Today, March 8, we celebrate International Women’s Day, observed since 19o8!  See what your sisters are doing here and on Facebook.

What’s the point of International Women’s Day? It’s a day to reflect on woman’s place in society. Do women have the same rights as men here in the US and everywhere? Well, in my opinion, it’s still a work in progress. Even here in the US, we still earn less than men for doing the same work. We still had to listen to ill-informed men with political influence explain to us how during a “legitimate rape”, we can avoid pregnancy by “shutting that whole thing down“. It is encouraging that idiotic statements like these received the derision they deserve.

We have more women in high profile positions than ever before. I think we may see a female US president in my lifetime. There is much to celebrate, but still work to do.

My 17-year old daughter rolls her eyes at me when I “get my feminism on”, which actually makes me both happy and sad. On the one hand, I am glad that she doesn’t see any obstacles in her future. She has plans for college, for a professional life and for a family some day and doesn’t assume she’ll need to give up one to succeed at the other. It makes me a little sad that her generation doesn’t really appreciate that equal rights aren’t enshrined forever but are constantly being adjusted, pushed forward and back. Most of us tend to be politically reactive, happy to ignore politics and get on with our lives, until we feel pain. We don’t react to protect our rights until we actually lose them for a while.

In 2013, we are still fighting the old battle for the right to decide if, how and when we become mothers. If contraception is not covered by our insurance plans or is otherwise made difficult to obtain, we aren’t really free. If we lose the autonomy over our bodies afforded us by Roe vs Wade, we aren’t really free. If the Personhood movement has it’s way, the theoretical rights of the embryo will trump the actual rights of the woman, then we aren’t really free. If we can’t afford infertility treatments, they become illegal or we are otherwise forced to delay effective treatments that make having a child possible, we aren’t really free.

In my perfect world, women would only have children when they want them and then, they would have them easily. I want every child to be a wanted child. I want to live in a society that supports women and their families. How about you?

What does your perfect world look like?

The Affordable Care Act, also called “Obamacare” became the law of the land on March 23, 2010 and was upheld by a Supreme Court decision in June 2012. What impact, if any, will it have on the ability of infertility patients to pay for infertility treatments? It’s impact is not clear because it will affect not only whether benefits are directly covered but also impacts tax credits and health savings plans which could also impact infertility care’s affordability.

The big changes that are positive for women who want to be pregnant (and most everyone) is that:

• Direct access to maternity and gynecological care is guaranteed.
• Medical care can not be denied to women based on pre-existing conditions. Pre-existing conditions have included pregnancy, prior C-section and infertility, depending on the specific plan. These pre-exisiting medical conditions can no longer be used to deny coverage.

Okay, that’s great but is infertility care an essential health benefit? The most straightforward piece of the Affordable Care Act (ACA) requires that “essential health benefits” be defined, and once defined must be included in every state-run health care exchange. The Department of Health and Human Services tasked the Institute of Medicine with defining this list of essential health benefits. They were also advised not to provide a list of specific medical treatments but instead list categories, leaving room for interpretation.

The Institute of Medicine recommended that these 10 health benefits be included in every state’s list of essential benefits:

• Ambulatory patient services
• Emergency Services
• Hospitalization
• Maternity and Newborn care
• Mental health and substance abuse disorder services,  including behavioral health treatments
• Prescription drugs
• Rehabilitation and habilitative services and devices
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including oral and vision care

Ambulatory patient services and Maternity and Newborn care might include infertility care as part of these broad categories but every state may have to hash that out in their own exchanges. At this point, it is not clear whether infertility care will be considered an essential health benefit for every citizen.

The ACA will impact tax credits and health savings accounts which are another way in which patients pay for infertility treatments. Currently, the IRS tax code considers “infertility enhancements” such as IVF, cryostorage of sperm and eggs, tubal surgery and vasectomy as non-reimbursable medical expenses. It is not clear if embryo storage also counts. Because they are considered non-reimbursable, you can include these expenses as you total up your medical expenses for the year. For the 2012 tax year, any non-reimbursable medical expenses that you incurred that exceeded 7.5% of your adjusted gross income could be deducted. So if you adjusted gross income was $100,000 per year, you needed more than $7,500 in medical expenses to quality for a deduction. The amount of your deduction was only the amount of expenses that exceed the initial $7500, so if you had $8000 in expense, $500 were deductible. The ACA actually will increase the 2013 threshold for qualifying for deductions to 10% of your adjusted gross income, meaning you need to have more expenses to qualify for a tax deduction.

Flexible health spending accounts are another strategy US families use to pay for medical expenses that aren’t covered. You can have money deducted from your paycheck,  before taxes are applied, reducing the amount of your taxes and letting you save these pre-tax dollars for medical expenses. Previously, the IRS has not limited the amount that can be saved in these plans but employers did. In 2013, under the ACA, there will be a limit on the amount that you can contribute to your FSA, namely $2500.  In some cases, this may be less than the employer allowed previously. Top-income earners are not eligible for these deductions. So at least in terms of tax credits and flexible savings plans, these money-saving strategies may become more anemic under the ACA.  This wouldn’t be a big deal if infertility were explicitly named as an essential health benefit, since insurance would cover it, but that is not clear at this point.

On a positive note, the adoption tax credit continues under the ACA and becomes refundable. Previously, the tax credit was used to off-set taxes due and then carried over toward the next year’s taxes, not refunded. The kicker is that congress may decide not to extend the adoption tax credit beyond 2013.

Patients using gestational carriers may benefit from the ACA, because the obstetrical expenses of gestational carriers would be covered. This assumes that there is no loophole that would specifically exclude gestational carriers from ACA protections for pregnant women- namely that pregnant women can not be denied coverage based on defining pregnancy as a pre-existing condition and that maternity services are explicitly defined as an essential health benefit.

Currently, 15 states have mandates that insurance companies must cover infertility expenses. Former NY Representative , Anthony Weiner, introduced a bill twice (2007 and 2009) to make infertility coverage a nation-widel benefit. Twice the bill died in committee. The Family Act of 2011 which specifically called for a FEDERAL tax credit for infertility treatments was also referred to committee which I think is synonymous with death by committee.  This brings home again how anemic the political activisim for infertility coverage is, but the results, or lack thereof,  speak for themselves.

The ACA does not directly advise states about how to handle their mandates, but if services outside of the ones considered “essential health benefits” are included at the state level, the state must pay for these services themselves. This drives home again, the power of including infertility care specifically as an essential health benefit. At some point, each state will have to grapple with the details of what exactly is covered–here is where every infertility patient has a stake in talking to their elected representatives and making their priorities known.

Even in states where infertility coverage is mandated, that does not insure that every employer is required to include it because federal law can exempt employers from obeying certain laws based on their size (eg. number of employees). For instance, the American Disability Act doesn’t apply to companies with fewer than 15 employees. Other laws have higher thresholds for applicability (eg. 50 or more employees). Federal law exempts companies with fewer than 50 employees from obeying state mandates on insurance, so your employer-specific coverage may still be less generous than another employer’s coverage, even in a mandated state.

The ACA in 2016 may also allow patients to buy insurance not only from their state exchanges but also in “compacts” their state set up with other states, allowing then to reach outside their state for insurance plans. Theoretically, patients in non-mandated states could buy coverage in mandated states, thus benefiting from infertility coverage inclusion in those states. Of course, the devil is in the details and due to the delay introduced by the Supreme Court challenge, we are still waiting to see how the details shake out.

I think the take-home message is that the Affordable Care Act is still a plan in progress and there is time to impact how it affects infertility care in your state. The infertility support group Resolve has a page devoted to the Affordable Care Act here. If you do want to work to influence your legislators, Resolve has some suggestions here for how you can volunteer and make a difference in your state. They are starting Project Protect to:

• “Generate action from your elected officials by making calls and writing letters.
• Monitor legislative issues in your state.
• Be the voice of the over 7.3 million Americans diagnosed with infertility.”

Fertility Within Reach is another great source for tips on how you can communicate effectively with your legislator to make it clear to your elected representatives what your priorities are. Even in times of fiscal crisis, legislators fund their priorities. As citizens, it is our job to make sure that legislators understand our needs and make funding those needs their priority.

This post is a summary of an article published in the March 2013 issue of Fertility and Sterility, The Affordable Care Act’s impact on fertility care., written by Kenan Omurtag, M.D., and G. David Adamson, M.D. Fertility and Sterility Volume 99, Issue 3 , Pages 652-655, 1 March 2013

IVF practitioners have long recognized that extremely high estrogen levels from ovarian stimulation cycles can result in a syndrome called ovarian hyperstimulation syndrome or (OHSS) which, if severe, can cause serious complications. Rarely, OHSS has caused patient deaths. In these high E2 cycles, the resulting embryos are often frozen and transferred in a later cycle when the symptoms of OHSS have resolved to avoid escalation of OHSS symptoms with pregnancy.

In an earlier post, “Freeze all” IVF with later FET may increase your pregnancy rate, I talked about research showing that frozen embryo transfer cycles often achieve better pregnancy rates than fresh cycles. The reason for these better outcomes may be because we have optimized cryopreservation with vitrification (so freeze damage is negligible) and the preparation for transfer works to optimize the endometrium for implantation.

We also know that IVF babies, even singleton birth babies, tend to have a lower birth weight than naturally conceived babies and their mothers are more likely to have some obstetrical issues (eg. pre-eclampsia, a disorder of abnormal placental development). This finding was surprising and largely unexplained. Two recent papers may provide a hormonal explanation for why these obstetrical problems persist for some IVF babies.

The article “Peak serum estradiol level during controlled ovarian hyperstimulation is associated with increased risk of small for gestational age and preeclampsia in singleton pregnancies after in vitro fertilization” demonstrated that patients with a high E2 (defined as greater than 3,450 pg/ml at time of hCG) were more likely to have low-birth weight babies and and suffer from pre-eclampsia than women with lower E2 levels.

The  second article ” Elective cryopreservation of all embryos with subequent cryothaw embryo transfer in patients at risk for obarian hyperstimulation symndrome reduces the risk for ovarian hyperstimulation syndrome- a preliminary study“demonstrated that patients with high E2 levels at hCG trigger who chose to freeze all their embryos and delay transfer were less likely to have  problems with pre-eclampsia and low birth-weight babies than women who proceeded with fresh transfer even with high E2 levels.

Dr. Anthony Imudia, an instructor in Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School and author on both of these studies, describes their clinical approach in a recent Science Daily article, “Our center takes a very individualized and conservative approach to ovarian stimulation, so fewer than 10 percent of our patients had extremely high estrogen levels of greater than 3,450 pg/mL. If other centers validate our findings by following the same approach and achieving similar outcomes, we would recommend that each patient’s hormonal dosage be adjusted to try and keep her estrogen levels below 3,000 pg/mL. If the estrogen level exceeds this threshold, the patient could be counseled regarding freezing all embryos for transfer in subsequent cycles, when her hormone levels are closer to that of a natural cycle.”

Non-human primate research has shown that E2 plays an essential role for normal development of arteries in the early placenta. In humans, we know that estrogen levels are relatively low (below 200 pg/ml) in natural cycles before transfer, so we might expect that 15 fold elevations in E2 may dysregulate the normal process of placenta formation. More research is necessary to understand exactly how E2 regulates placental development in pregnant women and why high E2 levels are problematic, but it seems clear that low estrogen at the time of transfer is preferable for best patient outcomes.

Selecting the best sperm for ICSI is not a big deal if most of the sperm are normal.  Where it becomes more tricky is when you are hard pressed to find a normal appearing sperm in the sample. Some defects like sperm with two heads, huge heads, two tails, kinked tails are easy to detect and avoid with standard magnification. Other defects, like vacuoles in the sperm head are not always glaringly obvious at the lower magnification (300x) used for selecting sperm for ICSI. In 2001 Benjamin Bartoov, PhD, published his work showing that high magnification selection of normal sperm free of head vacuoles resulted in better pregnancy rates. His 2004 publication further supported his conclusion that the ability to identify sperm with normal nuclear morphology using high magnification motile sperm organellar morphology examination (MSOME) was responsible for the better outcomes associated with IMSI.

Does IMSI produce better pregnancy and high birth rates for every patient? The clinical studies directly comparing ICSI to IMSI have not been entirely consistent with some studies showing benefit and others showing no benefit of using high power (1600-2500X) morphological selection of sperm.

Poor DNA repair may be the key to both cancer and egg aging, according to a new study.  “I think we have found a general theory of reproductive aging,” said Kutluk Oktay, a fertility specialist at New York Medical College and co-author of  “Impairment of BRCA1-Related DNA Double-Strand Break Repair Leads to Ovarian Aging in Mice and Humans”. Oktay’s research supports the idea that eggs decline and die with advancing maternal age because the genes responsible for repairing routine DNA strand breaks become less efficient or broken with age.

BRCA genes are known as tumor suppressor genes because they produce proteins which routinely repair broken strands of DNA.   If the BRCA genes have harmful mutations, they are unable to efficiently produce these DNA repair proteins, setting the stage for cell cancer. In eggs, the failure of these same DNA repair mechanisms appear to result in egg cell suicide or atretic eggs.

Oktay’s study looked at the reproductive effects of BRCA mutations and found these mutations were correlated with lower numbers of normal eggs in both women and mice. Under or over-expressing these DNA repair pathways by manipulating BRCA gene expression was able to degrade or improve egg’s ability to withstand exposure to mutagens in mice, raising the possibility that manipulating these pathways may give rise to future methods to protect ovarian reserve.

Ovarian reserve, the number of eggs within the ovary, was lower in women who had mutations in the BRCA1 and BRCA2 genes. Mice with these mutations had smaller litters than wildtype mice. Although women with BRCA2 mutations appear reproductively normal, there may be subtle effects accelerating the decline of oocytes that become more obvious at the end of the reproductive life span. In other words, these mutations may shorten the reproductive life span by accelerating the decline of the ovarian reserve, making reproduction later in life more difficult.

As women age, their ovarian reserve decreases. The natural decline in DNA repair mechanisms which accompanies aging may explain why fewer genetically normal eggs are available to older women. These observations can now be explained by disruption of a specific DNA repair pathway mediated by BRCA genes.

Sometimes a picture really is worth a thousand words, especially when you want to understand the microscopic world of embryology. The European Society of Human Reproduction and Embryology (ESHRE) recently published the Atlas of Human Oocytes and Embryos and have made it available for free on-line in either HTML or PDF form.

Click on the chapter links below to go to each on-line chapter with pictures.

Chapter One: The Oocyte Whether you are a patient trying to understand your embryology report or a embryologist trying to understand the basics of embryology development, this chapter is a useful primer for better understanding the human oocyte. Did you know that oocyte maturity is reached when BOTH the nucleus and the cytoplasm become mature and that sometimes, in gonadotropin stimulated cycles, these two types of maturity may not be well synched?  At retrieval, the presence of a polar body is routinely used to indicate that the egg reached nuclear maturity but that may not be sufficient. The postponement of ICSI or insemination for a few hours may be beneficial to allow lagging areas of egg development to catch up. You can see photos  of cumulus-enclosed oocytes and denuded oocytes with various features such as polar bodies (excess cytoplasmic and genetic “baggage”), the perivitelline space (space between the egg and the shell) and the  zona pellucida (the shell), This section discusses both normal variation in egg appearance and other abnormal, potentially lethal characteristics such as aggregations of smooth endoplasmic reticulum or giant oocytes (containing multiple genome sets). You can find pictures of eggs with a prominent germinal vesicle, a structure that exists in the immature egg, but disappears (germinal vesicle break down) with egg maturation.  You’ll see eggs with grainy or clear cytoplasm, cytoplasm containing vacuoles or refractile bodies and cytoplasmic areas of clustered organelles. For patients, these photos can be used as a glossary to decipher terms your embryologist throws at you. For the embryologist, these photos are useful standards to compare with your everyday observations of embryos in the lab.

Chapter Two:  The Zygote You may have asked yourself, “What the heck is this “two pee N”, that my embryologist is rambling on about?” A “2PN” is short hand for the number of pronuclei in the egg after it is fertilized. A fertilized egg briefly exhibits two pronuclei (one from mom and one from dad), before these dissolve and the embryo continues on as a new genetic organism. You can see many pictures of normal 2PN, as well as abnormal PN (multiple PNs such as 3PN, 4 PN etc.) zygotes What’s nice about the descriptions for the photos is that in many cases, there is information about whether these features resulted in a viable embryo or not, or whether it was transferred and sometimes whether the patient became pregnant.  Zygote scoring, one system of embryo evaluation,  is described in detail with these photos. Some programs, but certainly not all, have identified desirable characteristics of pronuclear alignment and size that they believe are useful in identifying those embryos most likely to implant. Whether these scoring systems really make a difference is not clear but embryologists are always trying to find better markers for embryo selection and zygote scoring is one such system. Particularly if your clinic uses this approach, it may help you understand what they are looking for in the embryos they prefer to transfer.

Chapter Three: The Cleavage Stage Embryo

In this chapter, you can learn more about what embryologists expect from your embryo as it develops. You can see what your embryo looks like as a “two-cell”, “four-cell” or “eight-cell” embryo.  Your embryologist may talk to you about seeing fragmentation in your embryos  or other cytoplasmic abnormalities. You can look at embryos with 15%, 25% or 40% fragmentation to give you an idea of what this looks like.   You can also look at diagrams that explain what normal development looks like, when cells divide in an organized fashion vs. unregulated chaotic generation of various sized daughter cells. Examples of embryos with various numbers of cell nuclei are shown and the implications for normal development and pregnancy are discussed. A cell should only have one nucleus, except if it is on the verge of dividing, then two might be okay. Multi-nucleated cells of higher order are always abnormal and embryos with these features are usually excluded from transfer. As the embryo develops, it transforms from a collection of loose cells to an interconnected entity, and the spatial orientation of cells within the embryo become increasingly important. As cells start to respond to internal signals of spatial orientation, cells start to “smoosh” together into a morula, the stage between the cleavage stage embryo and the blastocyst. Although scoring systems don’t really exist for the unattractive interim morula stage embryo, embryologists like to see that all of the embryo’s cells are included in the “smooshing” process.

Chapter Four: The Blastocyst

With the formation of a blastocyst, the embryo’s cells have taken on specific duties such as contributing to the cell lineages that become either the fetus itself or the fetal part of the placenta.  Your embryologist will describe your blastocyst by talking about its degree of expansion (partial or fully expanded) and the effect of this expansion on other structures of the embryo (eg. the zona pellucida thins and the perivitelline space disappears while a fluid-filled space (blastocoel) forms inside the embryo. You can see pictures of embryos with stages of blastocoel formation described by how much of the embryo’s volume is taken up by this space. Your embryologist may have spoken of a cytoplasmic string or bridge between the intracellular mass (the ICM= future fetal cells) and the trophectoderm cells (TE= future placenta cells). There are pictures of embryos with two, instead of one ICM, which is one cause of identical twins. There are pictures of embryos with dark cells, indicating that some cells have degenerated in the blastocyst which does not bode well for implantation.

If you are a patient, you’ll probably find out everything you need to know by reading the captions with each photo. If you are an embryologist, you’ll probably want to dig deeper into the text. If you are a teacher, you can download power point slides of  photos to share with your students. If you simply like looking at pretty (or weird)  pictures of eggs and embryos, you’ll enjoy this atlas too.

The College of Reproductive Biology is a professional society associated with the American Association of Bioanalysts whose members include embryologists, andrologists and other ART professionals. Last week, members received this update about new Personhood Initiatives.

Letter copied below:

“Personhood Bill Introduced in  House of Representatives 

Legislation that would give full legal rights to human zygotes from the moment of fertilization has once again been introduced in Congress. The Sanctity of Human Life Act (H.R.-23), introduced on January 3, 2013 by Rep. Paul C. Broun, (R-TX), would define the beginning of human life as “fertilization, cloning, or its functional equivalent, irrespective of sex, health, function or disability, defect, stage of biological development, or condition of dependency, at which time every human being shall have all the legal and constitutional attributes and privileges of personhood.” The bill currently has more than 20 co-sponsors to the bill, including Rep. Paul Ryan (R-WI). The bill has been sent to the House Committee on the Judiciary for further action.  

The College of Reproductive Biology wants the membership to be aware of this bill, and would like to encourage fervent opposition to it. Personhood initiatives are one of the most dangerous threats aimed at public access to fertility and perinatal care, and would stand to severely hinder our ability to treat infertility with most assisted reproductive technologies.   

Rep. Broun introduced an identical bill in January 2011; it attracted 65 co-sponsors, but was not brought to a floor vote. There have also been several attempts in recent years to enact an at-fertilization definition of personhood into U.S. state constitutions. Below are examples of proposed changes to existing legislation in various states, which, if passed, would have granted full legal protection and rights as persons to fertilized eggs and embryos.

• Colorado, Ballot initiative (2008): “[T]the terms “person” or “persons” shall include any human being from the moment of fertilization.”
• Georgia, SB 169 (2009): “A living in vitro human embryo is a biological human being who is not the property of any person or entity.”
• Georgia, HB 388 (2009): “.[T]he term ‘child’ shall include a human embryo.”
• South Carolina, S. 450 (2009): “The right to life for each born and preborn human being vests at fertilization.”
• Arizona, SB 1307 (2010): “A person shall not intentionally or knowingly engage in . nontherapeutic research that . results in the injury, death or destruction of an in vitro human embryo.”
• Mississippi, Ballot initiative (2011): “As used in this Article III of the state constitution, The term ‘person’ or ‘persons’ shall include every human being from the moment of fertilization, cloning or the functional equivalent thereof.”
• Virginia, HB1 and Oklahoma, SB 1433 (2012): “[T]he term ‘unborn children’. shall include . the offspring of human beings from the moment of conception until birth at every stage of biological development.”
• Oklahoma, HJR 1067 (2012): “[T]he term ‘persons’ . applies to every human being from the beginning of the biological development of that human being.. Only in vitro fertilization and assisted reproduction that kills a person shall be affected by this section.”

Even if H.R. 23 is not passed by Congress, it could encourage additional state-led initiatives. 

We encourage members, and especially those in states whose representatives have co-sponsored this bill or are members of the Judiciary Committee, to utilize their right to speak out against H.R. 23. Please contact your representative’s office, or Click here to  voice your opposition. Click here to access the full text of H.R. 23 and a list of co-sponsoring representatives here. Click here to access a list of members of the Judiciary Committee.”

Why should we care? While embryologists treat embryos with utmost respect, we understand that embryos, while having the potential to develop into persons. are not persons. The majority of embryos, created in a lab or in nature, do not survive and do not produce living children. This distinction is critically important and redefining an embryo as a person is not only a fallacy, but will have real medical consequences.

• The right to have a legal, safe abortion as determined by the Roe vs. Wade ruling would be null and void.
• Doomed pregnancies such as ectopics will be illegal to treat, causing death to the mother in some cases.
• The liability of creating embryos and storing embryos will be too great. IVF will disappear as a treatment for fertility , erasing 30 years of advances in reproductive medicine.
• Stem cell research using embryos will also become impossible to perform, if not outright illegal.

If any of these consequences are unacceptable to you, please let your representative know that you do not support these measures, particularly if you live in Colorado, Georgia, South Carolina,  Arizona, Mississippi, Virginia and Oklahoma, where Personhood Initiatives are pending.

I have to let you know about a great on-line video I just saw  that has lots of tips and ideas for affording infertility treatments. It’s called Financial Planning for Family Building, and was recorded live at the Fertility Planit Show LA 2013 earlier this month.  (You can watch all the Fertility Planit videos for free from this webpage.)  The Financial Planning video covers a live panel discussion with audience questions with four women who are each working on making IVF more affordable for patients.  Panelists include Davina Fankhauser, Founder of Fertility Within Reach, Nicole Lawson, Baby Quest  Foundation Founder, Kathryn Kaycoff-Manos, Co-founder Global IVF, and Attorney Wendy Hartmann, who specializes in estate planning for same-sex couples.  Each of them brings a unique perspective on the issue of paying for treatment, based on personal experiences with infertility which they also share. You can meet Davina and learn more about Fertility Within Reach’s mission by watching her video here.

Some of the topics they discuss are:

• How to get your employer or insurance company to cover IVF. Understanding and negotiating your infertility benefit is an older Fertility lab Insider post on the topic.
• Which states already cover IVF, and how to encourage your state to mandate  infertility coverage
• Infertility treatment loans through banks (Wells Fargo may now offer them, as per the panel) or through the clinic. (I previously posted on treading carefully when considering a loan through your clinic)
• Discounts on fertility medications from EMD Serono or Ferring, the two biggest companies that sell gondotropins.
• Seeking less expensive IVF, egg donation and surrogacy services abroad. I blogged about some of the  legal ramifications medical tourism previously. And another post on Global outsourcing of IVF.
•  IVF4Everyone site that offers free advice on how to find lower cost or even free IVF.
• Lists of employers that offer IVF coverage in their employee insurance plans on the INCIID website, another infertility support site.
• Banking on the Future, explained in this video; a program whose purpose to assist patients who need cryobanking services to preserve their fertility.

Listen to the interview but then also visit their websites and also the other linked urls in this post for more information:

Fertility Within Reach has a Financial Assistance Application Guide  page which has links to other sites that offer financial assistance to patients in the form of grants or loans. Some private foundations (Baby Quest is one of them) offers grants to pay for IVF to eligible patients. Baby Quest is less restrictive than many foundations because they don’t discriminate against same sex couples or single women or limit applications to their state or community.

Global IVF’s website has a Cost Comparison page which shows you how much less infertility services cost in some other countries. Even if you have no plans to travel abroad for IVF, it’s an eye-opener. You can also find a list of global companies that specialize in helping patients plan IVF trips. Their FAQs page is a quick guide to what you can expect from medical tourism. Two caveats with medical travel for IVF to other countries. Before you go, make sure you understand the laws of your county and the one you are going to–especially if you are using egg donation or surrogacy services– to understand the laws governing citizenship and also who can be named as parents on a birth certificate. Also, particularly with surrogacy, if you are using a surrogate abroad, you are going to have to be comfortable with even less control over the gestational environment for the surrogate.

Previous Fertility Lab Insider posts on paying for IVF include  Stretching the Infertility Dollar , Paying for IVF: Shared Risk Programs and Insurance Coverage for IVF.

Until we have universal coverage for infertility treatments, each patient will need to hobble together a plan to pay for these expensive treatments without going bankrupt or selling off all their assets. Bookmark this page and come back to check out all the urls– you might be surprised at what you can save! Good Luck!

For the last twenty years, I have been fairly obsessed with human fertility, both personally and professionally. Since 1995, I have been engaged in a profession that is clearly pro-life in that it seeks to solve the problem of human infertility, one patient at a time. I am also pro-choice. Those views are not opposites but two sides of the same coin.

During a second post-doc, my research study required me to ride the city bus to the abortion clinic in downtown Pittsburgh to get placental tissue samples. Every week I collected placental tissue from first trimester aborted fetuses. I was culturing the placental cells to study the mechanism behind parvovirus B19 infection during human pregnancy, one cause of miscarriage, especially in the first trimester. The point of the research was to better understand how parvovirus B19 infected the child through the placenta in order eventually to come up with better treatments for women at risk of losing their pregnancies. Ironically, in an effort to preserve future pregnancies, I had to use the remnants of aborted pregnancies.

Every week, sometimes twice a week, I had to walk past the anti-abortion protesters outside the door who screamed at me not to go in to the clinic to get an abortion. (Did they really think I was having two abortions a week(?!)- obviously there was a need for some remedial human reproduction classes on that sidewalk.) Once inside the building, I had to negotiate my way past a metal detector and armed guard because the clinic had been sent death threats and other clinics had been bombed. Imagine running a gauntlet like that to get any other kind of medical care?

I dreaded my weekly trip to the clinic because of the sidewalk harassment but then it got worse. Usually, I was given a plastic basin containing only placental tissue pieces that I would then transfer to a sterile collection cup and take back. The fetal remains had been removed. But not always. The first time I was handed a basin containing not only placental tissue, but also fetal remains, I almost vomited. I had this incredibly strong visceral and highly emotional response at seeing the tiny fetal remnants in the basin. I had two small children of my own by that time. Those fetal remains made me immensely sad for what could have been under other circumstances.

I thought a lot about that moment in the weeks to follow and at the apparent disconnect between what I had been doing in the lab (both as a researcher and then embryologist) to help women desperate to be pregnant and what was happening at the abortion clinic with women who were just as desperate not to be pregnant. If I could create a perfect world, I would create one in which both abortion and infertility treatment was completely unnecessary because only people who wanted to get pregnant would get pregnant and those who wanted to get pregnant could get pregnant easily when they were ready for the responsibilities of parenthood.

Reproductive Choice is a coin with two heads. On one side is the choice to become pregnant and the other side is the choice to prevent pregnancy or end a pregnancy. Women must have a choice about if, how and when they become mothers. I celebrate the fact that the Roe vs. Wade decision, which became law forty years ago today,  still exists to keep abortion both legal and safe in the US. I trust women to decide when they are ready to be mothers. Who ultimately benefits the most from allowing women to have this choice about if, how and when they become mothers? The child- who is wanted by its mother.  Those beliefs push me to work for better infertility treatments, healthier pregnancies and the right to safe and legal abortion.

This post is part of the Blog for Choice Day  2013.

On this Presidential Inauguration Day, I think about where we are in this country and where we are going. It’s also the time of year to think about professional and personal goals for 2013. What can we do better?

One of the professional goals I have is to try to make infertility treatments more effective and accessible to everyone who can benefit from them. My personal situation has obviously impacted what I can do on that front. When I  direct a laboratory, I can directly improve services.  As a blogger, I can indirectly  improve  the quality of IVF services through education. Patients can be empowered through a better understanding of IVF so that they can get the best possible care for themselves. This educational approach via blogging and outreach has the potential to be even more powerful over a larger scale than what I can ever hope to achieve in a handful of laboratories.

Still, ensuring that every patient is well-informed also has limited local value, in that it only changes the quality of the patient experience one patient at a time. Also those less informed and less empowered many not experience the full benefit of infertility treatment unless we can assure every program offers a high standard of care and every patient can afford to buy treatment.

Our current system does not provide uniform quality and accessibility to infertility treatments:  pregnancy outcomes from IVF range widely among clinics (9% to over 70% pregnancy rates per transfer; CDC stats), and some patients pay 100% and others pay nothing out of pocket for the same treatment. Our best hope for achieving uniform access and quality will require not only a major adjustment in how infertility is viewed as a medical problem but patients must also demand a raised bar for standards of quality and accessibility so more patients can benefit from new advances.

I’d like to imagine a future where infertility is recognized as a significant medical problem that is covered by every medical insurance plan, private or public. This is a tall order, considering that even a rather anemic national healthcare plan like Obamacare (aka, the Affordable Care Act) was practically strangled in its crib by vocal opposition–and a Supreme Court challenge-  before any  significant changes could even be put into effect. Even now that Obamacare has been upheld by the Supreme Court, infertility is not defined by the legislation as part of the Essential Health Benefit that must be covered under the plan.

The definition of what will and won’t be included in the Essential Health Benefit will largely be determined by states. Considering that only about 15 states require that insurance coverage for infertility be offered to patients, I am not optimistic for a 50 state buy-in of infertility treatment as an Essential Health Benefit– unless infertility patients become politically active in their states.

I think there are several unique impediments to  widespread access to and affordability of IVF which makes effective activism an uphill climb.

Infertility has a PR problem.

• Infertility is not seen as a real disease by most of the public.  In this study, looking at the public perception of infertility in the US, Australia and several European countries, less than half (38%) of those surveyed thought infertility was a real disease. In spite of the fact that most respondents knew someone with infertility, most respondents still had a poor understanding of the real incidence of infertility, typically underestimating how many people have it. In a July 2012 letter to the CDC, the infertility support group Resolve implores the CDC to adopt the definition of infertility as a disease as defined by ASRM. The letter states: “Most importantly, infertility must be defined as a disease. We must set forth this precedent and put to rest the public perception that infertility is a“lifestyle choice.” This is also a perception maintained by many insurers and policy makers.”
  

• Coverage of infertility treatments and patients in the media is most often salacious and not serious. If you remember the coverage of  “Octomom“, you remember how little real news was conveyed by most of the media coverage. Coverage quickly devolved to the lowest common elements of the story that could be peddled to the public. We didn’t hear much serious discussion of the risk of multiple gestation pregnancy. We heard lots about how she paid for IVF as a welfare recipient (actually, never heard of infertility being paid through either Medicare or Medicaid so this claim is highly dubious), whether she deserved to have more children because she already had six,  that she was unmarried, etc. etc. ad nauseum.
  

Infertility activism is relatively  weak compared to activism for other diseases like cancer or heart disease although infertility affects 1 in 8 couples and millions of people all over the world, both rich and poor. Why is political activism for infertility treatment relatively anemic?

• The problem of infertility is transient.  Most patients eventually become parents, one way or another and are understandably busy with their new responsibilities. One measure of this transition can be found in the blogosphere as the infertility blogs morph into mommy blogs and then fade away. This is normal progression and arguably good for the families, but it doesn’t fan the flames of sustained activism. Many patients who might otherwise be activists understandably don’t want to be reminded of the difficult emotional journey they traveled to get to parenthood. For the most part, only ART professionals and providers stay politically active for the long haul and their interests–especially if market-driven– are not always entirely aligned with patient interests.

• Infertility is still a very personal topic. Putting yourself on the front lines as an activist for change is not everyone’s cup of tea. Activism may expose the patient and their partner to unwelcome attention and even criticism from both friends and strangers. In some cases, going public with your infertility can create friction with your employer or your religious leaders. Most people are not overly eager to fight both infertility and public attitudes about it at the same time.

Research funding for IVF improvements or access to care is almost non-existent. In contrast to other diseases like cancer,  the federal government does not fund research toward better infertility treatments. Patients seeking treatments are primarily responsible for the advances in this field, found through trial and error as providers attempt to solve patients’ infertility problems on a case-by-case basis.  Recently, I tried to find a non-profit that would consider funding educational initiatives to help infertility patients. I found a list of 50 agencies that funded reproductive health initiatives. You might think that many of these would welcome an opportunity to support infertility treatment, advocacy or education. Only a handful of programs still looked like viable candidates after more research into what was actually being funded.  Most not-for-profit foundations that fund reproductive health areas limit funding to supporting contraception services, abortion services, and prevention of sexually transmitted disease but not anything to do with the improvement of infertility services or access to infertility treatments. Efforts to improve the quality and accessibility of  infertility procedures does not get much of the charity research dollar, either public or private.

So what can be done?

As I listened to the President’s Inauguration speech today, I was struck by his call for action. We the People are responsible for the type of country we live in. That is the point, after all, of this type of democratic government. If you don’t like something or see room for improvement, work to change it. If you agree that more can be done to make infertility treatments even more effective and more accessible to everyone that needs them, show it. Do something.

Make your elected officials aware that you exist and infertility is something that merits the same consideration for inclusion as an Essential Health Benefit under Obamacare as does any other medical condition.  States are deciding what benefits to include now for exchanges that will go into effect in 2014. Let them know that infertility treatment is not elective, but an essential health benefit. 

It is not a lifestyle choice to seek treatment for infertility. If you can’t afford treatment but want children, it’s not a lifestyle choice to stay childless if your “choice” is made because you have no other options. Freedom and the pursuit of happiness extends to being able to choose and afford effective treatment for infertility.

For more specific ideas on how you can get involved, check out these resources:

On the Fertility Within Reach website :Communicating with your Legislator

Personal letters are more effective than mass mailing to reach your legislator, but any communication must be better than silence. Copied from Fertility Within Reach- the graphic below summarizes their approach to empowering patients to get better healthcare for themselves.  You’ll find specific tips for patients for each one of these areas of advocacy–communication with your physician, your employer or your insurance company. Check it out.

Resolve’s Get Involved page also has tips for how you might be able to contribute towards more positive outcomes for infertile people. There are lots of options that don’t require a huge investment in either time or money. If everyone affected by infertility did one little thing this year to improve the status-quo, think what we could accomplish!  Ask the people who care about you to contact their state legislators too. If you have already reaped the benefits of treatment, please consider what you might be able to do to help ensure that others in your shoes get their happy ending too.

From President Obama’s inaugural address:

“You and I, as citizens, have the power to set this country’s course.

You and I, as citizens, have the obligation to shape the debates of our time – not only with the votes we cast, but with the voices we lift in defense of our most ancient values and enduring ideals.”