ACRM

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.

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.

ACRM’s Dr. Lisa A. Hasty is recognized as a 2011 Top Doctor

Please join ACRM in congratulating Dr. Lisa Hasty on her recent recognition as one of  Atlanta's 2011 Top Doctors   in  the July 2011 issue of  Atlanta Magazine . 

 

In Atlanta Magazine's annual Top Doc issue, Lisa A. Hasty, MD, has been recognized by hundreds of her esteemed colleagues and peers in the metro area as one of the most respected doctors in Reproductive Endocrinology for the second year in a row. 

Dr. Lisa A. Hasty is a founding partner of ACRM and is board certified in Obstetrics and Gynecology and Reproductive Endocrinology and Infertility.  She received her undergraduate degree in Pre-Med from Davidson College and earned her medical degree from Emory University School of Medicine.  In 1985, Dr. Hasty accepted a residency in Obstetrics and Gynecology at Pennsylvania Hospital in Philadelphia.  Following her residency in 1989, Dr. Hasty remained with the University of Pennsylvania.  Dr. Hasty is an elected Fellow of the America College of Obstetrics and Gynecology (ACOG) and an active member of the American Society for Reproductive Medicine (ASRM), the Atlanta OB/GYN Society, and the Atlanta Women’s Medical Alliance of which she is an appointed member of the advisory board.  Her particular areas of interest include in vitro fertilization, treating uterine myomas and third party reproduction.

Atlanta Magazine partnered with Castle Connolly Medical Ltd., a healthcare research firm based in New York, to complete this year's survey.  This unbias third party asked a randomly selected sample of board-certified physicians and key medical leaders to identify exceptional Atlantan doctors in their respective specialties.  As a result of the hundreds of medical professionals surveyed, Atlanta's Top Doc's are named. 

Please join ACRM in congratulating Dr. Hasty and the other esteemed physicians that have been recognized in Atlanta Magazine's 2011 Top Doc issue.

Stress and Fertility

By: André Denis, MD, MPH, FACOG, ACRM

There is a lot of confusion surrounding the impact of stress on reproduction. It certainly “makes sense” that stress would interfere with reproduction but that's not quite accurate.

We've known for years that stress can affect ovulation. Women under the impact of stress may skip menstrual cycles or they may stop having cycles altogether. A classic example of this may be the young woman who is leaving her parents' home for the first time to go to college. Although theses young women are excited and happy about this new phase of their lives, the underlying fear and stress of being away from home can affect ovulation and it isn't at all unusual to find that some of these women in the dorms may skip a few periods. As they get used to their new life and the stress of it recedes, normal, regular ovulation will return. There's nothing “wrong” in these cases, it is the consequence of a well understood interaction in the brain between the stress hormones (such as cortisol) and the hypothalamic area of the brain which controls ovulation. If a woman is not ovulating, of course she will not be able to conceive.

What is less clear is the impact of stress on the reproductive potential of a woman who continues to ovulate. Despite common belief, the presence of stress will not prevent pregnancy. Similarly a woman cannot stress herself into miscarrying. A woman cannot stress herself into infertility or miscarriage!  There is no scientific data showing this to be the case. If we consider extreme cases of stress, we can see how this is true. We see that women who are in tragic situations such as victims of sexual assault, or women who are caught in war zones, continue to conceive and give birth at normal rates. These women are facing the highest levels of stress imaginable and nonetheless their reproductive potential remains unaffected.

Should we just ignore stress then? Of course not. There was some very interesting research done in the past looking at the impact of stress on treatment.. What the research showed was that among the women who had self-perceived stress and who tried stress reducing interventions, fertility treatments were more efficient, leading to pregnancy more quickly. It is important to note that the interventions (counseling for example) did not eliminate the stress in their lives, instead the patients were given tools to deal with the ever-present in a pro-active fashion.

So what should couples do if they perceive stress in their lives? They should address it. The first level of intervention is the common sense approach. Make sure you're getting enough sleep. Exercise regularly, eat a balanced diet. If these approaches don't seem to be enough, it would then make sense to get some outside help, for example, to meet with one of our counselors or to start acupuncture. The reason we provide these services at ACRM is that they help our patients and may ultimately increase the efficiency of treatment. There's no honor lost in asking for help, and if our patients are pro-active in dealing with the stress in their lives, we know that not only will they feel better, but also there's a very good chance that they will conceive more quickly!

ICSI: The Technique

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

The power of Intracytoplasmic Sperm Injection (ICSI) is that it only requires one sperm to be effective, not 20,000,000.  ICSI is a simple and precise way to transfer one sperm directly into one egg.  Using a specially equipped microscope to see the sperm, an embryologist gently draws one sperm into a pipette.  The tip of the pipette is then guided into the egg.  The egg is held steady at the end of another glass pipette.  Now, with sperm and egg ready, the precision of ICSI is revealed.  With a steady and measured forward motion, the sharpened tip of the sperm-containing pipette is inserted into the egg.  Reversing the process that pulled the sperm into the pipette, the embryologist now injects the sperm into the egg.  And finally, the sharpened tip of the empty pipette is removed from the egg.  This is then repeated for each mature egg (keeping in mind that about 90% of eggs are mature).  In cases where very few sperm are present, it may take hours to find sperm, but only minutes to inject each egg.

Male Infertility & ICSI

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

Male infertility accounts for approximately 40% of the 2.3 million diagnosed infertility cases in the United States.  Traditionally, couples with male infertility had three options:  using donor sperm, adopting or electing not to have children.  The desire of patients with male factor infertility to have biological children was a strong force to further the development of new treatment approaches.  Treatment options for male infertility depend on the specific cause of the infertility and include surgery, pharmacotherapy, and/or microinsemination techniques.

Microinsemination is laboratory-assisted fertilization of an egg.  Intracytoplasmic sperm injection (ICSI), a specialized form of microinsemination, was first developed by reproductive medical specialists in Belgium to help couples overcome male infertility problems associated with an inability of sperm to fertilize an egg.  Since then, ICSI has been successfully used to treat male infertility and is helping more couples to realize their dream of having biological children.  Today, with thousands of “ICSI” babies born worldwide, the technique is no longer considered experimental. It has received endorsement from the American Society of Reproductive Medicine, formerly the American Fertility Society, and is among the routine services offered by our state-of-the-art reproductive endocrinology practice.