a consumers guide to infertility

By Randy S. Morris, M.D.

Board Certified Reproductive

Endocrinology and Infertility

A

Consumers Guide

To Infertility

& IVF

Separating Fact From FictionRandy S. Morris M.D.

Specializing in infertility and reproductive medicine since 1992

Certifications: Board Certified Reproductive Endocrinology and Infertility Board Certified Obstetrics and Gynecology

Appointments:Assoc. Clinical Professor, Div. of Reproductive Endocrinology,University of Illinois School of Medicine, Chicago, IL

Awards:President's Award Society for Gynecologic InvestigationPracticing Physician Award Pacific Coast Fertility Society

Society Memberships:American Society for Reproductive MedicineSociety of Reproductive EndocrinologistsSociety for Assisted Reproductive TechnologiesSociety of Laparoendoscopic Surgeons

Training/College:Northwestern University - Biochemistry and Molecular Biology

Medical School:University of Illinois School Medicine at Chicago

Residency:Lutheran General Hospital /University of Chicago

Fellowship:University of Southern California School of Medicine

Hospital and Surgical Center Affiliations:• Central DuPage Hospital--DuPage County. Winfield, IL• St. Alexius Hospital--Hoffman Estates, IL• Edward Hospital--DuPage County. Naperville, IL• Glenbrook Hospital--Cook County. Glenview, IL• Lutheran General Hospital--Cook County. Park Ridge, IL• Lincoln Park Hospital--Cook County. Chicago, IL• Evanston Hospital--Cook County. Evanston, IL• 900 North Surgical Center--Cook County. Chicago, IL• Downers Grove Surgical Center--DuPage County. Downers Grove, IL• The Center for Surgery-- DuPage County. Naperville, IL

About the Author

brochure 6/26/05 10:47 PM

First Some Definitions

Obstetrics: is the branch of medicine concerned with the care and treatment ofwomen during pregnancy, childbirth and theensuing period

Gynecology: is the branch of medicine concerned with the care andtreatment of the female reproductive system and includes:

• Family Planning and Contraception• Cancer screening (PAP smears, mammograms)• Menstrual problems • Pelvic pain• Fertility• Menopause

Obstetrician/Gynecologist: has received training in all of the above. Thesephysicians have completed 4 years of college, 4 years of medical school and 4years of a residency in obstetrics and gynecology. They are sometimesreferred to as general OB/Gyn's or simply as generalists.

Residency: is sort of an “on the job training program” where a recently graduated physician works under the direction of experienced doctors andassists in the care of patients. Most of the residency takes place in the hospi-tal setting but can also occur in an office setting. Each year, the resident isgiven an increasing amount of independence and responsibility for the careof patients. By the time the resident is finished, he/she is supposed to be able to practice in that area of medicine independently.

Fellowships: Once a doctor finishes residency, he/she may go on to setup apractice or he may go on to further train in one particular area in obstetricsand gynecology or subspecialty.

Most fellowships are three years in length. There are four types of fellowships in obstetrics and gynecology:

• Gynecologic oncology(Cancer of the uterus, ovaries)

• Perinatology(Handles high risk/complicated pregnancies)

• Gynecologic urology (Treats problems involving the the urinary system in women)

• Reproductive Endocrinology /Infertility (Deals with hormonally related problems,

infertility and recurrent miscarriage)

Obstetrician /Gynecologists are typically the first doctors to see and treatwomen with infertility. They will initiate some preliminary testing and, attimes, start some treatments. If pregnancy does not occur or it seems that aproblem has been discovered that is more complicated, they will refer thecouple to a reproductive endocrinologist for more advanced care.

You Are Not AloneIt is estimated that as many as one in sevencouples may suffer from infertility. Somehave never had a pregnancy (Primary infer-tility) but a larger percentage have beenpregnant at least once previously (second-ary infertility).

In 1995, 1.2 million women visited a reproductive professional.

It is estimated that 2 billion dollars are spent annually on fertilitydiagnosis and treatment in the United States alone.

With that much money changing hands, there are going to be abuses.Most abuses will not be obvious or flagrant but the charlatans and snakeoil salesman are out there - so be wary. You, as a patient and a consumerneed to be as well educated as possible in order to protect yourself.

This

is a

Big Industry

Fact #1Fact #1 What

Type Of

Doctors Treat

Infertility?

Fact #2Fact #2


Here is an excerpt from a medicalpractice website (The name has been changed):

We Care for Women, P.A. is a medical practice specializing inObstetrics, Gynecology, andInfertility. We have 14 physicians,11 of whom are Board Certified bythe American Board of Obstetricsand Gynecology, who offer state-of-the-art care to our patients at four locations in the Dallas area.

What does “Board Certified” mean?

The system for assessing doctor credentials is very confusing.

Let's try to clear it up.

When a student graduates from medical school, he earns the title “doctor”and gets an M.D. after his name. However, since he has not yet completed a residency, there isn't much he can do with that degree.

After finishing residency, a doctor can set up a practice in his field.However, there are no more initials that are added after his name.

A doctor can choose to become certified in his/her specialty by passing aseries of tests called “board exams”. They are called board exams becausethey are administered by a governing body or board setup by each specialty.For example the American Board of Obstetrics and Gynecology (ABOG)is the governing body that administers exams for general obstetrics andgynecology and all of the subspecialties.

The board exams are separated into written and oral tests.

After completion of the residency, a generalOB/GYN must first take and pass the general obgyn written exam. Then he must work for a yeartaking care of patients. He must record all of thepatients he sees in that year and submit it to theboard for approval. If the board believes thatvariety of patients is sufficient, then the doctormay take the oral examination. If he passes theoral examination, he is then said to be boardcertified in obstetrics and gynecology.

A reproductive endocrinologist who wants tobecome board certified must first finish thefellowship and then pass his written and oral examfor general obstetrics and gynecology and then hemust take and pass a written and oral examinationin reproductive endocrinology!

Board certification is the highest level of distinction possible in the field. Doctors who are board certified must recertify every ten years.

Why is “Infertility” listedseparately?The separate listing is meant to givethe impression that they havesome special expertise in infertilitytreatment. It really doesn't makesense. For example, you never see"Obstetrics, Gynecology andOncology" even though all OB/GYNsdo cancer screening.

What are reasons why doctors might not be boardcertified?• Some doctors never bother to take

the test• Some doctors have tried and failed

to pass the test

Can a doctor who is notboard certified still practice in the field?The answer is yes! There is no requirement to become board certified. Forexample, many insurance companies do not require board certification for adoctor to care for its patients.

Why does everyone want to become a fertility “specialist”?

• Infertility is a highly desirable medical practice• Usually involves young, healthy patients• Doctor's offices often don't deal with insurance• Malpractice premiums are lower than for those doctors who deliver babies• Infertility is an exciting, rapidly developing field

Take home point:

If your OB/GYN sends you to see a “fertility specialist”Make sure that he is board certified in Reproductive Endocrinology/Infertility.Some doctors will try to fool patients by stating they are board certified butnot specify what specialty they are board certified in. Others will try to implythey have special certification by listing their membership in various societies.

Understanding

Doctor

Certifications

Fact #3Fact #3


In some cases, membership in a medicalsociety can tell you about the qualificationsof a doctor. In other cases, it tells you nothing. Here are some examples from the infertility field:

Does NOT tell you about doctor qualificationsASRM- American Society for Reproductive Medicine

• Membership open to physicians and non-physicians• Membership is immediate upon receipt of the application fee• The largest and most active of the fertility related societies• Sponsors educational events and issues guidelines for practice

CARE- Chicago Association of Reproductive Endocrinologists• Amazingly you Don't have to be a reproductive

endocrinologist or even an ob/gyn to be a member• Membership immediate upon receipt of application fee• Sponsors a monthly dinner educational meeting

SART- Society for Assisted Reproductive Technologies• Society dedicated to the more advanced fertility treatments

such as in vitro fertilization• Membership open to physicians and non-physicians• Membership is immediate upon receipt of the application fee• In the past, was responsible for collecting data from in vitro

fertilization programs to send to the Center for Disease Control.As of 2005, they lost that responsibility to another agency

• The largest and most active in vitro fertilization related society• Sponsors educational events and issues guidelines for practice

DOES tell you about doctor qualificationsSREI-Society for Reproductive Endocrinology and Infertility

• SREI Membership requires certification by the American Board ofObstetrics and Gynecology in both Obstetrics and Gynecology and the subspecialty of Reproductive Endocrinology

• Sponsors educational events and issues guidelines for practice

Unfortunately, many couples do notinvestigate their doctor’s credentials andinstead focus on pregnancy rates. Ofcourse pregnancy rates are importantmeasures of success, however, the averagepatient has almost no ability to determinethe accuracy of pregnancy rates or to usethem to compare different fertilitytreatment programs.

What's more, the snake oil salesman areexperts at manipulating the numbers to make themselves appear to be better.Take this example:Pregnancy Rate

Dr. A 20%Dr. B 40%

Which doctor has a higher pregnancy rate? Most people would say Dr. B.Lets look a bit closer.

Pregnancy Rate Number of patientsDr. A 20% 200/1000Dr. B 40% 4/10

With a little more information, we see that Dr. B only saw 10 patients, anumber much too small to be able to determine a pregnancy rate accurately.

Pregnancy Rate Number of patients Entry requirementsDr. A 20% 200/1000 Any ageDr. B 40% 4/10 Under age 35 only

Now we find out that Dr. B restricts his practice to only younger women. Weknow from hundreds of medical studies that older women do not get pregnant asoften as younger women. By restricting his practice, Dr. B can inflate his preg-nancy rates and make it seem as though he has a better treatment program.

Across is a list of a few of the factors found to influence pregnancy rate.

These factors can have a dramatic impact on pregnancy rates. How a pregnancy rate is reported is also important. One must compare apples toapples. Lets take an example of a fertility treatment called Treatment X

Number of patients who start treatment 100Number of patients who complete treatment 70Number of patients with a positive pregnancy test 20Number of patients with a pregnancy seen on ultrasound 15Number of patients who deliver a baby 10

Dr A. Reports a pregnancy rate of 10%. Dr. B reports a pregnancy rate of 28.6%

Who is correct? Answer. They both are. Dr A reported the number of patients who delivered ababy divided by the number who started treatment. A more conservativemethod of reporting. Dr. B reported the number with a positive pregnancytest divided by the number who completed their treatment. Which one ismore misleading?

Unfortunately, for most treatments, there are no rules for how these rates arereported. If you were a patient who was trying to decide between Dr A andDr B based on pregnancy rates, it would be impossible to realistically com-pare the two. There simply is never enough information given to make aninformed choice.

Female age Older Female body weight Heavier Type of treatment Some are worse than othersGeographic location Certain problems may be endemicSeason Variation has been shown in studiesLength of infertility before seeking treatment Longer Number of previous failed treatments More previous failuresResults of pre-treatment testing Abnormal ovarian function

Factors That Influence Pregnancy RateFactor Variable associated with lower success

Understanding

Medical

Societies

Fact #4Fact #4Understanding

Pregnancy

Rates

Fact #5Fact #5


IVF is one of the most expensiveand invasive treatments that fertilityspecialists offer and so it deservessome special discussion.

The simplified steps involved in in-vitro fertilization are as follows:

1. Woman takes fertility medications2. She hopefully produces a number of eggs in her ovaries3. The eggs are removed (egg retrieval) 4. Attempt is made to fertilize the eggs in the laboratory5. If eggs became fertilized, the embryos are grown in the laboratory6. Some embryos are placed into the uterus (embryo transfer)

How IVF Programs Can Mislead Patients1. Not all programs report resultsIVF programs in the United States are supposed to report the results of IVFcycles to the Center for Disease Control. Unfortunately, not all do and theenforcement is lax. Even these reported pregnancy rates are subject to con-siderable problems. The CDC puts a disclaimer that these numbers shouldnot be used for comparisons between programs.

2. The Number of Embryos ImplantedIn addition to the factors listed above, there are other ways to misleadpatients about IVF pregnancy rates. One of the most important is the number of embryos that are placed into the uterus. Putting more embryosinto the uterus can increase the number of pregnancies up to a point.However, it also increases the risks of multiple pregnancy and we are not just talking about twins here.

Understanding IVF

(in vitro fertilization)

Pregnancy Rates

Fact #6Fact #6

Program A Program BNumber of cycles 332 192

Comment: Both programs have a good number of patients

Avg. number of embryos transferred 3.1 2.1Comment: B puts in less of embryos

% of cycles resulting In pregnancy 31.9% 39.1%Comment: B has a higher rate

% of pregnancies with twins 33% 25.3%Comment: B has less

% of pregnancies with triplets or more 9.4% 1.3%Comment: A has almost 10 fold higher risk of triplets or more

% of live births with multiples 34.7% 26.6%Comment: B has less With multiples

AA TT AA LL EE OO FF 22 PP RR OO GG RR AA MM SS

Lets try to compare the results fromtwo actual in vitro fertilizationprograms for women who are underage 35. (Program A and Program B)Since we have no idea about thepatient populations of these twoprograms its impossible to say by thepregnancy rates whether one is better.

However, Program A puts in moreembryos on average than Program B.By doing this, they have now placedtheir patients and their babies atgreater risk.

Think about it, about one in every tenpregnancies in program A is a triplet,quadruplet, quintuplet or higher!That only happened to Program B inabout one in a hundred patients.


First you must understand one thingabout yourself. regardless of theamount of education you have had,

YOU ARE AN EASY MARKFOR THE SNAKE OILSALESMAN!!

WHY Are You an EASY Mark?• You are very vulnerable. The couples we see are often desperate to have a

child and will do almost anything to get one.• You want to believe what they are saying.

If some one tells you they have cure that no one else has, we are more inclined to believe than to disbelieve.

• Patients always prefer to do “something” vs. “nothing” even if there are no differences between the two. If someone gives you the option of trying a treatment versus not doing anything, most people will try the treatment even if it is unlikely to really work.

• Most of you lack the skills scientifically to determine what is true and what is not. This can be true of doctors as well.

Some Guidelines When Evaluating “Miracle” Treatments”

If It Sounds Too Good To Be True, It Probably IsThe website below claims to be able to unblock fallopian tubes and remove adhesions from the pelvis simply by a few massage treatments.

Their claim: “High success rates without surgery or medication”They talk about a 75% success rate which if true would make it the most effective fertility treatment ever discovered.

Fact #8Fact #8Snake Oil Salesmen

And How To

Protect yourself

Almost all of our fertility treatments usefertility medications. The use of thesemedications can to various extentsincrease the chances for a multiple pregnancy. Most couples do not pay sufficient attention to this risk. In fact,most couples with infertility state theywould prefer to have a twin pregnancy.

By far and way, the greatest risk to the useof any of these fertility treatments is the risk of a multiple pregnancy.

It is important to know that all multiple pregnancies, including twins, havea greater rate of complications. Women with a multiple pregnancy have agreater chance for complications like:

Multiple Pregnancy Potential Complications

I. Preterm labor and delivery.• 50% of twin pregnancies are delivered prematurely• 90% of triplet pregnancies are delivered prematurely

II. Some of the complications of prematurity• Cerebral palsy• Blindness• Bleeding into the brain• Respiratory distress (breathing difficulty due to immature

lungs)• Can result in lifelong disability for the babies

III. Gestational diabetes.• This is a form of diabetes that occurs during pregnancy.• Related to an increase risk of birth defects• Often requires insulin injections • Can cause babies to grow too large or too small

IV. Pre-eclampsia. A problem of high blood pressure that occurs during pregnancy. Associated with other complications such as:

• Stroke & Seizures• Poor growth of the babies• Death of the babies in uterus• Death of the woman carrying the pregnancy• Increased risk for cesarean section• Increased risk for babies with birth defects• Increased risk for miscarriage

• Increased risk for babies that dieV. Twins are seven times more likely to die in the first month of lifeVI. Triplets are twenty times more likely to die in the first month of life

Doctors should carefully counsel patients about the risk of multiple preg-nancy associated with their age, infertility condition and treatment beingused. When performing in vitro fertilization, doctors shouldstrive to transfer the minimum number of embryos possible.

Gone are the days when a 30 year old woman has fourembryos placed into her uterus!

Fact #7Fact #7Understanding

Multiple

Pregnancy


If you are contemplating treatment with IVF and yourdoctor tells you that fourembryos are necessary to get you pregnant, then you shouldseek a second opinion!!!

In the last few decades, the treatment of infertility has becomemore effective. It has also become more complicated, moreexpensive and has greater risks. More “practitioners” are tryingto “get in on the gold rush” by offering ineffective treatments or using accepted treatments in an overly risky manner.

You must educate yourself as much as possible to protect yourself from these types of practices.

ConclusionsSome Guidelines When Evaluating

“Miracle” Treatments”

Beware The TestimonialConsider this actual unaltered testimonial taken from a web site of a local doctor:

“If you are struggling with miscarriage and need help, Dr. X is the only Doctor who can help you. Trust me, I know!!! This Doctor has the talent of Michael Jordan, the intelligence of Bill Gates, and the love for people in need like Mother Teresa. I say this because he is the first person in our lives (other than our parents) that cared enough about us and wanted to really help us. Dr. X is what a Doctor should be like. God bless you Dr. X.”

Beware Doctors Who Claim To Be Misunderstood OrPersecuted By The “Medical Establishment”Consider this actual unaltered excerpt from a web site

“Dr. Y has spent his entire academic life analyzing the impact of the immune system on infertility and the success or failure of a pregnancy.He has dedicated his professional life to analyzing couples with infertility, IVF or implantation failures and recurrent pregnancy losses who have been told by the medical community that their problem was due to bad luck or that there were no proven therapies for their problem.”

Don't Draw Unsupported Conclusions.This is the sequence of events:1) I had infertility2) Doctor Z waved his magic wand over me3) The next month I was pregnant

Conclusion: Dr Z's magic wand must have cured my infertility

This is a popular scheme seen on internet bulletin boards. There is a problem withthis logic. With every malady known to man, some people get better by doing nothing or by using a treatment that has no effect. This is known as the placeboeffect. The best way to determine if a treatment really works is to have two groups.One group receives the treatment being studied. The other group receives a placeboor dummy treatment. Ideally, neither the doctor nor the patients should know whogot what until after the study is completed. This is the only way that a true treatmenteffect can be proven.


Although we are best known known for ourIn Vitro Fertilization - IVF - and preimplantation genetic diagnosis - PGD -programs, you will find that we offer much,much more.

Acupuncture in infertility

Acupuncture in IVF

Insurance Coverage forInfertility

Your first interaction with our office will trigger our infertility insurance specialists to contact your insurance company to predetermine your infertility insurance coverage. By the time of your first appointment, we will be able to counsel you about your IVF in vitro fertilization insurance, and insurance coverage for infertility diagnostic tests and treatments.

Fantastic Office StaffOur past and current patients rave about our friendly and supportive office staff.From the front reception desk to our highly trained nursing staff.

Infertility TestingWe offer a wide variety of infertility testing

services including:Assessment of ovarian reserve using the clomid challenge test and transvaginal ultrasound for determination of ovarian volume and antral follicle counts.

The HSG (Hysterosalpingogram)is an infertility procedure used to diagnose uterine cavity problems (like fibroids and polyps) and fallopian tube obstruction.Our gentle techniques allow a nearly pain free HSG. Using tubal catherization techniques like selective salpingography and wire guide canalization, we can open blocked fallopian tubes and have helped many women avoid more invasive surgery.

Male Fertility TestsWe are also proud of our male fertility testing. Our advanced semen analysis uses sophisticated imaging and computerized analysis to get highly accurate and repeat able results for sperm counts, sperm motility, and sperm morphology.

IVF - In Vitro FertilizationIn vitro Fertilization - IVF is an increasingly popular infertility treatment.Our philosophy is to obtain the highest IVF ( in-vitro fertilization ) pregnancy

rates with the lowest risk for multiple pregnancy. To accomplish this, we maintain the highest and strictest standards for our IVF laboratory and utilize the most advanced IVF techniques such as intracytoplasmic sperm injection (ICSI), preimplantation genetic diagnosis (PGD) and blastocyst transfer.

With years of data that now indicate that blastocyst transfer can reduce the risk ofmultiple pregnancy while increasing the chance for IVF - in vitro fertilization - success, it is amazing that we are still one of the few programs the use blastocyst transfer on a regular basis.

Other Fertility TreatmentsOf course, we offer all fertility treatments here including intrauterine insemination (IUI), ovulation induction with Clomid (clomiphene Serophene), letrozole,glucophage, actos, avandia and gonadotropins such as Gonal F and Follistim.

Laparoscopy, Hysteroscopy andReproductive Surgery

Dr. Morris is an expert laparoscopic surgeon and performs laparoscopy for infertility problems such as endometriosis, pelvic adhesions,fallopian tube blockage,and uterine fibroids. He also frequently performs surgery inside the uterus (hysteroscopy) for polyps, fibroids and

intrauterine adhesions.

About IVF1

IVF1 and InfertilityOffice Locations

Chicago, Illinois IVF1 and Infertility Office900 North Michigan Avenue15th FloorChicago, IL 60611Phone: 312-440-5055

Naperville IllinoisIVF1 and Infertility Office636 Raymond DriveSuite 303Naperville, IL 60563Phone: 630-357-6540

www.IVF1.com


a consumers guide to infertility

Health & Medicine