By Psyche Pascual
CONSUMER HEALTH INTERACTIVE
Laura Lynch was only in her 20s when she found herself unable to have a child, despite years of trying.
So when a fertility specialist advised her to try in vitro fertilization, a then-experimental procedure that involved fertilizing her eggs with her husband's sperm in a petri dish, she jumped at the chance. Lynch's odds of giving birth were estimated to be less than 25 percent, and she wasn't sure how much, if any, of the bills her insurance would cover. "I didn't care how much it cost," she says. "I was obsessed with having a child." Lynch's determination paid off -- in 1984, she gave birth to twins, a girl and a boy.
Fortunately, the spend-your-last-dime approach to starting a family worked for the Lynches. But it left the couple with a staggering $25,000 bill, which Lynch, then a public school teacher in Utah, and her husband, an entry-level employee at an oil company, could barely pay off.
"We almost lost the house because we were in arrears. We sold our Toyota Celica. We sold our other car, a pickup truck. Then we bought a station wagon for $2,000 because that was all we had," recalls Lynch, now 44. "By the time we finished paying the bills off, the kids were in fourth grade."
Fortunately, a family member extended the Lynches a loan, saving them from foreclosure. But their situation is a common example of the financial setbacks many couples face in their quest to have a biological child.
Paying out of pocket
In 2001, the last year for which data was available, infertility treatments cost Americans about $2.7 billion. The vast majority of recipients did not have insurance that covers fertility treatments. Even if insurance pays some of the costs, many couples undergoing treatment must scrimp to pay for the rest themselves. "We have people that have either borrowed money from family members or have second-mortgaged their homes," says Susan L. Treiser, MD, PhD, a reproductive endocrinologist and co-director of IVF New Jersey, a fertility clinic. Others, she adds, take out loans or max out their credit cards.
Those sacrifices have led to an outcry among infertility experts about the need for such health coverage. "That's the heartbreak," says Pamela Madsen, executive director for the American Fertility Association. "Not everyone's wealthy. Not everyone has a house that can be mortgaged."
A single round of IVF averages about $12,400, not including blood testing or hormones, which can add up to $5,000. If a woman undergoes intracytoplasmic sperm injection (ICSI), in which a sperm is injected into an egg before being implanted, it costs an additional $1,500 or more. In 2006, the average success rate for a live birth for a woman under 35 was 39 percent, according to a report from the Centers for Disease Control and Prevention (CDC). For women 41 to 42, however, that percentage dropped to 11 percent. That's why most IVF cycles have to be repeated, and why it is not unusual for the bill to come to $30,000 or more.
Yet many couples and single women are tempted to beat the odds. Because assisted reproductive technologies (ART) such as IVF have improved over the last two decades, success rates have jumped, giving new hope to people grappling with infertility problems. Couples who have waited to have children until their 30s or 40s are increasingly paying for fertility procedures, and the number of doctors trained in performing fertility procedures on men and women across the US has grown.
Those are a few reasons why the number of ART procedures has also jumped. According to the CDC, 138,198 assisted reproductive technology procedures were performed in 2006.
Lack of insurance coverage
Unlike other health-care treatments, coverage for fertility treatment remains a controversial issue in the United States. One-fourth of corporations in America with 10 or more employees have plans that pay for fertility treatments, according to a 2001 report from the Mercer Human Resource Consulting. According to American Society for Reproductive Medicine, 14 states across the country have adopted laws governing insurance for fertility coverage, and some statutes are stronger than others. Some states, including California, have a law that requires health plans to offer coverage for infertility treatments, but does not require the health plan to pay for IVF, the most expensive infertility procedure.
But it's been a boon for some patients who are lucky enough to live in states with the highest rate of insurance coverage, such as Illinois, Massachusetts, and Rhode Island. In New Jersey, which passed a bill mandating companies with more than 50 employees to provide insurance coverage for fertility services, some people switch jobs to larger employers just to be eligible for such insurance, Treiser says. But even in states covered by the insurance mandate, many aren't eligible because they work for small companies that are exempt, or because they're self-employed. At IVF New Jersey, the fertility clinic in New Jersey, for example, only about 30 percent of the clinic's patients have some form of coverage, and even then only for certain types of treatment, Treiser says.
That's why most reputable clinics offer some sort of insurance counseling and financial planning assistance when patients first come in for fertility services. At some clinics, doctors work with patients to establish an extended payment plan for their treatment. Most also accept credit cards, and some work with financial services firms that find third-party loans to finance treatments. In this arrangement, payments can be made over a one-to-five year period instead of in one lump sum.
In recent years, however, the lack of insurance coverage has forced some doctors to provide flexible payment programs for patients who lack insurance coverage. One such program, developed by Advanced Reproductive Care, Inc., based in California's San Francisco Bay Area, has now spread to 90 clinics across the country. Doctors can offer discount rates for these procedures and medications, says company CEO and reproductive endocrinologist G. David Adamson, MD.
"We have patients who tell us they could not have afforded their infertility care if we didn't have our package pricing. They can plan, and that takes away a lot of the financial anxiety for people," Adamson says. In return, he says, "we ask our clinics to give a bit of a discount. We ask them for a package price discount. On top of that, we will finance that package -- so the patient can make it affordable."
The lack of insurance has also produced more creative financing. One new program, often called a refund guarantee or shared-risk program, involves offering a refund to women who don't give birth to a child. At Advanced Reproductive Care, for example, if the woman gives birth on a first attempt, but pays for three IVF cycles, the plan costs $28,735. Whether she gives birth after the first or third round, the doctor gets to keep the difference. But if a woman fails to give birth to a child following the third attempt, she gets a refund of $20,640.
Critics of the shared-risk program, however, say such programs are rife with flaws. Because the applicants are screened for eligibility, many clinics offer the money-back guarantee only to women under 35 -- those who are most likely to become pregnant. Critics also say doctors are more likely to implant more than one embryo in the hopes that a woman gets pregnant in the first round -- which would save them the costs of doing more cycles, but raises the risk of a multiple birth. In fact, according to one study, the risk of multiple pregnancies went down in states where insurance for IVF was offered. Still others charge that wagering doctors' fees on the success of treatment is not only unethical, it's a medical gamble.
"It is a gamble," says Adamson, the CEO of Advanced Reproductive Care. If couples are adequately counseled about their chances of pregnancy, then they should know how many cycles to try before they give up, he says. "Some couples say, 'If we don't have our baby, we want some money back to spend on adoption.' "
At other clinics, such programs aren't feasible. Instead, because of the growth of fertility clinics across the country and the competition for patients, they've opted to drop prices instead. At IVF New Jersey, for example, patients can pay a flat rate of $8,000 (plus the cost of medications) for a single cycle of IVF, regardless of whether it results in a live birth.
But even with the most advanced fertility treatments, women should be aware that a baby may not be in their future, says Madsen, the executive director of the American Infertility Association. In that case, they should investigate whether they can live without their own biological child, or consider adopting.
"One couple may feel they've done enough and want to move on. Another may feel they want to spend their last dime.
"Setting a limit may be hard, but they should set a plan when they go in about what they're willing to spend. What are they going to do if the cycle fails?" she says. "There should be a place where they stop and reevaluate, and look at their lives to see where they want to go."
-- Psyche Pascual is an articles editor at Consumer Health Interactive. She formerly worked as a staff writer at the Los Angeles Times and as a business writer for the Contra Costa Times.
For tips on how to pay for fertility treatments, click here to read Sources of Fertility Financing.
Interview with G. David Adamson, MD, infertility specialist and CEO of Advanced Reproductive Care Inc. and board member with the American Society of Reproductive Medicine
Interview with Susan Treiser, MD, PhD, reproductive endocrinologist and co-director of IVF New Jersey
Stephen, EH, et al. Updated projections of infertility in the United States: 1995-2025 Fertility and Sterility 70: 30-34 July 1998
Insurance coverage and outcomes of in vitro fertilization. Jain Tarun; Harlow Bernard L; Hornstein Mark D N Engl J Med 2002 Aug 29; 347 (9): 661-6
Why a Finance Issue, report from the American Infertility Association, May 2001
Assisted reproductive technology in the United States: 1998 results generated from the American Society for Reproductive Medicine/Society for Assisted Reproductive Technology Registry, Fertility and Sterility, Vol. 77, No.1. January 2002
State Health Facts Online, Henry J. Kaiser Family Foundation, State Mandated Benefits: Infertility Diagnosis and Treatment, 2001
American Society for Reproductive Medicine. Frequently Asked Questions About Fertility. http://www.asrm.org/Patients/faqs.html
Centers for Disease Control. Assisted Reproductive Technology Success Rates. December 2006. http://ftp.cdc.gov/pub/publications/art/2004ART508.pdf
Centers for Disease Control. 2005 Assisted Reproductive Technology (ART) Report: Section 1. December 2007. http://www.cdc.gov/art/art2005/section1.htm
Centers for Disease Control. 2005 Assisted Reproductive Technology (ART) Report: Section 2. December 2007. http://www.cdc.gov/art/art2005/section2_questions.htm
Centers for Disease Control. 2005 Assisted Reproductive Technology (ART) Success Rates. November 2008. http://www.cdc.gov/ART/ART2006/508PDF/2006ART.pdf
Reviewed by David Sable, MD, director of the division of reproductive endocrinology at Saint Barnabus Medical Center in Livingston, New Jersey.
Last updated April 29, 2009
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