Online Health Chat with Julie Tan, MD and Fertility Center Financial consultant Margie Clapp
November 30, 2012
In the U.S, infertility affects 7.3 million people—or one in eight couples—affecting both men and women equally. Infertility is defined as the inability to conceive after a year of unprotected intercourse, or an inability to conceive due to a known medical cause. Infertility diagnosis and treatment can be an extremely difficult road for many couples, and is expensive for many. Nevertheless, advances in the diagnosis and treatment of infertility allow many couples the opportunity to have a baby.
Medical conditions, such as endometriosis, polycystic ovary syndrome, poor egg reserve, male factor infertility (including too few sperm, significantly abnormal sperm shape, and sperm that cannot penetrate the egg shell), tubal damage and genetic defects, can interfere with conception. However, the cause of infertility may not be known even after testing.
Tests that are used to help diagnose infertility include karyotyping (to check the number of chromosomes), clotting profiles and HSG (hysterosalpingogram, an x-ray that shows the inside of the uterus, fallopian tubes, and surrounding area).
Medications, such as Clomid® and Femara®, can help a woman produce more eggs each month in the effort to become pregnant. In vitro fertilization, now considered a mainstay treatment, may be required. Other techniques used to help infertile couples conceive include intracytoplasmic sperm injection and intrauterine insemination.
For infertile couples, financial concerns about testing and treatment are an important consideration, and need to be addressed prior to treatment.
For More Information
On Cleveland Clinic
Cleveland Clinic's gynecology program is ranked No.3 in the nation by U.S.News & World Report and is the top ranked in Ohio. Cleveland Clinic fertility experts provide the full range of state-of-the-art services for the diagnosis and treatment of infertility, including in vitro fertilization. Patients are seen in a caring environment, where the major emphasis is not only technological excellence, but also accessibility, personal attention and emotional support. We have locations throughout Northeast Ohio for your convenience.
On Your Health
MyChart®: Your Personal Health Connection, is a secure, online health management tool that connects Cleveland Clinic patients with their personalized health information. All you need is access to a computer. For more information about MyChart®, call toll-free at 866.915.3383 or send an email to: firstname.lastname@example.org
A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® website. To request a remote second opinion, visit eclevelandclinic.org/myConsult
If you would like to make an appointment with Dr. Tan or another infertility specialist at Cleveland Clinic Women’s Health Institute, please call 800.223.2273 or request an appointment online by visiting www.clevelandclinic.org/appointments.
If you would like to contact Margie Clapp to discuss your Fertility Center financing call 216. 839.3153.
About the Speakers
Julie Tan, MD is a staff OB/GYN physician at Cleveland Clinic Women’s Health Institute, and is currently seeing patients at the main campus and Fairview Hospital. Dr. Tan completed her fellowship in reproductive endocrinology infertility at Duke University Medical Center, in Durham, NC after completing her residency in obstetrics and gynecology at University Hospitals of Cleveland. Dr. Tan completed her internship in OB/GYN at Emory University Hospital, in Decatur, Georgia after completing medical school at Mahidol University, in Bangkok, Thailand. She is board certified in obstetrics and gynecology with additional certification in reproductive endocrinology and infertility.
Dr. Tan’s specialty interests include in vitro fertilization, laparoscopic surgery, infertility surgery, laparoscopy, reproductive endocrinology, sterilization reversal and infertility.
Margie Clapp, financial consultant at Cleveland Clinic Fertility Center, helps patients understand the costs involved with infertility treatment. She also offers advice on how to finance the treatments.
Let’s Chat About ‘Have your Fertility Financial Questions Answered’
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic fertility specialist Dr. Julie Tan and Fertility Center financial consultant Margie Clapp. We are thrilled to have her here today for this chat on financing fertility treatments.
CL84: I am 28 years old and have not had a menstrual cycle since going off birth control, and my doctor recently prescribed Premphase® to help regulate my cycles. He said that, if I want to conceive, I would have to go through a process called superovulation. I would like to try some natural remedies before I try fertility drugs. Do you have any recommendations on natural remedies that I could take with Premphase®?
Dr_Tan: I think you should discuss with your doctor why you haven’t had a menstrual cycle yet, since you have stopped taking birth control. Some women who take birth control pills may not have menstrual periods. When birth control pills are stopped, it may take three to six months to resume regular ovulation and menstruation.
If you took a birth control shot called Depo-Provera® or have birth control implants, it might take longer than six months for your menstrual period to resume. If you just stopped birth control within the last three to six months and your period has not resumed, perhaps there is nothing to be worried about.
If you have stopped birth control more than six months ago, your physician might consider running some tests to see if you have any medical problems that might cause you to not have a period. Many medical conditions such as polycystic ovary syndrome, pituitary tumor, thyroid problems and premature menopause can lead to a hormone imbalance. Certain medications and certain lifestyle issues (including stress, being underweight or overweight, exercising excessively or having an eating disorder) can also cause some women to not have a period every month. Premphase® is a hormone replacement therapy normally used in menopausal women to help with hot flashes and other menopausal symptoms. So, taking Premphase® doesn’t fix the problem you have. Perhaps your physician placed you on Premphase® to prevent you from having bone loss due to not having a period and not ovulating for a very long time. If you do have medical problems that are causing you to have no period, the best way to take care of your menstrual problem is to treat those medical conditions.
szczotur_1: I have stage 4 endometriosis. I was told that it doesn't really cause infertility, but then when you go online it says it can. I am confused. My husband and I have been trying for awhile with no luck. Can it truly cause infertility?
Dr_Tan: In general, women with endometriosis have a lower chance of getting pregnant than women in the general population. Endometriosis itself can sometimes cause an unpleasant environment for the eggs and, in turn, this causes a decrease in fertilization. Many women with stage 4 endometriosis have scar tissue in the pelvis or around the fallopian tubes, which make the tubes unable to pick up the eggs each month. If you have a cyst from endometriosis (called endometrioma), the cyst sometimes destroys part of your normal ovary and could cause you to have a lower egg reserve (egg supply). If you have been trying to conceive for a while, you should go ahead and seek help from an infertility specialist to see if there is anything we can do to help you get pregnant soon. Despite that, we tell everyone to try to conceive for a year before seeking medical advice. Women with a history of endometriosis, previous pelvic infection, polycystic ovary syndrome, or low egg supply, or those with a partner with a low sperm count should consult with their physician sooner.
asisia79: I've lost four early pregnancies that were six weeks along or earlier. Is there anything beyond karyotypes and clotting profiles that we should be looking at? I've also had an HSG (hysterosalpingogram, an x-ray that shows the inside of the uterus, fallopian tubes, and surrounding area), which came back normal.
Dr_Tan: It looks like your doctor has done a great job of helping you find out why you have had four miscarriages. I assume that both you and your partner had karyotyping done to check your number of chromosomes. Along with clotting profiles and HSG, these are the most important tests we do for women with recurrent miscarriages. If there is a concern that you might have a problem with egg supply, you should also have that checked. This test is done by blood work and ultrasound. I also assume that your physician checked to make sure that you don't have any uncontrolled medical conditions, such as diabetes and thyroid disease, which also could cause miscarriages.
hrwright: What might a patient going through infertility and assisted reproduction overlook? What should we ask our doctors, the insurance company and the pharmacy?
Dr_Tan: Your question is quite broad because there are so many causes of infertility. If you have concerns that there may be things that your doctor might have overlooked, it would be best to seek a second opinion. We have six physicians in our division, with several offices located throughout the Cleveland area for your convenience (including Cleveland Clinic’s main campus, the family health and surgery centers in Beachwood and Strongsville, Solon Family Health Center, the Cleveland Clinic Richard E. Jacobs Health Center in Avon, and the Canfield Telemedicine Office for Youngstown).
Cleveland Clinic Telemedicine Services
Paula: I live in the Youngstown area and really cannot travel to Cleveland for a consult. Do you have any options for out-of-town people?
Dr_Tan: Yes, Cleveland Clinic offers the telemedicine service for patients who live in Youngstown and Pittsburgh areas (at the Canfield Telemedicine Office). Patient will go to our Cleveland Clinic office in Youngstown where you will meet with one of our medical assistants who will help you connect to me via video computer
I will discuss your condition face-to-face via video conferencing, just like we are meeting in person. If you are interested in the telemedicine service, please call 216.444.2240 to make an appointment.
CL84: I have been tested for polycystic ovary syndrome, a pituitary tumor and thyroid problems. I do have low estrogen and, therefore, the physician wants to protect me from bone loss. He is saying that it is unexplained infertility. Do you have any suggestions on other natural remedies that I could try in conjunction with Premphase®?
Dr_Tan: Approximately 10 percent of couples who are infertile are diagnosed with unexplained infertility. This means that physicians cannot determine the reason why you are unable to conceive. It seems as if your physician thinks that you might not be ovulating every month, and therefore you do not have a period on your own. Some natural remedies such as soy supplements might slightly increase the estrogen level in your body. However, it would be difficult to know if it would help protect your bone or not.
Momma_Kat: Can you take too much folic acid?
Dr_Tan: It is recommended that you take at least 400 micrograms of folic acid per day while trying to conceive. In women with a history of having a child with a birth defect called neural tube defects, the recommended dose of folic acid is 4 mg a day. Although it is quite a high dose of folic acid, it is safe to take. So, I don't think you need to worry about taking too much folic acid.
Medications for Infertility
nursencars: In women with polycystic ovary syndrome, can Femara® induce ovulation when Clomid® has not?
Dr_Tan: Yes. Femara® (or letrozole) is an alternative treatment to help with ovulation in women with PCOS. Femara® works a little differently than Clomid® in terms of how it helps your ovulation. While you are taking letrozole, which is given for five days starting on the third day of your menstrual cycle—just like how you take Clomid®, your body stops making estrogen for a couple of days. In turns, your body works harder to produce an egg (or ovulate). Another good thing about Femara® is that it has fewer side effects than Clomid®. This medication, however, is not FDA-approved for infertility treatment. Nevertheless, there are studies that show that it works as well as Clomid®, and it doesn't increase your risks of birth defects if you take it to help with ovulation. So, yes—in my opinion, Femara® definitely would be the next step if Clomid® doesn't work for you.
Momma_Kat: Would you recommend a combination of different medications like Clomid® and soy isoflavones together?
Dr_Tan: There are no studies showing whether adding supplements such as soy isoflavones would help Clomid® work better or not. I think that as long as those supplements are safe to take and you would like to take them, you should be fine to take them together. You and your physician should discuss whether the medications and supplements that you are currently taking are safe to take during pregnancy. If your physician feels that any of your medications are not safe to take during pregnancy, he or she might offer alternative options that are safer for you instead. We certainly encourage women who are trying to conceive to take a daily prenatal vitamin with folic acid to decrease the risk of having a baby with a neural tube defect.
sarah0808: I am 44 years old and have three children. I had a Gonal-f® injection, but it didn't work. I never had any problem getting pregnant before. Is there another medication that I could try?
Dr_Tan: I assume that you did respond to the hormone in Gonal-f®, a fertility shot to help you make two to three eggs each month, but you did not conceive. Unlike men, women are born with the all of the eggs they will ever have. The number of eggs (or ovarian reserve) declines with age. The rate of decline happens very rapidly when women are in their 40s. Therefore, women in their 40s have a hard time conceiving. Due to the decreased egg supply, fertility medications do not work as well in older women and it might not increase their chance of getting pregnant. So, unfortunately, I don't think that fertility medication will increase your chance of getting pregnant at this point. If you had no problem getting pregnant in the past, despite the odds being low, you might still have a chance of having another child on your own. Unfortunately, the fertility medication might not be helpful for you.
hrwright: Why wouldn't someone elect intracytoplasmic sperm injection (ICSI) during in vitro fertilization (IVF)? It seems you would get the most 'bang for your buck' using ICSI.
Dr_Tan: In vitro fertilization (IVF) is a method of assisted reproductive technology that involves removing mature eggs from women's ovaries, fertilizing the eggs with sperm, incubating the dividing cells (also called embryos) in a culture dish, and then replacing the developing embryo in the uterus at the appropriate time. IVF is indicated in couples with male factor infertility, tubal damage, genetic defects that require embryo testing, and for those couples who have failed other conservative treatments. IVF is also an option for women with poor ovarian reserve (low egg supply) and endometriosis. Prior to removing the mature eggs from the ovaries, the female partner will need to take fertility shots to increase the number of mature egg production (ovulation induction).
There are two ways to fertilize the eggs: traditional IVF and ICSI (intracytoplasmic sperm injection). During traditional IVF, sperm and eggs are placed in the culture dish overnight for fertilization. ICSI is a process whereby a single sperm is injected directly into a single mature egg. ICSI is usually performed when there are concerns of poor fertilization such as too few sperm, significantly abnormal sperm shape, and sperm that might have a problem penetrating the egg shell or a history of poor fertilization. Doing ICSI, however, doesn’t guarantee that all of your eggs will be fertilized. Since not all of the eggs and sperm are genetically normal, not all of the eggs will be fertilized during the IVF and ICSI procedures.
Regarding your question of why would someone not elect ICSI during IVF is likely due to the concern that ICSI might cause birth defects. The chance of having birth defects with assisted reproductive technology is approximate the same as in natural pregnancy which is one and one half to three percent. Certain very rare medical conditions have been associated with the use of ICSI. Those conditions, however, are very rare and occur in far less than one percent of babies conceived using this technique. Some of the sperm problems that lead to the need for ICSI may be genetic. Therefore, boys conceived with the use of ICSI may have infertility issues as adults. Because of these concerns, it is important that you and your infertility doctor discuss the advantages and disadvantages of these procedures before proceeding with fertility treatments.
Financial Arrangements and Costs
hrwright: For an employee with the Employee Health Plan insurance, what is the cost of IVF with ICSI?
Margie_Clapp: ICSI is included in our package. Please call the office at 216.839.3150, ext. 5 to discuss costs.
hrwright: For an employee with the Employee Health Plan insurance, what is the cost of cryopreservation of an embryo formed through IVF, and then transferring this embryo at a later time to the body?
Margie_Clapp: The cost to store cryopreserved embryos is $396 this year and does increase yearly by approximately three percent. For employee pricing, please call our office at 216.839.3150, ext. 5.
hrwright:Is money refunded if IVF is unsuccessful?
Margie_Clapp: If you purchase a package from a company called ARC, you can buy a guaranteed price refund package, but they are expensive. Their phone number is 888.990.2727.
hrwright: Does Cleveland Clinic and the pharmacy require all payment for assisted reproduction before the process begins? Are there incremental payment plans available?
Margie_Clapp: The medication is purchased from the pharmacy like all other medications. IVF does require the prepayment to be made by the time you start your first ultrasound treatment.
hrwright: Is the ARC (Advanced Reproductive Care loans) program credit-based? Does it honor Cleveland Clinic Employee Health Plan pricing?
Margie_Clapp: ARC does look at your credit and can refuse patients. If you are a Cleveland Clinic employee, it is not worth using the ARC package.
redmond: How much money should I expect to spend in medication for IVF?
Margie_Clapp: Generally, medication cost is approximately $2,800, but some patients may need to use more medication and others less, which affects the price.
asisia79: I live in central Ohio and have been consulting a doctor locally for the past three years, but I am starting to think I want a second opinion. My insurance coverage is 70/30, but my understanding is that second opinions aren't usually covered by insurance. So what does that look like financially?
Margie_Clapp: Please check with your insurance company to see if a second opinion would be covered. If you have a 70/30 split, your 30 percent is usually less than you think because of contractual agreements between the hospital and your insurance carrier.
hrwright: Does Cleveland Clinic accept CareCredit® Health Care Finance as a method of payment for assisted reproduction?
Margie_Clapp: We do not accept CareCredit® Health Care Finance.
szczotur_1: What is the cost for IVF and for artificial insemination?
Margie_Clapp: One cycle of IVF if your insurance covered nothing would be approximately $15,000. The cost of artificial insemination is $452.
DEATRA: Do you know of any type of grants or anything that can be used to cover some of the cost for fertility treatments?
Margie_Clapp: Typically there are no studies or grants for fertility service, but Cleveland Clinic has just started a fund called Harboring HopeSM. This program requires patients to pay for 1 cycle of IVF and then if they meet the Harboring HopeSM requirements, they could be eligible for a free or greatly reduced second cycle of fertility treatment.
misvt: I've been trying to conceive for almost four years with unexplained infertility. I have had two miscarriages and three failed intrauterine inseminations. What are the costs associated with infertility treatment at Cleveland Clinic
Margie_Clapp: It depends on the treatment that is recommended for you. Inseminations are $452 plus the cost of medications.
Infertility Clinical Trials
misvt: Do you offer infertility trials and what does that involve?
Margie_Clapp: Infertility is an elective procedure and clinical trials are very rare.
Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic specialists Dr. Julie Tan and Margie Clapp is now over. Thank you Dr. Tan and Ms. Clapp for taking the time to answer our questions today about financing fertility treatments.
Dr_Tan: Thank you for your questions today.
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