Medical Examiner

Pregnant Pause

Who should pay for in vitro fertilization?

Nadya Suleman

The recent birth of octuplets to 33-year-old Nadya Suleman was, if nothing else, at least a one-woman economic stimulus package for medical professionals in the Los Angeles area. Delivering the babies provided gainful employment to four dozen doctors, nurses, and affiliated staff. Apart from generating hundreds of thousands of dollars in billable care for the Kaiser Permenente Medical Center in Bellflower, where the octuplets are still hospitalized, Suleman’s actions also enriched the West Coast IVF clinic run by Dr. Michael Kamrava, which serviced the young mother by implanting at least a dozen viable embryos in her uterus thus far.

Still unclear is how Suleman paid for her multiple IVF procedures, since she is unemployed. Even if she did have employer-based health insurance, California, like most states, does not require insurers to pay for IVF—so many don’t. Suleman apparently collected $168,000 in disability payments for a back injury in 1999, which may have helped cover her procedures.

The octuplets’ birth has revived the debate about the proper means, if any, to regulate assisted reproduction. And though it’s tempting to see Suleman’s choices as nailing the case for making IVF less accessible, the data suggest such a strategy would have unintended consequences that would hurt children and families, and ultimately cost us all more money. We should be making IVF more accessible.

Roughly 10 percent of couples experience infertility, a rate possibly accelerated by the increasing average age of prospective mothers. This demographic trend of older mothers is encouraging (since higher maternal age is a powerful predictor of financial security and the child’s future social and educational attainment), but the odds of successful spontaneous pregnancy are lower. And so women increasingly turn to fertility treatments such as ovarian hyperstimulation, which forces the ovaries to pump out more eggs per cycle and increases the risk of having twins or triplets, and IVF, in which fertilized eggs, or embryos, are implanted in the uterus directly. Almost one in 80 newborns in the United States owes his existence to IVF.

To understand how financial incentives affect IVF practices, one must first grasp that the probability of a successful pregnancy is proportional to the number of implanted embryos. Implanting just one embryo leads to pregnancy roughly 40 percent to 50 percent of the time; two embryos are 75 percent successful; and three embryos are 87 percent successful. Because the cost of each IVF cycle is about $10,000, most women paying out-of-pocket want to succeed the first time and choose to implant three to four embryos.

More eggs also mean more twins, triplets, and higher-order multiples; generally, multiples are sicker at birth and cost more. Such births are responsible for one-quarter of all premature delivery before 32 weeks gestation and one-quarter of all very low birth weight (under 1.5 kilograms). They’re also an important contributor to infant mortality rates. Consider, too, that every preemie born before 28 weeks costs about $66,000 for neonatal care alone—not including future special education needs, chronic illnesses, family support services, and other expenses. Though it’s tempting to fixate on Suleman’s set of budget-busting octuplets, they’re just taking a tiny fraction of the total costs associated with the multiples who result from infertility therapy like IVF.

In 2002, Harvard Medical School researchers found, unsurprisingly, that compared with women who pay out of pocket, those whose insurance fully covered IVF were significantly less likely to have multiples since they chose to have fewer implanted embryos. And while international comparisons are fraught with confounders, it’s worth noting that Sweden and Australia have almost twice as many IVF births per capita as we do, yet their infant mortality rates remain comfortably lower. At least one difference may be that their national health insurances subsidize IVF, and thus there is less incentive to implant multiple embryos per cycle.

Another key difference is that many other countries also legally limit the number of embryos transferred in the first IVF attempts. (For example, Belgium permits only single embryo transfers.) Here, no legally binding regulations exist. The American Society of Reproductive Medicine recommends no more than two embryos in women under 35 years old, but flouting these policies doesn’t lead to a loss of license.

Taken together, America has selected a policy that encourages multiples. Since insurers aren’t compelled to cover costs for IVF, self-paying women attempt to get pregnant in as few cycles as possible. As a result, officials find it hard to justify legally restricting how many embryos can be implanted. Since they’re paying for it, the thinking goes, women should be free to implant as many embryos as they wish. The result? More multiples, more costs, poorer child health, and, on occasion, bizarre cases like that of Nadya Suleman.

There’s a cleaner way to handle the costs and regulation of IVF to reduce multiples, and that strategy was recently adopted by Sweden. In 2004, Scandinavian doctors reported that implanting one embryo at a time, repeatedly if necessary, resulted in the same final pregnancy rates as implanting several at once—with the incidence of multiples reduced to less than 1 percent of births in the sequential single-transfer group from 33 percent in the multiple-transfer group. The Swedes ran with the results: Their national health insurance now fully covers repeated IVF attempts with a single embryo but limits coverage if women instead choose to implant multiples embryos. It’s too early to quantify the results, but the approach makes a lot of sense.

Ultimately, mandating coverage for IVF won’t break the bank. According to one analysis, adding it would increase yearly premiums by only 0.1 to 0.3 percent (about $20 per year) and may lead to overall savings. Such coverage may also soften opponents of IVF regulation, so limits on embryo transfers could become politically viable, though it would presumably be a contentious issue. Most basically: Wouldn’t it be better, in the end, to allow eight previously infertile women to experience healthy single pregnancies and deliveries, rather than invest our collective medical resources to let one woman give birth to premature octuplets?