Cost Form

In Vitro Fertilization (IVF)

IVF is an elective procedure which is seldom covered by any insurance carrier. Our office billing office will be glad to assist you to determine if your insurance will cover any of the monitoring leading up to the procedure, the procedure itself and/or both. For IVF, fees are listed and you are responsible for payment of all fees which include supplies, staff support, IVF lab and Dr. Daly's professional services. For these elective services, payment in full is required the first day you begin your ultrasound monitoring with Dr. Daly in the office. We will give you any receipts you need to submit to your insurance and/or a flex benefit for reimbursement. If any procedure is not performed for any reason, you will receive a refund of your payment for the procedure not performed.

Cryopreservation of Embryos

If you elect to cryopreserve, the consent must be signed and payment made for both the freezing and the two-year storage period at the start of your IVF cycle. If there is no consent filed or payment made, no extra eggs will be exposed to sperm for fertilization. IF no cryopreservation takes place due to physiological limitations of the eggs & sperm available, you will receive a 100% refund of both the laboratory and storage fees. payment for cryopreservation is made in this office along with your IVF payment on the first day you start your ultrasound monitoring with Dr. Daly.

IVF Cycle Fees for Grand Rapids Fertility (prepay) New Prices as of January 2007
IVF Cycle Preparation Fees selected insurance may cover these fees)
Office visits during cycle preparation (x4)		$365
Vaginal Ultrasounds (x4)		$400
Laboratory monitoring of induction (x8)		$400
Subtotal		$1165

IVF procedure - oocyte retrieval and IVF lab
Egg Retrieval Embryo lab charges Prep for embryo transfer Embryo transfer Supplies		$1900 $1650 $310 $350 250
Subtotal		$4460
Basic IVF cycle - excl. medication, ICSI and Cryo - Total $5625
These charges will apply when indicated:
ICSI Charges (Direct sperm injection) 9 or less ooctyes 10 or more oocytes		$550 $850
Crypreservation laboratory fee Cryopreservation storage fee (2 yrs.) (storage fee will be refunded if all embryos used in 4 months)		$450 $500
Blastocyst Culture (culture of embryo past 3 days) Microdose Lupron		$250 $ 75
Total for IVF cycle as planned	$-----------------------------

Cost of medications are a separate expense and are not included in fee schedule. Estimated cost for one cycle of IVF is $2000 - $2500

This form must be returned to our business office along with the appropriate payments at the start of your ultrasound monitoring. Please retain this form until you start your cycle and bring it with you that day. The cashier will collect payment in our office. Checks are to be make out to Grand Rapids Fertility and IVF, PC.

PATIENT SIGNATURE:_____________________________________________________

Counseling Date__________________Potential cycle start date__________________

Counseled by:_____________________________________________________________

ZIFT is sometimes done in combination with IVF or IVF/ICSI. The additional charge for ZIFT is the laparoscopy, hospital, anesthesia & professional fees. We estimate the professional fee to be approximately $1300. The hospital and anesthesia fee is estimated at approximately $2500. Your insurance may pay or reimburse you for all or some of the laparoscopy charges.

GRAND RAPIDS
FERTILITY& IVF, P.C.

1900 Wealthy Street, SE Suite 315
Grand Rapids, Michigan 49506
Tel: (616)774-2030 Fax: (616)774-2053
Toll Free 1 (800) 695-5941

Douglas C. Daly, M.D.

Board-Certified Reproductive Endocrinology/ Infertility Board-Certified Obstetrics/ Gynecology