COSTLY CARE

In the United States, only 15 states currently mandate that health insurance policies must offer coverage for infertility treatment, and those that do often do not cover the more expensive treatments, like IVF. As a consequence, many patients must pay out of pocket. Because the costs of treatment are so high, many doctors find themselves under pressure to be aggressive with treatment with patients who have limited resources. Therefore, financial considerations can dictate a course of treatment, even when the treatment is unlikely to be successful or to be too successful, as in Suleman’s and Gosselin’s cases.

As of 2013, a single insemination treatment (including fertility drugs and monitoring) can cost as much as $1,200—steep, but barely one-tenth the cost of an average in vitro fertilization cycle. Many couples may choose insemination over in vitro fertilization simply because it is less expensive, even though the procedure has a low success rate. On average, only 10% to 20% of all insemination treatments result in a live birth. But younger women and women who take fertility drugs and, as a result, have multiple ovulations, tend to have higher success rates. The multiple ovulations increase the odds of a successful pregnancy by insemination.

IVF has a higher success rate—about 40%, according to ASRM—but if the woman must undergo multiple rounds before becoming pregnant, the $12,400 price tag can be prohibitive. This financial burden can cause couples to hedge their bets by choosing to implant more embryos at one time than is typically recommended. The more embryos that are transferred into a woman’s uterus during each round of IVF, the higher the odds of a pregnancy.

In the wake of the revelation that Suleman had received multiple rounds of IVF, many people wanted to know how an unemployed 33-year-old with six children afforded to pay for the costly procedures. Suleman has said in interviews that she saved money for several years while working at a state mental hospital and later supported her family with money from student loans. The Associated Press and various newspapers also reported after the octuplets were born that Suleman received at least $165,000 in disability benefits from the state of California between 2002 and 2008 for an on-the-job injury she sustained in 1999. In addition, Suleman has said she received unemployment insurance and food stamps, as well financial support from the state for her other children, some of whom have disabilities. But even with this governmental support, given her large family and lack of an income, her financial resources would have been limited.

Medical details revealed during a court case brought by the California Medical Board in 2009 against Suleman’s doctor, Michael Kamrava, show that Kamrava created 14 embryos and implanted a dozen of them—six times the recommended number for a patient Suleman’s age. Eight embryos survived, and the babies were delivered 9 weeks prematurely by cesarean section (C-section). The Associated Press reported that during the hearing Kamrava said he regretted implanting the 12 embryos and “would never do it again.”

Kamrava further stated that Suleman was adamant about using all 12 embryos, even though he suggested implanting only 4. “She just wouldn’t accept doing anything else with those embryos. She did not want them frozen, she did not want them transferred to another patient in the future,” he said, according to the AP story. Kamrava said that he consented only after Suleman agreed to have a fetal abortion if necessary to reduce risk. After the implantation, however, he only heard from Suleman after the birth of her octuplets, despite his numerous attempts to contact her.

From a medical perspective, the birth of multiples from any assisted reproduction procedure carries risks. According to the March of Dimes, 50% of twins and 90% of triplets are born prematurely, as are virtually all quads and quintuplets. A premature baby is defined as one born before 37 completed weeks of pregnancy. When babies are born prematurely, their organs may not be fully developed, which can lead to medical problems. In particular, their lungs are often immature and so the babies must be hooked up to mechanical breathing ventilators, which sometimes scar the lungs so that these children will for the rest of their lives be prone to asthma, pneumonia, chronic lung disease, and other respiratory disorders. And because their brains aren’t fully developed, premature babies are susceptible to brain hemorrhages and to developmental difficulties, including learning disabilities (see UP CLOSE: PRENATAL DEVELOPMENT).

These medical conditions impose a huge burden on the health care system. Experts who have considered Suleman’s case have stated that the medical bill for the delivery and postnatal care of her eight babies likely totaled $1.5 to $3 million. Kaiser Permanente, where Suleman delivered her babies, has asked MediCal, the tax payer-funded state health insurance system, to foot the bill.

To reduce the birth of multiples and prevent the associated health problems, in 2006 the ASRM recommended transferring no more than two embryos in women under 35 years of age and no more than five in women over 40, because as a woman ages the success rate tends to drop. These guidelines appear to have been helped: in 2009, 3.6% of all infants born via assisted reproduction were triplets, as compared to 6.4% in 2003. But assisted reproduction still results in a high number of twins—in 2009, 43% percent of births from IVF alone were twins, compared to 3% of all births.

Despite the drop in multiple births, some lawmakers want more control. The risk that doctors may act against the ASRM guidelines, with negative consequences for women and their babies, remains.

After a lengthy investigation, the California Medical Board revoked Kamrava’s medical license, effective July 1, 2011. The Board claimed he was negligent not only in Suleman’s case, but also in the cases of two other women who suffered serious medical complications because of aggressive fertility treatments.

Lawmakers are concerned that there is nothing to prevent cases like these from happening again. Several states are considering legislation that would regulate doctors. A Missouri bill, for example, would require doctors not to exceed the ASRM’s embryo-transfer guidelines, while a Georgia bill would put a strict limit on the number of embryos that can be transferred. But experts fear that regulation would hinder good care. Fertility doctors need flexibility to tailor treatment to a couple’s individual condition of fertility, they argue. Such legislation “seeks to substitute the judgment of politicians for that of physicians and their patients,” ASRM president R. Dale McClure said in a statement evaluating the Georgia bill.

Instead of putting controls on doctors, some groups favor regulation that would require health insurers to cover infertility diagnostics and treatment, for example. The 2010 Affordable Care Act, passed by Congress and signed into law by President Obama, does not include infertility treatments in the “Essential Health Benefits” that health insurers will be required to cover beginning in 2014. However, it does make changes to the tax code that would allow individuals to write off a larger portion of the cost of these procedures on their income taxes.

As long as fertility treatment continues to be a financial burden on couples, fertility doctors will face pressure from patients to give them the most for their money, says Barbara Collura, executive director of RESOLVE, an infertility advocacy group. Broad health insurance coverage would eliminate the cost factor. The result might be that couples would be able to forgo treatments such as insemination that have high risks with low success rates and skip directly to IVF when appropriate.

“If nothing else, these high profile cases have served as a wake-up call,” says Collura. The community of health care workers is examining its own procedures and methods because it would rather self-regulate than have regulation imposed on it from the outside, she adds. “After Suleman, the community is really looking into how it [the birth of octuplets] happened and how it can prevent it from happening again.”