Other Questions and Answers

• Our program
• Appointments
• IVF Cycles
• Financial considerations
• Donor oocyte/sperm/embryos
• Our patients
• Pregnancy

Our Program

Will I always see the same doctor?

No; there are 4 physicians, all fellowship trained Reproductive Endocrinologists, and REI Fellows who participate in your care. We pride ourselves in providing compassionate and consistent care for our patients.

Why can't I use my own eggs at 43 years of age?

We previously tried this and stopped as the success rate was extremely low. Women who are 43 may be considered if they meet certain criteria. We will suggest alternative treatments including the use of donor eggs or donor embryos that have much higher pregnancy rates.

Can I have blood work and ultrasounds done at the University of Iowa Center for Advanced Reproductive Care if ordered from an outside doctor?

Yes, if our department has had a patient-provider relationship in the past and the responsibility for interpretation of results has been defined.

Does smoking affect fertility?

Cigarette smoking is harmful to a woman's ovaries. Smokers enter menopause sooner. Studies have shown that smokers going through IVF have significantly lower estrogen levels, fewer follicles, fewer eggs retrieved, and fewer embryos per cycle than non-smokers. Smoking also increases your risk of miscarriage once pregnancy is achieved. Effects of smoking appear to be cumulative over the years and can cause irreversible harm to the ovaries. All smokers wanting to come through our program are encouraged to quit prior to their cycle.

Appointments

How long does it take to get an appointment?

A preliminary appointment can usually be scheduled within 1 month. You will be scheduled for a treatment cycle as soon as possible when all recommended testing is completed. You will probably begin medications for your treatment cycle within one to two months of your preliminary appointment.

If I have a referral from my doctor can I be seen earlier?

A referral is helpful, but not required. Emergent problems will be accommodated emergently.

If I have gone through another clinic, do I have to go through the preliminary appointment?

You still need the preliminary appointment as there are differences in programs; however, we attempt to limit redundant tests.

Can I be having my period at the time of my new patient appointment?

Yes.

What tests are required to be done prior to my preliminary IVF appointment?

Female Partner:

1. Current (within last year) pap smear and annual exam.
2. Blood test documenting immunity to Rubella. If non-immune, we recommend vaccination prior to proceeding with treatment.
3. If you have not had "chicken pox" in the past, we recommend vaccination prior to proceeding with treatment.

Both Partners:
Blood testing documenting non-reactive status to the following diseases:

1. HIV antibody
2. Hepatitis B surface antigen
3. Hepatitis C antibody
4. RPR (syphilis)

Completing the above tests prior to your IVF preliminary appointment will faciliate scheduling of your treatment cycle.

What tests will be done at my preliminary IVF appointment?

Female partner:

Vaginal Ultrasound: to detect for any abnormalities, to measure ovarian volume and to count the number of antral follicles.

Pelvic exam

Uterine Sounding: measurement of uterine cavity

Possible blood tests

Male partner:

Semen Analysis and sperm morphology

IVF Cycles

What protocols does our clinic use?

• Luteal phase "long" protocol
• Microdose Flare Protocol
• Antagon/gonadotropin cycle

How do you decide what protocol I will be on?

A decision is made by the IVF physicians after careful review of age, ovarian reserve, cause of infertility, and evaluation of previous cycles of ovarian stimulation.

What is ICSI?

Intracytoplasmic Sperm Injection (ICSI) involves the injection of a single motile sperm into the egg. It has proven to be an effective assisted fertilization technique for patients that produce a low number of motile sperm in the ejaculate or sperm that fail to fertilize eggs following conventional in vitro insemination (putting the sperm and the eggs together in a dish).

What is Assisted Hatching?

Assisted Hatching (AH) is a procedure that involves dissolving a small portion of the zona pellucida (outer surface of the embryo) with an acidic solution. The small hole created allows the dividing embryo to hatch more easily. AH might enhance the pregnancy rate and embryo implantation rate in some poor prognosis patients. The decision to do AH is made by the embryologist and is done just prior to embryo transfer.

What is PGD?

Preimplantation genetic diagnosis (PGD) is a procedure that can be used during IVF cycles to test embryos for genetic disorders, before transferring the embryos back to the patient. It is used for couples with serious inherited disorders to decrease the risk of having a child affected by the same problem. A single cell is removed from the embryo and then analyzed. After the testing, only the unaffected embryos are transferred.

PGD can also be performed to evaluate chromosomal numbers in the embryo. At this time, this is performed on a limited basis in our Clinic but may be considered for couples with recurrent pregnancy loss or infertility due to advancing age. In addition, chromosomal testing can be performed if there is a balanced translocation which is a chromosomal defect that causes recurrent pregnancy loss.

Does retrieval hurt?

Retrieval is done under ultrasound guidance in a special procedure room. Just prior to your procedure, an IV (intravenous) catheter will be inserted. Medications for sedation and pain will be administered by anesthesia personnel through the IV. A woman can expect only mild, if any, discomfort.

How much work will I miss during my cycle?

There are several appointments that will be necessary for you to attend during your cycle. Both you and your partner must attend the preliminary appointment, which usually takes from four to six hours. Near your cycle start, both you and your partner will need to attend an appointment where you will have an ultrasound and we will teach your partner to give you injections. If you already have experience with giving injections, then your partner may not need to come to that appointment. This appointment will require approximately three hours.

You will have a pre-operative appointment near the time of your retrieval where you will have an ultrasound, pre-operative teaching and sign consents with the physician. If your partner cannot attend this appointment, then he/she will need to sign consents the day of retrieval. Ideally, your male partner will need to be here to provide a fresh semen sample on the day of oocyte retrieval. An adult will need to be available on both oocyte retrieval day and embryo transfer day to drive you home.

You will be required to spend the remainder of the day at home resting on both oocyte retrieval and embryo transfer days. During your cycle, you will need to have your blood drawn several times, and depending on where you live, you may be able to get them done locally, instead of coming to our clinic.

What is a frozen cycle?

Additional embryos beyond those transferred during a fresh cycle may be produced during the IVF cycle. Good quality embryos produced through IVF, in excess of those cultured for transfer, can be frozen and preserved for future transfer. The embryos can be frozen at the pronuclear (PN) stage, or at the blastocyst stage ( ~ 150 cells). While embryos can be stored in a frozen state indefinitely, you may retain them for your use until age 50.

During a frozen cycle, the patient takes estrogen and progesterone to prepare the uterus for embryo transfer. The embryos are then thawed at a specific time and then transferred into the uterus. Approximately 85 percent of embryos frozen at the PN stage survive freezing and thawing. The cryopreservation survival rate for blastocyst embryos is approximately 50 percent. The delivery rate per transfer is around 25 percent.

Financial considerations

All Financial concerns may be addressed with our Financial Counselor, Krisanne Duhaime at 319-356-3145.

How much does in vitro fertilization costs?

The cost of in vitro fertilization is dependent upon several factors such as type of procedure and medications utilized. When comparing costs between centers, be sure to ask if the figure quoted includes the cost of medications. In general, the cost for the entire cycle, including medications and monitoring, is in the range of $11,000 to $15,000. As part of your preliminary appointment, you will meet with our Financial Counselor who will help you in determining the financial costs for your individual situation.

Does insurance cover in vitro fertilization?

Many companies provide at least partial coverage. However, you are responsible for contacting your insurance carrier to discuss whether ART is coveraged under your contract.

How much does a T.L. (tubal ligation) reversal costs and will insurance pay for it?

We estimate the cost for a TL reversal procedure to be approximately $12,000 to $17,000. The CPT code number is 58750; use this number when asking your insurance company if this procedure is covered. Before being placed on the surgical schedule, payment in full is required if no insurance coverage is available.

If I had a T.L. (tubal ligation) will insurance pay for in vitro fertilization?

This depends upon the insurance company and the type of policy under which you are covered. You are responsible for contacting your insurance company and verifying coverage for this procedure.

Donor oocyte/sperm/embryos

Do you have a sperm bank?

No. We utilize commercial sperm banks.

How does a donor egg cycle work?

For a donor egg cycle, the donor goes through stimulation and egg retrieval, while, (at the same time), the recipient is taking medications to prepare her uterus to receive an embryo. On the day of retrieval, the donor's eggs are removed and fertilized with sperm from the recipient's partner. The embryos are then cultured and returned to the recipient either three or five days later. The donor can be anonymous or can be someone that the recipient knows who is willing to donate her eggs.

What is the difference between donor eggs and donor embryos?

If a couple chooses to use donor eggs (because of the female partner's age, decreased ovarian reserve or inheritable genetic disorders), a known or anonymous donor can be used. The donor goes through a stimulation cycle and her eggs are retrieved. The male partner's sperm is then used to inseminate these oocytes and the resulting embryos can be cultured and transferred back to the female partner. Therefore, the resulting child is the genetic offspring of the male partner, but not the female partner.

A donor embryo cycle involves the transfer of frozen embryos donated by a couple that has completed their family building. This couple then provides (donates) embryos without compensation to others. The child born after a donor embryo cycle is not a genetic offspring of either partner.

Although there is no genetic link between the female partner (when donor oocytes utilized) or both partners (when donor embryos utilized), there is a biological link. When a pregnancy results, the female partner's gestational role allows for control of the prenatal environment and the experience of pregnancy and childbirth.

Information for Our Patients

How do I mix my medications?

• Remove the plastic tops from the vials.
• Wipe the rubber top of all vials with alcohol.
• Draw air into the syringe to equal the amount of diluent one to two ml (cc's).
• Inject the air into the vial of diluent.
• With the needle still in the bottle, turn the vial upside down and pull back on the plunger to withdraw of the diluent.
• Withdraw the needle from the vial and inject into the vial of powder.
• Gently swirl to dissolve the powder.
• With the vial upside down, pull back on the plunger to remove all the medication.
• As you withdraw the solution, you will need to partially withdraw the needle to keep the tip in the solution.
• Remove the needle from the vial.
• Check for air bubbles.
• Replace the needle cap; then remove the needle from the syringe by twisting.
• Attach the 25 gauge needle to the syringe.
• The medication is now ready for injection.
• How do I use the Follistin Pen®?

Which needle do I use?

• For leuprolide injections, use the insulin syringe with needle attached.
• For Repronex/hMG, use the 25 gauge 1 1/2 inch or 2 inch needle.
• For Progesterone in Oil, use the 22 gauge 1 1/2 inch needle.

Why can't I use a different form of progesterone than injections?

We are most comfortable using IM progesterone in IVF cycles to ensure absorption. If necessary, we can prescribe other routes of administration. After a pregnancy is established, you may be able to discontinue progesterone or utilize a different route of delivery.

Should I worry if I spot after my transfer or in the days preceeding my pregnancy test?

Spotting can occur after retrieval/transfer for various reasons. If you are having spotting or bleeding, you should call the clinic. Unless the bleeding is very heavy and associated with cramping, you may wait until regular offices hours to contact us.

Why do I have to take the birth control pill?

The birth control pill will prevent your body from producing the hormones it normally does during a menstrual cycle. It will allow us to regulate your cycle and make it easier to schedule your cycle appointments.

Why am I spotting while taking birth control pills?

The pill contains low doses of estrogen and progesterone. Because of this, it builds up a thin, unstable lining in the uterus. Therefore, spotting is common and does not mean anything is wrong. You need to continue taking your pill as instructed, in spite of the spotting.

Why do I have to take medrol and tetracycline?

These medications are given to enhance the probability of implantation after ICSI or Asisted Hatching. Because the decision to perform AH is not made until just prior to transfer, all patients take medrol and tetracycline, in case it is used for their embryos.

Pregnancy

I am newly pregnant and spotting. Should I be worried? What should I do?

It can be fairly common to spot when newly pregnant. It could mean absolutely nothing, or it could mean that you are at an increased risk to miscarry. We know that you will be worried. If you have any type of spotting or bleeding, we want you to call us. Most likely, you will receive an early ultrasound to see what is happening. Unless the bleeding is very heavy and associated with cramping, you may wait until regular offices hours to contact us.

What medications are safe to take during pregnancy?

Everything you take into your body passes from your blood to your baby's blood. Therefore it is best to avoid all over-the-counter medicines especially in the first ten weeks of pregnancy. The first eight weeks are when your baby's heart, lung and brain systems are being formed.

Before taking over-the-counter medicines, try other ways to relieve your symptoms.

For cold and cough symptoms it is recommended you rest, drink extra fluids, and use a cool mist vaporizer -- 18 inches from your face.

Occasionally it may be necessary for your doctor to prescribe medicines during pregnancy. Please take medicines exactly as prescribed. If you are unable to tolerate the medicine, call the clinic.

Medicines that are considered to be safe during pregnancy for common symptoms:

For cold symptoms

Clor-Trimeton - -antihistamine (If you have high blood pressure only take this)

Sudafed -- decongestant

Actifed -- antihistamine and decongestant

Cough Symptoms

Robitussin or Robitussin DM

Constipation

Docusate (Colace) 100 mg twice a day

Metamucil -- one to two teaspoons with 8 oz juice or water

Milk of Magnesia -- one to two Tablespoons every evening

We prefer these medications over the use on mineral oil.

Minor headache or body ache

Tylenol or any acetominophen preparations: two tablets or 650 mg every 4 hours

We prefer Tylenol to any aspirin, ibuprofen or naproxen products, such as Advil, Motrin, or Aleve.

If headache persists more than 24 hours, call your physician.

Heartburn

Amphogel

Gelusil

Maalox

We prefer these medications over the use of baking soda or Pepto Bismol.

Fever or chills

Take your temperature if you feel unusually hot or cold. If your temperature is above 100.5 call your physician. If your temperature is above normal but less than 100.5, take Tylenol every four hours. If your fever lasts longer than 48 hours, call the clinic.

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