By Robert T. Terenzio, Esquire
Future clients start most conversations with us about the lack of information or the abundance of misinformation regarding infertility and how to manage it. Generically, there are two categories of infertility, medical and social. Medical infertility may be anatomic (absence of an organ) or physiologic (absence of function). Social infertility is an absence of a member of the opposite sex. Either category will require engaging an Infertility Clinic.
Let’s start our conversation by looking at infertility, the need for clinical intervention, the types of clinics you may find around the U.S. and a mechanism to compare them.
INFERTILITY
Infertility as a diagnosis follows a determination that the patient has not become pregnant after 1 year of unprotected intercourse. Alternatively, six months of unsuccessful attempts, when the patient is over 35 years, will lead to the same diagnosis. If the patient has certain medical conditions like amenorrhea, sexual dysfunction, pelvic inflammatory disease, or prior surgery, fertility evaluations should begin immediately.
Typically, your primary care physician or an OB/GYN will begin testing to determine the cause for the infertility. Such tests can include blood workups, ovulation monitoring and post-intercourse examinations. If you are otherwise cleared medically, you may be prescribed a drug regimen or surgery. If the intervention does not work, it may be time to move your treatment into a fertility clinic also known as an In Vitro Fertilization (IVF) Clinic.
Most IVF Clinics rely upon a multi-disciplinary team of degreed individuals. During any single treatment cycle, you will meet many team members, in addition to your individual physician. You will have interactions with the receptionist, financial expert, embryologist, reproductive nurse and a cycle coordinator. Your expectation should have every one of the staff members providing support and empathy along with professional medical care.
Your treating physician in an IVF Clinic is a Reproductive Endocrinologist (RE). An RE specializes in reproductive disorders. They complete the same education and medical requirements as an OB/GYN, but will then have advanced training via a three-year fellowship in reproductive endocrinology and at least two years in a clinic setting. Reproductive Endocrinologists, who are board certified, will be certified in OB/GYN first. The RE will then complete a thesis and a written and oral examination to be recognized by the American Board of Obstetrics and Gynecology as a Board Certified Reproductive Endocrinologist.
REs offer extensive diagnostic methods and treatments generically termed Assisted Reproductive Technology that your OB/GYN may not have access to. Based on test results, your RE may recommend advanced treatments and specific courses of medications.
Assisted Reproductive Technology (ART) is widely available globally, and where the most common treatment is in vitro fertilization-embryo transfer (IVF-ET). ART also encompasses gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), and frozen embryo transfer (FET). A subset of the procedures offered through ART includes what is referred to as third party reproductive techniques. The title is a tacit recognition of a person(s) not of your immediate family who is providing the missing piece(s) of your reproductive puzzle. Some of the techniques addressed through ART include gamete donation (egg or sperm) and surrogacy.
Patients who will require ART will also need to consider the Embryologist who works for the Clinic. An embryologist will have a Masters degree or a Ph.D. and whose various responsibilities and duties are performed inside a laboratory. These duties include, maintaining the viability of retrieved gametes, culturing embryos, monitoring embryo development and embryo cryopreservation. As you may expect, viability and quality of gametes and/or embryo(s) can be enhanced or degraded in the lab. That enhancement or degradation will directly impact your attempt to extend your family and even possibly the costs associated with your course of treatment.
WHICH CLINIC IS BEST FOR YOU
Now that we have a basic understanding of Infertility and what services the Clinic staff will perform, how do we find a clinic to fit our needs? One strategy for choosing a Fertility Clinic is to divide your individual requirements into objective and subjective components. Objective categories would address the types of clinic structures and the success rate of the individual clinics themselves. Other objective categories could include determining the costs of necessary treatment and the types of treatment you may require. Subjective categories could include the type of relationship you expect to have with the Endocrinologist and the time constraints you have set to extend your family. Lets start with the types of clinics you may find around the U.S.
Reproductive Endocrinologists practice inside of many different types of clinic structures. No two clinics are alike and the structures are all over the place. There are pros and cons with each type, with no one type being generally better than another. Determining the right one always comes down to a personal decision based on your individual need. The different types include:
• Solo practitioners;
• Small practices with 2 – 8 member physicians;
• Large, full-service practices;
• Fertility networks;
• University-based clinics; and
• Hospital-based clinics.
Of course, the larger an office gets, the more patients it will administer to and with a larger staff. Conversely, the smaller an office is, the less patients it will administer to and with a better opportunity to receive personalized treatment and recognition by both staff and the physician(s).
Sole practitioners will generally offer a more personable experience than a larger practice, and you will have more direct access to the doctor. Solos will typically not have an Embryologist on staff or an embryology lab; instead they will share those services with other Clinics. Larger practices will have the benefit of an in-house lab and more resources. It is likely, however, that your line of communication in a larger practice will be with nurses and staff rather than the doctor. Additionally, doctors in larger practices may float between offices so you may not always see the same doctor appointment to appointment.
Fertility networks are groups of clinics that have come together under an umbrella organization. Having a stronger financial backbone, this practice type may offer more esoteric procedures such as robotic surgeries. With a wider and deeper financial backbone, networks may also offer various forms of creative financing to its patient population that would be otherwise unavailable.
Clinics residing in university hospitals are typically involved in research. The treating physicians are also teaching and often directing research projects or clinical trials. A University setting may be advantageous to some of the patient population as it offers access to the newest techniques derived from or through their research. The University setting sometimes provides patient discounts because of the research or because a governmental body is providing funding to the school. Be aware, however, that University hospitals are teaching hospitals. Medical students are being trained and may be present during your examinations.
With both university-based and hospital-based clinics, there are usually lots of resources, but an institutional bureaucracy will be obvious. I would suggest that you research the mission statements and funding sources of the individual institution prior to setting an appointment.
University hospitals will, for example, have to remain faithful to the directives that permitted it to open its doors. Thus, a university with strong religious underpinnings may not be tolerant toward certain aspects of reproductive technology. Such beliefs, may impact your desire to carry a singleton to term (selective reduction), remove or reduce the risk of a genetic disorder (Pre-implantation Genetic Diagnosis), or cryopreserve excess embryos for later use.
On the other hand, university and hospital-based clinics will have specific billing practices if they accept State or Federal funding and which may help you with your budgetary restrictions. You can be sure, however, that panels of fertility professionals will oversee the treatment planning and financial aspects of the cases the institution accepts. All of these factors will have to be evaluated by you along with the individual RE’s practicing inside.
Certainly, at some point you will get curious on how “good” a particular clinic or doctor is. A great objective standard to use are the IVF success rate statistics published by all of the reputable clinics. These statistics are available on the web from both the CDC (Centers for Disease Control) and SART (the Society for Assisted Reproductive Technology). The Centers for Disease Control is a US Government agency that provides basic research and education on those health issues that impact Americans. SART is a voluntary organization that promotes and advances standards inside of the practice of assisted reproduction.
The published reports include data on age, specific fertility causes, numbers of embryos transferred, and how many children were born. The reports are typically released about 2 years following the close of any calendar reporting period. So, for example, you can now obtain the statistics for 2012. The CDC report can be found here: http://www.cdc.gov/art/ARTReports.htm. The SART can be found here: http://www.sart.org/find_frm.html. Typically, SART will release their ART Report about 6 months prior to the CDC.
From the perspective of a patient who wants to have a pregnancy, the “statistics of live birth” will be very important. As you will see when you review the National report, as well as those for the Clinics you might be interested in, the statistics of live birth are correlated with the ages of the patients and even with egg donors. To make sense of the report you should look for a category that is most reflective of your age and diagnosis, and then cross-reference with your anticipated treatment plan. You can now put the statistics you learned into a real world perspective when you converse with the clinic’s personnel. Using these reports will provide you a better idea of how the RE and Embryologist stack up against the other Infertility Clinics in your geographic area.
ADDITIONAL CONSIDERATIONS
So now we know what services the Clinic members provide, the various structures we find those members within, and a mechanism with which to measure one Clinic to another. The remaining items to address are costs, time and relationship style.
As a good consumer, you will need to set out a budget in order to plan your treatment path. We always recommend speaking directly with the financial person at the clinic. That person will provide you a good basis for estimating costs of treatment. That person will also know what the various insurance programs will, or will not, provide to their insureds and what, if any, financial incentives are offered by the clinic.
Even with an unlimited budget, time is an issue. The clinic may have age limitations for certain types of treatments, i.e., no intervention if the combined ages of husband and wife are 80 years and older. Your insurance may have age limitations for when certain types of treatments have to begin, i.e., no fertility coverage after 45 years. Your egg donor may be leaving for college and be unavailable for a period of time. We know a surrogate that had to give birth prior to her children’s summer school break so that they could travel together. Your best friend with these sorts of issues will be the Clinic’s cycle coordinator. She understands these issues even better than the RE. A conversation with her will permit you to better see how to fit your needs into a real world medical calendar.
CONCLUSIONS
You now have had conversations with many persons in various clinics and about many topics, your fertility, a treatment plan, budgets and time constraints. Unfortunately we cannot provide you a Magic 8 Ball that will tell you which Clinic to work with. Every person that we have spoken with over the past 15 years or so has had their own unique fertility equation. Certainly, all of the equations contain the same variables; diagnosis, treatment plan, Endocrinologist and Clinic, percentages of live birth, costs or anticipated budget and time constraints. You can appreciate that everyone values the listed variables differently.
We see clients fly themselves and their egg donors or gestational surrogates all over the US because the most important thing in their personal equation is a particular Clinic. And, we see clients going to other countries and relying upon foreign doctors and surrogates because the most important thing in their personal equation is low cost.
You have to decide what your personal reproductive equation looks like. All of the items discussed above are on a sliding scale. All of the items discussed will be provided more or lesser weight by you after you have spoken to the doctors, the clinic managers, the financial experts and your family. But, when that equation is set, you will have the best clinic for you at that particular time. Good luck with your journey!
Author: Robert T. Terenzio
Robert T. Terenzio is a Florida attorney who practices exclusively in Assisted Reproductive Technology. Robert speaks worldwide to Intended Parents and Professionals alike about the intersection of Law and Fertility. Through the Law Offices of Robert T. Terenzio, Robert and Stephanie Bodolay provide domestic and international prospective parents education and advice about assisted reproduction, and design legally safe pathways through which families can grow via gamete donation and surrogacy. You can learn more at www.robertterenzio.com or send an email to Robert@robertterenzio.com.
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