Online Health Chat with Jeffrey Goldberg, MD & Margie Clapp
May 17, 2012
Cleveland_Clinic_Host: Infertility is defined as the inability to conceive after a year of unprotected intercourse. In the U.S., infertility affects 7.3 million people, or one in eight couples, and affects both men and women equally.
Jeffrey Goldberg, MD, received his medical degree from The University of Medicine and Dentistry of New Jersey, New Jersey Medical School in Newark, N.J. in 1983. He completed a residency in obstetrics and gynecology at Emory University in Atlanta, Ga., and a fellowship in reproductive endocrinology and infertility at The Ohio State University in Columbus, Ohio, where he remained on faculty until joining Cleveland Clinic in 1991. Currently, he is Head of the Section of Reproductive Endocrinology and Infertility at Cleveland Clinic and is a professor at Cleveland Clinic Lerner College of Medicine. He is also the director of the Reproductive Endocrinology and Infertility fellowship program.
Dr. Goldberg is board-certified in obstetrics and gynecology and subspecialty board-certified in reproductive endocrinology by the American Board of Obstetrics and Gynecology. His clinical interests are advanced endoscopic surgery, microsurgical tubal anastomosis, in vitro fertilization, and reproductive endocrinology. His research interests include endometriosis, reproductive surgery, and the effect of bariatric surgery on fertility.
Dr. Goldberg has published more than 200 scientific articles, abstracts, and book chapters, and co-authored two books on gynecologic endoscopic surgery. He is a Fellow of the American College of Obstetrics and Gynecology and is a member of the American Society for Reproductive Medicine, The American Societies for Reproductive Endocrinologists and Reproductive Surgeons and The American Association of Gynecologic Laparoscopists. He is chair of the American Society of Reproductive Surgeons Practice Committee and serves as an ad hoc reviewer for several journals, including Fertility and Sterility, The American Journal of Obstetrics and Gynecology, Obstetrics and Gynecology, and Human Reproduction.
He was co-recipient of the Computerworld Smithsonian Research Innovation Award for robotic surgery, received the American College of Obstetricians and Gynecologists National Faculty Award for excellence in resident education, and has been selected as a Top Doc in Cleveland and Best Doctors in America since 2001.
To make an appointment with Dr. Goldberg 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 financing call 216.839.3153
Cleveland_Clinic_Host: Join Cleveland Clinic Fertility Center on Facebook. Log on to clevelandclinic.org/FertilityFacebook. Click on "Ask to Join Group." Visit our Group Page often to interact with our physicians, nurses and embryologists as they share the latest information on infertility diagnoses, treatments and procedures. Engage with other patients facing the same challenges. Feel free to invite your family and friends to join our discussion too.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic fertility expert Dr. Jeffrey Goldberg and financial advisor Margie Clapp, who have just arrived. We are thrilled to have them here today for this chat. Dr. Goldberg and Margie will now begin answering your questions.
In Vitro Fertilization (IVF)
TheGoodLife: What are the costs of IVF (in vitro fertilization) at Cleveland Clinic? Are different packages offered?
Maggie_Clapp: The cost of one IVF cycle from start to finish is approximately $15,000 if your insurance plan covered nothing at all. Usually that is not the case; they cover pieces of the work-up. We have been working on different packages that should be available in the very near future.
gedbmom: Does the cost of the IVF cycle include prescriptions and/or the intracytoplasmic sperm injection (ICSI)?
Maggie_Clapp: One IVF cycle is approximately $15,000 if your insurance covered nothing at all. That does include the drugs and ICSI. Most insurance companies do cover bits and pieces of the testing.
klb123: Is there somewhere on the Intranet that we can find pricing information/financial options?
Maggie_Clapp: I would be happy to email you an IVF booklet with the cost breakdown. Please send me your email address to email@example.com, and I will forward the booklet.
Spring: What is the cost of IVF if a donor is needed?
Maggie_Clapp: If you are referring to the Donor Oocyte Program, the cost for the agency that finds the donors is approximately $10,000, and the medical portion here at the Cleveland Clinic is approximately $16,000.
sarahvyang: In the case that I would need IVF, do I need to put a large sum of money down?
Maggie_Clapp: Yes. The prepayment is $9,417, and medication is needed from the pharmacy, which is approximately $2,800. We do offer MAP loans through US Bank and the ARC infertility loans.
spring: What is the cost for IVF with an egg donor? What portion is for the donor and what portion is for the recipient? Are there programs to help offset cost and how are they administered?
Maggie_Clapp: The prepayment for an oocyte donor cycle at the Cleveland Clinic is $13,200. Most of this money will go for the donor's services. Her medications are separate and average $2,500. The only part of the prepayment that is for the recipient is embryo transfer - approximately $1,762.
rmeeks: My husband and I have been doing Clomid® (clomiphene) treatments for years on and off--I will be 39 in November--I am ready to maybe do IVF--should I try the fertility shots first or just do the IVF?
Dr__Goldberg: Clomid is only used for 6 cycles, as pregnancy is unlikely with prolonged treatment. Assuming that there are no other infertility problems to specifically treat, the other options for unexplained infertility are to perform intrauterine insemination with either Clomid or injectable FSH (follicle-stimulating hormone) versus going directly to IVF. Since you are already 39 with long standing infertility, I would recommend being more aggressive and skipping the Clomid insemination step. A recent large study from Boston compared 3 cycles of FSH and insemination then IVF versus going straight to IVF and found that the time and cost to achieve a pregnancy were better with the latter.
sarahvyang: Is there any financial help available for IVF patients?
Maggie_Clapp: We have different finance options: the clinic offers MAP loans through US Bank, and we also deal with ARC (Advanced Reproductive Care, Inc.). ARC’s phone number is 888.990.2727, and they will explain their products. gedbmom: What is the cost of a cycle using cryo-preserved embryos?
Dr__Goldberg: Approximate cost of a Frozen Embryo Transfer is $2,000, which includes the ultrasound that is needed.
szczotur_1: How long is a typical IVF cycle?
Dr__Goldberg: A typical IVF cycle starts with daily injections of Lupron® (leuprolide) to suppress the pituitary gland, beginning 21 days after the start of a period. This is to reduce the risk of ovulating prior to the egg collection. After 10 to 14 days, injections of FSH (follicle-stimulating hormone) are added. The patients are monitored every few days with ultrasounds of the ovaries and blood estrogen levels. The dose is adjusted based on these results and a final injection of hCG (human chorionic gonadotropin) is given to bring about complete egg maturation. The eggs are collected nonsurgically 36 hours later, and the fertilized eggs are transferred to the uterus 3 to 5 days after that.
sarahvyang: I found on a website that CCF offers something called "Partnership for Families" that helps with IVF; is it still available?
Maggie_Clapp: We do not have a Partnership Program anymore, but we do have a new program that is similar to that called Harboring Hope. You pay for one IVF on your own and then apply for the Harboring Hope program for a free second cycle.
sarahvyang: Is there contact info on Harboring Hope? I Googled it and nothing came up. I'd like to look into it.
Maggie_Clapp: It is a brand new program, and we are having a Charity Ball on November 10, 2012. The application to apply for funding will be available soon. You must pay for one IVF cycle here at the Cleveland Clinic and then apply for the Harboring Hope Program to pay for the second IVF cycle.
sarahvyang: Can I be monitored in the Columbus area? If so, how do I do this?
Dr__Goldberg: We do have a monitoring site in Columbus. Our IVF nurses can make those arrangements.
bethersreid: What is the Clinic's success rate with IVF for individuals over 40?
Dr__Goldberg: The live birth rate per egg retrieval for women 41-42 is 10.2% and 8% for patients over 42.
DEATRA: How many IVF treatments should you have before choosing to go with a surrogate?
Dr__Goldberg: IVF may not be successful due to either compromised embryo quality or the lining of the uterus may not be optimally prepared for implantation. Unfortunately, there are no clinical tests for either so there is no clear explanation when IVF fails. A gestational carrier is usually considered in cases where the uterus is absent or the cavity is severely scarred, or the woman has medical conditions where pregnancy is a health risk. A donor egg may be a better option than a gestational carrier following multiple unsuccessful IVF cycles. Clearly, a gestational carrier won't improve the chances if the problem is due to poor egg quality.
rmeeks: At what point do you decide to do IVF?
Dr__Flyckt: There can be many reasons to think of moving to IVF- it depends on your age, testing of your ovarian reserve (capacity of the ovary to produce fertilizable eggs), and history of prior treatments. It also depends on your partner's sperm test, because some patients require IVF for male-related problems. In the end, it will be an individualized decision based on many factors including whether you are ready for the time, cost, and schedule required to do an IVF cycle.
IUI and Superovulation
sarahvyang: What is the cost of an IUI (intrauterine insemination)?
Maggie_Clapp: The cost of an insemination is $452. That includes the sperm wash and insemination.
nursencars: Will there be any packages available for superovulation/IUI?
Maggie_Clapp: No, the packages are geared towards IVF.
nursencars: What is the cost of "superovulation" with Follistim® (follicle stimulating hormone)? Does CCF offer a discount to employees?
Maggie_Clapp: Approximate cost of medication is $800, 3 ultrasound @ $135 each, 3 office visits @ $30 each, and insemination $200 for CCF employees.
Polycystic Ovary Syndrome (PCOS)
outrajs: When it comes to diabetes and fertility...is it the insulin you take that causes the infertility or the natural insulin the body produces? How is insulin resistance associated with infertility?
Dr__Goldberg: Some women with polycystic ovary syndrome (PCOS) have insulin resistance. This means that their bodies are relatively resistant to the insulin that they produce, so to keep their blood sugar in the normal range, they have to compensate by making more insulin. The elevated insulin doesn't cause infertility, but rather not ovulating due to having PCOS.
rebma02: I have PCOS and have done 5 rounds of Clomid, 2 rounds of Femara® (letrozole) and a round of Femara with Menopur® (menotropins for injection), none of which have caused ovulation, what would my next option be and would it be wise to do an IUI or try IVF?
Dr__Goldberg: Ovulation induction for PCOS patients may occasionally be difficult and several medication protocols may have to be tried to find one that works. An outpatient laparoscopic procedure with the unfortunate name of "ovarian drilling" may enable Clomid-resistant women to either ovulate on their own or with the addition of Clomid. It can also reduce the higher miscarriage rate associated with PCOS, as well as improve acne and abnormal hair growth.
angmahon: Can a woman with PCOS and insulin resistance have a successful pregnancy?
Dr__Flyckt: Absolutely. Although there are more difficulties associated with getting pregnant and the pregnancy itself, it certainly is a common situation for our PCOS patients and, under the care of a fertility specialist and possibly later a high risk obstetrician, is a manageable problem.
Advanced Reproductive Care, inc. (ARC)
bethersreid: Is the Clinic involved with ARC (Advanced Reproductive Care, Inc.) or some other agency that would help with refunding monies if the procedure does not work?
Maggie_Clapp: Yes, we have been involved with ARC for many years. They are a good company to work with.
bethersreid: Can you explain the process with ARC?
Maggie_Clapp: ARC sells packages to patients, 1 cycle, 2 cycle and 3 cycles. All the packages include a free frozen embryo transfer (a $1,762 value). They also sell money back guarantees if cycles fail. The phone number for ARC is 888.990.2727.
aschneid38: My insurance only covers diagnostics and not treatments, are there payment options available once a diagnosis has been given?
Maggie_Clapp: The Cleveland Clinic has MAP loans available for infertility patients and we also deal with a company called ARC, phone number 888.990.2727.
Cleveland Clinic Employees
Brighton: Is there a CCF employee discount for IUI or IVF?
Maggie_Clapp: Yes. IUI is usually $452 and for an employee it is $200. An IVF cycle is usually $9,417, not including ultrasounds, but employees pay $4450, which includes the ultrasounds and office visits. Great deal!
nursencars: For CCF employees, how much are each of the estradiol blood draws?
Maggie_Clapp: Each estradiol level is $99.
nursencars: Is the initial consultation visit covered by CCF insurance?
Maggie_Clapp: It depends on how the diagnosis is coded as determined by the physician.
Brighton: Is there a CCF employee discount for semen analysis? Or is it covered by the CCF employee health plan?
Maggie_Clapp: There is no discount for a semen analysis. I am not sure if our CCF insurance is paying for it these days. They are really becoming very strict on what they cover.
Spring: What is the cost/discount for an employee for IVF with and egg donor? Donor cost and the recipient cost?
Maggie_Clapp: There are no employee discounts for the oocyte donor program. Most of the charges are for the oocyte donor, and they do not receive a discount. The cost is approx $16,000 for medical and $10,000 for oocyte donor agency.
addaboy: What tests are recommended for those suffering multiple miscarriages?
Dr__Goldberg: There are several potential underlying causes for recurrent miscarriage, though in the majority of cases, no cause is found. The causes and tests include:
Anatomic causes: a hysterosalpingogram (HSG, or X-ray dye test), fluid ultrasound, or office hysteroscopy will be performed to check for abnormalities in the cavity of the uterus such as polyps, fibroids, scar tissue, and congenital malformations. These may all be treated as an outpatient through a scope.
Immune causes: blood will be obtained for a lupus panel. Abnormalities are associated with recurrent miscarriage, intrauterine death and stillbirth, early pre-eclampsia, and blood clots in the mother. This is treated with heparin during pregnancy.
Hormone causes: blood is checked for thyroid and prolactin. These are treated with oral medication if abnormal. In addition, I have all of my recurrent miscarriage patients on vaginal progesterone after ovulation to provide additional hormonal support to improve the lining of the uterus to maintain the pregnancy until 10 weeks gestation.
Genetic causes: both partners will have a tube of blood drawn to check for chromosomal abnormalities. These are not inconsistent with having normal children but do increase the risk for miscarriage and birth defects. Couples are referred to genetics counselors and treatment may include IVF with pre-implantation genetic testing to make sure the embryos are normal. Alternatively, donor sperm or eggs may be used.
Spring: Do you offer shared cycle programs, and if so, how often are they used?
Maggie_Clapp: Yes, we do offer a Shared Oocyte Program, but it is not used that much anymore. Most recipients want to select their donors carefully and will pay the extra money to keep all the oocytes. The Shared Program divides the oocytes.
meeks: What determines the best option for each person for fertility treatment?
Dr__Goldberg: There is often no "best" option. Factors to consider are the woman's age, duration of infertility, infertility factors, prior treatments, risks, and costs. We will have a consultation with the couple to review the advantages and disadvantages of all of the options so that they can make an informed decision.
gedbmom: If you have an infertility diagnosis, but are blessed with a spontaneous pregnancy, do you need to redo all diagnostic testing in order to be eligible for fertility treatment should you desire another child?
Maggie_Clapp: You do not have to repeat the testing if it is within the last year.
addaboy: Can the use of generic drugs as opposed to brand drugs (levothyroxine for Synthroid® , for example) affect the ability to achieve pregnancy?
Dr__Goldberg: We do not believe that generic medications (e.g., synthroid) would have a significant impact on conception rates; you would just need to make sure that you are taking the correct dose under the supervision of your physician.
lesson_learned: How does HPV (human papillomavirus) affect infertility?
Dr__Goldberg: HPV doesn't affect fertility.
btrflyb: Does CCF have a surrogate program? What are the costs involved?
Maggie_Clapp: Yes, we have a surrogate host program. The medical portion for the treatment would be approximately $16,000.
addaboy: Is it possible that something could happen with a previous pregnancy that would cause secondary infertility?
Dr__Flyckt: Yes, that is a possibility. We recommend that patients with secondary infertility come for a visit to be evaluated for these types of concerns.
nursencars: Maggie, Are you available to meet with patients prior to under-going treatment to determine roughly the out-of-pocket expense expected?
Maggie_Clapp: Yes, you can reach me at 216.839.3150, option #5.
hopefully37: How much of an impact does having a TSH (thyroid-stimulating hormone) level above 2 or 3 (and knowing that the ideal range is between 1 and 2 for conception) have on becoming pregnant and maintaining the pregnancy?
Dr__Flyckt: Having an elevated TSH can impact chances for becoming pregnant, although in the range you mentioned it depends on the cutoff for the specific lab that did the test (they vary from lab to lab). Having an elevated TSH, or being hypothyroid, during a pregnancy can also affect the pregnancy itself if not regulated. Many practitioners increase the dose of synthroid immediately upon starting a pregnancy due to increased demands as pregnancy progresses.
addaboy: If taking Clomid, are you limited on your activities? Is running & exercise still okay? Or do you risk twisting or putting stress on the ovaries?
Dr__Flyckt: It depends where you are in your cycle as well as your ovaries’ response to Clomid. The risk of twisting an ovary (torsion) is higher when the follicles that develop on the ovary are large or numerous (usually around the time of ovulation). However, if you produce one follicle, your risk is probably the same as in a non-Clomid month. Moderate exercise is always okay, and we always tell patients to be careful as regards any sudden-onset lower abdominal pain. I would say no to the "stress" aspect of your question though; exercise should be fine in that regard.
i_can_fly: What are the chances of conceiving after having a blockage removed?
Dr__Flyckt: This is an important but complicated question. It depends on many factors such as the nature of the blockage and how it was fixed (I'm assuming you mean a blockage in the tube). What caused the blockage and if it might recur (such as endometriosis). Whether there are other fertility factors at play such as a male factor, lack of ovulation, your age, etc... So it's hard to give a precise estimate. If that was the only fertility issue and it was only affecting one tube, your chances of conception should approach those of an average woman your age.
no_one: I am 33 years old, and my husband and I have been trying to get pregnant for 2 years. How do you determine what is causing my infertility problem?
Dr__Flyckt: After two years of trying, I think you would benefit from a fertility evaluation. In addition to a detailed history and physical exam to identify treatable risk factors, we would probably obtain a semen analysis (30% to 40% of causes of infertility are male), a test to make sure your tubes are not blocked, and make sure you are ovulating (sometimes this can be done by menstrual calendars). Depending on the results of those basic tests, we would move on to next steps in your evaluation based on your specific situation.
out_of_the_way: My doctor told me that I have endometriosis and that I may have difficulties getting pregnant. I am 29 years old and getting married this year. Should we talk to a fertility doctor now?
Dr__Flyckt: This depends on the severity of your endometriosis. At the age of 29 (as long as no one in your family had premature menopause), I would recommend trying to conceive for 6 months and then coming to speak with a specialist if you have no success after that. Many patients with endometriosis are able to become pregnant on their own.
Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic fertility expert, Dr. Jeffrey Goldberg, Dr. Flyckt and financial advisor Margie Clapp is now over. Thank you both for taking your time to answer our questions today about infertility.
Maggie_Clapp: Thanks for asking questions and participating in our web chat. Please feel free to call me at 216.839.3150 option #5 for more information or questions.
Dr__Flyckt: Both Dr. Goldberg and myself would like to thank you for your time and interest today. We were both glad to chat with you. Thank you.
To make an appointment with Jeffrey Goldberg, MD 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 financing call 216.839.3150, option 5.
Cleveland_Clinic_Host: Join Cleveland Clinic Fertility Center on facebook. Log on to clevelandclinic.org/FertilityFacebook. Click on "Ask to Join Group." Visit our Group Page often to interact with our physicians, nurses and embryologists as they share the latest information on infertility diagnoses, treatments and procedures. Engage with other patients facing the same challenges. Feel free to invite your family and friends to join our discussion too.
Cleveland_Clinic_Host: If you are local and in the Greater Cleveland area - Thursday June 14 a symposium titled 'Endometriosis, Infertility and More' will be presented at the Richard E. Jacobs Health Center. Space is limited. Please call Susan Anton at 216.448.1020 or firstname.lastname@example.org for more information. A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit clevelandclinic.org/myConsult.
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