by Dr. Adam Fechner
The Wall Street Journal recently published an article entitled “10 Things Fertility Clinics Won’t Tell You.” (http://www.marketwatch.com/story/10-things-fertility-clinics-wont-say-2014-06-06). In it, the author discusses ten aspects of fertility care she feels are not made clear to patients. Some of her points are valid, others I would argue, and there are other misconceptions about fertility care she did not include that I feel warrant discussion. At the end of the day, a physician needs to be a teacher in addition to a clinician, providing the patient with a clear understanding of their condition and the pros and cons of each treatment option so they can make an informed decision. In order for patients to feel they are fully informed, however, we must make every effort to ensure they have a realistic understanding of their chance of success, the benefits and risks of each treatment option, and the cost of fertility care. Here are my impressions on this thought-provoking article.
“We can’t change basic biology.”
The author is absolutely correct in highlighting the fact that a woman’s chance of conception is most closely tied to her age. In counseling patients, I am surprised to learn that many women who delay childbearing until their forties are surprised when they are unable to conceive quickly on their own. The simple biological fact is that a woman is born with all of the eggs she will ever have, and both the quantity and quality decline with age. It is more difficult to get pregnant at forty compared to twenty or thirty because, not only are there fewer eggs left, but the eggs that remain have a higher chance of being chromosomally abnormal, meaning they cannot produce a healthy pregnancy. The preliminary blood tests and ultrasounds we perform can provide a sense of how the ovaries are functioning, but they cannot tell us how many eggs a woman has left or what percentage of them are “normal.” This absolutely does not mean that a woman in her forties has no normal eggs left or cannot have a healthy baby, and for women of all ages undergoing in vitro fertilization we can now perform genetic testing on the embryos, thereby ensuring that we only replace a chromosomally normal embryo into her uterus. Women should have children only if and when they are ready. But it is our job to ensure they understand the risks of delaying childbearing so they can make an informed decision.
“We’ll drain your savings” and “How much you pay may depend on where you live.”
Many patients assume their insurance does not cover any infertility treatment, and in many cases they are unfortunately correct. However, fifteen states currently have infertility insurance mandates. In the case of New Jersey, this mandate states that any insurance policy that covers more than 50 people and also provides pregnancy benefits must also cover the cost of infertility evaluation and treatment. There are ways around the mandate (e.g. a company is self-insured, religiously affiliated, or based in another state), but in many cases at least some if not all related costs are covered. So how much you pay absolutely will depend on where you live. What many patients don’t realize is that this statement can also be true for patients without any insurance benefits. Fertility practices within the same state (and in many cases within the same part of the same state) can charge significantly different amounts for treatment. Many offer package pricing for patients paying out-of-pocket, in some cases discounting subsequent cycles if the first is unsuccessful. Many practices also offer financing options to make care more affordable. Patients who think they cannot afford treatment at a particular office should feel free to seek a second opinion as other options may be available to them.
“It’s time to stop treatment.”
Recent criticism of the fertility industry has charged that patients are being encouraged to continue costly treatment even when there is little to no hope of success. We have all seen patients who come for second opinions after going through many IVF cycles elsewhere, and upon review of their records it becomes clear that their third, fourth, and fifth cycles had such a poor prognosis that their resources would have been better spent pursuing other options. In many cases, patients are adamant in their desire to continue treatment, even when quoted a chance of success well below 10%. Our job is to honestly counsel the patient as to her specific chance of success. One complicating factor in this discussion, however, is that infertility is rarely absolute. So long as a woman is still producing eggs and her partner has at least some sperm, pregnancy is a possibility. Unless a woman is in menopause, we cannot say that she has ‘zero’ chance of getting pregnant, and many patients cling to even the smallest sliver of hope. But these patients need to realize that, in many cases, there are other options that would provide them a much better chance of having a healthy pregnancy, most notably the use of donor eggs. If using eggs from a younger (typically anonymous) egg donor, a woman’s chance of success can jump from 10% or less to 50-60%. And in New Jersey, many patients with infertility benefits also have donor coverage so long as they have not already used up all of their existing benefits. For one reason or another, many patients will refuse this option and say it is one they would never consider. Regardless of how I think the idea may be received, however, it is up to me as a responsible provider to lay out all of the options, including the pros and cons of each, so the patient can make an informed decision.
“Preserving your eggs? Don’t bank on them.”
The author is completely correct in pointing out that “you can’t make the eggs younger,” and unfortunately many patients only start thinking about egg freezing once they are already in their late 30s or early 40s, at which point both the quantity and quality of eggs has declined. This isn’t to say that she has no normal eggs left, but the percentage of eggs that are genetically normal is lower. Patient pursuing this option need to understand that going through one cycle and freezing 4 or 5 eggs does not give them the best chance of conceiving in the future. Egg freezing is, in many cases, an insurance policy, but in order for it to be a reasonable policy a woman needs adequate ‘coverage.’ We generally recommend freezing at least 10 eggs (and the more the better), which for many women may mean going through more than one round of stimulation. Again, this should be very clearly explained prior to initiating treatment so a patient has realistic expectations and can make the appropriate arrangements. Recognizing that many women will need more than one cycle to obtain a reasonable number of eggs, some practices are now offering two-cycle packages so the patient can budget appropriately from the beginning.
And two more things that patients need to know about fertility treatment…
Infertility does not necessarily equal IVF
Many patients equate fertility treatment with IVF and often assume there are no other options. In many cases, patients are surprised to learn that other treatment options, such as intrauterine insemination, even exist. We in the field certainly do not do a good enough job of spreading the word, but we are able to help many patients conceive through methods other than IVF. In the case of some women who are not ovulating as part of their polycystic ovary syndrome (PCOS), they can achieve pregnancy by using an oral fertility drug and having properly timed intercourse. Some women don’t ovulate regularly due to an underlying medical condition, such as hypothyroidism or hyperprolactinemia, both of which are typically correctable with proper medication. In some cases of infertile women or those dealing with recurrent pregnancy loss, surgical correction of some anatomic problem is all they need to achieve pregnancy. And many patients with mild male factor infertility or ovulatory dysfunction conceive through IUI and never need IVF. We hear from patients all the time that they go for an initial consultation with a fertility doctor and are immediately fast-tracked to IVF when all they wanted was a discussion of their condition and possible options. The truth is that IVF does offer the best chance of success compared to other treatment options, can overcome most reproductive issues (except for poor egg quality), and although it is the most expensive, may be the most cost-effective under certain circumstances. But the patient should feel that she has made the informed decision to proceed to IVF if and when it is appropriate once all the details of her case have been clearly explained to her.
An initial evaluation is never wrong
I am a very firm believer that knowledge is power, so I want all women to understand the issues surrounding their fertility so they can make an informed decision about their family-building. The definition of infertility is the inability to conceive for one year (or six months if a woman is over age 35). Unfortunately in many cases, patients wait significantly longer to seek evaluation, sometimes saying they had been trying for the past 5 years or more without success. This may in part be due to the belief that “I’m sure they will tell me I need IVF and I cannot afford that so I won’t bother going to the doctor.” Patients must understand, however, that the longer they delay treatment, the poorer the prognosis because, at a certain point, age also becomes an issue. A patient with pure male-factor infertility (i.e. poor sperm) at age 34 has a very good chance of conceiving fairly quickly through either IUI or IVF. But that same patient who delays treatment for several years now has a much poorer prognosis if initiating treatment at age 40 since her ovarian function is now also an issue. Although less frequent, we also see the opposite: Young patients who are anxious and seek evaluation after only several months of trying to conceive. In some cases all that is required is reassurance and a review of how to properly time intercourse to optimize the chance of success. From a physician standpoint, we would much prefer patients to present for an initial consultation early rather than late, and patients should feel comfortable seeking evaluation without feeling rushed into treatment. In some cases we have identified issues, such as blocked fallopian tubes or a male partner with absolutely no sperm in the ejaculate, that cannot be overcome with any amount of intercourse. These patients have often been trying for years with no chance of spontaneous conception. This is not to say that everyone considering pregnancy should have the million dollar work-up right away. But if an obvious problem exists (periods only coming a few times a year, male partner unable to maintain an erection or ejaculate, etc), patients should not feel they have to wait a full year before undergoing an initial evaluation.