Making Your Fertility Treatment Plan: How to Avoid Hit-or-Miss Fertility Treatment

How Long Will It Take?
I try to give couples a treatment time frame so they know how long it may take to achieve a pregnancy. With this information they can assume more control over their time and money. For example, I told Steven and Kathy S. that if he elected to have his varicocoele repaired, it would be at least three months after the surgery before we would know if Steven's sperm count would improve. During that time Kathy could begin taking medication to induce her to ovulate. Within three months Steven's sperm count should improve and Kathy's cycle should be regulated.

Sometimes couples wonder why the workup often takes several months. Unfortunately, within one menstrual cycle we can try only a few things at a time. Since Kathy S. was not ovulating, my first priority was to induce ovulation. Once her body responded to that medication, I could then check other factors. As it turned out, I discovered a secondary problem which could prevent their fertilized egg from implanting in her uterus. So the next month I added a hormone to correct that problem.

It is for these reasons that your doctor cannot always tell you exactly how long treatment will take or how effective it will be. You do have a right to know, however, what results to expect if the procedure is a "success" or a "failure." And this knowledge will give you the tools you need to participate in the decision about what to try next.

Many people become discouraged with fertility treatment because they believe that in the first month they "become fertile" they will make a baby. We may work for four to six months regulating ovulation and improving semen quality to fertile levels. The seventh month passes_no pregnancy. The eighth month_no pregnancy. The ninth month_no pregnancy:

"I don't understand, Dr. Perloe," Margaret B. said.

"We've tried everything and I'm not pregnant yet."

"Do you have friends or relatives with children?" I asked.

"Yes, my brother and sister."V "Do you know how long they tried to get pregnant?"

"Well, my brother and his wife did it in two months. But my sister took five."

"Do either of them have a fertility problem?"

"No. But why are you asking me about them?" she said.

"Well, what makes you think that you'll get pregnant within two or three months of solving your fertility problem when it took your sister_who had no fertility problems_five?"

She paused for a moment. "Well, I've always done everything better than my sister, and I should be able to get pregnant faster, too." She burst into a laugh.

I laughed with her. "You see my point, Margaret? Fertile people have a 20 percent chance for pregnancy each month. And people who have been through fertility treatment have at the most a 20 percent chance, too. You could easily take six months to a year to get pregnant, even if everything is in perfect working condition.

"Fertility treatment is a tremendous strain," I added. "Getting pregnant_or not getting pregnant_is on your mind every day. Just don't get upset about it_not yet, anyway. Remember our plan? We will try three or four cycles and then, if you aren't yet pregnant, we'll consider other options. Next time talk to me before you become upset. Okay?"

How long will treatment take? Talk to your doctor, make a plan, and monitor your progress. And don't forget that "normally fertile" people may take up to a year to get pregnant.

What Price Pregnancy?
I find that many couples are reluctant to discuss money with me because they feel guilty about placing a "price" on pregnancy or having a baby. They tend to overlook insurance and money issues when developing their fertility treatment plan.

However, fertility treatment can be quite expensive_both in actual cost and in the time you may lose from work. In fact, some treatment regimens may be so demanding that your job is placed in jeopardy. For example, certain medications must be given by injection in the doctor's office several days a week; postcoital tests require you to come in two to four hours after having sex; and diagnostic surgeries may require that you miss several days of work It's only fair that you be aware of these requirements before committing yourself to a treatment program. Knowing what you're getting into may not change your choice, but it will give you the opportunity to plan your life and prepare your employer.

Before Michael and Shelley T. came to see me, they had had many squabbles about money. Since Michael did not understand why the tests and medications were necessary, he had no way of evaluating whether costs were getting out of hand. To make things worse, they'd bought a house, anticipating that Shelley's coming promotion would bring in more money. When Shelley's boss discovered that she'd filed insurance claims for fertility treatments however, he promoted someone else instead. The boss claimed that he passed her up because she was taking three to four afternoons off per month for tests. But Shelley heard through the grapevine that he didn't want to promote her because he thought she'd probably quit after she had the baby. He also mumbled something about her medical claims increasing the company policy premiums. Although not all employers will react this way, you may have to be careful how you present your planned absenteeism and your future employment plans to your boss. I'll tell you later how other couples have handled these dilemmas.

Because this couple had not agreed upon a financially manageable treatment plan, Michael felt that he was not in control of the situation. I can understand why, when faced suddenly with a $6,000 surgical expense, they refused the doctor's recommendation for diagnostic surgery. However, if from the beginning Shelley's doctor had included Michael in the plans for her treatment, the story might have been different.

Steven and Kathy S., for example, controlled their psychological and financial resources right from the start. As a runner, Kathy's athletic achievements were very important to her. After her initial workup, I pointed out to her that her physical exertion could very well be the reason that her menstrual periods had for the most part stopped. She decided, however, that she wanted to try to keep running and achieve pregnancy, too. So together we worked out a treatment plan based on that agreement.

Since Kathy didn't work, they had a limited budget. Steven checked out what his group insurance covered before beginning treatment. The policy would pay for most expenses; however, it didn't cover everything. (Trying to keep up with what one insurance company covers and what another company doesn't is nearly impossible. The logic insurance companies use for determining eligibility is sometimes a mystery.) In the course of making their fertility treatment plan Steven and Kathy decided to begin saving for the possibility of microsurgery or in vitro fertilization, which could cost up to $8,000 or $10,000 per procedure. Even though their insurance would pay 80 percent of up to two in vitro procedures, they knew that their bill could add up to quite a bit more (many people require three or four in vitro cycles before conceiving). Since banks don't make loans for babies, they wanted to be prepared to make the right choices without facing extreme financial pressures.

It was a good thing they started their savings account, because Steven's varicocoele surgery cost $5,400. We had to make a change in the fertility plan to include using his sperm for four cycles of artificial inseminations at $350 per cycle. (Remember that this expense was in addition to Kathy's ovulation induction of about $250 per month.) And if Kathy's oral medication hadn't worked, she might have had to take Pergonal injections and have blood tests costing nearly $400 per month. With the Pergonal, she would also need three to five $150 ultrasound readings to monitor her egg development, a total cost of about $2,500 per month. (Without ultrasound to determine the effects of the Pergonal she might risk having multiple births, and quadruplets were not in their plans.) I'll tell you how Kathy and Steven got their baby girl in a later chapter.

The point I'm making is that fertility treatment can be very expensive, and expenses may increase as you modify your fertility plan to accommodate your medical needs. Your ability to control your expenses is a vital part of your fertility plan. I suggest that you work with your doctor to estimate a best-case and worst-case scenario. That way you minimize the risk of any big surprises.

Insurance is No Guarantee
You should talk with your doctor about the costs and with your insurance carrier about what is and is not covered. Sometimes insurance companies have riders and waiting periods before you qualify for coverage. Some policies even exclude pregnancy and fertility payments altogether. Coverage may also differ from state to state. If your company transfers you from New York Blue Cross/Blue Shield to Georgia Blue Cross/Blue Shield, for example, you may not have the same protection. If you change jobs, or change your insurance carrier from your coverage to your husbands, infertility treatment may no longer be covered. A preexisting condition using allows them to avoid paying for any condition you were treated for during the previous year. While some plans cover diagnosis and treatment, others may only cover diagnosis or they may provide no infertility benefits. In addition, some fertility treatment procedures may be considered experimental and therefore will not be paid for by the insurance carrier. In vitro fertilization fit in this category for many years. Even now few companies pay for in vitro. Those that pay, often place a limit on how many cycles they will cover. You could find that an HMO (health maintenance organization offering prepaid medical care) will provide more complete basic coverage than standard insurance policies.

Only when you have these facts and figures can you develop a treatment plan within your means. The only way you'll know is by asking. Start by asking the insurance coordinator at your doctors office for advice. You can also gain information by talking to the benefits coordinator at work. Be careful when you call your insurance provider as they may mark your insurance claims for special review making any women's healthcare coverage difficult.

Later chapters will tell you more about the demands of specific tests and treatment regimens as well as how couples manage their jobs, their schedules, their money, and their personal lives.

A Seven-Day-a-Week Commitment
Fertility treatment is a seven-day-a-week proposition. If you ovulate on the weekend, you may find yourself in the doctor's office having ultrasound or artificial insemination. You can't spend hundreds of dollars a month to induce ovulation and blow it because it's the Sabbath. Discuss your feelings about the time involved.

You will see how other couples handled these problems in chapter 20. In addition, I will discuss such specifics as how you can schedule a vacation while in treatment_and how you can start having fun in bed again. As a couple you need to decide how you will handle emotional issues, schedule changes, and inconveniences. One partner cannot bear all the burden.

Examining Your Moral and Ethical Beliefs
You also need to discuss what types of treatment plans will fit into your moral and ethical beliefs. The evaluation test in chapter 3 may have helped you analyze these issues. But once you begin formulating your treatment plan, you will have to come to grips with some heavy decisions. How do you feel about your spouse risking major surgery? Are you willing to consider artificial insemination with your husband's sperm (AIH) or with a donor's sperm (AID)? What about using a donor egg (embryo) from another woman? I'll discuss the legal and ethical implications of these. And I'll also tell you about the decisions other couples have made.

When Will You Stop Treatment?
You should make a tentative decision about how long you will stick with one treatment approach. Although your decisions may change as you obtain more information from tests and treatments, you still should have short-term goals and concrete mileposts to measure your progress. For example, Steven and Kathy agreed to try AIH for six cycles before considering in vitro fertilization. Richard and Margaret limited themselves to three in vitro cycles. How long will you go through fertility treatment before considering adoption? Or when might you feel okay about deciding you want to remain childless?

Your decisions may be criticized by relatives and friends who don't share your sentiments. Michael and Shelley T. decided not to try AID or in vitro because of their parents' religious beliefs. I'm not sure they were totally comfortable with this turn of events, but they chose to keep peace in the family rather than be alienated.

I find that as my patients learn more about their fertility problem, as the significance of not having children sinks in, as the treatments tax their emotional and physical health, or as their bank account dwindles, they often change their minds about what treatment they want. In addition, new options arise every year from advances made in medical research: donor eggs, micromanipulation, laser surgery, embryo freezing and so forth. Many couples begin to consider options that seemed less attractive or simply were not available earlier in their treatment. For example, although Robert and Martha W. at first wouldn't even consider AID, they eventually decided that using donor sperm for artificial insemination would be better than going through in vitro fertilization procedures. They now have a beautiful, curly-haired baby girl whom they adore. Some couples decide that adoption is their best alternative. When Jamie L. dropped by my office to show me her newly adopted son, I remember her saying, "I wish now I hadn't thought of adoption as the last resort. I wouldn't trade my baby for anything."

Your plan is only a guide, a road map. At any point in the journey toward your happy ending, you can choose a different route. The chapters to come will help you become an informed consumer, so you will be able to assess all your options and take advantage of the best.

For more information on your initial visit to your physician read the
INCIID Routine Fertility Workup or IVF.com Homepage.

Miracle Babies and Other Happy Endings
for Couples with Fertility Problems
Copyright © 1986 Mark Perloe M.D., and Linda Gail Christie.