ACRM

TTC, When should we get help?

by Mirrin Reagan, RN, CNS, WHNP, MSN

"Is it crazy to see a specialist when we've only been trying for 8 months?"

"I have no idea when I ovulate - my periods are so unpredictable since I stopped the pill.  Should we see a specialist just to help with timing???"

"We haven't even started trying yet, but I'm turning 40 next month and I'm worried about our chances."

Nearly all subfertile couples will worry about these issues when deciding when to seek help from an infertility specialist.  Believe it or not – there are some simple answers. If you are under 35 years old and have been trying for one year or more, you should seek help. If you are over 35 and have been trying for 6 months or more, you should seek help. There are some situations when you should see a specialist even sooner.

• If either partner has ever been through cancer treatment.

• If either partner has had a vasectomy or had her “tubes tied.”

• If the female partner has infrequent or no spontaneous periods.

• If the male partner is taking testosterone or a medicine for high blood pressure called a “Calcium Channel Blocker” - both of these medications can drastically lower sperm count.

• If your gynecologist has ever told you that you may have difficulty getting pregnant.

• If you are getting pregnant but having recurrent miscarriages.

 “We aren't ready to do IVF even though we've been trying to get pregnant for two years. Should we even bother seeing a specialist?”

 One big misconception is that if you decide to see a fertility specialist you will probably have to do In Vitro Fertilization (IVF). Actually, approximately 75% of all patients seeking treatment with a Reproductive Endocrinologist will begin with simple treatments like Intrauterine Insemination (IUI). At ACRM, approximately 25-30% of our patients become pregnant with less invasive treatments including IUI.

If you're wondering if you should be seeing an infertility specialist now, go ahead and schedule a consultation with a Reproductive Endocrinologist to find out what you may could do own your own to increase your chances of pregnancy or what the specialist would recommend next on your journey to growing your family.  

 Mirrin Reagan, Director of Clinical Services, joined ACRM in 2003.  She received her undergraduate degree in nursing at Emory University and completed her graduate training at Georgia State University where she received her Master of Science in Nursing (MSN) in a dual degree program as a Clinical Nurse Specialist (CNS) in Perinatology and a Nurse Practitioner (WHNP) in Women's Health.  She is a board certified Nurse Practitioner and licensed in the State of Georgia. 

Mirrin is a member of the RESOLVE National Nurses Advisory Board and the American Society for Reproductive Medicine Nurses Professional Group.  She is also adjunct faculty and a clinical preceptor in the graduate program at Emory University's School of Nursing.

Recipient-Donor Matching Process

By: Tamara Ard, RN, Third Party Coordinator, ACRM

Matching recipient patients to egg donors is an important part of my job here at ACRM. I like to meet with all of my recipients face to face to get a feel for what is important to them in finding a donor match. It’s sometimes hard for patients to communicate these things over the phone and often times they don’t really know what to say or questions to ask. I assure them that all of the donors are healthy, and screened prior to the matching process. The first piece of criteria, to narrow the pool, for most couples is ethnicity. Once this is discussed, we move to blood type match. If the recipient couple does not want to disclose that an egg donor was used, the donor must be a blood type match to the couple as well. Then it’s a matter of finding a donor candidate that has similar physical features. Lastly, we try to satisfy any personality traits or level of education the couple feel is important to them.

Here at ACRM, we realize that if given a choice, patients would want to use their own eggs to achieve their family and that this is not always an easy process. By carefully matching recipients individually with donors on a one to one basis, we feel we are giving the patients the next best thing.

Test Tube Sperm

By: Chad Johnson, PhD, HCLD, ACRM

In new research, scientists removed stem cells and cultured sperm in the laboratory in a breakthrough that could lead to new treatments and drugs for men currently unable to have children. The development raises hopes that young boys undergoing chemotherapy for testicular cancer will still be able to father their own children when they grow up.

The sperm was produced in a test-tube from the cells taken from a newborn mouse testicles and then injected into eggs to produce to twelve healthy babies, four male and eight female, which were all fertile and able to reproduce themselves in adulthood.

Dr Takehiko Ogawa, an urologist at Yokohama City University in Japan, said the production of sperm in the testes is one of the most complex processes in the body. It has never been reproduced in a test tube in mammals before. They achieved the feat by providing most of the cellular components found in the testicles in a dish and watched as the stem cells grew into sperm cells. They then used IVF (in vitro fertilization) techniques to produce male and female offspring that were themselves fertile.

The researchers, whose findings are published in Nature, said: "The obtained sperm resulted in healthy and reproductively competent offspring."

The testes tissue was still worked after being frozen in liquid nitrogen and could still be used several weeks later – suggesting it may be possible in humans to produce their own biological offspring years later.

"In men, this problem can be mitigated by banking sperm before treatment. The solution is less straightforward in prepubescent boys.

"In this scheme, boys would undergo testicular biopsy before chemotherapy or radiation therapy, to obtain tissue for cryopreservation (freezing).

If infertility occurs, the testicular fragments could be thawed and sperm obtained from organ culture for IVF. This could help discover new drugs or treatments to stimulate infertile men to produce more or better sperm. It also may help preserve the fertility of some males.

You've Had a Tubal Ligation and Now You Want to be Pregnant: What Are Your Options?

By: Robin H. Fogle, MD, ACRM

Once you have had your tubes “tied”, there are two options available to help you get pregnant:  1)  put the tubes back together, called tubal reanastamosis or 2) in vitro fertilization (IVF).   The best option for a patient is dependent on many things including her age and ovarian reserve, the way in which the tubes were “tied”, and what the partner's sperm looks like.  There are pros and cons for each option.

Tubal reanastamosis requires a surgical procedure.  This can be done robotically or through a small “bikini cut” incision.  The patient may have to stay in the hospital overnight and will require from 1 to 4 weeks to fully recover.   The benefits of this approach are that the couple can try  “on their own” without any medical or technological intervention, and therefore the risk of twins is very low.  The downsides of this option include a requirement to undergo surgery, a potentially longer time to conceive, an increased risk of tubal pregnancy, and a need for contraception if more children are not desired.

IVF also requires a procedure (the egg retrieval), but it only takes 20 to 30 minutes.  The patient is typically discharged 1 to 2 hours afterwards.  Hospitalization is not necessary in the vast majority of cases.  Time to conception is much faster, but there is an increased risk of twins and multiple pregnancies with IVF.  After pregnancy, contraception is not required because the patient's tubes remain tied.

Let's look at some examples to help understand why a couple might choose one option over the other.

Suzy Q is 30 years old and newly remarried.  She had her tubes tied 5 years ago. She and John Q want to have at least 2 kids together.  All of her ovarian reserve testing is normal, and John's sperm look great.  This couple might benefit from having a tubal reanastamosis.  On the other hand, they would also be great candidates for IVF.

Mary T is 41 years old.  She and husband, Mark T, have decided that they want one more child even though 5 years ago Mary T had her tubes tied.  Her ovarian reserve testing is normal for her age, but John's sperm count is a little lower than normal.  Because of her age and decreased natural ability to get pregnant, along with John's slightly lower sperm count, this couple should strongly consider going straight to IVF.

There are many other scenarios, so each couple's choice has to be based on their unique situation.

At ACRM, we are happy to walk couples through these choices and outline the pros and cons of each option.  We are comfortable performing both robotic tubal reanastamosis and IVF and will help you figure out which is the best option for you to as you work to grow your family.

Having a Baby After a Vasectomy

By: André L. Denis, MD, MPH, ACRM

Vasectomies are a widely used method of contraception today. The failure rate is extremely low such that they are a very dependable way of avoiding unwanted pregnancy. Sometimes a man who thought his family was complete may changes his mind and wants to have more children after a vasectomy has been performed. There are a couple of ways of resolving this dilemma.

The traditional approach has been to carry out a second surgical procedure wherein the severed vas deferens (the tubes within the scrotal sac which carries sperm from the testicles to the outside world) is sewn back together. This is a microsurgical procedure which is actually far more technically involved and complicated than the original vasectomy where a piece of the vas was burned, removed or clipped. The procedure will typically take a couple of hours to perform and is done by urologists with who have undergone specialized microsurgical training. The procedure can be technically successful in 60-70% of cases if the vas deferens was not excessively destroyed in the original vasectomy procedure. Unfortunately, these results are not always the case and the actual patency rate (i.e. sperm are found in the ejaculate after the procedure) is lower. The other complicating factor with surgical repair is the prevalence of anti-sperm antibodies. These antibodies will prevent normal sperm function if they are present. They are found increasingly frequently the longer it has been since the original vasectomy was performed. Most researchers agree that they are rarely found within 5 years from the original vasectomy and are almost always present more than 10 years from the original procedure. In these latter cases, even if the vasectomy reversal procedure is technically successful, the sperm will not be normally functional therefore the surgery probably will not lead to successful conception. It may take a few months to see sperm within the ejaculate following a reversal procedure and unfortunately in some cases despite sperm being present initially post-operatively, there is progressive scarring which leads to re-closure of the vas.

The other approach available today is to carry out In vitro fertilization (IVF) and intra-cytoplasmic sperm injection (ICIS) using aspirated sperm. We've always been able to aspirate sperm using a fine gauge needle directly from the testicles. Under local anesthesia, it is quite realistic to pass a needle directly through the scrotum into the testicle itself or the epididymis (the network of tubules adjacent to the testicle where sperm finish their maturation process and are stored prior to ejaculation) and aspirate sperm. The limiting factor has always been that we can only retrieve thousands of sperm in this fashion and we need tens of millions for intercourse to establish pregnancy or millions for inseminations to do so. Using the technology of IVF/ICSI however, we only need one sperm for each egg available. Since we may typically get 10-15 eggs during an IVF cycle, we'd only need 10-15 sperm for success. Therefore the sperm aspirated in this fashion are more than enough for multiple attempts. The advantages of IVF/ICSI versus vasectomy reversal are multiple. Success rates do not depend on how much damaged was caused by the original vasectomy. The presence or absence of anti-sperm antibodies is irrelevant because the sperm do not need to be able to swim on their own during IVF/ICSI. Also because IVF is being done, female fertility problems such as tubal issues, endometriosis, ovulation problems and so on are all automatically being bypassed. Success rates for IVF/ICSI using aspirated sperm following vasectomy are among the highest in couples doing IVF and the live birth rates are certainly equal if not better than those seen following vasectomy reversal. Lastly this approach is far more efficient in that the whole process from beginning of testing to starting obstetrical care could certainly be carried out in a 2-3 month time frame whereas the surgery itself may be carried out a month or so after testing, it may require months to see normal sperm in the ejaculate and the couple may then have to try for several months before conceiving.

In summary, in couples wishing to have a pregnancy following vasectomy,  IVF/ICSI using aspirated sperm is at least as successful as reversal surgery, its risks are extremely low and it costs about the same as surgery and it is far more efficient than surgery in terms of time to conception. Couples undergoing IVF/ICSI can continue to work normally and lead their regular lives without the need for a convalescence period and lastly after the couple has had a successful conception they still have a very reliable method of contraception in place.

Top Questions to Ask your Insurance Company

By: Steven C. Gerson, CPA, MPAcc, Chief Financial Officer, ACRM

One of the best ways to be certain that there are no surprises with your infertility insurance coverage and payments is to be sure to ask a lot of questions to your insurance company, and to ask the right questions.  Here’s a guide for you in talking with your insurance company.

Do you know what type of fertility coverage your insurance company provides?

GENERAL:

What are my fertility benefits?

• Do I need a referral to obtain fertility treatments?
• Do I need a pre-certification to obtain fertility treatments?
• Do I have co-pay or deductible for fertility treatments?
• Do I have a lifetime maximum benefit for infertility?
• Maximum allowed attempts for IUI and/or IVF?

 

COVERED SERVICES:

Do you cover medication administration education (mixing medications and injections)?

What treatments or procedures related to treatments are covered?

• Ultrasound?
• Medical Fertility Therapy?
• IUI/artificial insemination?
• IVF?
• Intracytoplasmic Sperm Injection (ICSI)?
• Cryopreservation?
• Assisted Hatching?
• Preimplanation Genetic Diagnosis (PGD)?

Are there any requirements which must be met before my fertility benefits become effective?

• Certain number of IUIs before IVF can be attempted
• Documented medical history of infertility?

What diagnostic testing is covered?

• Diagnostic prenatal labs (Hep B, Hep C, HIV, etc)?
• Progesterone, Estrogen and AMH levels?
• FSH, LH, TSH and Prolactin levels?
• Semen analysis?
• Hysterosalpingogram (HSG), sonohysterogram (SHG), endometrial biopsy, ultrasound?

Are prenatal screening (infectious diseases) and genetic carrier screening tests covered?

Are lab services covered at the infertility clinic’s lab, or am I restricted to certain lab/facilities?

What treatments are excluded?

Are donor sperm and/or egg options covered?

Is cystic fibrosis carrier screening covered?

• CPT codes 83894, 83896, 83912, 83901
• ICD9 code V26.3

MEDICATIONS:

Which medications are covered?

• Clomiphene Citrate (Clomid)?
• Letrozole?
• Gonadotropin Injectibles (FSH or LH medications: Follistim, Gonal-F, Bravelle, Luveris,

                            Menopur, Repronex and others)?

• GnRH Agonists/Antagoinists (Lupron, Ganirelix, Cetrorelix and others)?
• Progesterone/Prometrium/Endometrin  (tablets, suppositories, injections and others)?
• Estrogen/Estrace (tablets or patches)?

 

(Note: These questions are meant as a guide only. You should be aware all expenses may not be covered.)

What to do if your claim is denied

By: Irene Laschuk, Manager, Patient Financial Services, ACRM

Knowing what your infertility benefits are isn't enough.  You need to make sure you're receiving the benefit you're entitled to.  Every claim will generate an “Explanation of Benefits” from your insurance company.  In most cases, your “EOB” should be available online.  If you can't access it, then call your insurance company and ask one be mailed to you.  Your EOB details exactly how your insurance company processed your claim.  It will let you know what was paid to the doctor by them, and how much you owe (patient responsibility), if anything.   

It's important for you, as the consumer, to understand how the insurance company processes your claims (either pay or not pay).   They look at (1) whether all provisions of the plan have been met (authorizations, referrals, etc.); (2) are the services (procedures) rendered covered by the plan; and (3) is the reason (diagnosis) for providing the service covered by the plan.   To ensure your claim processed correctly, you should determine whether or not these requirements have been met.   

If you think your provider may have made an error in the information submitted to the insurance company, your best avenue for resolution is to contact your nurse and verify that the clinical information submitted is correct.  If an error was made, please ask that a corrected claim be submitted.  If not, then no change in coding is in order.  

• If you believe your claim processed incorrectly, you should appeal the decision.  Be sure you have the following information as you get ready to file your appeal. 

 

• The reason for the denial.  The specific provision in your policy that excludes this treatment should be cited in the explanation of benefits (EOB).  

 

• The process (required by your plan) to be followed in filing an appeal.  Normally, this process will need to be followed to the letter.  

 

• The name and phone number of a contact person at your insurance company.  Your health plan administrator should be able to give you the name of the appropriate person to contact.  

When you contact your insurance company, let them know you're calling about a claim that you believe was processed incorrectly.  Always get the name of the representative to whom you are speaking, and a call reference number (if available).  Should you need to make several appeals, this documentation will prove to be very helpful. 

At ACRM, our patient account representatives are always available and happy to assist our patients with understanding their benefits and how their claims processed. 

Are You Overweight? How Your Weight May Be Impacting Your Fertility

By Paige Espenship, RD, ACRM

   Are you at a healthy weight?  If not, you may be decreasing your chances of becoming pregnant.  Women and men who are over or underweight are more likely to have hormone imbalances which can directly impact your fertility.  In addition to setting yourself up for a healthy pregnancy and creating a healthy environment for your children, a healthy weight can increase your chances of conceiving and carrying a child to full term.

   A healthy weight is not necessarily a normal weight.   Keep in mind that 60% of Americans are overweight or obese.  So the majority of our country is not anywhere close to their ideal weight.  In fact, when I tell patients what they should weigh, many of them balk in disbelief stating that they haven’t weighed that since their early high school years. 

   Body Mass Index (BMI) is the main tool that we use to determine a person’s ideal weight.   BMI is just a quick look at a person’s height and weight.  It started in the 1940’s with data collected by the Metropolitan Life Insurance Company’s tables which showed a very clear connection between  height, weight and death rates.  The BMI range that consistently shows the best health and the lowest death and illness rates is 18.5 to 24.9.  This also happens to be the Fertility Zone, the weight range for your height that promotes the healthiest hormonal environment.  For a woman who is 5’5” that translates to a weight range of about 111 lbs to 149 lbs, anything above or below that range is considered less healthy.  Like all great things in life, BMI charts do not come without some exceptions to the rule.  BMI does not work for athletes (people who are trained to compete in sports and possess physical strength, speed, agility and stamina).  It tends to overestimate an athlete’s fat mass.  Now, just because you go to the gym and do the elliptical and lift some weights for 45 minutes 4 or 5 times a week, you are not considered an athlete.  Athletes generally make exercise at least a part time job.  BMI is also not a good reflection of true health for the elderly population because it overestimates muscle mass.  But for the majority of us, BMI is an excellent indicator of our true health status as it relates to weight.   You can calculate your BMI by going to www.nhlbisupport.com/bmi

   So again, the majority of us in this country are overweight.  How does this impact fertility?  Too much body fat can dramatically alter your hormones, which can directly affect your chances of conceiving and sustaining a healthy pregnancy.  Extra body fat is associated with excess insulin and insulin like growth factor and a decrease in sex hormone binding globulin which leads to excessive testosterone production in women and excess estrogen production in men.  These equal problems for conception for both men and women.

  Fat tissue, also called adipose tissue, is not just a place to store fat.  Adipose tissue is very hormonally active and plays a major role in appetite, weight, activity, and reproduction.  Adipose cells make a very helpful protein called adiponectin which normally tells your body to burn extra fat and increases insulin sensitivity, however too much fat actually decreases the amount of adiponectin, which works to your disadvantage by decreasing insulin sensitivity  and slowing metabolism. 

   Too much body fat also increases levels of interleukin-6, leptin, plasminogen activator inhibitor-1, resistin, and tumor necrosis factor, all hormones that stimulates cell growth, communicate info about energy stores, inhibit blood clots, influence insulin sensitivity, and mediate inflammation.  This can mean problems with ovulation or interference with implantation of a fertilized egg. 

   The same may be true for men.  Even though there is not yet a good measure of a man’s ideal “fertility zone” for BMI.  The same hormonal factors may influence a man’s fertility by interfering with insulin, testosterone and estrogen balance.

   So, with all of that said, what if you are a long way off from your ideal weight range?  Don’t despair.  Moving in the right direction and losing 10 percent of your body weight may be enough to help eliminate some of these hormonal problems.  Weight loss should be slow and steady.  It is better to lose 4 to 8 pounds per month than it is to lose 20 pounds all at once.  The slower you take it off (as long as you keep taking it off), the more likely it is that you are burning the unhelpful fat cells while maintaining your muscle mass.

   Here’s a start.  Try these 10 tips to help you lose 10 pounds over the next couple of months.

1. Eat at least 4 cups of non-starchy vegetables everyday. The darker the color of the vegetable the better. 
2. Check labels for all of your dried packaged grains like cereal, bread, pasta, rice, crackers, popcorn, bakery items, etc.  Look for and buy foods that have more dietary fiber than sugar on the nutrition facts panel.
3. Cut out sweetened drinks and artificial (zero calorie) sweetners.  This will go a long way in saving you extra calories.   People who eat or drink artificial sweetners tend to eat more calories throughout the day.  They also interfere with insulin sensitivity.
4. Eat between two and four cups (or pieces) of fresh fruit per day.  Avoid drinking fruit juice, you get more nutrition and fewer calories from eating the fruit.
5. Choose lean meat almost always.  Five or six days a week don’t let skin on poultry, fatty cuts of pork, beef or fried anything near your lips.
6. Keep the amount of added fat in check.  This means ordering your salad dressing on the side and only add what you need for flavor.  Spread peanut butter, mayo or butter thin on your bread.  One handful of nuts is plenty as a snack.
7. Do something physically active for 30 minutes every day.
8. Drink enough water.  Generally speaking you need 1 liter of water for every 1000 calories you eat.  So if you are on a 1500 calorie diet, you need about 6 eight ounce glasses of water.  For every 30 minutes of exercise, drink another 8 ounces.
9. Earn or burn your extra luxury calories with extra exercise.  You know when you are indulging.  If you order that slice of chocolate cake after dinner, do some extra exercise that same week to afford those calories.  Think in 100 calorie increments.  For every 100 calories of junk (cake, cookies, milkshakes, candy) you eat, do another 20-30 minute workout to afford it. 
10. Keep a food record.  Write down everything you eat and drink.  This goes a long way in keeping you on track.

What is the Attain IVF Refund Program?

By: Irene Laschuk, Manager, Patient Financial Services, ACRM

The Attain IVF Refund Program is how you can take the financial risk out of trying.  It can take several attempts at IVF before realizing a successful outcome leaving some to wonder, “How do I pay for multiple cycles?”  “What if it doesn't work?”  “Will we have anything left to explore other options?”  The IntegraMed Attain IVF Refund program, offered exclusively through ACRM, has a way for you to put these concerns aside.

The Attain IVF Refund Program is a six-cycle treatment package with a refund guarantee.  Those who qualify pay approximately the cost of two IVF cycles upfront and get up to three IVF cycles and three frozen embryo cycles.  If you do not take a baby home from the hospital, you are entitled to a refund up to 70% of the program fee. 

Around 60% of patients under 35 will need more than one cycle to achieve success.  As patient age increases, so do the number of cycles. Patients who commit to multiple IVF cycles almost double their chance of having a baby. 

With the Attain IVF Refund Program, you're able to pay a fixed, discounted fee for multiple chances at success.  You can now concentrate on your treatment.  We have dedicated customer care groups at ACRM and IntegraMed that are happy to assist you with financial options, financing and work with you through the entire process.  For more information about the Attain IVF Refund Program please visit our website and select financial services.

Tubal Disease, Hydrosalpinges and Infertility

By: David L. Keenan, MD, FACOG, ACRM

Approximately 25% of female infertility is due to blockage of the fallopian tubes. The fallopian tubes are very delicate structures that are responsible for picking up the egg and providing the site for fertilization and early embryo development. The tube is narrowest at the inner portion that joins the uterus and then widens in the outer portion that has finger-like projection called fimbria. The fimbria are responsible for picking up the egg. The cells lining the tube produce secretions that nourish the egg and embryo. The tubes are frequently damaged by infections (e.g., chlamydia, gonorrhea) or other pelvic conditions such as endometriosis or even severe appendicitis.

Scar tissue and blockage can occur at either the inner or outer portion or in both of those regions of the tube. If blockage occurs at only the outer portion then the secretions of the tube will be unable to drain out of the end of the tube and swelling of the tube will occur. This is known as hydrosalpinx (literally water in the tube.)

There are two different approaches to treating infertility that results from tubal damage. If there is mild damage then surgical repair can be attempted. If there is severe damage then the results of surgery are poor and IVF (in vitro fertilization) is recommended to bypass the fallopian tubes.