High Quality Affordable Fertility Care Kit

1. High Quality Affordable Fertility Care Kit Paul C. Magarelli, MD, Ph.D. Reproductive Medicine & Fertility Centers University of New Mexico IVF Center Mountain View Wellness & Reproductive Medicine 877-475-BABY(2229) info@RMFCfertility.com www.RMFCfertility.com www.RMFCfertility.com www.IVFNewMexico.com

2. Section 1 Overview of HQA and what we needSection 2 IVF Manual Used by permission of RMFC and Dr. Magarelli

3. 5 Star Service is the Cornerstone of our HQA program • HQA-IVF include 5 Star Service: • You will be greeted and known by our staff with both a smile and desire to help you • You will know, up front, all the costs, there are no hidden charges • You will see the doctor, the nurse practitioner, and the embryologist… we want to get to know you and your family… this is the right way to create OHB™! • Our Patient Advocate service personnel will help you through the process… it can be scary and confusing… we will help • You will get our phone numbers, even our doctor’s personal cell if you need it… no worries. • We will celebrate and cry through all your struggles…. we love what we do • If for any reason you are unclear, confused, scared, disappointed… we will give you access to our management and doctor… we want this experience to be the best ever for a medical practice… please tell us if we fail to meet the 5 Star… 4 Star is unacceptable OHB = One Healthy Baby!

4. What is High Quality Affordable Fertility Care? • HQA-Fertility Care recognizes that reproduction is a biologic need and that there are situations in which couples or individuals are unable through intercourse to achieve a pregnancy… HQA-FC creates an affordable opportunity to provide these Key Clinical and Therapeutic Actions: • Access for Patients to a Board Certified Reproductive Endocrinologist and Infertility Specialist • Free 30 min Infertility Phone Consults • Free 20 min Infertility In Person Consults • Free IVF for Colorado & New Mexico Cancer Patients at our RMFC facility • Testing at RMFC Colorado Springs • Usually insurance health plans will cover testing, however if they do not or you do not have an insurance plan, we provide extremely cost effective testing of the following: • Sperm, our Semen Analysis are only $ 25 • Eggs, our Ovarian Assessment tests are only $ 145 • Uterus and Fallopian Tube tests Package$ 400 • Ultrasound/Physical Exam & Uterus confirmatory tests, Diagnostic hysteroscopy, are only $ 800 • Treatments at RMFC Colorado Springs • Our IUI fees are $ 250, including ultrasounds, sperm prep, insemination • Our Premier IVF (HQA-IVF) fees are $ 4,800 (see next page) • Our IVF with Comprehensive Chromosomal Screening (CCS) HQA-IVF/CCS fees are $ 8,000 (see next pages) • Cancer Patients that live in Colorado & New Mexico that need IVF are at no cost, including medications, in our RMFC facility in Colorado Springs (there may be fees for Anesthesia and incidentals). • Fees • All fees are subject to change and based on your individual needs, there may be additional fees (e.g., positive hepatitis requires isolation in separate cryogenic tanks… so fees will apply in these situations that are not “standard”)

5. HQA-IVF - $ 4,800* • HQA-IVF is a full IVF cyclewith standard medications (not lower dose meds) • HQA-IVF provides comprehensive and frequent ultrasound monitoring and blood work (not minimal ultrasounds and blood work that may lead to cancelled cycles or Ovarian Hyper-stimulation -OHSS) • HQA-IVF is Egg retrieval of maximal numbers of eggs, not limited numbers of eggs (the more eggs, the more embryos, the more embryos the more likely chance of finding a normal embryo) • HQA-IVFis full 5 to 6 day Blastocyst culture (rather than shortened day 2 or day 3 culture – this allows the embryos to express their full potential to create an OHB – One Healthy Baby™) • HQA-IVFincludes ICSI, this is a painstaking process to individually select the right sperm to inject into each egg, thereby increasing the creation of more embryos, therefore, more selection, and hence better outcomes, an OHB! • HQA-IVFincludes Assisted Hatching if necessary, this process has been shown to increase the odds of pregnancy, especially in women that are older than 35 years of age • HQA-IVFincludes Fresh or Frozen Embryo Transfer, to be sure, in 2015 it is likely that most IVF programs in the know will start doing only Frozen Embryo Transfers (FETs), because more and more data suggest better outcomes, remember OHB™! • HQA-IVFincludes freezing and short term storage of Frozen Embryos, this allows two very important advantages… 1) if you do not get pregnant with the Fresh cycle then you have a second chance and 2) if you want more children you now already have the embryos stored! • HQA-IVF includes FETs if you do not get pregnant! The typical cost for an FET ranges between $3000 to $ 5000; however, in our program there are no ART costs, none. The only caveat is that you will need to be monitored, that cost in our program is $ 500 for ultrasounds and blood work (yes you can get those monitored at your own Ob/Gyn office if you prefer) All fees are subject to change and based on your individual needs, there may be additional fees (e.g., positive hepatitis requires isolation in separate cryogenic tanks… so fees will apply in these situations that are not “standard”) * On site in Colorado Springs

6. HQA-IVF/CCS $ 8,000* • HQA-IVF/CCS includes everything in HQA-IVF in addition it includes: • Comprehensive Chromosomal Screening for up to 8 embryos (if you have more than that, great, it is a small additional fee so no worries) • Checks all 23 Chromosomes • Checks X and Y Chromosomes • You will know if the embryo is a boy or a girl All fees are subject to change and based on your individual needs, there may be additional fees (e.g., positive hepatitis requires isolation in separate cryogenic tanks… so fees will apply in these situations that are not “standard”) * On site in Colorado Springs

7. Summary of the Type of HQA Fertility Care Treatments – FROZEN EMBRYO Transfer • All fees are subject to change and based on your individual needs, there may be additional fees (e.g., positive hepatitis requires isolation in separate cryogenic tanks… so fees will apply in these situations that are not “standard”) * If Fresh Embryo Transfer requires 7 to 9 days in Colorado Springs

8. What if you live outside of Colorado or New Mexico?We can still help! • Contact us – 877-475-BABY(2229) or info@RMFCfertility.com • Get Free Phone Consultation • Ask for HQA-IVF consult • Arrange LOCAL monitoring.. See next page for details • If you can not get LOCAL monitoring, we will help you here in Colorado Springs… no worries… just ask for our “Colorado Springs Travel Guide” • Plan to have two trips to Colorado Springs • One Trip to remove eggs and be sure you either have sperm here or your male partner comes with you • Second Trip to put back the Frozen Embryos • There is no additional RMFC fees for this service • If you prefer, you may stay in Colorado Springs for both the egg retrieval and then the fresh embryo transfer… figure about 8 days

9. Contact Us 877-475-2229 Send & Confirm Your Paperwork info@RMFCfertility.com Or 719-475-2227 FAX Free 30 Min HQA-IVF consult With Dr. Magarelli 877-475-2229 Travel LOCAL MONITORING: If needed get Tested For: Eggs, Sperm and Your Uterine cavity, see next page for helpful hints Plan to Have your IVF Cycle in Colorado Springs 265 Parkside Drive,#200 Colorado Springs, CO 80910 719-475-BABY(2229)

10. LOCAL MONTIORINGHelpful Hints to Save Money and Insure Success! • Locate an Ob/Gyn that will do the following: • Work with you to create an OHB (One Healthy Baby™) • Willing to send Ultrasound and Lab reports to RMFC on same day that it is done • Willing to assign one or a group of nurses to work with the RMFC team • Willing to provide Vaginal Ultrasounds with the following information and on SPECIFIC days: • Presence of absence of cysts • Presence or absence of fibroids • Presence or absence of Polyps • Size of Ovaries, left and right • Number of follicles over 10mm in each ovary • Measurements of the 4 largest follicles in each ovary, length and width • Measurements of thickness of uterine lining (endometrium) • Quality of endometrium (thin, menstrual, Trilaminar, uniform) see figure • Willing to get blood draws for the following information • Estradiol levels, results are SAME day • Progesterone levels, results are SAME day • HCG levels, results are SAME day • Willing to provide a cell phone or afterhours person to contact if labs and ultrasound information are NOT received • Willing to code V26.29 Procreative Management, other investigation and testing or • Willing to charge a “reasonable fee” for 5 ultrasounds and 5 Estradiol and 3 Progesterone and 2 HCG levels • Usually between 800 to 1500 dollars

11. What we are measuring with an Ultrasound Follicle Sizes Length & Width Perfect T Uni form Endometrial Lining Size & Characteristics: We want Trilaminar …think Mick Jagger's Lips!

12. Example of Note sent to your provider 5 Star Service is the Cornerstone of our HQA program To Our IMPACT Team – our goal OHB* Embryo Transfer: • ___________________ and _________________ had their embryos transferred today: • __________ Day ___ ___ FRESH __FROZEN • __________ Day ___ ___ FRESH __FROZEN • __________ Day ___ ___ FRESH __FROZEN • __________ Day ___ ___ FRESH __FROZEN • Our Patient ____________________ will need to have her blood drawn 12 to 14 days from today. We will need to have drawn: □Serum Progesterone and □ Serum Quantifiable HCG □Serum Estradiol • Please call/fax/or email the results to us • FAX – 719-475-2227 • Email – info@RMFCfertility.com • Call 877-475-2229 • Our patient may experience some spotting, please assure her that it is normal, please remind them to stay on their Aspirin, estrogen, progesterone until they are told to stop, no exceptions! ! Also Prenatal vitamins and extra folic acid. • Our patient may experience some cramping, this is not good, tell her to add fluids, and bed rest (They are ALWAYS on Pelvic Rest, no Intercourse) • Please call us with any questions or concerns… • 877-475-2229 days, 719-440-3884 evenings, UrgentDr. Magarelli 719-331-6392 *OHB = One Healthy Baby!

13. Example of Note sent to your provider 5 Star Service is the Cornerstone of our HQA program To Our IMPACT Team – our goal OHB* Egg Retrieval: • ___________________ and _________________ had their eggs retrieved today: • # of Eggs Retrieved: __________ • Our Patient ____________________ will be called tomorrow and be told how many eggs were fertilized. • Our Patients will then be called tow days after that (Day 3 of culture) and 2 days after that (Day 5 of culture) to tell her about the status of her embryos. Most of our patient will get a Frozen Embryo Transfer next month, however some may have a Fresh Embryo Transfer. If your patient is having a Fresh Embryo Transfer then the box below will be checked: • □Fresh Embryo Transfer • We will send you an update AFTER the embryo transfer • Our patient may experience some spotting, please assure her that it is normal, please remind them to stay on their Aspirin, estrogen, progesterone until they are told to stop, no exceptions! Also Prenatal vitamins and extra folic acid. • Our patient may experience some cramping, this is normal, tell her to add fluids, and bed rest (They are ALWAYS on Pelvic Rest, no Intercourse). She should be taking an opiate, pain medication every 4 to 6 hours, 1 or 2, especially before bed. • Please call us with any questions or concerns… • 877-475-2229 days, 719-440-3884 evenings, if Urgent then call Dr. Magarelli 719-331-6392 *OHB = One Healthy Baby!

14. Please compare us with “them”

15. Notes HQA-Working like a well oiled machine™

16. Contacts:Paul C Magarelli, MD, Ph.D.877-475-2229 or 719-331-6392 after hoursDeb Wicklund, Patient Advocate, Financials 877-475-2229 or 719-475-2229 (office hours)Ceese (Nurse Practitioner) 719-440-3884 after hoursCynthia (Las Cruces) Nurse Practitioner 575-496-3599 after hours)Tammie Parker (Albuquerque) IVF Coordinator 505-291-0191 after hours)

17. Notes HQA-Working like a well oiled machine™

18. HQA-Working like a well oiled machine™ High Quality AffordableFertility Care Paul C. Magarelli, MD, Ph.D. Reproductive Medicine & Fertility Centers University of New Mexico IVF Center Mountain View Wellness & Reproductive Medicine 877-475-BABY(2229) info@RMFCfertility.com www.RMFCfertility.com www.RMFCfertility.com www.IVFNewMexico.com Contact us… you will be pleasantly surprised, we Promise! 719-475-2229

19. Section 1 Overview of HQA and what we needSection 2IVF Manual Used by permission of RMFC and Dr. Magarelli

20. Your IVF Manual

21. What’s Inside • Step One – Realize you are on a journey, not a race • Step Two – You are an important member of your IVF Team • Step Three – IVF is a stressful process – learn some tricks to cope – Think Acupuncture! • Step Three B – How Traditional Chinese Medicine helps create an OHB – One Healthy Baby ™ • Step Four – Positively, Absolutely, Must DO’s! • Step Four B – What we Must Have: Sperm/Eggs & Place to put them! • Step Five – IVF Consents • Step Six – IVF Financials • Step Seven – IVF Calendar • Step Seven B – What happens during the IVF cycle • Step Eight – IVF Medications • Step Nine – Procedures, all of them • Step Ten – Egg Retrieval/ Oocyte Pick up • Step Ten B – What is Batching and Why do it? • Step Eleven – Waiting and Schedule of Calls • Step Twelve – Day of Embryo Transfer • Step Thirteen – Worries, OHSS, and more • Resources

22. Step One – Realize you are on a journey, not a race • It has taken you both time and heartfelt concern about your fertility to get you to the point of accepting that IVF is your Treatment of Choice • Wonderful, now breathe • You will be going though many different feelings and “invasions of privacy” as we test and determine the best course of treatment • Try to understand that our goal, like yours, is an OHB • One Healthy Baby … so yes, it is worth it • There WILL BE CHANGES as you go along • We Personalize your care… no cookie cutter, so your biology will dictate the treatments • Be Flexible • We do NOT expect you to be an expert! Ever! • So call us, ask questions, do not leave until you understand the steps, BUT, do the steps, do NOT try to “game” how we do things • This will INTERFERE with you work, your play, your family, your friends, your free time, your plans • John Lennon quips, “Life is what happens between plans…” embrace the chaos!

23. Step Two – You are an important member of your IVF Team • You are the KEY member of the IVF Team • You must READ everything we give you • You must understand and ask questions if you do not • You must Follow the Plan…even as it varies • You must set alarms for when you have to take your meds, or when you need to come to the clinic • We recommend at least two or three alarms per event • Timing is Everything • You must understand the consents, BEFORE you sign them • You must track your medications • Do you have enough? • Do you need more? • How many more days do you need your meds? • Is it the weekend…do you have refills? • Call with your period, first day! • Why? • The call helps us coordinate your testing, your care plan, your treatments, lets us check to ensure that you are in-sync! • Your PARTNER has tasks and duties too! • If male, need sperm and bloodwork • If female, need bloodwork • Whether your partner is male or female he/she MUST SIGN CONSENTS

24. Step Three – IVF is a stressful process – learn some tricks to cope • They have called the IVF process an “emotional rollercoaster” • It definitely is for two reasons • You are “out of control” or at least that is what it feels like • You are in an hormonal soup! • Estrogen keeps women able to cope with stress by crying • Crying cleans the tear ducts… we have plenty of Kleenex • Walks, simply walking outside for 20 min each day can and will relieve stress • Yes you can make the time • Acupuncture or TCM • We have done many years of study that demonstrate the TCM in the form of acupuncture can increase your odds of an OHB (One Healthy Baby) but it has been demonstrated repeatedly that it can reduce stress • Talk and talk and talk to your friends, family, partner and us… it is OK… we know it is different and strange, just remember we have been doing this for years and we probably heard you concerns a hundred times… we can help… ask.

25. Step Three B – How Traditional Chinese Medicine helps create an OHB – One Healthy Baby ™ Acupuncture improves THB (Take Home Babies) when you combine it with your IVF cycle. • East Winds Acupuncture offers RMFC patients a CARE package with deeply discounted fees supporting High Quality Affordable IVF Care at RMFC. • How does acupuncture work to improve IVF outcomes? • Our published Research has shown: by adding CMAP (Cridennda Magarelli Acupuncture Protocol) • – More Take Home Babies! • – Fewer Miscarriages • – Fewer Ectopic pregnancies(pregnancies outside of the uterus) • – Fewer Multiples • One in every 4 couples will not have to repeat and IVF cycle if they have CMAP acupuncture. • See our original published research at www.EastWindsAcupuncture.com How do I Start? • We would like you to start acupuncture 4-5 weeks before your retrieval, 8 CMAP protocol treatments plus 1 Pre Embryo Transfer Treatment and 1 Post Embryo Transfer Treatment, total 10 treatments. • CARE package is priced at $600 and gives you a significant savings of $215, this is our way of supporting High Quality Affordable Fertility Care • Acupuncture is also the number one fix if you have a tendency to “Hyper stimulate” during your cycle. Please call for more information 719-520-5056 We are on call 24-7 for you. “The decision to have a child is to accept that your heart will forever walk about outside your body.” Katherine Hadley

26. Step Four – Positively, Absolutely, Must DO’s! • CALL with your period EACH and EVERY month until you are pregnant! Really • This keeps us all in the know! • Mark your calendar four weeks after your first day of bleeding with your menses, then the next four, etc. • Critical for Testing • Critical for Treatments • Critical for keeping you progressing to your OHB • Critical for us to monitor the risks for Ectopic pregnancies • Critical for our PCOS patients, CALL WHEN you THINK you should have your period… every 28 SDAYS… mark your calendar • CONSENTS • Must be complete and YOU must confirm receipt by a member of my team • SPERM • We must have fresh or frozen ON SITE… it doesn’t help if the sperm are in another state and your eggs are in Colorado Springs! • PAYMENTS • Your payments allow us to get the supplies we need, the equipment kept at optimal functioning, the staff happy and our lights on… please put on your calendar when your payments are due… we will try to remind you, but honestly, it is your responsibility to keep track of all required dates for treatments and payments. • Tell us if your missed your medication or made an medication error. Let us know if you will be out of town or can’t make an appt. Make sure we know if you are running out of your medications, having issues with your medications, issues with your injections or timing, having cash flow problems or just simply confused. We have a 24 hour phone line, and Dr. Mag’s cell phone is 719-331-6392…call it if something urgent comes up… he is happy to help • MUST take the meds how we prescribe it… do not vary in our protocols and even if you do or did, TELL US

27. Step Four b – What we Must Have: Sperm/Eggs & Place to put them! • Sperm • Fresh collection after 3 to 5 days of abstinence • Frozen sperm, ON SITE, 2 weeks before retrieval • Yes, they work just as well as fresh ejaculated sperm, so no worries • Eggs • Fresh retrieval • Frozen (own) eggs • Yes, they work really well now that we do Vitrification, a new form of freezing eggs. • Frozen (Donor) eggs • Fresh Donor Eggs • Embryos • Fresh • Frozen (own) embryos • Frozen (Donated) embryos • Frozen Donor Egg Embryos • Uterus • Patient • Gestational Carrier – Known • Gestations Carrier – Designated via agency

28. Step Five – IVF Consents • CONSENTS • For treatments • For medications • For procedures • For IVF • For Trial Transfers • For Embryo Transfers • For Selective Reduction of Embryos • For Surgery • For number of embryos to transfer • For use of Donor eggs if applicable • For use of Gestational Carrier if applicable • For saving Frozen Eggs, if applicable • For Efficiency Cycles, to use only 6 eggs from a Donor if applicable • For getting your OLD RECORDS • For allowing us to share your information with other doctors or your partner

29. Step Six – IVF Financials • Financials are simple and straight forward • Premier IVF at RMFC is $ 4,800 • Includes everything except medications • Medications run between $ 1500 to $ 5500 based on test results • Yes we give you applications to help you pay for your meds, that YOU submit • No promises, it is based on YOUR income • HQA-IVF with monitoring in your city • Fees in addition to the IVF charges above for Ultrasounds and Bloodwork at YOUR city vary between $ 800 to $ 2200 • We have NO control of what your doctor charges but will help if we can to find alternatives • In Las Cruces, Mountain View will do the monitoring for $ 800 • In ABQ, UNMwill do the monitoring for $ 2200 • These are only examples • If you want to add Comprehensive Chromosomal Screening (CCS) to an RMFC IVF Cycle, then the fee is $ 1000 biopsy + $2200 CCS or $3,200 for 8 embryos, more if there are more embryos • So you can add CCS to one cycle, so $ 4,800 + $ 3,200 = $ 8,000 • If two Fresh cycle and one CCS = $ 7,800 + 1,000 + 3,200 = 12,000 • If three Fresh cycles and one CCS = $ 10,800 + 2,000 + 3,200 = $15,000 • Remember medications are in addition to these costs • Also, if you do not get pregnant with Fresh transfer, a Frozen transfer is $500 for ultrasounds and bloodwork if done at RMFC • There are two parts to the CCS payments, $ 1,000 for biopsy of the embryos and $ 2,200 (you pay this directly to the Lab) for Genetic detection of chromosomes. • All payments must be made and confirmed 4 weeks prior to your IVF cycle… no exceptions, sorry. • Deb is your contact 877-475-2229 – 719-475-2229 • dwicklund@rmfcfertility.com All fees are subject to change and based on your individual needs, there may be additional fees (e.g., positive hepatitis requires isolation in separate cryogenic tanks… so fees will apply in these situations that are not “standard”)

30. Step Seven – IVF Calendar • Your IVF Calendar of Treatments • What it is: • A GUIDE to your care based on the “average’ response of an IVF patient to her medication • It is NOT an ABSOLUTE guide… it can and may vary based on your responses • What it is NOT: • An ABSOLUTE guide to dates and times of your visit… you can and may vary based on your biology… I already said that  • How to use it • Tell your employer that you need time off • Day of egg retrieval PLUS the next day – usually, but remember each person is unique so you may need additional days • The following month after your Fresh Retrieval, our Freeze All policy requires a different month to replace your embryos. So when you do replace your embryos you will need the Day of Embryo transfer PLUS the next 4 days • Do not go OUT OF TOWN • For 10-15 days during your stimulation with fertility medications, you will need to be able to get an ultrasound, bloodwork, trial transfer, physical exam, emergency medications if you did NOT keep track, additional medications as Dr. Mag orders, follow up etc… • So Plan to be IN TOWN during your days of care… please!

31. Step Seven B – What happens during the IVF cycle • You will take twice per day injections for about 12 days • You will take baby aspirin and pre natal vitamins • You will have four to six clinic appointments for ultrasounds, bloodwork, trial transfer visits • You will have to fast after midnight on the evening before your egg retrieval • You will need to have someone drive you to the clinic on the day of egg retrieval and embryo transfer – you must stay in town for minimum of 24 hours after each procedure… no exceptions. • You MAY have a Frozen Embryo Transfer, based on your response to medications and BEST practices for your OHB (One Healthy Baby)

32. Step Eight – IVF Medications • What they Are • Lupron– keeps you from losing the wonderful eggs your growing in your follicles • This medication (some will be on Ganirelix, see below) is THE most critical medication • You miss your dose… YOU LOSE your eggs, simple. • Do NOT miss any doses, call us if you are unsure at all • Ganirelix– keeps you form losing the eggs you are growing in your follicles, like Lupron, see above • Do not worry about which medication, Lupron or Ganirelix, that you are on • For some of you : YOU MAY BE ON BOTH!! • Follistim (F) , Gonal F (GF), Bravelle (B) – this are your follicle stimulation medications, they help you grow the follicles that will give us our eggs • Your doses and timing are IMPORTANT • Write down what you take each and every day • See next page for Log sheet • Calculate your doses and calculate how many days worth of medications you have and TELL us at each visit what you have left • Especially if the weekend or holidays are coming up • We do have an emergency supply but DO NOT count on it • Menopur • Dr. Magarelli sometimes uses a “missed protocol” that means he has you take Menopure for your evening dose instead of the F, GF or B above • This are usually and almost ALWAYS Intramuscular with a 1.5 inch needle • Be sure you know which needles go with which medications • Ask • We also can direct you to websites for instructions • www.FertilityJourney.com ???? • Miscellaneous medications • Doxycycline (if NOT allergic) for both partners starting usually after Stim Start • Medrol and anti-inflammatory medication usually started • Pre natal vitamins, extra folic acid, baby aspirin • Men, Mega Man Vitamins • Anti-nausea medications on day of egg retrieval • Pain medications on day of retrieval and thereafter as needed, no worries if you need more… rare, but do not hesitate to ask

33. Bring To Clinic Your Diary

34. Step Nine – Procedures Vaginal Ultrasound IVF Egg Retrieval Vaginal Ultrasound IVF Embryo Transfer

35. Step Nine – Procedures continued

36. Step Ten – Egg Retrieval/ Oocyte Pick up (OPU) • The Egg Retrieval is usually scheduled after 11 days of fertility medications • On Day 11 of fertility medications or there abouts, you will be told EXACTLY what time to take your “trigger shot” or HCG • This shot is usually in the very late evening, and/or early morning hours 1am or so • Set THREE alarms… timing is CRITICAL • The dose is usually 5000 to 10,000IU and is given intramuscularly • You WILL be told… ASK if uncertain, then ASK again • 34 to 36 hours later, usually 35 hours later, we will take the eggs out via a vaginal procedure… see Step Nine • You will be asleep with a CRNA at your side giving anesthesia medications… do NOT eat after midnight on the day before your egg retrieval • That day and the next day you REST • We will tell you the Number of Eggs retrieved • We will then fertilize the eggs using a procedure called ICSI • See Step Nine – Procedures continued • Must have someone drive you, NOT A TAXI!

37. Step Ten B – What is Batching and Why do it? • What is Batching • When a couple is in a situation where they are likely to have less than 6 blastocysts from their IVF procedure and would like to know the chromosomal status of the embryos BEFORE they are transferred than we can BATCH the Fresh IVF cycles, make lots of embryos, biopsy them as a group and send them in for evaluation as ONE GROUP • This potentially can save the couples thousands of dollars in CCS testing • Why? The CCS Labs charge the same fee for 1 embryo or in some cases up to 8 embryos, so why not? • Why would you NOT do Batching? • Usually it is due to the cost of IVF, however at RMFC our High Quality Affordable IVF is priced to allow our patients a choice • Most IVF programs charge from 30,000 to 42,000 per IVF with CCS cycle • At RMFC each cycle is $ 4800 for one • If you want to do 2 batches, then $ 7800 for two • If three, then $ 10,800 • In addition is the fee for CCS $ 3,200 • We do not test each batch (we test the embryos after ALL the batches are done) , or else the fee would be $ 3,200 for each test and our patients would lose the enormous savings on repeated testing

38. Step Eleven – Waiting and Schedule of Calls** • Waiting and Scheduling of Calls • We KNOW you are nervous about your eggs, embryos and future babies… we KNOW • We will call you at the end of each day, usually between 4 and 6pm • If no call… call us 19-440-3884 or if the nurse does not get back to you within 2 hours, then call Dr. Mag 719-331-6392 • My staff MUST get approval for prescriptions, etc. and we will have them usually within 24 hours of your call, not before… so please plan ahead! (not the same day… sorry) • If Dr. Mag calls, usually it means that there is a medical decision to be made… do NOT panic… he is doing his job! • Your Ultrasounds and Clinic Appointments • Ultrasounds at RMFC are usually done between the hours of 7am and 10 am • Be sure to be there 5 min before, it will get busy • Be sure you know when your NEXT appointment is • Do NOT leave the clinic until you know…this is Critical for your stimulation and other procedures • If unsure ASK, then ASK again • Labs and Embryo Reports can take us late into the afternoon and early evening to report • Do NOT worry, see above (usually you will hear by 6pm Mountain Time) • If you are being monitored in a clinic other than RMFC, we are at the mercy of that team… so PLEASE reinforce to your care provider how important it is to SEND the results to RMFC 719-475-2227 is fax, info@RMFCfertility.com and DrMag@RMFCfertility.com • Do NOT worry, Dr. Mag has been doing this for many years and can help mitigate late results, one day does matter, however, we are able to offset lack of data with clinical experience • However, please, again, tell you providers to send the info… it is that important! ** really important that you give us TWO cells phone Numbers and your Personal Email… communication is everything!

39. Step Twelve – Day of Embryo Transfer • Embryo Transfer Day – Wow – what a trip! • This will usually occur, one month after you’re your Egg Retrieval (we do Freeze all cycles) see section on Why Freeze All Cycles • Call on Cycle Day 1 • Our goal is to safely transfer your future baby or babies • Our goal is OHB, One Healthy Baby, really, one is what you want • We know Twins are cute, but they do have issues with survival and safety and future growth, so please have as your goal an OHB • Likely you will receive one (1) embryo and possibly two (2) during the transfer… yes we check your name multiple times to ensure it is YOU and YOUR embryo! • We use an abdominal ultrasound to monitor the progress of the embryo transfer • HAVE a FULL and slightly UNCOMFORTABLE bladder! • It really helps • Even if requested by accident by a new MA, please do NOT pee when you get to RMFC… FULL BLADDER is what we need unless you are told otherwise • Your Partner and Mom or best friend CAN be in the room for the embryo transfer… we love it! • You CAN NOT drive after the transfer… we will be giving you valium… so no impaired driving… • Bring Water for both pre/post transfer to drink • Be sure to schedule your Pre/Post Acupuncture treatments… we really recommend it!

40. Lab & Other Stuff • Our Laboratory team is dedicated to managing your sperm, your serum for hormones, your eggs, your embryos • The INSIST on accuracy, precision and RIGHT person, RIGHT test, RIGHT time • So, be sure you and YOUR PARTNER have a valid ID • Drivers license • PLUS insurance cards • You MUST have a photo taken of you and your partner which is placed in our Electronic Medical Record • Why? You want your sperm, your eggs, your embryos • We are certified by CAP, CDC, FDA, AAS organizations to ensure safe and accurate laboratory measurements and techniques

41. Step Thirteen – Worries, OHSS, and more • Worries • What if I do not respond to the medications? • We will adjust the dose, but if you truly are NOT responding you will have a discussion with Dr. Mag • What if we miss taking our Lupron? • NOT a good idea, so CALL immediately, we may be able to rescue your cycle • What if things are going TOO WELL, i.e., Ovarian Hyper stimulation (OHSS) is starting? • We will ask you to start consuming VAST amounts of protein, over 150 grams additional per day • We will ask you to contact an Acupuncturist , ABORM certified, to help manage your OHSS…real important • We will INSIST that you measure your weight each and every day • We will INSIST that you contact us if you notice more than 1 pound of weight gain • We will INSIST that you TRACK all your protein consumption • We will INSIST you take frequent breaks from standing and recline • We will INSIST that you consume lots of fluids, especially some with electrolytes like bouillon, Gatorade, Recharge, etc. • What if our embryos do NOT grow? • This rarely happens, usually it is because the embryo, in nature’s wisdom, is not growing normally… Dr. Mag will discuss this with you, but likely no embryo transfer • What if we run out of medications? • This really should NOT happen, see Step Two, but if you do, be SURE to tell us… we usually have a stash of meds… • On Stim Day eight (8) of your stim cycle, count WITH THE NURSES the amounts of medications you have left… Please call for refills two days before you run out… this seems like an obvious statement, believe us, it is not! • What if we do not get a call back? • If you have waited until 6pm or so and no call back… CALL Us 719-440-3884 or if urgent Dr. Mag 719-331-6392 • Worse case, take the same amount of Lupron or Ganirelix and your stimulation medications like Gonal F, Follistim, or Bravelle or Menopure

42. Why Freeze All Cycles O H B That’s the reason…read on…

43. Freeze All IVF cycles Meeting the needs of our patients by providing the finest technology known to help produce and OHB! One Healthy Baby!

44. Why Freeze All? • Meta Analysis of three major IVF studies • 633 IVF Cycles • Results • Odds of Ongoing pregnancy (after heart beat detected) were 30% higher in Frozentransfer versus Fresh • Statistically Significant change • Odds of miscarriage were 17% lower in FrozenEmbryo Transfers versus Fresh • Not Statistically Significant change The study recorded an ongoing pregnancy rate of 38% in fresh transfer cycles, and 50% in the Frozen Embryo Transfer (FET) cycles.

45. How does it work? • "The pooled data demonstrates that embryo cryopreservation and subsequent FET (Frozen Embryo Transfer) may improve the outcome of assisted reproduction treatment," said Professor Checa. • Professor Checa also explained why FET in a later non-stimulated cycle might improve IVF results. He noted that the multiple eggs generated by ovarian stimulation will increase release of the hormone estradiol from the ovary, which affects the receptivity of endometrial tissue. In addition, some recent studies have shown that ovarian stimulation causes changes to the endometrial DNA pattern, which are not evident in the normal receptive endometrium. • Other benefits of Freezing embryos • Reduce higher order multiple births • Reduces OHSS, ovarian hyper stimulation syndrome • Need to transfer fewer embryos • Reduce small for gestational age babies • Reduce preeclampsia

46. 6 things to Know About Frozen Embryo Transfers (FET) at RMFC • Enhance the Ongoing Pregnancy Outcomes • FET are easier to undergo than Fresh IVF cycles • Less time commitment • Fewer Injections and medications • More predictable… you will KNOW the day that you will get your transfer • At RMFC your FET is at no charge to you if you have done a Fresh IVF cycle that created these frozen embryos • If you do NOT get pregnant on the FET, and you have more frozen embryos, your next FET will be $ 500 (cost of Ultrasounds and Bloodwork) • Current literature suggests that you are more likely to have an ongoing pregnancy with FET (statistically significantly more likely) plus a numerical reduced chance of a miscarriage • Frozen embryos do not have an expiration date… you can wait months to years to put them in • Frozen embryos potential for success remains frozen over time (excuse the pun) so that if your get pregnant on the first FET and wait two to three or more years for another baby, then the embryos remain at the age at which you froze them… neat huh?

48. Your Notes

49. My Chances of PregnancyMy Chances of an OHB(One Healthy Baby)

50. Female Age is probably the most important determinant since women do not make eggs during their lifetime so the eggs you have you were born with • You lose approximately 1000 eggs each month after puberty, many more before puberty • Fertility is 20% in women age 20 years old • This refers to the likelihood of pregnancy after intercourse with normal eggs and sperm • If there are sperm issues, then usually drops to below 5% success per month • Sperm count, motility, and shape • Any one or two or three factors will significantly reduce the success of intercourse, regardless of a person’s prior success at creating offspring How do we determine your chances of getting pregnant with a given procedure?