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This answer may contain sensitive images. Click on an image to unblur it.Q. How do I contact an ob-gyn in the US for an IVF consultation?A. 10 Best Fertility CentersIn the first-ever investigation of its kind, find out which of the nation's centers offer the greatest chance of success.By Karen CiceroLaura StojanovicFertility stories are always filled with emotion, uncertainty, and controversy -- childless couples who would make great parents, thrifty insurers who refuse to pay for treatments even though infertility stems from a medical problem, and ethical dilemmas that would make Hippocrates' head spin. So when we embarked on the searnodch for the best fertility centers in the country almost two years ago, we were prepared for challenges. But we didn't expect that they would be nearly insurmountable.Our goal was to rank centers based largely on their success rates with in-vitro fertilization (IVF), a form of assisted reproductive technology (ART) that involves removing eggs from a woman's ovaries and combining the eggs with sperm. We asked medical experts for advice, as we always do for our 10 Best investigations. But top fertility groups, unlike organizations in other rankings we've undertaken, didn't cooperate.Still, with the help of several doctors and a pile of studies, we persevered and in 2004 sent an extensive survey to more than 75 of the nation's 400-plus centers that met our initial criteria, which included having a certified laboratory and maintaining at least average live-birth rates without high rates of triplets. Our data on these centers came from the Centers for Disease Control and Prevention (CDC), which publishes success rates for most clinics at www.cdc.gov/reproductivehealth.The problem: Just a handful of centers returned the form. While some claimed they didn't have time to fill it out, others said they didn't want to release the information. A representative of one well-known center wrote: "They [the administrators] felt that they needed to reveal too much info about the clinic. They felt that a lot of the questions in the survey ask for things that they don't even have to provide to the CDC."Our response: Wasn't that the point? The CDC's report gives consumers only a partial picture -- for instance, it doesn't publish success rates at individual fertility centers by diagnosis even though the chance of bringing home a baby ranges from 14% to 34% depending on the reason for infertility -- and it doesn't tell consumers whether a center handles a large or small percentage of difficult cases, which influences its success rates. "A huge number of clinics select the most favorable cases to make their success rates look good," says Sherman Silber, M.D., author of How to Get Pregnant With the New Technology.We felt the public deserved better, given that treatments for infertility are emotionally draining, financially devastating, and may even pose a risk to a woman's health because there hasn't been a definitive assessment of the long-term consequences of taking fertility medications (although studies thus far have been reassuring). So this spring we sent smaller surveys to centers that had achieved high live-birth rates without high triplets rates. Like the initial questionnaire, this one examined the complexity of the cases, research endeavors, and range of services. Between the two surveys, nearly 40 centers replied.While lack of cooperation put limits on this special report, it's nevertheless the first-ever data-driven comparison of fertility centers. Read on to learn about our 10 winners, where medical breakthroughs happen routinely. (If your case isn't difficult, a local facility may be best for you. For guidance on evaluating your options, see "Judging for Yourself").Top 10 Fertility Centers1. Colorado Center for Reproductive Medicine, EnglewoodNumber of ART cycles and transfers in 2002: 912 (Nearly all ART cycles use IVF. If a patient uses donor eggs or frozen embryos, the CDC labels the procedure a transfer rather than a cycle.)Percentage of ART cycles from non-donor fresh embryos resulting in live births in 2002: 60% (under age 35), 51% (ages 35-37), 44% (ages 38-40), 23% (ages 41-42)Boasts 2002 IVF success rates that are twice the national average for women ages 38 to 42 who are using their own eggsIs researching ways to improve the chance of pregnancy for patients with endometriosis or polycystic ovarian syndromeAttracts 40% of its patients from outside the Colorado areaFor most women trying IVF, physicians return two to seven fertilized eggs, called embryos, hoping one will implant. But about 30% of women who become pregnant are carrying twins, and 7% are expecting triplets or more. "Twin pregnancies are at a three- to five-fold greater risk for pregnancy complications and perinatal mortality [death between 28 weeks gestation and a week after delivery] compared to carrying one fetus. With triplets, there's at least a seven-fold greater risk," says Eric Surrey, M.D., medical director of the Colorado Center for Reproductive Medicine (CCRM) and president of the Society for Assisted Reproductive Technology, a top group in the field.Dr. Surrey's team recruited patients, 48 in two years, between ages 26 and 48 to study the feasibility of returning just one embryo. "This is common in some Western European countries, but the success rate is about 30% to 35%," says Dr. Surrey. "We wanted to see if we could improve on those rates."Earlier work at CCRM paved the way for embryos, which used to be returned three days after fertilization, to develop into blastocysts, a process that takes about two more days. Waiting longer gives doctors a better idea of the embryos' quality and helps them decide which one has the best chance of survival.Half the women in the study received one embryo, and the remainder got two. All were given the option of freezing leftover embryos for use at another time. In the group receiving a single embryo, 61% had a clinical pregnancy (a heartbeat shown on ultrasound) and there were no twins. By comparison, the ongoing pregnancy rate in the group receiving a pair of embryos was 76%, but nearly half the pregnancies resulted in twins. "The slightly lower chance for pregnancy in the single-embryo group outweighs the significant risks associated with multiples," says Dr. Surrey. "Larger trials will more carefully define just who the ideal candidates for this approach will be."2. The Center for Reproductive Medicine and Infertility at NewYork-Presbyterian Hospital/Weill-Cornell Medical Center, New York CityNumber of ART cycles and transfers in 2002: 2,012Percentage of ART cycles from non-donor fresh embryos resulting in live births in 2002: 48% (under age 35), 43% (ages 35-37), 30% (ages 38-40), 18% (ages 41-42)Is one of the most experienced centers in the U.S., with 11,000-plus babies born through conventional IVF and 4,000 through ICSI -- a technique that injects a single sperm into an egg; ICSI, invented by the center's lab director, is a must for couples with severe male factor infertilitySpecializes in preserving fertility in cancer patientsPerformed the first genetic testing on embryos for sickle cell anemia and retinoblastoma, an inherited eye cancerPriding themselves on a difficult caseload, doctors at The Center for Reproductive Medicine and Infertility (CRMI) conduct more than one-third of their IVF cycles on patients who have had two or more failed attempts at other clinics. "Other fertility specialists send us their patients who haven't gotten pregnant," says the clinic's director, Zev Rosenwaks, M.D.Because many couples who have experienced several unsuccessful cycles want to put back more embryos than they did on the first few tries, the center's triplets rate in women ages 35 to 37 is the highest of our top 10. But its live-birth rate using non-donor fresh embryos is remarkable: 30% to 70% above the national average, depending on the woman's age. How is that possible? In a word: research. Since 2002, the center has published more than 200 studies in medical journals -- the most of our survey. Among them: autologous human endometrial co-culture, which means growing a couple's embryos on a woman's endometrial cells instead of in the standard IVF liquid.Before starting an IVF cycle, a woman undergoes an endometrial biopsy, in which a small piece of her uterine lining is removed. The sample is frozen until the next month, when the woman's eggs are retrieved, fertilized, and put on her endometrial cells to grow. A study by CRMI researchers on 1,000-plus patients, who on average had three failed IVF attempts, found the technique improved embryo quality and resulted in an impressive clinical pregnancy rate of 42%.3. University Fertility Consultants at Oregon Health & Science University, PortlandNumber of ART cycles and transfers in 2002: 505Percentage of ART cycles from non-donor fresh embryos resulting in live births in 2002: 34% (under age 35), 39% (ages 35-37), 34% (ages 38-40), 7% (ages 41-42)Reported the first live birth from an ovarian tissue transplant in a primate, paving the way for cancer patients to freeze their ovarian tissue before treatmentMinimizes high-risk pregnancies; while the center's live-birth rate for women ages 35 to 37 undergoing IVF with their own eggs is about 25% above the national average (39% vs. 31%), its percentage of pregnancies with multiple fetuses is roughly half the average in that age rangeBoasts a very experienced lab staffSome fertility centers don't allow women to try IVF with their own eggs if their level of follicle stimulating hormone (FSH) is over 10. FSH, produced by the pituitary gland, causes eggs to mature; a high level of it, measured on the third day after menstruation begins, may indicate that few eggs are left in the ovaries.But physicians at University Fertility Consultants routinely take patients whose FSH is up to 15. In a recent study of 350 women over age 35, they found that the clinical pregnancy rate for women with FSH levels of 10 to 15 was about 33% -- below the 42% pregnancy rate when a patient's FSH is under 7, but still pretty good. "My overall success rates are lower because about 25% of the women in my caseload have high FSH levels," says the center's director, Kenneth Burry, M.D. "But I don't feel comfortable referring patients for egg donation when they have a reasonable chance of success using their own."4. New York University School of Medicine, Program for In-Vitro Fertilization, Reproductive Surgery, and Infertility, New York CityNumber of ART cycles and transfers in 2002: 1,362Percentage of ART cycles from non-donor fresh embryos resulting in live births in 2002: 45% (under age 35), 42% (ages 35-37), 24% (ages 38-40), 17% (ages 41-42)Sees many difficult cases; about 70% of patients have failed at least one IVF cycle elsewhereOffers a patient library equipped with computersIs developing an egg-freezing programThirteen years ago, Jamie Grifo, M.D., Ph.D., was the first fertility specialist in the U.S. to successfully perform pre-implantation genetic diagnosis (PGD), the screening of an embryo for a specific inherited condition, such as cystic fibrosis. "It's heartbreaking to talk to couples whose children have died from a genetic disease," says Dr. Grifo, director of the division of Reproductive Endocrinology at New York University. "They tell me they couldn't go through it again -- all they want is a healthy baby."Dr. Grifo, who has been at NYU for the last 10 years and did his early work with PGD at Yale and Cornell, has begun to apply the technique to women who have suffered recurrent miscarriages. "We're searching for abnormalities in chromosomal numbers, and often we find them," he explains. "Last year, I started one of my patients, who had gone though five miscarriages, on an IVF cycle. She produced 11 eggs, which fertilized. When we checked them, we found that only two were normal. We put both back, one implanted, and she gave birth recently."In fact, more than 70 babies have been born to NYU clients using the technique -- which involves making a hole in the outer coating of the embryo and removing a single cell for analysis -- and the clinical-pregnancy rate per cycle is about 40%. "If done properly, it really doesn't make the embryo much less likely to implant," he says. What about future consequences? Although long-term effects are still unknown, a recent study of 754 PGD babies suggests that they're no more likely to have birth defects than children conceived conventionally.5. The Infertility Center of St. Louis at St. Luke's HospitalNumber of ART cycles and transfers in 2002: 176Percentage of ART cycles from non-donor fresh embryos resulting in live births in 2002: 35% (under age 35), 26% (ages 35-37); there were too few cycles in women ages 38-42 to report the results as a percentageIn 2002, performed the greatest percentage of IVF cycles due to male factor infertility of any center in the country; many cases involved very complex problemsHas completed more than 4,000 microsurgical vasectomy reversals over the last 30 years, reporting in a recent study that nearly 90% of patients were able to impregnate their partnersConducted the world's first ovarian transplant, in which an infertile identical twin was given one of her sister's ovaries; the woman had a healthy baby girl in JuneOver the last 30 years, Sherman Silber, M.D., founder of the Infertility Center of St. Louis, has published more than 200 studies on infertility, pioneering or advancing techniques that help men with little or even no sperm become fathers. Much of his research has focused on the estimated 2% to 5% of infertile men with congenital absence of the vas deferens, a condition in which the tubes that carry sperm from the testes haven't developed normally. "These men make sperm, but it's not in the ejaculate," says Dr. Silber. "We do a procedure to extract sperm from the testicles."He's usually able to retrieve sperm to fertilize eggs through ICSI (see page 3 for ICSI description). He often recommends that couples in this situation have their embryos screened for genetic abnormalities since a higher percentage of them may contain the wrong number of chromosomes even though they look normal. "By doing the testing, we can boost the chance of a live birth from about 35% to 45%," he says.Filling his practice with extraordinarily difficult cases has taken a toll on Dr. Silber's success rates, but he doesn't mind. "For me, it's not about the numbers," he says. "It's about giving couples what they want most -- a child."6. The Nevada Center for Reproductive Medicine, RenoNumber of ART cycles and transfers in 2002: 281Percentage of ART cycles from non-donor fresh embryos resulting in live births in 2002: 52% (under age 35), 49% (ages 35-37), 38% (ages 38-40); there were too few cycles in women ages 41-42 to report the results as a percentageIs testing a new form of progesterone -- a hormone that helps sustain a pregnancy -- to see if it's better than the types currently availableHas a successful donor-egg program; the 2004 pregnancy rate approached 70% for fresh embryos in women of all agesArranges travel and sightseeing for out-of-town patientsDoctors can often tell by the quality of the blastocysts -- embryos that have been grown for about five days -- how likely a patient is to get pregnant. "But in some older patients who have repeated failed cycles, the blastocysts look beautiful," says Russell Foulk, M.D., director of the Nevada Center for Reproductive Medicine.Dr. Foulk and other researchers working with the National Institute of Child Health & Human Development may have figured out what's causing the problem for at least some of these patients. They found that at the time of implantation, the blastocyst expresses much larger amounts of a protein called L-selectin than it does beforehand. If a woman's uterus doesn't have receptors for this protein, Dr. Foulk theorizes, the blastocyst won't attach. "I've started doing uterine biopsies recently and discovered that two of my patients lacked these receptors," he says. "One of them had nine unsuccessful transfers -- all with good-looking embryos."Future studies may confirm that checking for the receptors should be part of fertility screening. If that happens, Dr. Foulk says, some couples may avoid repeated failed cycles. Rather, they could consider surrogacy or adoption from the start.7. Presbyterian Hospital ARTS Program, Dallas and Plano, TXNumber of ART cycles and transfers in 2002: 1,180Percentage of ART cycles from non-donor fresh embryos resulting in live births in 2002: 49% (under age 35), 38% (ages 35-37), 23% (ages 38-40), 12% (ages 41-42)Is studying whether antibodies in a woman's blood affect her ability to get pregnantOffers an incentive program for the transfer of a single embryo to patients (age 37 or under if using their own eggs) who have two or more blastocysts; 200-plus couples have signed up, and more than six in 10 have conceived on the first tryHas a policy that embryologists, in conjunction with nurses or administrative staff, give couples trying IVF a daily status report on how well their embryos are growingSince about 90% of genetic abnormalities are caused by the egg alone, doctors in the Presbyterian Hospital ARTS Program are studying the feasibility of routine analysis of polar bodies, which are formed outside the egg after fertilization. "These are waste products -- they degenerate within one to two days -- but they provide mirror images of what's inside the egg," says scientific director Marius Meintjes, Ph.D. "With them, we can look for genetic problems, passed on by the mother, that would make the resulting embryo less likely to implant or more likely to cause a miscarriage."Why might it be more beneficial to do that than screen the embryo for genetic problems, especially when you can't detect abnormalities passed on by the father? The test has no chance of damaging the embryo, unlike pre-implantation genetic diagnosis, which requires the removal of a small piece of the embryo.8. Florida Institute for Reproductive Medicine, JacksonvilleNumber of ART cycles and transfers in 2002: 832Percentage of ART cycles from non-donor fresh embryos resulting in live births in 2002: 44% (under age 35), 40% (ages 35-37), 33% (ages 38-40), 17% (ages 41-42)Cancels a low percentage of cycles, which suggests a good response to treatmentsIs one of a handful of centers that publish comprehensive results on their Web sitesHas persuaded drug companies to donate medications for the institute's cancer patients who are freezing their eggs, saving each person about $3,000When a woman doesn't conceive on her first IVF cycle using fresh embryos, she may be able to try again at about one-fifth the cost if she has embryos to freeze. The Florida Institute for Reproductive Medicine is a leader in freezing techniques, called cryopreservation. "Most of our patients get enough high-quality embryos to have one fresh and one or two frozen cycles, adding a great deal to their cumulative chance of conceiving at a reasonable cost," says Kevin Winslow, M.D., the center's director.What the center has learned from embryos over the years has also helped them freeze unfertilized eggs for more than 200 patients, and they are continuing to study the technique to pinpoint the optimum environment for frozen eggs. "We have 33 babies born and nine ongoing pregnancies with this technique to date -- the most of any center in the country," says Dr. Winslow.Egg freezing is an option for cancer patients who want to preserve their fertility or those who fear they will be too old to conceive before they're ready to start a family. "But we only do it for women 38 and under," says Dr. Winslow. "After that, the eggs aren't of high-enough quality to freeze."9. Southern California Reproductive Center, Beverly HillsNumber of ART cycles and transfers in 2002: 217Percentage of ART cycles from non-donor fresh embryos resulting in live births in 2002: 68% (under age 35), 56% (ages 35-37), 26% (ages 38-40), 21% (ages 41-42) (These numbers refer only to the practice of Hal Danzer, M.D.; occasionally, fertility centers provide the government with statistics based on the practice of individual physicians rather than the overall center.)Reported no pregnancies with triplets or greater in 2002 for women under 35 despite the fact that the live-birth rate for these patients was nearly twice the national averageIn 2002, performed 98 of its IVF cycles on patients who had at least two previous failed attemptsConstructed a state-of-the-art lab with triple-gas incubators and a sophisticated air-filtration system to promote the best environment for growing embryosOnce a couple's embryos are ready, doctors put them in a woman's uterus, where the hope is that they'll implant -- a process called embryo transfer. "Most transfers are easy. But in about 10% of patients, pinpointing the placement of embryos is difficult because of the shape or position of the uterus," says Hal Danzer, M.D., a reproductive endocrinologist at the Southern California Reproductive Center (SCRC). The center is one of the few nationwide that use four-dimensional ultrasound for every transfer; it provides 3-D images in real time. A new SCRC study on more than 100 patients suggests the new technology does slightly increase pregnancy rates.Another way the center makes transfers smoother: "Before every transfer, women are given the option of having an acupuncture treatment to help them relax," says Dr. Danzer. "Some research suggests that acupuncture helps improve pregnancy rates in women undergoing IVF."10. Center for Reproductive Medicine of New Mexico, AlbuquerqueNumber of ART cycles and transfers in 2002: 183Percentage of ART cycles from non-donor fresh embryos resulting in live births in 2002: 57% (under age 35), 55% (ages 35-37), 29% (ages 38-40); there were too few cycles in women ages 41-42 to report the results as a percentageOpened in 1986, making it one of the oldest fertility centers; at that time, there were approximately 40 centers in the U.S., compared to the more than 400 todayIs one of five U.S. facilities collaborating on the development of quality-control measures in the analysis of sperm samplesBoasts a 2002 live-birth rate of 72% for fresh embryo transfers from donor eggs, above the national average of 50%Running the Center for Reproductive Medicine of New Mexico in a poor state that doesn't require insurers to cover infertility, Jim Thompson, M.D., focuses on giving patients value for their money. "My exam rooms and waiting areas have no frills," says Dr. Thompson, the center's director. "Instead, we try to keep our costs low and our success rates high."He seems to be doing a good job at both: In 2002, the center's live-birth rate for women ages 35 to 37 using their own eggs was about 70% above the national average -- 55% compared to 30% -- though its price for a standard IVF cycle (not including medications) is $8,500, less than the typical charge. He also has stellar success rates for women under age 35 and those who are 38 to 40 years old.Judging for YourselfDo you have to go to one of the fertility centers on this top 10 list to have a successful IVF cycle? Probably not. If you don't have a highly complex diagnosis, shop locally first because many centers have strong programs and traveling may add unnecessary stress. Here, six things to keep in mind during the interviews.1. Talk in the same termsOnce a couple's embryos are ready, doctors put them in a woman's uterus, where the hope is that they'll implant -- a process called embryo transfer. "Most transfers are easy. But in about 10% of patients, pinpointing the placement of embryos is difficult because of the shape or position of the uterus," says Hal Danzer, M.D., a reproductive endocrinologist at the Southern California Reproductive Center (SCRC). The center is one of the few nationwide that use four-dimensional ultrasound for every transfer; it provides 3-D images in real time. A new SCRC study on more than 100 patients suggests the new technology does slightly increase pregnancy rates.2. Inquire about your specific conditionYour chance of a successful IVF cycle depends on your diagnosis. For example, in 2002 only 14% of IVF cycles in the U.S. in women who were diagnosed with diminished ovarian reserve resulted in a live birth compared to 32% when endometriosis was to blame. While male factor infertility has a high live-birth rate of 34%, the success rate for specific conditions within this category can be much lower.3. Review the center's experienceAsk about the number of patients your age with the same diagnosis. Also make sure the doctors and lab staff responsible for the success rates you're being quoted still work there, says Thomas Pool, Ph.D., scientific director of the Fertility Center of San Antonio in Texas.4. Consider the rate of multiple births, especially triplets or greaterNew guidelines suggest the number of embryos transferred shouldn't exceed two in women under 35, two to three in 35- to 37-year-olds, and four in women 38 to 40 if a patient's chance of success is favorable. Implanting more embryos may slightly boost success rates, but it may also create dangerous pregnancies and complications for both mother and child. For instance, the rate of cerebral palsy is 17 times higher in a triplet birth than a single one.5. Speak to the lab staffThese employees handle your eggs, sperm, and embryos, so you have to be as confident of their competence as you are of the physician's, says Dr. Pool.6. Calculate the valueThe cost of IVF even within the same city can vary widely; charging up to $35,000 per attempt isn't unheard of, but prices don't necessarily reflect quality. Request a written estimate including the price of the medications, testing, and special techniques you need, and factor it into your decision. If your insurance covers IVF, ask if the center accepts it.Do You Need IVF?The majority of couples who have trouble conceiving don't require in-vitro fertilization (IVF). Fertility drugs, interuterine inseminations (where washed sperm is placed in a woman's uterine cavity to bypass the cervix, which stops a lot of the swimmers), or a combination of the two will do the trick in many cases. "IVF is indicated as a first-line treatment only in women with severe tubal disease, men with an extremely low sperm count or no sperm present in the ejaculate, or couples who need their embryos screened for a genetic condition," says Kenneth Burry, M.D., director of University Fertility Consultants at Oregon Health & Science University in Portland. However, he notes that if other treatments don't work in six cycles (three if you're over age 35), you should talk to your doctor about whether it's time to move on to IVF.Centers That Didn't CooperateThe Centers for Disease Control and Prevention in Atlanta is required by law to collect data on fertility centers. More than 90% of centers supply the information. But the following centers either failed to supply data for 2002 (the most recent year for which data are required) or didn't provide enough proof that the information was accurate.Advanced Reproductive Health Centers; Orland Park, ILThomas Annos, M.D.; Short Hills, NJAppalachian Fertility & Endocrinology Center; Kingsport, TNBeach Center for Fertility, Endocrinology & IVF; Virginia Beach, VABrandeis Center for Reproductive Health; New York, NYCenter for Advanced Reproductive Medicine; Springville, UTCenter for Women's Care; Chicago, ILCenter for Women's Medicine; Houston, TXChapel Hill Tubal Reversal Center; Chapel Hill, NCFertility Associates of Idaho; Boise, IDGynecology & Infertility Associates; Baltimore, MDAbraham Halfen, M.D.; East Setauket, NYIVF Hawaii; Honolulu, HIIVF Reproductive Services; Manhattan, KSIVF South Bend; South Bend, INKentucky Center for Reproductive Medicine; Lexington, KYLuana J. Kyselka, M.D.; Troy, MILa Jolla IVF; La Jolla, CALife-Women's Health Center; Berwyn, ILMetroHealth Medical Center; Cleveland, OHMid-Missouri Center for Reproductive Health; Columbia, MOBrenda Moskovitz, M.D.; Troy, MINew England Fertility Institute; Stamford, CTSiu Ng-Wagner, M.D.; Potomac, MDThe Reproductive Center; Youngstown, OHReproductive Genetics In Vitro; Denver, COReproductive Genetics Institute; Chicago, ILReproductive Health Institute; Orlando, FLReproductive Institute of South Texas; McAllen, TXReproTech IVF Program; Allentown, PASan Antonio Fertility Center; Upland, CAIssa Shamonski, M.D.; Santa Monica, CASher Institute of Reproductive Medicine; Chicago, IL; Creve Coeur, MO; and Sacramento, CAJames A. Simon, M.D.; Washington, DCTyler Medical Clinic; Los Angeles, CACenters We CommendIn 2004, Child magazine sent an extensive survey to more than 75 fertility centers that had very good success rates. The majority of centers didn't return the form. But we commend the following centers for doing so.Bethesda Center for Reproductive Health and Fertility; Cincinnati, OHThe Center for Advanced Reproductive Services; Farmington, CTThe Center for Fertility & Reproductive Endocrinology at Virginia Mason; Seattle, WACenter for Human Reproduction, North Shore University Hospital; Manhasset, NYCenter for Assisted Reproduction; Bedford, TXCenter for Reproductive Medicine; Minneapolis, MNFertility Center of San Antonio; San Antonio, TXFertility Treatment Center; Chandler, AZThe GBMC Fertility Center; Baltimore, MDHenry G. Bennett Jr. Fertility Institute; Oklahoma City, OKInfertility and IVF Center; St. Louis, MOInstitute for Reproductive Health; Cincinnati, OHIVF of North Jersey, PA; Clifton, NJLong Island Fertility and Endocrinology IVF Associates; Melville, Port Jefferson, and Lake Success, NYMcFarland Clinic PC; Ames, IAPennsylvania Reproductive Associates; Philadelphia and Plymouth Meeting, PAReproductive Medicine & Infertility Associates; Woodbury, MNThe Reproductive Medicine Group; Tampa, FLReproductive Partners-UCSD Regional Fertility Center; La Jolla, CASouth Florida Institute for Reproductive Medicine; Miami, FLStrong Fertility & Reproductive Science Center; Rochester, NYWest Coast Fertility Center; Fountain Valley, CAWomen & Infants' Hospital/Tufts-New England Medical Center; Providence, RI, Boston, MA, and six satellite location

Coronavirus disease (COVID‐19) and immunity booster green foods: Here is my explanationAbstractThis review focused on the use of plant‐based foods for enhancing the immunity of all aged groups against COVID‐19. In humans, coronaviruses are included in the spectrum of viruses that cause the common cold and, recently, severe acute respiratory syndrome (SARS). Emerging infectious diseases, such as SARS present a major threat to public health. The novel coronavirus has spread rapidly to multiple countries and has been declared a pandemic by the World Health Organization. COVID‐19 is usually caused a virus to which most probably the people with low immunity response are being affected. Plant‐based foods increased the intestinal beneficial bacteria which are helpful and make up of 85% of the immune system. By the use of plenty of water, minerals like magnesium and Zinc, micronutrients, herbs, food rich in vitamins C, D and E, and better life style one can promote the health and can overcome this infection. Various studies investigated that a powerful antioxidant glutathione and a bioflavonoid quercetin may prevent various infections including COVID‐19. In conclusion, the plant‐based foods play a vital role to enhance the immunity of people to control of COVID‐19.1 INTRODUCTIONCovid‐19 attacks people with low immune systems and people especially people of under and over ages. The immune system is built on beneficial live bacteria that lives in the gut which protect the human body from various diseases. When the immune system response is low, weak, or damaged, it becomes an open invitation for infections such as coronavirus or other diseases like diabetes, heart disease, or cancer. Plant‐based foods increase and help the intestinal beneficial bacteria, and the overall gut microbiome health which makes up to 85% of the body's immune system. On the other hand, excess of animal foods deplete the body from good bacteria, promote inflammation, and are the underlying cause of diabetes, chronic obstructive pulmonary disease cardiovascular diseases, hepatitis B, cancer, and chronic kidney diseases.Patients of coronavirus must have plenty of water, as that will keep their mucous membranes moist which can further lower the chances of cold and flu. If they do not sense thirst that much, then they can prepare soup for them or have coconut water, milk, green tea, and even some homemade fruit juice will be helpful. There is currently no evidence of COVID‐19 virus survival in sewage or drinking water.The COVID‐19 virus' morphological characteristics and chemical composition are similar to other human surrogate coronaviruses on which data are available to both sustainability in the environment and efficient coagulation measures (WHO, 2020).A myth that potable water must keep coronavirus at bay each fifteen minutes had been running in the headlines around the world a few days before. Although drinking water does not ensure that you would not contract the coronavirus, remaining hydrated can improve your health and make sure the immune system can defeat the virus if it is transferred to you. The drinking water works to help your cells to oxygenate. Cells can compete at their best if they get enough oxygen that helps them protect the body from any infectious agents that attempt to enter, or if they do, they fight them.According to Centre for Disease Control and Preventative, hydration often plays a major role in monitoring your body temperature. However, if you have a fever, if it is a side effect of COVID‐19 or some other infection or disorder in the body, drinking plenty of water is really important. Drinking enough water is essential, for a lot of reasons, as shown in a Havard Health report, and keeping the risk of disease lowered is one of them. Staying hydrated also enables to transmit nutrients to all parts of the body and helps to maintain all body functions and organs working potentially to decrease body infection. Dryness in the bodies can be caused by the drugs we take if we have a virus infection—such as common cold, and flu. As well, when we are sick, we start losing much of the body's water in the form of mucus, and that is the way our body removes the infection‐causing pathogens from the body. Until we drink too much water, we remain hydrated, and we can remove more mucus (along with germs) from our bodies.Until we get a cure and a novel coronavirus vaccine, taking all preventive measures and keeping ourselves healthy and safe is crucial. Although drinking lots of water does not guarantee you would not contract the novel coronavirus, it can be effective in reducing your danger to a large extent, and can also help you recover from the illness.2.ZINC AND MAGNESIUMimage:1 ZINC contained food,image:2 MAGNESIUM contained foodAn essential micronutrient is used in DNA synthesis and cell proliferation (Fuhrman, 2020). It is also involved in the regulation of innate and adaptive immune responses, cell signaling, and production of immune cells (Wessels, Maywald, & Rink, 2017). Foods that contain Zinc include red meat and shellfish (West, 2018).A very vital mineral for our immune system, magnesium, is also an important electrolyte that helps our body strengthen our immune system's natural killer cells and lymphocytes. It is also a key source of energy for our cells called adenosine triphosphate (ATP), which is so crucial that without this energy, our cells cannot function properly. Magnesium helps the hemoglobin in our blood which is responsible for delivering oxygen from our lungs to the entire human body, which assists in a COVID‐19 infection since the virus attacks the respiratory system (Sanderson, 2020). Foods rich in magnesium are dark chocolate, black beans, avocados, and whole grains (Spritzler, 2018).3.VITAMIN D RICH FOODSVitamin D and Mechanisms for Reduction of microbial infection. General metabolism and vitamin D activities are also well recognized (Pike & Christakos, 2017). Within the skin, vitamin D3 is formed by the interaction of UVB radiation approaching 7‐dehydrocholesterol throughout the skin, accompanied by a thermal reaction. The oral vitamin D or vitamin D3 is turned into 25(OH)D in the liver and then into 1,25(OH)2D (calcitriol) hormonal metabolite in either the kidneys or any other organs as desired. All of the impact of vitamin D comes from the entry of calcitriol into the nuclear vitamin D receptors, a DNA‐binding protein which often communicates directly with regulating sequences around specific genes and recruits active chromatin complexes that genetically and epigenetically participate in transcriptional production modifications. Some well‐known role of calcitriol is just to help manage the serum calcium concentrations, although it does in such a parathyroid hormone (PTH) feedback loop, which has many significant roles in the organism itself. Various reports discuss how vitamin D decreases the risk of viral diseases. Vitamin D has several pathways by which the danger of viral infection and mortality is reduced. A study of the importance of vitamin D in decreasing the common cold risk categorizes these elements in three categories: adaptive immunity, physical barrier, and natural cellular immunity. Vitamin D helps to promote gap junctions, junctions of tight, and junctions of adherents (e.g., by E‐cadherine). Several studies addressed how viruses damage the integrity of the junction, growing virus contamination as well as other micro‐organisms. Vitamin D improves cellular innate immunity in part by inducing 1,25‐dihdroxyvitamin D into antimicrobial peptides, like human cathelicidin, LL‐37, and defensines(Beard, Bearden, & Striker, 2011). Cathelicidins demonstrate strong antimicrobial activity by a variety of microbes including Gram‐negative and Gram‐positive bacteria, encased and un‐enveloped viruses, and fungus. Such host‐derived compounds destroy the foreign pathogens by destroying their membranes and thus can suppress the endotoxin's biological activities. Like mentioned therein, they have so many more functions. In a mouse model, LL‐37 decreased replication of the influenza A virus. From another laboratory study, 1,25(OH)2D minimized rotavirus replication by another method, both in vivo and in vitro. A clinical study stated that vitamin D supplementation with 4,000 IU/d reduced infection with the dengue virus. Vitamin D also improves cellular resistance, by raising the cytokine storm that the innate immune system causes. As found in COVID‐19 patients, the innate immune system develops both anti‐inflammatory and pro‐inflammatory cytokines in response to bacterial and viral infectious diseases. Vitamin D may decrease the development of pro‐inflammatory Th1 cytokines, known as tumor necrosis factor α and interferon ÿ (Hewison, 2012). Vitamin D administration decreases the production of pro‐inflammatory cytokines and enhances the production of anti‐inflammatory cytokines by macrophages and their references. Vitamin D is an effective immunity modulator; 1,25(OH)2D3 stimulates responses induced by T‐helper type of cell 1 (Th1), primarily by trying to suppress inflammatory cytokine production IL‐2 and interferon gamma (INFπ). In addition, 1,25(OH)2D3 encourages the development of cytokine by the T‐helper type 2 (Th2) cells, which helps to improve the indirect inhibition of Th1 cells by supplementing this with actions influenced by a variety of cell types (Wei & Christakos, 2015). In addition, 1,25(OH)2D3 facilitates activation of T regulatory cells and thus inhibits inflammation processes. Concentrations of serum 25(OH)D continue to decline with age that may be significant for COVID‐19 as case fatality rates (CFRs) raise with age; reasons are including insufficient time spent in the sunlight, and decreased vitamin D production due to lower skin levels of 7‐dehydrocholesterol. Furthermore, certain prescription medications by stimulating the pregnane‐X receptor decrease serum 25(OH)D concentrations are also regulated. These include anti‐neoplastic, anti‐epileptics, anti‐inflammatory agents, antibiotics, anti‐retroviral, anti‐hypertensive, endocrine medicines, and certain herbal medications. Consumption of pharmaceutical drugs usually increases with age. Supplementation with vitamin D also improves the production of anti‐oxidation‐related genes (glutathione reductase and subunit controller glutamate–cysteine ligase). The increased production of glutathione spares the use of ascorbic acid (vitamin C), which also has antimicrobial properties, and has been suggested for COVID‐19 prevention and treatment. In addition, he was a former Center for Disease Control and Prevention Director (Holick, 2007).4.VITAMIN C AND E RICH FOODSVitamin C is an important aspect of improving immunity, for the kids, adults, or even elderly people. Fruits like oranges, papaya, kiwi, and guava are rich in vitamin C and should be included in diet. Moreover, some vegetables like eggplant, bell peppers, beetroots, spinach, and cauliflower are known to be quite rich in vitamin C and are good for immunity. Green vegetables like broccoli, mushrooms, and even kale are a few immunity boosters that one can include in the diet. They improve the immune system of older people quite rapidly. Berries can also be included in the diet along with foods rich in omega‐3 fatty acids—beans, flax seeds, and even some nuts. Elderly people should consume Spirulina and Curcumin, as they are extremely rich in vitamin C and minerals. These super foods help in building and strengthening immunity at great level.Water‐soluble vitamins have significant benefits in treatment of sepsis and septic shock, a life‐threatening condition, which is caused by inflammation produced by pathogenic organisms. Other ways vitamin C aids the body are as a pro‐oxidant for immune cells, antioxidant for lung epithelial cells, and immunosuppressive effects (Erol, 2020). Foods that contain vitamin C are oranges, kiwi, kale, and broccoli (Hill, 2018).Vitamin E is vital for maintaining the overall health of elderly people, including their immunity. Vitamin E is a powerful antioxidant that can protect you from various infections, bacteria, and viruses. Soaked almonds, peanut butter, sunflower seeds, and even hazelnuts should be consumed to get the daily dose of vitamin E. Vitamin E functions primarily as an un‐specific, chain‐breaking antioxidant that bans the spread of lipid peroxidation. This vitamin is often a radical peroxyl scavenger that protects the polyunsaturated fats in plasma membranes and lipoproteins (Liang et al., 2003). F2‐isoprostan quantification is the most effective indices of free‐radical production and oxidative lipid destruction in vivo (Lin et al., 2002). The F2‐isoprostans are enhanced, and their emission may be reduced by taking supplements with vitamin E. Vitamin E performs a significant part in preserving immune responses, with such a small deficiency effecting immunity, or supplements with rates higher than prescribed, improving elderly people's humoral and cell‐mediated immunity (Mastaloudis, Leonard, & Traber, 2001). These observations have developed interest in whether or not vitamin E supplementation during heavy stress can attenuate immunosuppression and oxidative stress. Some work has shown that 1–5 months of supplementation with vitamin E (200–1200 IU dl –tocopherol) raises tocopherol plasma level but has almost no impact on athletic efficiency of muscle damage indices caused by contraction and a varying effect on oxidative stress caused by exercise. The equivocal existence of these findings is linked to the study of design problems, like the subjects' timing and type of exercise, fitnessor age levels, the volume and shape of the vitamin E supplement, and methods for oxidative stress assessment (Itoh et al., 2000). The impact of vitamin E supplements is still not studied in sufficient aspect and equivocal on the immune and inflammatory response to sustained exercise. The ROS–immunity relationship is still described, but growing evidence indicates a link (Haidari, Javadi, Kadkhodaee, & Sanati, 2001).The generation of ROS and the antioxidant position were linked to immune differences in some disease processes and the healing process, but this interaction is unexplored in the human athletic effort. In an earlier study by some researcher, supplementation with vitamin C during an ultra‐marathon did not influence oxidative stress and immune abnormalities induced by physical activity (Hartmann, Nieβ, Grünert ‐Fuchs, Poch, & Speit, 1995). In vivo vitamin C mainly provides antioxidant protection as a radical scavenger of peroxyl and oxygen in the aqueous phase. We argued that although vitamin E inhibits the spread of lipid peroxidation, the above multivitamin has a greater potential to act as a defensive measure to changes in immunity and lipid peroxidation induced by activity than vitamin C.The aim was to assess the impact of vitamin E ingestion on oxidative stress or immune changes following the Triathlon World Championships in Kona, Hawaii. Thirty‐eight randomized, dual‐blind triathletes received vitamin E (800 IU dl D — tocopherol) as well as placebo capsules for 2 months until the event of the race. It is conclude that vitamin E supplements would alleviate physical activity‐induced rises in immune alterations in the sense of severe discomfort, oxidative stress, and inflammatory cytokines (Haddad & Fahlman, 2002).5.HERBSSome of the immunity‐boosting herbs are garlic, black cumin, and liquorice. Include them in the diet of the elderly in the form for tea or by adding them in their food. This will not enhance their immunity but improve their gut as well. Herbal treatment is very well known in Traditional Chinese Medicine (TCM).Traditional Chinese Medicine has a longer history and is an essential part of the treatment or prevention of certain outbreak diseases. The TCM intervention also achieved impressive therapeutic effect during SARS epidemic in 2003. During the COVID‐19 recovery period, more than 3,100 TCM medical personnel were assigned to the province of Hubei as well as the TCM program was included in COVID‐19 Testing and treatment Guideline, and TCM specialists were fully involved in the entire rescue process (Wu et al., 2020). TCM's decoction, Chinese trademark medicine, acupuncture, as well as other characteristic treatments were used extensively and are mainly based on differentiation of the syndrome. Different TCM clinics were arranged and the specified hospital was established, while the TCM team is also collectively involved in the treatment. Currently, the total number of actual situations being handled by TCM has exceeded 60,107. In 102 cases of TCM signs that decreased clinical symptom demise time by 2 days, decreased body temperature recovery time by 1.7 days, decreased hospital stay average by 2.2 days, increased CT image enhancement rate by 22 percent, increased clinical survival rate by 33 percent, the hospital stay rate decreased by 27.4 percent as well as 70% increase in lymphocyte Additionally, in the treatment of serious TCM patients, the actual length of service in hospital as well as the time of a nucleic acid transmission harmful was shortened by more than 2 days.Traditional Chinese Medicine, focused on an overall major cause of COVID‐19 pneumonia patients, may have beneficial prescriptions, like those of gancaoganjiang decoction, qingfeipaidu decoction (QPD), qingfeitouxiefuzhengrecette, sheganmahuang decoction etc. qingfeipaidu decoction which comprised of, Polyporus Gypsum Fibrosum, Armeniacae Semen Amarum Cinnamomi Ramulus, Atractylodis Macrocephalae Rhizoma, Poria, Alismatis Rhizoma, Glycyrrhizae Radix et Rhizoma Praeprata cum Melle, Scutellariae Radix, Bupleuri Radix, Zingiberis Rhizoma Recens, Asteris Radix et Rhizoma, Pinelliae Rhizoma Praepratum cum Zingibere et Alumine Farfarae Flos, Rhizoma, Aurantii Fructus Immaturus, Belamcandae, Asari Radix et Rhizoma, Dioscoreae Rhizoma, Pogostemonis Herba, and Citri Reticulatae Pericarpium the COVID‐19 diagnostic and treatment plan has been introduced as the general prescription in China. Of the 701 reported cases handled with QPD, 130 cases were successfully treated and released from hospital, 51 clinical symptoms faded, 268 cases of ailments helped to improve, and 212 cases of non‐aggravated stable symptoms. QPD's useful survival rate against COVID‐19 exceeds 90%. COVID‐19’s target location really is the lung according to TCM theory, and the pathology characteristic is "humid and toxin plague." The pharmacology analysis of the network demonstrated that QPD has an aggregate administrative impact over multi‐target and multi‐component. Perhaps, the primary pharmacological site is the lung, since 16 lung meridian herbs indicate that decoction is primarily specific to lung disease (Xu et al., 2020). This can also perform Dehumidification roles rise and fall through spleen and stomach, as well as exhibit kidney, heart, and other organs protection. One of the prospective specified screens, many of non‐expressed with ACE‐2, the COVID‐19 molecule can inhibit COVID‐19 replication by acting upon numerous ribosomal proteins.COVID‐19 can contribute to trigger the immune system as well as a nominal increase in inflammation. Analysis of functional enrichment has shown that QPD can inhibit and mitigate improper immune system response and remove infection by trying to regulate the pathway associated with cytokine action and the immune‐related pathway. In addition, by predicting patchouli alcohol, molecular docking, shionone and ergosterol, were found to have a good anti‐COVID‐19 influence in the formula, which provides new chemical compounds for the development of new drugs.Here, to prove its effectiveness, we take for example one identified COVID‐19 patient handled with TCM. Few days before the beginning of the infection, the male patient was also on a work tour in Wuhan (Xu et al., 2020). Fever and cough have been repeated during admission timespan, and respiratory rales were also not evident for both lungs. West antibiotics were first used, such as taking ganciclovir intravenous infusion, oseltamivir phosphate capsule orally, and recombinant inhalation of human interferon a1b aerosol. Even though the nucleic acid test became negative, the results of chest CT revealed that there was increased fusion of two lung glass darkness and increased density, which was much more complex than admittance. Severe illness is associated with the performance of the patient's moist‐heat syndrome as well as the temperature is much more severe than humidity, QPD has been applied for diagnosis.Traditional Chinese Medicine has its own attributes, like differentiation therapy, Yin and Yang balance, disorder differentiation, holistic concept, strengthening body resistance to microbial factor elimination. TCM must have decades of experience in body monitoring and pandemic resistance, with new perspectives and experience in treatment and prevention (Wu et al., 2020). TCM's early intervention can prevent the illness from converting into severe and crucial illness for mild and prevalent patients. In the serious cases, by improving ailments, TCM has gained time to rescue them. COVID‐19 rehabilitation practice has shown that earlier time TCM operation is a fundamental way of improving cure rate, shortening disease course, delaying disease progression, and minimizing death rates. In addition, the reason why TCM operates was not only to prevent the infection, but also could prevent the disease, legislate the immune system, promote body repair, and cutoff the inflammatory storm.In addition, COVID‐19's prevention and control measures fully reflect the “preventive treatment of disease” ideology. In addition to the pandemic diseases recorded during the Han Dynasty, TCM's preventive measures should also include sports, psychology, medication, and diet (Xu et al., 2020).In COVID‐19's treatment and prevention, this should offer the benefits of TCM in differentiating syndrome and reduces both health problems and mortality rate. Furthermore, scientific research on the TCM with clear healing efficacy of COVID‐19 must also be passed out in order to fully evaluate its mechanism of action and deep understanding of COVID‐19 (Zhu et al., 2020).6.LIFESTYLEStress negatively alters the immune system responses within the body (Salleh, 2008). Stepping away from the media and TV is also very important in letting one's mind distress from the world a bit. Try limiting yourself to about an hour in the morning and at night to just catch up and see if there are any important changes.Sleep, a huge influence on the immune system, gives the body an opportunity to heal and rest, especially in critical illnesses (Kamdar, Needham, & Collop, 2012). Furthermore, sleep was considered extremely important by doctors in the recovery of their patients during the Spanish Flu Pandemic (Abascal & Yarnell, 2006).Exercising helps raise the levels of white blood cells and antibodies that fight off infections (Join & Calendar, 2020). Exercise is especially important after a critical illness to improve muscle mass, strength, and resiliency (Heyland et al., 2016). Exercise can also help with the prevention of blood clots, which have been a symptom for some people who contracted COVID‐19 (Clerkin et al., 2020).Eating a well‐balanced, healthy diet and staying away from processed junk food is very important to maintain overall health, as well as to support immune functions. Eat as much fresh produce as possible, but if it is not in season or hard to find then the next best thing is fermented or frozen. These items are normally picked at the peak of the season and then frozen or fermented straight away (Join & Calendar, 2020), also, make sure to eat sufficient protein (Hyman, 2020).7 ANTIOXIDANTSGlutathione is a powerful antioxidant in the body, it scavenges damaging free radicals and is involved in tissue repair and builds chemicals and proteins that are used for the immune system. N‐Acetylcysteine, or NAC, promotes the production of glutathione and is also used as a supplement. Studies in animal models of other viral infections have shown that NAC reduced the severity and duration of symptoms by increasing cellular defense and repair. NAC is taken in doses of 500‐600 mg. Glutathione can be taken orally 500 mg or by IV 400–2400 mg with a doctor's order (Center and fees, 2020).Quercetin is a bioflavonoid found in a variety of fruits and vegetables. Animal and laboratory studies have demonstrated that quercetin can inhibit a wide range of virus infections including a COVID‐19‐related coronavirus SARS CoV. Quercetin supports antioxidant capacity and protects lung tissue. As a supplement is combined with vitamin C, bromelain is sold as a single supplement. Recommendation is between 500 and 1000 mg daily (Center and fees, 2020). Major sources are leafy green vegetables, dill, peppers, apples, grapes, fennel leaf, red onion, oregano, chili pepper, green tea, and black tea (Centre and fees, 2020).8 CONCLUSION AND FUTURE PERSPECTIVEPeople with low immunity are more prone for this world pandemic named as COVID‐19. To help or boost the immunity, the plant‐based foods play vital role by promoting beneficial bacteria in the body. Various vitamins like C, D, and E are investigated to provide important aspects for improving immunity. Fruits like oranges, papaya, kiwi, and guava are rich in vitamin C, while vegetables like eggplant, bell peppers, beetroots, spinach, and cauliflower are known to be quite rich in vitamin C and are good for immunity. A very crucial micronutrient is used in DNA synthesis and cell proliferation, which regulate innate and adaptive immune responses. Vitamin D improves cellular resistance, partially by raising the cytokine storm that the innate immune system causes. Green vegetables like broccoli, mushrooms, and even kale are a few immunity boosters that improve the immune system of older people quite rapidly. Moreover, some herb combination in TCM is also known to play crucial role in the prevention COVID‐19. Future aspects of this account for more research which is needed significantly on physical behaviors or exercises and their role in immunity‐related issue thus preventing COVID‐19 aspects. More research is needed to know about the behavior of coronavirus and the role of food in its prevention. Immunity‐boosting food combinations should be studied which, in combination, provide one and one makes eleven roles. In nutshell, green foods are vital against novel coronavirus by improving the immunity of all aged groups.ACKNOWLEDGMENTSThe authors are highly thankful to Government College University Faisalabad‐Pakistan and Higher Education Commission of Pakistan for providing free full‐length papers.