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mercredi 29 octobre 2008

Fertility After A Tubal Ligation

Posted on 10:38 by Unknown
Several times a month I am asked about tubal reversal surgery. Performing a tubal reversal is actually something of a vanishing art among reproductive endocrinologists. Personally, it has been over 10 years since I last did one and if a patient really wants to pursue this option, then I refer them to Dr. Gary Berger in Chapel Hill, NC. Dr. Berger has a great set-up for doing tubal reversals and his price is hard to beat along with his level of experience. And I do not receive any kick-backs from Dr. Berger. In fact, I am sending business out the door, but I really believe that it is not appropriate for a patient to pay more to have me do this surgery when she can have it done for less with a guy who can put tubes back together in his sleep. This surgery is often done with the operating microscope and requires steady hands as all movements are greatly magnified under the scope.

During medical school I asked a famous RE how he kept his hands so steady? “Well, John” he replied, “the key is to have sex the night before the surgery!” “Yeah, “ the resident told me later, “his wife is getting pretty sick of him doing so many tubal repairs!” So with that bit of gossip, let’s turn to that great repository of knowledge: 100 Questions and Answers about Infertility for the Question of the Day.

29. If I had my tubes tied, can I have them untied?

Fertile women who have had their “tubes tied” (tubal ligation) may do very well and achieve pregnancy with tubal reparative surgery. Pregnancy rates of 70% to 80% are noted in women who undergo a tubal reversal procedure, depending on their age, the type of tubal ligation procedure performed, and the presence (or absence) of other infertility factors.

Most often, this repair (tubal reanastamosis) requires a laparotomy, which involves opening of the abdomen. This major surgery requires 2 to 4 weeks for recovery, and most insurers do not cover it. Some physicians have reported good success with laparoscopic tubal reanastamosis, but this approach can be more technically challenging. As a consequence, most female patients choose to undergo a nonsurgical IVF procedure instead. Studies have shown that IVF is usually more cost-effective than surgical reanastomosis of the fallopian tubes. Specifically, if the surgery fails to establish a pregnancy, then IVF may be necessary anyway.
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vendredi 17 octobre 2008

Can Fallopian Tubes Be Repaired?

Posted on 08:57 by Unknown
As readers of this blog are aware…my family is not really sure that I am a “real” doctor since I am not a general surgeon. As IVF success rates have climbed, the number of reproductive surgeries perfomed has plummeted. When I was a Duke medical student I still remember the REs scheduled 5-10 laparoscopies every day that they were in the operating room! My how times have changed. The problem with most surgeries aimed to improve fertility is that they often don’t help very much. In addition, since infertility is a couple’s disease and half the problems are with the men, fixing tubes or zapping endometriosis doesn’t help much if his “swimmers” are more like “floaters.”

So here is today’s Question of the Day from 100 Questions and Answers about Infertility.


27. Can fallopian tubes be repaired?

Prior to the advent of IVF, surgical repair of damaged fallopian tubes was considered standard medical care. Unfortunately, most patients did not become pregnant following this procedure, and 10% to 20% experienced tubal (ectopic) pregnancies. Today, IVF has replaced reparative tubal surgery for most patients with damaged fallopian tubes for two reasons: (1) IVF is a nonsurgical treatment and (2) it results in excellent pregnancy rates, especially for patients with tubal disease.

Some patients ask, “Why is it so difficult to repair damaged tubes?” Unfortunately, the problems that cause tubal disease, such as pelvic infections, usually damage the tubal fimbria—that is, the delicate finger-like projections at the end of the tube that are responsible for capturing the egg when it is released from the ovary. Pelvic infections may also damage the tubal muscle and inner mucosa, leaving behind a scarred, nonfunctional organ that is not amenable to surgical repair. In general, most patients with tubal disease are best treated using IVF. Tubal reparative surgery is usually not effective and, in fact, it may increase the woman’s risk for having an ectopic or tubal pregnancy. If a couple is not interested in IVF or if they are not deemed to be good candidates for IVF, then tubal surgery may be the only option available to them in terms of fertility treatment.
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jeudi 2 octobre 2008

How Expensive Are Infertility Treatments?

Posted on 07:00 by Unknown
The economic news lately has been sobering to say the least and certainly a drop in the economy usually forces patients to carefully assess their options when considering various treatment options. Fertility treatment can be very expensive and life would be so much easier if I had a crystal ball that allowed me to predict with 100% certainty when and through what means a couple (or individual) would achieve success. But life is not like that and so we are left to counsel patients using our best advice as to how to proceed.

We have certainly seen an increased interest in Natural Cycle IVF as the cost per attempt is less than traditional stimulated IVF and not much more than for a clomid/IUI cycle. Still, the more expensive, more invasive treatment options tend to work better. I tell all my patients that I cannot compete with traditional adoption in terms of return on investement, but this is a pathway to parenthood that may not be acceptable to all patients. Embryo adoption/donation is another path that is very successful and less expensive but is limited by the laws of supply and demand.

So in returning to that famous repository of infertility advice...here is the Question of the Day from 100 Questions and Answers about Infertility. If you don't already have this book, then go to Amazon.com and order it right away ... and make sure that you post a 5 star review ... and tell all your friends to buy it... and come by and visit me at Dominion Fertility or come to the MidAtlantic RESOLVE meeting on October 18th to tell me how much you love this blog. Also, for those of you who missed our recent stint on the Kane show on 99.5 here in Washington you can listen online as they have it set up as a podcast. My kids thought I sounded halfway intelligent which is heady support from teenagers...


19. How Expensive are Infertility Treatments?

The cost of fertility treatments may be covered by some insurance plans. In those patients without insurance coverage, the cost of fertility treatments varies widely depending upon the specific treatment utilized. For example, a cycle of ultrasound monitoring without the use of fertility medications culminating with intrauterine insemination may cost $1300 to $1500 in many clinics. Compare this with the cost of IVF with ICSI, freezing of extra embryos, and assisted embryo hatching and the price tag can reach approximately $14,000 to $16,000 plus the cost of injectable fertility medications which may cost $2,000 to $4,000. The use of donor-egg IVF, although extremely successful, is also very expensive as the cost of reimbursing the donor for her time and effort must be included in the treatment. The typical price range for donor-egg IVF is between $25,000 and $30,000 depending upon the clinic.


In most cases the more expensive, more invasive fertility treatment usually results in the highest pregnancy rates, and therefore couples are advised to carefully consider the proposed course of treatment and the costs that may be involved. Around the country several IVF centers offer money back refund programs. In these situations a couple accepted into the program pays a premium which covers several fresh IVF cycles as well as frozen embryo transfers. If they fail to conceive or are deemed no longer to be appropriate candidates for treatment, then all or a percentage of their initial payment is refunded. These programs have remained somewhat controversial but can allow couples to pursue other options if IVF is unsuccessful.

According to the ASRM Ethics Committee Statement of June 2006: The controversy surrounding such programs relates in part to the concern that such arrangements “appear to violate long-standing ethical prohibitions against paying contingency fees in medicine. This concern is based on Opinion 6.01 of the AMA Code of Medical Ethics, which states, “a physician’s fee should not be made contingent on the successful outcome of a medical treatment.”

Furthermore, the Committee Statement (which can be found on the ASRM website at http://www.asrm.org/Media/Ethics/ethicsmain.html) concludes, “the risk-sharing form of payment for IVF is an option that might be ethically offered to patients without health insurance coverage for IVF if certain conditions that protect patient interests are met. conditions are that the criterion of success is clearly specified, that patients are fully informed of the financial costs and advantages and disadvantages of such programs, that informed consent materials clearly inform patients of their chances of success if found eligible for the risk-sharing program, and that the program is not guaranteeing pregnancy and delivery. It should also be clear to patients that they will be paying a higher cost for IVF if they in fact succeed on the first or second cycle than if they had not chosen the risk-sharing program, and that, in any event, the costs of screening and drugs are not included.

“The Committee was especially concerned about incentives that risk-sharing programs create for providers to take actions that might harm patients in order to achieve success and avoid a refund. For risk-sharing programs to be ethical, it is imperative that patients be aware of this potential conflict of interest, and that risk-sharing programs not overstimulate patients to obtain a large supply of eggs or transfer more embryos than is safe for the patient, fetus, and prospective offspring. Patients should be fully informed of the risks of multifetal gestation for mother and fetus, and have had ample time to discuss and consider them prior to egg retrieval.”
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