Services

WE ARE MANHATTAN REPRODUCTIVE GROUP

People In Reproduction

In Vitro Fertilization (IVF)

First In- Vitro Fertilization (IVF) baby was born in 1976 in England and Louise Brown is Mom herself. Today IVF has been used safely and effectively to help create families. IVF improvements dramatically increased pregnancy rates helping millions of patients around the world to get pregnant and have children. One in every 60 world babies is now born after IVF treatment

Today patients use the same medications; most of ART laboratory equipment and culture medias are obtained from the same sources. Surprisingly however, with all these similarities the IVF results are not uniformly the same. Explanation for those differences is simple; IVF is an art form combination of skills and science. Master paintings are unique although all of them were created with tools available to other less talented artists. MRM creates superior work and IVF baby is a very special gift for all patients and their families who underwent difficult journey to become parents

Originally designated to treat tubal disease, In-vitro became the number one therapy regardless of what is causing the couple’s infertility. Older patients should consider foregoing conventional therapy (including Inseminations) as they benefit more from having IVF as their primary therapy

where women’s egg is fertilized with man sperm. Fertilized eggs are placed in the incubator and kept there under optimal conditions. Fertilized eggs progress into multi- cell embryos and some embryos are placed (transferred) in the women’s womb (uterus).

After transfer, best embryos attach to the uterine wall and complete implantation process forming pregnancy. Early placental tissue begins to produce pregnancy hormone (HCG) easily detected by patient’s pregnancy test. Positive pregnancy test validates successful treatment. Key elements in every IVF cycle are ovarian stimulation with fertility medications, eggs (oocytes) retrieval and fertilization, followed by embryo transfer:

IVF patient takes injectable medications as Gonal F, Follistim, and Menopur to produce eggs. Treatment progress is monitored with sonograms and blood tests during frequent office visits. Ovarian stimulation is completed with final injection of HCG (Profasi, Ovidrel) given 32- 36 hours before egg retrieval. Rare complication caused by stimulation is hyperstimulation syndrome, caused by patient’s overreaction to infertility injectable medications

Oocyte retrieval is a minor surgical procedure performed under anesthesia or sedation given by our Board- Certified Anesthesiologist. In the Embryology Lab, retrieved eggs are inseminated with partner sperm or a single sperm is injected into the egg (ICSI procedure). Fertilization occurs in the laboratory in a dish containing reach media to support and nourish growing embryos. Within three to five days after fertilization, embryos with highest implantation potential are transferred into the women’s uterus

Embryo can be placed into the womb as early as two days and as late as five days after egg retrieval. On Day 5 best embryos are in blastocyst stage of development. Blastocyst transfer combined with assisted hatching for older patients, gives embryos best chances to attach to the uterus (implantation) and pregnancy

Lower quality embryos with lower chances for advanced development may benefit from early (cleavage stage) transfer to the uterus. SART, the US data-collecting agency, advocates Single (one) Embryo Transfer (SET) to eliminate multiple pregnancies. Embryo biopsy, and additional step in the IVF cycle (removal a small piece from the embryo) for genetic screening is performed by some IVF laboratories before SET embryo transfer to the patient. Embryo biopsy, that risks tissue damage and screening testing are not mandated by SART

Our cutting-edge Laser Equipment attached to high power microscope increases precision of IVF micromanipulation techniques. Laser practically eliminates tissue damage impossible to avoid with standard techniques. We use Laser to benefit IVF processes such as ICSI, assisted hatching and embryo biopsy for genetic testing (See our video)

Women age 35 – 40 with many of them with failed previous IVF, are majority of our patients. Our pregnancy rates for patients over 35 using own eggs are one of the highest IVF rates in the New York area. Hard work produces great results for our patients

including progesterone (oral capsules, vaginal inserts and injections) doctors routinely prescribe for IVF pregnancy. After successfully completed pregnancy 10^th week, patient’s obstetrician will take over care of our pregnant patient

Majority collected data reassure that IVF techniques do not cause birth defects and IVF babies, including twins, are born healthy although more often prematurely. IVF pregnancy is considered High Risk with additional surveillance needed for the very best outcome. Medical conditions present before treatment and other health issues may complicate IVF pregnancy; advanced maternal age, hypertension, elevated blood sugars or previous surgeries have a negative effect on normal placenta function and fetal growth increasing risk for late miscarriages and premature delivery

Patient compliance with recommendations and medications, healthy diet and close medical attention will help to prevent pregnancy complications

Poor Egg and Low Ovarian Reserve

Women age is one of the most important predictors for the infertility treatment success

and older patients, when over 35 years of age, she should seek help, preferably infertility specialist after six (6) months of unsuccessful trying. Patients over 40 years old who are trying to conceive should right away see infertility specialist for evaluation. Although number of good oocytes decreases with age in all women, there is a better chance for conception and pregnancy with normal FSH/AMH values and when additional infertility factors have been corrected

Delaying seeing a doctor to ‘WAIT AND RELAX’ can dramatically reduce women chances for successful pregnancy and baby

Diminished ovarian reserve (DOR) defined by FSH over 10 and/or AMH less then 1 regardless of women age, prognoses less eggs left in the ovary and lower chance for spontaneous pregnancy and successful treatments. Low ovarian reserve potentiates negative age factor effect on egg number and quality. Patients with lower reserve have lower pregnancy rates then patients with normal ovarian reserves due to poor response to medications, lower total number oocytes harvested and eggs inferior quality. Poor quality eggs, often with broken zona pellucida or other oocyte defects produce poor quality, weak embryos and miscarried pregnancies or failed fertilizations Often Growth Hormone (GH) is added to IVF meds in women with poor eggs and in older patients with some higher pregnancy rates but inconsistent outcomes. GH is started 6- 8 weeks prior to treatment cycle. GH is expensive, over $5,000 oer cycle cost, considered experimental, not covered by insurance and with unreliable outcomes at the end

Our customized ovarian stimulation is helping all women produce more higher quality eggs. High quality eggs in sufficient number and quality embryos are the bases for IVF success. Minimum or no medication lower chances for pregnancy by bringing poor- quality eggs especially in older women. ‘Mini’ IVF or ‘natural’ IVF usually eliminates use of injectable fertility medications but the same time the ‘super eggs’ production step is eliminated

Chances for a quality embryo produced by a single, sub-fertile oocyte is too low to recommend. Too often patients with multiple failed Mini IVF or ‘natural IVF cycles’ are looking for second opinion and after she was told already that her FSH is too high to continue treatment. Our pregnancy rates for older patients, over 35 using own eggs, are one of the highest in New York area over 50% per IVF treatment for women age 35-40 are higher than national under 40% pregnancy rates

Oocyte (Egg) Donation

Today women over forty tend to be fit and healthy. Advances in medical science improved treatment of many medical ailments and patients are happy to fully enjoy life More women in forties and fifties are fit for motherhood. Are the forties ‘new thirties?’ Perhaps not, but older mothers make a new trend in our society
Many well-liked celebrities lead by example as they had her children later in life with facts to prove it: Nancy Grace and Geena Davis; both twins at 48, Marcia Cross and Jane Seymour, both twins at 44, Holly Hunter pregnant at 47, Cheryl Tiegs, twins at 52 and that list is growing

Menopause is premature for women who lost menses under age of 40 and typically is preceded by diminished ovarian reserve, AMH less then 1, and with less and poor- quality eggs. Menopausal ovaries, including premature menopause, produce no eggs and no hormones needed to sustain menstrual cycles necessitating egg donation to become pregnant

Donor egg pregnancy is more appealing option then ADOPTION for many patients ready to start new family. Women after menopause who want to get pregnant utilize donor eggs (oocytes) the most. Donated oocytes come from healthy, young women known to the recipient (directed donors), usually family members and friends or from anonymous (donors unknown to recipients) with pregnancy rates 60- 65% in our oocyte recipients that resulted in live births, and higher than national rates (below 45%)

Our oldest first- time mother was 55 and with pleasure we report that she is very happy to enjoy her son childhood!

Positive attitude and compliance with instructions are crucial for successful outcome

Single Women Motherhood

Growing generation of single career women are reaching their late 30s unmarried but still desperate to become mothers. Many are embarking on parenthood alone, never to look back. We are working with all sperm banks licensed in New York State and we help as needed with donor selection for donor inseminations

We assist women without partners in her decisions on motherhood to become parent with oocyte freezing. We gladly help to arrange necessary counseling and encourage all women to know their AMH value

Egg freezing for ‘social’ reason (no partner to start family with) became the newest service for ART patients. Women, often single who are not ready to start families enthusiastically welcomed new avenue to preserve declining youth and fertility

Many centers advertise egg-freezing services claiming uniform success in predicting frozen gametes (oocytes) future. ‘Freeze your eggs now and enjoy motherhood in 20 years!’. Nobody today can guarantee that individual Egg Banking is a SURE alternative to getting pregnant at the younger age regardless of all glossy promises. Long term experience with frozen sperm and frozen embryos should curb overwhelming optimism. Egg donor pregnancy rates using frozen donor eggs are lower than fresh egg cycles

Medication injections for ovarian stimulation, egg retrieval, egg freezing and storage.

That is followed at later time, sometimes years later, by

Eggs removal from the storage and thawing, eggs fertilization with the sperm, embryo culture, and embryo transfer to the uterus

Advances in oocyte freezing gave a chance, and frequently the only chance, for future fertility in women who were diagnosed with cancer and who must to undergo chemotherapy that certainly will damage her ovary and eggs. For this group of patients eggs stay frozen for shorter time

Medication injections for ovarian stimulation, egg retrieval, egg freezing and storage.

That is followed at later time, sometimes years later, by

Eggs removal from the storage and thawing, eggs fertilization with the sperm, embryo culture, and embryo transfer to the uterus

Success of oocyte freezing depends on the egg chronological age at the time of freezing, and women age at the time of freezing is mainly responsible for thawed egg outcomes. Egg freezing for future pregnancy is less successful for older women who, at present constitute majority of the cases considering procedure. Effects of a very long storage on cryopreserved egg quality are not yet known

Embryo Adoption

Women especially those with limited resources are using frozen, frequently abandoned embryos in hope to become pregnant. Frozen embryo transfers after embryos left in storage for many years, usually bring low pregnancy rates

Miscarriages

Miscarriages and pregnancy losses at different stages of pregnancy, complexed medical puzzles, are on the increase

Most of the Ob/Gyn doctors have no time and no experience to treat patients who lose every pregnancy they conceive. “Miscarriage work up” testing with hysterosalpingogram, x- ray of the uterine cavity and tubes, ‘thick blood’ coagulation factors and both parents

karyotype seldom brings definite answer to etiology (reason) for the losses

No explanation and no clear directions is given to patient what should she do in the future. When a routine evaluation ‘miscarriage workup’ turns negative problem remains unsolved with encouraging advise ‘try again since everything is fine with you’

Genetics are most often investigated, but genetic problems are found in only 3% of patients who suffer frequent miscarriages. Carriers of genetic diseases are served best with IVF with embryo biopsy and genetics testing utilizing Pre-implantation Genetic Diagnosis (PGD) to select disease free embryo for the implantation in the uterus

Patients with recurrent losses have rightfully difficulties to accept grim prognosis that nothing could be done to protect her tiny baby from destruction early on in the womb. Patient becomes withdrawn depressed and surely convinced that she will never become a mother

Recent advances in understanding maternal Immune System role in early pregnancy gave much needed in- site into demystifying nature of the many unexplained miscarriages. Abnormal maternal immune responses may cause recurrent implantation failure producing chemical pregnancies and failed multiple IVF attempts

New therapies emerged giving good chances to reverse ‘bad luck’ needed to for successful pregnancy. In early miscarriages it is absolutely essential to implement therapy as early as possible, virtually at the START of pregnancy. IVF and embryo transfer gives unique opportunity to synchronize time of starting medications that will protect early pregnancy and neutralize destructive, aberrant reactions at the time when embryo is small and defenseless

Unfortunately, hardly ever any patient is referred with recommendations to be treated with IVF and/or undergo advanced investigation; both needed to improve outcomes

Women who were born without uterus or had surgery need gestational carrier (other women) to carry and deliver her baby. Many recurrent miscarriages patients feel that use of somebody else’s uterus is going to solve problem of their body ‘killing’’ pregnancy.

Finding a suitable gestational carrier, hire lawyer to prepare legal contract before treatment, is a difficult task. When there is no a family members or friend to become a carrier and help, patients look for a stranger to ‘hire’. There are professional agencies contracting ‘third-party reproduction’ (name used for gestational carrier services).

Not many families, however, can afford surrogacy service fees that average between $80-100, 000 charged by those agencies. The good news is that majority of our pregnancy loss patients successfully carried pregnancy in their own wombs

Female Infertility

Female infertility is caused by poor ovulation (egg production), damaged fallopian tubes or problems with the womb (uterus) where the pregnancy grows. After infertility testing, women can be treated with medications, surgery, intrauterine inseminations (IUI) or In Vitro Fertilization (IVF)

Clomid (Clomiphene Citrate, 50 mg oral pills) is prescribed to improve egg ovulation and it takes 2-3 months on Clomid therapy to conceive pregnancy. Clomid is one of the oldest prescriptive fertility medications, most often used for patients with PCOS (Polycystic Ovary Syndrome) to treat infrequent or absent ovulation and irregular menses

Clomid helps to restore ovulation and many of patients get pregnant. Although designated to improve ovulation, Clomid is prescribed for all-type infertility patients. Therapy is monitored for effectiveness (ovulation blood test) and for side effects; ovarian cyst, hyperstimulation, mood swings, hot flashes, abdominal pain and visual disturbances

Women naively believe in ‘magic Clomid pills’ that after years of unsuccessful attempts to conceive, Clomid will perform a miracle. When not pregnant after months on Clomid, patient refuses to stop medication, changes doctor to get new prescriptions, risking disappointment and side effects

Healthy fallopian tubes pick up eggs produced by women ovary. Pelvic infection (PID) and tubal inflammation is the most common cause for tubal damage, loss of tubal function and tubal infertility. Infection, especially one caused by chlamydia, may spread from vagina or cervix to the upper pelvis and damage fallopian tubes. Chlamydia PID is implicated in tubal disease, ectopic pregnancy, tubal blockage and tubal infertility. Following PID fallopian tubes are frequently closed and swollen at the end, forming hydrosalpinx. Hydrosalpinx lowers chances for successful IVF and should be removed before IVF treatment

Ectopic Pregnancy located in the fallopian tube, happens when fertilized egg get stuck in the tube unable to reach uterus. Tubal pregnancy may rupture and bleed heavily necessitating surgery to remove ectopic or a tube. Unruptured ectopic is often treated with medication (Methotrexate injections)

Fallopian tubes may remain open after ectopic giving patient chance for pregnancy, but after failure to conceive for six months or longer, hysterosalpingogram (HSG test) will determine tubal condition and patency. History of tubal repair; tuboplasty or reconstruction and many non- tubal surgical procedures including appendectomy may increase risk for ectopic pregnancy. Tubal infertility, including tubal ligation, is best treated with IVF

Myomectomy

Myomectomy is surgery to remove fibroids (myomas), uterus non- cancerous growths. Fibroids change shape and characteristics of the uterine tissue, causing pain, heavy periods and bleeding, pressure on the bladder with frequent urination and other symptoms. Large fibroids are often removed to relief symptoms and to allow pregnancy to grow. Surgery benefits outweigh surgical risks. Patient with small fibroids may have successful pregnancy without surgery or to have less invasive hysteroscopy. Myomas are the most common indication for hysterectomy (removal of the uterus)

Many women never conceive after myomectomy after post- surgery scarring precludes pregnancy implantation and growth. Extensive scarring may damage fallopian tubes and lower chances for pregnancy, especially in older patients. Oocyte or embryo freezing before myomectomy is a valid consideration. Uterine Artery Embolization, another treatment for fibroids, carries risk of permanent loss of menses (amenorrhea), with no periods and no chances for pregnancy

Surgical treatment for pelvic endometriosis frequently involve multiple procedures and in severe cases surgery potentiates endometriosis-damaging effect on ovaries with loss of follicles and eggs. For women with advanced endometriosis, especially these who lost one ovary and at risk for early menopause, egg freezing is of great value

Endometriosis is a medical condition common in infertile women, known to produce inflammation and hostile environment for implantation and pregnancy, increased risk for miscarriage and tubal damage from the scar tissue. Patients with endometriosis often undergo IVF to conceive. Several cycles of IVF treatment are often needed, but at the end, more than 50% woman with minimal to mild endometriosis, and 30∼40% of women with severe disease have a baby

Semen Analysis

Our office performs semen analysis for male fertility testing and sperm quality. Please call our office 212-794-0080 Monday- Friday to schedule appointment.

We provide sterile cup for the specimen collection that can be produced at home or in our office. Bringing from home, you will have 1.5 hours for specimen transport while keeping specimen in the body temperature condition.

Report is ready in two days after test and doctor will answer all questions you may have

Male Infertility

Healthy lifestyle and diet naturally enhance male fertility potential and have natural remedies work for you! Fertility herbs have been used to bust male fertility for hundreds of years. Herbs are ‘natural’ medications with a moderate potential to increase fertility, but herbs may have site- effects. Safe and most effective when supervised by licensed professional. Natural remedies are not effective for very low sperm counts

Male infertility (male factor) is diagnosed by abnormal semen analysis, that examines sperm quality) is responsible for approximately half of all infertility cases. Egg rejects defective sperm in the failed egg (oocyte) fertilization process.

Inseminations, medications and varicocele surgery are effectively used to improve sperm quality and capability to fertilize egg. Sperm production (count) and sperm motility (swimming) respond better to treatments then sperm defective morphology (abnormal shape), main cause of long-standing male infertility. Treatment recommendations are made today based on women’s age and both partners diagnosis to benefit infertile couple. For example, for women tubal factor (blocked fallopian tubes), IVF became primary infertility treatment regardless of sperm quality

Varicocele, dilatation of the scrotal veins, detected by physical exam and confirmed by ultrasound, is associated with diminished sperm production (low count) and low motility (slow movement). Surgery used to be recommended routinely for men diagnosed with varicocele. Additional prolonged medication protocols usually followed

Inseminations (IUI) with Partner Sperm

IUI is a medical procedure to introduce sperm separated from seminal fluid into women uterus (womb). Couple with partner having over 5 million motile sperm count in ejaculate benefit from inseminations the most. IUIs are primary treatment for erectile dysfunction

Complex cases, very low sperm counts (less then 5 million motile sperm in ejaculate), failed inseminations and cases of azoospermia (no sperm) are indications for IVF with ICSI with a single sperm injected inside the egg

No Sperm (Azoospermia) and TESA

In the past, men with no sperm in semen analysis (azoospermia) never fathered a biological child. TESA, procedure to recover sperm from testes followed by ICSI (sperm injection inside the egg), now offers 50% pregnancy rates for azoospermia in men

With TESA, small needle is used to sample testicular tissue with no bleeding and no stitches needed. Sperm obtained from the testis is too immature and weak to be used for insemination and ICSI is a technique of choice to fertilize eggs with testicular sperm

TESA sperm can be cryopreserved (frozen) and stored for the future use with over 80% recovery rate. TESA is effectively used for men who earlier underwent vasectomy and superior to reversal surgery

Intrauterine Inseminations

Intrauterine Insemination (IUI) is a medical procedure, infertility treatment to introduce sperm separated from seminal fluid and processed (sperm washing) into women uterus (womb). Minimum 5- 7 million moving (motile) sperm is needed for insemination to work

Sperm washings for insemination is fresh or frozen specimen special processing to separate sperm from seminal fluid and to isolate sperm cells. Sperm undergoes incubation with special nutritious media and concentration. Incubation with media enhances sperm fertilizing capacity and boosts sperm vital motility (moment) necessary for sperm swim to reach women egg

Patient is placed on the exam table with stirrups (like for a PAP- smear collection) and

speculum is put inside vagina. Insemination catheter, a sterile, narrow plastic tubing loaded with washed sperm is passed through the cervix, high into uterus where sperm is injected. From the uterus, sperm travels into fallopian tubes to fertilize egg brought there by fimbria. Fertilized egg travels to the uterus ready to implant and produce

pregnancy

Chances for each IUI treatment to produce pregnancy is 15% and it may take several attempts before successful conception. Therapeutic IUI is most often performed using patient’s male partner sperm. Older patients and those with lower quality eggs have less chance for pregnancy with the IUI

IUI is most effective treatment for couples with minor sperm deficiencies, erectile dysfunction and for women using frozen donor sperm