Recently it was calculated that approximately 125 IVF cases per 1 million capita are performed in in the USA during the course of a year. In most of the major westernized countries in Europe they are performing between 400 – 500 cases per 1 million capita. That is just one fourth of the cases that are done in these other countries! Despite the fact that on average USA IVF success rates are higher than those countries, we do not help nearly as many people. Why? The answer is obvious. IVF is not a covered medical treatment in the USA and so, the overwhelming majority of Americans just can't afford the procedure. In many European countries there is generally some form of coverage, but  if the family has to pay out of their own, the costs are less than half than what they are in this country. With one in seven couples in the USA struggling to build their families, that leaves many people left to fend for themselves.

Two and half years ago, we opened the Fertility Partnership with the goal of providing state-of-the-art reproductive health care in a caring and compassionate environment. As we opened our doors in the heart of the worst economic crisis in 70 years, it was clear that the best way to be compassionate was to make it as affordable as possible. In August 2010 the Fertility Partnership was featured in  Newsweek Magazine describing our efforts to lower the cost of Advanced Reproductive Technology. It was a fascinating article that stirred up some controversy. For example, it touched upon some difficult topics such as the "economic selection" that created by the high cost of fertility procedures . That is to say, only infertile couples with economic means will be able to reproduce. We have learned a lot since we've opened, and so I thought it appropriate in honor of National Fertility Week to reflect on what we've learned during our quest to provide the best care at the most reasonable cost.

The fact of the matter is that the materials and equipment needed to run and maintain an IVF laboratory, staff an IVF clinic, and all that is needed to maintain state-of-the-art clinic in full compliance with all regulatory statutes is just very expensive. So how do you bring the cost down? Some clinics have tried what are called "shared risk programs". That is where you pay for more than one round of IVF upfront and are given certain assurances that there will be a successful outcome. There are even promises or guarantees to return money if all attempts fail. We initially considered pursuing this at Fertility Partnership because there is something to be said about calming the frightened couples with guarantees and opportunities to try more than once. What eventually dissuaded us from pursuing this practice is the simple fact that some of the companies that provide these services are publicly held and annual profits are visible to any and all. They are apparently doing quite well financially with these programs and post millions of dollars of gains each year. This somehow seems too businesslike to us and not in the spirit of practicing medicine. Also, typically patients can only get in on these "shared risk" programs if they meet certain criteria which in fact make them very likely to be successful at IVF, ad so they are "safe bets". I like to use the metaphor of throwing darts at a balloon. IVF is like paying thousands of dollars for a dart to hit a balloon and win the most wonderful of prizes. But, there are no guarantees. I believe that you have to keep your darts very sharp, that is to say the best science and medical/clinical care. You have to engage your patients and keep them focused and calm as they take their shot at being successful. Also, our philosophy has been to provide each dart at the lowest cost possible. We are not going to “sell” you two or three darts at a time with guaranteed results. In the end, we believe that works out better for the patients.

So what about "low intensity" in vitro fertilization? It comes under various names such as "low dose", "micro", and other names that are in fact trademarked and so I will not mention them. It is my understanding that these protocols for IVF were developed with the idea that there are women who would benefit from lower doses of fertility medications during their cycles. Unfortunately it has not panned out. In a recent publication Dr. Norbert Gleicher reported on their results. He states that "with an identical number of embryos transferred, after adjusting for age, patients using standard IVF demonstrated a 7-fold better odds for pregnancy and a cumulative pregnancy rate that was more than six times higher than that achieved in patients using low intensity IVF cycles". He also calculated that the average cost to bring a baby into the world from these technologies i.e. live birth, was “$23,100 when low intensity IVF cycles were used and $20,333 when standard IVF cycles were used (these are cumulative results, meaning multiple attempts may have been necessary). Dr. Gleicher concluded from his research that "low intensity IVF currently lacks clinical and economic foundations, and therefore should be offered only under experimental study conditions". Unfortunately, there are some clinics that are marketing these protocols as low-cost alternatives to standard IVF. I feel certain that there are some couples who could benefit from this approach; however we do not know who these couples are at this time. At Fertility Partnership we don't provide low intensity IVF, but, it's in fact quite easy to do and we are ready to implement these protocols once we are convinced that is beneficial for a particular couple.

So what's the answer? How do you lower the cost of in vitro fertilization? The answer is by doing just that, lower the cost of in vitro fertilization. I believe that physicians need to lower their expectations of what they will ”earn"  from each cycle and be prepared to provide care to the increased number of couples who will come seeking care because it's less expensive. We are only taking care of one fourth of the patients in the USA who require in vitro fertilization and all that goes with it. Clinics need to just lower their prices and roll up their sleeves to work harder and provide good care for more people.

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Let's face it, it's time for us to reinvent how we look at infertility. All these years, we have been viewing infertility as a quality of life issue. In fact, it is more like a disease, because human organs are not working as they should. A woman's right to try to get pregnant should be the same as a person's right to not have a broken bone or an infection. Nevertheless, we find ourselves in a situation where only people who can afford it and the few who have insurance can be appropriately treated.

Since infertility care is not generally covered by insurance, the medical community has become reactive as opposed to proactive in our management. Couples often wait a very long time before they seek help, as they fear what lies in store for them if infertility is in fact diagnosed. As a result, many women wait too long and are faced with a serious egg reserve problem. Imagine if a woman or man could find out that there is a problem even before they try to have children. If they found out early on, they could prepare themselves emotionally and financially for the upcoming struggle.

Fertility Partnership has created the Fertility Profile to give women an opportunity to get a snapshot of their reproductive health. If the results indicate that there is a significant depletion in their egg reserve, they can make decisions before it's too late. While the Fertility Profile can give women a good snapshot of their current health, however, it cannot predict that the egg reserve will remain within healthy ranges for a long time. In fact, I have seen women whose fertility indicators have changed dramatically over a very short period of time – as little as six months. But, if there is a problem, a woman has a right to know as soon as possible. As it stands now, a woman generally has to try to get pregnant for a year – six months if over age 35 – before most doctors will initiate a comprehensive workup. At the Fertility Partnership, my objective is to always be proactive and look for problems early on so that big decisions about having a baby can be made in a timely fashion.

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Donna Nichols is one of the most courageous and inspiring women you'll ever meet. Here's her story, courtesy of KTVI-TV, about battling the physical and emotional trauma of nine miscarriages before finally giving birth to two beautiful baby boys. Thanks, Donna, for sharing your story and giving hope to many other women dealing with the sorrow of recurrent miscarriage.

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As Fertility Partnership gathers momentum, we’re continuing to use a variety of methods to spread the word about our clinic’s unique mission and services. I am thrilled that our second cycle has twice the number of patients as our first, but I still cannot help but wonder why OB/GYNs don’t more readily refer patients to fertility doctors. I have a unique perspective on this issue, because I am sure I am one of the few obstetricians who was engaged in IVF while also practicing general obstetrics and gynecology.

The fact of the matter is that many obstetricians don’t want to refer onward. Several reasons come to mind, most of them involving good intentions. First, they know how expensive advanced reproductive technology is and want to solve the problem for their patients much more affordably using simpler, less expensive measures. Some don’t refer because they simply enjoy being a doctor and want to be involved in the “healing process.” From personal experience, I can tell you there’s no greater thrill than calling a patient who’s struggled to have a baby and saying to them, “Guess what? You’re pregnant!”

I am sure there are those doctors who just don’t like admitting they don’t know what to do when a patient can’t get pregnant, so they simply say, “Well, let’s just give it a few more months.” Also, there sometimes is a concern that if they refer their patient out to a fertility doctor, the patient will never come back - their doctor-patient relationship will be undermined by the process, or the specialist will send the successfully pregnant patient to a high risk obstetrician or to another physician who is a better referral source.

In the end, precious months are often wasted. Clomid is given inappropriately, for the wrong reason, and for too long. With the recent study from the University of St. Andrews and Edinburgh University in Scotland that found a woman loses 90 percent of her egg quantity by age 30, we should all be concerned about not wasting valuable time. I built the Fertility Partnership with a goal of developing strong relationships with referring doctors so that many of the obstacles to timely reproductive care can be overcome. We will not price-gouge their patients, we will communicate well with the referring doctor and ensure the patients return to them if the patients choose to, and we will work with the doctors who want to solve the problems in their own practice. It’s just one of the reasons our name is Fertility Partnership.

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