Noble Fertility Center Brochure

GUIDE FOR NEW PATIENTS
NOBLE FERTILITY CENTER
For Reproduction & Recurrent Miscarriages
Peter L. Chang, M.D., F.A.C.O.G.
137 East 36th Street, New York, NY 10016
Ph. (212) 804-6666 FAX (212) 502-3386
Email: NobleFertilityCenter@yahoo.com
www.NobleFertilityCenter.com
formerly Beth Israel Center for Infertility
but still:
Small enough to know you.
Sophisticated enough to help build your family.
I. INTRODUCTION

Thank you for choosing our Center to help you realize your dream of having a family. Please accept our
warmest welcome to you. We understand the struggles that you face and we truly strive to provide the
finest care in a compassionate and professional environment. Our staff is highly trained in the area of
reproduction and will do everything possible to help you through this challenge.
The information contained herein is to provide you an overview of the Center, its staff members, services,
treatments and risks. Before embarking on a therapeutic program, which can be expensive and
emotionally draining, have all your questions answered and evaluate your options. Overall, for the
majority of couples facing the challenge of infertility or recurrent miscarriages, the outlook is more
promising than ever. Remember, there is hope! Indeed, the majority of infertile couples seeking medical
help eventually succeed in having children.
Why go anywhere else?
From the start, we have remained small enough to get to know our patients but sophisticated enough to
help build their family. We are very proud of the work that we have achieved and of our success rates
over the past 15 years. And that’s because we employ the most advanced methods under the care of the
field’s most respected specialists. Furthermore, our team is committed to provide individualized care and
the best treatment option while trying to minimize your expenses.
The Next Level in Care — “Our Difference”:
1. Never Seen Before Dedication: We see each and every egg and embryo as another opportunity to
successfully grow a family. We’ve cultivated advanced methods that target the growth of
individual eggs and embryos. The success of in-vitro fertilization can still rely on immediate
action and precise timing—especially in the earliest stages of the process. Fertilization, for
instance, can only occur at the proper stage of an egg’s development, but sometimes this
maturation may not happen until early morning or very late at night. While most labs will wait
“long enough” (usually 5pm) and hope for the best, we always wait until the ideal moment for the
egg to mature. Even if the ideal moment arrives in the middle of the night, our dedicated
embryologists will be there to fertilize the egg immediately, thereby improving the number of
healthy embryos and the odds of overall success. We understand that when it comes to the
delicate process of in-vitro treatment, every minute makes a difference and every egg/embryo
counts.
2. EMBRYOPLASTY — Breakthrough Technology – “The Difference”
Embryos with fragmentation? Not a problem. We can remove these microscopic fragments and
lead to redintegration or restoration of the embryo to health. (read more about it under Section IV.
TREATMENTS).
Fragmented Embryo
Fragment Removal
Embryo without Fragments
Fragments removed
Overall, we employ the most sophisticated methods under the care of the field’s most respected specialists
to successfully grow your family.
History: This Center was created in 2001 at Beth Israel Medical Center as Beth Israel Center for
Infertility and Reproductive Health (BICFI) to serve the reproductive endocrinology & infertility
needs of the lower Manhattan that was non-existent at the time and still today.
Since 2015, we have relocated to a new location 137 East 36th Street/Lexington and renamed ourselves as
Noble Fertility Center For Reproduction & Recurrent Miscarriages.
What we do: We specialize in treating Infertility, Recurrent Miscarriage and Fertility Preservation. We
perform diagnostic work-up, and all advanced fertility treatments including: ovulation induction, artificial
insemination, in-vitro fertilization, intracytoplasmic sperm injection (ICSI), assisted hatching with laser,
egg and embryo cryopreservation, and Embryoplasty. (read more about it under Section IV.
TREATMENTS).
In addition, we have also been very successful in fertility preservation or cryopreservation of oocytes for
later use. We use the latest technology, vitrification, to achieve the highest results. We also offer very
competitive fees for such service compared to other NYC fertility centers.
To find out more, please visit our old website www.bicfi.com. Our new website is still under
construction.
Confidentiality: All services provided at our Center are confidential except as required by law. Our
physicians and the Center will not reveal any information about you or your treatment without your
consent. However, specific medical details may be used in professional publications as long as personal
information about you is not disclosed. Statistics concerning your treatment (without your name or other
personal information) will be included in information that the Center provides to the Society for Assisted
Reproductive Technology and the federal Centers for Disease Control and Prevention. Any other use of
information about yourself or your treatment will require your specific written consent.
Payment Policy: (also see Financial Agreement form) Payment is due in full when you come in for
your treatment cycle start (day 2 or 21). The Center accepts payment in the form of cashier check, cash,
and credit cards. Full payment for egg or embryo freezing/cryopreservation is due on that day. In the
event of a cancelled cycle, you will be charged for services rendered and a credit will be given for the
remaining amount.
We participate with various insurance plans. For patients with insurance coverage, we will be happy to
help you understand your coverage. If we do not participate directly with your insurance, there still
may be “out of network” benefits which may be recovered on your behalf by our billing department. All
insurance payments will be applied to your account according to the explanation of benefits. Our billing
services are provided to you as a courtesy at no charge.
If you have any questions, please do not hesitate to call us with any questions at 212 804-6666 or email
NobleFertilityCenter@yahoo.com.
II. PHYSICIANS & STAFF
Peter L. Chang, M.D., F.A.C.O.G., Director
Dr. Chang is board certified Reproductive Endocrinologist & Infertility who specializes in treating
infertility, recurrent miscarriage and fertility preservation. After 13 years as Division Chief of
Reproductive Endocrinology Infertility at Beth Israel Medical Center and Director of Beth Israel Center
for Infertility, he has recently moved his private practice to Murray Hill. However, he remains affiliated
with Mount Sinai Beth Israel Medical Center and also as Assistant Professor of Obstetrics & Gynecology
and Reproductive Science at Icahn School of Medicine at Mount Sinai.
Dr. Chang did his fellowship at Columbia University, College of Physicians & Surgeons, where he
remained as an Assistant Professor with his own basic science research lab. In 2001, he was asked to join
Beth Israel Medical Center as Division Chief of Reproductive Endocrinology as well as Assistant
Professor of Obstetrics & Gynecology and Women’s Health at Albert Einstein College of Medicine,
Bronx, NY.
He is also author of more than 70 published journal articles, textbook chapters and abstracts. He is
recipient of various research grants and publication awards and has presented his research at national and
international conferences. He is a member of several medical societies and serves as American Society
for Reproductive Medicine’s Program Committee Abstract Reviewer and Society for Gynecologic
Investigations’ Program Committee Abstract Reviewer as well as an ad hoc reviewer for various
reproductive journals.
In addition, Dr. Chang has been nominated one of the best doctors by Consumer’s Research Council of
America – “America’s Top Obstetricians & Gynecologists”, New York Times’ New York Super Doctors,
New York Metro Area's Top Doctors by Castle Connolly Medical ltd., U.S. News & World Report’s "Top
Doctors", and Top Reproductive Endocrinologists on the list of U.S. News & World Report’s Top
Doctors for several past consecutive years.
With more than 15 years of experience in this field, he and his staff remain committed in treating their
patients with compassion, respect and the most advanced therapy available.
Stephan Quentzel, M.D., Psychiatrist
Stephan J. Quentzel, MD, a psychiatrist and a family physician, is the chief of primary care psychiatry at
Beth Israel Medical Center. He leads the effort to integrate sound mental health care into various
ambulatory medical services of the hospital. This includes providing the psychiatric services for the
Center. Dr. Quentzel received his medical degree from the University of Illinois, and did his
undergraduate work at the Massachusetts Institute of Technology. His family practice and psychiatry
residencies were integrated and both done at Beth Israel Medical Center. Dr. Quentzel enjoys the whole
person orientation of his clinical practice and can be reached at (212) 844-8602.
Carlos Acosta, B.S., Embryology Director
Mr. Acosta was originally trained at the Jones Institute in Norfolk, VA and Cornell University. He has
more than 25 years of human embryology experience and expertise in micromanipulation techniques
including Embryoplasty. Because of his expertise, his laboratory’s success rates are among the best in the
NY area. Mr. Acosta can be reached at (212) 677-5118.
Yan Zhang, R.N., Clinical Coordinator
Ms. Zhang has more than twenty years of experience with all aspects of infertility testing and treatment
including in-vitro fertilization and egg donation. She is in charge of coordinating all aspects of your
infertility care. In addition, she is also fluent in Chinese and has a doctorate of medicine from China. Ms.
Zhang has worked with Dr. Chang for the past 13 years. She can be reached at (212) 804-6666 during
business hours or by email NobleFertilityCenter@yahoo.com.
III. PATIENT SERVICES
In order to better serve you, the following items are available to you as a patient of this
Center. Please feel free to ask our staff about the following aspects of our program:












Infertility or Recurrent Miscarriage Consultation/Evaluation
Endocrine Testing
Ovarian Reserve Screening
Hysterosalpingogram
Sonohysterogram
Semen Analysis
Psychological Counseling
Genetic Counseling
Social Worker
Injection Teaching
Medication Cost Assistance
Insurance Coverage
IV. TREATMENTS
 Initial Consultation―you will meet with your physician for a thorough evaluation of your
reproductive problem (both female and male). Your previous tests and treatments are reviewed and the
best individual plan of care is presented for future treatments. If you have not had complete testing,
this will be set up at this time.
 Diagnostic Testing―if necessary, your physician may order the following diagnostic tests: baseline
hormone tests; day 3 hormone levels (FSH/estradiol) and/or AMH to check your ovarian reserve; day
21 progesterone to confirm your ovulatory status; hysterosalpingogram to evaluate your fallopian tubes
and uterine cavity or sonohysterogram/hysteroscopy to evaluate your uterine cavity; semen analysis to
rule out male factor infertility. If you have recurrent miscarriage, a complete work-up will be
performed.
 Ovulation Induction―ovaries are stimulated to develop multiple mature eggs with use of oral
medications such as clomiphene citrate (Clomid, Serophene) or injectable medications such as
Follistim, Gonal F. At the time of ovulation, either intercourse or intrauterine insemination can be
done to achieve conception.
 Intrauterine Insemination―at the time of ovulation, using a small catheter, washed/processed sperm
is placed through the cervix into the uterus. Therefore, the cervical mucus is bypassed which
sometimes can be detrimental for the sperm. Donor sperm can also be used.
 Reproductive Surgeries―operations such as laparoscopy and hysteroscopy can correct problems
related to endometriosis, fibroids, polyps and pelvic adhesions.
 Frozen Embryo Transfer―is a cycle in which previously frozen embryos are thawed for embryo
transfer in an attempt to conceive.
 Gestational Carrier―is a woman who carries an embryo/pregnancy that was formed with the egg of
another woman; after delivery, the gestational carrier is expected to return the infant(s) to the genetic
parents.
 Preimplantation Genetic Diagnosis (PGD)―embryos are biopsied in order to identify the ones that
do not carry the gene for inheritable diseases. This also can be done for deciding the sex of your child.
 Male Factor Infertility―Any deficiencies in sperm quantity, motility and morphology may make it
difficult for a sperm to fertilize an egg under normal conditions. If necessary, we will be happy to
make the referral.
 Egg Freezing and In Vitro Fertilization (IVF)―is a procedure that involves removing the eggs from
a woman’s ovaries and fertilizing them outside of her body. The resulting embryos are then transferred
into her uterus through the cervix in an attempt to establish a pregnancy. It generally involves the
following:
 Ovarian Suppression: ovulation suppression drugs (gonadotropin releasing hormone agonist
such as Lupron®/Ganirelix acetate®/Cetrotide®) are used in order to control egg development
and prevent ovulation. These drugs will require daily injections to be done by you or your
partner from 5 to 21 days.
 Ovarian Stimulation: Fertility drugs (i.e. clomiphene citrate, Follistim®, Gonal-F®, or
Bravelle® and human chorionic gonadotropin, Ovidrel) are administered to increase the
number of follicles/eggs available for collection during an IVF cycle. The dose and duration
of each drug is tailored to each individual patient. These drugs will require daily injections to
be done by you or your partner over a period of 10 to 14 days. The growth and development
of follicles are monitored by ultrasound examinations using a transvaginal probe and by assay
of estrogen levels in your blood. This will require frequent visits to the office. When your
follicles have matured sufficiently, human chorionic gonadotropin (hCG) is administered by
injection to initiate the final stages of egg maturation prior to egg retrieval. Your partner
should ejaculate on the day of hCG and then abstain until the egg retrieval.
 Egg Retrieval: This is done under anesthesia (intravenous conscious sedation) and takes
approximately 10 minutes. A needle is passed through your vaginal wall into the ovarian
follicle under direct visualization with sonogram. Suction is then applied to retrieve the
follicular fluid. The embryologist examines the fluid obtained from each follicle in order to
identify the eggs. On this day, semen is collected usually by masturbation. The day after your
retrieval, you will be given progesterone every day to help support the early pregnancy.
 Egg freezing: your treatment ends at this time. The eggs will be frozen the same day.
However, after you get your menses, you should schedule a follow up with your physician to
make sure your ovaries have returned to normal size.
 Insemination: in most cases (unless otherwise indicated), the egg(s) and sperm will be
processed and placed together in a drop of culture medium in the laboratory to allow
fertilization to occur. If indicated, ICSI will be performed instead.
 Intracytoplasmic Sperm Injection (ICSI): this procedure is routinely recommended in cases
of: severe male factor (very low sperm count, motility and/or morphology), surgically obtained
sperm specimens, or previous history of poor fertilization rate. In these instances, this
procedure has been shown to increase fertilization rates. Individual sperm is injected into each
mature egg under the microscope with specially designed tools.
 Embryo Culture: Normally fertilized egg(s) are transferred into culture dishes with culture
medium necessary for growth until time of embryo transfer/cryopreservation.
 Assisted Hatching: using a microscope and specially designed tools, a small opening is
created in the clear shell (known as the zona pellucida) of the embryo(s) in order to assist the
normal hatching process of the embryo. At this time we also perform Embryoplasty.
EMBRYOPLASTY — Breakthrough Technology – “The Difference”
Fragmentation occurs frequently in embryos produced by in-vitro fertilization. The higher
percentage of fragmentation is related to lower quality embryos, implantation and pregnancy
rates. Studies have shown that fragmentation is the result of programmed cell death or
apoptosis. Furthermore, these fragments have been shown to secrete apoptotic substances that
can spill out onto surrounding healthy cells and cause damage. Thus, they may induce arrest
and apoptosis of remaining cells, resulting in a poor grade embryo with lower implantation and
pregnancy rates.
Fortunately, years of laboratory research and the development of custom micro-surgery
instruments have given way to a highly advanced process of microscopic embryo
manipulation, called Embryoplasty. Using this method, we can remove from the embryo these
microscopic fragments and lead to redintegration or restoration of the embryo to health.
Studies have shown that the embryoplasty of embryos resulted in similar implantation and
pregnancy rates compared to embryos initially without fragmentation.
Because of this technique’s complexity and the expertise required to conduct it correctly and
effectively, we are one of the few embryology labs nationwide to employ this revolutionary
method.
Fragmented Embryo
Fragment Removal
Embryo without Fragments
Fragments removed
 Embryo Transfer: after several cell divisions, the embryo(s) will be transferred into the
uterus by means of a small catheter inserted through the cervix. Embryo transfer typically
occurs 3-5 days following aspiration of the eggs. The number of embryos to be transferred
will be determined on a case-by-case basis and the decision is made with your physician.
 Cryopreservation: some couples have more quality embryos than can be transferred. We
offer the option of embryo freezing and cryopreservation for future frozen embryo transfer
cycles.
 Pregnancy Tests: A blood test will be performed during the second week after the embryo
transfer to determine if pregnancy has occurred. If so, additional blood samples will be drawn
at regular intervals to determine the progress followed by ultrasound exams to visualize the
fetal sac(s) and fetal heart beat(s).
 Egg Donation Program―Some women are unable to produce healthy eggs because of disease,
ovarian failure or advanced reproductive age. For these women, we offer anonymous or directed egg
donation program in order to help them achieve pregnancy. In this process, the patient (the recipient)
uses the eggs donated by a young healthy woman (the donor) for insemination with her partner’s
sperm. The resulting embryos are then transferred into the recipient’s uterus in an attempt to conceive.
The donor relinquishes all parental rights to any resulting offspring. This is a highly successful
alternative for women who are unable to get pregnant using their own eggs and allows them to
experience pregnancy and childbirth.
 Anonymous Donors: Young healthy donors are recruited through advertisement, public
speaking and word of mouth. They are carefully screened to determine their physical, genetic
and psychological suitability by New York Medical Services for Reproductive Medicine. All
potential donors undergo a comprehensive screening process that involves the following:
1. Initial screening over the phone
2. Completion of application and questionnaire
3. Interview with the clinical coordinator
4. Comprehensive medical screening with the medical director
5. Genetic screening with geneticists
6. Psychiatric screening with psychiatric team
7. Screening for general and reproductive health including infectious and genetic diseases.
 Directed Donors: The infertile couple is welcome to bring their own egg donor. This
individual may be a relative, a friend or acquaintance. Although this donor is non-anonymous,
our policy requires her to undergo the same comprehensive screening in order to determine
suitability for egg donation. We do reserve the right to not use a particular donor.
V. MEDICATIONS
 Clomiphene Citrate: Clomid, Serophene ― A weak synthetic estrogenic compound given
orally to induce ovulation in anovulatory women or to induce development of more than one
dominant follicle in an ovulatory woman.
 GnRH Agonists: Lupron ― It suppresses natural ovulation during an IVF cycle by blocking the
secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) by the pituitary.
 GnRH Antagonists: Ganirelix acetate, Cetrotide ― It has the ability to complement the
actions of Follistim, Gonal F by preventing the premature release of the eggs from the follicles.
 Human Chorionic Gonadotropin (hCG): Novarel, Profasi, Pregnyl, Ovidrel ― Injectable
hormone that acts like luteinizing hormone (LH) and is used to cause the final maturation and
release of the eggs.
 Human Recombinant FSH (hrFSH): Follistim, Gonal F ― Formulation made up of only
follicle-stimulating hormone (FSH) produced by recombinant DNA technology. The injectable
agent is used to stimulate follicular development in both anovulatory and ovulatory women.
 Progesterone: Prometrium, Progesterone ― Hormone given as vaginal suppository or in oil by
intramuscular injection in order to maintain the luteinized endometrium and support a pregnancy.
It is used after an intrauterine insemination, egg retrieval, donor egg or frozen embryo cycle.
VI. RISKS AND SIDE EFFECTS
 Adnexal Torsion: in less than 1% of the times, the stimulated ovary can twist on itself, cutting off its
own blood supply. Surgery is required to untwist or even remove it.
 Assisted Hatching: there is a small risk of injury to the embryo(s) that could result in damage and
non-viability. Although some studies show clear improvement in implantation following assisted
hatching, others show no benefit. If pregnancy is successfully established, miscarriage, ectopic
pregnancy, stillbirth, multiple births, and/or birth defects may still occur. There is insufficient
information at this time as to whether the occurrence of any of these problems are increased or
decreased by assisted hatching.
 Birth Defect: the rate of birth defects after gonadotropin or IVF is not higher than in the general
population (2-4%). Furthermore, these children are developmentally not different from their peers.
 Egg Retrieval: is an outpatient procedure performed under anesthesia. It may cause moderate
discomfort after the procedure. Incidental puncture of the bladder may lead to transient hematuria
(blood in the urine). There is a small possibility (1/1000) of infection, bleeding or damage to
bowel/abdominal organs that may require further observation or emergency surgical procedure to
correct the incurred injury. There are also the risks associated with the sedation/anesthesia: nausea,
respiratory depression, headaches, and cardiovascular collapse. There have been deaths reported from
the use of anesthetic agents used during the retrieval, although such events are extremely rare.
 Embryo Transfer: usually causes minimal discomfort/cramping. There is a possibility of bleeding
and a very small risk of developing a pelvic infection or a tubal pregnancy.
 Fertility Drugs (clomiphene citrate, Follistim, Gonal-F): may result in the enlargement of the
ovaries and development of ovarian cysts that may cause pain, bloating and discomfort in the lower
abdomen but the ovaries eventually return to the normal size and shape. Individuals should not be
physically active during this time since cysts may rupture and cause problems, some serious enough to
require hospitalization and even surgery. Very rarely, overstimulation or “ovarian hyperstimulation
syndrome” (OHSS) may cause abdominal swelling and fluid retention severe enough to lead to
cardiovascular collapse (shock). The risk of this serious complication is rare (<1%). If severe OHSS
occurs, it may require hospitalization for intravenous fluids and monitoring until the syndrome
resolves. Therefore, careful monitoring during the use of these drugs is required in order to minimize
these risks. Finally, there has been much speculation as to whether or not the use of fertility drugs
causes ovarian cancer. To date the answer to this question remains unknown. Previously, there were
three poorly designed studies that suggested an increased incidence of ovarian cancer in women who
have received fertility drugs. However, there are more recent studies that do not show such an
association. There are no studies to date that demonstrate a definite cause and effect relationship
between fertility drugs and ovarian tumors/cancer (both benign and malignant).
 GnRH Analog (Lupron): may be associated with temporary hot flushes, body aches, vaginal dryness
and other menopausal-like symptoms during the time in which the estrogen levels are low.
 Intracytoplasmic Sperm Injection (ICSI): although this procedure increases the chances that the
eggs will be fertilized, fertilization may still not occur. There is a small risk of injury to the egg(s) that
could result in damage.
 Multiple Pregnancy: up to 20% of pregnancies resulting from gonadotropins are multiple gestations,
in contrast to a rate of 1-2% in the general population. Typically twins occur in approximately 25%35% and triplets 5-10% of the pregnancies. Triplet and higher order pregnancies are high risk events
and are associated with poorer obstetric outcomes than singleton births. Multiple birth pregnancies
have a higher rate of preterm labor, stillbirth, neonatal deaths, maternal morbidity and mortality
compared to singleton births as well as increased financial costs and emotional stress. The opportunity
to reduce the number of fetuses (multifetal reduction) to a smaller number will be discussed with you,
including the associated complications inherent to this procedure.
 Progesterone: may cause the woman to feel pregnant. Side effects include: bloating, nausea,
depression, increased appetite, weight gain, fatigue, sleepiness, headache, and sleep disorders.
VII. OTHER CONSIDERATIONS

Psychological Stress: After deciding to have a baby, most couples are surprised and disappointed when
pregnancy does not occur as quickly as they would like. A diagnosis of infertility or recurrent miscarriage
can therefore be particularly unsettling for couples whose hearts are set on children. Choosing to undergo
fertility treatment is a major step that presents with many decisions. Psychological stress may be
increased during the course of evaluation, treatment and/or treatment outcome. By supporting and
communicating with each other, many couples find that their relationship can grow stronger. However, if
you or your partner feels a need to talk to someone, emotional and psychological support and counseling
are available at the Center upon your request.
Alternatives: It is important to decide how far you and your partner are willing to go with infertility
treatments. You should be aware of other options available to you such as adoption, foster care and
childfree living.