Money matters have a way of making so many situations uncomfortable; especially when it comes to infertility, which already has so many awkward facets. I have a form of elitist guilt as I am fortunate enough to be able to afford fertility treatments, when I know there are so many infertile couples who can not. A friend, who is an infertility survivor via domestic open adoption, recently pointed out that there are public funds available for low income uninsured or under insured women who do not desire pregnancy and want contraception, or who are pregnant and need an abortion or prenatal care; but no help exists for such women who are experiencing infertility. After I told Myrtle about my first RE visit, she told me "I know how lucky I am, I wouldn't be able to afford IVF." I was stunned by her admission. Myrtle is a trust fund baby and has had almost no financial worries for most of her life. Did she just not know the actual estimated costs for an IVF cycle? Probably not, why would she? I didn't ask any follow up questions as I didn't want to pry into her current situation. A male colleague, who also hails from money, told me that he describes the cost of an IVF cycle "like buying a Kia". Sigh. Not everyone can afford a Kia, and financing options exist for buying a car.
I was following the posts of one particular member on the infertility forum. Her husband was found to have a sperm count of 300K with abnormal morphology and motility during their infertility work-up. Her RE initially recommended AI or IUI with donor sperm as the most likely to be successful and cost effective treatment method, as he doubted they could achieve fertilization with ICSI. The couple met with a geneticist and a urologist and actually found an answer. He had a congenital absence of the vas deferens, but after starting some supplements his counts improved and they were re-considered to be ICSI candidates. When they shared the diagnosis and these developments with their parents, his mother's first response was to ask, "How do you know they're not just trying to take your money?"
For so many reasons, it's hard for parents to accept the diagnosis of their grown children's infertility. The emotional response is overwhelming and especially if they didn't experience any infertility issues, they may not be versed with the mechanical particulars. As he came from a large family and no one else seemed to have any fertility issues, I can definitely appreciate where she was coming from. Yet, it was interesting to read her response in the setting of such a clear-cut diagnosis; especially knowing that the RE leveled with them initially and advised against IVF when he thought it wouldn't work. However, she does make a good point: How do you know they're not just trying to take your money?
Admittedly, infertiles are a vulnerable population. We come to the office expecting to pay a large sum of money.While I hesitate to use the word desperate, there is a certain willingness to succeed no matter the cost. It's like the Mastercard commercials: Initial RE Evaluation $300, Semen Analysis $200, Hystersalpingogram $1200, Ovarian stimulating drugs $3,500, One IVF cycle $9,975. Holding your baby in your arms: priceless. At the same time, it's valid to question if you are getting a fair deal from your RE. Unfortunately, it's not always easy to achieve a straight forward answer. REs can be victims of the 'damned if you do, and damned if you don't' mentality. If one recommends doing a few IUI cycles before IVF, he or she could be accused of wasting a patient's time and money, but he or she could also be suspected of financial motivation if IVF is advised straight away. (For the record, some studies have noted that couples who start with IVF achieve a pregnancy sooner and spend less money in total.)
I attended a conference on infertility last September, and gained some perspectives from REs themselves. One shared an observation of visiting a clinic with low success rates and noted many patients were of higher ages, had high FSH levels and not surprisingly had poor response to stimulation with low retrievals. He questioned the professional ethics of leading women through this process and collecting fees when the data shows the failure is so high. However, others pointed out that some women with those parameters are willing to pay as they hope to become an outlier. A few commented that they've adjusted their documentation to emphasize when they've recommended against using own eggs and patients insist on proceeding with a cycle. Another commented on a trend he witnessed where an RE will refer a patient with DOR to another RE in the community promising the claim, "You should see Dr X, he has great success rates with low AMH levels". Thus, the underlying motivation is to skip out on the revenue from this patient in order to maintain higher success rates and make the practice attractive to new clients. Always an eye on the bottom line.
I think ultimately it relies on trusting your instincts while making some efforts to be a savvy consumer. I confess that I anonymously ran my case by another RE to check my RE's recommendations. Another benefit of networking with other infertiles is being able to observe treatment plans and protocols with others who have similar situations, which helps establish trends for standards of care. It's one more challenge to address while navigating through infertility.
This discussion continues in my next post...stay tuned!