Costly choices, no guarantees: The maze of fertility services
Women need advice, support before launching quest for fertility
Infertility treatment is big business. As women in their late 30s to middle 40s try to start families, drug companies and reproductive clinics keep pace with the trend. In fact, the dance between consumer demand and market response has created a $2.6 billion industry. And the surge hasn’t peaked yet. (See chart, p. 82.)
The infertility industry is largely unregulated, and that’s why your center belongs in the picture. Even if your center doesn’t offer infertility services, women need your objective guidance to negotiate their way through this complex industry.
"Something that falls through the cracks is the emotional need of the patients," says Jennifer Jones, NP, certified nurse practitioner with Centennial Valley Women’s Clinic in Louisville, CO. "That need has little to do with the medical services or the pocketbook."
Patients have a need for straight talk about infertility procedures, Jones says. Further, they need to sort through their reasons for wanting a child and their alternatives if infertility treatments fail.
Here’s the infertility treatment hierarchy that can take up to two years to complete:
• basic evaluation of both partners’ reproductive systems;
• pharmaceutical treatment to enhance ovulation;
• assisted reproductive technology, including artificial insemination with the partner’s sperm or that of a donor. Fertility clinics do in vitro fertilization, in which eggs are removed from the ovary, fertilized in the lab, and placed in the uterus.
Many older couples spare no expense in trying to conceive. Sue Becker, who coordinates the Women’s Health Source at St. Luke’s Hospital in Chesterfield, MO, says, "We see women typically in their late 30s and early 40s. Time’s running out for them, and they want to get pregnant now. Often they’re focused on artificial insemination. This makes them vulnerable and unthinking."
Infertility is like a puzzle, Becker says. "The pieces are different for each woman. Some 40-year-olds still believe that if they just have
sex, they’ll get pregnant, because their mothers told them they would. But they don’t get pregnant, because they have endometriosis. They should be having a hysterectomy, not a child."
If they still insist on trying for conception, she adds, it’s the job of women’s health professionals to explain the dangers. Becker says women’s health providers have an ethical obligation to at least mention genetic risk factors. Couples tend to overlook them in the rush to conceive before their reproductive time runs out. Many with family histories of diabetes or heart disease, for example, might not be prepared for the medical implications of passing on those genes to their offspring, she says.
Couples need to understand that fertility treatments carry no guarantees. They have the right to frank disclosure that the odds of conception are stacked against them when they reach the point of seeking professional help to achieve what didn’t happen naturally.
Check the physician’s credentials, Becker urges her patients. "When they’re going through these expensive procedures, they should make sure who’s doing them."
She teaches women to verify degrees and certifications through the credentialing department of the hospital or university where the provider practices. The state board of certification is another source women can use to check a health care provider’s background.
Reputable providers offer complimentary interviews, explains Cynthia Rogers, WHCNP, PNNP, nurse practitioner with the OB/GYN and infertility practice of Janet Dean, MD, in Denver. They also ensure the couple has completed the basic work-up which, Rogers points out, a primary care physician or OB/GYN can do. That work-up includes a thyroid function test, semen analysis for the man, and a few months on fertility drugs such as Clomide (by Hoechst Marion Roussel in Kansas City, MO).
"Sometimes patients don’t need anything more aggressive than that," Rogers says. "If the provider doesn’t answer patients’ questions and make them feel 100% comfortable, patients need to find someone else."
Patients also need to look elsewhere if their provider continues treatments too long without results, she notes.
"Any practitioner that doesn’t send you to an infertility clinic after six [months] of Clomide or artificial insemination is taking your money for nothing," she says. "Every time we fail, it increases the odds against us. At the six-month point, patients should go to a higher level, to someone who does nothing but infertility procedures all day every day."
At that stage, women are pretty much on their own. Fees are sky high, and few insurance plans will touch them. Becker tells patients to ask their primary providers for the names of local infertility specialists. Another way is to call around and ask practitioners whom they refer to, Rogers says. Soon, two or three names will surface repeatedly, and those are the ones to consider, she explains. With infertility clinics, the essential question is, "How many procedures have you performed in the last year, and how many have resulted in full-term pregnancies?"
Ethical providers will talk straight about money, Rogers says. A patient should be able to get information about fees for lab work, office visits, artificial insemination, and in vitro fertilization procedures.
Trying to conceive can cost as much as a new car. Rogers and Jones say the following expenses are typical: For starters, Clomide costs $60 to $250 for a one-month round. The cost escalates as the dosage increases with each unsuccessful attempt. Routine office visits are $40 to $70 each. Lab tests can amount to $300 apiece. In vitro fertilization procedures cost an average of $10,000 each time.
"This is why patients deserve as much feedback as they can get about their chances of success," Jones explains.
Some providers offer fee adjustments if conception doesn’t occur. At Rogers’ facility, the bill for first-time artificial insemination is $500. The second time, the bill is $400, and it decreases for each repetition. "It rarely works the first time," she says.
On the other hand, Jones says, "Infertility services are a big moneymaker for providers. A lot of them don’t get involved in discounts. Many women don’t let money get in their way, either. They go to a lab or a physician on the basis of the conception statistics."
Fourteen states currently require insurance and managed care plans to cover infertility services. (See map, at left.) While many plans don’t pay for infertility services, per se, the initial treatment is often allowable as medical care. Thyroid imbalance or irregular ovulation inhibit fertility, for example, and they’re also medical problems, Rogers says.
"Even with insurance, it’s sometimes a lot of juggling," she says. "Once you mark infertility on a patient’s chart, the plan watches everything you do. Women’s concerns are not insurance’s concerns." ß
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