Half Science Half Miracle

Transcription

1 Half Science Half Miracle Your guide to fertility treatment Servy Institute for Reproductive Endocrinology Servy Massey Fertility Institute Written by: Beth Purvee Assisted Reproduction Coordinator 1

2 The female anatomy The female reproductive system has six (6) main parts; vagina, cervix, uterus, endometrium, fallopian tubes and ovaries. The vagina is an expandable cavity that serves several functions. The first is to allow the penis to enter for sexual intercourse. The second is to allow menstrual blood to pass from the uterus out of the body. The third is to serve as the passage for the baby during childbirth. The cervix is the connector between the vagina and the uterus. The cervix produces a mucus that is constantly changing to first help the passage of sperm and secondly to protect the growing baby from infection or premature childbirth. The cervix leads into the uterus, a thick muscle about the size and shape of a small pear. The lining of the uterus is the endometrium. The endometrium becomes thick during a woman s monthly cycle to provide a cushion for the growing baby to snuggle into. If conception does not take place, the lining will shed at the end of her monthly cycle, also known as your menses. Two arms extend out of the uterus called fallopian tubes or oviducts, which means egg canal. The end of the tube is shaped like a flower, whose petals sweep the ovary like a broom at the time of ovulation to pick up the eggs as they are released from the ovary. These tubes are the place where the egg and sperm meet and the egg is fertilized. The ovaries rest at the end of the fallopian tubes. The ovaries are about the size of a large grape and serve several purposes. First they grow and release an egg(s) each month in the process called ovulation. Secondly, they are a part of the endocrine system because they are responsible for producing the hormones estrogen and progesterone. 2

3 A woman is born with all the eggs she will ever have. When a girl is born, she has about 1 million eggs. At puberty, the number of potential eggs has decreased to only 300,000. The eggs grow inside a house called a follicle. We can measure the size of a follicle by ultrasound, but we can only see the egg with the use of a microscope, outside the body. A woman s monthly cycle is determined by four primary hormones and several secondary hormones. Two hormones, Lutenizing Hormone (LH) and Follicle Stimulating Hormone (FSH) are both produced by the Pituitary Gland. Estradiol and Progesterone are both produced by the ovaries. The levels of these hormones rise and fall each month depending on the phase of your cycle to support ovulation (the process of releasing eggs) and implantation of a young embryo. They are also responsible for your monthly menses. The next picture shows you an average rise and fall of hormone and how they relate to your monthly cycle. The male anatomy 3

4 The male reproductive tract consists of 3 major organs, two testicles and a penis and 3 tubes, 2 vas deferens and the urethra. The testicles are responsible for producing sperm and hormones such as testosterone. Immature sperm then travel to the epididymis portion of the testicle where sperm are stored until maturity. It takes about 70 days for sperm to reach full maturity. During ejaculation, sperm travel from the epididymis, through the vas deferens and into the urethra and out from the penis. The urethra also carries urine from the bladder into the penis during urination. Seminal fluid is produced by the prostate gland which mixes with the sperm shortly before it is ejaculated to form semen. One milliliter of semen may contain 20 million or more sperm. How conception takes place Near the middle of a woman s monthly cycle, the ovary will release an egg that will travel into the fallopian tube. During intercourse, semen is deposited into the vagina. The cervix makes special mucus during the time of ovulation that allows the sperm to travel into the uterus and then to the fallopian tubes. If sperm are waiting in the fallopian tube when the egg reaches it, fertilization may take place. The fertilized egg, now called an embryo, will spend two or three days traveling through the fallopian tube. On day 4 or 5 of the embryo s life it will travel into the uterus where on day 6 or 7 it will implant into the endometrial lining that has built up. 4

5 Many eggs will be fertilized during the reproductive years, but only a few will complete the process of implantation and continue growing. Some embryo will not be allowed to travel through the fallopian tubes for various reasons and the embryo will continue to grow there. This is known as an ectopic pregnancy. Sometimes these embryos stop growing on their own. Other times, it requires medical or surgical treatment to remove the pregnancy from the tube. If you have had an ectopic pregnancy in the past you are at a higher risk for having another one. 5

6 Diagnosing Infertility Our belief is that no infertility is unexplained. We also believe in finding the problem and correcting it to allow you to conceive in the most natural way available to you. We will run a variety of diagnostic tests to try to identify the problem before treatment begins. Female Testing On or near your first visit, you will have a complete exam and history and a pap smear, if you have not had one in the last year. It is important to be clear, honest and accurate about your medical history. You will also be scheduled to have an ovarian reserve test. These tests must take place on day two or three of your menses unless otherwise instructed. For the ovarian reserve test, you will have an ultrasound and bloodwork. The ultrasound will show us your uterus and ovaries. We will be counting your potential follicles (a.k.a. antral follicles) and determine if there are physical reasons you may not be getting pregnant. For the blood work, we will be checking several hormones, both primary and secondary hormones, looking for imbalances. Some tests include: 1. Estradiol an ovarian hormone released as follicles mature. Estradiol also supports an early pregnancy until the placenta is established at 8-10 weeks. 2. FSH a pituitary hormone that helps us determine the quantity and quality of remaining eggs in the ovary. FSH is responsible for follicle and egg production. This test is only reliable when measured on day 2-3 of your menstrual cycle. 3. LH a pituitary hormone that is responsible for triggering ovulation. LH must be in balance with the other hormones for ovulation to take place correctly. 4. Prolactin is a hormone responsible for breast milk production. If the level of prolactin is too high, it will interfere with FSH and LH production. 5. TSH and Free T4 These are both thyroid test that evaluate how well your thyroid gland is working. If your thyroid function is too high or low, it will prevent the ovaries from working properly. 6. Progesterone- an ovarian hormone released by the follicle after ovulation. It helps build the endometrium for the future embryo. 6

7 Depending on your specific exam and/or history, there are other test we may order that may include glucose and insulin test and androgen hormone tests. We also may ask you to record your basal body temperature (a.k.a. BBT) beginning with your next cycle. This is done very simply by checking your temperature with a digital thermometer before you get out of bed each morning and recording the temperature on a graph. This is the most simple and cost effective way to determine if you ovulate regularly. The temperature rise in the second phase of your cycle is directly related to the presence of progesterone. Your temperature may be abnormally elevated or lowered if you take Tylenol, Ibprophen, etc. before bed, drink alcohol and walk around during the night. If you become ill during the month, that may also change your temperature. BBT is useful to the physician to tell if or when ovulation took place during your last cycle. It is also useful in determining the length and quality of progesterone released by the ovary. You can obtain a BBT chart from our office or there are many available online. A few examples are or Picture from early-pregnancy-test.com We will want to check if your tubes are healthy by ordering a Hysterosalpingogram (HSG). This is a test performed by the doctor at an outpatient surgical or radiology center and must be done after your menses finishes and before you ovulate. Dye will be injected into your uterus and its progress will be watched with x-ray. This test takes about 30 minutes with minimal discomfort. It is very important to tell your doctor if you have ever had an allergic reaction to iodine, betadine, shell fish and/or squid or octopus, or CT contrast. The black area you see in the picture is the HSG dye filling the uterus and beginning to fill the fallopian tubes. 7

8 A Saline Infusion Sonogram (SIS) is a test performed in the office to check the endometrial lining of the uterus. It tells us if there are polyps or fibroids growing into the lining that would prevent an embryo from implanting. The black area in the center of the picture is the fluid, the grey area around it is the uterus. The first picture is of a normal SIS, the second picture is of a SIS that showed a polyp in the lining of the uterus. 8

9 A Post Coital (PK) test is a test that checks your cervical mucus and your partner s sperm. This test is performed at the time of ovulation. You will be instructed to have intercourse the night before the test and you will be seen the next morning. It is important not to use any type of lubricant during intercourse for this test. A sample of your mucus will then be examined under the microscope. We use this test to determine if you need to have intra-uterine insemination (a.k.a. artificial insemination or IUI). Repeat Miscarriages A certain group of couples come to see us that have no trouble conceiving, but the embryo stops growing each time. We refer to this as repeat fetal loss. For these couples we have a set of test that includes genetic studies and antibodies. A woman may have antibodies in her blood that fight the embryo, just as it would a cold or food allergy. Most of the time these antibodies can be treated very simply once we have them identified. A caryyotype is a study of the chromosomes to make sure there is no abnormality with their chromosomes. This test does not check for specific genetic disorders. If you have a family history of a genetic disorder, please let us know, so we can check for that specific disease. Repeat fetal loss can also be due to an infection or a chronic inflammatory process. Male Testing On or near your first visit, you will be asked to provide a semen sample. Your sperm will be checked for quantity, movement, shape and signs of infection. If you have ever had a semen analysis in the past, please provide us with a copy. The lab we refer men to does several tests most labs do not do that are specific to our treatments. If another lab performed your test, you may be asked for another sample. If your semen analysis is abnormal, we may order blood work that may include a caryotype, cystic fibrosis and hormone levels. You may also be asked to have an exam to check for testicular abnormalities. 9

10 Surgery Depending on the results of your test, history and exam, your physician may recommend surgery. There are three main types of surgical procedures; hysteroscopy, laparoscopy and laparotomy. A hysteroscopy is a thin flexible scope and light that is inserted into your cervix to look inside your uterus. This procedure is especially helpful if you have a history of abnormal bleeding or heavy periods or have scar tissue inside your uterus. Most repairs can be done at this time including the removal of polyps and scar tissue. A laparoscopy is a thin flexible scope and light that is inserted through your belly button. It is used to look around your pelvis at the outside of your uterus, ovaries, tubes and other nearby organs. Most repairs can be made by two tiny incisions along your bikini line. On occasion a small incision or mini-laparotomy is needed. This is common for large fibroids or complex repairs to the ovaries or fallopian tubes. 10

11 Roadblocks to Fertility There are many events that must take place for conception to happen. If any one of these events is disturbed in any way, it can cause infertility. Female Diagnosis s There are three main areas where problems can occur within the woman; the uterus, the tubes and/or ovaries and hormonal abnormalities. For some women, there is only one problem that will need correction. For others, there may be multiple problems, related or unrelated to each other that will prevent conception from happening. Uterine Conditions The uterus is a smooth muscle about the size and shape of a pear. Some women will develop muscular growths within the wall of the uterus called fibroids or myomas. These fibroids may or may not cause a problem. If the fibroid is situated near the endometrial lining or grows into the lining, it can cause irregular bleeding or interfere with the implantation of an embryo. If your fibroids are thought to be a hindrance to conception, surgery is the best way to remove them if you are trying to conceive. There are two other methods to treat fibroids, embolization and monthly injections of long acting inhibors. They both can affect your ovarian function. Endometritis is a condition where the uterus has an infection. The most common symptoms of endometritis are a history of vaginal discharge and pelvic pain; although many people do not have any symptoms. When you are examined, the doctor may notice the discharge or feel that you have fever in your uterus or pelvis. The diagnosis can be confirmed by biopsy. Another indication of infection is tenderness when one area of your pelvis is touched. Most often the couple together will be treated with several rounds of antibiotics to clear the infection. Endometritis is not a STD, although the bacteria causing it can be passed back and forth between partners. The men may store the shared germs in their prostrate. Most men report not having any symptoms at all although some have lower back ache or chronic fatigue. Asherman Syndrome is a condition where scar tissue grows within the uterus. This scar tissue will interfere with the implantation and growth of the embryo. Asherman can be diagnosed and sometimes treated by hysteroscopy. Cervix 11

12 Many women have problems that lie within the cervix. The cervix is the canal that connects the vagina to the uterus. It creates different types of mucus that changes as your hormones change. If your cervix does not create enough mucus or the mucus is too thick, the sperm cannot swim into the uterus to reach the fallopian tubes and the waiting egg. Another potential problem may be chronic cervicitis, an infected cervix may be described as a strawberry cervix, a cervix that is red, inflamed and has polka dots. Treatment may include oral antibiotics, vaginal cream antibiotics, and/or freezing of the cervix. You may also have had treatment on your cervix because of an abnormal pap smear or infection. If you have had a LEEP (laser procedure) or cone biopsy treatment on your cervix, it may have disrupted the ability of the cervix to create the proper mucus. As the baby grows, it causes more weight and pressure on the cervix. On occasion, the cervix can be recognized as being incompetent, meaning it is too short or too weak to hold a pregnancy until full term. It may begin to dilate or open before it is time, causing premature delivery. This can be prevented by putting a stitch around the cervix to keep it closed and give it strength. This is normally done around 12 weeks of pregnancy, although sometimes it is done later if a problem arises later in the pregnancy. Ovaries and Tubes Approximately 10-15% of women with infertility trouble suffer from a condition called poly-cystic ovarian syndrome or PCOS. This begins with an imbalance which can affect the androgen hormones (testosterone belongs to this group) being overproduced. Women may experience excessive hair growth, obesity, pre-diabetes, hypertension, acne, irregular menses, decline in ovulation, and problems with glucose and insulin balances. On ultrasound the ovaries may have a pearl necklace appearance. These ovaries hoard their eggs like a squirrel hoarding nuts for winter. If a normal ovary looks like a chocolate chip cookie with about 8 chocolate chips, a PCOS ovary will have or more chocolate chips. If you are not trying to become pregnant, oral contraception, or birth control pills, may be prescribed to help regulate your menses, and help with hair growth and acne. If you are tested for glucose and insulin abnormalities, you may be asked to begin a mild diabetes medication to help regulate your glucose insulin response. 12

13 If you are ready to conceive, we will begin infertility treatment. Most of the time, this will require fertility medication and either insemination or in vitro fertilization. Women with PCOS are at a slightly higher risk for hyper stimulation, too many eggs growing at once. Recent literature suggests that losing 5-7% of your body weight, around 15 pounds for most people, can improve ovulation and fertility in 75% of women and greatly reduce other symptoms. Some women have ovaries that just do not work well. Two common diagnoses include ovarian dysfunction and premature ovarian failure or POF. Treatments for these conditions are similar and are usually hormonally related. First we try to establish the cause and correct it to make the ovaries function better. Treatment will normally include fertility medication at a higher dose than the average person her age. Another possibility when discussing ovarian dysfunction is the release of eggs. Some women will stimulate well and produce follicles containing eggs, but the follicles do not release these eggs. In vitro fertilization is the next best option. Peri-tubal disease refers to fallopian tubes which are damaged, usually by scar tissue. Scar tissue may be present within your tubes for various reasons, including a former ectopic pregnancy. Women with peri-tubal disease are at a higher risk for having an ectopic pregnancy. A Hydrosalpinx is a collecton of fluid trapped within the tube, usually caused by infection or inflammation. Surgery is usually required to treat tubal disease and every effort is made to maintain the integrity of the tube, allowing you to conceive on your own. If your tubal disease is severe and has required the removal of your tube(s), conception is still possible through in vitro fertilization. Endometriosis is a condition that involves both the ovaries and the tubes. Endometriosis is when menstrual blood collects outside of the uterus in the pelvis. It may grow on the ovaries, tubes, outside the uterus, bladder and intestines. Endometriosis may be mild to severe and can only be diagnosed by laparoscopy. It may be suspected by symptoms or examination and surgery may be recommended. Endometriosis may affect conception in multiple ways. First, it may prevent the ovaries from producing and releasing eggs. It may affect the transfer of the egg to the fallopian tube. It may affect all of the organs by pulling them in an abnormal position. It may also cause pain, from mild to severe, that may be present only occasionally to 13

14 everyday. It may cause intercourse or bowel movements to be painful, depending on the location and severity of the endometriosis. For most people, endometriosis can be treated and removed allowing them to lead normal lives and conceive. For a few people, endometriosis will be recurrent, requiring multiple surgeries throughout their life. Pelvic Adhesions can affect the pelvic organs in similar ways as endometriosis. Pelvis adhesions are the same as scar tissue that is formed after surgery. It can be caused from having surgery, past infections, or pelvic inflammatory disease. Adhesions are suspected based on symptoms and exam, but can only be truly diagnosed and treated with surgery. Chronic Pelvic Inflammatory Disease or PID is a condition of inflammation and/or infection in the pelvis that affects the ovaries, tubes and uterus. It is often the left over result of sexually transmitted disease, although may start other ways as well. The most common symptom is pelvic pain and discharge. PID may leave behind pelvic adhesions that also cause pain and infertility. PID may also lead to peri-tubal disease. Many of the diagnoses that have been discussed, chronic PID, pelvic adhesions, chronic endometritis, peri-tubal disease and cervicitis are all conditions that may be related and multiple problems may occur or feed other problems. These are all conditions that need to be fixed before conception is attempted. These are not problems that can be ignored and will go away. Taking a little extra time in the beginning to address these issues will make pregnancy much easier. Hormonal Imbalances The Pituitary gland is located at the base of the brain. It is a pea size gland that weights about the same as a small paperclip. Although small, this gland has a large job, as it is responsible for most of the hormones that your body needs. It would take an encyclopedia to describe it fully, so you are getting the short version. The pituitary is responsible for FSH and LH production. FSH is necessary for the ovaries to begin maturing eggs. LH is necessary for ovulation to take place. The pituitary also makes TSH, the hormone that makes the thyroid gland do its job. The thyroid gland is a butterfly shaped gland in the neck that weights about as much as three regular paperclips. The pituitary gland makes TSH to stimulate the thyroid gland to produce T3 and T4. The more TSH that the pituitary gland makes, the more T3 and T4 the thyroid makes. Without adequate T3 and T4, you may have an irregular menstrual cycle, not ovulate properly, or a slow metabolism to name a few. 14

15 Another hormone produced by the pituitary gland is prolactin. Prolactin is the hormone responsible for breastfeeding. When prolactin levels are high, FSH and LH are not produced properly, interfering in the menstrual cycle and egg development to stop. This is the reason that most women do not have a menses while they are breastfeeding. Once hormonal abnormalities are identified, most can be treated with medication. Sometimes the treatment will be short term until conception takes place. Other hormones will need to be given long term. Male Diagnosis Understanding your Semen Analysis As discussed earlier in this booklet, your SA will look at the motility, shape and quantity of your sperm as well as signs of infection. First we calculate the concentration of sperm per milliliter (ml) of semen and the total number of sperm. In most cases, the more the better. Next we determine how many are moving. These are broken up into four catergories: rapid progression (I-20 drivers), sluggish (the Sunday drivers), non-progression (race car drivers, only in circles) and non-motile (broken-down). Next we look at shape or morphology. A normal sperm has a head and a tail that are in proportion to each other, they really do look like a tadpole. Abnormal sperm may have a head that is too big, a tail that is too short or maybe two tails or etc. A healthy morphology result is greater than 4%. This information is used to help determine your best treatment method. Abnormal motility and morphology can sometimes be treated medically. We can also increase the concentration of normal sperm in the lab and place it inside the uterus to bypass the cervical barrier (a.k.a. insemination). If the number of healthy sperm is very low, the only option may be in vitro fertilization. Thanks to progress in technology we can initiate fertilization by injecting one sperm into a mature egg (a.k.a. ICSI or Intracytoplasmic Sperm Injection) 15

16 Lifestyle Weight There is a lot to be said about maintaining a healthy weight. You probably have already heard most of them. So, here are some you probably have not heard before. 1. Your ovaries will work better, and this goes for being overweight and underweight. 2. In most cases, you will need fewer fertility drugs, which may significantly reduce the cost of fertility treatment. 3. If you have PCOS, a healthy weight usually reduces the severity. You may have fewer symptoms and better ovaries. It also reduces the risk of PCOS related diabetes. 4. A healthy pregnancy is much more fun! Worrying about gestational diabetes, high blood pressure and low/high birth weight babies gives you less time to worry over what color to paint the nursery, what to name your little angel, and what flavor of ice cream you want. Smoking You probably have heard it all here too; however, here are a few disadvantages to smoking 1. Lower quality and quantity eggs. 2. Lower quality and quantity sperm. 3. It takes longer to get pregnant. 4. Requires more fertility drugs. 5. Increased risk for anesthesia. 6. Increased risk of miscarriage. 7. Increased risk of genetic abnormalities. 8. Increased risk of low birth rate babies and premature labor. 9. Increased risk of Sudden Infant Death Syndrome (SIDS) 10. Second hand smoke is almost as bad as smoking yourself. 16

17 Stress Now that we have told you to stop smoking and either gain or lose weight, I have to tell you not to worry about it. Infertility treatment can be stressful; money, time, will it work, and finally, it did work, which has its own stress. Try to talk to your spouse about your stress. Maybe a friend, another couple or a counselor will help you identify or reduce your stress. Remember: during this process it is half science and half miracle. You can only control so much, so you have to know when to let go of that control so the miracle part can start. 17

18 Treatment Hormonal correction During the investigation period, we may discover that your thyroid is not functioning properly or your prolactin is too high. There is medication to fix these problems that are effective in 99.99% of the cases. It usually requires several blood tests to find your most effective dose, but this is a relatively simple solution. Often, we will treat thyroid or prolactin functions along with other fertility treatment. So, it may not always be the only problem. Clomid Clomid is often a first-line of defense drug, and is often prescribed by your regular OBGYN before you were referred to a fertility specialist. Clomid works by lowering estrogen levels so that more FSH is produced. This allows the ovary more of a chance to mature an egg and allow ovulation to take place as it should. Clomid is frequently used by itself or in combination with FSH drugs, to create a better response. Clomid is sometimes given to a patient to try to conceive on her own, or in combination with monitoring her cycle. Clomid has side effects. It may cause ovarian cysts or may become ineffective if used too many months. There is also a small increased risk for twins. FSH Gonadotropins FSH Gonatropins are drugs that contain FSH which stimulates the ovary to mature more eggs. This class of drugs is exclusively given in the form of shots. These may be taken daily or every other day. This shot is usually given in the evening between 5:00-7:00pm. The side effects of this group include injection site redness, swelling or itching, moodiness or ovarian cysts. There is also a small increased risk for twins. Chorionic Gonadotropin Chorionic gonadotropin, (a.k.a. hcg or trigger shot), is always used in IUI or IVF cycles. This drug tells the ovaries when to release the eggs that they have been maturing. It also allows us to time the insemination or egg retrieval. 18

19 Monitored Cycle During your treatment cycle, you will be monitored very closely. This monitoring starts on the 2 nd or 3 rd day of your menses. On that day, we will do an ultrasound to make sure you do not have an ovarian cyst and to count your antral follicles, bloodwork is sometimes done. You will be given your medication plan and all of your medication will be ordered. Below is an example of a monitored cycle plan: You will then return around cycle day 10 for another ultrasound and more blood work. You may be asked to return to the office for several more visits like this one. When your follicles have reached the 2cm size, you will be instructed when to take your hcg shot. Insemination An insemination, (a.k.a. IUI), is performed following a monitored cycle. This procedure will be scheduled according to your hcg shot time and your LH level. It is usually performed about 40 hours after your hcg shot is given. During the IUI, a thin catheter is passed through the cervix, midway up the uterus and your sperm sample is released. 19

20 This procedure is extremely helpful for women with a problem cervix or to improve sperm motility. In Vitro Fertilization In Vitro Fertilization, (a.k.a. IVF), is a very high tech procedure that is very effective in most cases at achieving pregnancy. It requires very close monitoring and high doses of medication to encourage the ovaries to make multiple eggs. When the follicles are the appropriate size, the hcg shot is scheduled. The retrieval is scheduled for 36 hours later. Using an ultrasound guided needle, the follicle fluid is removed from the ovary and is passed to the embryologist for evaluation and identification of eggs. About 6 hours later fertilization will begin either by ICSI or normal penetration of the egg by the sperm. In ICSI, the healthy sperm are chosen, the tail is removed and the head of the sperm, which contains the genetic information, is injected into the egg. The next morning, we will know how many of your eggs have been fertilized. 20

21 Nucleus from the egg Nucleus from the sperm The embryologist provides the needed nutrition for early embryo growth and monitors them closely. Sometime between day 3 and 5 of the embryo s life, 1-3 embryos will be transferred back into your uterus. The first picture is of an eight cell embryo or three days following insemination. The second picture is a Blastocyst, about 250 cell or five days following insemination. This is the placenta This is the baby At this time, assisted hatching may be performed. Embryos will make a shell, much like a chicken egg. If the embryo cannot hatch out of its shell, it cannot attach itself to the endometrium. If assisted hatching is done, 1-2 small pin holes are made in the shell to allow the embryo to break out when it is ready. The transfer is performed with a special catheter inserted through your cervix, 2/3 rd the way into your uterus, where the embryos are released. This is performed under the guidance of ultrasound. This is very similar to the IUI. IVF does require more pre-testing and planning that a monitored cycle or IUI cycle does. For that reason, it will take 2 months to complete an IVF cycle. The first menstrual cycle month will be spent pre-testing and an IVF class will be scheduled with the couple. The second menstrual cycle is when the actual treatment will take place. 21

22 Donor Selection When selecting a sperm donor, the task can be daunting. Here are a few tips to help your selection process. Also listed below are a few banks that we have worked with in the past, although you are not limited to these choices. The amount that you pay per vial is directly related to how much information you want about your donor. Also, the education level of your donor raises the price. Remember, these donors are screened several times to reduce the risk of sexually transmitted disease (STD). We are unable to guarantee there is no risk of contacting a STD using a donor sample, but the risk should be minimal. 1. Only purchase one vial the first time. After the first insemination, when we know the quality of sperm, you may purchase multiple vials. When you achieve a pregnancy, if you like, you have the option of purchasing multiple vials to store for a genetic match for any siblings. 2. Purchase unwashed or ICI vials. We prefer for our lab to do all the processing of the sperm. We can more closely evaluate the post-thaw quality of the sperm. 3. Pay attention to the CMV test result of your donor. If the patient receiving the insemination is CMV negative, you should select a donor who is also CMV negative. If you are CMV positive, it does not matter. If you do not know your CMV status, we can order a blood test to determine your status. 4. If the patient receiving the insemination blood type is negative (A-, B-, AB- or O) you should try to pick a donor whose blood type is also negative. If, not you may require Rho-GAM injections during pregnancy. 5. Pick a donor whose donation date is 2005 or later. These donors have been through more complete disease screening due to FDA regulations. Xytex Fairfax Cryobank European Crypbank

23 Patient Information In most cases, we first start with diagnosis and then move to treatment of your infertility. Our goal is to help you conceive in the least invasive or most natural means possible. This means, we try to tailor your treatment to your personal needs. However, there are certain guidelines that we must operate within. Some of these guidelines are set for us by the government (FDA and CDC), some by medical boards, (AMA, SART, ASRM), and some because we know what works and what doesn t. We try to accommodate your needs for appointments as much as we can, but at times we have to respect the schedule of others. For example; the lab picks up blood samples at 9:00 so that we can have results before 2:00. Therefore, your blood must be drawn between 8:00-9:00. If you need special accommodations, please ask. Sometimes we are able, other times we are not. We don t know what your needs are until you ask. 23

24 Business When you first decide to begin infertility treatment, we will verify your insurance benefits. If you have infertility coverage, you will be charged according to your plan guidelines, either co-pays or percentage of total cost or both. If you do not have insurance coverage, you will be responsible for 100% of the cycle charges on cycle day 2 or 3, which is the first day of treatment. On the day of your IUI, embryo transfer, or the end of your monitored cycle, your charges will be submitted to insurance. When you are being treated for infertility, your diagnosis is infertility and we cannot change your diagnosis to encourage insurance payment. Some insurance companies will cover some of your charges. If so, that money will be refunded to you. If you have insurance benefits for infertility, you must find out all available laboratories in your network. When you are going through a treatment cycle, we can only send your bloodwork to those labs who guarantee us results by 2:00. If you have bloodwork on the weekend, your blood will have to go the available lab. You also need to know which specialty pharmacy your insurance will cover for your infertility medications. These medications cannot be purchased at your local Walgreens, CVS, etc. If you do not have coverage for infertility, your lab charges will be included into your cycle fees. You must have a clear balance on your account, in order to proceed with a treatment cycle. Reproductive Lab of Augusta (a.k.a. RLA) will be processing your sperm for IUI cycles and is the embryology lab for IVF. They are a separate business with separate insurance contracts. All financial and insurance questions should be directed to the business manager of RLA. 24

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