Kristy will be scheduling many of your appointments and procedures. Kristy joined us in 2003.
NURSES (see photo under Fertility Drugs):
Paula
Bauguess, R.N. has been with us since 1990. She does many of the
ultrasounds and inseminations. She also calls many of the patients
regarding their lab tests.
Carolyn Huffman, MSN, WHNP helps with
the overall running of the center. She also assists with ultrasounds
and inseminations when needed.
Angela Reagan, RN, BSN is our IVF
nurse coordinator and has been with us since 2005. She oversees the
running of the IVF program.
LABORATORY
Kelly Thompson,
B.S., MT (ASCP) is the lab supervisor and has been with the team since
2004. She will be performing most of the lab procedures, including
blood tests, sperm analyses, and insemination preparations.
We
welcome you to our program. Our staff are extremely knowledgeable and
we want you to feel comfortable asking us any question. Please feel
free to discuss either any aspect of your treatment or other avenues
such as adoption with us. Welcome!
Information about your Hysterosalpingogram
THE
ABOVE PICTURE SHOWS A NORMAL HYSTEROSALPINGOGRAM. THE TRIANGULAR WHITE
STRUCTURE IN THE CENTER REPRESENTS THE UTERINE CAVITY AND THE SMALL
LINES ATTACHED TO THE UTERUS ARE THE TUBES.
1) CALL (336) 841-7070 WHEN YOUR PERIOD STARTS TO SCHEDULE THE PROCEDURE.
HYSTEROSALPINGOGRAM (x-ray of uterus and tubes)
A
hysterosalpingogram is an x-ray study of the uterus and tubes. This
particular test is used to determine if the tubes are open, or if they
show signs of adhesions or blockages which could inhibit or prevent the
fertilization process. The cavity of the uterus is also examined during
this test. The hysterosalpingogram is a necessary step in determining
the cause of your infertility, and can sometimes create a better
atmosphere for conception.
The x-rays are viewed from several
different angles after the uterus is filled with a clear contrast
fluid, which is inserted into the cervix. The contrast agent shows up
on an x-ray while being injected by your doctor. During and after the
test, cramping may occur, and we recommend that you take 600-800 mgm of
Ibuprofen (Advil, Nuprin, etc.) approximately one hour prior to the
procedure.
When the uterus begins to fill, the contrast fluid
will follow its path to the tubes and hopefully flow out the ends of
the tubes. The contrast fluid ends up in the pelvis, is absorbed and
disappears in time. If it does not flow through the tubes easily, then
there could be a blockage of some kind. The blockage can be a result of
an infection or some sort of scarring around the tubes, either of which
can be interfering with the fertilization process.
Some side
effects which MAY occur during or immediately after the procedure are
cramping, nausea, or dizziness. These usually disappear within 30
minutes. For precautionary measures, it would be best to have someone
with you to drive you home.
Semen Analysis Information and Scheduling
1.
The semen specimen may be collected at home or in our collection room.
If the specimen is collected at home, it must arrive at the laboratory
within one hour of collection. Specimens should be collected into a
sterile container with a screw-on lid. A sterile container can be
obtained from our office or your family physician. The container must
be placed in a ziplock bag for transport. All containers must be
labeled with your name, wife's name physician, and date and time of
collection.
2. The sample should be kept between room and body
temperature (70-98.6 F). Do not heat or refrigerate the sample while
transporting it to the laboratory. The sample must be delivered to the
laboratory within one hour of collection for accurate results.
3.
Please abstain from any ejaculation two days but no longer than seven
days before your appointment. Abstinence for a longer or shorter period
of time may affect the results. The preferred method of specimen
collection is by masturbation. Do not use a condom or lubrication while
obtaining the specimen. Most condoms contain a spermicide which will
adversely affect semen quality.
4. Please bring a form of
picture identification with you at the time of your scheduled
appointment for identification verification.
5. The results of
your semen analysis will be sent to your physician who will review the
interpretation and recommendations with you. PLEASE DO NOT CALL THE
LABORATORY FOR RESULTS AS WE CANNOT RELEASE THEM TO PATIENTS.
6. ALL TESTING REQUIRES AN APPOINTMENT.
SEMEN
ANALYSES are performed most days except Thursdays, 8:30 a.m.-12:30 p.m.
BY APPOINTMENT. The cost of the semen analysis is $110.00. Please call
(336) 841-7070 to arrange an appointment.
ANTIBODY ANALYSES are
performed BY APPOINTMENT. The cost of the antibody analysis is
$200.00/patient. Please call (336) 841-7070 to arrange an appointment.
SEMEN
CRYOPRESERVATIONS are performed Monday through Friday, 9:00 a.m.-12:00
noon BY APPOINTMENT. The charges for cryopreservation are $175.00
annual storage fee, $85.00 semen analysis/visit and $85.00 for semen
cryopreservation. Please call (336) 841-7070 to arrange an appointment.
IVF
WORK-UPS are performed BY APPOINTMENT. Refer to the IVF brochure for
costs. Please call (336) 841-7070 to arrange an appointment as directed
by the IVF nurse coordinator.
FEES ARE SUBJECT TO CHANGE 08/2006.
Fertility Drug Information (Gonadotropins)
NURSES: Paula Bauguess, Angela Reagan, and Carolyn Huffman
GONADOTROPINS FOR OVULATION INDUCTION
Gonadotropins
include Follistim, Gonal-F, Repronex, Humegon, and Pergonal.
Gonadotropins act directly on the ovaries and stimulate follicular
(egg) development.
DESCRIPTION
HMG (Humegon, Repronex,
Pergonal) is a mixture of follicle stimulating hormone (FSH) and
luteinizing hormone (LH) in a 1:1 ratio and FSH (Follistim, Gonal-f) is
a pure preparation of FSH. They are mostly packaged in snap-top
ampules, but Humegon is dispensed in vials. HMGs are extracted from the
urine of post-menopausal women, purified, and then freeze-dried into a
powder, while the FSH preparations are made in the laboratory
(recombinant). Before injection, gonadotropins must be reconstituted
with diluent and then administered immediately by intramuscular
injection or SC injection.
MODE OF ACTION
Gonadotropins
act directly on the ovaries to stimulate the growth of follicles.
Gonadotropins stimulate growth and maturation of follicles, but usually
do not trigger ovulation (the release of the eggs). Therefore human
chorionic gonadotropin (hCG) must be administered when the eggs are
mature to mimic the hormonal surge that causes ovulation.
INDICATIONS
Gonadotropin therapy is indicated in the following situations: 1. Women who fail to ovulate or conceive after optimal doses of clomiphene citrate.
2. Couples with infertility and normal tubal anatomy who have failed
simpler forms of therapy. In this situation it is often combined with
intrauterine inseminations.
MONITORING AND ADMINISTRATION
Call with the first full flow day of your period, and take your weight prior to starting injections.
Monitoring
the patient's response to gonadotropin therapy is essential in order to
adjust dosage and to minimize the possibility of adverse reactions. A
combination of both ultrasonography and estradiol measurements provides
practitioners with an acceptable method of monitoring gonadotropin
therapy. Estradiol is an indirect indicator of follicular maturity,
while ultrasonography visualizes the number and size of developing
follicles.
Estradiol monitoring is generally begun on day 4 or 5
after initiation of gonadotropin therapy and continued every day or
every other day until the hCG injection. Estradiol levels are obtained
in the morning and decisions about the next dose of therapy are made
when the laboratory results are obtained in the afternoon. This
facilitates gonadotropin dosage adjustments that afternoon or early
evening. The timing of the hCG injection is based on both the size of
the eggs and the estradiol level.
Sequential ultrasonography
usually begins when estradiol levels reach 150 pg/ml or greater. Scans
may or may not be done as frequently as estradiol monitoring, but every
other day scans are necessary once a dominant follicle reaches a size
of about 14 mm.
GONADOTROPIN DOSAGE
It should be given at
about the same time each day--in either the late afternoon or early
evening. This ensures accurate measurement of the patient's estradiol
response. Blood for an estradiol level is best drawn 12 to 18 hours
after the gonadotropin injection, making sure that the time interval is
consistent day-to-day. If the estradiol level is below 2000 pg/ml and
the dominant follicles are 16-18 mm, then the hCG dose can be given.
hCG DOSAGE AND ADMINISTRATION
Because
most patients do not ovulate with gonadotropin treatment alone,
ovulation is triggered with intramuscular injection of 10,000 U of hCG
when the eggs are mature. This is usually administered 24 hours after
the last gonadotropin injection. hCG acts like the LH surge and causes
ovulation, which should occur about 36 hours after the injection. Other
names for hCG are Pregnyl, Profasi and Novarel.
ADVERSE REACTIONS
Side
effects associated with gonadotropin therapy include local irritation
at the site of the injection and excessive ovarian stimulation (see
below). Other reported side effects, such as dizziness, nausea,
headaches, irritability and hot flashes, have been reported and may be
associated with increased estrogen levels.
Applying warm, moist heat to irritated areas can provide relief to local irritation.
Improper
injection techniques may result in injury or damage to the nerves.
Therefore, it is important to review injection technique with your
nurse and follow the injection instructions provided.
OVARIAN HYPERSTIMULATION
Mild
to moderate uncomplicated ovarian hyperstimulation, which may be
accompanied by abdominal distension and/or abdominal pain, occurs in
approximately 20% of patients treated with gonadotropins and hCG. It
generally regresses without treatment within two to three weeks.
However, if a pregnancy occurs, it may persist several weeks into the
pregnancy. Patients experiencing mild to moderate ovarian enlargement
usually report pelvic fullness and some abdominal pain and discomfort,
usually about four to ten days after administration of hCG. The degree
of hyperstimulation is related to both the estradiol level and the
number of eggs. Moderate or severe cases may need hospitalization
(greater than 10 pounds weight gain).
If there is a concern about hyperstimulation, please follow the instructions below and report the following:
- weight gain of 5 lbs. or greater - severe pelvic pain - decrease in urine output
Also, refrain from the following:
- intercourse - strenuous activity - letting anyone perform a pelvic exam - running/jumping type exercise
If
your estradiol goes above 2000 and you develop many eggs, your cycle
will be canceled due to the fear of severe hyperstimulation. If this
happens, hCG will not be given and you may be placed on birth control
pills.
MULTIPLE BIRTHS
The incidence of multiple
gestation is approximately 30% and roughly 5% of all gonadotropin
pregnancies results in triplets or greater. Multiple pregnancies can be
complicated by premature delivery, hypertension and diabetes. If there
is a significant concern of multiple births, then hCG and intercourse
can be withheld.
MISCARRIAGE, CONGENITAL ANOMALIES
The
incidence of miscarriage (15-25%) or congenital anomalies (2-5%) is
felt to be no greater with gonadotropins than that found with
spontaneous conceptions. However, taking 400 mcg (micrograms) of folic
acid everyday has shown a decrease in neurotube defects in infants.
PREGNANCY RATE
Obviously, the pregnancy rate depends on the indication for gonadotropins.
1. The woman with irregular periods who has failed clomiphene citrate
therapy and has no other cause for her infertility stands a roughly 25%
chance of conception per cycle.
2. The couple with unexplained infertility or endometriosis stands a roughly 10-20% chance of conception per cycle.
If conception does not occur after four cycles of gonadotropins, you should meet with your physician.
COST
The expense of treatment includes:
- Gonadotropins ($50-55 per amp - 15 to 25 vials or amps/cycle)
- Ultrasounds ($200 per exam - 3 to 5 per cycle)
- Estradiols (3 to 5 per cycle)
Insurance may or may not pay for the gonadotropin treatment.
There is some concern that the use of ovulation induction agents may
increase a person's risk of developing ovarian cancer. One in 424 women
will develop ovarian cancer before the age of 40. There is, however, no
conclusive evidence that the use of gonadotropins or hCG increases a
woman's risk of ovarian cancer. Women with a history of infertility,
independent of their use of gonadotropins or other ovulation induction
agents, do have a higher incidence of ovarian cancer. Pregnancy and
past use of oral contraceptives, appear to have a protective effect.
SCHEDULING
IS AN ESSENTIAL PART OF THERAPY, BOTH FOR INJECTIONS AND FOR OFFICE
VISITS, FOR SERUM ESTRADIOL LEVELS, ULTRASONOGRAPHY, AND POSSIBLY OTHER
TESTS OR PROCEDURES.
Urine LH testing and inseminations
THE
ABOVE PICTURE SHOWS HOW THE CATHETER IS PLACED DURING THE INSEMINATION.
NOTICE THE UTERUS IS BETWEEN THE BLADDER AND THE RECTUM. FOR THE
MAJORITY OF WOMEN, THE IUI INVOLVES EITHER NO PAIN OR MINIMAL CRAMPING.
1.
Most inseminations are timed using an ultrasound. Our staff will give
you instructions based on the ultrasound and tell you the day of the
insemination.
INSTRUCTIONS FOR THE SEMEN SAMPLE
1. The
semen specimen may be collected at home or in the collection room
across the hall from the laboratory. If the specimen is collected at
home, it needs to arrive at the lab within one hour of collection. The
IUI specimen MUST be collected into a sterile, screwtop container which
the lab will supply.
2. During transport, the container must be
placed in a ziplock bag. All specimen containers brought in for IUI
procedures must be labelled with the names of both partners, the
physician, and the date and time of collection.
3. Keep the specimen between room and body temperature (70-98.6 degrees). Do not heat or refrigerate the specimen.
4.
To obtain optimal semen specimens, it is recommended that an abstinence
period of at least 1 day but not more than 5 days be observed. The
specimen should be obtained by masturbation without the use of a condom
or lubrication. Most condoms contain chemicals that kill the sperm.
5.
Please bring a picture ID with you at the time of the scheduled
procedure. The wife's ID will work if the husband is not going to be at
the actual IUI.
6. For the very first IUI, make sure the
appropriate consent forms have been signed by BOTH the husband and
wife. If the husband will be at the first IUI, it can be signed at that
time. Otherwise, arrange for it to be done ahead of time with a
notarized signature. Consents are updated on an annual basis.
7.
The IUI cannot be performed if the container is not appropriate OR if
we do not have a current consent signed by both people.
8. If
you have any questions regarding this procedure, please contact one of
the staff at 336-841-7070 ahead of time. Thank you!
9. DONOR SPERM CAN BE OBTAINED FROM CRYOGENICS OR XYTEX (see web links on the home page). Please check with us for details.
Tubal surgery or IVF?
There
are two options available to you if your tubes are tied. Please be
aware that insurance companies often DO NOT COVER either approach.
TUBAL SURGERY
Depending
on the type of tubal ligation you had performed, it may be possible to
put your tubes back together. The following applies to tubal surgery:
1) If insurance does not pay for the procedure, you will need to pay $8,000 - $10,000 before the surgery is done.
2)
The average success rate is 50-60% but may be somewhat higher or lower
based on your condition. Many women do not get pregnant after the
procedure.
3) The surgery involves an incision in your lower
abdomen and you will need to stay in the hospital overnight. Most
people need a 4-6 week recovery period.
4) If you get pregnant
after the procedure, there is a 15-20% chance of a tubal pregnancy.
These must be removed with either medicine or surgery.
5) We always perform a sperm count and a dye study of the uterus before the surgery.
6) If you come for an appointment to discuss the surgery, please bring a copy of your operative note (or have it faxed to us).
7) We rarely perform tubal surgery if the woman is over 39 years of age.
IN VITRO FERTILIZATION (IVF)
IVF
is the method of choice if the sperm are abnormal or if a lot of tube
was destroyed at the time of your tubal ligation. The following applies
to IVF:
1) This is a non-surgical approach to getting pregnant if your tubes have been tied. It involves 4 steps:
a. Fertility shots to develop a lot of eggs. b. Needle guided egg retrieval c. Fertilization with sperm in a dish outside the body. d. Transfer of embryos back into your uterus.
2) For costs, see the "IVF Information" link on the left side of the home page.
3)
For the chance of a pregnancy, see "IVF Success Rates" on the left side
of the home page. You may also want to check the other web links shown
on the home page.
4) If you know for sure you want to do IVF, let the receptionist know when you call so the appropriate appointment can be made.
PROXIMAL TUBAL OCCLUSION
If
your tubes were not tied but have a proximal blockage at the uterus,
you may be a candidate for a TUBAL RECANALIZATION. This procedure is
done in Radiology and uses xray to guide a wire into the start of your
tube. An IV is placed and you are sedated during the procedure. The
procedure is successful in opening up the tube in a majority of cases.
It is a non surgical approach to opening up a tubal blockage at the
junction of the uterus and tube. It can be performed by Dr. Ron Zagoria
at the Wake Forest University Baptist Medical Center. The cost includes
physician and hospital fees and totals $1,300.00 If you have any
questions please feel free to contact us.
Ectopic Pregnancy
ECTOPIC PREGNANCY
In
the majority of cases when a woman becomes pregnant, the fertilized egg
attaches inside the woman's uterus and begins to grow. However, in
about one in a hundred pregnancies, the fertilized egg begins to grow
outside of the uterus. This is referred to as an ectopic pregnancy. The
most common site of an ectopic pregnancy is in the fallopian tube.
There are other sites where this can occur such as the ovary or the
abdomen, but these are very rare. The symptoms of ectopic pregnancy
often include the symptoms of pregnancy such as breast tenderness
and/or nausea. Some women may not have any symptoms and may not even
realize they are pregnant. Symptoms of an ectopic pregnancy may include
abnormal vaginal bleeding, abdominal pain, shoulder pain, weakness,
dizziness or fainting.
The diagnosis of ectopic pregnancy is
often difficult to make. Special tests to confirm the diagnosis are
often required. Blood pregnancy tests are performed. Often, special
blood pregnancy tests called Beta-HCG are done on an interval basis to
help distinguish a normal pregnancy from an abnormal pregnancy (ectopic
or miscarriage). This particular test gives a numerical value. By
repeating the test at frequent intervals and following the numerical
value, it can be determined whether the ectopic pregnancy is resolving,
getting worse, or staying the same. Transvaginal ultrasound is
performed to aid in the diagnosis of ectopic pregnancy. Ultrasound
involves the use of sound waves bouncing off internal organs and
converting these to an image on a television screen. In some cases,
laparoscopy is required to establish the diagnosis of ectopic
pregnancy. In a laparoscopy, a special light-transmitting telescope is
inserted through a small incision in your belly button to enable the
gynecologist to visualize your fallopian tubes.
Because an
ectopic pregnancy is outside the uterus, it cannot develop normally and
usually must be treated. Because the fallopian tube is narrow and has a
thin wall, pregnancies that wind up in the fallopian tubes can only
grow to about the size of a walnut before the tube bursts. This can
occur anytime during the first three months of pregnancy. Because the
tube may burst and cause major bleeding in the abdomen or even death,
tubal pregnancy must be treated promptly once diagnosed.
One
treatment for an ectopic pregnancy is surgery. In surgery for an
ectopic pregnancy, the ectopic pregnancy is removed from the fallopian
tube. The exact procedure performed on the fallopian tube depends on
how much damage the ectopic pregnancy has done. If there is minimal
damage to the fallopian tube, then a small opening in the fallopian
tube can be made, the ectopic pregnancy removed, and the tube allowed
to heal (salpingostomy). If this type of surgery is performed, your
pregnancy hormone level will be monitored on a weekly basis until
negative. If the fallopian has undergone more extensive damage, that
portion of the fallopian tube must be removed (salpingectomy). The
above types of surgery on tubal pregnancies can usually be performed
through laparoscopy.
There is available a newer treatment that
does not involve surgery for selected patients with ectopic
pregnancies. Not all patients with an ectopic pregnancy are eligible
for this medical treatment. Criteria for medical therapy for ectopic
pregnancies include: 1) that there be no evidence of excessive
intra-abdominal bleeding (shock); 2) that the pregnancy be less than 1
1/2 inches (3.5 cm) in size based on either laparoscopy or ultrasound;
3) that the Beta-HCG values are not declining on their own; and, 4)
there is no liver disease, blood disease, or kidney disease.
The
name of the drug is Methotrexate. Methotrexate in large and frequent
doses is used as a chemotherapy for some cancers. In small doses taken
orally, it has also been used for rheumatoid arthritis and psoriasis.
In the case of ectopic pregnancies, the dose administered is a moderate
amount, as a single injection into the buttocks. The drug Methotrexate
administered in this fashion stops growth of the pregnancy tissue and
allows the body to absorb the pregnancy over time. Methotrexate only
works when the pregnancy is small, the tube has not ruptured, and there
is no excessive bleeding from the ectopic pregnancy. Careful follow-up
over approximately one week is necessary for this form of therapy.
Three days after the treatment, you will need to return to the lab for
a repeat Beta-HCG. Then again on the seventh day following treatment,
you will need to return to the lab for Beta-HCG repeat blood count and
a liver enzyme test.
The chance of successful treatment after a
single dose of Methotrexate is 95%. However, approximately 6% of
patients will require surgery on their fallopian tube because the drug
has not completely worked. As with any therapy, be it medical or
surgical, there are side effects and complications. The overall rate of
side effects and complications with Methotrexate is very low. This is
less than the side effects and complications associated with surgery.
The potential risks of Methotrexate are: irritation of the stomach,
nausea, inflammation of the mouth, lips, tongue or gums, liver
inflammation, reduced white blood cell count, and reduced blood
platelet count. If these side effects occur (1%), they are temporary
and usually resolve on their own without any further treatment.
Methotrexate
may be less damaging to the fallopian tube than surgery in some
patients. Approximately 85% of patients receiving Methotrexate for
tubal pregnancy will have open tubes if a special x-ray called a
hysterosalpingogram (HSG) is preformed after treatment. This is similar
to and possibly better than the rate tubes remain open following most
surgical procedures for ectopic pregnancies.
Following
Methotrexate treatment, there are important precautions to take: First,
you must not consume anything containing alcohol for one week. Second,
you need to be at pelvic rest, including avoiding intercourse, until
the ectopic pregnancy has fully resolved and a normal period has
occurred. Third, it is important not to take any vitamin (including
multi-vitamins) containing Folic Acid until the ectopic pregnancy has
fully resolved and your Beta-HCG level is negative. Fourth, if your
blood count is low (hematocrit less than 35), you will need to take
Iron Sulfate (325 mgs.) twice a day for one month. Fifth, following the
ectopic pregnancy, you will need to use either birth control pills or
barrier methods of contraception (condoms, sponge, and/or diaphragm)
for two months following the ectopic pregnancy in order to avoid
getting pregnant and allowing the fallopian tube and uterus to fully
heal.
The majority of patients develop an increase in
abdominal/pelvic pain after Methotrexate treatment. This is generally
relieved by Ibuprofen or Tylenol. If after your Methotrexate injection,
you develop abdominal pain or pain that you had prior to the injection
worsens, you will need to contact your gynecologist.
It is
important for you to realize that as with any treatment for ectopic
pregnancy, including surgery, there is about an 15% chance that, if you
get pregnant in the future, the pregnancy would once again be an
ectopic pregnancy. In the event that you get pregnant in the future, it
is important to quickly verify whether or not you are pregnant by a
pregnancy test, and then verify by means of an ultrasound that the
pregnancy is in the uterus between 6 and 8 weeks after your last
menstrual period. In the event that you develop abdominal pain,
shoulder pain and/or vaginal bleeding, you will need to seek immediate
medical attention to make sure that you do not have a repeat ectopic
pregnancy.
METHOTREXATE FOR ECTOPIC PREGNANCY PATIENT INSTRUCTIONS
1.
Refrain from alcohol use, multivitamins containing folic acid, and
sexual intercourse until hCG titer is negative. Limit sun exposure.
Avoid gas-forming foods.
2. Call your physician if you experience prolonged or heavy vaginal bleeding.
3.
You may experience mild lower abdominal or pelvic pain during the first
7-14 days of treatment. Call your physician if the pain is prolonged or
severe. No pain medications, including over the counter medicines.
4. Make sure all your questions have been answered.
5. Approximately 6-10% of women experience unsuccessful methotrexate treatment and require surgery.
6.
You will be seen following the methotrexate in 4 and 7 days. If the hCG
(pregnancy hormone) titer is not decreasing appropriately, a second
dose of methotrexate will be given. After the hormone level falls to
low levels, you will be seen weekly until it is negative.
METHOTREXATE PROTOCOL FOR MEDICAL TREATMENT OF ECTOPIC PREGNANCIES OR PERSISTENT HCG LEVELS AFTER SURGICAL TREATMENT
DAY 1: Serum hCG, SGOT, CBC with diff, platelets. Give 1st Methotrexate shot (1 mg/kg IM)
DAY 4: Serum hCG
DAY 7: Same labs as day 1. Repeat dose if necessary (see below)
1. A transvaginal ultrasound must show no intrauterine gestational sac. 2. The hCG titer on day 4 may be higher than hCG on day 1 in the majority of patients. 3. If <15% decline in hCG titer between day 4 and 7, give second dose of methotrexate 1 mg/kg IM. 4. If >15% decline in hCG titer between day 4 and 7, follow hCG titers weekly until <5 mIU/ml. 5. If Rh-negative, give RhoGAM on day 1 or 2. 6. If HCT <35%, given FeSO4 325 mg b.i.d.
Contraindications to Methotrexate:
1. Transvaginal ultrasound demonstrating an ectopic pregnancy >3.5 cm in greatest dimension. 2. Hemodynamically unstable. 3. Significant abdominal pain. 4. Hepatic dysfunction: SGOT >2 X normal. 5. Blood dyscrasia: WBC <2,000 cells/cm3. 6. Thrombocytopenia (platelet count <100,000). 7. Renal disease: serum creatinine >1.5 mg/dl. 8. Cardiac activity in the ectopic pregnancy is a relative contraindication.
Precautions:
1. No intercourse 2. No pelvic exams 3. Limit sun exposure 4. No pain medication 5. No NSAID 6. Avoid gas forming foods
Risks:
Stomatitis (2-3%) Increase liver function tests (6% transient) Hemorrhage at site of tubal pregnancy (~6-10%) Decrease blood count, platelets Bloating Gas pains
CONSENT FORM FOR METHOTREXATE TREATMENT
At
the recommendation of my physician, I am requesting to be treated with
Methotrexate as a medical alternative to either surgery or continued
observation. I understand that this treatment consists of an injection
of Methotrexate, a drug used in cancer, to kill pregnancy tissue for a
maximum of four doses. Blood work will be monitored for any changes.
This will consist of a blood count (CBC with diff, platelets) a test of
liver function (SGOT), and the pregnancy hormone (hCG). Treatment will
cease if a significant decrease in hCG levels occur. I will be seen
after the methotrexate is given and hCG levels (pregnancy hormone) will
be checked. If the hCG level is not going down, a second dose of
methotrexate will be given and the pregnancy hormone levels followed.
If the hCG level is falling to low levels, I will be seen weekly until
the hormone level is negative.
I am aware that I need to observe
the following precautions: no intercourse or pelvic exams; limit sun
exposure; no pain medication or non-steroidal, anti-inflammatory drugs;
avoid gas forming foods. I have been given written instructions and
will comply with them.
Some of the risks that may occur include
stomatitis (mouth ulcers) (2-3%), increase in liver function tests (6%
transient), hemorrhage at site of ectopic pregnancy (6-10%)
necessitating surgery, decrease in blood counts, platelets, bloating
and gas pains.
Approximately 4-5% of patients do not respond to methotrexate and require surgery.
I
understand that if during the treatment I should have any change in
abdominal pain, feeling weak or faint, or increased vaginal bleeding,
or have any problems that I feel are related to the treatment, I should
contact my doctor.
I have read and understood this consent form.
I understand that any questions that I may have had have been answered
to my satisfaction. I also understand I may withdraw my consent at any
time and choose an alternative approach to my problem.
Financial Information
Financial Information Insurance
coverage for infertility services varies greatly. Most health plans
reimburse diagnostic services that enable the physician to determine
the cause of your infertility but few plans reimburse treatment
procedures such as intrauterine insemination (IUI) or in vitro
fertilization (IVF).
Financial Counselor Lois Solomon is
the Premier Fertility Center Financial Counselor. She will meet/talk
with you, discuss your current insurance coverage, and determine if a
payment is necessary for the procedure(s) you will be having. Prior to
your first appointment you will need to contact your health insurance
carrier and determine if infertility benefits (diagnosis and treatment)
are available to you.
Financial Policies We would like to
make you aware of our current financial policies regarding services
performed at the Center. The Center participates with most health
insurance plans. Please check with us to confirm we participate with
your plan.
Covered Services If the Center participates with
your current insurance carrier(s) and the service performed is a
covered benefit, we will accept the amount your carrier deems
reasonable or allowable. If our charge is greater than the allowable
amount determined by your insurance, as participating providers we will
reduce our charge to the allowable amount. Your responsibility may be a
co-payment (a fixed dollar amount per visit) or co-insurance (a
percentage of the allowable amount). The Center requires all
co-payments be made at the time of service. Otherwise you will be
billed for co-insurance amounts.
Non Covered Services If
the Center determines any service is not covered by your insurance
carrier you will be required to pay for those services when rendered.
The Center also offers self-pay packages for IUI and IVF cycles that
are not covered by insurance. The package amount includes all
monitoring services and the treatment procedure. You will be billed for
a single total amount instead of each service separately. The package
amount will be calculated by Lois, will be due prior to the beginning
of your treatment cycle and will be posted to our computer system when
received. Non covered charges will not be submitted to your insurance.
We will provide you with a receipt for the package amount.
Any
outstanding balances must be paid in full prior to beginning treatment.
Balances from prior treatment cycles must also be paid in full prior to
beginning a new treatment cycle.
Payment Types The Center accepts checks, cash, debit cards, Visa, MasterCard, or Discover.
Initial Visit Some
patients are enrolled in HMO?s (health maintenance organization) or POS
(point of service) health insurance plans. If this applies to you, it
is your responsibility to obtain the appropriate referral(s) for your
initial visit from your primary care doctor. You will meet with Lois
during your initial visit and review your current insurance coverage
with her. After your initial appointment, Lois will investigate which
future services need referral or pre-authorization.
Billing of Services Infertility
is a disease process that involves two individuals which complicates
the billing of services rendered. The majority of infertility charges
will be billed to the female. The male will be billed for all sperm
related charges. It is important for you to review your health
insurance coverage(s) since both of you will be billed for infertility
services. The Center has created patient fee sheets that detail the
costs of services and who those costs will be charged to. Lois can
provide these to you.
Other Financial Considerations Flexible
Spending Benefits: Some employers allow employees to set aside a
specified amount of your salary on a pretax basis for unreimbursed
medical expenses. This allows you to pay your medical bills with
pre-tax versus post-tax dollars. Check with your employer and determine
if flexible spending benefits are offered to you or your spouse.
Income
Tax Deduction: If your out-of pocket medical expense is high you may be
able to deduct a portion of your medical bills on your income tax
return. To do this you must be able to itemize deductions on your tax
return and your medical expenses must exceed 7.5% of your adjusted
gross income (AGI). Consult your tax advisor for details. Home
Equity Line of Credit ? HELOC: Refers to a loan in which the lender
agrees to lend a maximum amount within an agreed period. HELOC loans
have become very popular in the United States in recent years, in part
because interest paid is typically (depending on specific
circumstances) deductible under federal and many state income tax laws.
This effectively reduces the cost of borrowing funds. Consult your
banker and tax advisor for details. Alternative Forms of Payment:
Other payment options you may want to consider include using a credit
card for medical payments. Some credit cards offer perks such as
airline mileage, a percentage back of total charges or percentage
discounts on automobiles or other services. Remember, however, you may
not wish to pay with a credit card unless you can pay the balance in
full before you incur finance charges.
QUESTIONS If you have any questions regarding any of the above information please contact us at 336-841-7070. Thank you.
