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07/26/2010

-0.005E% coherent, whatever the hell that E means

For some reason I'm having a hard time getting my head together today.  I just feel kind of fuzzy.  Case in point: It took me about nineteen minutes to try to figure out how much more expensive IVF is in the U.S. than it is in Canada before I abandoned the problem entirely, deciding it must not be important.  (The answer: 47%.  I think.  Or -0.00005E%.  I don't know.  Shit.)

But I wanted to post about this article.  Even though I know I'm not doing it justice, I didn't want to let it go unremarked.  See, this week Newsweek asked, Should IVF Be Affordable for All?

Let me try: Yes!  Whoa, short article.  Next!

Okay, there was slightly more to it than that.  I'm not going to summarize the article because I think the author, Iva Skoch, laid the facts out very clearly, and the study she references about costs from country to country is pretty easy to understand.  I just want to mention a few things that stood out to me:

Dr. Sherman Silber, a reproductive specialist at St. Luke’s Hospital in St. Louis and author of the book How to Get Pregnant, argues that cost alone shouldn’t be the sole deciding factor for patients, and that the fertility field shouldn’t be viewed as an industry. “This isn’t Walmart. Embryos aren’t like toothpaste,” he says. “You can’t do a recall on embryos.”

I don't know anyone who's chosen a clinic on cost alone.  I'm sure it happens, but probably not as often as Silber, who kiiind of comes across as a dick in this article, seems to fear.  In fact, plenty of infertile people I've known have agonized over whether a scant few percentage points' increase in success rates were worth an extra $5,000 — and have often decided they were.  I think his admonition is begging the question.

The greater issue is that cost alone frequently determines whether someone seeks help at all.  To me, that's a much more worrisome reality than an informed patient comparison shopping between reputable, accredited clinic A and reputable, accredited clinic B.  I'd love to know what Silber and other doctors who might "feel threatened" by lower-cost IVF are doing to make treatment more accessible.

I'm going to ignore the Wal-Mart toothpaste bit.  Instead I'm going to roll this one around on the tongue a bit: "The fertility field shouldn't be viewed as an industry." That...tastes hilarious.  And also faintly minty.

Further:

David Fleming, director of the Center for Health Ethics at the University of Missouri, says the main concern with making fertilization affordable for more people is the risk of “commoditization” of babies. “The more you have access, the more people will do it,” says Fleming, arguing that the unfortunate part of making IVF more widespread is its increased ethical stakes, such as those surrounding more premature births, which ultimately increase the cost of health-care coverage for everyone, and more babies with congenital malformations, which are twice as common in babies conceived through IVF than naturally.  "The concern is that we are placing these little humans in danger,” he says.

First, is this true, that IVF babies are that much more likely to be born with "congenital malformations"?  I'm honestly asking.  I don't know the answer, but I'd bet my babies' malformed congenitals that that number is wildly inflated. [Edit: e kindly sets me straight in the comments.]

Second, I'm astonished by the claim that reducing the cost of IVF will result in the "commoditization of babies."  Seems to me that by making the cost unaffordable to all but a small segment, that's already been neatly accomplished.

Third, "The more you have access, the more people will do it"?  Fleming seems to be suggesting that if the barriers to entry are lowered, people will do IVF just for the sheer giddy thrill of it, which is nonsense (Gillian St. Lawrence notwithstanding).  Does he mean instead, "The easier it is for people who really, really want children to have them, the more people who really, really want children will"? Uh, yeah, well, see, I guess I don't view that as a problem.  Not even as an ethical one, in fact, because...

...Fourth, Fleming's statement boneheadedly ignores what seems obvious to me: If IVF were more affordable, a much more persuasive case for single-embryo transfer could be made, thereby reducing the current rate of preterm birth after ART, and consequently decreasing the danger "these little humans" face.  That's a good thing.

Fifth,

“IVF, with all due respect—is it a question of need or a question of want?"

I'm not going to fall back onto the rhetorical position of likening infertility to a life-threatening condition.  I think that's a cheap tactic; moreover, I don't think it's an accurate analogy.  But I do wonder if Mr. Fleming would make a similar statement about things like compassionate treatment for the mentally ill, or palliative care for the dying, or assistive devices for the disabled.  These are measures that we as a society largely agree are necessary, not for the simple continuation of life but for the enrichment of our quality of life.  Why is treating infertility — a failure of normal reproductive function — any less important?  With all due respect, indeed.

And then we go back to Silber:

“It’s hard to call infertility a disease. It’s normal aging,” he says, adding that only about 20 percent of women who seek treatment have what’s called a “valid diagnosis,” such as that they don’t ovulate. “Most of the time you can’t make a valid diagnosis,” Silber says. “The incidence of infertility is zero to 1 percent in teenagers. For women in their early 20s, only 1 to 2 percent are infertile. In their late 20s, 16 percent of women are infertile, and in their mid- to late 30s, 25 percent are infertile. By age 40, more than half of women are infertile, and pregnancy beyond age 43 is very uncommon.”

Again, I don't know that those numbers are strictly accurate, but I don't really want to linger on his point, which is...well, sort of a pointless point.  I mean, aren't we all dying every day?  When you get right down to it, aren't we all slowly terminally ill?  No, what jars me most is what reads as a certain lack of empathy: "It's hard to call infertility a disease."  There's a lot implied by that statement, and it's very easy to use it as an argument against improving access to medical treatment for what is generally — sorry, Doctor — a medical condition.  Sadly, statements like Silber's, even at their most benign, come awfully close to branding infertility a lifestyle choice and shore up opposition to making treatment more accessible.

I wish the article had been able to answer the questions it raised: Why is IVF so expensive in the U.S. compared to other countries?  Why, if there's no shortage of reproductive services in the U.S., hasn't the cost of IVF come down?  Why, if doctors like Silber don't want their specialty thought of as a profit-driven industry, aren't they doing more to equalize access to treatment?

I'd like to know what your experience has been if you've shopped around for IVF clinics: What influence has cost had on your choice?

In keeping with my overall slowness today, I don't have any clever conclusions or insightful whaddyacallits or ringing denunciations or even funny swears to end this with.  Help me out here, please, if you do.

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