The Infertility Center of St. Louis

The clinic feels outdated in general. Small clinic, but only meet there once as all other testing/monitoring is done within St. Luke's Hospital. The hospital staff was often not on the same page/team as Dr. Silber. Strengths: nice phone etiquette

I had one face-to-face appt with Dr. Silber and it felt rushed. He had incorrect information about my case history despite providing them with medical records in advanced timeframe. My IVF coordinator sent me emails meant for other patients as well as lab orders with other womens' names on them on multiple occasions. My IVF protocol did not feel personalized to my specific needs-- he has his protocol and he sticks to that.

Kelsey sent me emails and labwork that were intended for other women on multiple occasions. She called me or emailed me with test results. I was only given the opportunity to meet with her face to face on one occasion, immediately following our initial IVF consultation. My chart was lost on one occasion. There was a miscommunication between her and Dr. Silber about which trigger shot to prescribe resulting in a failed egg retrieval.

I elected to work with Dr. Silber because of my diagnosis of diminished ovarian reserve-- he is reportedly a pioneer in the area of IVF for women with this condition. Various miscellaneous errors took place when it came to coordinating my care (wrong lab work, receiving emails and labs belonging to other women), but the biggest error was being prescribed the incorrect trigger shot prior to my third egg retrieval. When Dr. Silber came into the pre-op room prior to the retrieval, he questioned why I had taken a particular injection that he prescribed. Turns out, he and the IVF coordinator had a miscommunication which resulted in me taking the wrong drug. They were able to retrieve one egg only. Then, they forgot to call me with the results and subsequently lost my chart. I called to check on the status of the fertilization results and found out that the one egg did not make it to day 3 status. Dr. Silber does not believe in fertilizing embryos to day 5 blastocysts.

Be prepared that you will likely feel like a number. Dr. Silber travels a lot so then when he is home and working, he tries to cram in all of his patients at once. I often waited hours for bloodwork and ultrasounds amongst a huge group of women who'd traveled from all over to work with him. For the amount of travel that I did to work with him myself, I would've wished for more face time with him. That would've helped me feel more trust in him as my physician (one consultation with him and with my IVF coordinator, otherwise just saw him in pre-op prior to my retrievals and transfer).

Denmark Mini IVF Protocol- follistim 150mg- cycle cancelled prior to retrieval Mini IVF Protocol used for two retrievals- 50mg clomid daily leading up to retrieval- 5 eggs retrieved first time around (2 made it to day 3 embryos), 1 egg the second time around that did not fertilize Both protocols were recommended due to my dx of diminished ovarian reserve Frozen transfer of the two day-3 embryos that we had- negative

Monitoring had to be completed between 6-8am at the hospital for all women undergoing a cycle at the same time. Dr. Silber starts all of his cycles on the scheduled dates so a large number of women are going through monitoring at the same time. The radiology techs seemed stressed by the amount of work they were expected to complete within a short duration of time.

Completed 3 egg retrievals (one cancelled prior to retrieval-- lost $1500 on that round), ICSI, and one frozen transfer for $30,000 (including cost of meds)

He recommended transferring two embryos and said that I would have a 60% chance of success due to my age (under 35)-- negative pregnancy test outcome

Strengths- Well trained lab. Leader in trying new protocols and technologies, provided Silber thinks the data is good on it. They take difficult cases, older women, and still have decent stats. Experienced with mini/low dose IVF. Has more willingness to try different things than you would think given how he comes across at first. They handle quite a volume of cases given that it is just Silber and one other assisting GYN as the only doctors. He truly loves what he does. Weaknesses- No portal in which to exchange health info securely so you either have to be okay using personal email that is not secure or working over the phone. The clinic also doesn't routinely communicate a lot of info about the embryos other than pictures and generally whether they look good (no grading info that some other places provide these days) unless you request it. Silber has some strong opinions about certain diagnostic tests, methods, and complementary medicine that may be off putting to some folks. The procedures are done through the hospital and so stuff like the ultrasounds and labs end up working in a first-come first-serve methodology rather than a dependable appointment time so going super early or at the tail end makes for usually a shorter overall visit. The egg retrieval and embryo transfer procedure times can't be known more than 2 days ahead and may run late or earlier than predicted that day. I also had a hospital nurse attempt to put an IV in my hand for the egg retrieval (contrary to a much less painful approach on my arm that was done the times I had retrievals elsewhere). I also had nurses in the hospital fail to relay some info back to me from the doctor even after asking repeatedly.They don't do mock transfers. There are lots of separate payments to the various parties between the clinic, hospital, GYN, anesthesia rather than being able to pay in one transaction for each cycle or transfer. If you are an out-of-towner, the vast majority of the ultrasound assessments must be done at the clinic so you must either travel there several times or be prepared to stay at least 7-10 days. And lastly as a mostly one-man show, you can have a longer wait time to get on the schedule your next cycle or transfer in than other clinics.

This center sees a lot of patients for having just one Reproductive Endocrinologist. I was sometimes frustrated with the generic template instructions given for each treatment cycle as aside from updating it to your treatment dates, they lumped in advice for FETs with stuff only needed for IVF (cycles for egg retrieval). This led to me needing to clarify a bunch of stuff with my assigned coordinator, to make sure I knew what stuff applied to me. I found the wait times to get into the clinic rotation to be 2-4 weeks longer between cycles than other clinics I or peers have dealt with. I did feel like mostly they respected my requests for how to communicate with me best, but they did have to be reminded a few times. Also because of them trying to be efficient in patient volume and cases, they can't tell you your procedure time until 2 days before it is scheduled, which makes it very difficult to line up things like supportive pre and post procedure acupuncture.

My care coordinator was generally good at answering my questions in a timely manner. She was also great about sending prescriptions to various pharmacies so I could save money on medications. Sometimes she forgot what was my preferred communication method and one time forgot to relay some specifics about medication dosing right before a procedure that would have been helpful. There were quite a few times when she was out on vacation or otherwise and I wished I had been alerted to when she was out because I might have tried to coordinate talking with her earlier to avoid times when she was out.

Dr. Silber has a pretty old school doctor demeanor in how he operates. He clearly has a passion for cutting edge technology and has a lot of expertise but at the same time can have some very strong opinions that can be off-putting or seem like possibly he is discounting something that might have scientific merit. This is what I would expect from someone who has been practicing medicine for 30+ years. He can be blunt but I was going to the clinic for the lab expertise rather than super awesome patient bedside manner. He is very willing to take difficult cases and is not screening out anyone to make his stats look better. He is not super open to certain things like acupuncture/herbs/supplements. He is confident in his lab and yet was conservative in his estimates of what we could expect as an outcome and we were pleasantly surprised with our results. I did appreciate his willingness to accommodate our conservative approach to generate as many possible embryos and not take measures that could lead to discarding one that could have been viable (for example we chose not to do PGD testing because of false positives, and not make all embryos grow out to day 5). He also very generously offered to take previously frozen eggs and fertilize them alongside a current cycle with no additional charges. We had other clinics get skittish at the idea of handling any frozen eggs they did not create.

He is pretty direct, and has some strong treatment preferences. Further discussion with him has shown he is somewhat willing to try alternatives if you have had issues with past protocols. He only does in-person consults. For FETs you are asked to have no food or drink and to hold your urine from midnight until after the procedure. I never made it through the night without having to go but still had a full enough bladder for the procedures.

We did the japanese mini-IVF protocol since in his experience this typically gives the best quality eggs for older women with age-related DOR. We only did one cycle and got 1 dominant follicle which was less than the typical 2-4. Prior to this I had been getting 2-4 during medicated IUIs at similar doses of follistim, so I'm not sure if my body didn't like this particular protocol with the clomid or if it was just what was going to happen that cycle regardless. The 1 egg retrieved did make it to day 3. In addition I had some previously frozen eggs from my 30s fertilized and almost 40% of them that made it to day 3 or day 5. With the japanese protocol there are no fresh transfers due to the ovulation induction med used (makes for poorer uterine lining). We have done 2 frozen embryo transfers (FET) with 1 embryo transferred (day 5's from my previously frozen eggs) each time and are now pregnant after the second try. We were trying to maximize the number of embryos so we liked his strategy to achieve this by foregoing PGD testing (some percentage of embryos that fail PGD actually can still be viable), freezing everything that looked great on day 3, and growing out anything that seemed less great till day 5 to freeze if it looked good enough.

There are general hours for monitoring appointments that are basically first-come first-serve, even though you call at least a week ahead and set an appointment time. The time doesn't mean anything other than they know you will show up sometime during screening hours that day. I was usually done with labs and the ultrasound in about an hour most times.

I think my mini-IVF was about 12,000 plus meds(~1800) , and that includes one FET. Additional FETs run about 5000 plus meds (~600 through 2 wks post transfer).

Dr. Silber mostly recommends 1-2 embryos per transfer. If you desire to put in more you must indicate on the procedure form that you will consider selective reduction in the event you carry more than twins.

Someone always answered the phone when I called. I just wanted to speak to my physician which wasn't an option. The charting system seem very outdated. There was construction around the lab and that made me nervous about the lab quality. Also since they only wanted to do day 3 embryos I wondered if there is a lab quality issue. Why not day 5?

I could never get in touch with my doctor. I didn't live locally and he wouldn't do phone calls. All of my results were given to my the coordinator (who I don't think was even an RN). There was not f/u after negative tests. The only time I talked to him was right before the egg retrieval or transfer when he said "if this doesn't work we will do the same thing again." He never dx with diminished ovarian reserve I had to figure that out from my medical records.

I don't think she could accurately explain in detail what I wanted to know about my treatment plan or my lab results. I would have preferred to have a RN.

He was never on time, wouldn't take phone calls or call me with results. I'd get mail from him that included information that was already outdated. He never discussed my labs with me or my results to troubleshoot. He just wanted to do the same protocol again and again until it worked. I finally requested my medical records and found that during my fresh transfer my progesterone was 1.7 (I've been told that over 1.5 before transfer =canceled transfer, but he went ahead with it). I only had two ultrasounds before my FET without any change in medications....it's just not an individualized plan for anyone.

RUN FAST, take a look at their outcomes on the CDC website they are below national levels by a lot.

Mini Denmark-lower medication stimulation plan. I thought we used this because I was a "healthy" and my husband had malefactor. After more research I also have fertility issues. Dr. Silber did minimal diagnostic workup.

Monitoring appointments were pretty easy.

$15,000 for the egg retrieval and TESE

He had a strong preference for day 3 embryo transfers and not doing genetic testing.

The first meeting will be a long wait time, and he’s at a hospital instead of a clinic so I wasn’t used to the crazy appointments for ultrasounds, bloodwork etc and since he’s so popular it took up a lot of time.

He knew everything about me before I met with him, he asked a lot of questions and spoke into a recorder and had an assistant in the room taking notes. He took the time to listen and get to know my situation.

Extremely responsive, organized, caring. Very detailed.

He is extremely knowledgeable and understanding. We had some news at our transfer appointment that i should have had a follow up test done and he wasn’t sure if we should move forward. We chose to and wish we would have listened to his opinion. He already had another protocol ready to go.

He is older so very by the books and smart. Be prepared for a lot of information and a very straight forward answer.

IVF treatment included follistim, ganirelix, Lupron, estrogen patches, estradiol pills, progesterone shots after transfer. We completed egg retrieval and got 14 eggs, 5 mature, 4 embryos, 2 of which were watched for 5 days and didn’t make it. 2 embryos were frozen on day 3 and we had to freeze due to overstimulation from PCOS. I started progesterone shots and after getting a positive test we found out it was a chemical.

Monitoring was during certain hours, you don’t meet with Dr Silber or staff until major appointments or procedures. Scheduling all the tests were easy.

The first round of IVF, 500 deposit, 6300 due 4 weeks before, 1350 for assisting OBGYN, 3500 to the hospital, 400 for anesthesia, 150 for radiology, 2500 for medication.

He said no more than two and you have to sign consent if you want more than that. His preference was 2, higher chance of pregnancy but not as dangerous as multiples.

I think it was neat how they had all of his articles and accomplishments displayed in the waiting room. It gave us a boost of confidence in him before we even met him. It also gave us a chance in a way to get to know what he is all about. The environment was very clean.

Dr. Silber was very kind and compassionate in our appointment. Instead of remaining in a patient room the whole time, he took us to his office. There he got to know us as a couple, individually, and we got to know him. He answered all questions no matter how big or small with patience and explainations. His nursing staff was also prompt with information and have kept in contact very quickly whether it was via phone or email. Compassion is key in the healthcare field, and I can personally say that being a nurse.

Strengths are compassion, friendly, prompt in responding. We haven’t had any negative issues at this time.

As a patient having a doctor get to know your husband, yourself, and then you both as a couple is refreshing. He took the time to move us from patient room once the clinical part was finished to his office for a more personal conversation. He answered every question and showed compassion the entire time. He also allowed us to learn a little about him as well. He made sure before we left we had no other questions. It was very reassuring.

Go Go Go and see what he can do for you!

We were on clomid and are currently saving for IVF. Due to our infertility factors IUI is not an option. We haven’t been able to afford a round of IVF yet.

I remember his consulation was absolutely FREE and I thought that was amazing. We only paid for the ultrasound.

He told us he bases it on the persons history and that he doesn’t always go one or the other

All of the staff at this clinic is extremely helpful and friendly. You are greeted with a friendly smile from the beginning and they are willing to be there for you when needed. It is a clinic that is extremely busy though, so if you are looking to go to a clinic that has a small environment/atmosphere this place may not be the best for you.

I felt like his office had a really high number of patients which made it very difficult for him to develop a personal relationship with us. The only time we saw him was at the egg retrievals. Although he is very friendly, I would have liked more communication with him directly throughout the IVF process.

Our nurse coordinator was extremely friendly and always willing to answer any questions we may have. However, there were a couple times I feel like things could have been more organized.

Dr. Silber is extremely knowledgeable in the field of infertility, and he was very good at explaining everything and the process to us. I do think there are a couple things though where he follows more of an old fashion approach (ex: freezing embryos at day 3 instead of day 5) which does work for some patients but not all. If there was something along the way that I thought should be done different (after doing my own research and communicating with other IVF patients), I would have to be my own advocate and ask that we do it (ex: growing all my embryos out to day 5, doing a uterine scratch after a failed transfer, etc). Although Dr. Silber was willing to do my wishes, I sometimes felt like I should have been given alternate options and processes instead of discovering it on my own. He is a very friendly doctor though and is willing to take on the most complicated cases.

Be your own advocate! If there is something you are wanting to try different speak up and see if he is willing to do it. He is very personable but will also be honest and upfront about your chances of success.

As a 27 year old I suffer from diminished ovarian reserve, so my best treatment option was mini IVF. For my first cycle, my protocol was Clomid for 7-8 days, Follostim every other day beginning on day 3 of meds, 1 injection of Ganirelix and then triggered with Novarel. We were able to retrieve 9 eggs, 7 were mature, 5 fertilized, and we ended up with 3 3-day embryos. For my second cycle, Dr. Silber wanted to do Denmark mini-IVF to try to produce more embryos so my meds were a little different. I don’t remember the specifics, but I did Follostim every day, micro dose Novarel every other day along with Ganirelix, and then triggered with Novarel. There were 11 eggs retrieved, 8 were mature, 7 fertilized, and we ended up with 5 blastocysts and 1 morula. We have transferred 2 3-day embryos and 2 blasts but nothing has stuck and got negative betas.

Due to Dr. Silber having a high number of patients, monitoring appointments were often crazy. Monitoring was supposed to take place between 5:45-8:30. However, if you arrived at the hospital after 7:30, you could easily expect to be there for 2-3 hours due to a long list of patients waiting to get the same monitoring done.

For our first cycle of mini-IVF we paid around $10,500 plus the cost of meds ($1,500-$2,500). The cost of the first transfer is then around $3,900. Any additional transfers are $7,900. For my second cycle of Denmark mini-IVF, we paid around $14,000 plus the cost of meds ($2,000-$4,000).

When we did our first transfer with 3-day embryos, Dr. Silber was open to a multiple embryo transfer. However, when we transferred 2 5-day blasts, he only wanted to do a single embryo transfer, but we stated that we wanted a multiple embryo transfer, so he was fine with us transferring two.

I have talked to a staff member or two that I was not completely crazy about..but for the most part all of the staff that I am in direct contact with are very friendly. Also, the location of the clinic and outpatient testing are a bit confusing in the hospital..it took my husband and I awhile to figure out the hospital.

Dr. Silber’s staff is very efficient and friendly. Dr. Silber himself is very confident and knowledgeable.

Mindy is great. She is responsive to my questions and you can tell that she cares. She has been working with Dr. Silber as an IVF coordinator for over 10 years. We feel that we are lucky to have Mindy on our IVF team.

We are starting the birth control for our first IVF cycle today 9/25. So far Dr. Silber has been great. My husband and I left our first appointment with him feeling relieved and confident. He has been around for the entirety of IVF and has seen every possible situation. He gave us hope, he is blunt, and knowledgeable.

A prospective patient of Dr. Silber should be ready for a plan of action when they arrive to their first appointment. Dr. Silber welcomes you with knowledge, facts, his opinions, and his plan. We were ready and willing to pursue IVF when we arrived to our first consultation and that is the approach Dr. Silber has us taking.

Dr. Silber is having us do Denmark Mini IVF vs. doing Traditional IVF due to the fact that my husband and I are young and I still have an abundance of eggs. He feels there is no need to potentially over stimulate my ovaries whenever the mini IVF should produce a good number of good quality eggs.

Dr. Silber does not have a consultation fee. He requires you to have a trans-vag ultrasound before your first consult though. I would say the costs are average

If your out of state, know that your consultation appointment can change even if you’ve already booked your flight and stay. We were told we had to change our appointment date and time due to scheduling conflicts. This information was provided less than 48 hours before our original flight. Due to this scheduling conflict we ended up paying an additional $1500 for plane tickets and accommodation changes. The thing is in your consent paperwork that you have to sign as a patient they tell you how they keep your deposit and how no refunds are allowed at certain stages if cancellations are required. I found it unethical for them to want to keep our funds but not reimburse us or lower the cost of services due to errors on their end (scheduling conflicts).

During our consultation with Dr. Silber he took as much time as we needed to answer all our questions and concerns. We were provided with a fertility coordinator who would be there to assist us with any questions or concerns we had during the process. From emails to personal calls on restaurants to try in the area; Dr. Silber and his team provided assistance. From the most detailed questions regarding my medical history and age to the simplest ones on our unborn children’s personalities. He took time, paid attention to our questions and answered them appropriately.

She was nice when we met, the office was extremely busy on our initial meet so I’ll attribute some of that to being tired and the businesses of the office. I had lots of questions being that I was from out of town and at times it was hard to reach her, but she always responded once she was available and ended each conversation with “feel free to call me anytime.” She provided local restaurant selections since we were from out of state. The office staff knew me by name (not sure if that’s because I called often or if they just remembered). But finally, all my questions were answered and now I’m in St. Louis preparing for my first retrieval.

Dr. Silber is a man of short stature but talk in wisdom and knowledge within the fertility industry. Through his experience and education he has become one of the most sought after Fertility Doctors. I personally call him the Father of Infertility, based on the research he has pioneered. Personally he’s full of life, laughter, jokes and joy. He knows how to make you smile when you want to cry. He does his best to provide you with all the details and information you’ll need during your consultation. After which you are turned over to your coordinator. The next time I’m scheduled to see Dr. Silber will be at my retrieval. This is because I’m an out of state patient. So I have to travel for every appointment which we’ve kept down to a minimal amount. He’s a strong believer in Faith and what you believe can happen, in my opinion. He’s allowing me to use my own eggs during the process and that’s my hearts joy.

Have your questions and concerns written out on piece of paper when you go in to meet with him. He’ll take the time to answer them. No question is a dumb question. Be prepared for possible changes in appointment dates because they do fluctuate. This is because other patients are being seen and based on how the medication responds to their bodies their retrieval date could change, which may affect your appointment date. Be open for change.

Based on my medical history, we started off with blood labs to make sure I didn’t have a translocation gene. Once those results came back normal we proceeded with the set protocol. THE PROTOCOL: Step 1: birth control pills for 25 days. Step 2: call doctors office with day 1 of my next cycle. Step 3: Stem Start testing was completed on day 31 (you can have this completed in your home town if you’d like, however the results have to be back to Dr. Silbers office well before close of business on the same day of testing so they can tell you when to start your medications. I opted to travel to St. Louis because I was unable to find a lab or doctors office that could complete the testing and get the results back in time. This process may require approximately a 13 days stay in St. Louis at a local hotel. Dr. Silbers office does have a relationship with local hotels that provide a discounted rate for his patients or patients of the hospital. Step 4: I began my medication protocol on day 32. This was colmid 50 mgs (1 tablet for 2 days); day 34, a Follisitm injections of 150 iu and 1 clomid 50 mgs on the 3rd day my medication protocol. On day 4 (med. protocol but process day 35) I took 1 more 50 mgs clomid table and on Day 5 (day 36) I’ll be back at the center for blood labs and ultra sounds to see how the follicles are developing. Once that process is completed I’ll be provided with additional instructions on what to do and if my retrieval will be scheduled within the next 34-36 hours. If the follicles have not developed to the desired state additional medication protocol will be established along with additional blood labs and ultrasounds until retrieval date. After retrieval we are required to stay in St. Louis for 24 hours before heading back home. We are then instructed to wait 3 months before implantation. This time period is to allow for the medication to leave the system and make sure that the lining of the uterus is back to its normal state of thickness. After the 3 months/ 3 cycles have passed then you return back to St. Luke’s Hospital in St. Louis for the implantation procedure. You will be in St. Louis for two days this time because you have to wait 24 hours after the procedure before heading home. 11 days after implantation you are required to take a pregnancy test (blood test not the standard test from the drug store or wal-mart.) Once you have the results you contact Dr. Silbers office and go from there.

For the minimal IVF procedure the cost was approximately $12,000 - 14,000.00 with me using my own eggs and my husbands specimen sample, testing and freezing for 1 year. This also include my egg freezing for one year as well. Along with the hospital charges and assisting physician (GYN).

Based upon my age and ovarian reserves Dr. Silber advised that he’d implant 2 embryos at implantation. Of course, the results could end up with twins of which we welcome and accept. His method is based upon medical history and age.

Dr Silber is the only doctor but there are a couple assisting doctors who do the egg retrievals-- they work at other clinics but show up on retrieval day to do procedures. Dr Silber does the embryo transfers. The people at St Luke's Hospital are very nice and the nurses in the procedure area were great. If you do get pregnant, Dr Silber dismisses you after the second HCG test (assuming it is doubling). This can be a shock, especially if you are out of state, because all of a sudden you have no doctor. I had a miscarriage at 8 weeks and had no idea what to do, how to find help, etc and all the clinic kept telling me was that Dr Silber was not an Ob/gyn and I would have to find help on my own.

I was an out of state patient. Dr Silber never called me after retrievals to regroup. I one time had to beg for a phone call after failed retrievals (no embryo) in a row so I did get a call then. I asked for a call before one of my transfers and was not granted it. I did not feel like I had a doctor looking after my case. All the women have their cycles coordinated to fit his schedule, so there was no flexibility in protocol. I wish I had been tried on different protocols because I may have had a better outcome.

I was not very happy with my nurse but she was not terrible. One of her main jobs really is blocking for Dr Silber so it puts her in a tough position. I was only allowed to ask questions through her, and she did not seem to have good medical knowledge, so I always wondered if my questions/concerns got presented correctly/how I intended them to be to the doctor

Dr Silver did not alter my protocol at all, even after multiple failed retrievals; he just encouraged me to keep doing retrievals. I feel that he allowed my lead follicles to get too big, thereby compromising the quality. I did not know this until after I had left and had my records reviewed elsewhere, when this was Brough up. I never got a call after any retrievals. I had a miscarriage at 8 weeks and a second chemical pregnancy and he never called. On a final transfer, he insisted on transferring even though the lining was 6mm. I requested a call to speak to him about this and initially was told he would call, then the nurse called me back and said he would not be calling, that he said to tell me "he does things his way and if I don't like it I can go elsewhere". This was after being his patient for two and a half years (with a break in between). I had only spoke to him once on the phone and only had two clinic visits with him. I was paying a lot of money and could not even get a ten minute call to discuss my concerns before the transfer. It was too late for me to go elsewhere. My transfer did not work. Also, I was later diagnosed with immune problems which he never tested me for.

I can not recommend this clinic. Even though he markets his clinic as good for women in their 40s and good at mini-IVF I think his protocol was still too much medications for me. For people who are very poor responders, I feel there are better clinics. I was extremely disappointed that I was not permitted to easily communicate with the doctor and discuss my care with him. I did not feel my input or concerns were taken seriously. Dr Silber said some very hurtful things to me that were unsolicited and I feel uncalled for. For example, he told my husband (when I was present, although speaking about me in the third person) that "he was scraping the bottom of the barrel" to get my eggs. It was humiliating, hurtful and degrading. I was able to go to another clinic and collect 20 embryos (still being transferred) and that was a couple years later so he wasn't even entirely correct that I had no more eggs left.

All the cycles were the same: birth control, and then started clomid daily (I believe 50 mg a day) and follistim 150 mg every other day. When they decided to trigger, they also have you take ibuprofen (or some kind of NSAID) in the 24 hours before retrieval to try to prevent early ovulation. You take clomid almost the whole time to try to prevent early ovulation

I believe it was around 7-8K including the hospital part but the prices have gone up since then

Dr Silver does not generally believe in day 5 testing and recommends day 3 transfers for most women, especially those with DOR. He will transfer up to four day 3 embryos

I discussed this previously. The whole clinic revolves around Silber's reputation. He's the only doctor there that I can tell. They send out cd/dvds discussing his reputation, so it centers around his expertise... and so does what you pay.

I discussed several times with the RE (I only spoke with Silber once) my concern that Dr. Silber did not take into consideration my PCOS and pre-diabetic status. He still took me off metformin. When I asked about Ovasitol (from Inositol) as an alternative, he did not know what it was-- either the brand or inositol as a well known treatment for PCOS. I explained that it was akin to a vitamin, but the RE claimed that he did not wish for me to take anything. I found this very concerning but I complied. When it was time to begin the process, my first day clearly showed that I did not have clearly defined follicles. This was a drastic change from four months prior where i had 8 very clear follicles. In fact, this has never been a problem for me because of the PCOS. Obviously age is a factor and quality, but never number until now. Despite clear indications that taking me off my medication might have impacted me, Silber continued forward. Needless to say, it was cancelled because the follicles did not respond to medication. Although I am not at all happy with the approach, I do understand the possibility that such a thing can happen. I left and expected to receive the reimbursement for the cancelled IVF. I had no problems working with the financial officer who promptly returned all my funds to my card, but I had to wait for Sibler's signature for the reimbursement by direct check. I waited and waited until I called to ask about its status. According to the office, they were still waiting for him to sign the check. This is approximately 5 weeks after the cancellation. I still have not received my reimbursement and I finally made it clear that I wanted to speak with him or someone higher than the financial officer since she can not write out a check. It's not her job!!! Still, they kept sending me to her and until I made a big stink about speaking to someone who has the power to reimburse me instead of them blaming someone who cannot. Now, I am dealing with the office manager. I have no idea when this will end, but it's a terrible way to end an already lackluster interaction. I will update regarding this matter.

I discussed this previously. They were really, really nice. All of them were professional, returned emails in a timely fashion, and genuinely sorry that things did not work out.

His main strength is that he will accept older women. A bit patronizing, but still nice. If his regular treatment works for you, then you'll be happy. The RE was really nice, and the poor financial officer was really kind though she was placed in an unenviable position. Asking to go beyond that however will not work well. First, he only meets you once. I'm really tired of doctors who do this. My last one was similar, but not nearly as bad. Silber does not appear to be up on the latest IVF news anymore. Finally, I think it is unconscionable to have people chase you down for their money. It's bad enough when you're desperate and things do not go well. I paid on time and based on the schedule. Had he not received his money, I would not be scheduled. How is it that he gets to take his time returning my reimbursement?

Honestly, find another doctor. He takes no health insurance and insists you pay out of pocket for his services. Plus, you have to argue with people about returning your money in a reasonable time. Who wants to do that?

birth control pils Clomid, Folistim 150iu Lupron I cant recall the rest.

12,000 out of pocket not including medication, also out of pocket

The clinic has a long wait in the waiting room to see Dr. Silber and the St. Luke’s Hospital has a ridiculously long waiting period, sometimes 4 hours a day for 3 days in a row, etc. It gets old. You feel like sardines next to other people jammed in hallways in the hospital, people being wheeled past you who are sick of just out of surgery. But we wait. We wait because Dr. Silber is the best we have ever heard of.

There were too many women waiting for treatment on some days at St. Luke’s Hospital which made the staff and patients nervous and cranky. However, whenever I am with Dr. Silber, he treats me well, as though no one else matters.

Mindy is my coordinator. She gets back to me in a timely manner and answers all of my questions quickly even if she needs to ask Dr. Silber himself.

Dr. Silber’s strengths are his years of experience and all of the conditions he has treated and all of the peopke he has been able to help. He is also straightforward; he will tell you if it may or may not work. Dr. Silber’s weaknesses are his Clinic is in a hospital which he knows little about how the patient is treated when he is not there. The hospital also charges a lit and is not straightforward with how much they charge if you choose to use insurance for some procedures. The hospital can keep you waiting for 4 hours for an appointment and Dr. Silber does not know because his office is not in that hospital or department. Dr. Silber is very clinical and although being sensitive to my emotions after a failed procedure; he could not understand why I did not want to hear about donor eggs while still under anesthesia and expecting to use my own eggs. It is the same he says. To a woman who expects to have her own eggs that day; it is not the same and takes some time to process.

He’s very knowledgeable but very old and is more on the clinical side vs emotional side. He did not like to see me cry. See this is why we use donor eggs! OMG.

He used a low dose hormone protocol for Diminished Ovarian Reserve. It was not successful in making any eggs.

A cattle call with a long, long line.

About 16,000.00 per egg retrieval attempt.

He was well informed and explained why to transfer one egg vs more and in which situations and age of the patient. Then he asks you what you think.

On the first visit, we sat in the waiting room forever...and ever. With many other couples. We had all been scheduled at 30 minute intervals. I think there were 4 couples in the waiting room by the time we were seen which means they were two hours behind schedule and we were supposed to be the first patients seen after lunch. Knowing what I know now, that means he was held up at the hospital that morning taking care of his other patients. When we finally got to see Dr. Silber he was on top of his game, very intelligent, seemed like he knew exactly what he was talking about and had done a thorough review of all of our records we had sent to him. We were seen within the week of calling for our consultation appointment. We haven't stepped foot back in the clinic for an office visit since that day. Everything has been done through correspondence with the coordinator, the lab at the hospital, the assisting obgyn's office, the radiology department at the hospital, and the surgical center on the day of the procedures. You have to coordinate your payments to all of the providers used for a cycle. You don't just write one check to Dr. Silber. You pay about 6 different providers before your cycle begins.

All of the corespondence is pretty cookie cutter, the coordinator doesn't necessarily check for specifics about your case before sending out instructions which results in you having to ask questions about your own specifics.

She was always friendly, sympathetic, and empathetic to our situation. She wanted the best for us. Some of the correspondence seemed like form letter correspondence and should have been reviewed before being sent to us, as each case has a unique set of circumstances. When I would receive the form letter correspondence I would have to ask clarifying questions for our circumstances but she was always quick to respond with answers to my questions.

He thinks he's right all the time and down plays anything you've been told by a previous Doctor, unless he shares their opinion. He's smart. Really smart. And tries new things. He thinks outside of the box. He said to us directly that he isn't worried about his stats or success rates, he does what's best for the patient and the numbers will work themselves out later if they are doing the best thing. His bedside manner is a little lacking but he has great assistants who make up where he leaves off. I'm always comforted the our assisting Doctor DeRosa.

He will be blunt and direct. Listen to him, he knows his stuff, even if it's not what you want to hear.

I did "Mini IVF" three times. Each time I started with 50mg Clomid every day, on the third day I started 150 units injections of Follistim. This continued through my daily monitoring of blood draw and ultrasounds. I would end the medications when instructed and follow with Ganirelix and Indocine tablets before retrieval. One cycle we attempted Denmark Mini. The only difference here was that I took the Follistim injections every day. The end of this cycle would have had some different medications but I did not respond well to this treatment, and the cycle was cancelled. I don't remember the plan for medications at the end of the cycle.

There was a window of time each morning to be received at the hospital. My first round I followed the instructions and called for a "scheduled time" during that window. I found out quickly that the scheduled time didn't mean anything. The best thing to do was to show up as early as humanly possible and get on the list at the door. The first day of a cycle was the busiest. All of the women in that cycle had a day one appointment. We all had ultrasound and labs. After my first day, I learned that if ultrasound was backed up it was wise to walk to the lab and see if i could get blood drawn while I waited. If the lab was backed up, I would go make sure I was on the ultrasound list and/or how far down the list I was. In the beginning, before I had learned all the tricks it could take up to three hours to be seen by both ultrasound and lab. By the end of my fourth monitoring cycle, I was in an out in under an hour. Showing up early....like thirty minutes before the monitoring time frame window opened was critical.

About $15k for the first Mini IVF cycle (I'm including the cost of my medications). This also includes the first transfer. All cycles after this were about $10k (again, including my medications) but this does not include any transfer procedures. If you end up requireing additional transfers, above the first one you pay for with the first cycle, then you are looking at around $5k.

He will only transfer two embryos at a time unless you sign a form that you will use selective reduction. I wouldn't sign the form. I never had the possibility of more than two embryos transferred at once.

Dr. Silber is in high-demand, so knowing this up-front may help relieve some anxiety for a new patient who may not know if he will be the right doctor for their situation. He has been in the game for decades, he knows what he's doing, and while he will be gently blunt with you, he will let you know everything you need to know before starting any cycles with him. There are infertility clinics that are set up with multiple doctors and a team of support, however Dr. Silber's office is set up around him, supported by his attending physician (who does the egg retrieval while Dr. Silber does ICSI immediately post-retrieval), and further supported by a staff of Coordinators assigned to each couple and various office staff to take care of the rest.

Dr. Silber is world-renown and knowing this going in, we realized he would be a very busy man. His office staff has been very friendly, professional and understanding. We have met with Dr. Silber in-person 3 times now: first for our initial consult; second just before our 1st egg retrieval surgery; and third immediately following the retrieval and ICSI. We are currently in the middle of our 2nd egg retrieval and will personally see Dr. Silber at least 2 more times before the end of May. In the interim, we have been paired with a Coordinator who we can contact via email or phone during business hours Mon-Fri. She has gotten answers for us quickly, she has shared in our joy and she has commiserated with us when our numbers weren't where they were expected to be. She has been so patient with us in all our questions, she has explained any situation and answered every question in such a way that we understood completely what we were facing in the days/weeks to come. I also had an appointment with the attending physician before the egg retrieval to go over the procedure. He was very personable, professional, and easy to trust. My husband and I both agree we have found our "fit" with the Doctors, Nurses, Aides, Technicians, and Coordinators.

Our coordinator, Rachel, seemed always available and ready with answers to any and all questions I had. She was sympathetic to our situation, understanding and was very helpful for a couple who lives a 3-hour drive away from St. Louis. We couldn't have asked for a better coordinator to be paired with!

Our initial consultation was delayed due to a high-risk procedure he had been called on. Once we were led to his office, we met a very funny man who takes his job seriously and personally. We discussed our medical histories, his practices and what he thought would be our best route to take in our journey to build our family. He assigned us a coordinator and from there, we had continued nearly all communication with Dr. Silber through her. When we met Dr. Silber again for our surgical consult immediately prior to our 1st egg retrieval, he was alert, concerned for our nerves (understandably a high-anxiety moment), and was easily able to put both of us at our ease. After the retrieval, Dr. Silber met with my husband (I was in the room coming out of anesthesia) to discuss the procedure and its results, the ICSI and its results, as well as our next steps for the following 48 hours. We are looking forward to seeing him again in the weeks to come.

I would suggest any prospective patient to be prepared. He will answer any and all of your questions, and you should be prepared to discuss intimate details of your infertility with a man who may resemble your Grandfather. His office may be busy, as is he, but he will treat your time together personally.

We are "ideal candidates" for Dr. Silber's Mini-IVF procedure. This is "minimal stimulation IVF" where the woman is given lower doses of Clomid, Follistim, Ganirelix, Indocin, Lupron, Gonal-f, and/or Prefera during the egg retrieval cycle. The body will still stimulate multiple eggs to mature, however the quality of the eggs is the main target and not so much a large quantity of poor eggs. Our retrieval cycles included Clomin, Follistim, Ganirelix, Indocin and Lupron. Our 1st cycle resulted in 5 mature eggs retrieved, and 2 successfully fertilized embryos. Our 2 little embys are chilling out, waiting for their sibling embryos to join them in May, and their chance at life in September.

My monitoring experience was what I would expect while in a hospital setting rather than in a clinical office setting: between certain morning hours (6am-8:30) on the days I was directed to monitor, I would write my first name only on the list and wait in the waiting room with any other waiting patients. Sometimes there were quite a few people, other times it was just me and one other person. It being a hospital, not every person in the waiting area is a patient of Dr. Silber, however the technicians are highly skilled and very adept at their careers. In our first cycle, I saw roughly 4 different ultrasound technicians who were very kind, professional and understanding. Their level of discretion is outstanding, and I felt each one respected me and my body during the entire process.

In our initial consultation, we were provided with a bill of $10,400 which covered fees for the Doctors, hospital, anesthesiologist, and diagnostic imaging for our 1st round of egg retrieval and includes 1 transfer at a later date. The cost of medication was separate, and totaled roughly $1,052 for the 1st cycle. We have signed on for a separate egg retrieval cycle, which is totaled at $7,050, not including medication which will total roughly $1,052 again. In addition to the costs of care, we do not live near the St. Louis area and so we would have also incurred hotel and transportation fees, if not for a very hospitable friend-of-a-friend who opened her family home to us during our time in the area. Also as gas prices have been on the decline in the Midwest, our transportation fees have been manageable.

We have not yet progressed enough in our journey to the transfer stage, so I cannot speak to this. As I will never be as young as I am at this moment, we agreed the more embryos we can freeze now will give us as many chances at building our family as we can have.

I was in a herd of 30 other women with the same target date as myself. I met with Dr Silber only once during the consultation and was assigned a coordinator that was supposed to facilitate the process. Aside from an inch thick packet of information they mailed to me, I was not given any other information unless I asked. The first day I was supposed to start injections I discovered the lab didn't send me a pen to do so - I immediately called Silbers answering service and the lady said she left him a message. No call back and his office insisted they never got a call from the service. The day of my egg retrieval Dr Silber saw me beforehand (13 mos after my initial consult) and had no knowledge of my personal situation. In fact he made general assumptions that based on my age I had low ovarian reserve - which was completely untrue. He then gave me trouble about waiting 13 mos to have the egg retrieval so I had to inform him that during that time I saw his reproductive endocrinologist who diagnosed and corrected a septum in my uterus that would have caused ivf failure. So unfortunately I got upset and again felt like a single cattle in a herd going into my egg retrieval. Such disappointment.

Dena communicated through email very well but don't expect a call back if you leave her a message.

I was in a herd of 30 other women with the same target date as myself. I met with Dr Silber only once during the consultation and was assigned a coordinator that was supposed to facilitate the process. Aside from an inch thick packet of information they mailed to me, I was not given any other information unless I asked. The first day I was supposed to start injections I discovered the lab didn't send me a pen to do so - I immediately called Silbers answering service and the lady said she left him a message. No call back and his office insisted they never got a call from the service. The day of my egg retrieval Dr Silber saw me beforehand (13 mos after my initial consult) and had no knowledge of my personal situation. In fact he made general assumptions that based on my age I had low ovarian reserve - which was completely untrue. He then gave me trouble about waiting 13 mos to have the egg retrieval so I had to inform him that during that time I saw his reproductive endocrinologist who diagnosed and corrected a septum in my uterus that would have caused ivf failure. So unfortunately I got upset and again felt like a single cattle in a herd going into my egg retrieval. Such disappointment.

If you are a first time ivf patient please find someone who has experienced this to help you through the process. It's overwhelming and their paperwork doesn't fully explain what to expect.

I did mini ivf treatment and my protocol was 50 mg of clomid days 3-trigger shot with 150 iu of follistim 3 days. I took Ganirelix then Lupron to trigger.

Blood work and ultrasounds were at St Lukes hospital.

Mini ivf ran $10,500 plus meds

I think the Doctor and nurses are very good at their jobs. The only recommendation I would have is getting everyone to communicate within the clinic a bit better. I also had to postpone my cycle due to a medical situation (I had a bulged disc in my neck and was doing physical therapy and pain medication) and I didn't think charging me a $3,000 cancellation fee was appropriate as it wasn't my fault for the cancellation and the clinic even told me that with being on the pain medication, they would not recommend that I proceed.

I felt like he was good at his job and didn't want to waste my money or time (like my prior doctor had) with procedures that were not going to work. We ended up only trying one cycle, but he cancelled it because I was not responding and he determined that I was not going to be able to continue with my own eggs. I am still a patient of Dr. Silber and he has my donor sperm frozen at his facility. I am wanting to proceed with donor eggs but simple cannot afford to do that at this point. I do look forward to being able to continue with my treatment with him.

I originally had a nurse for my IVF cycle, but Stacie is my new nurse for donor cycles. She has been very supportive and has helped me try to get grants by completing paperwork for me. I have tried to get a Baby Quest grant the 3 times maximum for applying. It is an email from Baby Quest how I found out about the Fertility IQ grant. I will contact Stacie at Dr. Silber's office who will have the fertility assessment prepared that you need.

He was very forthright. He seemed very knowledgeable. He also didn't seem to want to bill for every little thing - he has a flat rate that covers whatever is necessary without adding to the charges for extras that you might need.

I would go to him first - I wish I had known about him earlier. I went to a local doctor who (after I got my medical records) transferred an embryo that the embryologist had listed as not transferrable (he got paid for that). I did have two perfect embyos that were transferred but I miscarried them. I also had a chemical pregnancy. I feel that had I went to Dr. Silber earlier, I would have been able to have a child using my own eggs because I was responding back then to the medications.

We used injections and oral medications. Dr. Silber said due to my age, he wanted to do a series of 3 "mini IVF's" to get as many eggs out as possible and freeze them as embryos prior to moving on with putting them in for pregnancy. Unfortunately, by the time I found Dr. Silber, I was no longer responding to the medication so he cancelled the cycle and told me I would need donor eggs prior to us moving forward.

Dr. Silber - $10,900, Hospital costs - $2,500, Anesthesiologist - $400 and Radiologist - $150

I don't. He said he would only transfer 2 embryos in me (he would only transfer 1 embryo in a younger person). I think that is responsible so you don't get the octomom situation.

The staff was all very nice. The waiting room is a little small but didn’t bother me. I didn’t like that i couldn’t see anyone behind the counter (the glass had a filter over it). The wait time was very short from what i was told to expect so that was a plus.

They were very personable and took time to answer our questions

Dena was very helpful and gave us all the information we asked for plus more

I love the fact that we got to spend a good amount of Dr Silber and that he was patient with us and answered all our questions. His nurse also was wonderful! I wasn’t expecting much time with Dr Silber but he got to know our personal history and was able to answer our questions about IVF. The treatment plan was all set up on our first visit but they gave us time to make our decision as well. I look forward to the rest of our appointments!

Just go and see him! He is worth it!

Dr Silber has suggested Denmark mini IVF for us due to the amount of follicles that I produce due to PCOS. He doesn’t want to over stimulate my ovaries with too much medication. He wants to do low doses of FSH and HCG.

Our total procedure cost is $11,700

Dr Silber will only allow up to two embryo transfer and that is what we have decided to do.

This clinic is a "well oiled machine." I never dealt with anyone that wasn't able to help or answer questions when I needed it. Everyone was kind and professional. It is a large practice, but I never felt that I wasn't a priority. In fact, I felt as if everyone knew me and cared about me.

He listened to our situation and gave us hope.

Quick to respond to any questions or concerns. Compassionate and understanding.

He has been in the field for many years and I trust his experience. He is very kind and genuine. On our first visit he assured us that he could help us and he did not fail us. He runs his clinic very smoothly and I was always given very specific instructions for each transfer and/or retrieval. I never doubted that they knew what they were doing.

Be patient for results. Do not lose hope. Reach out to Dr. Silber or his staff. They are very compassionate and excellent at helping through this process.

I think a retrieval was about $12,000. A frozen transfer is $5,000. Plus cost of medications.

Dr. Silber had been practicing for a long time and had seen many different patients...so he had a lot of experience. He seems to attract a lot of patients and causes it to be really busy. Appt times run past by 1.5 hours most for monitoring.

Never really spoke to dr. Silber until day of retrieval. Many emails from nurse for instructions but never spoke in person

Silber came from a glowing referral by my obgyn. He is known world wide as an amazing doctor for ivf. However, they don’t know how communicate to you. Not good in explaining the steps and answering the questions that we had

We did Mini IVF that was unsuccessful. And now we are doing agnoganists and it is looking good so far

Very busy. You made an appt time but everyone would arrive at 6am and not leave until 8:30am. Too many people trying to get their monitoring done at the same time

Dr. Silber has a flat fee and does not work with insurance of 6000 (which included blood work and ultrasounds) and then other costs could be through insurance

Dr. Silber was kind and upfront with the statistics. He did not sugar coat anything and gave us our best options considering the money we had already spent and the money that it was going to take to move forward. The nursing staff was willing to work with us on the scheduling and money front.

Dr. Silber was very compassionate. He was very direct as to what I should expect. He felt I should try with my own eggs once then proceed to donor embryos.

The nurse that works directly with Dr. Silber was very compassionate and patient. She even called several times afterwards to follow -up

I decided not to do the procedure with mini ivf due to the distance and time it would take. If I lived in St. Louis I would have proceeded for sure. I really trusted him and appreciated his very direct approach.

Be open to his direct approach and honesty. I felt he had a great deal of integrity.

He suggested 1 round of mini ivf and then suggested donor embryos

I dont remember - sorry bacause I didnt move forward with the treatment. He did the testing at the facility and we had the results the same day. He charged that to our insurance. I believe I paid maybe 400 out of pocket for all the testing. Not quite sure

for my age he recommended mini ivf for the highest quality eggs

This clinic was located in an older hospital complex in suburban St Louis, right off the highway so it was easy to find. I didn’t have problem with the facilities. I thought it was fine. Most of testing and procedures were done in the hospital.

I had a coordinator that worked with me and gave me timely instructions and test results and answered all my questions. So I knew exactly what to do during each cycle.

Always called and emailed me info, instructions on a timely basis. I always knew what I had to do.

I am an older woman and his clinic gave me hope in trying for a baby. In retrospect, I wish I had used donor eggs in the first place but that was entirely my choice to try using my own eggs. I just didn’t accept that my eggs weren’t viable. I responded to Dr Silber’s protocol very easily during each cycle so I think that if I had used donor eggs I might have better results.

If you’re over 40, definitely consider donor eggs. And don’t wait too long to decide on IVF.

I really don’t remember the specifics. I just remember injections every night.

The ultrasounds were done in the hospital. The wait was never very long.

Around 10000 for each cycle

I had multiple embryos transferred because of my age I think

Anticipate being prescribed a course of treatment that is not modified based on outcomes of previous cycles.

Each cycle has a set number of patients all running through a similar monitoring protocol. Many times women would arrive hours early for blood draws and ultrasounds just to get a preferential spot in line. It was first come, first serve, very competitive and cold.

Kelsey is a good communicator and timely in providing monitoring results.

This is not a provider that I can recommend. His demeanor was dismissive and he was very clear that unless I was being treated by his clinic, that my chances for success were minimal.

I cannot recommend this clinic.

Minimal stimulation IVF with embryo banking. CGH testing was discouraged due to concerns with potential embryo loss in the testing process.

Monitoring appointments were a complete cattle call. Patients would show up hours early to obtain a preferential spot in line. Going through infertility treatments is already a stressful process, this made me feel like if I got to the clinic any later than 6:00 am, I had already failed.

My costs were reasonable as I had a mini-stem cycle with Dr. Silber.

It's a busy clinic but they manage everyone well. It is well organized and communication is good. You do not feel like a number.

I felt like a human because if I had questions they answer right away. Called to check on you after procedures.

She is good about explaining results, meds, and doctor comments.

He is very through and knowledgeable. Very honest and blunt. Had options and recommendations that worked for my situation. He is particular about patient satiafaction.he work along side other doctors who specialize in women's health.

Write down you questions and concerns. On the first visit be patient. He will give you his attention and answer anything you need.

I have diminished ovarian reserve so he recommended mini ivf which gave me better egg qualities with the lower dose meds.

Cost were cheaper than my first cycle. 500 dollar deposit for procedures. 10000 for retrieval and one transfer. 5000 for each egg transfer.

They let you choose between one or two but recommend one depending on age.

Within the first fifteen minutes of our first consultation Dr. Silber discovered why we had not had success at our other clinic and personally apologized for all the unnecessary procedures and grief we had been through.

Very organized and kind

Dr. Silber is a master doctor. He has incredible knowledge and expertise in the field of reproductive endocrinology.I immediately recognized his intelligence in the field and trusted him completely. He was definitely a straight-shooter and did not waste time with procedures he knew would be unsuccessful. He was very apologetic to us for the unnecessary procedures and treatments we'd received at our first clinic. Because of his high demand and busy schedule, we only saw him a few times throughout our entire process, however, that didn't matter due to the absolute impeccable and successful care we received.

Don't delay making an appointment with him!