In Vitro Fertilization Orientation

Transcription

1 In Vitro Fertilization Orientation 1 Please Silence Your Cell Phones and Handheld Devices Visit us online at Copyright NYU Langone Fertility Center rev. 09/24/2014

2 Meet Our Physicians 2 Dr. Frederick Licciardi Dr. James Grifo Dr. Nicole Noyes Dr. Alan Berkeley Dr. David Keefe Dr. M. Elizabeth Fino Dr. Brooke Hodes-Wertz Dr. Kara Goldman Dr. Lisa Kump-Checchio

3 Reproductive Endocrinology Fellows 3 The NYU Langone Fertility Center is part of the Division of Reproductive Endocrinology and Infertility (REI) at NYU School of Medicine s Department of Obstetrics and Gynecology. Our division offers a 3-year fellowship program in Reproductive Endocrinology and Infertility approved by the American Board of Obstetrics and Gynecology. Fellows are licensed physicians and have completed 4-year residencies in Ob-Gyn and have elected to subspecialize in REI. Throughout your time at the NYULFC, you will interact with our fellows who provide clinical care and provide on-call responsibilities (including emergencies).

4 Reproductive Endocrinology Fellows 4 Jason Kofinas, MD Nidhee Sachdev, MD Susan Maxwell, MD Alexis Masbou, MD

5 Satellite Programs Madison Women's Health & Fertility, P.C. (select physicians only) 50 East 77 th Street, New York, NY Phone: (212) Maureen O. Moomjy, MD Jessica R. Brown, MD Greenwich Fertility and IVF Center, P.C. 55 Holly Hill Lane, Suite 270, Greenwich, CT Phone: (203) Barry R. Witt, MD Anate Aelion Brauer, MD Laura Meyer, MD 5

6 Laboratory Schedule The NYU Langone Fertility Center s Embryology Laboratory closes three times a year to perform maintenance. Closures occur in: April August December 6 NYULFC continues to provide monitoring, consultations and non-ivf procedures during the closure period. When scheduling your IVF or FET cycle, please make sure that you can meet the cut-off dates before each shut down. Contact the Patient Coordinator at (212) with any questions you have regarding the cut-off dates.

7 IVF Patient Care Staff IVF Nursing Peggy Chin (212) Kamini Persaud (212) Diane Gandolfi (212) Nancy Kerns-Amsel (212) Christina Obin (212) Imelda Weil (212) Lindeena Harris (212) Viola Perez (212) Lavina Mui (212) IVF Patient Coordinator/ Male Services Maribel Feliciano (212) Analuisa Andujar (212) Medical Assistants (212) Billing Associates Group (212)

8 Cycle Monitoring Frequency of morning monitoring is based on individual results of treatment. Blood Test and Ultrasound Hours: 7:00AM to 9:00AM, 7 days per week, no appointment necessary Please try to avoid the 8:59AM rush, particularly on weekends. 8 We will call with medication instructions the afternoon of your visit. Be prepared and have all medications you will need early in the day and before weekends. Follow instructions exactly. Call with questions: Best time to call nurses: after 9:30AM until 5:00PM If your orientation nurse is out of the office, other IVF nurses can assist you.

9 The Female Reproductive System 9 Fallopian Tube Ovary Uterus Location of Organs Vagina Fallopian Tube and Ovary Illustration Courtesy of Organon

10 Ovulation and the Role of Hormones 10 Desired Hormone Levels FSH < 13.5 IU/L Estradiol < 75 pg/ml Illustration Courtesy of Organon

11 In Vitro Fertilization 11

12 Prerequisite Tests, Consents & Appointments 12 Required consultations and tests must be completed before your IVF cycle begins. Please inform us if you or your partner have any medical condition or allergies, or are on any prescription medications or herbal supplements. Some medical conditions will require documented clearance from your personal physician or specialist. Your Advance Directive ( if you have one) should be provided at the start of treatment. Information available from your MD s assistant. All consents for procedures and releases from cryopreservation must be completed, properly signed and witnessed prior to starting any medication. Incomplete testing or consents will delay the start of your cycle. No consent or lack of required testing means No Start.

13 Morning Monitoring Hotline Please call us at (212) on the day or evening prior to your: 13 Day 1 Microdose Lupron start date Day 21 Lupron start date Day 2 or Day 3 start date for IVF or FET Record your name (spell it out), physician and your IVF protocol type. Notification will allow your chart to be available before you arrive.

14 Getting Started 14 At today s orientation Your medication protocol and your IVF scheduling will be reviewed. If you are considering whether or not to move forward, please call your orientation nurse or the patient coordinator, Maribel Feliciano, at least one month prior to when you want to start to reserve a place on our start calendar. There are times when we are fully booked or in downtime and your treatment cycle may be delayed. *** If you have any insurance, be sure to consult with our billers regarding your financial responsibility. Cycles and medication must be authorized as per YOUR benefit. Do not start any medication unless you have received the approval of the billing group. If on a LUPRON protocol or Estrogen Prime Visit us on cycle day 21 between 7:00AM to 9:00AM for a progesterone blood test if your cycle is 26 to 30 days long; Otherwise, call us to confirm the date of the progesterone test. Depending on this test result, you may begin Lupron as instructed. If on a NO LUPRON protocol Visit us on day 2 of your menses between 7:00AM to 9:00AM for FSH and estradiol blood tests and a baseline sonogram.

15 Stimulation Options 15 Lupron Microdose Lupron Birth Control Pills No Lupron Antagon (ganirelix acetate) Cetrotide (cetrorelix acetate) Estrogen Prime Clomid

16 IVF Medication Pre-Certification 16 Pre-certification for your IVF medication in addition to your IVF procedure may be required by your insurer. We will assist you with the process, but all information must be provided based on your individual insurance requirement. Every cycle, even repeats must be authorized in advance. Allow 3 weeks for pre-certification of your medication. Contact Shalanda Davis (212) or Charmaine Chestnut (212) Please provide us with all forms required by your pharmacy plan. Your pharmacy benefit plan will determine the type and quantity of medication that can be dispensed for your IVF cycle at any one time. Patients must be aware of the pharmacy benefit and its limitations - we can assist you, but we are unable to circumvent the plan s requirements.

17 Anesthesia Evaluation 17 In cases where the patient s weight is greater than 200 lbs. and/or BMI indicates the patient is overweight, the patient must see the anesthesiologist for an examination of the airway and to determine IV access before starting medications. In some instances, where the airway is compromised or access cannot be determined, the patient will not be cleared for anesthesia administration and can elect to cancel, undergo the retrieval without anesthesia, or return after weight loss.

18 IVF Medication Your physician has determined your medication protocol. If you have questions or concerns, please address them BEFORE you start the cycle. 18 The decision to start a patient s medication is usually based on your Day 2/Day 3 blood test and approval of your insurance carrier. Some patients may be instructed to delay their IVF cycle and will not start. Therefore, you should be aware that if you purchase your medications in advance, and are cancelled, you will not be able to return the medication. If you have a history of being cancelled and not starting due to hormone irregularities, you should wait to fill your medication prescription until you receive the go-ahead to start. This means you will need to plan, by having a pharmacy ready. If you have insurance coverage, abide by the carrier s guidelines.

19 Proper Needle Disposal is the Law Please collect your needles and syringes Use a red sharps container (available at your pharmacy) or Use a clean soda bottle with a cap or similar container 19 Bring the closed containers to us and we will legally dispose of them with our licensed medical waste company Your local hospital may accept the used items for disposal You can call your local health department for a legal drop-off facility Do not mail your syringes and or needles to NYULFC for disposal

20 Required Follicular Medications Gonadotropins: Stimulate the ovaries to develop multiple follicles containing the eggs. Gonal F, Follistim, Bravelle : Follicle Stimulating Hormone (FSH) Repronex or Menopur : Follicle Stimulating Hormone + Luteinizing Hormone (FSH + LH) GnRH Antagonists: Antagon (ganirelix acetate) Cetrotide (cetrorelix acetate) GnRH Agonist: Lupron (leuprolide acetate) Antibiotics are prescribed for the male partner to protect against bacteria that may be present in semen. 20

21 GnRH Antagonists 21 Purpose: To suppress the release of LH, which could cause premature ovulation. Brand: Antagon, Cetrotide Cycle Day Started: Usually begun on cycle day 7 to 9 (but depends on your response to gonadotropin injections). Once begun, this medication is continued until the day of hcg administration. Administration: Subcutaneous injection Possible Side Effects (incidence < 5%): Abdominal bloating, bruising or reaction at injection site, headache, nausea or vaginal bleeding.

22 GnRH Agonist 22 Purpose: To suppress the natural hormone cycle. Usually begun on cycle day 21 (but this depends on your normal cycle length); menses usually follows in 8 to 10 days. Brand: Lupron (Leuprolide Acetate) Administration: Subcutaneous injection Possible Side Effects: Bloating, bruising at injection site, hot flashes, headache, mood swings, insomnia, vaginal dryness. Most of these effects happen only after menses has occurred.

23 Antibiotics for Male Partner Purpose: Protects against infection of the embryos. Type: Doxycycline Ciproflox will be prescribed for patients allergic to doxycycline. Please inform us if you have an allergy to Cipro or other medications. Administration: oral medication, 100 mg twice a day (10 12 hours apart) for 10 days, beginning on the start day (Day 2 or Day 3) of the female partner s stimulation cycle. Advise your nurse of any medication or food allergies. Possible Side Effects: photosensitivity, gastro-intestinal distress. 23

24 Gonadotropins (HMG, FSH) Purpose: Stimulate the ovaries to produce multiple follicles. Types: FSH Gonal F, Follistim, Bravelle (administered by subcutaneous or intramuscular injection) also via the Pen HMG Repronex (administered by subcutaneous injection) or Menopur Possible side effects: Breast tenderness, rash or swelling at injection site, mood swings, depression, abdominal bloating or discomfort, hyperstimulation syndrome (<1%). Once you begin stimulation, limit exercise to walking. 24

25 Human Chorionic Gonadotropin (hcg) Purpose: Mimics the surge of luteinizing hormone(lh) and to fully mature the oocytes or eggs. 25 Administration: hcg (intramuscular) or Ovidrel (subcutaneous) injection must be taken within 10 minutes of the scheduled time and in the exact dose instructed failure to do so may result in cancellation of the egg retrieval. Set your alarm clock! Possible side effects: headache, bloating, irritability, pain at the injection site, ovarian hyperstimulation syndrome (<1%).

26 Alternate Ovulation Trigger 26 Sometimes Lupron (Leuprolide Acetate) is used instead of hcg as the drug to cause the final maturation of the eggs If so, it will be administered as a 0.4cc dose Your physician will decide which medication you receive

27 Oocyte Retrieval Do not take aspirin or NSAIDs (Motrin, Aleve, Advil, Naprosyn) during the 7 days prior to the retrieval, as there is a risk of hemorrhage. The procedure is scheduled 34 to 36 hours after the hcg or Lupron ovulation trigger. The patient must not eat or drink after midnight the evening prior to retrieval. If prescribed, take your usual medications with a sip of water only! Please confirm your arrangements if you are using frozen or donor sperm or bringing the semen specimen from home. Frozen or donor sperm must be in the laboratory prior to starting medication. Sperm is generally collected from the male here at NYULFC. Both male and female partners should arrive 1 hour prior to the scheduled retrieval time. An anesthesiologist will administer IV sedation for the egg retrieval procedure. 27

28 Oocyte Retrieval (continued) The procedure takes approximately 20 minutes; recovery usually takes 1 hour but can be longer. The patient will be informed of the egg count on the day of retrieval. The patient will be evaluated for pain and given post-operative instructions. Because you will receive anesthesia, the patient must be discharged to the care of an adult escort. No Escort. No Retrieval. No Kidding. The patient will begin an antibiotic, usually doxycycline, to prevent infection, and Medrol, a medication to help with implantation. Please advise the nurse or MD if there are any medication allergies. Retrieval is considered Cycle Day 14, no matter what day of the cycle it falls on. 28

29 Oocyte Retrieval 29 Retrievals begin around 10:00AM each day and continue to be scheduled every half hour. We must have a sperm specimen the day of your egg retrieval! If you have a male partner, he will be directed to the semen collection room when you arrive. If you are using donor sperm or cryopreserved sperm, the specimen must be physically in the laboratory before the day of your egg retrieval. Illustration Courtesy of Organon

30 Embryology and Andrology 30

31 Embryology and Andrology 31 Embryologists Andrologists

32 Embryology and Andrology At retrieval, eggs are examined and evaluated by the embryologist. In routine cases, sperm is added to the lab dish containing the eggs and a special medium for fertilization. The dish is placed in an incubator where normal fertilization occurs. The resulting embryos are evaluated and the best are placed into the uterus. The patient has the option to cryopreserve (freeze) excess, good-quality embryos; this requires a separate consent form. 32

33 Embryology 33 Illustration Courtesy of Organon

34 Micromanipulation: ICSI Intracytoplasmic Sperm Injection a single sperm is injected into the egg to assist fertilization 34

35 Indications for ICSI 35 Low sperm count and/or motility at semen analysis Clinical history of poor fertilization efficiency Acute drop in motility following sperm preparation on the day of egg retrieval Male partner medication use of: Calcium channel blockers (Procardia, Norvasc, Adalat, Calan, Verelan, Tiazac, Dilacor, Nisoldpine, Caduet)

36 Embryo Development 36 8-Cell Embryo Blastocyst Day 3 Day 5

37 Embryo Transfer The day after retrieval, you will be contacted to see how you are feeling and to receive preliminary results of fertilization and instructions for progesterone administration from the nursing staff. Please ensure the telephone number we have on file is correct. Embryo transfer is generally scheduled for 5 days after the retrieval. The NYU Langone Fertility Center physician will advise each patient about the number of embryos to be transferred. 37 Selected embryos are transferred directly into the uterus during a 10 to 15 minute procedure; sedation usually is not required and there is no recovery period.

38 Blastocyst Transfer on Day 5 38 Purpose: To reduce the occurrence of multiple gestation without compromising the pregnancy rate. Rationale: The blastocyst stage represents the most advanced stage of embryo development in the laboratory. These embryos have the best chance of implanting. As a result, the transfer of fewer embryos will achieve a clinical pregnancy as often as more embryos transferred earlier in the cycle.

39 Embryo Transfer Guidelines The number of embryos to be transferred is determined by program guidelines and is influenced by factors including patient history, age and embryo quality. Recommended limits on the numbers of embryos to transfer Prognosis Cleavage-stage embryos a Blastocysts a It is very important to discuss these guidelines with your physician prior to the start of your IVF cycle. Some insurance carriers and states limit the number of embryos that may be transferred to maintain insurance coverage. Single embryo transfers are also performed at the patient s request and sometimes at the program s recommendation. Some insurers encourage SET. 39 Age <35 yrs yrs yrs yrs Favorable b All Others Favorable b All Others a See text for more complete explanations. Justification for transferring one additional embryo more than the recommended limit should be clearly documented in the patient s medical record. b Favorable = first cycle of IVF, good embryo quality, excess embryos available for cryopreservation, or previous successful IVF cycle. Practice Committee Number of Embryos Transferred. Fertil Steril 2009.

40 Embryo transfer 40 The decision regarding the number of embryos to replace in your Embryo Transfer (ET) is an important one for you and, if applicable, your partner. The decision has significant implications for your health, the health of your pregnancy and that of your children should you achieve pregnancy. Please review the information regarding clinical pregnancy outcomes and multiple gestation as impacted by the number of embryos replaced. This data is derived from IVF cycles conducted here at the NYU Langone Fertility Center in

41 Clinical Pregnancy Rate per Embryo Transfer 41 Patient Age at Egg Retrieval Elective Single Embryo Transfer (SET) Day 5 Two Embryo Transfer Day 5 <35 65% (50/77) 63% (203/322) % (25/43) 59% (131/223) % (9/15) 53% (124/235 )

42 Progesterone Purpose: supports the uterine lining to sustain embryo implantation and pregnancy Administration: injectable progesterone or a vaginal suppository is started the day after retrieval. Do not stop progesterone unless instructed by a staff member. Possible side effects: cramping, headache, nausea, breast tenderness, mood swings or vaginal irritation. 42 Please let your physician or IVF nurse know if you have any nut allergies.

43 Post-Transfer Monitoring (Luteal Monitoring) 43 Progesterone blood test: 1 week after retrieval. Pregnancy blood test: mandatory 2 weeks after retrieval; repeated 1 week later if positive, often sooner if level is borderline to identify the potential for ectopic or chemical pregnancy. Pregnancy ultrasound: 1 to 2 weeks after the second pregnancy blood test. Transfer to obstetrician of your choice: once detection of fetal heartbeat is documented.

44 Frozen Embryo Transfer Cycle (FET) An FET cycle can only be initiated after consultation with your physician and a reservation is in place. Insurance authorization may also be required. A reservation will not be provided unless authorization is verified. Patients undergoing FET must have a properly signed and witnessed consent before starting treatment. Patient cannot start a cycle without an FET consent and partner release form, as well as completion of all prerequisite blood tests. Visit us on day 2 of your menses between 7:00AM to 9:00AM for a blood test and sonogram. Begin oral Estrace as directed by your physician. 44 Visit us on day 14 of your menses between 7:00AM to 9:00AM for a blood test and a sonogram, and to schedule a transfer date. We will call you with the date and instructions regarding your transfer and start date of progesterone administration.

45 Informed Consent 45

46 Consent Forms Required IVF and Embryo Transfer - which includes consenting for ICSI Embryo Cryopreservation and Frozen Embryo Transfer (FET) 46 Donor sperm (if needed) An additional consent is required for the use of donor sperm. Release for Frozen Sperm A release is required before a frozen sperm specimen (donor or male partner) can be thawed. PGD/PGS (if needed) - Be sure you have received the PGD/PGS packet and have confirmed the PGD/PGS schedule with Reprogenetics or other PGD lab directly. NYU School of Medicine Institutional Review Board consents for research studies

47 Research Consent All research at NYU Langone Medical Center must be approved by an ethics review board consisting of physicians, researchers and non-medical staff. This panel, called the Institutional Review Board (IRB), decides what research may be performed. IRB research consent permits use of discarded materials for research. Only materials that would otherwise have been discarded will be used for research studies. Providing consent for research on discarded materials will not in any way jeopardize your medical treatment. Declining consent will not adversely affect your medical treatment. 47

48 Research Consent 48 Providing consent permits us to improve scientific techniques and to further understanding of infertility and its treatment. Without the consent of patients like yourselves, IVF would never have been developed. Only through your consent can the techniques for in vitro fertilization be developed further.

49 Research Consent Examination of genetic abnormalities in embryos that have stopped dividing and are therefore not suitable for transfer or freezing. Analysis of follicular fluid to determine whether molecular signals in this fluid will predict which eggs and embryos are most likely to create viable pregnancies. Examination of signals from cells surrounding the developing oocyte to help predict which oocytes are likely to create pregnancy. Continuous monitoring of the discarded embryos for several days in a special incubator to gain more information about early embryo development. NYU Langone Fertility Center is not involved in any activity that promotes human cloning. 49

50 Pregnancy Rates For your individual situation, please contact your physician , NYU Langone Fertility Center performed 12,790 IVF cycles using fresh, non-donor eggs, resulting in 10,618 retrievals and 3,661 deliveries. Patient Age at Retrieval 50 # of Oocyte Retrievals Deliveries (Live Births) < % 35 to % 38 to % 41 to % % A comparison of clinic success rates may not be meaningful because patient medical characteristics, treatment approaches and entrance criteria for ART may vary from clinic to clinic.

51 Euploidy Rates with TE Biopsy 51

52 Euploidy Rates with TE Biopsy Cont d 52

53 Donor Egg Pregnancy Rates From , the Center performed: Fresh embryo transfers in donor egg cycles that resulted in 799 deliveries (57.4% live birth rate) 369 Donor egg FET cycles that resulted in 116 deliveries (31.4% live birth rate) A comparison of clinic success rates may not be meaningful because patient medical characteristics, treatment approaches and entrance criteria for ART may vary from clinic to clinic.

54 Issues to Consider Before IVF 54 Potential risks and side effects of IVF Hyperstimulation which can result in hospitalization While hyperstimulation is rare, it is a serious risk Requires hospitalization and time off from work Adverse reaction to medications Multiple pregnancy Elective reduction of multi-fetal pregnancy Pre-term labor and cesarean delivery Prematurity Cryopreservation of additional embryos The decision to cryopreserve is an important one that should be made prior to creating embryos Custody in the event of death or divorce Donation for research Discard

55 Issues to Consider Before IVF Multiple pregnancy (continued) 55 In 2010, the Program reported 239 deliveries resulting from fresh, non-donor egg cycles. Of these, 59 or 25% were multiple births all twins, no triplets. This data does not include PGD cycles. Patient Age at Retrieval Singletons (%) Twins (%) Triplets + (%) < > A comparison of clinic success rates may not be meaningful because patient medical characteristics, treatment approaches and entrance criteria for ART may vary from clinic to clinic.

56 Additional Services: PGD, PGS, Egg Freezing Preimplantation Genetic Diagnosis (PGD) Single Gene Defect, Aneuploidy, Translocations Fees for NYU and for Reprogenetics or other PGD labs 56 Under certain circumstances may be covered by insurance carriers Egg Freezing: Elective or Medical No services affiliated with egg freezing are covered unless you have insurance coverage specifically for egg freezing

57 Ectopic Pregnancy Even though we put the embryos in the uterus, sometimes they can wander into the tube, or more rarely, down into the cervix. 57 Tubal pregnancies occur in about 2-3% of IVF pregnancies. Tubal adhesions increase the risk of an ectopic. Treatment is with medication (Methotrexate) or surgery.

58 Wellness Program 58 Monthly Calendar of Wellness Events Can Be Found in the Lobby

59 For Information and Support... Ask questions during your visits or call us at (212) during regular hours of 9:00AM to 5:00PM. Use the written materials and videos available in our library, located off the patient waiting area. Visit our web site at Injection training videos are available (English and Spanish) through our website look for this icon on any page except the homepage Ask our staff for the names of additional patient advocacy, education and information programs. Wellness Program Services are most effective when started prior to your cycle. 59

60 Psychological Support Staff 60 Shelley S. Lee, Ph.D. (212) Mindy R. Schiffman, Ph.D. (212)

61 Psychological Support Services Consultations, treatment/support sessions for couples and individuals 61 Consults are mandatory for all patients using donor gametes All patients/couples may utilize the services of our psychologists-call for an appointment and fee schedule at Patient support groups, including: Stress Management Donor Egg Forum Therapies related to the mind-body connection and IVF

62 Acupuncture Services 62 Services are provided by Lara Rosenthal, L.Ac. Belinda Anderson, Ph.D., L.Ac. Sara Frohlich, L. Ac. Offered onsite Offsite appointments are also available Can safely be used prior to and concurrently with fertility medications and procedures

63 Mind/Body Support Group Services are provided by Helen Adrienne, LCSW, BCD 63 Offered as a series of individual classes or as a one-day group program Individual consultations are also available Main goal is to help patients realize that while you can t control infertility, you can control how you navigate it.

64 Yoga for Fertility Services provided by Tracy Toon-Spencer Classes are held onsite and offsite (265 W. 72 nd St., 2 nd Fl.) Bring your own mat or one will be provided for you Gentle practice focuses on deep relaxation, guided visualization and breathing to trigger the relaxation response Safe to practice at any time during your treatment Restorative Yoga offered by Barrie Raffel 64 Classes are held offsite (371 Amsterdam Avenue) Soothing practice designed to elicit deep, conscious relaxation using props and lengthening time in poses to deepen their effects

65 Nutritionist Kimberly Ross, MS, RD, CDN offers integrative holistic nutritional counseling for fertility patients 165 West End Ave., Suite 1K Fridays at the NYU Langone Fertility Center By appointment 65 Appointments made through Ms. Ross office. (212)

66 Signing Consents Consents must be completed in advance of the retrieval. Not the day of retrieval. Program Consents Patient: Initial Each Page Sign and date the last page Spouse or Sexually Intimate Partner (if applicable): Initial Each Page Sign and date the last page Please DO NOT use a checkmark for consent elements which require a specific decision. Record your initials where appropriate. Research Consents A research consent CANNOT be witnessed by a Notary Public. 66

67 Signing Consents: Program Consents 67

68 Financial Considerations 68

69 Financial Policy You are responsible for payment of all charges. Payment for the full IVF cycle is due on day 2 or 3 of your cycle; other services (e.g., cryopreservation), as indicated per our payment policy. By law, coinsurance, co-pays and deductibles must be paid and will not be waived. Payment of co-pays, deductible, coinsurance or any fees due to the doctor or program, can be made by cash, check or credit card (Visa, MasterCard or American Express). If you have infertility insurance coverage for advanced reproductive technologies, confirmed in writing by the carrier, we will provide a statement indicating: The appropriate diagnosis as determined by your physician Services rendered and applicable charges Participating insurers: Aetna, United Healthcare, Empire Plan (Center of Excellence), Optum Health/URN, Oxford Insurance carriers have specific authorization requirements and these must be met by the patient. Do not start a cycle if you have not been authorized for the cycle ( including repeats and FETs). Starting without insurance authorization will result in the patient being responsible for all charges. Check your policy to identify if IVF/ART is a covered benefit - not all plans cover IVF/ART. Providers such as anesthesiologists, laboratories, geneticists, radiologists, or pharmacy and hospital fees are separate from the cycle fees. Your insurance may or may not cover these fees. Contact the provider directly for information. This is a sample list of sources of additional charges and cannot be considered complete. NYULFC cannot be held responsible for any charges related to your cycle that are billed by an outside provider. 69

70 IVF Charges IVF Cycle* 70 Endocrine assays and phlebotomy charges Follicular ultrasound monitoring Medical management Oocyte retrieval and embryo transfer Embryology services Semen preparation Luteal monitoring up to initial pregnancy test *Payment due day 2 or 3 of IVF cycle for self pay patients/charges. Cycle will be cancelled for nonpayment of any charges including but not limited to co-pays, co-insurance, deductible and non-covered services. Individual insurance plans dictate what is included in a cycle. Authorization must be obtained where required in advance of the cycle start.

71 IVF Charges Donor IVF Cycle (Shared or Exclusive Donor)* 71 Basic IVF cycle charges Oocyte donor screening and treatment Oocyte donor compensation Oocyte donor medication Oocyte recipient screening (if required) Oocyte recipient treatment *Payment due upon notice of donor match. If an exclusive donor is used per couple s choice or due to cancellation of a shared cycle, most donor-related charges are doubled. Please read donor oocyte financial information form CAREFULLY!

72 IVF Charges Frozen Embryo (FET) Cycle* Endocrine assays and phlebotomy charges Follicular ultrasound monitoring Medical management Embryo transfer Lab culture and fertilization 72 Luteal monitoring up to pregnancy test Payment due at cycle start for self pay patients/non-covered charges. Cycle will be cancelled for nonpayment of any charges including but not limited to co-pays, co-insurance, deductible and non-covered services. Individual insurance plans dictate what is included in a cycle. Authorization must be obtained where required in advance of the cycle start.

73 Other Cycle-Related Charges Anesthesia (paid to NYU Langone Anesthesia Associates) ICSI and PGD/PGS* and/or Assisted Hatching and Extended Blastocyst Culturing Semen cryopreservation (including 6 months of storage) Additional storage billed semiannually Initial Embryo & Egg cryopreservation (includes first year of storage) Additional storage billed annually on 1st day of anniversary month Diagnostic semen analysis Non-covered, excluded or experimental services as determined by your benefit plan *PGD/PGS fees come from 2 sources: NYULFC for embryo biopsy and Reprogenetics or other genetics lab 73

74 Other Cycle-Related Charges Psychological services at NYULFC Urology services* Outside physician/surgeon and NYULFC Andrology lab services Fertility and other medications Outside pharmacy Surgical facility charges (non-ivf) for male partner Luteal monitoring and OB ultrasounds (following positive pregnancy test) All tests performed by outside laboratories: PGD-Reprogenetics, Enzo, Genzyme, Quest, Lab Corp, NYU Genetics *Services payable to NYULFC and outside provider of service 74