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A Consumers Guide To Infertility


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A Consumers Guide To Infertility

  1. 1. A Consumers Guide To Infertility & IVF Separating Fact From Fiction By Randy S. Morris, M.D. Board Certified Reproductive Endocrinology and Infertility
  2. 2. Fact #1 This Fact #2 What Type Of is a First Some Definitions You Are Not Alone Doctors Treat Big Industry It is estimated that as many as one in seven couples may suffer from infertility. Some Infertility? Obstetrics: is the branch of medicine have never had a pregnancy (Primary infer- concerned with the care and treatment of tility) but a larger percentage have been women during pregnancy, childbirth and the pregnant at least once previously (second- ensuing period ary infertility). In 1995, 1.2 million women visited a reproductive professional. Gynecology: is the branch of medicine concerned with the care and treatment of the female reproductive system and includes: It is estimated that 2 billion dollars are spent annually on fertility • Family Planning and Contraception diagnosis and treatment in the United States alone. • Cancer screening (PAP smears, mammograms) • Menstrual problems With that much money changing hands, there are going to be abuses. • Pelvic pain Most abuses will not be obvious or flagrant but the charlatans and snake • Fertility oil salesman are out there - so be wary. You, as a patient and a consumer • Menopause need to be as well educated as possible in order to protect yourself. Obstetrician/Gynecologist: has received training in all of the above. These physicians have completed 4 years of college, 4 years of medical school and 4 years of a residency in obstetrics and gynecology. They are sometimes referred to as general OB/Gyn's or simply as generalists. Residency: is sort of an “on the job training program” where a recently graduated physician works under the direction of experienced doctors and assists in the care of patients. Most of the residency takes place in the hospi- tal setting but can also occur in an office setting. Each year, the resident is given an increasing amount of independence and responsibility for the care of patients. By the time the resident is finished, he/she is supposed to be able to practice in that area of medicine independently. Fellowships: Once a doctor finishes residency, he/she may go on to setup a practice or he may go on to further train in one particular area in obstetrics and gynecology or subspecialty. Most fellowships are three years in length. There are four types of fellowships in obstetrics and gynecology: • Gynecologic oncology (Cancer of the uterus, ovaries) • Perinatology (Handles high risk/complicated pregnancies) • Gynecologic urology (Treats problems involving the the urinary system in women) • Reproductive Endocrinology /Infertility (Deals with hormonally related problems, infertility and recurrent miscarriage) Obstetrician /Gynecologists are typically the first doctors to see and treat women with infertility. They will initiate some preliminary testing and, at times, start some treatments. If pregnancy does not occur or it seems that a problem has been discovered that is more complicated, they will refer the couple to a reproductive endocrinologist for more advanced care.
  3. 3. Fact #3 Here is an excerpt from a medical Understanding practice website Why is “Infertility” listed (The name has been changed): separately? Doctor Certifications We Care for Women, P.A. is The separate listing is meant to give a medical practice specializing in the impression that they have Obstetrics, Gynecology, and some special expertise in infertility Infertility. We have 14 physicians, 11 of whom are Board Certified by treatment. It really doesn't make the American Board of Obstetrics sense. For example, you never see and Gynecology, who offer state-of- "Obstetrics, Gynecology and the-art care to our patients at four Oncology" even though all OB/GYNs locations in the Dallas area. do cancer screening. What does “Board Certified” mean? What are reasons why The system for assessing doctor credentials is very confusing. doctors might not be board certified? Let's try to clear it up. • Some doctors never bother to take When a student graduates from medical school, he earns the title “doctor” the test and gets an M.D. after his name. However, since he has not yet • Some doctors have tried and failed completed a residency, there isn't much he can do with that degree. to pass the test After finishing residency, a doctor can set up a practice in his field. However, there are no more initials that are added after his name. Can a doctor who is not board certified still practice in the field? A doctor can choose to become certified in his/her specialty by passing a series of tests called “board exams”. They are called board exams because The answer is yes! There is no requirement to become board certified. For they are administered by a governing body or board setup by each specialty. example, many insurance companies do not require board certification for a For example the American Board of Obstetrics and Gynecology (ABOG) doctor to care for its patients. is the governing body that administers exams for general obstetrics and gynecology and all of the subspecialties. Why does everyone want to become a fertility “specialist”? The board exams are separated into written and oral tests. • Infertility is a highly desirable medical practice After completion of the residency, a general • Usually involves young, healthy patients OB/GYN must first take and pass the general ob • Doctor's offices often don't deal with insurance gyn written exam. Then he must work for a year • Malpractice premiums are lower than for those doctors who deliver babies taking care of patients. He must record all of the • Infertility is an exciting, rapidly developing field patients he sees in that year and submit it to the board for approval. If the board believes that Take home point: variety of patients is sufficient, then the doctor may take the oral examination. If he passes the oral examination, he is then said to be board If your OB/GYN sends you to see a “fertility specialist” certified in obstetrics and gynecology. Make sure that he is board certified in A reproductive endocrinologist who wants to Reproductive Endocrinology/Infertility. become board certified must first finish the Some doctors will try to fool patients by stating they are board certified but fellowship and then pass his written and oral exam not specify what specialty they are board certified in. Others will try to imply for general obstetrics and gynecology and then he they have special certification by listing their membership in various societies. must take and pass a written and oral examination in reproductive endocrinology! Board certification is the highest level of distinction possible in the field. Doctors who are board certified must recertify every ten years.
  4. 4. Fact #4 Fact #5 Unfortunately, many couples do not Understanding Understanding investigate their doctor’s credentials and In some cases, membership in a medical Pregnancy instead focus on pregnancy rates. Of Medical society can tell you about the qualifications course pregnancy rates are important Societies of a doctor. In other cases, it tells you Rates measures of success, however, the average nothing. Here are some examples from patient has almost no ability to determine the infertility field: the accuracy of pregnancy rates or to use them to compare different fertility treatment programs. Does NOT tell you about doctor qualifications What's more, the snake oil salesman are experts at manipulating the numbers to make themselves appear to be better. ASRM- American Society for Reproductive Medicine Take this example: • Membership open to physicians and non-physicians Pregnancy Rate • Membership is immediate upon receipt of the application fee Dr. A 20% • The largest and most active of the fertility related societies Dr. B 40% • Sponsors educational events and issues guidelines for practice Which doctor has a higher pregnancy rate? Most people would say Dr. B. CARE- Chicago Association of Reproductive Endocrinologists Lets look a bit closer. • Amazingly you Don't have to be a reproductive Pregnancy Rate Number of patients endocrinologist or even an ob/gyn to be a member Dr. A 20% 200/1000 • Membership immediate upon receipt of application fee Dr. B 40% 4/10 • Sponsors a monthly dinner educational meeting With a little more information, we see that Dr. B only saw 10 patients, a SART- Society for Assisted Reproductive Technologies number much too small to be able to determine a pregnancy rate accurately. • Society dedicated to the more advanced fertility treatments Pregnancy Rate Number of patients Entry requirements such as in vitro fertilization Dr. A 20% 200/1000 Any age • Membership open to physicians and non-physicians Dr. B 40% 4/10 Under age 35 only • Membership is immediate upon receipt of the application fee • In the past, was responsible for collecting data from in vitro Now we find out that Dr. B restricts his practice to only younger women. We fertilization programs to send to the Center for Disease Control. know from hundreds of medical studies that older women do not get pregnant as As of 2005, they lost that responsibility to another agency often as younger women. By restricting his practice, Dr. B can inflate his preg- • The largest and most active in vitro fertilization related society nancy rates and make it seem as though he has a better treatment program. • Sponsors educational events and issues guidelines for practice DOES tell you about doctor qualifications Across is a list of a few of the factors found to influence pregnancy rate. SREI-Society for Reproductive Endocrinology and Infertility These factors can have a dramatic impact on pregnancy rates. How a • SREI Membership requires certification by the American Board of pregnancy rate is reported is also important. One must compare apples to Obstetrics and Gynecology in both Obstetrics and Gynecology apples. Lets take an example of a fertility treatment called Treatment X and the subspecialty of Reproductive Endocrinology Number of patients who start treatment 100 • Sponsors educational events and issues guidelines for practice Number of patients who complete treatment 70 Number of patients with a positive pregnancy test 20 Number of patients with a pregnancy seen on ultrasound 15 Number of patients who deliver a baby 10 Dr A. Reports a pregnancy rate of 10%. Dr. B reports a pregnancy rate of 28.6% Factors That Influence Pregnancy Rate Factor Variable associated with lower success Who is correct? Answer. They both are. Dr A reported the number of patients who delivered a Female age Older baby divided by the number who started treatment. A more conservative Female body weight Heavier method of reporting. Dr. B reported the number with a positive pregnancy Type of treatment Some are worse than others test divided by the number who completed their treatment. Which one is Geographic location Certain problems may be endemic more misleading? Season Variation has been shown in studies Length of infertility before seeking treatment Longer Unfortunately, for most treatments, there are no rules for how these rates are Number of previous failed treatments More previous failures reported. If you were a patient who was trying to decide between Dr A and Results of pre-treatment testing Abnormal ovarian function Dr B based on pregnancy rates, it would be impossible to realistically com- pare the two. There simply is never enough information given to make an informed choice.
  5. 5. Fact #6 Understanding IVF (in vitro fertilization) IVF is one of the most expensive A TALE OF 2 PROGRAMS Pregnancy Rates and invasive treatments that fertility specialists offer and so it deserves some special discussion. Lets try to compare the results from two actual in vitro fertilization The simplified steps involved in programs for women who are under in-vitro fertilization are as follows: age 35. (Program A and Program B) Since we have no idea about the 1. Woman takes fertility medications patient populations of these two 2. She hopefully produces a number of eggs in her ovaries programs its impossible to say by the 3. The eggs are removed (egg retrieval) pregnancy rates whether one is better. 4. Attempt is made to fertilize the eggs in the laboratory 5. If eggs became fertilized, the embryos are grown in the laboratory However, Program A puts in more 6. Some embryos are placed into the uterus (embryo transfer) embryos on average than Program B. By doing this, they have now placed their patients and their babies at How IVF Programs Can Mislead Patients greater risk. 1. Not all programs report results Think about it, about one in every ten IVF programs in the United States are supposed to report the results of IVF pregnancies in program A is a triplet, cycles to the Center for Disease Control. Unfortunately, not all do and the quadruplet, quintuplet or higher! enforcement is lax. Even these reported pregnancy rates are subject to con- That only happened to Program B in siderable problems. The CDC puts a disclaimer that these numbers should about one in a hundred patients. not be used for comparisons between programs. 2. The Number of Embryos Implanted In addition to the factors listed above, there are other ways to mislead patients about IVF pregnancy rates. One of the most important is the number of embryos that are placed into the uterus. Putting more embryos into the uterus can increase the number of pregnancies up to a point. However, it also increases the risks of multiple pregnancy and we are not Program A Program B just talking about twins here. Number of cycles 332 192 Comment: Both programs have a good number of patients Avg. number of embryos transferred 3.1 2.1 Comment: B puts in less of embryos % of cycles resulting In pregnancy 31.9% 39.1% Comment: B has a higher rate % of pregnancies with twins 33% 25.3% Comment: B has less % of pregnancies with triplets or more 9.4% 1.3% Comment: A has almost 10 fold higher risk of triplets or more % of live births with multiples 34.7% 26.6% Comment: B has less With multiples
  6. 6. Fact #7 Fact #8 Almost all of our fertility treatments use First you must understand one thing Understanding fertility medications. The use of these Snake Oil Salesmen about yourself. regardless of the medications can to various extents And How To amount of education you have had, Multiple increase the chances for a multiple pregnancy. Most couples do not pay Protect yourself Pregnancy sufficient attention to this risk. In fact, YOU ARE AN EASY MARK most couples with infertility state they FOR THE SNAKE OIL would prefer to have a twin pregnancy. SALESMAN!! By far and way, the greatest risk to the use of any of these fertility treatments is the risk of a multiple pregnancy. WHY Are You an EASY Mark? It is important to know that all multiple pregnancies, including twins, have • You are very vulnerable. The couples we see are often desperate to have a a greater rate of complications. Women with a multiple pregnancy have a child and will do almost anything to get one. greater chance for complications like: • You want to believe what they are saying. If some one tells you they have cure that no one else has, we are more inclined to believe than to disbelieve. Multiple Pregnancy Potential Complications • Patients always prefer to do “something” vs. “nothing” even if there are no differences between the two. If someone gives you the option of trying a I. Preterm labor and delivery. treatment versus not doing anything, most people will try the treatment • 50% of twin pregnancies are delivered prematurely even if it is unlikely to really work. • 90% of triplet pregnancies are delivered prematurely • Most of you lack the skills scientifically to determine what is true and what II. Some of the complications of prematurity is not. This can be true of doctors as well. • Cerebral palsy • Blindness Some Guidelines When Evaluating “Miracle” Treatments” • Bleeding into the brain • Respiratory distress (breathing difficulty due to immature If It Sounds Too Good To Be True, It Probably Is lungs) The website below claims to be able to unblock fallopian tubes and remove • Can result in lifelong disability for the babies adhesions from the pelvis simply by a few massage treatments. III. Gestational diabetes. Their claim: “High success rates without surgery or medication” • This is a form of diabetes that occurs during pregnancy. They talk about a 75% success rate which if true would make it the most • Related to an increase risk of birth defects effective fertility treatment ever discovered. • Often requires insulin injections • Can cause babies to grow too large or too small IV. Pre-eclampsia. A problem of high blood pressure that occurs during pregnancy. Associated with other complications such as: • Stroke & Seizures • Poor growth of the babies • Death of the babies in uterus • Death of the woman carrying the pregnancy • Increased risk for cesarean section • Increased risk for babies with birth defects • Increased risk for miscarriage • Increased risk for babies that die V. Twins are seven times more likely to die in the first month of life VI. Triplets are twenty times more likely to die in the first month of life Doctors should carefully counsel patients about the risk of multiple preg- nancy associated with their age, infertility condition and treatment being used. When performing in vitro fertilization, doctors should strive to transfer the minimum number of embryos possible. Gone are the days when a 30 year old woman has four embryos placed into her uterus!
  7. 7. Some Guidelines When Evaluating If you are contemplating Conclusions “Miracle” Treatments” treatment with IVF and your doctor tells you that four Beware The Testimonial embryos are necessary to get Consider this actual unaltered testimonial taken from a web site of a local doctor: you pregnant, then you should “If you are struggling with miscarriage and need help, Dr. X is the only Doctor who can help you. Trust me, I know!!! This Doctor has seek a second opinion!!! the talent of Michael Jordan, the intelligence of Bill Gates, and the love for people in need like Mother Teresa. I say this because he is the first person in our lives (other than our parents) that cared enough about us and wanted to really help us. Dr. X is what a Doctor should be like. God bless you Dr. X.” In the last few decades, the treatment of infertility has become more effective. It has also become more complicated, more expensive and has greater risks. More “practitioners” are trying Beware Doctors Who Claim To Be Misunderstood Or to “get in on the gold rush” by offering ineffective treatments Persecuted By The “Medical Establishment” or using accepted treatments in an overly risky manner. Consider this actual unaltered excerpt from a web site “Dr. Y has spent his entire academic life analyzing the impact of the immune system on infertility and the success or failure of a pregnancy. You must educate yourself as much as He has dedicated his professional life to analyzing couples with possible to protect yourself from these infertility, IVF or implantation failures and recurrent pregnancy losses types of practices. who have been told by the medical community that their problem was due to bad luck or that there were no proven therapies for their problem.” Don't Draw Unsupported Conclusions. This is the sequence of events: 1) I had infertility 2) Doctor Z waved his magic wand over me 3) The next month I was pregnant Conclusion: Dr Z's magic wand must have cured my infertility This is a popular scheme seen on internet bulletin boards. There is a problem with this logic. With every malady known to man, some people get better by doing nothing or by using a treatment that has no effect.This is known as the placebo effect. The best way to determine if a treatment really works is to have two groups. One group receives the treatment being studied. The other group receives a placebo or dummy treatment. Ideally, neither the doctor nor the patients should know who got what until after the study is completed.This is the only way that a true treatment effect can be proven.
  8. 8. About IVF1 Although we are best known known for our Male Fertility Tests In Vitro Fertilization - IVF - and We are also proud of our male fertility preimplantation genetic diagnosis - PGD - testing. Our advanced semen analysis programs, you will find that we offer much, much more. uses sophisticated imaging and computerized analysis to get highly IVF1 and Infertility accurate and repeat able results for sperm Acupuncture in infertility counts, sperm motility, and sperm morphology. Office Locations Acupuncture in IVF IVF - In Vitro Fertilization In vitro Fertilization - IVF is an Insurance Coverage for increasingly popular infertility treatment. Infertility Our philosophy is to obtain the highest Your first interaction with our office will IVF ( in-vitro fertilization ) pregnancy Chicago, Illinois trigger our infertility insurance specialists rates with the lowest risk for multiple to contact your insurance company to pre pregnancy. To accomplish this, we IVF1 and Infertility Office determine your infertility insurance maintain the highest and strictest 900 North Michigan Avenue coverage. By the time of your first standards for our IVF laboratory and appointment, we will be able to counsel utilize the most advanced IVF techniques 15th Floor you about your IVF in vitro fertilization such as intracytoplasmic sperm injection insurance, and insurance coverage for (ICSI), preimplantation genetic diagnosis Chicago, IL 60611 infertility diagnostic tests and (PGD) and blastocyst transfer. Phone: 312-440-5055 treatments. With years of data that now indicate that Fantastic Office Staff blastocyst transfer can reduce the risk of Our past and current patients rave about multiple pregnancy while increasing the our friendly and supportive office staff. chance for IVF - in vitro fertilization - From the front reception desk to our success, it is amazing that we are still one highly trained nursing staff. of the few programs the use blastocyst transfer on a regular basis. Naperville Illinois Infertility Testing IVF1 and Infertility Office We offer a wide variety of infertility testing Other Fertility Treatments services including: Of course, we offer all fertility treatments 636 Raymond Drive Assessment of ovarian reserve using the here including intrauterine insemination Suite 303 clomid challenge test and transvaginal (IUI), ovulation induction with Clomid ultrasound for determination of ovarian (clomiphene Serophene), letrozole, Naperville, IL 60563 volume and antral follicle counts. glucophage, actos, avandia and gonadotropins such as Gonal F and Phone: 630-357-6540 The HSG (Hysterosalpingogram)is an Follistim. infertility procedure used to diagnose uterine cavity problems (like fibroids and Laparoscopy, Hysteroscopy and polyps) and fallopian tube obstruction. Reproductive Surgery Our gentle techniques allow a nearly pain free HSG. Using tubal catherization techniques like selective salpingography and wire guide Dr. Morris is an expert laparoscopic surgeon and performs laparoscopy for infertility problems such as endometriosis, pelvic adhesions, canalization, we can open blocked fallopian tube blockage, fallopian tubes and have helped many and uterine fibroids. He also frequently women avoid more invasive surgery. performs surgery inside the uterus (hysteroscopy) for polyps, fibroids and intrauterine adhesions.