Perhaps it’s unfortunate that fertility doctors have to be so concerned about their patient’s pocket books unlike other fields of medicine that are usually covered by some measure of insurance.  But in the case of infertility with only a handful of states having some kind of mandated coverage – not everybody in the United States -  mandate or no mandate for infertility  -even has health insurance!  Many fertility patients are in some form or another “cash pay” patients.  One of the most popular places that patients visit when they go to any fertility clinic’s website is the finance page.  This is simply a fact of life.

For this reason I have developed many programs that will create access to fertility care for as many people as possible.  But here is the catch! One program does not fit all. These are simply not over sized tee shirts – each of these programs represent a certain course of  medical care – and each individual and couple needs the assistance of a caring doctor to help them choose the right program that will fit their own particular medical history.  In addition to the NY State DOH Grant Program and our own East Coast Fertility Grant Program, we have the Micro-IVF Program, The Money Back Guarantee Program,  and The Single Embryo Transfer Program.  The most effective treatment and the most efficient is always a full stimulation IVF. However, if someone has insurance coverage for IUI and meds but not IVF then they may prefer to do IUI. If they do not have coverage for IUI either then it may be more cost effective to do the Micro-IVF Program or minimal stimulation IVF at 2-3 x the success of IUI with less risk than gonadotropin IUI and less cost per pregnancy. Yet at a price of $3900 it may be more attractive than a full stimulated IVF. There is also The Single Embryo Transfer Program where we reward patients transferring one embryo at a time by making their cryo, embryo storage and unlimited frozen embryo transfers for free.  Others prefer the insurance of The Money Back Guarantee Program where patients are offered six IVF retrievals and frozen embryo transfers for a fixed fee that is refunded if they do not result in a live birth.   In order to inform patients about our success and programs that make IVF more available to them we offer free consultations.

In today’s world of fertility care – a good doctor will help a patient find not only the right treatment but how to access that care.  In order to do that – a doctor may have to do what some may think is unseemly – and that is to talk about money.

It has become commonplace for women who have been frustrated with repeated unsuccessful attempts to conceive naturally on their own to see their gynecologist who often times will try clomid therapy on them. Clomid, the traditional brand name for clomiphene citrate, is a competitive inhibitor of estrogen. It stimulates the pituitary gland to produce follicle stimulating hormone (FSH) which in turn will stimulate the ovaries to mature follicle(s) containing eggs. Estrogen normally has a negative effect on the pituitary: Clomid blocks estrogen and leads to pituitary FSH production and ovarian stimulation.

Infertility patients — those under 35 having one year and of unprotected intercourse without a resulting pregnancy and those over 35 having six months without pregnancy — have a two to five percent pregnancy rate each month trying on their own without treatment. Clomid therapy increases a couple’s fertility by increasing the number of eggs matured in a cycle and by producing a healthier egg and follicle. The pregnancy rate with clomid therapy alone is approximately ten percent per cycle and 12 -15 percent when combined with intrauterine insemination (IUI). Women who are unable to ovulate on their own experience a 20 percent pregnancy rate per cycle with clomid, the equivalent to that of a fertile couple trying on their own.

Clomid and Your Cervical Mucus

Women who are likely to conceive with clomid usually do so in the first three months of therapy, with very few conceiving after six months. As clomid has an antiestrogen effect, the cervical mucus and endometrial lining may be adversely affected.

Cervical mucus is normally produced just prior to ovulation and may be noticed as a stringy egg white like discharge unique to the middle of a woman’s cycle just prior to and during ovulation. It provides the perfect environment for the sperm to swim through to gain access to a woman’s reproductive tract and find her egg. Unfortunately, clomid may thin out her cervical mucus, preventing the sperm’s entrance into her womb. IUI overcomes this issue through bypassing the cervical barrier and depositing the sperm directly into the uterus.

However, when the uterine lining or endometrium is affected by the antiestrogic properties of clomid, an egg may be fertilized but implantation is unsuccessful due to the lack of secretory gland development in the uterus. The lining does not thicken as it normally would during the cycle. Attempts to overcome this problem with estrogen therapy are rarely successful.

Side Effects

Many women who take clomid experience no side effects. Others have complained of headache, mood changes, spots in front of their eyes, blurry vision, hot flashes and occasional cyst development (which normally resolves on its own). Most of these effects last no longer than the five or seven days that you take the clomid and have no permanent side effect. The incidence of twins is eight to ten percent with a one percent risk of triplet development.

Limit Your Clomid Cycles

Yet, another deterrent to clomid use was a study performed years ago that suggested that women who used clomid for more than twelve cycles developed an increased incidence of ovarian tumors. It is therefore recommended by the American Society of Reproductive Medicine as well as the manufacturer of clomiphene that clomid be used for no more than six months after which it is recommended by both groups that patients proceed with treatment including gonadotropins (injectable hormones containing FSH and LH) to stimulate the ovaries in combination with intrauterine insemination or in vitro fertilization.

Success Rates

For patients who fail to ovulate, clomid is successful in achieving a pregnancy in nearly 70 percent of cases. All other patients average close to a 50 percent pregnancy rate if they attempt six cycles with clomid, especially when they combine it with IUI. After six months, the success is less than five percent per month.

In vitro fertilization (IVF) is a successful alternative therapy when other pelvic factors such as tubal disease, tubal ligation, adhesions or scar tissue and endometriosis exist or there is a deficient number, volume or motility of sperm. Success rates with IVF are age, exam and history dependent. The average pregnancy rate with a single fresh IVF cycle is greater than 50 percent. For women under 35, the pregnancy rate for women after a single stimulation and retrieval is greater than 70 percent with a greater than 60 percent live birth rate at East Coast Fertility.

Young patients sometimes choose a minimal stimulation IVF or MicroIVF as an alternative to clomid/IUI cycles as a more successful and cost effective option as many of these patients experience a 40 percent pregnancy rate per retrieval at a cost today of $3,900.

Today, with all these options available to patients, a woman desiring to build her family will usually succeed in becoming a mom.

Dr. Kreiner with Drs. Howard and Georgeanna Jones

In 1987, I completed my Reproductive Endocrinology and Infertility fellowship under  Drs. Howard W. Jones Jr. and his wife Georgeanna Seegar Jones, the two pioneers of in-vitro fertilization in the USA and the entire western hemisphere.

This picture was taken at their house on the Elizabeth River in Norfolk during one of the bimonthly journal clubs.  It was routine for the Joneses to host the journal clubs twice a month during which the entire Reproductive Endocrinology team would discuss interesting cutting edge research in the field.

Learn more about the History of IVF at the Jones Institute here.

Dr. David Kreiner of East Coast Fertility is using his conscience and his expertise to provide solutions in the fertility industry. He is the first in the country to offer an In-Vitro Fertilization (IVF) package using Single Embryo Transfers (SET) at one set price to patients, while still providing high quality care. It can save the healthcare industry $1 Billion.

Plainview, NY, September 23, 2009 –(PR.com)– With all of the negative publicity surrounding the fertility industry in the wake of “octomom” and other sensational news stories, it is no wonder public opinion has turned sour towards the doctors and clinics that perform the services. Society now questions the safety, practicality and costs of aggressive treatments that often result in multiple births. So how do infertile couples pursue a more conservative route to parenthood – one that’s safer for them and their baby, still offers high success rates, yet is affordable? Dr. David Kreiner of East Coast Fertility is using his conscience and his expertise to provide a solution. He is the first in the country to offer an In-Vitro Fertilization (IVF) package using Single Embryo Transfers (SET) at one set price to patients.

In a typical IVF cycle, a doctor will transfer two, three and sometimes more embryos back into the uterus, depending on many factors, in order to achieve the highest chance of success. However, this protocol lends itself to a high risk of multiples, making risky pregnancies, long NICU stays, babies with developmental problems and handicaps, and thus extremely high healthcare costs.

With a Single Embryo Transfer, just one embryo is placed back into the woman’s uterus, nearly eliminating the chance of achieving multiples. The remaining embryos are frozen and can be transferred to the woman in future cycles.

While SET is the optimal choice for many women, the current cost structure favors transferring multiple embryos over this method. Because transferring a single embryo has a lower success rate than transferring multiple embryos, a patient may have to undergo several SET cycles before achieving a successful pregnancy. Clinics charge for each additional procedure. The patients are expected to absorb what could add up to $100 million per year in extra costs. Thus, patients and programs are pressured to transfer dangerously high numbers of embryos. The real irony lies in the fact that research has shown that universal adoption of single embryo transfers could save the healthcare system a total of $1 billion in healthcare costs. Yet, the patients who choose SET are expected to foot the bill.

That’s all changing at East Coast Fertility. Their Single Embryo Transfer Program attempts to take the financial incentive out of this push to put “all your eggs in one basket.” Dr. Kreiner and his staff are making it cost neutral to transfer only one embryo at a time by offering free cryopreservation, free embryo storage and free embryo transfers until a patient achieves a live birth, all for the cost of a single IVF cycle. ECF absorbs the extra costs in cases where successive transfers are needed. So, the patient can choose the more conservative route without having to worry about the financial implications. Dr. Kreiner believes the benefits to the patient and society are obvious, and he doesn’t feel he is sacrificing the success of his practice. “It is with confidence in our highly successful embryo cryopreservation program that we are able to limit the number of embryos transferred without decreasing the number of births that result from IVF cycles at ECF. We are willing to sacrifice some margin in those cases where patients need successive transfers.”

It remains to be seen if other clinics will follow ECF’s lead. Perhaps society should demand that fertility doctors start doing what is best for the patient even if it means having to cut into their profits on occasion. “Hopefully talking about these issues will highlight some of the negative incentives that exist in the world of Reproductive Endocrinology, and bring about change in the industry,” says Pamela Madsen, fertility blogger (www.thefertilityadvocate.com) and founder of The American Fertility Association. She continues, “It is refreshing to see Dr. Kreiner as an ethical standout in the fertility world – a patient activist who is not letting greed get in the way of practicing good medicine.”

The sobering truth: multiple pregnancies — even with ‘just’ twins — are sometimes dangerous to the health and well-being of both mother and babies.

I was on the cutting edge of IVF development in the 1980’s, a time when assisted reproductive technology was so new and inefficient, transferring six embryos in one IVF cycle was the norm.

Since then, thanks to dedicated research to fine-tune IVF, much has been learned about both clinical practice and laboratory technique. IVF is no longer experimental.

One of the most important recent developments — single embryo transfer, or SET — is being consistently backed up by study after study as the optimal IVF method for patients with a good prognosis.

The SET Program

The safest pregnancy with the greatest chances for an optimal outcome — a healthy baby — is a singleton pregnancy. In 2007, East Coast Fertility started leading the field of reproductive medicine by establishing our own SET Program.

Confidence in our high quality embryology laboratory and immensely successful embryo cryopreservation program has afforded ECF the ability to limit the number of embryos transferred, essentially eliminating the risk of triplets or more.

We understand that you’re anxious for fertility treatment to work. Besides your compelling desire to have a baby, you’re coping with worries about the costs — in time, money, and discomfort — of IVF.

So to encourage patients with good prognosis to utilize SET, we offer the following incentive:

For the cost of an IVF cycle, SET Program patients will receive free cryopreservation of their embryos, free storage and free frozen embryo transfers until you have your baby. This represents a savings of up to over $12,000. It also ensures a much better chance of a healthy baby.

Plus, some patients can take advantage of MicroIVF and save even more money and physical discomfort.

Is SET for you?

Each patient’s case is considered individually. Each factor impacting conception and pregnancy is taken into account, such as:
patient’s age
embryo quality
number of prior failed IVF cycles
use of frozen-thawed embryos

Single embryo transfer is appropriate in certain situations where the likelihood of a multiple pregnancy is high. This may include:
women younger than 35 years
women who conceived with first IVF cycle
women with concerns about multiple gestation
donor egg recipients

Single Embryo Transfer is revolutionizing the practice of reproductive medicine, and the team at East Coast Fertility is committed to their collective pledge to lead the way in creating safe, healthy pregnancies.

Sperm Meets Egg

Why me? My wife never had an infection, surgery or any other problem? I have no difficulty ejaculating and there’s plenty to work with so why can my friends, neighbors and coworkers get pregnant and we can’t?

I hear these questions daily and appreciate the frustrations, anger and stress felt by my patients expressing these feelings through such questions. There are many reasons why couples do not conceive. An infertility workup will identify some of these. A semen analysis will pick up a male factor in 50-60% of cases and in more than half of these cases the male has the only problem. An hysterosalpingogram will locate tubal disease in about 20% of cases. Another 20-25% of women do not ovulate or ovulate dysfunctionally preventing conception.

Even when a semen analysis is normal it is possible that a post coital test may identify that the problem is that the sperm is not reaching the egg. It may not be able to swim up the cervical canal into the womb and up the tubes where it should normally find an egg to fertilize. When these tests are normal a laparoscopy may be performed to identify the 20-25% of infertile women with endometriosis. However, even when the infertility workup is normal and there is no test that logically explains the lack of success in achieving a pregnancy; an IVF procedure may both identify the cause as failure of the egg to fertilize and treat it successfully by injecting sperm microscopically into the egg by a procedure called Intracytoplasmic Sperm Injection or ICSI.

What causes male factor infertility?

There are several potential causes of male factor infertility. Hormonal causes can be caused because of problems at the hypothalamic-pituitary level or at the testicular level. Normally, the hypothalamus regulates pituitary production of Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH). FSH and LH drive the testis to produce sperm and testosterone. Deficiency of FSH or LH can lead to lack of ability to drive the testicular production of sperm and testosterone just as lack of gas will prevent a car from being able to run. Today, the most common reason for a man to have FSH and LH production shut off is from his use of anabolic steroids such as testosterone, hcg (human chorionic gonadotropin) and clomiphene (clomid). These all may provide negative feedback on the pituitary turning off FSH and LH production. One can also see elevated testosterone shutting down the testis with congenital adrenal hyperplasia and adrenal tumors.

Pituitary tumors, infarction, surgery, radiation and infiltrative processes can also diminish FSH and LH production. In the presence of low FSH and LH it may be useful to check for elevated prolactin levels to rule out a pituitary prolactinoma and obtain an MRI to check for other tumors or pituitary pathology.

Isolated deficiency of LH and FSH can occur (Kallmann’s syndrome) and lead to diminished testis (hypogonadism). This occurs in 1 in 10,000 men. Less common defects are seen in hypothalamic stimulation of the pituitary and are usually associated with other congenital findings.

Abnormal thyroid and glucocorticoid (prednisone) excess can result in decreased spermatogenesis through effects on the hypothalamus and LH production or conversion of androgens (male hormone) to estrogens.

Testicular causes include the presence of tumor, chromosomal abnormalities, congenital absence of germ cells, drugs and radiation that are toxic to the testes, undescended testes and varicocoele.

Ten per cent of males with a sperm count under 10 million and 20% of men with azospermia have a chromosomal abnormality. Kleinfelter’s syndrome is a genetic disorder due to the presence of an extra x chromosome in the male. This occurs in 1 out of 500 males and is often seen in the mosaic form where some cells are 46 xy and some are 47 xxy. The testes tend to be small and these men have delayed sexual maturation, azospermia and gynecomastia (enlarged male breasts). There has been some success with ICSI of biopsied immature sperm cells.

Sertoli-cell only syndrome or germinal cell aphasia may have several causes including congenital absence of the germ cells, genetic defects or androgen resistance. Testicular biopsy shows complete absence of germinal elements. Men are azospermic yet virilize normally. Testes may have normal consistency but be slightly smaller in size. Testosterone and LH levels are normal but FSH is usually elevated. Men with testicular failure secondary to mumps, cryptorchidism or radiation/chemotherapy damage have smaller testes with a non uniform histologic pattern. The testes may have severe sclerosis and hyalinization. There is no treatment for this form of azospermia.

Gonadotoxic drugs like chemotherapy or radiation can effect the germinal epithelium because it is a rapidly dividing tissue and is susceptible to the interference imposed by these toxins on cell division. At radiation exposure below 600 rads, germ cell damage is reversible. Recovered spermatogenesis may take up to 2-3 years even when exposed to low doses of radiation. Elevated FSH levels reflect the impaired spermatogenesis and return to normal once the testes recover.

Orchitis occurs in 15-25% of males who contract mumps which is unilateral in 90% of cases. Testicular atrophy may take years to develop. At least two thirds of men with bilateral orchitis remain infertile for life.

Trauma either through accident or torsion of a testis is a relatively common cause of subsequent atrophy with potential diminished fertility.

Medical conditions such as renal failure, cirrhosis of the liver and sickle cell disease can all lead to low testosterone levels and decreased spermatogenesis.

Cryptorchidism occurs in 1 in 12 males. The undescended testis becomes abnormal after age 2. Even when unilateral, cryptorchid patients have reduced fertility potential.

The varicocoele is the most common finding in infertile men. It is the result of backflow of blood due to incompetent valves in the spermatic veins. 90% occur on the left and is found in 20% of males 40% of the infertile population. 50% of men with varicocoeles are fertile. It is thought that a varicocoele can cause infertility by elevating the temperature of the testis. Varicocoelectomies however are not universally helpful and remain somewhat controversial for many cases of infertility.

Unfortunately, at least 25-40% of infertile men have idiopathic infertility for which no cause may be identified.

Other causes of azospermia include congenital absence of the vas deferens or obstruction secondary to infection or surgery. These cases may be amenable to surgical reconstruction and/or ICSI with epididymal aspiration or testicular biopsy to obtain sperm. These are the most successful cases of ICSI associated with azospermia.

Sperm antibodies may be a relative cause of infertility in about 3-7% of cases. Treatment has been successful with intrauterine insemination and with ICSI.

Infections can affect sperm motility secondary to e coli, Chlamydia, mycoplasma, ureaplasma and trichomonas. Culture and treatment for asymptomatic infertile males remains controversial.

Sexual dysfunction is a presenting cause of male infertility in about 20% of cases. Decreased sexual drive, erectile dysfunction, premature ejaculation and failure of intromission are all potentially correctable causes of infertility.

Treatment of Male Infertility
Treatment depends on diagnosis. In cases where the FSH and LH are low with a normal head MRI, clomiphene may be of benefit. Clomiphene citrate (Clomid or Serophene) is one of the most widely used drugs in male infertility. It is a weak anti-estrogen that interferes with the normal feedback of circulating estrogens and results in an increase in GnRH that stimulates gonadotropin secretion. The resulting elevation in LH and FSH increases intratesticular testosterone levels and in theory should improve spermatogenesis. Gonadotropin therapy may be used if clomphene is unsuccessful in the face of low FSH and LH.

If a pituitary tumor is found, surgery or medications to lower prolactin may restore spermatogenesis to normal.

An obstructed vas may be microsurgically reconstructed. Surgery may also be performed in the presence of a varicocoele.

Intrauterine insemination may improve delivery of sperm to an egg or in the absence of any sperm, artificial insemination with donor sperm is often successful.

Intracytoplasmic sperm injection into the egg in an IVF procedure is highly successful when sperm may be obtained through the ejaculate and even through testicular biopsy. When normal mature sperm are rare such as in testicular failure, associated with elevated FSH, ICSI is much less likely to result in fertilization and pregnancy. Immature sperm cells rarely can result in a healthy pregnancy.

Naturopathic Treatment

Naturopathic treatment for male infertility focuses on improving sperm quantity, sperm quality, and overall male reproductive health. There have been reports that sperm counts have fallen almost 50% since the 1930s. Although some dispute these findings, it is generally accepted that sperm counts are declining. The cause may be environmental and dietary and lifestyle changes may interfere with men’s sperm production. If this is so, improving diet and making healthy lifestyle choices should positively impact male reproductive health.

Nutrition

The importance of a healthy diet cannot be overstated. To function properly, the reproductive system requires the proper vitamins and minerals. Nutritional deficiencies can impair hormone function, inhibit sperm production, and contribute to the production of abnormal sperm

• Eat a natural foods diet that focuses on fresh vegetables, fruits, whole grains, fish, poultry, legumes, nuts, and seeds.
• Drink 50% of body weight in ounces of water daily (e.g., a 150 lb man would drink 75 oz of water).
• Eliminate processed and refined foods (e.g., white flour), junk food, sugars, alcohol, and caffeine.
• Avoid saturated fats and hydrogenated oils (e.g., margarine); use olive oil.
• Pumpkin seeds are naturally high in zinc and essential fatty acids which are vital to healthy functioning of the male reproductive system. Eat pumpkin seeds to help maintain a healthy reproductive system.

Supplements

The following supplements may increase sperm count and/or motility. Allow 3-4 months for the supplements to work. The following is a list of supplements with their supposed benefit.

• Arginine – Take 4 gr daily. Needed to produce sperm. If the sperm count is below 10 million per ml, arginine probably will not provide any benefit.
• Coenzyme Q10 – Take 10 mg daily. May increase sperm count and motility.
• Flaxseed oil – Take 1 tbsp daily. Is a source of essential fatty acids.
• L-carnitine – Take 3-4 grams daily. Required for normal sperm function.
• Multivitamin-mineral – Buy a high-quality product and take one serving size (differs from brand to brand).
• Selenium – Take 200 mcg daily. May improve sperm motility.
• Vitamin B-12 – Take 1000 mcg daily. A B-12 deficiency reduces sperm motility and sperm count. Even if no deficiency exists, B-12 supplementation may help men with a sperm count of less than 20 million per milliliter or a motility rate of less than 50%
• Vitamin C – Take 500 mg 2 times daily. Is an antioxidant.
• Vitamin E – Take 400 IUs 2 times daily. Is an antioxidant and may improve sperms’ ability to impregnate.
• Zinc – Take 30 mg 2 times daily. Required for a healthy male reproductive system and sperm production.

Herbal Medicine

Herbal remedies usually do not have side effects when used appropriately and at suggested doses. Occasionally, an herb at the prescribed dose causes stomach upset or headache. This may reflect the purity of the preparation or added ingredients, such as synthetic binders or fillers. For this reason, it is recommended that only high-quality products be used. As with all medications, more is not better and overdosing can lead to serious illness and death.

The following herbs may be used to treat male infertility:

• Ginseng (Panax ginseng) – Known as a male tonic (an agent that improves general health) and used to increase testosterone levels and sperm count. Siberian ginseng (Eleutherococcus senticosus) may also be used.
• Astragalus (Astragalus membranaceus) – May increase sperm motility.
• Sarsaparilla (>Smilax spp.) – Known as a male (and female) tonic.
• Saw palmetto (Serenoa repens) – Used for overall male reproductive health.

Other Recommendations:

Avoid alcohol. Alcohol consumption is associated with an increased number of defective sperm.
• Consider acupuncture.
• Do not smoke, or quit smoking. There is an association between smoking and low sperm count, poor sperm motility, and abnormal sperm.
• Proxeed – is a new nutritional supplement that may improve sperm health and fertility rates. The ingredients include L-carnitine and acetylcarnitine, two vitamin-like substances synthesized naturally by the body. These chemicals are involved in cellular metabolism and are found in semen at a rate that is proportionate to the amount of healthy sperm. Proxeed is purported to improve sperm count, concentration, and motility when taken orally for about 2 months. It is reported that approximately 30% of couples using it conceive. It is available without a prescription, although couples considering it should consult their physician.

My first day of fellowship training in Reproductive Endocrinology at the Jones Institute was the day the Institute moved from the old quarters at the medical school to their new location at Hoffheimer Hall.  Movers carried boxes laden heavy with text books and the physician giants of IVF I had up until now only read about were picking up odds and ends from their recently departed offices.  Howard and Georgeanna Jones looked to me on that auspicious day like someone’s old grandparents rather than the father and mother of IVF.  Dr. Georgeanna, as she liked to be called, reminded me of my own grandmother.  I feared that I had come too late, that they were way past their prime and I would not be able to learn from them.  It was after all 1985 and they had been leaders in infertility since the 1960’s.  Dr. Howard was let go from Johns Hopkins Hospital almost 7 years earlier for reaching the retirement age.

They had planned to settle on the Maryland shore and spend time on their second love after fertility, sailing.  Instead, an old friend of theirs from Johns Hopkins from the 1960’s, Mason Andrews, helped found a new medical school in Norfolk, Virginia and now wanted their help to build the division of reproductive endocrinology, infertility (REI).  Eastern Virginia Medical which later changed its name to the Medical College of Hampton Roads was new and barely known by anyone outside of Virginia at that time.  Mason, a southern gentleman in his 60’s, soft spoken with a sharp wit and former Mayor of Norfolk, was successful in talking them into spending a few more years teaching so they bought a cozy house on the Elizabeth River 10 minutes from the school.

The Joneses hadn’t finished unpacking when the greatest fertility event of all time hit the news.  Patrick Steptoe and Robert Edwards had succeeded in Great Britain with creating a new life through a process known as In Vitro Fertilization.  The Joneses had worked with Professor Edwards years ago and were themselves well known in the field so it was natural that journalists came to their home to interview the erudite couple.  Dr. Howard talked about the genius of Professor Edwards and how he was not surprised that he achieved success.  Almost as an afterthought at the end of the interview, Dr. Jones was asked if IVF could be performed successfully in Norfolk.  In Dr. Howard’s pinpoint precision fashion and with his classic radio announcer voice, proclaimed that they certainly could develop IVF and with sufficient funds they could even create a successful program in Norfolk.  I have seen videotapes of Dr. Howard talking about this moment and it conjures up images of Babe Ruth promising to hit a homerun for the sick boy in the hospital then pointing to the fence just prior to him knocking one out of the park.

Well, the Joneses hit the homerun as predicted and by the time I arrived in 1985, Norfolk was the center of the IVF universe. Experts worldwide travelled to Norfolk to train and to teach.  Prior to the Joneses entering the playing field of IVF, the world averaged one baby a year from IVF.  Dr. Georgeanna introduced the concept of stimulating a woman’s ovaries with gonadotropin hormones in order to produce multiple eggs, thereby increasing the odds of retrieving healthy mature eggs, getting them fertilized and creating embryos that had good pregnancy potential.  Patients travelled from all over to have their IVF at Norfolk where the success rate, in 1985, was a world leading 15%.

I was excited beyond belief that this was my world now.  I arrived early that first day of my fellowship dressed in a brand new shirt and tie eager to learn and impress.  I managed to be accepted to this most competitive fellowship in part because I had been reading reproductive endocrinology for over 5 years.  I went through my ob gyn residency with the intention of specializing in REI and IVF.  In 1980 I began my training in REI mentored by Zev Rosenwaks, who convinced me that I could not possibly learn as much in any other residency as I would with him in Stony Brook.  So, I joined Zev, who had trained with the Joneses at Johns Hopkins, and he helped me start a residency clinic in REI at StonyBrook where I trained until 1985. Those five years I had been preparing for this moment in July 1985, to do my fellowship with Howard and Georgeanna Jones at the world famous Jones Institute in Norfolk, Virginia.

That first day, during office hours, I was following Dr, Georgeanna who was seeing her private patients.  Training begins.  She asked, do I know about the two cell theory to the luteal phase? I was dumbfounded.  I  had never come across such a concept in any of my reading.  Little did I know, Dr. Georgeanna had a knowledge base and theories in reproductive endocrinology that few others could rival.  She explained about the large cell and small cell and how the small cell is activated 10 days after ovulation by the pregnancy hormone, hcg.  In its absence the large cell dies, progesterone decreases and a woman menstruates.  In its presence the activated small cells continue to pump out progesterone and support the pregnancy.  How exciting! I realized that I would spend every possible free moment talking reproductive endocrinology with Dr. Georgeanna. She knew all the REI secrets.  She was the endocrinologist expert of the team.  She was also the heart of Norfolk.  She empathized with her patients and would go out of her way for them to help her patients achieve their dream, and that dream was to build their family.  Dr. Howard was the surgeon, the geneticist and the spokesman in addition to being the leader.  He was able to motivate and direct like a general leading his troops to battle.  Everyone on his team was critical in his view to their ultimate success.  He loved to say, “a chain is only as strong as its weakest link”.  He did what he could to ensure the integrity of each link.

Despite his age which was into his 70’s, Howard exercised regularly, was in excellent shape and in my mind was the original Macho Man.  I remember observing him operate, not always delicate, but experienced in fertility surgery like few others.  He was never intimidated and if the job called for raw muscle he was eager and willing to provide it himself.

I completed my two year fellowship in 1987, having learned an enormous amount of information and prepared to start my own IVF program.  However, the Joneses asked me to stay on as an assistant professor, to help start an embryo cryopreservation program and direct the donor egg program.  How could I refuse such an opportunity? I saw patients next door to Dr. Georgeanna and around the corner from Dr. Howard. Zev Rosenwaks was down the hall.  I could present every patient to whomever I thought would know the most about my patient’s problems.  This became an even better learning experience than my fellowship.  There were four of us in the IVF rotation, Zev Rosenwaks, myself, Suheil Muasher, a fellow who was two years ahead of me in training and Anibal Acosta, the Howard Jones of Argentina.  Rosenwaks and Acosta were often lecturing so Suheil and I performed more of the IVF that year. It was an exciting time.  We started doing retrievals transvaginally instead of laparoscopically.  We were experimenting with lupron and pregnancy rates were exceeding 25%.  I was doing my life’s dream working in IVF, helping women in need of help with conception achieve their dream of making their family.

Times were changing. Successful IVF programs were springing up throughout the nation.  It was the spring of 1988 when I returned home and started the first successful IVF program on Long Island dedicated to Howard and Georgeanna Jones who through their time, efforts and knowledge trained me and in so doing passed the baton of successful family building through the miracle of IVF.  Today, we remember these giants of IVF who started it all.  Mason Andrews and Dr. Georgeanna have since passed on.  Dr. Howard, now in his 90’s and how he describes it as late in the 9th inning is still occasionally involved in trying to make IVF more accessible to the public.  They were erudite medical pioneers who are responsible for the hundreds of thousands of babies who have been born through the technology that they helped create and promote.  They were the original teachers of IVF who selflessly shared their knowledge with others so that they also may help their patients conceive.   I am eternally thankful for the opportunities and training I received there from them, from Zev Rosenwaks, Suheil Muasher and from others at the Institute.

Young, healthy patients and patients with many follicles such as those with polycystic ovarian syndrome have the best response to the minimal stimulation with a result that typically includes multiple high quality embryos often even allowing for cryopreservation of embryos for a potential additional transfer in the future. When combined with East Coast Fertility’s Single Embryo Transfer Program, the cryopreservation, embryo storage and future frozen embryo transfers are free.

As an alternative to intrauterine insemination, patients can triple their success and lower their risk at pretty much similar costs. Of course patients with pelvic adhesions/scarring, blocked fallopian tubes, endometriosis and severe male factor have an even lower or no chance of success with intrauterine insemination but yet their probability of success with MicroIVF is as good as that of any other patient.

The fee at East Coast Fertility for MicroIVF is currently $3900 but an additional $1000 fee is added if patients require ICSI to facilitate fertilization and/or $550 if anesthesia is requested. An IUI with hormone injections ranges from $3500 to $4500 including medication. The medication cost for MicroIVF is not much more than $100. Furthermore, one need not worry with MicroIVF that all the eggs ovulated may fertilize and implant as could happen with intrauterine insemination. The risk of high order multiple pregnancies that one faces with intrauterine insemination is eliminated with MicroIVF. You control how many embryos with which you can potentially get pregnant.

There is a risk of hyperstimulation syndrome associated with hormone injections that is essentially eliminated with MicroIVF. This condition can result in enlarged ovaries, abdominal swelling and bloating, fluid that can push up on the lungs causing difficulty with breathing. Patients can develop dehydration that can place them at risk of developing a blood clot. This is not a concern with MicroIVF as it is with intrauterine insemination.

In summary, MicroIVF, especially as an alternative to intrauterine insemination, offers a low cost, safer and more efficient means to build a family.

I. Dr. Rudy Quintero, M.D., F.A.C.O.G. (on the CON side of the debate) Founder and Medical Director of C.A.R.E. Fertility in Los Angeles, CA.

“IVF over the past twenty years has evolved and been optimized from a point where pregnancy rates were at best quoted to be 10% back then to about 50% today. We have become better with stimulation protocols and techniques over this time period. Nevertheless, this success has unintended consequences including the possibility of embryo overproduction and multiple births.

Minimal Stimulation IVF is currently being touted as a solution for this, and we all hope that it soon will be. However, we lack sufficient data from clinical trials to support its use. In one of the better trials to date from Pelinck et al (Netherlands), an 8% pregnancy rate was noted, with a 20.8% pregnancy rate after three attempts with Minimal Stimulation IVF. Some authors have published success rates of up to 40% using Minimal Stimulation IVF, but percentages may be influenced by bias and other study errors due to their retrospective design.

More data needs to become available to truly assess the success of this protocol for different types of patients.”

II. Dr. David Kreiner, MD, F.A.C.O.G. (PRO Micro IVF), Medical Director of East Coast Fertility in NYC.

“Micro IVF is a great way to assist patients with achieving their goal of having a single baby while minimizing their risk of complications such as multiple pregnancy, hyper-stimulation syndrome or producing financial hardship. Its lower cost and risk should outweigh diminished pregnancy rate which for young high responders and older poor responders will be minimal. The reason these groups would see a minimal decrease in success is that the younger high responders have a higher implantation rate per embryo and do not need as many embryos to produce the healthy one that will result in a baby. The older poor responders do not make extra embryos with aggressive stimulation and have nothing to gain by adding gonadotropins in a conventional IVF cycle.”

III. Dr. Eva Littman, M.D., F.A.C.O.G. (CON)

Founder & Medical Director of Red Rock Fertility in Las Vegas.

“My biggest fear is that this procedure will be misused by couples and patients who require conventional IVF, but because of the economy they opt for the lower price and subsequently, the lower chance of success. It worries me that in order to try to save money, patients may fall for a ‘gimmick’ and use up funds that could have gone towards a real chance at success.”

As a new procedure, time will tell what its ultimate role will be as one of the fertility treatments offered by fertility specialists. My opinion is that for patients without insurance coverage for intrauterine insemination, for a few extra dollars it offers a better success rate with lower risk of multiple pregnancy and hyperstimulation syndrome.

Lets break it down for you.  We have the NYState DOH grant that for patients who qualify for this income based grant will pay between $2,000 and $12,000.  The amount of money provided by the state is limited so it is not available for patients who require high doses of medication.  It does include frozen embryo storage for 1 year and 1 frozen embryo transfer, ICSI and medications.

1- NY State DOH grant based on combined income includes 1 year of storage and 1 FET, meds and anesthesia is covered. Does not include Procedure room fee + assisted hatching = $1500.

2- ECF grant- $6950-$9950 based on combined income from <$100k- 200k, $6950 for $100k and lower, 1/2 price for all additional procedures, meds, anesthesia and procedure room fee not covered but PR fee 1/2 price ,$500.

3- Embryo freezing study- $3000 stipend, most meds covered, coculture and embryo glue included. Procedure room fee not included. If combined with ECF grant basic IVF cost is $6950. If pt selected for freeze all then cryo and storage for 1 yr and up to 3 FET free.

4- Egg freezing study- most meds covered, coculture and embryo glue and ICSI, procedure room fee and anesthesia included. Cryo and FET of frozen eggs included. Cost $8850.

5- Mini (Micro) IVF- minimal stimulation IVF $4900. Through the month of June $3900. This includes monitoring, retrieval, transfer and basic IVF lab and procedure room fee. Does not include meds, anesthesia ($550)- optional, ICSI or any other additonal IVF procedures other than basic.

If you have a question regarding these programs, please don’t hesitate to contact me at dkreiner@eastcoastfertility.com.