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Moving On: Finding Dr. Magic’s Clinic

Moving On: Finding Dr. Magic’s Clinic

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Sorting through SART statistics
The Society of Assisted Reproductive Technology (SART) is an organization
affiliated with ASRM (American Society of Reproductive Medicine), the organization for healthcare professionals involved with reproductive medicine.
SART’s members are the approximately 430 IVF clinics in the United States
that submit the following information to SART for publication each year:
ߜ The number of cycles they do
ߜ The types of infertility their patients have
ߜ The outcome of their cycles
ߜ Pregnancy rates
ߜ Multiple pregnancy rates
ߜ Miscarriage rates
ߜ Cancellation rates
In short, the clinics provide information on just about anything and everything concerning their patients’ IVF cycles.
SART takes the information and compiles a booklet of information about
every one of the 437 clinics and distributes it to its members; it also publishes the data on its Web site. SART data is also found with other data from
the Centers for Disease Control and Prevention (CDC).
Clinics that are members of SART can be audited and their data checked for
accuracy. The amount of information required by SART is astounding: Your
age, Social Security number, infertility type, and type of cycle are reported to
SART for every IVF cycle that you do. In most medium to large clinics, compiling and reporting SART data take a tremendous amount of time.
SART confirms clinic-reported data by visiting about 30 clinics a year and
auditing selected patients’ charts to make sure that the submitted information is accurate.
Individual clinic statistics presented on their Web sites can be difficult to
read because not all clinics report their numbers in the same way. For example, one clinic may report pregnancy rates per retrieval, and another may
report per transfer. One advantage of the SART data is that it does allow you
to compare apples to apples when sifting through SART data. But remember
that statistics do not tell the whole story. For example, SART statistics don’t
tell you anything about the clinic population except for its breakdown by age.
A center dealing with only the crème de la crème of patients, the place everyone else calls the “Mecca,” certainly has higher pregnancy rates than the
center that treats everyone, including patients rejected at the Mecca.

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Looking for a clinic
Although SART statistics make interesting reading and may help you decide
which clinic to use, they don’t tell the whole story. You also need to check
into the following information:
ߜ The clinics that are nearest to you. Long-distance IVF is possible but
complicated.
ߜ The clinics that are accepting new patients.
ߜ How much clinics charge if you don’t have insurance.
ߜ Whether the clinics take insurance — not all do!
ߜ Whether the clinics treat patients like you, an important consideration if
you’re over age 40 or have been turned down by another clinic.
ߜ The kind of feeling you get from the clinic. For the answer to this question, you’ll probably need to make a consultation appointment with a
doctor. The clinic usually charges for this appointment. However, compared with all of the other costs associated with fertility treatment, the
cost of the initial consultation is a relative bargain! You will have uninterrupted “quality” time with the doctor for 45 minutes to an hour. Before
deciding on the clinic with which you are going to work, you should seriously consider visiting two or three that you picked out. You will find
that this is a worthwhile investment of time and money.
You don’t need to commit to a program at your initial consultation. It never
hurts to go home and think everything over before you go any further.
Remember, also, that if you’re at one of the big-name clinics, you’re also
being sized up as a candidate for its program, and you could be turned down
for treatment if you don’t fit the clinic’s criteria. Some centers don’t want to
give you false hope if they don’t believe that they can help you, and others
don’t want to bring down their statistics.
Whether you need or want to know everything about a clinic before you go
there depends on your personality. You may be happy to go wherever it was
that your best friend went, or to go where your insurance tells you to go, or
to go to the clinic around the corner. There’s nothing wrong with trusting
your instincts and other people’s personal experiences. However, if you’re
already filling up infertility notebook number three, your family doctor’s recommendation that you just go to his golfing buddy probably isn’t going to
convince you.

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Evaluating a clinic’s personality
IVF clinics have personalities just like people do, and just like with individuals, you may find your personality is a better fit at some clinics than at
others. Usually, but not always, the head honcho or main doctor at the clinic
sets the tone for the whole office. Sometimes instead of one main doctor, a
clinic has a team of fairly equal doctors, all of whom leave their impression
on the way the clinic functions. Here’s a rundown on the most common types
of offices and what you may encounter when you enter their doors:
ߜ The razzle-dazzle office: They have the name recognition and reputation as the “Meccas of infertility.” These places are selective and often
expensive, but you’ll probably feel like you’re in first class if you go
there. And because their reputation is based on success, you may well
get pregnant here — if they’ll take you as a patient.
ߜ The serious office: Dr. Serious and his cohort, Dr. Seriously Published,
take infertility very seriously indeed. Their offices are quiet, well organized, and feature conversations peppered with statistics. If you’re a
serious type yourself, you’ll love Dr. Serious.
ߜ The gloom-and-doom office: If you have a naturally pessimistic nature,
Drs. Gloom and Doom will foster your natural tendencies. They want to
make sure you understand all the problems you’ll have getting pregnant,
so they dwell on them in great detail. A visit with Dr. Doom and Gloom
may cause you to need antidepressants before each visit.
ߜ The chaotic office: They lost your appointment, can’t find your chart, and
dropped your blood down the sink by mistake? Welcome to Dr. Chaotic’s
office, where nothing ever seems to go the way it should. However,
because Dr. Chaotic is often an original thinker with great ideas, wade
through the chaos if you think he can help your unique situation.
Just keep duplicate copies of everything.

Why IVF Costs So Much — Especially
Without a Free Toaster
No, you won’t get a free toaster at your IVF clinic, but you may feel like you
should. Why on earth does IVF cost so much? Although supply and demand
may have a bearing on costs — in other words, doctors respond to market
pressures — the fact is that IVF costs are high because IVF is a high-tech
procedure and high tech costs money. An IVF lab costs over a million dollars
to set up, and you will see lots of employees — nurses, lab personnel, ultrasound techs — when you go for your consultation.

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However, it’s hard to feel sorry for your fertility clinic when you’re the one
who will be pouring thousands of dollars into its coffers. In the next sections,
we help you get every penny out of your insurance company to which you’re
entitled to help pay for your IVF cycle.

Discovering what your insurance
plan really covers
Even if you have insurance coverage, you may be amazed to see how little of
your IVF bill is covered. Some insurance plans cover only monitoring, meaning the frequent blood draws and ultrasounds. Because these can run well
over $2,000 per cycle, this coverage is a help. Other plans cover only the
medications, which is a help, but not by any means relief from the total cost.
Nor is it easy in some cases to decipher your insurance plan. Check out your
plan before you start treatment. Even if you live in a state with mandated coverage, your particular employer may find several loopholes to slip through.
Finding out you’re not covered at the pharmacy the night before your cycle is
supposed to begin isn’t a good way to start treatment.
Many insurance companies require preauthorization even if you do have coverage. Preauthorization can take several days to complete, so don’t leave this
step until the last minute!
You may be covered only if you go to an “approved” clinic. But what if you
don’t want to go to this clinic? Maybe it doesn’t offer treatments you want, or
it doesn’t have high success rates. In that case, you’ll be forced to make an
unpleasant choice: Will you go for care that costs you less but may not succeed, or will you pay more for a higher chance of success? These decisions
would have had even King Solomon, the master of wise decisions in the Old
Testament, in a quandary.

Insurance 101: The differences
between types of insurance
You may be confused over whether your insurance is public or private, group or individual.
Public insurance is paid for, at least in part, by
the government. Medicaid, for those on public
assistance; Medicare, for those over age 62 or
disabled in some way; and CHAMPUS, for military families, are public insurances. Private

insurances are paid for by you, either directly
or indirectly. If your employer pays the costs for
you as part of a benefits package, you have
group insurance. If you pay the entire cost
yourself, you have an individual policy, which is
usually quite expensive.

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Changing jobs or changing insurance
to get infertility coverage
People have been known to change jobs to get better insurance, or to drop
insurance at their place of employment and pick up coverage under their
spouse’s policy, even if it costs more per month.
Is it worth taking a lesser-paying job to cover IVF costs? If the drop in pay
isn’t too much, it might be. Three or four IVF cycles could certainly cost you
more than $40,000 over a year or so.
Consider a part-time job as another means for establishing fertility coverage.
Some companies offer insurance to part-time (20 or more hours a week)
employees — insurance that may cover fertility treatments.
For a listing of major companies that offer infertility coverage (of some sort),
visit http://www.inciid.org/article.php?cat=benefits&id=243.
You still need to confirm this information with the organization (after you get
the job, that is!) to determine the specifics of the plan. And remember, most
companies have a waiting period, which could last from 30 days to one year,
prior to the time when you are eligible for insurance. So don’t cancel your old
policy until/unless you know that your new policy kicks in. Going from one
group insurance plan to another gives you an automatic acceptance regardless
of pre-existing conditions. You don’t want to get caught with a lapse in coverage, however. Not only is that a precarious situation for your health and your
finances, but it could also affect what your new insurance will or will not cover.
Before you throw away your law career or consider moonlighting, you may
want to check out any other insurance your company may offer. Some companies offer a choice of plans. You may pay more for a plan that covers infertility, but the savings may be worth the extra cost.
Some companies allow you to change insurance only at certain times of the
year; this is usually called open season. Check out your choices ahead of time
so that you can have your insurance in place before you need to start using it.

Getting coverage from professional
associations
So your insurance company won’t give an inch, and the option of a new or
second job is just not an option at all. Is it over? Maybe not.

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States are in charge — for now
No federal mandate for insurance coverage
for infertility treatment exists at this time,
although a few bills were sent to Congress in
2002. When you consider that the federal government has spent years arguing over general
health care coverage for U.S. citizens, one can
only imagine how bogged down a specific coverage for infertility treatment would become in
Washington.
For now, it’s up to individual states to pass and
enforce infertility coverage. States can force

employers to cover treatment in two different
ways:
ߜ They can mandate companies to cover
infertility treatment.
ߜ They can mandate that employers offer
coverage.
If your employer is only mandated to offer coverage, you’ll usually have to pay extra for the
coverage, in the form of a rider, or extra policy,
attached to your main insurance coverage.

That flier inviting you to your industry association dinner may come in handy
after all. Many organizations have professional associations that offer open
enrollment programs for insurance, meaning that if you’re a member (you
pay the monthly dues), you can’t be turned down for insurance. Because
these associations generally boast large memberships, you benefit from
group coverage, which may include some of the extras not found in smaller
companies or individual plans. You can start by checking out associations
within your profession.
Long-time resources for the self-employed, who often have trouble getting
coverage of any kind, professional and trade organizations are a popular way
to cover yourself. Associations can be found in almost any field, particularly
those that tend toward the self-employed or those underrepresented in business. Examples include the National Writers Union, Graphic Artists Guild,
Public Relations Society of America, American Marketing Association, and
Women in Communications. Often, you must be a member for a period of
time before you can enroll in an insurance program. Sometimes, the insurance policy may have a one-year preexisting condition rider as well.
The type of insurance available to you will also depend upon where you live,
even if you are part of an association or professional group. Typically, the tristate area of New York, New Jersey, and Pennsylvania tends to offer more
plans for freelancers and the self-employed. These plans are not necessarily
available for those that live outside of the area.

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Touring the States That Mandate
Fertility Coverage
As of this writing, 15 states mandate some sort of reimbursement for in vitro
fertilization. No consensus exists between states on how coverage should be
applied or who has to offer it. This coverage is still a mixed bag for the average patient; even if your state mandates insurance coverage, your employer
may be exempt from offering coverage if he meets certain requirements listed
below.
States that currently have some infertility coverage mandates are Arkansas,
California, Connecticut, Hawaii, Illinois, Louisiana, Maryland, Massachusetts,
Montana, New Jersey, New York, Ohio, Rhode Island, Texas, and West Virginia.
Remember, state mandates affect the states where your employer/corporation
reside. So, even if you are a sales representative living in a covered state, if
your employer is based out of a noncovered state, your insurance will reflect
the laws of your employer’s domicile, not yours. The opposite applies as well.
You may live/work in a state that is not mandated but your company headquarters are in a state that is. Don’t just assume. That’s what human resource
departments are for!
Here are the state requirements:
ߜ Arkansas: Requires coverage for infertility, including IVF up to a lifetime
cap of $15,000.
ߜ California: Employers must make available a policy covering infertility
treatment, excluding IVF but covering gamete intrafallopian transfer
(GIFT), a type of IVF in which the egg and sperm are placed in the fallopian tube before fertilization takes place. This avoids the religious/ethical
difficulty of having embryos in the lab, but adds a laparoscopy to the
mix, which adds cost and invasiveness to the procedure.
ߜ Connecticut: Must offer a policy covering infertility, including IVF.
ߜ Hawaii: Requires coverage, including one cycle of IVF.
ߜ Illinois: Requires coverage of diagnosis and treatment of up to six IVF
cycles. Employers with fewer than 25 employees are exempt.
ߜ Maryland: Requires coverage for IVF after certain conditions are met;
HMOs and companies with fewer than 50 employees are excluded.

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ߜ Massachusetts: Requires comprehensive coverage.
ߜ Montana: Requires HMOs to cover infertility as part of “preventive care.”
ߜ New Jersey: Requires coverage, including IVF.
ߜ New York: Requires coverage of diagnosis and treatment as part of a
correctable medical condition.
ߜ Ohio: Requires HMOs to cover infertility under “preventive care.”
ߜ Rhode Island: Requires comprehensive coverage but allows a 20 percent co-pay for consumers.
ߜ Texas: Requires certain insurers to offer coverage for IVF only.
ߜ West Virginia: Requires HMOs to cover infertility costs.
Some states exempt HMOs from mandated coverage. Some states make
HMOs cover infertility treatment. Some states cover everything except IVF;
others cover IVF but not medications.
After you get past what is and isn’t covered, in some states your employer
can refuse to pay for infertility treatments if:
ߜ The company has fewer than 50 employees.
ߜ The company doesn’t cover maternity care.
ߜ You haven’t done at least several cycles of intrauterine insemination
(IUI) before moving to IVF.
ߜ You’ve had a vasectomy or tubal ligation.
ߜ You’re over a certain age.
ߜ You haven’t had two years of documented infertility.
If you are still unsure of your state’s policy, you can always contact your local
RESOLVE chapter (www.resolve.org) to find the information for your area.
State mandates are always an issue under consideration in the legislature. If
you are feeling particularly motivated or vocal in trying to get your state covered for infertility, contact your local RESOLVE chapter. They are generally on
the front lines when it comes to advocacy in this area. They can let you know
“what’s on the table” and how you can help.

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Fighting City Hall: Insurance Appeals
Insurance appeals need to attack one of the three basic reasons insurance
companies give for not covering infertility treatments:
ߜ Infertility is not an illness.
ߜ Infertility treatments are not medically necessary.
ߜ Infertility treatments are experimental.
You need to address one of these issues to win your claim. In some cases, your
doctor may write a letter of “medical necessity” for some of your treatment.
A policy with vague wording may be easier to appeal than coverage that
specifically excludes infertility treatment.
Take it up the ladder. Don’t just settle for a “No” from the first person who
gives it, particularly if you feel that there is a legitimate “Yes” that should
apply instead. Generally, decisions or reversals get made at a higher level.
Keep asking for a supervisor’s name (and their supervisor, and their supervisor, and so on). If you’re going to get turned down, put up a good fight and
besides, you just might win after all!

When Having Insurance Doesn’t Help
You can have the world’s most comprehensive infertility insurance that can
end up being worth nothing to you if your clinic is not on the preferred
provider list. This is why the best kind of insurance is the type that pays a
certain amount, regardless of where you go. Why would a clinic choose not to
contract with an insurance company? For one thing, the amount the insurance offers isn’t enough, in the eyes of the clinic. Clinics that won’t take
insurance are usually the “Mecca” types; they’re the best, they know it, and
they don’t see why they should accept the typically low payment that your
insurance offers. But there are other reasons. Insurance contracts are convoluted, may require the doctors to fill out special forms, and the insurance
company may refuse to pay for a given treatment because some procedure
was not followed correctly. Because the contract is between the clinic and
the insurance company, this is not your problem, but it may be a serious
enough problem for the clinic to cancel that particular insurance contract.

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Some clinics take your insurance amount but require you to pay the rest of
the bill out of pocket. If a clinic is a preferred provider for that insurance, it’s
generally required to accept the amount offered as payment in full. If a clinic
doesn’t want to accept the amount offered, which is usually quite a bit below
what most clinics charge for high-tech treatments (such as IVF), it may simply
refuse to take the insurance at all. But this is not allowed if the clinic is on the
preferred provider list! So double-check the list and contact the insurance
company if you see the clinic there.

Getting Creative When You’re
Out of Other Options
If you don’t have insurance or if your insurance doesn’t pay anything toward
IVF treatment, you may need to get creative. There are ways to have your IVF
cycle paid for if you meet certain requirements and are in the right place at
the right time!

Donating eggs to reduce costs
A few clinics have innovative donor egg programs that let you donate half
your eggs to another couple in return for treatment. The recipient of your
eggs pays for your medications and your IVF retrieval and transfer. You need
to pay for your own pretesting (such as infectious blood work and a hysterosalpingogram), blood and ultrasound testing, and the cost of freezing any
excess embryos you have.
Usually you must meet certain requirements to be an egg donor. Generally,
you must be under 35 years old and have a normal follicle-stimulating hormone (FSH) level. Usually a donor list is sent out every month or so by the
clinic, and you need to be picked by a recipient to be able to do a retrieval
cycle. The donors and recipients need to be matched ahead of time so that
their cycles can be synchronized, thereby ensuring that both the donor and
the recipient can have a fresh embryo transfer.
Your chances of getting picked are highest if you meet the following
requirements:
ߜ You’re young, preferably under 30: The younger you are, the better the
chance that you’ll make a lot of eggs.
ߜ You’re of normal weight and height: Overweight donors aren’t usually
a first choice. Recipients may worry that obesity is hereditary and also

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may be concerned that they may have infertility problems, such as polycystic ovaries, a condition in which many eggs are made but the egg
quality may be lower than normal.
Very short donors may also not be picked as quickly because, given a
choice, more people choose to have a taller donor (and hopefully taller
children).
ߜ You have proven fertility: If you have children already, you’re more
likely to be picked as a donor.
ߜ You have a male-factor issue: If your only fertility issue is male factor,
you may be picked because you don’t have any fertility issues yourself.
ߜ You have a good family background: You have lots of brothers and sisters with lots of children, no genetic diseases, and no mental illnesses.
These factors make you a prime candidate.
Everyone has some problem in her background — after all, our grandparents had to die of something. So if your grandfather died of cancer at
85, that’s not likely to be a deterrent to getting picked. If your mom died
at 40 from breast cancer, you may have more problems being selected.
ߜ You’re a nonsmoker: Evidence exists that smoking can damage eggs,
plus nonsmokers are perceived as healthier people who take better care
of themselves.
Egg recipients are often looking for someone whose blood type matches
theirs and who has certain physical characteristics or racial background, so
you may be selected faster if you have what a lot of people are looking for: a
common blood type, or a rare one if someone on the list is looking for that.
Your savings as a donor could equal between $8,000 and $12,000, but you
need to be comfortable with the idea that your genetic child could be growing up with another family, or that the recipient could get pregnant with your
egg and you may not. Only you can say whether you can accept the emotional repercussions of donating eggs to another couple.
Some women say that they don’t feel a genetic connection because their egg
isn’t being fertilized with their partner’s sperm, so the child created isn’t the
same as the offspring from their own relationship. Other women become very
angry when their recipients get pregnant and they don’t. This is another one
of those times where “know thyself” is of the utmost importance.

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