New Patient Primer

May 2, 2006 - Tuesday
7:46 PM to (EST)
Guest Speakers: Shaun Williams, MD
Connecticut Fertility Associates

Categories
Insurance • IUI • IVF

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S.Williams	Hello Lisa. Are you there?
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S.Williams	Hello Janna.
Lisa_Rosenthal	Hi Dr. Williams and Janna, thanks for joining us this evening! I was just getting set up.
Janna	Hi Lisa and Dr. Williams
Janna	Dr. Williams, where in CT are you located?
S.Williams	My group has two main offices: Norwalk and Bridgeport/Trumbull.
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Lisa_Rosenthal	Welcome Orly, good to see you here this evening...
Orly	hi
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Orly	Dr., do you approve of single embryo transfer? how often do you do them?
S.Williams	I am delighted to be here to answer any questions that you may have.
S.Williams	Orly, I think single embryo transfers are an ideal situation--unfortunately, few individuals undergo a single transfer--it requires good quality embryos during good prognosis cycles.
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S.Williams	Most couples would rather have two replaced in all honesty.
Lisa_Rosenthal	tbsuds, thanks for joining us this evening.
Lisa_Rosenthal	Symharmony, good to see you here... jump right in with any questions that you may have.
S.Williams	But tonight I hope to be able to help elucidate the beginning of the process--IVF may be that for some, but usually treatments begin following an initial evaluation.
Orly	If you're 38 or 28, is there a difference to the beginning of the process?
S.Williams	Once many log on, it is difficult to answer every inquiry, so please take advantage of the low volume now!
tbsuds	I am wondering if for unexplained SIF with 3 failed IUI's with injectables going on to IVF, would Crinone be considered instead of IM progesterone?
S.Williams	Orly--it depends. For a 28 year old with tubal abnormalities or sever male factor abnormalities, IVF is the first step (usually). For a 38 year old, simple treatments such as clomid can be successful--it depends on the underlying causes.
S.Williams	tbsuds--Most studies have shown no difference in pregnancy rates following IVF using either vaginal prog. or IM progesterone---many physicians find it hard to switch from IM to vaginal preparations because the serum levels are always lower, even though studies demonstrate higher P levels within the uterus using vaginal preparations. There is no best way.
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tbsuds	Thanks...could you explain the purpose for BCP at the beginning of an IVF cycle?
S.Williams	Crinone (or Prochieve, as it is called these days), has been as effective as IM progesterone--and less of a pain in the rear.
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tbsuds	I used Crinone with my IUI's but my Luteal phase was still only 12days but when AF came, flow was much heavier.
S.Williams	tbsuds--BCP's at the beginning of a cycle can serve different purposes--using these can prevent cysts from being present when an IVF cycle is scheduled to start, as well as help keep eggs from growing too soon. Pills can also help schedule a cycle more effectively by inducing a menstrul period when all are ready to proceed with a cycle.
JBOOTH129	What is considered the normal amount of time to be on BCP
S.Williams	Sometimes supplemental progesterone still cannot prevent a menstrual bleed if the ovaries begin to decrease progesterone production, epecially if pregnancy has not occurred. IM progesterone definitely results in serum levels much higher than acheived in natural cycles, so there is sometimes comfort in being able to demonstrate that there is adequate circulating progesterone at the appropriate time.
Janna	Do you accept insurance in your office and how does the mandate affect the cost in CT?
S.Williams	JBOOTH--Normally, prior to an IVF cycle women are on BCP's for 2-6 weeks; most are on simply for one pack, as they would take if using for contraceptive purposes.
tbsuds	Oh...so if they switched me to progesterone there would be reassurance that it was "working".
S.Williams	Yes, we have staff that work with your insurer to determine benefits and for billing purposes. The mandate has not really affected the cost of services in CT, and the mandate unfortunately still does not apply to many women.
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Lisa_Rosenthal	Welcome Stephen...
Stephen	Dr. Williams, what should be done at the same time for the mane incase it is not the female's problem?
S.Williams	tbsuds: Sometimes measuring these levels are treating the physician--we see high levels and can say "hey look, these levels are great", but whether the supplemental progesterone is enough to ensure that there will be absolutely no lutela phase or early pregnancy abnormalities, we never know until one gets there. Changing progesterone, using IM or even a combination of IM and vaginal progesterone is doing all that one can do to ensure adequate progesterone levels are reaching the uterine musculature.
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tbsuds	If you hyperstimmed(minimally with 2 cysts, disappeared after skipping a cycle) while on low dose Follistim for IUI, are you at greater risk for hyperstimming for IVF. I know that the dose will be higher...I guess I'm asking that is my personal risk higher. And, what do you suggest as treatment we can do at home to help this...
Lisa_Rosenthal	Welcome wannababy...
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S.Williams	Stephen--there should always be an evaluation of the male partner during the initial evaluation, even if there is an obvious problem with the female partner. Many couples have both male and female factors. A simple semen analysis is usually the first step to identify a male factor problem. (and sometimes the only step for the male partner.)
Lisa_Rosenthal	Dr. Williams, thank you so much for joining us this evening, and giving of your time, energy, and knowledge. We appreciate it.
tbsuds	Yes...thank you for responding to all my questions!!!
S.Williams	tbsuds--The hyperstimulation risk can be higher during IVF. Dosing adjustments are made to help prevent this if your physicians have an idea how you respond to the medication. All women have some degree fo hyperstimulation--we try to get 15-20 eggs to develop, so all have some bloating, discomfort, hormonal changes, etc after the stimulation. We try to prevent the severe forms of hyperstimulation. Having residual cysts after a single stimulation is normal--there are always more with IVF.
wannababy	How is beginning treatment different for a single gal?
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Stephen	If the problem is with the male, how much treatment does that entail for the woman?
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SBR44	Sorry I'm late, did I miss everything?
Lisa_Rosenthal	Welcome SBR44, you are right on time!
S.Williams	Wannababy--Well, we expect most single women to have no fertility abnormalities, but that is not always so. If there are risks that can be identified prior to using donor sperm (if that is the course chosen) such as irregular menses, prior uterine infections, prior surgeries, etc., then those should be addressed. Many women elect to just try an insemination for several months, then decide to look into any potential problems if it is unsuccessful. This may be a waste of resources--donor samples are expensive.
Lisa_Rosenthal	Good time to repost Dr. William's introductory paragraphs, and here they are.
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Lisa_Rosenthal	Welcome Ally...
S.Williams	For single women, I usually recommend making sure the tubes are open, and that there are no otehr hormonal abnormalities, such as thyroid disorders, etc. I then recommend using clomiphene during the insemination attempts to increase the likelihood of success with each insemination. Some women don't acept the 6-8% risk of twins with clomid, but if clomid can produce 2-3 eggs each month, instead of the usual 1, then there are more opportunites per (sometimes expensive) insemination.
SBR44	Hi, so what is the work up for us old ladies? I'm 44
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Lisa_Rosenthal	Elizabeth, thanks for joining us this evening.
Lisa_Rosenthal	Dr. Williams, you are doing a great job this evening, thanks for being here with us!
S.Williams	SBR44--Well the only thing old at 44 is (sometimes) the eggs. So, an initial evalution would be the same but particular attention is paid to testing the ovarian function, and unfortunately there are no good tests for egg quality--
Elizabeth	when is it time to move from your ob to a specialist?
JBOOTH129	what is considered to be "Aggresive" treatment?
Orly	what if a patient wants to go straight to IVF, do yo uinsist on clomid?
Lisa_Rosenthal	Sorry for the double post.
S.Williams	Egg quality is difficult to measure. A good egg is one that leads to a pregnancy not associated with chromosomal abnormalities such as Down syndrome. Most specialists measure hormonal levels early in the cycle to determine how well the ovaries are functioning (FSH, inhibin, etc.) But even women who are in the upper 40's may have normal hormone levels, but we know that pregnancies just don't happen as often at that age, mostly because of egg quality.
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Orly	KathMI and danig70, thanks for joining us this evening!
danig70	thanks orly
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Lisa_Rosenthal	Hey Orly, that's my job, but thanks...
Lisa_Rosenthal	Texas2step, we appreciate your coming by this evening...
texas2step	why THANK you
Lisa_Rosenthal	Now is a good time to remind you of some information that Dr. Williams wanted you to know so I will post it.
S.Williams	Elizabeth--some OB's are very good at managing the inital evaluation and some simple treatments. Some refer right away. As a Reproductive Endocrinologist, I would prefer patients be referred right away--it almost always decreases the time it takes to start appropriate treatments.
Elizabeth	Dr. Williams, can you post your phone number for us?
Lisa_Rosenthal	Great idea Elizabeth, Dr. Williams, please do.
S.Williams	Jbooth--Agressive treatment is different for each person. Using more potent medications during an IUI cycle, or IVF are sometimes considered aggressive, but these may be the most appropriate treatment for some.
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SBR44	So, Doctor, if my FSH is good, under 8, do I have to do donor just because I'm 44? I have friends my age who get pregnant with no help at all?
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texas2step	dr williams, will you be speaking at the afa conference on sunday?
S.Williams	Orly--IVF will always be our most effective treatment to help a couple achieve pregnancy in most situations. It is not the only method, but it is very effective, and carries relatively few risks. The time to move to IVF is unfortunately dictated by cost or coverage, but I think it is very appropriate to move to IVF as an initial step as long as the patinets involved understand the options.
breanna	I've been having sex for a year with no birth control and I'm 27, dshould I see a doctor?
Lisa_Rosenthal	Breanna, thanks for joining us. Dr. Williams is answering a couple of different questions right now, but he'll get to you!
Lisa_Rosenthal	texas2step, Dr. Williams was supposed to join us on Sunday, but unfortunately cannot. We are hoping that a nurse/practioner from his practice will be able to join us instead.
danig70	Dr. Williams: I am going to be doing IVF in the next couple months, and I haven't had my initial consult for IVF yet with my RE. I am just curious about the Lupron shots I here everyone talking about. What does Lupron do?
S.Williams	SRB44-That is the problem with tests for egg quality. They never tell us if you can or can't get pregnant, only how difficult it may be. We are limited in what we can do as women get over 43 and 44--it is usually egg quality issues that we are faced with. The only good menas of overcoming this is with donor eggs, but a woman at 44 or 45 may release a good egg at any time that may lead to pregnancy--we just are severly limited at helping make that happen.
SBR44	Doctor, my fsh is under 8 and with clomid, I have produced between 10 and 14 eggs, isn't that a pretty good predictor?
Ally	Dr. Williams, could you please post your phone number?
S.Williams	Breanna- If you have been actively trying to get pregnant for the past year, then at 27 an evaluation is appropriate. About 85% of women over 35 get pregnant within a year of attempts. The 15% that don't have a higher likelihood of having an identifiable problem that may be addressed. But if your cycles are irregular, or you know that you have had gynecologic issues in the past such as endometriosis, and evaluation sooner is recommended.
S.Williams	Danig70--Lupron has been used for many years now to prevent a premature ovulation of the eggs we are trying to stimulate. We have also found that for some women, it can help improve the number of eggs that are produced.
danig70	thank you Dr. Williams
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S.Williams	Lupron does shut down the pituitary gland to produce a "medical menopause" for abotu a week befroe the cycle actually begins, and symptoms may arise at this time (hot flashes, mood changes), but they are short lived. Most do very well on the short course of Lupron before IVF.
Lisa_Rosenthal	Dr. Williams, please post your phone number, we want to make sure that folks can find you easily.
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Lisa_Rosenthal	jbooth129, thanks for joining us this evening.
S.Williams	Ally--You can visit my web site at www.CTFertility.com. The number will be there and we are always more than willing to answer any questions emailed to us from the site.
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Lisa_Rosenthal	Hi Jess, thanks for joining us this evening.
Janna	hi
Janna	How long should you stay with a doctor, even one you like, before getting a second opinion? I"ve been with my re for 3 years with no pregnancy
tbsuds	Thanks again for helping us with our questions...Good luck to all!
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Lisa_Rosenthal	FloK, thanks for joining us this evening.
Jess	thanks for the website address dr
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S.Williams	Im so sorry I was disconnected there and had a difficlut time logging back on.
Lisa_Rosenthal	Ladies and gentlemen, I am so pleased to have moderated tonight's session. Great questions, great answers. We have about 10 minutes before the session ends. Don't forget that our message boards are moderated by physicians daily, who answer your specific questions. And that we have these educational sessions every Tuesday. A very appreciative thank you to Dr. Williams for being with us this evening and handling all these questions so graciously.
Lisa_Rosenthal	No problem, glad you were able to rejoin us
Lisa_Rosenthal	Folks, if you posted a question in the last several minutes, please repost as Dr. Williams was off line.
S.Williams	Please repeat any questions I may not have come to. I have lost the transcript.
FloIK	Can you describe some of the initial tests in more detail? the one with the dye sounds scary and painful
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