The International Council on Infertility Information Dissemination, Inc

PreTreatment with IVIg Letter to Insurance

TEMPLATE LETTER OF PRE-TREATMENT MEDICAL NECESSITY
AND/OR POST-TREATMENT ROUTINE APPEAL

 
 
TO WHOM IT MAY CONCERN:
 
RE:
 
 
            High dose intravenous immunoglobulin (IVIg) therapy is clinically beneficial and not experimental in a variety of immune disorders associated with human reproductive failure and pregnancy.  Examples include: autoimmune diseases, Rh sensitization, hypogammaglobulinemia, recurrent fetal loss and infertility associated with antiphospholipid antibodies, intrauterine growth retardation and idiopathic thrombocytopenia.  The effects of high dose immunoglobulin infusion include:
 

  • Feedback inhibition of antibody synthesis
  • Down regulation of EDGE Fcg receptor
  • Blockage of placental transport of maternal endogenous Edge
  • Regulation of idiotype network
  • Alteration of T and B lymphocyte functions
  • Down regulation of natural killer cell function and tumor necrosis factor secretion.

           

            The beneficial effects of this medication are documented in the literature involving treatment for autoimmune disorders, organ transplant and bone marrow rejection and autoimmune disorders associated with infertility and pregnancy. Therefore, its use can no longer be labeled as experimental.
 
           

            Women with the autoimmune disorder antiphospholipid antibody syndrome are at risk of infertility and should they conceive, will often experience recurrent pregnancy losses, intrauterine growth retardation, intrauterine fetal death, and maternal complications such as thrombosis (arterial and venous), stroke and transient ischemic episodes.  More than one third of infertile women have circulating antiphospholipid antibodies and antithyroid antibodies that may prevent or impair implantation by compromising syncitalization of the early trophoblast and/or causing local venous and arterial thrombosis. The administration of IVIg in association with infertility treatment and during subsequent pregnancy is often the only method by which reproductive failure can be avoided.
 
Women at risk of pregnancy complications show alterations in their immunophenotype lymphocyte sets particularly in elevations in CD56+ natural killer cells that secrete tumor necrosis factor (TNF).  This factor results in decidual necrosis, death of the placental cells, coagulopathy and eventual death of the infant.  The only medication effective in reducing these natural killer cells and TNF secretion is IVIg.  Other corticosteroids or immunosuppressants are either ineffective or contraindicated during pregnancy.
 
This patient will continue to be at risk of serious complications without IVIg therapy.
 

 

Sincerely,
 
 
 
 
 
REFERENCES

 
1.       de la C-mara C, Arrieta R, Gonz-lez A, Iglesias E, Ome-aca F.  High dose intravenous immunoglobulin as the sole prenatal treatment for severe Rh immunization.  N Engl J Med  

          1988;318:519-520.
 
2.       Smith CIE, Hammarstrom L.  Intravenous immunoglobulin in pregnancy.  Obstet Gynecol 1985;66:39s.
 
3.       Scott JR, Branch W, Kochenour NK, Ward K.  Intravenous immunoglobulin treatment of pregnant patients with recurrent pregnancy loss caused by antiphospholipid antibodies

          and Rh immunization.  Am J Obstet Gynecol 1988;159:1055-1056.
 
4.       Parke A, Maier D, Wilson D, Andreoli J, Ballow M.  Intravenous gammaglobulin, antiphospholipid antibodies, and pregnancy.  Ann Int Med 1989;110:495-496.
 
5.       Rose V, Gordon Ll.  Idiopathic thrombocytopenic purpura in pregnancy.  Successful management with immunoglobulin infusion.  JAMA 1985;254:2626-2628.
 
6.       Bussell JB, Pham LC, Aledort L, Nachman R.  Maintenance treatment of adults with refractory immune thrombocytopenic purpura using repeated intravenous infusions of gamma

          globulin.  Blood 1988;72:121-127.
 
7.       Mannhalter JW, Ahmad R, Wolf HM, Eibl MM.  Effect of polymeric Edge on human monocyte functions.  Int Arch Allergy Appl Immunol 1987;82:159-167.
 
8.       Sultan Y, Maisonneuve P, Kazatchkine MD, Nydegger UE.  Anti-idiotypic suppression of autoantibodies to factor VIII b high dose intravenous gammaglobulin.  Lancet 1984;i:765-

          768.
 
9.       Sher G, Feinman M, Zouves C, Kuttner G, Maassarani G, Salem R, Matzner W, Ching W, Chong P.  High fecundity rates following in vitro fertilization and embryo transfer

          (IVF/ET) in antiphospholipid antibody (APA) seropositve women treated with heparin and aspirin.  Human Reproduction  1994;11.
 
10.     Tsubakio T, Kurato Y, Katageri S, et al.  Alteration in T cell subset and immunoglobulin synthesis in vitro during high dose gammaglobulin therapy in patients with idiopathic

          thrombocytopenic purpura.  Clin Exp Immunol  1983;53:697-702.
 
11.     Wapner RJ, Cowchock SF, Shapiro SS.  Successful treatment in two women with antiphospholipid antibodies and refractory pregnancy losses with intravenous immunoglobulin

          infusions.  Am J Obstet Gynecol 1989;161:1271-1272.
 
12.     Kwak JYH, Gilman-Sachs A, Beaman KD, Beer AE.  Reproductive outcome in women with recurrent spontaneous abortions of alloimmune and autoimmune etiologies; pre vs.

          post conception treatment.  Am J Ostet Gynecol 1992;166:1975-1987.
 
13.     Kwak JYH, Gilman-Sachs A, Beaman KD, Beer AE.  Autoantibodies in women with primary recurrent spontaneous abortion of unknown etiology.  J. Reprod Immunol 1992;22:15-

         31.
 

Children First: Making the Paradigm Shift from Infertility to Adoption By Patricia Irwin Johnston, MS

Moving from infertility to adoptive parenting is a complicated emotional process. In transferring from the process and the culture of infertility and its treatment to the process and culture of adoption, consumers are expected to make a huge shift. The Barrier? Medical treatment is centered on the needs and wishes of the paying-client—the adult who wanted a baby (that’s you!). Adoption’s culture is centered on the needs and best interests of the one client who has no say in the process and who bears no financial responsibility—the child (not you!) Adoption is child-centered rather than adult-centered. But you, one of three clients in the picture, will carry all of the financial risk and burden.

Not fair, you say? I understand. Been there. Felt that. But as my children by adoption have grown up, as our relationships with them and some of their birthparents have developed, I’ve changed my thinking a lot.

Here’s something you probably don’t understand if you are not yet a parent. Parenting itself changes everything. From the moment you become a parent forward, your child’s needs will always come before yours and before anyone else’s in your life. For those who conceive their children, that shift comes automatically as part of the pregnancy experience. Indeed, it’s that shift in thinking that makes it possible for birthparents to plan an adoption.

For those who adopt, however, making that shift is not automatic. Unless one makes a deliberate choice to shift thinking, to participate in an adoption expectancy period, the shift won’t likely happen until after the child arrives. And by then, many infertile couples can have made some pretty bad choices already—choices rooted in their frustration, in their reactions to many losses that infertility has brought to them, in the desperation they have begun to feel about ever being able to parent.

Over the past twenty years or so, changes in adoption have done little more than move the locus of power in adoptions. First power was moved from adoption professionals to adoptive parents, and now it has been transferred to birthparents. But changes in who holds the power have not often included the education necessary for all of these parties to understand and accept what children themselves need from adoption. And what is it that children need? They need well-prepared, unafraid, stable and loving families over their entire lifetimes!

Too many of those involved in adoption right now seem to experience it as a competition. Agencies compete with other agencies and with independent service providers to draw in limited numbers of birthparents whose healthy babies can be offered to an apparently unlimited supply of prospective adopters. Special needs agencies compete with one another for public and private grant money, and often trash one another and their differing approaches to counseling and preparation. Prospective adopters compete with other prospective adopters for the opportunity to adopt available babies. They look for too many shortcuts to “faster” placements by looking for providers who will not require education, extensive preparation, and screening, because it is too “invasive and unfair.” Adopters attempt to demonstrate to expectant parents that their adoptive family would offer a "better" life for the child about to be born than would the child’s family of origin or any other prospective adopters. When an expectant parent has a change of heart about adoption during the window of time a state or province grants for the change-of-mind process, many adopters and their professional advisors take the stance that possession-is-nine-points-of-the-law and go to court so that they might "keep" the baby, even though they are not yet the legal parents. Adopters, birthmothers and professionals often conspire to keep birthfathers and their families out of the picture entirely.

Ideally, changing adoption so that it really meets the needs of children would begin with fundamental changes in thinking and in the law. Different thinking would end the adversarial aura that surrounds adoption. If adoptions really kept the child's interests center-stage, everybody involved in any untimely pregnancy would be seeking the best possible solution for the child to be born. This solution would find him with his permanent family (birth or adoptive) as soon as possible after his birth.

Getting off to this kind of a "clean" start in an adoption, however, demands a tremendous amount of understanding and emotional work on the part of both sets of parents, as well as careful judgment on the part of well trained and well informed professionals. Those working to launch a child-centered adoption must be helped to understand how each of the decisions made and each of the procedures followed will help the child at the adoption's core.

For a baby's launch to be optimal, everyone involved must be committed to being honest with everyone else in the adoption. Birthparents must be honest with one another, with helping professionals, and with prospective adopters. Adopters must be scrupulously honest with professionals and expectant parents. Intermediaries must be scrupulously honest with expectant parents and prospective adoptive parents. There must be no assumptions that “leaving that little something out” “letting that little something go,” causes no harm. Scrupulous adherence to ethical standards that keep the child at the center while respecting the needs and interests of both adoptive parents and birthparents is absolutely crucial in making all decisions concerning an adoption.

As an adoptive parent, wife, sister-in-law, daughter-in-law, cousin-in-law, sister-in-open-adoption to my child’s birthmother, and adoption educator, I hold those who elect to join to adopt to very high standards. That’s because this is what children deserve from their parents.

Patricia Irwin Johnston. is an INCIID Advisory Board Member. She is a long-time advocate, infertility and adoption educator and author of several books, including Adopting after Infertility, Launching a Baby’s Adoption, and INCIID’s own Adoption Is a Family Affair, written with the participation of the INCIID community members on two of the forums which Pat moderates: Exploring and Expecting through Adoption.

Contact Information:

Phone: (317) 872-3055

Email: patjohnston@perspectivespress.com

Website: http://www.perspectivespress.com

Press Release: Class Action Law Suit Filed Against Blue Cross Blue Shield of California

October 26, 2007

PRESS RELEASE

[For Immediate Release]

 

A lawsuit charging Blue Cross of California with failing to offer infertility benefits required by California law was certified as a class action on Tuesday.  This will allow the class representative and her attorneys to seek an injunction directing Blue Cross to offer much broader infertility coverage to group health plans covering employees of governmental entities and many religious institutions.  Blue Cross currently offers only a limited benefit of $2,500 a year, and requires plan members to pay 50% co-pays.

According to attorney Mark F. Didak of Los Angeles, who represents the class, California Health & Safety Code and Insurance Code require health plans to offer infertility coverage on the same terms as they cover other health conditions, without lower coverage limits or higher co-pays.  “The benefit should cover all infertility diagnosis and treatment services ‘consistent with established medical practices,’” Didak said, “except that health plan providers are not required to offer coverage for the actual laboratory procedures involved in in vitro fertilization.”  The last part is important, says Didak, because health insurers typically refuse to pay for anything associated with in vitro fertilization, which can cost anywhere from $10,000 to $25,000 per cycle.  “The law only allows them to not offer coverage for the lab procedures, which usually cost between a few hundred dollars and $1,500.”  Didak hopes to persuade the court to issue an injunction that might serve as an example to the health insurance industry by clarifying what infertility benefits must be offered and which ones they can choose not to offer.

The lawsuit was filed in 2006 by plaintiff Deborah Dunn Yeager and is pending before Judge Victoria Chaney of the Los Angeles Superior Court.  Prof. Dunn Yeager, who teaches communications at Westmont College in Santa Barbara, enrolled in a Blue Cross plan at work believing it covered infertility problems, only to have her benefits claim denied.  Her college, she discovered, had not been offered infertility coverage on the terms required byCalifornia law.  The statutes, Health & Safety Code section 1374.55 and Insurance Code section 10119.6, also mandate that “every plan shall communicate the availability of that coverage to all group contractholders and to all prospective group contractholders with whom they are negotiating.”

Up to 15% of all couples of child-bearing age suffer problems conceiving.  The problems are often treatable, many times with relatively inexpensive methods.  “When the California Legislature passed the law requiring health plans to offer this coverage in 1989, they found that infertility ‘affects millions of Californians,’” said Mr. Didak. “The Legislature also found that ‘[i]f properly treated, successful pregnancies can result in 70 percent of [infertility] cases,’ but that ‘[i]nsurance coverage for infertility is uneven, inconsistent, and frequently subject to arbitrary decisions which are not based on legitimate medical considerations.’”

Mr. Didak continued, “what’s clear is that if infertility coverage is always offered as the law requires, it will be sold more often, solving the problems the Legislature was trying to address.  It will also bring the price of coverage down as more and more groups purchase it.  Blue Cross will no longer be able to deny necessary medical treatment to people who want the chance to start a family or have another child.  It’s one of the most fundamental rights any person has.”

 

[For more information, please contact class counsel Mark F. Didak at (310) 689-7022 or mdidak@selmanbreitman.com.]

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