By Kathleen Nelson
Thursday, July 10, 2003
Assisted reproductive technologies have become mainstream in the United States, where close to 10 percent of the population is infertile. But techniques used and the lack of insurance coverage has exacerbated health risks for women.
(WOMENSENEWS)--When the first baby was born on July 25, 1978, by means of in-vitro fertilization, she was hailed as a medical miracle. By now--as that erstwhile baby is nearing 25--more than 1 million babies have come into the world with the help of this and other so-called assisted reproductive technologies. The babies are still considered miracles, but mostly to their infertile parents. Technology-assisted births have become common enough to have disappeared from the headlines.
Infertility treatment remains, however, if not in its infancy, at least in its youth. It is fraught with health risks that doctors and advocates say can be exacerbated, especially in the United States, by insurance-coverage limitations.
The American Society for Reproductive Medicine reports that 10 percent of the U.S. reproductive-age population--6.1 million--experience infertility. The disease affects men and women equally, reports the society, a voluntary, nonprofit organization based in Atlanta. It provides safety guidelines for infertility clinics and new therapies.
Among these technologies, in-vitro fertilization is the most common. In this procedure, women take drugs to stimulate their ovaries to produce eggs, after which the eggs are surgically removed, fertilized and transferred to the uterus. Other types of assisted reproductive technology include artificial insemination, ovulation stimulation by drugs called gonadotropins and embryo freezing. Another technique, pre-implantation genetic diagnosis, screens embryos for genetic defects before implantation.
The likelihood of successful embryo implantation depends upon maternal age, genetic abnormalities and other factors. Many women undergo multiple embryo implantations to boost the likelihood that at least one will survive. As a result, 25 percent of these women in Europe and 35 to 40 percent of those in the U.S. have multiple births, said Dr. Hans Evers, a professor of obstetrics and gynecology at the Academic University in Maastricht in the Netherlands.
"The most serious side effect of assisted reproduction," he said in an interview, "is the huge number of multiple pregnancies." Evers is the outgoing chairman of the European Society of Human Reproduction and Embryology, based in Grimbergen, Belgium. "I speak from a European perspective," he said, one that seemed to prefer increased regulation on multiple implantation.
Multiple implantations that succeed pose myriad health risks. In a multiple pregnancy, risk of miscarriage is near double and the risk of pregnancy-onset diabetes and preeclampsia--a type of hypertension that can be fatal to both mother and child--increase. Preterm births and Caesarian deliveries are also more common.
Meanwhile, research by Australian researcher Jim Catt, embryology director of Sydney IVF, Australia, presented findings at the European society meeting that suggest that single-embryo transfer can be just as successful as multiple transfers if women can take the time to try for a few cycles.
Catt studied women who had two embryos transferred in their first cycle and found they were more likely to successfully give birth than women who underwent single embryo transfer. But when women who at first didn't give birth underwent a second transfer of another frozen embryo, the odds of success evened out. Overall, the group had exactly the same rate of live births.
However, women often times have to undergo several fertilization procedures in order to have a successful delivery when only one embryo is transferred. "Undergoing more procedures also poses risks to women's health and I'm not sure that is the answer," said Sandra Carson, a physician and president of the American Society for Reproductive Medicine. "With each cycle, women have to take medicine every day and they may undergo painful procedures and experience an emotional rollercoaster."
The higher percentage of women taking their chances with multiple births in the United States, according to Evers, has to do with a combination of limited healthcare financing policies and regulations that are more permissive than in most European countries.
In the U.S., assisted reproductive technology is mostly not covered by insurance and the mean number of embryos implanted is between three and four, said Evers. "That's way above European figures, where almost all countries accept two as the limit. Some Scandinavian countries allow just one."
The average cost for one cycle of in-vitro fertilization in the U.S. is $7,800. Few insurance companies cover infertility treatment and types of coverage vary greatly depending upon the plan and the state. There is no federal mandate to offer infertility treatment, and at present only 13 states mandate that health insurance companies cover some type of infertility treatment, which may have a deep impact on a couple's financial well-being. Medicaid does not finance infertility treatments.
In 1998 Elise Linder had trouble becoming pregnant, but her insurance didn't cover any diagnostic testing or treatment. Like many other couples, she and her husband agreed to do whatever it took, including taking on debt, to have the baby they wanted. In August 2000 they had a son named Ian whom they lightheartedly refer to as "a $22,000 baby, worth every cent."
Although in-vitro fertilization has a reputation for being expensive, the procedure accounts for just three hundredths of one percent of U.S. healthcare costs, according to American society. Carson, the society's president, would like to see expanded coverage of reproductive therapy to give more couples a chance to treat their infertility.
If insurance covered more procedures, utilization would likely increase. But some experts suggest the number of multiple births and prenatal care needed may decrease because women would feel financially more able to choose several single implantations rather than multiple implantations in each cycle.
Several health insurance plans provide alternative payment options for infertility that individuals can purchase out-of-pocket.
"If assisted reproductive technology was covered by health insurance, the financial motive would be removed from the patient's decision-making," said Dr. Richard Paulson, director of fertility programs at the University of Southern California School of Medicine in Los Angeles.
"Transferring more embryos increases the chances of success, but also increases the risk of multiple pregnancy. Women can already choose to have only one embryo placed in their uterus. Mandating such a decision with increased regulations might help to protect women from themselves, but would also risk limiting their reproductive options," said Paulson.
"Even close friends and family sometimes don't understand how difficult infertility can be," said Linder, a clinical social worker. She joined RESOLVE, a nationwide education and advocacy organization for men and women with infertility, for emotional support in 1998. Linder is now a coordinator for Miami RESOLVE meetings.
Hormones can play havoc with emotions and many women feel overwhelmed by the expensive, invasive and sometimes painful medical procedures they face, or the pressure of deciding how long to pursue a course of treatment.
"Treatment was a total rollercoaster for me," said Linder. "I was either waiting to start a treatment cycle, waiting to find out if I was pregnant or waiting to decide what to do next."
"What often frightens people during infertility treatment is the intensity of their feelings," said Nancy Docktor, a clinical psychotherapist and consultant to the Fertility Center of New England in Reading, Mass. The intensity of the emotional difficulties can depend upon how long a woman has been pursuing assisted reproduction. Failure--especially if a woman has a miscarriage--may intensify psychological risks and occasionally women develop anxiety or depression that warrant clinical help, said Docktor. She adds, however, that she has also seen the experience bring about "emotional hardiness" in women, as well.
People think of pregnancy as something that's supposed to just "happen," Linder added. "Often women who turn to RESOLVE are successful in every other arena of their lives. If they want something, they continue to work hard until they succeed," said Linder. "But with infertility, the rules change."
Kathleen Nelson is a journalist in New York City.
American Society for Reproductive Medicine:
European Society for Human Reproduction and Embryology:
RESOLVE: The National Infertility Association: