Medicare has announced plans to stop payment for this service beyond a simple office visit despite the significant extra time and effort required.  I understand the need to cut costs and reform but eliminating the minimal extra payment for the lengthly extra service delivered is not the right way to go. 

While the document is 1,669 Pages in length, Pages 162 - 206 contains commentary and CMS’ responses about the elimination of all consultation codes except for three telehealth consultation G codes beginning on January 1, 2010. Medicare fee-for-service will no longer accept or reimburse for any consultation codes for services rendered on or after January 1, 2010. Billing for consults will need to be billed using the most appropriate E&M code for office or inpatient, new or established visit code.

Please read the attached CMS Press Release. The full Federal Register text is contained in this document.

A Really Bad Day…

The study looked at 48,682 IVF cycles. Women were categorized by BMI (adjusts for height and weight (here’s how to calculate yours)  There were 3 categories of BMI–Women were categorized by their body mass index (BMI) as normal (18.5-24.9), overweight (25.0-29.9), or obese (Class I, 30.0-34.9; Class II, 35.0-39.9, Class III, ≥40.0).

The odds of pregnancy were significantly reduced for obese women  9% , 28%, and 35%  for Class I, II, and III), and the odds of a live birth were reduced for overweight and obese women. 

Worse yet –the odds of stillbirth were increased more than twofold for obese women as was the odds of preterm birth.

Here’s the data they presented: 

The odds of pregnancy were significantly reduced for obese women (0.91, 0.72, and 0.65, respectively for Class I, II, and III), and the odds of a live birth were reduced for overweight and obese women (0.87, 0.80, 0.74, and 0.75, respectively). The odds of stillbirth were increased more than twofold for obese women, significantly for Class I and II. Among live births, the odds of early preterm birth significantly paralleled increasing obesity (1.26, 1.52, and 1.59, respectively for Class I, II, and III), and the odds of preterm birth were significantly increased for all women (1.16, 1.33, 1.38, and 1.34, respectively).

What You can Do About It:  Obviously the strongest recommendation is for weight loss.  In my practice at Gold Coast IVFwe individualize the approach for overweight women to maximize their chances of delivering a healthy baby.  Due to this we do not see this degree of adverse pregnancy rates.  Our interventions include

1. aggressive screeing PRETREATMENT for all risk factors and optimization PRIOR to treatment.  This includes heart disease hypertension and diabetes and prediabetic insulin resistance
2. Individualized diet and exercise programs
3. Nutritional counseling and assistance
4. Medication regimens tailored for weight
5. Special techniques for insemination or embryo transfers in the obese women
6. Special hi resolution ultrasound equipment for the obese
7. Coordination with medical weight loss programs for those at weight extremes
8. Coordination of care with patient’s Ob.

 See here for other breaking research on IVF and embryo genetic screening from ASRM. 

I use a smartphone on verizon wireless to continuoulsy synch my office schedule wirelessly with my GE office management centricity ((former millbrook).  The iphone just did not sync with my practice management program continuously via wireless so I went with verizon for a windows mobile 6 Samsung Omnia.  My previous Motorola Q also worked.  The omni virtual touch keyboard is so small its practically unusable without a stylus. The droid looked like the best way to go with built in synch, video features, google map nav and hi speed processor.

Check out the post to see all the specs on what’s coming next.  As he reports:

One of our really solid connects just had some information for us and we think you’re going to love it. With the Motorola DROID being Verizon’s hot handset at the moment, you’d figure that the Moto would be it for a while, right? Well, if our guy is right, we could soon be bombarded with a lot more handsets. Apparently if the DROID launch/sales go really well, (is probably will) Verizon will push up handset releases and practically aim for the smartphone crown. Were talking HTC Passion, Motorola Calgary, Curve2, etc.

Apparently the Curve2 or HTC Passion / Dragon will launch on Black Friday, “whatever is ready first.” The second device would be used in a holiday push around mid-December. I asked why Verizon wouldn’t space this out more and he/she said “best network, best smartphones campaign.” Fair enough.

There’s also some handsets coming soon that we “don’t know about,” apparently. Could all four Android devices really launch on Verizon before the end of the year, or really close to it? Plus a couple BlackBerrys, and some other stuff that hasn’t surfaced yet? It seems a little crazy, but hey, more power to them.

UPDATE: We’ve also been told that Verizon will release 15 new phones, mostly smartphones, starting with the BlackBerry Storm2 and continuing into the end of December.

My big di,emma is what phone number to choose.  So far you can’t yet port your old cell # to GV.  That leaves two options  1) pick an cool easy to remember word spelled out in the number– advantage –slick but it will be in an area code far from where you have ever lived or 2) a local number that’s yet another random set of digits.

I went for the easy to remember non-local number.  Unfortunately I now have an endless series of “when did you move to Chicago?” questions.  Not the mention friends with landlines too upset at the toll charges.

Seems like a $10 fee to google will let me change to the meaningless local number.  Wish a local number could spell something easy to remember in NY.

Details just released on the specs performance dates and costs of Red’s new video still camera device poised to blow away both still and film worlds.  Of course I have been waiting for this for the operating room to couple to my scopes….

Red is the company who I collaborated with for my recent ultra HD operating room visualization project.   They are the leaders in Hollywood in ultra HD “4k” digital cinemal cameras.  As a result of our collaboration and their support of my work in the operating room of the future I have been following their development schdule for the next generation of Hollywood camera innovation.

What’s so significant— it will be an ultraHD resolution motion camera ( more than just “video” more like digital cinema) at 5K (5X HD) with massive frame rates for super smooth slo-mo and a digital still camera all in one with a completely modular design at a fraction of the price of any video even close to its specs.

Official Specs:

RED DSMC (Digital Stills and Motion Camera)- New MYSTERIUM-X 5K sensor
5K (2:1) at 1-100fps/4K (2:1) at 1-125fps/Quad HD at 1-120fps/3K (2:1) at 1-160fps/2K (2:1) at 1-250fps/ 1080P (scaled from full frame) at 1-60fps
Increased Dynamic Range, reduced noise
Time Lapse, Frame Ramping—ISO 200-8000

More specs

Completely Modular System, each Module individually upgradeable
Independent Stills and Motion Modes (both record full resolution REDCODE RAW)
5 Axis Adjustable Sensor Plate
Multiple Recording Media Options (Compact Flash, 1.8” SSD, RED Drives, RED RAM)
Wireless REDMOTE control
Touchscreen LCD control option
Bomb-EVF, RED-EVF and RED-LCD compatible
Multiple User Control Buttons
Interchangeable Lens mounts including focus and iris control of electronic RED, Canon and Nikon lenses (along with Zoom data)
“Touch Focus Tracking” with electronic lens mounts and RED Touchscreen LCDs
LDS and /i Data enabled PL Mount
Rollover Battery Power
Independent LUTs on Monitor Outputs
Independent Frame Guides and Menu overlays on Monitor Outputs
Monitor Ports support both LCD and EVF
True Shutter Sync In/Out and Strobe Sync Out
720P, 1080P and 2K monitoring support
Gigagbit Network interface and 802.11 Wireless interface
3 Axis internal motion sensor, built in GPS receiver
Enhanced Metadata
Full size connectors on Pro I/O Module. AES Digital Audio input, single and dual link HD-SDI
Support for RED, most Arri 19mm, Studio 15mm, 15mm Lite, Panavision and NATO accessories

Dimensions- Approx. 4”x4”x5.5”
Weight (Brain only)- Approx. 6 lbs (2.72kg)

Handheld Specs Increased to Compete With Nikon and Canon

Scarlet 2/3″ Program. Given the recent new VDSLR releases, we have decided to up the capability of the Scarlet 2/3″ Fixed 8x and interchangeable models. Several new features are being added that will NOT impact the release schedule (anymore than it would have been otherwise) but it will mildly impact the pricing. We should have all the details ready by the end of this month.

Some of the new Scarlet 2/3″ capabilities include:
1. Increased REDCODE data rates
2. New FLUT Color, Gamma and Sensitivity Science. Now same as EPIC.
3. More extensive modular system integration.
4. Interchangeable Lens mounts including focus and iris control of electronic RED, Canon and Nikon lenses, along with Zoom data (Scarlet 2/3″ Interchangeable)
5. “Touch Focus Tracking” with electronic lens mounts and RED touchscreen LCD’s (Scarlet 2/3″ Interchangeable and 8x Fixed)
5. Two independent microphone level channels, balanced input circuits, 48V Phantom Power, digitized at 24-bit 48KHz.
6. GigaBit Ethernet port
7. Scaled 1080P at 60fps

Sensors Going to 28X HD!  (28,000 X 9885 res in video!!!)

Here’s the abstract they presented (requires registration)-it was a finalist for a prize paper. 

Why Genetically Test an Embryo?  In IVF we join a sperm and eggs in the lab and let thee develop into embryos which are then transferred into the mother’s uterus.  We learned over the last decade that perhaps the number 1 reason treatments are unsuccessful is due to “aneuploidy” or genetic abnormalities of the embryo.  While these can come from the developing embryo itself or the sperm the vast majority come from the egg and are directly related to the age of the potential mother.  Fixing this would revolutionize fertility treatments.  We see in some women all of their eggs may be abnormal.  While rates increase in the mid-thirties they are astronomical in a woman’s 40s.

The Tests: The technique of PGDwas developed to test embryos for lethal single gene genetic diseases (like CF or tay sachs etc).  On the third day of development we open the developing embryo and take one its 6-8 developing cells out.  This precious cell is tested for the gene to see if it has it or not.  We have to get the results in 48 hours to catch the window where we need to replace the embryo into mom. Some interesting ethical questions about this test are here.

PGS - preimplantation genetic screening is different.    Here we do the same biopsy but test for 9 or 11 chromosomes to see if the age related abnormalities are present (not a familial single genetic disease).  The idea was that we could do the test and virtually guarantee choosing a normal embryo– guaranteeing pregnancy and eliminating miscarriage from these factors.  But there was a huge problem–in addition to simple testing inaccuracies, we learned that embryos have mosaicism-not all of the cells are identical!  In fact, we now know that embryos can have a few cells that are abnormal and “self correct” itself as it develops over the next few days.  So when we test just a single cell we could pick up an isolated abnormality that will self correct.  Or we could pick up one of the few normal cells in an embryo that is overwhelmingly abnormal and will never survive.  This technique once thought to be revolutionary was shown in many studies to actually decrease overall pregnancy results.  Most fertility centers have dramatically curtailed or eliminated its use for this simple screening idea.  The current thought is that we would need the ability to test for many more chromosomes and to test more than a single cell for the technique to really change overall pregnancy rates.

Both PGS and PGD are offered at my fertility practice Gold Coast IVF but I really try to use it in just those patients who have genetic riks factors clearly identified - as opposed to centers who try to push this limited technique on everybody.  We are intergrated the new chip technologies into practice now but again their use is not for everybody doing IVF!

The new research presented at ASRM–currently the testing of isolated chromosomes is via a technique called FISH.  A newer version of this called cGH was promising, but takes many days to get a result.  So for it to be used we have to biopsy embryo freeze it wait a week for the results (or more) and then put the embryos identified as normal back into the mother after thawing them a month down the road.  The new technique called array cGH (aCGH) allows the testing of all chromosomes and gives a result in less than 24 hours.  I had an opportunity to listen to the research presentation on its development and initial testing and spend some time with the head of the company who manufactures the chip answering my questions.

The company is called BlueGnome and they call the chip technology 24sure - more info here.  Here is a link to a powerpoint presentation from the European Fertility Meeting ESHRE that traces in techical complex details (not for the layman) the other options. 

Previous research on this method  full chromosome abnormalities were diagnosed with a 6% error rate, but not structural abnormalities. taken into account.   Thirty five embryos were tested -3 did not produced results (9%). Twenty one embryos were abnormal (65%) 10/11normal embryos were insered into the potential mothers.  95% of the abnormal embryos were confirmed by the old FISH technique which would have detected 70-80% Vof the abnormalities and missed the rest.

The new research presented:  6/55 tested embryos did not yield results (10.9%). 59% were abnormal  One embryo classified by the new methods as normal had a trisomy 22 by FISH ( 5% false negative rate). 2 teed abnortmal were normal by FISH ( 7% false positive rate). The total error rate for full chromosome abnormalities was  (6%).  Overall aCGH seems to detect about 20% more abnormal embryos than FISH with a 6% error for full chromosome abnormalities.

Conclusions:  this is a major technological step towards a more accurate and usable genetic method of testing embryos to improve pregnancy rates and reduce miscarriage rates.  While some still feel that the test is too early to be reliable it is being introduced clinically and centers are beginning to use it.  It is one of the only methods to test all chromosomes in an embryo and be able to put them back in the same cycle.  As the technology improves the 6% error rate will decrease.  More importantly the very wrapped up turnaround which is now less than 12 hours should allow the testing of multiple cells and allow a more accurate confirmation of the embryos true genetic nature.  Techniques like this, we hope will be able to begin to identify healthy embryos and transform the practice of fertility treatment through technology.

Groundbreaking egg research study using this technology announced:  recently the European fertility group announced a multicenter study using this genetic chip to test what are called “polar bodies” in eggs.  This test is being done on volunteer women who are donating their eggs.  The vintage here is that the egg can be tested before it is fertilized eliminating the whole problem of mosaicism and allowing testing of eggs before fertilization occurs-which for some is morally more acceptable.

Here is another prize paper from the meeting– on how obesity adveersely affects IVF success rates. 

After some sould-searching and planning and discussions with my good friends and fellow med bloggers Nick Genes and Gene from Medgadget  I have decided to jut add all that content here to docinthemachine.  While it does not have a sexy-fertility name its a part of me that has a fantastic group of readers…  Everyone I spoke with unanimously agreed to just expand the content here!

So stay tuned for more fertility related posts in the days to come.