ON THE Cutting Edge

cutting-edgeBy : Danielle Lane, M.D

Across the field of fertility, patients are asking for more precision in their outcomes. Can we have a singleton? Can we guarantee the genetic health of the baby? Is there an opportunity to avoid known mutations? Can we balance our family using gender selection? Whether we agree with all of the applications of technology or not, the ability to apply it to our care exists. In the next issue of Lane Fertility Magazine, we will discuss the benefits of pre-implantation genetic testing.

With ever-rising costs of technology, we will will also address the expense of treatment and discuss how to get the most from your insurance benefit. Dr. Das Gupta will provide some insights about mother-daughter dynamics and their impact on the fertility journey. Additionally, we will discuss the current state of fertility preservation and its ability to change the way women balance their lives.

Stay focused on your
successful fertility journey!


A Motherhood Miracle

motherhood-miracleBy : Camille T.C. Hammond, M.D. , MPH. CEO, Cade Foundation

A recent study revealed that 49% of women and 15% of men describe infertility as the most upsetting event of their lives. Dr. Camille Hammond experienced firsthand how infertility can have disabling effects that impact our community. After years of dreaming, hoping, praying, and crying, she experienced many highs and lows during her quest to have children. In 2004, Drs. Jason and Camille Hammond were given the gift of parenthood from Camille’s 55 year-old mother Dr. Tinina Q. Cade who served as her daughter’s gestational surrogate and delivered her own grandchildren: triplets.

After so many years of trying, the Hammond family was blessed with the births of their three children. In honor of her mother’s incredible gift, Dr. Camille Hammond started “The Tinina Q. Cade Foundation” to provide other infertile couples with the opportunity to grow their families. Since 2005, the Cade Foundation has been providing support and financial assistance to help disadvantaged families overcome infertility by awarding Family Building Grants of up to $10,000 annually, to assist with the costs of fertility treatments and
domestic adoptions.

“The Cade Foundation’s mission is to promote awareness of infertility and related issues among people who suffer from the condition”

grandma-on-bikeThis dual approach distinguishes the Foundation as the only organization of its kind in the nation. The Foundation provides a vehicle through which families who have already “overcome” infertility can support families who are still struggling with infertility. The Cade Foundation believes that everyone with the desire to love and raise a child should have that opportunity.

Through its signature fundraising events and outreach efforts, the Foundation has provided 31 families with financial support and there are presently 21 Cade Foundation babies!

The Cade Foundation’s mission is to promote awareness of infertility and related issues among people who suffer from the condition, as well as the general population and to eliminate existing stigma by educating those who are unaffected in meaningful and significant ways.

For more information about The Tinina Q. Cade Foundation, please visit www.cadefoundation.org.

The ASRM recommends that gestational surrogates should be younger than the average age of menopause (51 years old). Additionally, many states mandate that gestational
surrogates should not carry more than a twin gestation.






CamileeCamille T.C. Hammond, MD, MPH, CEO, Cade Foundation, Physician-Researcher, Author, Educator. Dr. Hammond completed her medical training at the Univer-sity of Maryland School of Medicine and Johns Hopkins University. She now runs the Tinina Q Cade Foundation (Cade Foundation), a non-profit organization that she and her husband, Dr Jason Hammond, to provide support to families with infertility.




Budgeting Your Fertility Journey

By : David Jaramillo

budgetingInsurance and Billing Frequently Asked Questions

1. Understand the difference between HMO and PPO plan.

A PPO (preferred provider organization) is a plan that specifically allows for self-referral to a specialist physician. This does not mean that all future services with that specialist will be covered, but you will be able to visit them for consultation without a referral from your primary care provider or Ob/Gyn. An HMO (health maintenance organization) is the type of plan that requires you to obtain a referral to even see a specialist physician. Furthermore, all services performed by the specialist will require a current authorization prior to obtaining the service or procedure.

2. Understand your benefits and the monetary limitations that they have.

Many plans offer infertility benefits but have very low monetary limits. This is most often a function of the number of employees. For example, in the Bay Area, larger corporations such as Google, Salesforce and Bank of America offer very robust plans with coverage from 15,000.00 to an unlimited lifetime maximum in some cases. Other smaller corporations will have plans with much less of a benefit package. Many plans ONLY cover diagnostic testing to try and determine the underlying cause of infertility (laboratory testing, hysterosalpingogram, surgery), but no benefits for actual fertility treatment (insemination or in vitro fertilization services). In addition, medical procedures and prescription benefits can be either combined under a single coverage limit, or separated with two individual policies and monetary limits.

3. Who determines procedure & diagnosis coding?

Most medical conditions and procedures have codes associated with them (procedure and diagnosis codes). This coding must reflect the purpose for which a visit or procedure occurs.
Diagnosis and procedure codes are provided by the Physician when billing a service through an insurance carrier. ONLY a physician can review and change this coding. Further, the insurance company has the right to audit a chart and reverse a decision on payment if they feel that coding is fraudulent. Therefore, just because a claims person indicates that a given procedure could possibly be paid if re-coded does not mean the original coding given is incorrect or can be legally changed.

4. What is the difference between a Co-pay, Co-insurance, a Deductible, and Out-of-pocket expenses?

Typically a co-payment refers to the payment accompanying any office visit (i.e. $10.00 copay). The term co-insurance refers to the percentage of a total charge that the patient might be responsible for (i.e. insurance pays 80% and patient pays 20%). A deductible usually refers to a calendar patient responsibility such as $500.00 per calendar or fiscal year. The deductible renews annually and must be met by the subscriber before anything is paid by the Insurance carrier. The out-of-pocket amount is a monetary limit placed on most plans by the carrier. Once met, the carrier will then pay all further claims at 100% up to any benefit limitation (for example the lifetime maximum on an insurance benefit). Some plans do not include the annual deductible into the out of-pocket maximum while others combine the two costs.

5. What does it mean to coordinate my benefits?

In some cases, you may have a primary AND secondary insurance plan. If active coverage exists under more than one carrier, it is important to provide your physician’s office with
both plans. Your physician’s office is required to bill the primary carrier first, regardless of whether the fertility benefit exists. In the case of a denial from the primary plan, the biller can
then coordinate benefits through the secondary plan with a copy of the Explanation of Medical Benefits for payment.


David Jaramillo is the Financial Specialist for Lane Fertility Institute. He works to provide a high level of assistance to patients trying to navigate the complexities of fertility benefits. From insurance and billing questions, to self-pay agreements, David will work to ensure that you understand your options. The goal of David’s position is to provide patients with a
resource and advocate within the practice. We aim to increase your satisfaction and reduce your anxiety during this fertility experience.

David has over 30 years of experience working in health care finance. He spent over a decade as the financial specialist at the UCSF Center for Reproductive Health where he pioneered the systems that are still used there to this day. He looks forward to helping you navigate your fertility experience.

Dinner forTwo

By : Kellie Nugent

halibut-recipeSEARED HALIBUT
with Green Tea Broth
& Buckwheat Soba Noodles


• 2 wild Pacific halibut fillets (6 ounces each)
• 2 tablespoons canola oil
• 1 piece fresh ginger (2 inches), peeled and finely chopped
• 1 garlic clove, finely chopped
• 1 small head baby broccoli (aka broccolini), trimmed and cut into bite-sized pieces
• 1 cup frozen shelled non-GMO edamame, thawed
• 1 cup baby Portobello mushrooms, stems removed, caps wiped clean and sliced
• 1/2 cup snow peas, strings removed
• 2 green tea bags
• 3 tablespoons low-sodium tamari soy sauce
• 1 tablespoon local honey
• 4 ounces (or half the package) 100% buckwheat soba noodles
• 1 scallion, trimmed and sliced on the diagonal – optional for garnish
• ½ teaspoon red pepper flakes – optional for garnish
• Pea Shoots – optional for garnish

Measuring spoons
Chef’s knife
Cutting board
Tea kettle
Heatproof 4-cup liquid
measuring cup
Large stockpot
Large skillet
Ovenproof baking dish
Fish spatula, wooden spoon,
thongs and ladle


1. Preheat oven to 350 degrees Fahrenheit.

2. Bring 2 cups water to boil. Transfer boiling water to a heatproof 4-cup liquid measuring cup and add green tea bags. Set aside to steep.

3. Fill large stockpot with 6 cups cold water, cover, and bring to a boil.

4. Meanwhile, salt and pepper the halibut fillets. In a large skillet, heat canola oil using medium heat. Cook halibut for about 2 minutes per side. Add fillets to ovenproof baking dish and cook until halibut is opaque – about 8 to 11 minutes.

5. While halibut bakes, add ginger, garlic, baby broccoli, edamame, baby Portobello mushrooms and snow peas to the skillet. Sauté on medium-high heat until mushrooms become slightly tender, about 2 to 3 minutes. Add green tea, low-sodium tamari soy sauce and honey. Cook until vegetables are crisp tender, about 4 minutes. Reduce heat to low/simmer.

6. A dd soba noodles to stockpot of boiling water and cook according to package instructions.

7. Divide soba noodles, vegetables and green tea broth between two deep bowls and top with the halibut fillets. If using, garnish with red pepper flakes, scallions and pea shoots.

SUGGESTIONS – Chef’s No tes

1. Halibut fillets – According to the Monterey Bay Aquarium Seafood Watch West Coast Sustainable Seafood Guide, one should purchase Pacific (US ) halibut and avoid California halibut due to concerns about mercury or other contaminants.

2. L ow sodium tamari soy sauce and 100% buckwheat soba noodles – The attached recipe is gluten-free due to the use of tamari and 100% buckwheat soba noodles. I like Eden Foods brand soba noodles, which may be purchased at Whole Foods or similar markets.

3. Canola oil and edamame – I believe one should aim to avoid foods that are genetically modified, looking for the label “Non-GMO Project Verified”.

4. With regard to seasonality, according to The Local Foods Wheel for the SF Bay Area, broccoli and mushrooms are in season year round. Snow peas are in season in April, but available year round. The recipe can be made without snow peas substituted with green beans, which are in season in the Bay Area in September/October. Check your local food source for the vegetable in season for this recipe.

5. I f you are allergic to fish, you could substitute grilled boneless, skinless chicken breast, thinly sliced, or pan-seared boneless pork, also thinly sliced. If you aren’t allergic to shellfish, wok-tossed or seared shrimp would work well too.


KellieKellie Nugent, Freelance TV Chef, Culinary Instructor, Blog Editorialist. Kellie has a passion for converting recipes from traditional to health-supportive. After receiving her culinary degree in New York City, she worked for Martha Stewart Living Omnimedia on several television shows. She is currently continuing her work in San Francisco.


The Thyroid & Fertility; There’s a Link?

By : Jennifer Agard, M.D.

thyroidThyroid disease is the second most common endocrine disease affecting women of reproductive age, with a prevalence as high as 7-8%. Many people have known a friend or a family member with thyroid dysfunction, or have it themselves. In addition, with increased awareness of our bodies and overall health, thyroid function is a popular cause of concern. However, many people do not realize that the thyroid affects a woman’s reproductive function, including her ability to become pregnant, stay pregnant, and to have a healthy baby.

Classically, hypothyroidism presents with low blood count (anemia), cold intolerance, fatigue, constipation, hair loss, elevated lipids, delayed reflexes, memory loss, and decreased
exercise tolerance. Many of these symptoms are general and vague, so to delineate whether the cause is the thyroid, a thyroid stimulating hormone (TSH) level should be checked. Traditionally, hypothyroidism is defined as a TSH above 5- 10 mIU/L, and a low free T4 (thyroxine hormone). However, studies have shown that the TSH level should be below 2.5 mIU/L in women who are trying to conceive. Well-established causes of hypothyroidism are autoimmune (Hashimoto’s), iodine deficiency, thyroidectomy, inflammation of the
thyroid (thyroiditis), medications (iatrogenic), and systemic or psychiatric illness. With such a long list of causes, it is easy to see why thyroid dysfunction can be so common.

In classic hypothyroidism, a woman has increased risks for an unhealthy pregnancy. Risks to the pregnancy include miscarriage, low birth weight, premature delivery, congenital hypothyroidism in the newborn (hypothyroidism at birth), preeclampsia, and placental dysfunction.

“many people do not realize that the thyroid affects a woman’s reproductive function, including her ability to become pregnant, stay pregnant, and to have a healthy baby”

Obviously normal thyroid function is crucial to a healthy pregnancy and a healthy baby. But wait, there’s more. Within the last 10 years or so, a lot of attention has been drawn to a
condition called subclinical hypothyroidism.

Subclinical hypothyroidism is a condition where a TSH is elevated, however, the thyroid hormones are normal and the person is typically asymptomatic. In 2005, a study was done on pregnant women with subclinical hypothyroidism and their subsequent children. This study found that women with subclinical hypothyroidism were at two times greater risk for
preterm delivery, and three times greater risk for a pregnancy complication called placental abruption. Since then, studies over the last few years have shown that in couples being treated for infertility, subclinical hypothyroidism is associated with increased miscarriages and decreased pregnancy rates. So far, the Endocrine Society has been most progressive in addressing subclinical hypothyroidism with recommendations to consider treatment if there are certain risk factors including pregnancy loss.

Finally, TSH is tied to another hormone called prolactin (a hormone that is typically present in breastfeeding moms). Low TSH, can result in increased prolactin. Prolactin is the
hormone that stimulates lactation in the breast, allowing for nipple discharge, even in a woman who hasn’t had a baby. Prolactin has a large effect on fertility. It can prevent ovulation of an egg, create irregular menstrual cycles, or even completely prevent menses from occurring.

Managing the thyroid gland is of vital importance as you prepare for pregnancy. Ensuring that you have discussed this with your physician is critical to ensure early recognition and resolution!


JenniferJennifer Agard, MD, Reproductive Endocrinology and Infertility Specialist. Dr. Agard completed her medical training at UCLA, Saint Barnabas Medical Cen-ter, and Eastern Virginia Medical Center. Her special interests are in polycystic ovarian syndrome, thyroid disease, therapeutic reproductive surgery, and di-minished ovarian reserve. Dr. Agard is committed to the model of delivering individualized patient-centric care. ??er greatest reward is being able to help create the family and life plan that is unique for each of us.