Skipping Baby Steps
The case for going straight to IVF.
If you go in for fertility treatment, here are the rounds you'll likely make. First step: clomiphene pills to help you ovulate while your doctor shoots sperm directly into your cervix. If that doesn't work after three tries, you move to the second round: hormone shots that make you pump out a lot of eggs at once, with three more tries of sperm shooting. If you're still not pregnant, you graduate to the Last Resort of fertility medicine, in-vitro fertilization. For about $10,000 a pop, doctors remove drug-matured eggs from your ovaries, inject them with sperm in a lab, and put the best embryos back into your uterus in hopes that at least one will take hold.
Fertility specialists have gotten better at IVF—the latest government data show a 34 percent pregnancy rate per attempt in 2005. (The average age of the women who were tracked is 36, so the figures are even better for younger women.) In contrast, the standard second-round fertility treatment, hormone shots with insemination, has a success rate of 10 percent to 15 percent, at a cost of about $3,000. (The $500 first-round pills-insemination combo works about 6 percent to 9 percent of the time.)
So it makes sense that some researchers are pushing to skip the middle step and go straight to IVF when the first-round effort fails. In a study presented last month at the annual meeting of the American Society of Reproductive Medicine, doctors from Dartmouth Medical School and Boston IVF concluded that women who were fast-tracked to IVF got pregnant three months faster on average, and spent $10,000 less than those who went through the usual preliminaries. These kinds of data may be just what the doctor ordered to get more insurers to cover IVF treatments.
In their randomized trial, which was sponsored by the National Institutes of Health, the Dartmouth-Boston IVF researchers studied about 500 couples of various ages who were unable to get pregnant naturally after trying for a year. In the first group, which went through all three of the standard therapies, about 75 percent ended up getting pregnant within 11 months on average. In the group that went straight to IVF when clomiphene (Clomid) with insemination failed, the same percentage got pregnant—within only eight months on average. Collectively, they endured 337 fewer treatment cycles to get similar pregnancy rates. Perhaps the most surprising finding was that the fast-track protocol cost less in the long run: on average, $61,000 instead of $71,000.
The reduced time it takes to get pregnant on the IVF fast track is a significant advantage. What do three months matter? A lot for older women with few fertile years left. In fact, time is so critical to these would-be mothers that the researchers are conducting a second trial looking at recommending IVF right away, without any Clomid first, for women between the ages of 38 and 43. Shorter waits bring welcome psychological relief. One study claimed that women going through infertility treatment were as distressed as women diagnosed with cancer, heart disease, or HIV. Fast-tracking can mean fewer episodes of dashed hopes. That could lead to less depression, anxiety, and stress, which hurts marriages and, some claim, may lower one's chances of conceiving.
There are even more compelling reasons to get couples' reproductive bits in the Petri dish sooner than later. The first is the potential to prevent higher-order multiple births—triplets, quadruplets, and beyond, which carry a greater risk to the mother's and babies' health. Women who get pregnant from injections with insemination face a 10 percent to 15 percent chance of carrying litters because the drugs can make them release six or more eggs. There's no way to control how many get fertilized. With IVF, by contrast, doctors create embryos in a lab and choose how many to transfer back to the womb, bringing the risk of triplets and beyond down to 2 percent to 4 percent. (The odds of conceiving triplets naturally are between 1 in 6,000 and 1 in 8,100.) That IVF figure is likely to decline further as doctors increasingly transfer fewer embryos.
None of this is to say that the IVF fast track is for everyone. Injections with insemination certainly are less invasive. IVF patients inject stronger drugs, which carry a greater risk of ovarian overstimulation, and they have to go through minor surgery to have their eggs retrieved. They also take more hormones to prepare for the embryo transfer. Finally, people might not want to sign up for the most extreme option first. "People hold up IVF as their last hope, and it's scary to go to that last hope first," explains Joann Galst, Ph.D., a Manhattan psychologist who specializes in infertility issues.
Still, the benefits of the fast track should help convince insurers to approve IVF without requiring patients to exhaust all other treatment options first. At present, only 15 states have a mandate for insurance companies to offer or cover infertility treatments, which means that across the country, many patients have to write their own checks. (Small employers or those who are self-insured also don't fall under state coverage requirements.) And the coverage that states do mandate is often stingy. For example, Connecticut allows insurers to offer a maximum of only two IVF cycles ever, and Arkansas caps IVF coverage at $15,000 for a lifetime. The poster child for a state with comprehensive fertility coverage is Massachusetts, where many insurers routinely approve up to six cycles. (The Dartmouth and Boston IVF researchers conducted their study in Massachusetts, where patients have access to such benefits, and achieved a 75 percent pregnancy rate.)
This is worth rethinking in light of the findings about the IVF fast track because the cost to insurers for the treatment isn't all that expensive. In a separate study, Emory researchers analyzed data from the mid- to late 1990s and found that premiums for policies that included any kind of IVF benefits rose only 26 cents to $1.71 per member per month. Congress is beginning to get this: New federal legislation recently introduced in the House would require insurers to cover four IVF cycles. (Plus two more if one results in a live birth.) But, like many state mandates, it also makes couples run the gamut by trying other methods first.
Why should infertility patients have to go through such rigamarole? Doctors treating bladder infections don't make you drink cranberry juice before dispensing antibiotics. Nor do chiropractors mandate stretching before they crack your back. To make some infertile couples waste time with way-station options is similarly illogical.
Sarah Elizabeth Richards is the author of Motherhood, Rescheduled: The New Frontier of Egg Freezing and the Women Who Tried It
Photograph of blastocyst courtesy RWJMS IVF Program/ekem on Wikipedia.