Describe your experience with RMA of Philadelphia.
Strengths- small, well managed, concerned about the level of patient care and taking steps to improve patient education over the year and a half I have been there.
Weaknesses- have to travel for Egg retrieval and Embryo transfer procedures (although not exceedingly far, but turnpike closed for first Embryo transfer and had to fill my bladder twice! 120oz's over the course of 2hrs!). Sometimes miscommunications happen in the Pinnaclehealth system when testing needs to be done on weekends at Harrisburg hospital, or at outpatient testing clinic in the Fredrickson building during weekday monitoring. Communications seems to have also improved since I first started with Dr. Nguyen, and was not really the fault of RMA.
During treatment, did you feel like you were treated like a number or a human?
My "chemical pregnancy" during IUI was actually presumed ectopic and my "miscarriage" from a PGS IVF fresh cycle was unfortunately a termination for medical reason at 21weeks. We received a non-compatible with life fetal diagnosis at our 19 week anatomy scan. I wasn't sure how best to mark this loss on the survey.... My daughter could have survived to full term, but had a prognosis of living for only a few minutes to days at most after birth.
Even though I was no longer in Dr. Nguyen's care at the time in my pregnancy, she called me the day after diagnosis as soon as she was informed by Maternal Fetal medicine. My regular OB has not demonstrated the same level of compassion and care that Dr. Nguyen has consistently given me and my husband as we have struggled with infertility and pregnancy loss. It is a small office. Dr. Nguyen is efficient, but always makes sure if she does not have the time to answer your questions at a monitoring appointment, a nurse will follow up before you leave. She has gone out of her way to schedule consults for us when needed and they have always been within a week of our initial request. She and her staff are a big reason my husband and I felt comfortable continuing with FET cycles after the devastating loss of our daughter and why we have not given up on having a biological child altogether.
Describe your experience with your nurse.
Melissa, Stephanie and the other staff at RMA Central PA (Landy, Jamie and new hire Kristy) are very professional and compassionate. Melissa is the only other staff member who will perform ultrasounds. She handles medication protocols and will go the extra mile to make sure you understand medication changes and administration. Steph is extremely organized, knowledgeable and a calm reassuring presence. They have helped me tremendously through two terminations, and are always improving customer care so that visits are efficient but I never leave without feeling that my needs and concerns have been met.
How was your experience with Kara Khanh-Ha Nguyen?
We have been through a lot of ups and downs in Dr. Nguyen's care. On the compassion scale she gets a 10 out of 10 every time. I have needed to seek outside resources to better explain protocols at times, but she does a great job of explaining the basics and nurse consults have always filled in the gaps. She is not one to push for excessive testing when not called for, but does listen and supports patients needs. She is a very scrupulous and skilled provider.
What one piece of advice would you give a prospective patient of Kara Khanh-Ha Nguyen?
Don't hesitate to ask questions. They will get answered one way or another in her office. You're in good hands so relax:)
Describe the protocols Kara Khanh-Ha Nguyen used in your cycles and their degree of success.
Monitoring hours - 7am to 9am, M-Fri STAT blood drawn at onsite clinic, transitioning toward in office blood draws.
(I'm a tough blood draw so very happy to go to seasoned phlebotomists;)
Weekend monitoring done at Harrisburg Hospital and only time you will have an ultrasound performed by non-RMA staff (between 7am-9:30am)
Bloodwork results and medication adjustments provided same day by nursing staff (usually between 2:30 to 3:30). Dr Nguyen will generally call with initial Beta results or if complications occur.
IUI 1 & 2- Day 3 baseline u/s & E2, LH & Prog. bloodwork, clomid (can't remember when started, probably Day 2 or 3). Monitoring Day 9 (or perhaps earlier) thru LH surge, Ovidrel trigger night before IUI. Semen sample taken to office 45 minutes prior to IUI procedure for processing. Private room available for men if traveling a distance for procedure. Done during monitoring hours in a relaxing room. Beta hCG, E2 and Progesterone levels tested 9DPO. If positive, Beta and hormone levels taken every two to three day at least twice more. If normal- U/S follow up week 5 or 6 through 9 when referred back to OB. If abnormal- options for termination discussed or consulted through miscarriage. If negative,
IUI 2 Beta was positive, but slow rising and indicative of possible ectopic implantation. In addition to Beta monitoring, had a diagnostic transvaginal u/s at 6 weeks, however Beta levels were too low to confirm place of implantation, tubes appeared normal. Pregnancy was terminated with Methotrexate injection and Beta was followed to 0. Liver panel and CBC was monitored prior to and after in office injection by nurse.
IVF- estrogen primer protocol for low responders selected due to maternal age and unexplained infertility history (just turned 38 that month). Counseled to have PGS testing also due to age and hx-- Select CCS (Comprehensive Chromosome Screening). Monitored cycle prior to Stims to start estrace a week or two before Day 1. Day 2 AM u/s & bloodwork (E2/LH/Prog./FSH?)/PM first dose Gonal f & low dose hCG subcutaneous injections. Monitoring continued every other day to daily with medication adjustments, cetrotide added sometime around day 7-9 to suppress ovulation, hCG injection trigger 2 nights prior to retrieval with bloodwork monitoring the following AM to confirm it was administered properly.
Egg Retrieval and Embryo transfer procedures are preformed at the King of Prussia surgical center NE of Philadelphia (1.5 hr from Harrisburg). ER scheduled generally before 9 am. Given a report of egg count post procedure after anesthesia recovery. Restart estrace (vaginally), start steriod, antibiotic, and crinone (progesterone vaginal gel).
Fresh embryo transfer scheduled for same time as ER on Day6 (if embryos make it to blastocyst stage by Day 5 and test euploid). Given report by embryology Day1, Day3 and Day5. Reports- 21 eggs retrieved, 17 fertilized normally by Day1, 10 Day3 with normal cleavage, 3 Day5 blastocyst tested- 1 euploid, 2 Day6 blastocyst tested, both euploid and frozen.
Day6 fresh transfer (It's a girl!) (No anesthesia necessary, but have to drink 50-60oz water starting 1.5 hour prior to procedure. Very uncomfortable!) Beta follow up was normal. Embryo measured normal week6Day0 u/s. Heartbeat detected in week 7 Day 0 u/s. Continued monitoring through week9 and referred back to OB. Was told to follow up with NT scan and amniocentesis, but no further genetic screening was necessary due to PGS. We ignored Dr. Nguyen's advice and did not have an NT scan done between 12-14 weeks, thinking we had it covered on the genetic defect front and I was eating well/taking prenatals so not overly concerned about NTD. Unfortunately at our week 19 anatomy scan our daughter was diagnosed with Exencephaly a fatal NTD. Amniocentesis results indicated that karyotype was also normal. It was a "fluke" developmental defect. Follow your RE's advice, get the NT scan.
FET cycles- Dr. Nguyen allowed me the choice of having a synthetic or natural cycle (with estrogen primer control of ovulation or without estrogen) I opted both cycles for the greater predictability of synthetic cycle. Estrace started orally Day2 in the PM after AM u/s and bloodwork- taken AM & PM, dose upped then taken back down at ovulation. Progesterone in oil intramuscular shots started evening of ovulation (1/2cc) as well as steroid (7days). Progesterone upped to 1cc until Beta and continued to 10 weeks is positive. Both cycles failed so I discontinued PIO and estrace day of Beta.
Have consulted with Dr. Nguyen on next possible steps-
Another stim cycle with either same estrogen primer protocol or a lupron microflare with PGS-- both are low responder protocols. My AMH has dropped from 2015 (2.27) to this September (1.32). Egg quality is a major concern, but Dr. Nguyen believes I will have a similar outcome to my first IVF cycle. Genetic screening protocols are changing in their lab, so we will not have the option for fresh cycle transfer, but will have both chromosome and karyotype testing performed for frozen transfer. She is also willing to perform an endo/scratch the cycle prior to our next transfer because we have had two implantation failures with euploid embryos. We may choose to have further immunological testing done prior to our next cycle due to our multiple losses (a blighted ovum- spontaneous conception, a presumed ectopic with IUI and our daughter's NTD, also euploid), and am in the process of looking into reproductive immunologists to work in consult with Dr. Nguyen. We are still unsure if we how far we will pursue further testing.
Describe the costs associated with your care under Kara Khanh-Ha Nguyen.
IUI cycle- $1,200 includes bloodwork through first Beta, u/s monitoring and IUI procedure
Does not include medication- Clomid covered by my insurance with copay. Ovidrel- ~ $100 including shipping w/pharmacy discount through RMA
(Note: options are changing in 2017 due to new PGS protocols)
IVF Multicycle Option w/RMAid 7.5% discount & Select CCS-~ $13,400
includes Dr. & Nurse consults mock embryo transfer (cycle prior to stim), bloodwork through 1st Beta, monitoring, anesthesia, egg retrieval, ICSI, embryo culture/embryologist fees, fresh cycle embryo transfer, also covers one Frozen embryo transfer in the event that fresh cycle transfer cannot be performed, fresh transfer failure or loss of pregnancy if FET can be performed within a 9 month period. (We ended up not having to pay additional fees for our first FET after our loss at 21weeks post fresh transfer). I believe this may have also covered vitrification of frozen embryos.
Additional costs- $3,000 genetic testing (covers 10+ (don't remember exact #) of embryo biopsies and can be transferred to multiple stim cycles if you do not meet the maximum number in any given cycle. We had 5 tested from our first IVF cycle, so will most likely not have to pay more for additional preimplantation genetic diagnosis in future cycles. I've talked with finance at RMA and this will be honored with the additional karyotype screening that will be added to the protocol in 2017.
(Note- all RMA multi-cycle options will be changing in 2017 due to new PGD protocol. My next stim cycle will likely be a single IVF cycle paid "ala" carte by service since I will not need to pay additionally for PGD. I was quoted and expense of ~$12,000 in expected costs including one FET transfer.
Stim cycle medications (gonal-f 900cc injections pens, cetrotide, low dose hCG, hCG trigger shot & pregnancy support (Crinone 8%) through 10 weeks-
$~6,000.00 with 25% compassionate care discount through Freedom Pharmacy. I was not aware to shop around for Crinone coupons and additional discount programs. I could have saved more.
Co-pay through insurance- ~$30 to 60 for estrace pills, medrol (steroid) and antibiotic
FET cycle- $3,500 (without RMAid discount, but possible to qualify for financial aid through practice based on income/insurance coverage).
Meds- estrace copay ~$20 -30, progesterone in oil intramuscular injections ~$40.00 for 30 day supply including shipping.
Not covered procedures not covered in RMA plans- diagnostic exams and tests like maternal and paternal genetic screens, salinesonograms, hysteroscopy. I've had several genetic screens, (2) salinesonograms, (2) hysteroscopies including (1) endometrial polypectomy performed by Dr. Nguyen and all were covered by insurance. The RMA financial team and staff work hard to code procedures accurately, but in a way that will be accepted by most insurance carriers. I have a very restrictive HMO that does not cover any infertility treatment, but diagnostic screening and tests short of an infertility diagnosis are covered.