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Confronting the real cost of IVF Treatment

by Dr. Geoffrey Sher on February 8, 2016

There are about 1.0 million infertile couples in the United States, for whom IVF offers the only rational opportunity to have a baby. About 10% of these women (100,000) undergo approximately 150,000 fresh IVF cycles annually. This represents a significant underservicing of the demand. The fact that more than onehalf of all IVF procedures are conducted by fewer than 10% of the programs, with the remainder being divided among the rest of the clinics means that most IVF centers in the USA perform fewer than 150 fresh IVF procedures annually. This makes it very difficult for all the IVF practitioners (physicians and embryologists) to gain optimal hands-on experience. In fact, with such small numbers of IVF procedures being performed by half the IVF programs in this country, it is virtually impossible even to develop meaningful statistics.

The main reason for the underutilization of IVF in the United States, is the matter of cost and affordability. Presently most IVF costs represent out of pocket expenses. A study reported in “Human Reproduction” a few years ago by the European Society of Human Reproduction and Embryology (ESHRE) revealed that direct costs of fertility treatment vary considerably from country to country with the United States topping the list. For example, the average price of IVF treatment is about $4,100 in Japan, $3,100 in Belgium, $8,750 in Canada and a whopping $13,800 in the U.S. Moreover, these costs have risen further, quite substantially, over the last few years. Simply stated, when it comes to IVF in America, the size of the pocket book usually determines the ability to have a family.

Central to making IVF affordable lies the need for insurance coverage”. However, Insurance companies are reluctant to cover IVF because of two main concerns:

  • First, is the fact that the there is an absence of access to accurate IVF outcome data that would actuarially determine cost. Unfortunately annual IVF outcome reports by  the Society for Assisted Reproduction (SART) largely relies on self-reporting of statistics by individual IVF clinics and does not require consistent  validation through oversight or auditing. Hopefully, this will change because until and unless it does, insurance companies will likely remain reluctant to cover IVF.   
  • Second is the fact that the high incidence of IVF multiple births, largely brought about by a lack of control over the number of embryos being transferred per IVF procedure. The high incidence of serious complications resulting from prematurity-related complications drives up cost to payers, creating a strong disincentive to cover IVF services. drives up cost per baby.

Given a roughly 35% National IVF birthrate in women under 39Y of age ( and this declines with further advancing age), it follows that most women will require more than one (1)  IVF attempts to have a baby. As such, the traditional “fee for service” system of payment will often put having an IVF baby outside the reach of many infertile patients requiring this service. It was against this background that I, more than 20 years ago first introduced the concept of Financial Risk Sharing with patients undergoing IVF. One example is the very popular “Two Cycle Plan” (which for a set fee which is slightly higher than the cost of a single IVF attempt) they gain access to up to two (2) fresh IVF cycles with as many fresh or frozen embryo transfers as needed to either achieve a live birth or use up all available embryos generated

Here I wish to offer a word or two of caution…… Beware of comparing one program’s quoted cost of IVF directly to another’s at face value.  As with the purchase of any product or service, it is always important to first look at the base cost and then to evaluate the fees for additional services (“add-ons”).  IVF Program A might include the cost for add-ons such as intracytoplasmic sperm injection (ICSI), assisted hatching and initial freezing and storage of embryos in their “base price” while Program B  might quote a lower IVF fee that does not include the cost of some/all such add-ons. Unless this is taken into consideration, it is possible to erroneously consider the cost of IVF at Program B as being lower than at Program A .It is important to always compare “apples with apples”. First, examine the base fee per cycle, add the inevitable cost of anesthesia and fertility drugs and then ask about the extra cost of any “add-ons”.

Finally, patients are advised to view the cost of an IVF procedure as the cost of having a baby and not the cost of each individual cycle of treatment. Thus, another important consideration issue is the experience, quality and expertise of the doctor and lab, as this inevitably impacts the likelihood of a successful outcome (live birth).

The emotional cost of IVF
To describe the effects of preparing for, participating in, and post IVF anticipation as a “roller coaster ride” is a gross understatement.  Anyone who has been through the process, whether successfully or unsuccessfully will attest to the fact that in the final analysis the emotional price turned out to be far greater than the financial.

Unquestionably, the majority of US women/couples going through IVF find the financial burden to be overwhelming. They have to massage every dollar available to afford a single cycle of treatment. As such they view the financial challenge as great. For them the knowledge that if they do not succeed the first time around, they might not be able to afford a second attempt, only serves to deepen their emotional stress. Here, it becomes even more important to seek out the best possible available venue for IVF services, in their area or out-of-town.

More than 70% of my IVF patients travel from out of town, state or country to Las Vegas for treatment with me. I fully recognize that for some, traveling away from home for IVF often denies access to built-in support systems and, as such, might represent a hardship and a sacrifice.  That is where we I and my team come in to the picture. We strive to provide such support through being available and affable at all times. I personally provide all active patients with my cell phone number and invite them to call me at any time with questions, comments, concerns or any other issue(s).

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    Dr. Geoffrey Sher - August 22, 2017 reply

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    Dr. Geoffrey Sher - August 19, 2017 reply

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  • Ameera Bousaid - April 24, 2017 reply

    I would like to ask what are the preparations you did upon having IVF treatment? And was there really a thing called gender selection with gender selection? I heard that they offer that in Bournhall Clinic in Dubai

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - April 24, 2017 reply

    a. I am sure they offer gender selection at Bourne Hall.

    b. The objective with In Vitro Fertilization is to initiate a healthy, viable pregnancy. In order to avoid high order multiple pregnancy (triplets or greater) no more than one or two “competent” embryos should be transferred at a time and to optimize implantation, the uterine lining (endometrium) should be rendered optimally embryo-receptive. Achievement of these objectives requires a very individualized and meticulous approach to the evaluation and treatment of those factors that can influence IVF outcome:

     The contribution of Clinical versus Laboratory Performance on Embryo quality and IVF outcome.
    In 70-80% of cases, failed reproduction is a consequence of egg/embryo incompetence. The number of eggs a woman produces is influenced by her ovarian responsivity to gonadotropin fertility drugs. This responsivity in turn relates to her proximity to menopause. Ovarian responsiveness can be assessed by measuring FSH/estradiol (E2) , the antral follicle count (AFC) at the commencement of the cycle, and AMH, anytime. If one or more of the following is detected; plasma FSH level >9.0MIU/ml in association with plasma estradiol level of less than 70pg/ml, AFC <8 and/or the AMH of less than 1.5 ng/ml it is suggestive of diminishing ovarian reserve (DOR) and the need to be more aggressive and strategic in the design of an individualized protocol used for controlled ovarian stimulation. By far the most important variable that can be influenced IVF is the protocol used for ovarian stimulation, how it is constructed and implemented. Certainly the quality of the IVF laboratory is also pivotal. However, in my experience that most reputable IVF programs have laboratory staff who are highly disciplined and efficient when comes to structure and process and are very capable of performing highly technical procedures such as intracytoplasmic sperm injection (ICSI), embryo biopsy and assisted hatching (AH). In fact poor IVF outcome results can usually be traced to clinical, rather than laboratory deficiencies. IVF procedures should only be performed by those who have the necessary experience and skill set, lest fertilization rates and embryo quality be severely compromised.

     Ensuring Optimal Potential for Embryo Implantation.
    1. Assessing the anatomical integrity of the uterine cavity: Hysterosonography (Fluid ultrasonography-FUS) is a simple office procedure performed under mild sedation, where a sterile salt/water solution is injected into the uterus and an ultrasound exam is performed. The procedure permits a detailed inspection of the inside of the uterus for surface lesions such as polyps or fibroid tumors that may be protruding into, encroaching upon, or distorting the uterine cavity. Such lesions compromise the ability of the embryo to attach to the uterine wall, and as such should be removed before initiating fertility treatment. Sometimes, direct visualization of the uterine cavity is needed. This calls for the performance of hysteroscopy, a procedure where a thin, telescope-like instrument is inserted through the cervix into the uterus for visual inspection of the cavity. Diagnostic hysteroscopy can readily be performed in the doctor's office using local anesthesia and mild sedation. A dye X-Ray test or Hysterosalpingogram (HSG) is NOT sufficiently sensitive or specific to exclude the presence of small lesions in the uterine cavity.
     Ultrasound assessment of the uterine lining: An additional uterine factor that can affect the success of IVF is the thickness and consistency of the endometrial lining following administration of fertility medications. This can be evaluated through the performance of an ultrasound starting about 1 week after initiating ovarian stimulation or estrogen therapy for embryo recipient cycles (i.e., FET, egg donor IVF, Embryo donation, gestational surrogacy) or by the day of the hCG trigger, by which time it needs to have reached > 8mm in thickness.
     Immunologic implantation dysfunction (IID): In about 15- 20% of cases there will be an underlying autoimmune or alloimmune immunologic implantation dysfunction (IID). I require that an immunologic evaluation for uterine natural killer cell activity (Nka) using the K-562 target cell test and/or uterine cytokine analysis be performed prior to IVF in the following circumstances where the chance of an IID is increased:
    • “unexplained infertility”
    • “Unexplained repeated IVF failure”
    • Recurrent pregnancy loss (RPL)
    • Personal or family history of autoimmune disease (e.g. Lupus erythematosis, hypo/hyperthyroidism, rheumatoid arthritis, etc.)
    • Endometriosis

     Sperm Quality and Function.
    Prior to the advent of IVF, treatment of moderate and severe male factor infertility yielded dismal results. The introduction of IVF offered the first ray of hope but results were still disappointing. It was not until the advent of ICSI, where a single sperm is directly injected into each egg that this changed. Now, as a result of ICSI, IVF birth rates in cases of male infertility are not much lower that with conventional IVF. In fact, since ICSI apparently does not cause an increase in miscarriages or birth defects when it is performed for indications other than male infertility and averts unnecessary failed fertilization of eggs, I advocate it for all my IVF cases.
     Embryo Transfer.
    There can be little doubt that embryo transfer is a critical determinant of IVF outcome. It is important to recognize that this needs to be done under ultrasound guidance and only by those who are proficient in the process. It is definitely a rate-limiting factor when it comes to IVF outcome.

    No one gets through the IVF process without paying an emotional, physical and financial toll. Accordingly, all patient participants should learn what they can reasonably expect before committing to IVF. Simply put, it is important to establish realistic expectations from the very outset and to plan this trip before embarking on the journey. That is why all patients should be fully informed of the services contemplated, through detailed interactive medical consultations and that that relevant consent forms and agreements be carefully reviewed and signed prior to initiating a cycle of treatment.

    ——————————————————————————
    Tests required (some selectively).to prepare patients for IVF:

    A.FEMALE TESTS:

    BLOOD TESTS
    1. Tests for ovarian reserve: (basal FSH, E2 and AMH)
    2. CBC
    3. TSH
    4. Prolactin
    5. Rubella antibodies
    6. ABO/Rh
    7. Hepatitis-B surface antigen
    8. Hepatitis-C antibodies
    9. RPR/VDRL
    10. HIV
    11. Cytomegalic virus antibodies
    12. Genetic/metabolic tests (e.g. Tay Sachs, Nieman Pick etc.)-selectively done.
    13. Tests for blood disorders such as Cystic Fibrosis, Sickle Cell Disease and Thalassemia-selectively done
    14. Tests for immunologic implantation dysfunction (IID) (selectively done)
    a. Antiphospholipid antibodies (female partner)
    b. Reproductive Immunophenotype (female partner)
    c. Antithyroid antibodies (female partner)
    d. NKa using the K-562 test/endometrial cytokines (female partner)
    e. DQalpha/HLA genetic test

    B.MALE TESTS:

    BLOOD TESTS
    1. FSH/LH/Testosterone/Prolactin –selectively done
    2. Hepatitis B surface antigen
    3. Hepatitis C antibodies
    4. HIV
    5. RPR/VDRL
    6. DQalpha/HLA -selectively done
    7. Anti-sperm antibodies selectively done

    SEMEN TESTING
    1. Semen analysis
    2. Sperm Chromatin Structure Assay –SCSA-selectively done
    ————————————————————————–
    There may be additional tests selectively required

    I prepare my patients for an IVF cycle using a combination of the Birth Control Pill (BCP) to launch the cycle of treatment. Then, by shortening or lengthening the duration on the BCP, we can orchestrate the exact time of menstruation. This allows for “batching of patients into about 10 calendarized 2 week cycles through the year, during which I treat between 30 and 50 cases. This arrangement benefits patients and staff alike. It facilitates planning and scheduling months in advance, with precision.

    For conventional IVF cycles patients need to be present onsite for monitoring and treatment. Frozen embryo transfer (FET) cycles require a 10 day commitment and Staggered IVF cycles as well as Embryo banking (where the patient does not undergo ET in the same cycle that the ER is performed) require patients being present for 7- 8 days.

    Geoff Sher

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    Dr. Geoffrey Sher - April 12, 2017 reply

    Thank you!

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  • robert - November 14, 2016 reply

    Thank you for great idea. this is really helpful. Thank you for sharing

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - November 14, 2016 reply

    You are very welcome Robert!

    Geoff Sher

  • cheyne suker - May 16, 2016 reply

    Thanks for sharing information about IVF.. Can this IVF treatment is risky for health above 40…
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    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - May 16, 2016 reply

    It is a relatively safe procedure provided appropriate protocol and precautions are taken.

    Geoff Sher

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