Your guide to infertility treatment at Reproductive Medicine Associates of New Jersey
HOW IVF WORKS
step by step
Q&A
with three
fertility specialists
Ways to start your
family
SPECIAL HELP
on the road
to parenthood
‘The day I felt a kick’
HAPPY MOMS AND DADS TELL THEIR STORIES RMA_Supp1009REV1.indd 1
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You’re trying to have a baby…
Welcome to Reproductive Medicine Associates of New Jersey. Ten years ago, when we founded this practice, our mission was to build upon our years of experience to provide patients with exceptional infertility care, cuttingedge research and expeditious treatment to help couples struggling with infertility to fulfill their dream of having a baby. We pledged to invest considerable resources and use our knowledge of best practices—and our love of this specialty—to establish the most comprehensive infertility treatment center in the world. Over the past decade, we have focused on our mission and core values and helped thousands of patients and couples build their families. With our large physician team, we are each able to specialize in particular areas of diagnosis and treatment, thus providing a level of expertise and success rates that are not found elsewhere. Our clinical, research, financial and support teams provide the full spectrum of infertility care. On these pages, we invite you to read about our innovative diagnostic and treatment services, the exciting research we are conducting and the way we’ve helped to change lives. You may also visit our web site at www.rmanj.com for detailed information about all our services. We encourage you to give us a call when you are ready to take the first step toward infertility treatment. All our best,
Michael R. Drews, M.D., F.A.C.O.G.
Paul A. Bergh, M.D., F.A.C.O.G.
Richard T. Scott, M.D., F.A.C.O.G.
Richard T. Scott, M.D., F.A.C.O.G. Paul A. Bergh, M.D., F.A.C.O.G. Michael R. Drews, M.D., F.A.C.O.G.
contents
FOUNDERS AND PARTNERS, REPRODUCTIVE MEDICINE ASSOCIATES OF NEW JERSEY
3
clinical focus
complementary care
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11
Special help on the road to parenthood
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success stories
15
your choice
the challenge
Understanding the causes of infertility
what to expect
step by step
Q& A
with three
fertility specialists SPECIAL HELP
family
10
“We’re here to help”
HO W IVF WO RK S
Ways to start your
3 4
introduction
es of New Jersey ctive Medicine Associat treatmen t at Reprodu Your guide to infertility
to parenthood
on the road
11 3
Determining your best treatment
three key approaches
• The basic steps • Assisted reproductive technologies • Advanced options
In vitro fertilization, step by step
Satisfied RMA patients whose lives have entered the diaper-changing phase
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Why RMANJ?
‘The day I k’ felt a kic DADS
HAPPY MOMS AND IES TELL THEIR STOR
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introduction
“We’re here to
help”
Our physicians
The patient liaisons answer questions about our program and schedule appointments for all NJ locations.
We know that your first step toward infertility treatment can feel like a monumental leap. That’s why Reproductive Medicine Associates of New Jersey has assembled a compassionate, worldrenowned team of specialists to guide you on your journey to parenthood. Our state-of-the-art laboratory, imaging and surgical diagnostics assist us in pinpointing the best treatment method for you based on your individual medical and psychosocial needs. At RMANJ, we offer all the infertility treatments available today, including medications to induce ovulation; in vitro fertilization and other assisted reproductive technologies; egg, sperm, and embryo donations; laparoscopic and hysteroscopic surgical intervention; gestational carriers; pre-implantation genetic diagnosis; and complementary and alternative medicine options. Our specialized e-learning modules allow patients to learn about infertility treatments in the privacy and comfort of their own homes. Our support services—including financial counseling, support groups and educational seminars—
Amr Azim, M.D., F.A.C.O.G.
Michael R. Drews, M.D., F.A.C.O.G.
Board-certified in obstetrics and gynecology; board-eligible in reproductive endocrinology and infertility
Partner; RMANJ, board-certified in reproductive endocrinology and infertility, obstetrics, gynecology; clinical associate professor of obstetrics, gynecology and reproductive science: UMDNJ– Robert Wood Johnson Medical School
Paul A. Bergh, M.D., F.A.C.O.G. Partner; RMANJ, board-certified in reproductive endocrinology and infertility, obstetrics, gynecology; clinical associate professor of obstetrics, gynecology and reproductive science: UMDNJ–Robert Wood Johnson Medical School
Michael K. Bohrer, M.D., F.A.C.O.G. Board-certified in reproductive endocrinology and infertility, obstetrics, gynecology; clinical associate professor of obstetrics, gynecology and reproductive science: UMDNJ–Robert Wood Johnson Medical School
help couples understand and navigate insurance and other payment issues, learn coping strategies and share experiences with others who have similar concerns. For more than 20 years, our team has also conducted clinical research that has contributed to major advances in the field of reproductive medicine, including our 24-chromosome aneuploidy screening, which helps determine the risk of genetic abnormalities in IVF embryos. We are also recognized worldwide for our IVF blastocyst culture, which gives embryos extra time to grow and develop in our lab before they are transferred back into the patient. During the last 13 years, RMANJ’s founding partners and staff physicians have helped bring approximately 20,000 babies to loving parents. You are not alone in this journey. Our team is available at all times to answer your questions and guide you through your treatment. Our main office in Morristown and our satellite offices in Englewood, Summit, Somerset and West Orange offer flexible appointment times and early-morning monitoring. We are open 365 days a year. To make an appointment in any of our locations, please call a patient liaison at 973-656-2089 or visit our web site at www.rmanj.com.
assistant professor of obstetrics, gynecology and reproductive science: UMDNJ–Robert Wood Johnson Medical School
assistant professor of obstetrics, gynecology and reproductive science: UMDNJ–Robert Wood Johnson Medical School
Thomas J. Kim, M.D., F.A.C.O.G.
Richard T. Scott, M.D., F.A.C.O.G., H.C.L.D.
Board-certified in reproductive endocrinology and infertility, obstetrics, gynecology
Partner and scientific director, RMANJ; board-certified in reproductive endocrinology and infertility, obstetrics, gynecology; board-certified as an embryologist, andrologist and high-complexity laboratory director; professor of obstetrics, gynecology and reproductive science, and division director of reproductive endocrinology: UMDNJ–Robert Wood Johnson Medical School
Rita Gulati, M.D., F.A.C.O.G.
Thomas A. Molinaro, M.D., F.A.C.O.G.
Board-certified in reproductive endocrinology and infertility, obstetrics, gynecology; clinical assistant professor of obstetrics, gynecology and reproductive science: UMDNJ–Robert Wood Johnson Medical School
Board-certified in obstetrics and gynecology; board-eligible in reproductive endocrinology and infertility
Doreen L. Hock, M.D., F.A.C.O.G. Board-certified in reproductive endocrinology and infertility, obstetrics, gynecology; clinical
Jamie L. Morris, M.D., F.A.C.O.G. Clinical supervisor of academic programs, research and thirdparty reproduction: RMANJ; board-certified in reproductive endocrinology and infertility, obstetrics, gynecology; clinical
Shefali Mavani Shastri, M.D. Board-eligible in reproductive endocrinology and infertility, obstetrics and gynecology
sweet dreams
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the challenge “First comes love, then comes marriage, then comes Mommy with a baby carriage.” The familiar childhood rhyme describes a simple sequence that for some of us isn’t so simple. Month after month, the flat blue line on the pregnancy test’s dipstick brings another wave of disappointment when there is no impending baby to celebrate. About 7.3 million Americans face the challenge of infertility. Simply defined, infertility is the inability to conceive after one year of unprotected intercourse. But infertility is not a simple disorder. It can result from a confluence of anatomic, genetic, hormonal and behavioral factors. In some 50 percent of cases, doctors cannot find an explanation for a couple’s infertility. Why does conception happen almost effortlessly—or even unexpectedly—for some couples, while almost 10 percent of all couples struggle to become parents? “Perhaps the biggest barrier to fertility is the reluctance of couples to seek treatment when they are having trouble becoming pregnant,” says Jamie L. Morris, M.D., F.A.C.O.G., a reproductive endocrinologist at Reproductive Medicine Associates of New Jersey’s Morristown and Summit offices.
“In high-school sex ed classes, we all learn how not to become pregnant, but no one teaches us how to become pregnant when we are ready and nothing is happening.” For many couples, there are psychosocial, financial and sometimes medical hurdles to seeking infertility care. But there is also a ticking clock. “My heart breaks,” says Dr. Morris, “when a couple comes to me and says they have been trying for six years and I know that if they had come to see me five years ago I could have had a much better chance of helping them to conceive than I do now.”
The mechanics of reproduction Conception occurs after a carefully orchestrated chain of events that starts with hormones produced in a woman’s hypothalamus and pituitary gland in the brain. To mature one of the millions of eggs stored in a woman’s ovaries, the hypothalamus and pituitary glands release hormones that signal the ovaries to produce a fluid-filled follicle that contains an egg. Hormones help the follicle mature and the uterus thicken so that it will be prepared to receive a fertilized embryo. At about the 14th day of a woman’s menstrual cycle, more hormones stimulate the follicle to release the egg in a process called ovulation. The egg travels down one of the woman’s fallopian tubes. If it is fertilized, it continues its journey down the tube and implants itself in the lining of the uterus. If it is not fertilized, the uterus sheds its lining and the woman menstruates.
Why no pregnancy? Given that reproduction is such an intricate process, a large number of things can go wrong. If the woman’s fallopian tubes are blocked by scar tissue
Jamie Morris, M.D., F.A.C.O.G.
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Amr Azim, M.D., F.A.C.O.G.
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How fertility declines with age from endometriosis or a sexually transmitted disease, the egg cannot pass through them to be fertilized. If the woman produces excessive or insufficient hormones, ovulation may not occur. If a woman’s egg quality or quantity is poor because of age or other factors, conception may not happen or a miscarriage may occur. If the man has a low sperm count or the quality of his sperm is poor, the sperm may not reach the egg for fertilization. The egg may even be “repelled” by the man’s sperm. “If you add in some lifestyle behaviors—such as smoking, which can damage eggs; excessive exercise, which can cause a woman not to ovulate or menstruate; female obesity, which can lead to hormonal imbalances; tight clothing worn by the man, which can affect sperm production—then you can see the many variables that can affect reproduction,” says Amr Azim, M.D., F.A.C.O.G., a reproductive endocrinologist at Reproductive Medicine Associates of New Jersey’s Englewood and Morristown offices.
Chance of Pregnancy per Month 100 10 1 0.1 0.01 0.001 0.0001 0.00001
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Age (year of prospective mother)
The age factor Poor egg quality due to the aging process is one of the leading reasons for infertility. Increased educational and career options for women over the past 30 years have resulted in a greater number of women delaying pregnancy and childbirth. But the ability to conceive begins to decline at age 30 and drops precipitously after age 38. For women with a condition called premature ovarian failure syndrome, the ovaries’ ability to produce eggs can end even in the 20s. “I can’t begin to tell you how many women come to me in their late 30s or early 40s who are surprised they cannot conceive,” says Dr. Morris. “While we have ways to help them build a family, they may not be able to conceive using their own eggs, because the eggs have aged, changed over the years, or have diminished in quantity.” One of the most important pieces of information a woman’s ob/gyn or reproductive endocrinologist can convey is the impact of a woman’s age on reproduction. “We are not going to tell a woman, ‘Have a baby in your mid-20s before it’s too late,’ ” says Dr. Morris. “But we do inform our patients that it gets harder to become pregnant as they get older—and then let them make their own decisions. After all, knowledge is power.” If you are under 35 and have not become pregnant after one year of unprotected sex, or are over 35 and have not conceived after six months, ask your ob/gyn if it’s time to consult a reproductive endocrinologist. Causes of infertility may lie with the man or woman or, in 20 percent of cases, with a combination of male and female factors. Ten percent of couples have what reproductive endocrinologists call “unexplained infertility”—reasons that can’t be pinpointed with
RMANJ’s Andrology Laboratory
diagnostic methods. But with today’s state-of-the-art technology, sophisticated lab and imaging tests and thorough medical histories and physical exams, most reasons for infertility can be detected within one menstrual cycle. “No matter what the diagnosis, male or female or both, my patients tend to come together as a team and say, ‘Where do we go from here?’ ” says Michael Bohrer, M.D., F.A.C.O.G., a reproductive endocrinologist at RMANJ with 23 years of experience in diagnosing and treating infertility.
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what to expect
At RMANJ, every patient begins with an hour-long consultation with one of the reproductive endocrinologists, followed by a visit with a primary nurse to go over a potential treatment plan. Patients discuss their medical history, including past pregnancies, menstrual cycles, surgical history, other medical issues such as diabetes or hypertension, family medical history and any other factors that might affect fertility. The next step is usually a transvaginal ultrasound exam of the woman, during which her physician looks for structural abnormalities of the uterus, fallopian tubes or cervix; the presence of uterine fibroids, polyps or ovarian cysts; scar tissue in the
Michael Bohrer, M.D., F.A.C.O.G.
Doreen L. Hock, M.D., F.A.C.O.G.
Anne McGuire, B.S.N., R.N.
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fallopian tubes; or the number of egg follicles she has within her ovaries—an indication of the quality of her eggs and how many she may have left that can be fertilized. “Every female baby is born with all the eggs she will ever have—about 1 million—but over time those that do not ripen for ovulation break down and are absorbed within her body,” explains RMANJ reproductive endocrinologist Michael K. Bohrer, M.D., F.A.C.O.G. “Every month a number of follicles, the sacs that contain eggs, get ready and one pulls ahead of the pack to release the egg for ovulation. The number of follicles a woman has in both her ovaries prior to ovulation is proportional to how many eggs she has left.” On the third day of a woman’s menstrual cycle, a lab test that measures the amount of follicle-stimulating hormones the woman’s brain produces to signal the ovaries to ovulate can also give her physician an indication of her eggs’ potential for fertilization. “If a woman’s FSH levels are high, that means her body is working overtime to get the ovaries to make follicles,” says Dr. Bohrer. “This indicates that the quality of her eggs is poor.” Imaging tests that may be performed at one week into the menstrual cycle include a hysterosalpingogram, when dye combined with X-rays helps physicians view the uterus
Rita Gulati, M.D., F.A.C.O.G.
and fallopian tubes to check for growths or blockages, or a hysterosonogram, an ultrasound exam that involves injecting saline into the uterus to check for factors that might interfere with an embryo’s ability to implant and develop in the uterine lining. Other lab tests assess the production and performance of female hormones, whether the woman has immunity to rubella, and whether the man or woman has a sexually transmitted disease, hepatitis or HIV. The last important diagnostic test is the semen analysis to evaluate the reproductive function of the male partner. “The man produces a sample after abstaining from sexual relations for 2–5 days,” explains Andrew Ruiz, M.S.T.S., manager of andrology for RMANJ. “With this sample, we can check the quantity and quality of the sperm— whether they have the potential to make the long journey up the woman’s vaginal canal, through her uterus, and into her fallopian tubes to fertilize an egg.” Once all tests are completed, an individualized treatment plan is developed by a woman’s reproductive endocrinologist and coordinated by her primary nurse, who is with her at every stage of treatment. RMANJ’s registered nurses are responsible for making sure each patient or couple understands their treatment and follows a precise schedule. “We have very little nursing turnover,” says Anne McGuire, R.N., director of clinical services. “A majority of the nurses who were with us since the inception of RMANJ are still with us.” Each patient is also assigned a clinical coordinator, who handles scheduling, paperwork, nonmedical questions and e-learning.
Shefali Mavani Shastri, M.D.
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three key approaches ON THESE PAGES, YOU’LL READ CONVERSATIONS WITH LEADING SPECIALISTS AT REPRODUCTIVE MEDICINE ASSOCIATES OF NEW JERSEY ABOUT THE THREE PRINCIPAL KINDS OF TREATMENT WE OFFER FOR INFERTILITY:
The basic steps
can start with a conservative approach. If not, it makes sense to move right on to more appropriately aggressive methods.
TO BOOST MOTHER NATURE’S POTENTIAL, SO THAT ADVANCED PROCEDURES SUCH AS IN VITRO FERTILIZATION ARE NOT REQUIRED. IN A RECENT CONVERSATION, MICHAEL DREWS, M.D., A PARTNER IN RMANJ, EXPLAINED THESE METH-
If conception doesn’t occur, is it time for intrauterine insemination?
Then our goal is to make reproduction more efficient, and we have two ways of doing that: by helping the woman make more eggs, and by helping the sperm get closer to the egg.
That’s right. In this process, the male partner produces a sperm specimen, we concentrate the sperm into a tiny amount of fluid, and the fluid is drawn up into a little catheter. In the office we guide the catheter up through the cervix and into the uterus. Then we inject the sperm near where the uterus and a fallopian tube join. This reduces the sperm’s journey by up to two-thirds.
Helping the woman make more eggs— that’s superovulation, right?
How successful are these conservative methods?
Yes, and it’s also known as controlled ovarian hyperstimulation, or COH. We use two principal medications. We start with clomiphene citrate (trade name Clomid), which encourages the pituitary gland to send a strong signal to the ovaries to mature and release more than the one egg they normally produce during a woman’s monthly cycle. It’s a numbers game. With more eggs, there’s a greater chance that one will be fertilized by a sperm cell. The couple then times intercourse to ovulation. We usually advise them to use clomiphene citrate for at least three menstrual cycles.
When the woman is under 35, we sometimes see cumulative pregnancy rates of 60 to 70 percent over three monthly cycles.
SOMETIMES CONCEPTION CAN BE ACCOMPLISHED WITH COMPARATIVELY SIMPLE NUDGES
exam. We take the guesswork out of the picture because with these medications, we can time ovulation almost down to the hour.
Let’s say the pieces are in place. What then?
ODS AND HOW THEY ARE TYPICALLY APPLIED.
What are the “conservative” approaches to treating infertility? Superovulation and intrauterine insemination, or IUI.
Are these methods tried first? Yes, when couples are eligible. And I’d say somewhat more than 50 percent of the couples who come through our doors are eligible.
How is that determined? By the time a couple reaches us, they’ve probably been advised by the woman’s ob/gyn to either chart her basal body temperature or use an ovulation predictor kit that can be bought inexpensively at a pharmacy, so they’re choosing the best times for intercourse. Our first job is to perform laboratory and imaging tests to assess whether three important pieces of the conception puzzle are in place: the number and quality of the man’s sperm, the number and quality of the eggs in the woman’s ovaries and the woman’s pelvic anatomy— including the shape and size of her uterus, the status of her fallopian tubes, and the presence or absence of ovarian cysts.
What tests do you employ? They include pelvic ultrasound exams and a hysterogram x-ray to evaluate the woman’s pelvic anatomy, a follicle-stimulating hormone [FSH] test to measure the potential of her ovaries to produce quality eggs and a semen analysis. If all three pieces are in place, we
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And if nothing happens, what’s next? Injectable medications called gonadotropins bypass the pituitary gland altogether and send a direct signal to the ovaries to release the eggs. These drugs can now be given with the same type of auto-injection pen that many people with diabetes use to administer insulin. The couple usually administers the injections into the woman each evening. We then monitor the ovaries’ response in the morning with a blood test and ultrasound
Michael R. Drews, M.D., F.A.C.O.G.
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three key approaches
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likely implant and grow into a healthy baby, then we could transfer just that one embryo. IVF would no longer produce multiple births, and all the accompanying medical risks, and expenses, would be avoided.
When is 24-chromosome aneuploidy screening used, and how does it work? IF CONSERVATIVE TREATMENTS DON’T BRING A PREGNANCY, A COUPLE MAY ELECT THE MORE COMPLEX ASSISTED REPRODUCTIVE TECHNOLOGIES (ART). THE KEY ONE IS IN VITRO FERTILIZATION (IVF—“IN VITRO” IS LATIN FOR “WITHIN THE GLASS”), WHICH IS FERTILIZATION OF THE EGG BY THE SPERM OUTSIDE THE WOMB. RICHARD T. SCOTT, M.D., F.A.C.O.G., H.C.L.D., SCIEN-
What is pre-implantation genetic diagnosis, or PGD? It’s a process by which we screen embryos for viability after they have been fertilized via IVF. One of the most exciting advances in ART is a PGD technique on which we’ve been privileged to do important research right here. It’s called 24-chromosome aneuploidy screening.
TIFIC DIRECTOR OF RMANJ AND ONE OF THE PRACTICE’S FOUNDERS, RECENTLY DISCUSSED
Why do embryos need to be screened?
IVF AND HOW PRE-IMPLANTATION GENETIC
The ultimate goal of reproductive endocrinology is “one embryo, one baby.” If we could know for certain which embryo out of those produced in our lab for a couple or single wouldbe parent would most
DIAGNOSIS (PGD) HELPS PHYSICIANS SCREEN IVF EMBRYOS FOR GENETIC DISORDERS.
How does in vitro fertilization work? Using hormonal medications, we stimulate a woman’s ovaries to produce extra egg follicles—the fluid-filled sacs in which eggs mature. When ovulation is just about to occur, we retrieve the eggs from her ovaries. In our embryology laboratory, we fertilize the eggs with sperm and then let them grow in the lab for three to five days. When the eggs are ready, we transfer one or several of them back into the woman’s uterus, where they implant and grow to form a baby. (For more on IVF, see page 10.)
Are there other assisted reproductive technologies? Yes. Intracytoplasmic sperm injection involves injecting the sperm directly into the egg. We may use that if the man has a low sperm count or poor-quality sperm. We may also employ a technique called assisted hatching, in which an embryologist makes a small hole in the embryo just before it is transferred back into the woman’s uterus, helping it to implant there more effectively. There is also the use of donor oocytes (eggs) for older women or those who do not produce quality eggs, and freezing extra embryos for future use.
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If an embryo is at risk for a genetic abnormality, the couple may opt to employ this technique before the embryo is transferred back to the mother. Our researchers study the chromosome makeup of the embryo for aneuploidy—an abnormal number of chromosomes. Every human cell has 23 pairs of chromosomes, one member of each pair from the mother, one from the father. The 23rd is the sex chromosome, which determines the baby’s gender. Occasionally an embryo’s cells have an extra chromosome (trisomy), which indicates that it is affected with Down syndrome or another genetic disorder that may be incompatible with life, such as trisomy 16. Once we know this, we will not transfer the abnormal embryo. With our testing, we can also determine whether the aneuploidy is from the mother or father.
Will research speed the day of ‘one embryo, one baby’? We think so—and we think that day is not too far away. Our laboratory does research of two kinds: basic—in the lab, and translational—from lab to patients. All of a person’s hereditary information is encoded in his or her genes, and if we can apply this research to reproductive endocrinology, we can learn which embryos have the most potential to become healthy babies. This will improve pregnancy rates and outcomes and cut down on multiples. What we can do at RMANJ with our laboratory technology and expertise surpasses what can be done at most of the world’s other fertility centers.
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3 key Approaches
treatment and are now not wanted. This option can be attractive to a woman who wants to experience pregnancy and childbirth but cannot conceive on her own.
What about gestational carriers, or surrogates? They’re different in that a gestational carrier bears a baby to whom she is not genetically related, while a surrogate is related through the use of her own egg. Surrogacy is illegal in New Jersey, so we use only gestational carriers at RMANJ.
SOMETIMES IT TAKES MORE THAN TWO PEOPLE TO MAKE A BABY. SAME-SEX COUPLES, COUPLES WITH MEDICAL PROBLEMS THAT FORBID OTHER APPROACHES OR THOSE FOR WHOM OTHER METHODS HAVE NOT BROUGHT CONCEPTION MAY WISH TO CONSIDER A REPRODUCTIVE OPTION INVOLVING A THIRD PARTY. SUCH
When is that a good option?
METHODS ARE EXPLAINED HERE BY
It can be right for women who do not have a normally functioning uterus, who have medical conditions that make it dangerous to carry and bear a child or who have had multiple miscarriages.
RMANJ PARTNER PAUL A. BERGH, M.D., F.A.C.O.G.
Let’s start with the simplest method, sperm donation. It’s an option for couples in which the male partner produces no sperm, or for single women or same-sex female couples. The donated sperm can come from someone the couple knows—this is a “designated” donation—or from an anonymous donor. The use of frozen sperm from a man who has stored it with us prior to treatment for cancer is also an option.
How is the insemination performed? If the woman partner has no fertility issues herself, the donated sperm will be simply placed into her vaginal canal at the approximate time of ovulation.
What about egg donation? The use of donor eggs has risen dramatically in the past decade, mostly because more and more women are postponing childbirth beyond age 35. By the time they come to us, their own eggs are sometimes of poor quality due to the natural aging process. Other candidates for egg donation include women with a condition called premature ovarian failure or those with genetic disorders or chromosomal abnormalities in their own eggs. Donated eggs are also used by women who have no ovaries or have sustained cancer treatment to their ovaries, and by same-sex male couples.
What is the process?
Where do you get the eggs for the donation? A couple can use a designated donor egg, say from a sister or cousin, or an anonymous donor egg. We recruit egg donors throughout the tri-state area. Many patients use private agencies to acquire the eggs. We carefully screen egg donors for medical and psychosocial issues. Patients can choose their egg from donor profiles. There is currently about a twoto three-month wait for donor eggs.
What is the procedure for egg donation? The cycles of the woman who will donate the egg and the one who will receive it are synchronized with the use of medications and hormones so that when the egg is ready, it is fertilized with the sperm in our laboratory and then placed into the woman who will carry the pregnancy.
Do some couples use donated embryos? Yes, many couples choose to use frozen embryos that were healthy extras from other couples’ IVF
We recruit gestational carriers from all over the United States through independent agencies or attorneys who specialize in reproductive arrangements. We carefully screen them for medical and psychosocial issues. The intended parents and gestational carrier enter into a contract; usually it permits the intended parents access to the carrier’s prenatal visits, obstetrician consults and childbirth. The gestational carrier’s cycle is timed to the cycle of the woman who is providing the egg. The sperm of the male intended parent or donor is then joined with the egg in our laboratory. The egg is then placed into the gestational carrier’s uterus, where she will carry it throughout the pregnancy and then give birth.
Are these options covered by health insurance? Most are. The state mandates that health insurance carriers cover these options known as third-party options to some degree as well as other infertility treatments. Coverage is different for every insurer, and most couples do incur some out-of-pocket expenses.
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clinical focus
In vitro fertilization STEP by STEP
Thirty years ago, news of the birth of the first “test tube” baby—England’s Louise Brown—made headlines around the world. Since then, more than 3 million babies have been born who were conceived through in vitro fertilization (IVF). And in the last two decades, advances in fertilizing and growing the embryos in the lab have helped to raise the average pregnancy rate for a 30-yearold woman using IVF from 10 percent to 60 percent. IVF involves the fertilization of an egg with sperm outside the woman’s body in a laboratory. The fertilized egg is then placed back into the woman’s uterus, where it grows and develops into a baby. RMANJ’s reproductive endocrinologists start an IVF treatment cycle with injections of follicle-stimulating hormone (FSH) to stimulate the woman’s ovaries to produce multiple egg follicles. Other hormones are used to prevent the ovaries from releasing the eggs too soon. “Normal ovulation is an intricate process determined by a woman’s brain, her pituitary gland and her ovaries,” explains Thomas J. Kim, M.D., F.A.C.O.G., a reproductive endocrinologist at RMANJ. “In the first phase of IVF, we take direct control of the communication between the brain and ovaries, bypassing the pituitary’s influence. This allows us to time each phase of her cycle.” Blood tests and ultrasound exams over the next couple of days enable the woman’s physician to monitor the follicles. When the follicles have reached a certain size, the patient receives an injection of a hormone called hCG (human chorionic gonadotropin) to mature the eggs inside the follicles. Thirty-six hours later, on “Day 0,” the physician removes the eggs from the patient’s ovaries using a thin needle with ultrasound guidance. Progesterone injections
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or suppositories help prepare her uterus for implantation of the embryo. The retrieved eggs are then washed and prepared for the sperm, which is produced by a male partner, provided by a donor or drawn from frozen storage. Later that day, an embryologist, a laboratory specialist, manages the insemination of the eggs. If the man has a low sperm count or poor sperm quality, a needle may be used to inject a single sperm directly into the egg—a procedure called intracytoplasmic sperm injection. The eggs are then placed for three days in an incubator in a dish, where they are bathed in a special culture that mimics the temperature, moisture level, glucose level and Ph balance of a fallopian tube. On Day 1, the eggs are checked by embryologists for fertilization. On Day 3, embryologists determine whether any of the embryos are of sufficient quality to be transferred back into the woman. A screening called pre-implantation genetic diagnosis may be performed before the embryo transfer if there are concerns about genetic abnormalities. A procedure known as assisted hatching, in which an embryologist makes a hole in the outer layer of the embryo, may be used to help it implant in the uterus. On Day 3, if one or several embryos are deemed healthy they will be transferred back into the woman’s uterus using a thin needle. If more time is needed to determine the quality of the embryos, they will be transferred into a different medium, one that mimics the atmosphere of the uterus, where they would be now if fertilization had occurred normally. By Day 5, when they have reached what is called the blastocyst stage, they are implanted. RMANJ is recognized worldwide for its aggressive blastocyst culture and transfer services and for its highly selective techniques to determine the best embryos so it can limit multiple births.
Thomas J. Kim, M.D., F.A.C.O.G.
Thomas Molinaro, M.D., F.A.C.O.G.
Dr. Kim says the number of embryos transferred back into a patient usually depends on her age (or the egg donor’s age). Older eggs have a greater risk of not implanting or having abnormalities that could affect development. Three to four days after the transfer, the woman’s progesterone levels are checked. About 10 days later, a pregnancy test is given. If it is positive, an ultrasound exam will be performed one week to 10 days later (35 to 40 days after conception) to confirm the pregnancy and check for a fetal heartbeat.
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SPECIAL HELP
complementary care
on the road to parenthood
On some days, just watching a toddler
play in the park may bring tears. Fertility problems can be emotionally difficult, and isolating as well. There may be no one among a couple’s family and friends with whom to share frustrations, hopes and sorrows— lacking similar experience, these well-intentioned folk don’t really understand. When you turn to Reproductive Medicine Associates of New Jersey for help in conceiving, you have a partner in navigating the rocky emotional and physical terrain you may encounter on the road to parenthood. It’s called the Complementary Alternative Medicine Program. “We educate individuals and couples and help them sort through their feelings, build coping skills, communicate with their partners and make life-altering decisions,” says psychologist Andrea M. Braverman, Ph.D., program director. Dr. Braverman has specialized in infertility counseling and research for more than 20 years. She and her colleagues, certified acupuncturist Marc Passman and licensed clinical social worker Bette Galen, offer patients: • individual or couples counseling—one to six sessions to cope with issues related to infertility treatment, egg donation, gestational carriers, in vitro fertilization, interpersonal communication and informed decision-making • specialized support groups for individuals and couples who are trying to conceive, for egg and sperm donors, and for donated egg and sperm recipients • relaxation techniques, including deep breathing, guided imagery, therapy and yoga • counseling and education for those using sperm or egg donors—four specialized weekly sessions • psychological assessments and screening services for egg and sperm donors, gestational carriers, and parents who choose to build their families through third-party reproduction, including using egg and sperm donation or a gestational carrier • acupuncture using thin needles or
laser techniques may reduce pain, increase pregnancy rates for in vitro fertilization, reduce stress, improve blood flow to the pelvic area and uterine lining, regulate menstrual cycles, ease the discomfort of endometriosis and relieve back pain, headaches and digestive problems Fortunately, knowledge in this field is growing rapidly. The Complementary Alternative Medicine Program currently participates in a number of clinical research projects that are exploring, among other topics, the impact of in vitro fertilization on relationships, the effect of assisted reproductive technologies on families and the result of better educational preparation for couples prior to treatment. The team is involved in a five-year follow-up study of egg donors to evaluate their attitudes and reactions after they have completed their donation. They are also following gestational carriers (those who carry a baby for women who cannot) throughout their pregnancies and into the postpartum period. As Dr. Braverman explains, complementary/alternative services can often bring couples together “on the same page.” “It is very common to have one partner feel that pregnancy will happen if they just relax and take their time, while the other one says, ‘No, we must take action now,’” she says.
Andrea Braverman, Ph.D.
“Couples counseling can help them see things from each other’s perspectives, respect each other and then meet in the middle to make decisions about treatment.” Her advice to individuals and couples considering complementary/alternative therapies? “Don’t be afraid to give our methods a try,” she says. “In life, there is no ‘one size fits all.’” For more information about RMANJ’s Complementary Alternative Medicine Program, call 973-656-2087 or visit www.rmanj.com.
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success stories Alison Bender of Old Bridge recalls that when she first heard her baby’s heartbeat just before Christmas 2006 at six weeks of pregnancy, she felt her own heart stop. “When you’ve tried to become pregnant for three years and finally it happens, you’re afraid even to imagine that it’s possible,” says Alison. “Only when I felt the baby kick for the first time did I feel I could exhale.” Lucas Murphy Bender was born on August 9, 2007, at Overlook Hospital in Summit after several treatment methods were used by Alison’s doctors at RMANJ to assist her in becoming pregnant. Alison, a drama and English teacher at Marlboro High School in Monmouth County, and her husband, Ryan, a warranty manager for BMW, had tried to become pregnant for about a year before scheduling an appointment with RMANJ’s Doreen Hock, M.D., F.A.C.O.G., at the Somerset office in 2005. Basic test results of the couple were
Finally, feeling a
normal except for a small cyst on one of Alison’s ovaries, which Dr. Hock did not feel would be an issue. The couple began using the oral medication clomiphene citrate, or Clomid. Though it helped Alison to ovulate, fertilization never occurred, even after three cycles of the medication were combined with intrauterine insemination (IUI) to move Ryan’s sperm closer to the egg in Alison’s uterus. But the couple was buoyed by Dr. Hock’s optimism. “When you experience infertility, you feel like you are the only ones,” says Alison. “But Dr. Hock was on our side. After our failure to become pregnant, she suggested we consider in vitro fertilization.” After taking several months off, the couple began phase I of the IVF cycle: Alison was injected with a medication called a gonadotropin, which bypasses the pituitary gland and stimulates the ovaries directly to produce multiple egg follicles for ovulation. The injections and subsequent early-morning ultrasound monitoring to determine the time of ovulation had to be timed carefully.
“If we were out to dinner we would excuse ourselves and quietly go the car for my injections,” says Alison. When ovulation was imminent, phase II involved retrieving eight egg follicles from Alison’s ovaries and inseminating them with Ryan’s sperm in RMANJ’s embryology laboratory at the Morristown office. Of the eight eggs, four were not viable, one didn’t fertilize, but three were strong. The three embryos were then transferred back into the uterus three days after the retrieval during phase III. Near the end of the pregnancy, Alison was put on bed rest due to low amniotic fluid, which could have put her at risk for a premature delivery. Happily, Lucas arrived on time, at a healthy 7 pounds, 9½ ounces. Today, he’s affectionate and chatty. He likes to chase bubbles, play on the swings, look at books and swim. And Alison, 35, and Ryan, 33, would like to add to their family. “We’ll be heading back to RMANJ and Dr. Hock in the future,” says the happy mom.
kick
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success stories Two-year-old Madison Amelia Jackson enjoys swimming, gymnastics and perusing books—upside-down or right side up. She’s a healthy, independent toddler with an impressive vocabulary who walked before age 1 and is thoroughly potty-trained. To her parents, Nicole and Dwayne Jackson of East Orange, she’s worth every minute of the nearly four years it took to have her. But there was some heartbreak along the way. The Jacksons married in October 2003— she was 28; he was 32. They weren’t using birth control, and although at first they didn’t plan a pregnancy, Nicole says it would have been a blessing if she had conceived. When time passed and the stork still kept his distance, they paid a visit to the West Orange location. “I did my research and found out that RMANJ was tops in the country for success rates and treatment,” says Nicole. “After speaking with Jamie Martelli, one of rmanj’s patient liaisons, and others on the phone, I sensed that I would receive the best care there.” In Nicole, Rita Gulati, M.D., F.A.C.O.G., diagnosed polycystic ovarian syndrome, a disorder often brought on by excess weight. Women with this syndrome have a hormonal imbalance that causes them to produce egg follicles that do not grow into mature eggs for ovulation. Instead, the follicles remain fluidfilled cysts that cling to the ovaries. An oral medication called clomiphene citrate, or Clomid, helped stimulate Nicole’s pituitary gland to signal her ovary to release more than the one egg a woman normally produces in a menstrual cycle. More eggs meant an increased chance that at least one of them would be normal. Nicole subsequently became pregnant two times through a combination of clomiphene citrate and intrauterine insemination (IUI), during which her egg was fertilized with Dwayne’s sperm near the juncture of her uterus and fallopian tube. The couple lost their first pregnancy when she went into premature labor at 16 weeks’ gestation. The second pregnancy ended in miscarriage at 12 weeks. Through a combination of intrauterine insemination and an injectable medication that stimulated her ovaries directly to release
If at first you don’t
succeed…
the eggs, Nicole conceived again. This time the pregnancy was ectopic—the fertilized egg had implanted in her fallopian tube before it reached her uterus. Dr. Gulati was able to conserve the tube despite the ectopic pregnancy. Several months later, Nicole conceived again, this time with twins. At 16 weeks’ gestation, due to her history, her obstetrician placed several stitches in her cervix to keep it from opening prematurely. Three weeks later, the Jacksons’ hopes for a family were dashed again when Nicole’s water broke and she went into premature labor. The twins were too young to survive. “I wanted to die,” says Nicole. “I was depressed and cried all the time. Finally, with the support of Dwayne, my family, friends and prayer, I got out of bed and went back to work.” The couple took nine months to heal. Although they investigated adoption, Nicole
still wanted a biological child. “Jamie and Dr. Gulati pulled me up every time I lost a baby and gave me hope,” she recalls. “Dr. Gulati said to me, ‘You are young. We are here for you if you want to try again.’ I went back to her on my 31st birthday. We wanted to try one more time.” This time Nicole conceived quickly. At 12 weeks of pregnancy, her obstetrician again put several stitches in her cervix. The rest of the pregnancy proceeded uneventfully, and Madison Amelia was born June 30, 2007, at Saint Barnabas Medical Center in Livingston. Asked if the Jacksons will consider adding to their family, Nicole answers quickly. “Oh yes,” she says. “I’ve lost 115 pounds after gastric bypass surgery, so my doctors think the polycystic ovarian syndrome may not be an issue. But if I need fertility treatment again, you can be sure I will return to Dr. Gulati and RMANJ.”
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success stories
Two
approaches— and two girls When Leslie of Hunterdon County watches her daughters Allison and Nicole swim, kick a soccer ball or play “princesses,” she sometimes thinks of the many attempts it took for her and her husband, Jeff, to become parents. In March 1997, Leslie, then 30, first became a patient of RMANJ co-founder Michael Drews, M.D., when he was on staff at Saint Barnabas Medical Center in Livingston. Leslie and Jeff had been trying to conceive for six months. Leslie’s general gynecologist surmised that prior gynecologic problems, including an ovarian cyst at the age of 12 and irregular menstrual cycles, might be interfering with her becoming pregnant. Diagnostic testing ordered by Dr. Drews
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revealed a septum of excess tissue down the middle of her uterus, dividing it into two small sections, neither of which could accommodate a growing fetus. Instead of being shaped like a pear, Leslie’s uterus resembled a heart. Dr. Drews used a hysteroscope and special instruments to cut away the septum. “Then I was fine, structurally; tests showed I was producing and releasing eggs but I still wasn’t getting pregnant,” she recalls. “After 14 cycles of Clomid and intrauterine insemination (IUI), an ectopic pregnancy, laser surgery to remove endometrial scar tissue from my fallopian tubes and several early miscarriages we still didn’t have a baby. Jeff told me, ‘When you’re done, we’re done.’ But I still wanted to have a baby.”
Because Leslie was producing viable eggs, Dr. Drews felt that in vitro fertilization might be successful. By this time, he and his partners had opened Reproductive Medicine Associates of New Jersey in Morristown. Leslie was one of their first patients. Although her first IVF cycle didn’t result in a pregnancy, the second did. Allison was born on December 17, 2000, at Hunterdon Medical Center, weighing 8 pounds, 8 ounces. Leslie was 33; she and Jeff decided they would try for another baby within a year. But uterine polyps that had to be removed by Dr. Drews slowed them down. Three attempts at IVF failed, because the few egg follicles she produced were of poor quality. Finally, during the fourth attempt, when Leslie was 35, egg quality had deteriorated to a hopelessly low level. “Dr. Drews sat me down and said, ‘You fought the good fight, but with no more quality eggs there will be no more babies unless you choose to use a donor egg and IVF,’” Leslie says. “Jeff wasn’t sure, but I took the information from Dr. Drews, and once I got home I was convinced that a donor egg would work for us.” RMANJ recruits egg donors and also uses those provided by reproductive attorneys and independent agencies throughout the tri-state area. Donors undergo medical and psychosocial screenings by RMANJ physicians and psychologist Andrea Braverman, Ph.D. RMANJ staff matches an egg donor to a couple based on criteria chosen by the couple, such as eye and hair color and ethnicity. The couple either selects the first profile or waits for a second donor to become available that meets their criteria. There is about a two-to threemonth waiting period for donor eggs at RMANJ. Once Leslie and Jeff chose their egg donor, the women’s cycles were synchronized with hormonal medications so that when the egg donor’s follicles were ready for retrieval, Leslie’s uterus would be ready to accept the embryo after it was fertilized in the lab with Jeff’s sperm. A successful pregnancy resulted, and Nicole was born November 21, 2003, at Hunterdon Medical Center weighing 8 pounds, 14 ounces. “I was with Dr. Drews for six years, through many ups and downs,” says Leslie. “I always believed he was the one who would help me, and I was right.”
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your choice
Why
With e-learning, your home is your classroom
Nathan Treff, Ph.D.
RMANJ? RMANJ’s research laboratory
There are close to 20,000 reasons to consider Reproductive Medicine Associates of New Jersey when you are ready for infertility treatment. That’s the number of babies we have helped to bring to life. Whether this is your first encounter with infertility treatment or you are coming to us after being treated elsewhere, we offer you world-class expertise and 20+ years of experience in reproductive medicine. In our field of medicine, as in other specialties, the ability to do something well is based on substantial experience doing it. While other fertility centers may perform about 200 cycles of in vitro fertilization each year, we do more than 2,000. We are highly skilled in other treatment methods as well, including ovulation induction medications, intrauterine insemination (IUI), egg donation and other assisted reproduction technologies, and third-party options. A word about numbers. In reproductive medicine, success rates can be difficult to establish; often you will see figures based on the criteria a center wishes to focus on. At RMANJ, we measure
success in babies born, not pregnancies achieved. You may view our success rates at our web site at www.rmanj.com. Over the years, our team has been responsible for many of the innovations used in reproductive medicine. “Our technology, pre-implantation genetic diagnosis screening methods and blastocyst culture transfers
R EP R O D U C T I O N I S A C O M P LI C AT ED P R O C E S S . Understanding infertility and keeping on track with treatment schedules can be confusing. At RMANJ, our individualized elearning modules make it easy for busy couples to learn about IVF and other treatment methods in their own homes on their own timetables. Each videotaped educational session is followed by a selfassessment quiz.
surpass those available at most centers around the world,” says Nathan Treff, Ph.D. It is not unusual for us to treat successfully patients who have suffered prior treatment failures or who come to us from other nations. And through our Foundation for Advanced Reproductive Science, we share our research in diagnosis and treatment with other specialists around the world. Our office staff will be happy to answer any questions you have or set up an initial consultation appointment for you. Our main location in Morristown and satellite offices in Englewood, Somerset, Summit and West Orange can be reached by calling 973-656-2089. Best wishes! We are ready when you are ready.
Infertility treatment may be within your financial reach W H AT E V ER YO U ’ V E H E A R D, you should not conclude that infertility treatment is too
expensive for you until you’ve done a little homework. In New Jersey, the Family Building Act of 2001 mandates that infertility treatment be covered to some extent by health insurance policies after patients meet certain criteria. To learn more about the mandate, visit www.rmanj.com All RMANJ patients meet with a financial counselor during their initial consultation to review health insurance benefits and go over their finance options, including out-of-pocket expenses. “It is critical that patients understand their own specific health insurance policies, because there are many variables to what insurers will pay for,” says Lena Mignone, director of patient financial services. “Each patient is assigned a financial counselor, with whom we encourage patients to stay in touch at all times.” RMANJ offers financial options that include: • help in dealing with health insurers and coordinating benefits • medical financing through shared-risk programs such as Attain IVF • payment by credit card • payment through employers’ flexible spending accounts For more information about RMANJ’s financial services, call 973-971-0612.
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MIRACLES NJ Monthly 8x10:Layout 1
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Miracles do happen.
The decision to have a baby is as wonderful and exciting as any decision you’ll ever make. And for those experiencing fertility problems, reproductive medicine has advanced to the point where we can offer safe and effective treatment options for many couples. Amr Azim, MD Paul A. Bergh, MD Michael K. Bohrer, MD Michael R. Drews, MD Rita Gulati, MD Doreen L. Hock, MD Thomas J. Kim, MD Thomas A. Molinaro, MD Jamie L. Morris, MD Richard T. Scott, Jr., MD, HCLD Shefali M. Shastri, MD
At RMA, we’re thrilled that over the past thirteen years our founding partners and staff physicians have helped bring close to 20,000 babies to loving parents. This incredible record of success makes us one of the largest and most experienced centers for infertility treatment in the world. As a patient at RMA, you are attended to by a medical team with unmatched skills and experience using the most effective options to treat infertility: State-of-the-art laboratories for embryology, endocrinology, andrology and pre-implantation genetic diagnosis (PGD). Just as important, you will be introduced to a focus on superior care and compassion that is simply unparalleled. So now that you’ve made the decision to have a baby, make one more: let RMA help you. Because sometimes, it takes a little help to have a miracle.
973.656.2089 www.rmanj.com ENGLEWOOD | MORRISTOWN | SUMMIT | SOMERSET | WEST ORANGE
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