often makes you do this). Do you have a deductible or maximum amount they will pay out? Ask if the doctor you are planning on seeing is in their network or not. Be an advocate for yourself and learn as much as you can about your coverage. Your doctor's office may be able to help, but you are ultimately responsible for knowing your insurance coverage.
There is one more question you should ask, but this one is of your doctor. Even if your doctor is in your insurance network, sometimes they have a lab or IVF center that is not. This is unusual, but it does happen. This could mean that your insurance pays for you to see the doctor, but not your testing and treatment. Ask your doctor's office whether they will send your lab tests to a lab that your insurance covers and whether procedures such as IVF will be done through a center that is covered by your insurance. This will help you avoid unpleasant surprises when you open up your bills. If you are wondering, the answer to both questions for our office is yes.
Usually the first step a Reproductive Endocrinologist will want to take is to do some testing to see why you are not conceiving. This is often covered by insurance. Even if you do not have coverage for fertility testing, some of the tests may get billed out with another diagnosis such as ovulation dysfunction, pelvic pain, etc. This may increase the chance that insurance covers it. Many fertility centers, such as ours, also have special deals with laboratories such as Quest or LabCorp to get very good pricing on the common fertility blood tests for couples who do end up having to pay out of pocket. For instance, the common blood tests we do will only cost $50-$60, if you have no insurance coverage. A semen analysis to look at the sperm may also be needed. If your partner has different insurance, don't forget to check and see what his will cover. A semen analysis, if it is not covered, is usually about $75-$100.
There is one test that usually does get billed out as fertility testing and therefore may be denied by your insurance company, if you don't have coverage for fertility testing. That is the hysterosalpinogram or HSG. This is a test to see whether the fallopian tubes are blocked (see previous blog on blocked fallopian tubes for more on the subject). Not all women will need this test; so if your insurance does not cover fertility testing, ask your doctor whether you need the test done or not. If you have no risk factors for blocked tubes like pelvic surgeries or infections, then he or she may be willing to forego the HSG or order a blood test for Chlamydia antibodies instead. Chlamydia is a silent cause of blocked tubes, and a negative test lessens the chances that you have blocked tubes. You may also want to ask about a FemVue procedure (see same blog as above) instead, which may be less expensive. Many hospitals, such as our hospital, also have special deals for couples who pay up front rather than wait to be billed. At Rose Medical Center, an HSG ends up being about $800, though. So even with the discount, it is on the expensive side.
Fertility treatment varies tremendously in cost. The simplest treatment is Clomid or clomiphene citrate (see previous blog on Clomid for more about this medication). Clomid is one of Walmart, Sam's Club, Target, and Kings Sooper's $9 per month prescriptions. If you don't have one of those stores near your, call around. Your local grocery store or pharmacy may have a similar deal. Clomid is sometimes combined with intra-uterine inseminations (IUI). This is a procedure that deposits sperm at the top of the uterus to get get it closer to the egg. An IUI usually costs about $400, depending on the center. An ultrasound may also be used to monitor the ovaries response to the Clomid, and that will probably cost about $200. Oftentimes insurance will pay for the ultrasound. We get about a third of our patients pregnant with Clomid, so many patients never need to go on to more expensive treatments.
Beyond Clomid, things get more expensive. Injectable medication (see blog on injectables) can be as little as $600 a cycle and as much as $4,000 a cycle depending on the dose and how long you end up having to take it. When using injectable medication with IUI, a typical cycle would run about $1,000 - $1,500 in medication. Several of the manufacturers of injectable medications have samples or programs for couples struggling with the cost of medication. Therefore you may be able to get free or at least reduced price medication for a cycle or two. There are ultrasounds and blood tests needed, and the cost will vary depending on how many are necessary. Again, insurance will often cover these as testing. A good estimate would be $1,000 in blood tests and ultrasounds, if insurace does not pay a thing. When using injectables with IVF, the costs are going to be more in the $3,000 to $4,000 range. An entire IVF cycle will typically cost about $14,000 - $16,000 with the medication. The most expensive options involve egg donors or gestational carriers. If another woman's eggs or uterus is needed, then the costs are probably more in the $30,000 (for egg donors) to $100,000 (to hire someone to carry the baby for nine months) range.
So, again, infertility treatment can range from $9 for Clomid to $100,000 for an IVF cycle with a gestational carrier. Many more couples will end up in the few hundred dollar range than in the hundred thousand dollar range, so don't panic. Do a little homework first to see what insurance coverage you have, but then at least go talk to a specialist. You may find that you have a condition that's easy and inexpensive to treat, and, in any case, you will at least get some answers. Don't be afraid to talk to you doctor about any concerns about costs. We understand how expensive certain treatments can be. We will work with you to try to keep the costs down. If your doctor is not receptive to these discussions or seems to be trying to "sell" you an expensive treatment, you may want a second opinion. There are lots of great doctors out there, and we would love a chance to help you get pregnant!
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