Egg Thaw Cycle Orientation - NYU Langone Medical Center

Egg Thaw Cycle Orientation
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Please Silence Your Cell Phones and Handheld Devices
Visit us online at www.NYUFertilityCenter.org
 Copyright 2008 – 2013 NYU Fertility Center – rev. 06/05/2013
Meet Our Physicians
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Dr. Frederick Licciardi
Dr. James Grifo
Dr. Lisa Kump-Checchio
Dr. Nicole Noyes
Dr. M. Elizabeth Fino
Dr. Alan Berkeley
Dr. David Keefe
Reproductive Endocrinology Fellows
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The NYU 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 NYUFC, you will interact with our fellows
who provide clinical care and provide on-call responsibilities (including
emergencies).
Reproductive Endocrinology Fellows
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Brooke Hodes-Wertz, MD
Kara Goldman, MD
Jason Kofinas, MD
Satellite Programs
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Madison Women's Health & Fertility, P.C.
(select physicians only)
50 East 77th Street, New York, NY 10021 | Phone: (212) 639-9122
Maureen O. Moomjy, MD
Jessica R. Brown, MD
Cristina Matera, MD
Greenwich Fertility and IVF Center, P.C.
55 Holly Hill Lane, Suite 270, Greenwich, CT 06830 | Phone: (203) 863-2990
Barry R. Witt, MD
M. Elizabeth Fino, MD
Laboratory Schedule
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The NYU Fertility Center’s Embryology Laboratory
closes three times a year to perform maintenance.
Closures occur in:
April
August
December
NYUFC continues to provide monitoring, consultations and non-egg/embryo thaw
procedures during the closure period.
When scheduling your thaw cycle, please make sure you
can meet the cut-off dates before each shut down.
Contact the Patient Coordinators with any questions you
have regarding the cut-off dates.
Patient Care Staff
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Nursing
Peggy Chin
(212) 263-3385
Kamini Persaud (212) 263-7647
Diane Gandolfi (212) 263-2728
Nancy Kerns-Amsel (212) 263-0036
Christina Obin
(212) 263-5078
Viola Perez
(212) 263-6674
Lavina Mui
(212) 263-7931
Imelda Weil
(212) 263-7976
Lindeena Harris (212) 263-0026
Patient Coordinators
Maribel Feliciano (212) 263-7967
Jackie Hernandez (212) 263-0375
Shantel Morrison (212) 263-8652
Male Services ( S/A Appts)
Cris Serrano (212)263-0079
Medical Assistants
(212) 263-6498
Billing Associates Group
(212) 263-8647
Cycle Monitoring
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Frequency of monitoring is based on your 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.
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: 212-263-8990
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.
The Female Reproductive System
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Fallopian Tube
Uterus
Ovary
Location of Organs
Vagina
Fallopian Tube and Ovary
Illustration Courtesy of Organon
Egg Thaw Cycle
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Prerequisite Tests,
Consents & Appointments
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Required consultations and tests must be completed before your thaw 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”.
Morning Monitoring Hotline
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Please call us at (212) 263-8999 on the day or evening
prior to your:
Day 2 or Day 3 start date for Egg Thaw or FET
Record your name-spell it out, physician and your
protocol. Notification will allow your chart to be
available before you arrive.
Getting Started
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At today’s orientation
Your medication protocol and your egg thaw schedule will be reviewed.
If you are considering whether or not to move forward, please call one of our
patient coordinators, Jackie Hernandez or 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.
For Egg Thaw
Visit us on cycle day 2 between 7:00AM to 9:00AM for an estradiol blood test and a
baseline sonogram.
If you need your prescriptions, obtain them from the nurse on Day 2 while at
morning monitoring. If you do not require prescription authorization the
prescriptions can be called in to your pharmacy. Please have the pharmacy
information available.
Medication Pre-Certification
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Pre-certification for your medication in addition to your 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) 263-6498 or Jennifer Bush (212) 263-0392 (MondayFriday only). Please provide us with all forms required by your pharmacy
plan.
Your pharmacy benefit plan will determine the type ofand quantity of
medication that can be dispensed for your 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.
Egg Thaw Medication
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Your physician has determined your medication
protocol. If you have questions or concerns, please
address them BEFORE you start the cycle.
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. Medications, once dispensed,
cannot be returned to the pharmacy for credit, so wait
for your instructions before filling your medications.
Egg Thaw Medications
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Estradiol -Estrace™
Doxycycline (antibiotic)
Methylprednisolone -Medrol ™
Progesterone
An antibiotic is prescribed for the male partner
Proper Needle Disposal is the Law
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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
Bring the closed container 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 NYUFC for disposal
Antibiotics for Male Partner
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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 Day 5 of the female
partner’s stimulation cycle. Advise your nurse of any
medication or food allergies.
Possible Side Effects: photosensitivity, gastro-intestinal
distress.
Embryology and Andrology
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Embryology and Andrology
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Embryologists
Andrologists
Embryology and Andrology
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The same day the eggs are thawed, the partner produces a fresh sample.
Date and time determined by the embryology lab staff.
If you are using donor sperm, it will be thawed the same day as the eggs.
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 for 3 to 6 days; 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.
Embryology
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Illustration Courtesy of Organon
ICSI Protocol
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To optimize fertilization, all Egg thaw cycles use
Intracytoplasmic Sperm Injection (ICSI) – a lab procedure
when a single sperm is injected into the egg
Assisted Hatching
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Assisted Hatching – this is very rarely used- an opening
may be made in the “shell” surrounding the embryo to
assist implantation when transfer is on Day 3
Embryo Development
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Fertilized Egg
Day 2 Embryo
Blastocyst
Embryo Transfer
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The day after thaw, you will be contacted to receive
preliminary results of fertilization. Please ensure the
telephone number we have on file is correct.
The Fertility Center physician will advise each patient about
the number of embryos to be transferred. Because we may
need to change the day of your transfer from Day 3 to Day 5,
please ensure the staff can reach you by telephone.
Selected embryos are transferred directly into the uterus
during a 10 to 15 minute procedure; sedation usually is not
required.
Blastocyst Transfer on Day 5
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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.
Criteria for Day 5 Transfer
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Number of eggs at retrieval, fertilization rate and
embryo development by day 3 post-retrieval determine
day of transfer.
Many patients 42 years of age and older do not have
sufficient numbers of good quality embryos for Day 5
Transfer.
The decision to transfer on Day 3 or Day 5 has to do with
the ability to accurately select the best embryos for
transfer.
Embryo Transfer Guidelines
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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
Age
<35 yrs
35-37 yrs
38-40 yrs
41-42 yrs
Favorableb
1-2
2
3
5
All Others
2
3
4
5
Favorableb
1
2
2
3
All Others
2
2
3
3
Cleavage-stage embryosa
Blastocystsa
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.
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.
Embryo Transfer
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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 Fertility
Center in 2009-2011.
Clinical Pregnancy Rate
per Embryo Transfer
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Patient Age
at Egg Retrieval
Elective Single Embryo
Transfer (SET) Day 5
Two Embryo Transfer
Day 5
<35
65%
(50/77)
63%
(203/322)
35-37
58%
(25/43)
59%
(131/223)
38-40
60%
(9/15)
53%
(124/235 )
Progesterone
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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.
Please let your physician or nurse know if you have any nut
allergies.
Post-Transfer Monitoring
(Luteal Monitoring)
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Progesterone blood test: day of transfer.
Pregnancy blood test: mandatory at a date to be
determined by the Fertility Center. May be repeated 1 week
later if positive, often sooner if level is “borderline” to identify
the potential for ectopic or chemical pregnancy. Your
insurance may dictate the # of pg tests it will cover.
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.
Frozen Embryo Transfer Cycle (FET)
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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.
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.
Informed Consent
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Consent Forms Required
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Embryo Cryopreservation and Egg Thaw Consent.
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
Signing Consents
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Consents must be completed in advance of the procedure. Not the day of thaw.
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.
Signing Consents: Program Consents
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Research Consent
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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.
Research Consent
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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 or
egg freezing would never have been developed.
Only through your consent can the techniques for
fertility preservation or infertility treatments be
developed further.
Research Consent
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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 Fertility Center is not involved in any activity that promotes human
cloning.
Pregnancy Rates
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For your individual situation, please contact your physician.
2001- 2010, NYU 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
# of Oocyte
Retrievals
Deliveries
(Live Births)
<35
2778
51%
35 to 37
2264
43%
38 to 40
2598
32%
41 to 42
1654
20.4%
43+
1324
8.4%
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.
Issues to Consider Before Thawing Eggs
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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
Issues to Consider Before Thawing Eggs
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Multiple pregnancy (continued)
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+
(%)
< 35
56
44
0
35-37
88
12
0
38-40
79
21
0
41-42
84
16
0
>42
100
0
0
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.
Additional Services:
PGD, PGS, Egg Freezing
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Preimplantation Genetic Diagnosis (PGD)
Single Gene Defect, Aneuploidy, Translocations
Fees for NYU and for Reprogenetics or other PGD labs
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
Ectopic Pregnancy
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Even though we put the embryos in the uterus, sometimes they can
wander into the tube, or more rarely, down into the cervix.
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.
Wellness Program
www.NYUFertilityCenter.org/wellness
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Monthly Calendar of Wellness Events Can Be Found in the Lobby
For Information and Support . . .
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Ask questions during your visits or call us at
(212) 263-8990 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 www.NYUFertilityCenter.org
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.
Psychological Support Staff
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Shelley S. Lee, Ph.D.
(212) 263-0060
Mindy R. Schiffman, Ph.D.
(212) 263-0061
Psychological Support Services
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Consultations, treatment/support sessions for couples
and individuals
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 212-263-0054
Patient support groups, including:
Stress Management
Therapies related to the mind-body connection and
infertility treatment
Acupuncture Services
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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
To schedule an appointment with any of the acupuncturists,
please call (212) 807-6769 or email [email protected].
Mind/Body Support Group
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Services are provided by
Helen Adrienne, LCSW, BCD
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.
If you would like to register, please contact:
Helen Adrienne, LCSW, BCD
(212) 758-0125
[email protected]
http://www.mind-body-unity.com
Yoga for Fertility
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Services provided by Tracy Toon-Spencer
Classes are held onsite and offsite (265 W. 72nd St., 2nd 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
(212) 375-1688 or [email protected]
Restorative Yoga offered by Barrie Raffel
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
[email protected]
Nutritionist
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Kimberly Ross, MS, RD, CDN offers integrative
holistic nutritional counseling for fertility patients
165 West End Ave., Suite 1K
Fridays at the NYU Fertility Center
By appointment
Appointments made through Ms. Ross’ office.
www.kimrossnutrition.com
(212) 877-7043
Financial Considerations
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Financial Policy- Egg Thaw
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You are responsible for payment of all charges. Payment for
the full egg thaw fee is due at the start of medication; other
services (e.g., cryopreservation), as indicated per our
payment policy. By law, co-insurance, 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).
Participating insurers: Aetna, United Healthcare, Empire Plan
(Center of Excellence), Optum Health/URN, Oxford
Financial Policy- Egg Thaw
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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. NYUFC cannot be held responsible for any charges
related to your cycle that are billed by an outside provider.
Egg Thaw Charges
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Egg Thaw Cycle*
Endocrine assays and phlebotomy charges
Follicular ultrasound monitoring
Medical management
Embryo transfer
Lab culture
Semen preparation
Luteal monitoring up to initial pregnancy test
*Payment due at medication start 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 every cycle start.
FET Charges
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Frozen Embryo (FET) Cycle*
Endocrine assays and phlebotomy charges
Follicular ultrasound monitoring
Medical management
Embryo transfer
Lab culture and fertilization
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 every
cycle start.
Other Cycle-Related Charges
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Anesthesia (paid to NYU 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:
NYUFC for embryo biopsy and Reprogenetics or other genetics lab
Other Cycle-Related Charges
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Psychological services at NYUFC and Wellness services
Urology services* – Outside physician/surgeon and NYUFC Andrology lab
services
Fertility and other medications –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 NYUFC and outside provider of service
Thank you
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I F YO U H AV E A N Y
Q U E S T I O N S , P L E A S E C O N TA C T U S
212.263.8990
W W W. N YU FE R T I L I T YC E N T E R .O R G
BILLING: 212.263.8647