Evaluation and Treatment of Infertile Couple

PREVIOUSLY, THE GREATEST OBSTACLE AN INFERTILE COUPLE HAD TO OVERCOME IN THEIR QUEST TO HAVE A BABY WAS THEIR INSURANCE COMPANY

NOW, IT IS ALSO THE STATE IN WHICH YOU LIVE

NEW JERSEY NOW MANDATES INFERTILITY COVERAGE FOR ALL PERSONS INSURED IN A PLAN OF MORE THAN 50 PEOPLE – SO DOES NEW YORK

IF YOU LIVE IN PENNSYLVANIA, WRITE YOUR STATE REPRESENTATIVES AND ASK WHY YOU ARE NOT GUARANTEED THE SAME COVERAGE

Around 200 years ago, a French surveyor said: “It is better to be unsure of where you are then to be absolutely certain you are somewhere where, in fact, you are not.” Too often, infertility couples are subjected to tests and therapies when a valid reason for their use has never been established. We now know too much for such an approach. The only reason now is if a couple’s insurance will not pay for the therapy best suited to their problem and it is necessary to choose less effective or less well documented therapy instead.

We can provide infertility care to anyone wishing to have a baby, always keeping in mind one major fact – namely that to obtain that care, you may have to pay thousands of dollars out of your own pocket.

How much you might have to pay depends on the type of insurance coverage you have. Generally, Blue Cross/Blue Shield with Major Medical and many of the “commercials” are the best. HMO’s are the worst. If you are insured by an HMO, there is usually very little I can do that will be covered by your insurance other than the most superficial evaluation and treatment unless you are prepared to pay the difference.

You must understand that a modern infertility evaluation and treatment program is very “high-tech”. The tests are expensive, the treatments are expensive, and the drugs are more expensive. HMO’s usually cover almost none of it, especially the drugs. Literally almost every day in my practice, I have to tell a couple covered by an HMO that I could help them have a baby but their insurance will not pay for the treatment necessary and they cannot afford the large amount of money their treatment would require.

The same is true for many (but not all) Personal Choice plans. Some Personal Choice infertility coverage is rather good, whereas other plans cover little more than an HMO. Even then, there will be some out-of-pocket expenses but less than if you have an HMO. This is particularly true for certain hormone levels that I will occasionally have to perform in my own lab because to wait for the results to come back from the commercial lab would seriously compromise your treatment. I have complained to the HMO’s and to Personal Choice but they don’t care. They are more interested in profit than your welfare.

Many patients come to the office thinking they have good coverage because they believe the ads they see on television. They often discover that what they thought was good insurance is in fact, rather poor. Many couples who think they have infertility coverage discover that their plan will cover the diagnosis of Infertility but not the treatment. What a cruel deception that no one told them (or perhaps deliberately withheld) in advance what would be covered. Compared to the treatment, the diagnosis of infertility is usually relatively inexpensive.

More and more, I am seeing people come to the office with such poor insurance that it is virtually impossible to provide any care, let alone infertility. Even worse, they are often paying rather substantial premiums for the poor coverage. I actually saw a woman whose total benefit package was equal to her annual premium! In other words, she had insurance in name only.

The sad thing is that many employers choose one plan over another with little or no consideration as to how that plan impacts their employees’ ability to obtain any health care, not just infertility. Your ability to obtain the type of quality health care you want for any medical problem is a direct function of the type of coverage you have. You must investigate and you must complain to whomever is providing you with insurance to make sure you are getting the best coverage possible.

If you are self-employed, you can get good coverage with a good plan for less money than you might think. Please talk to us and let my office staff guide you.

Aetna-USHealthcare used to provide full infertility coverage. They canceled the “Infertility Network” they established to provide IVF and similar therapies for Aetna-USHealthcare subscribers. When the cutback was announced, there was a great public outcry and Aetna-USHealthcare “backed down” – a little.

People with Aetna-USHealthcare will still be able to get basic infertility care. Aetna-USHealthcare will still offer infertility coverage but there is a hooker – previously the infertility network covered not only regular infertility care but the “Assisted Reproductive Technologies” – IVF and related therapies. As of April 1, 1998, IVF and related procedures are no longer be covered by Aetna-USHealthcare unless you have a special rider.

Keep in mind that even couples obtaining care through the Aetna-USHealthcare infertility network still had to pay for their own injectable drugs – something that cost them thousands of dollars each cycle!

For many couples, it would actually be cheaper to buy their own Blue Cross/Blue Shield with Major Medical. The amount paid in premiums would be far less than the amount they would have to pay out of their own pocket if they have insurance that does not cover infertility care.

MAKING BABIES

Infertility is like no other area in medicine.

Most people’s encounters with medicine – particularly if you are in the age range where most infertile couples are found – tend to be for acute problems such as a respiratory infection, a gastrointestinal infection, or perhaps a low back strain. You go to your physician whose history and physical examination centers around whatever specific problem is bothering you at the moment – a diagnosis is made – and appropriate therapy is initiated.

You have no further contact with the medical profession until your next acute episode – the only exception being those people who go regularly just for a check-up, which in younger people tends to be principally women having pap smears.

Even if you have a chronic condition such as diabetes or hypertension, after the initial encounters and adjustment of medication, follow-up visits are usually on the order of every six weeks to three months and tend to be focused principally, if not exclusively, on your blood sugar or your blood pressure or whatever other problem you might have. Other areas are ignored unless you have a specific complaint.

Contrast all of this to the field of infertility where young, otherwise healthy, individuals – principally women – may see their physician two or three times a week depending upon where they are in their menstrual cycle and what therapies have been initiated to achieve a pregnancy.

Not only are the visits to the physician much much more frequent, consider the areas of discussion. When was the last time an ear, nose, and throat specialist or an allergist asked you how many times a week you have intercourse, if you use lubricants, what positions you use, and other related topics that most people feel (and rightly so) is something so private that they would never share it with the outside world.

Suppose you had a hernia or your gall bladder was diseased. You would be sent to a surgeon who would repair the problem. Once that had been accomplished, it is highly unlikely that you would have to see that surgeon again. A doctor/patient relationship, in the true meaning of the term, is never established.

In infertility, not only do you have a true doctor patient relationship – it centers on the most intimate areas of human existence. The relationship between a physician and his/her patient in the field of infertility is like no other in medicine.

If you need a hernia repair, does it really matter that much whether you have a great relationship with the surgeon? As long as he/she is competent and, otherwise a likable person, you know that the relationship is going to be short- lived and, for several visits, you will put up with it.

In an infertility doctor/patient relationship, you have to like the person who is treating you. You have to feel comfortable with that person and you have to completely trust that person. You are literally baring yourself – both physically and emotionally.

This is especially true because an infertility evaluation and treatment program is an emotional roller coaster for most couples. There is the two weeks prior to ovulation where preparations are being made either with medication or some other treatment. Once ovulation has been triggered, you have to have sex. If you don’t the whole cycle is lost. You have to have sex whether you want to or not, whether you are not feeling well, whether you had a fight with your spouse, whether your in-laws are visiting for the weekend, or whatever. Every infertile couple sooner rather than later reports that sex has become perfunctory. It is definitely true that if you are trying to have a baby, you can either make love or you can have sex – but you can’t do both.

Those of us in the field of infertility have recognized this for a long time. We know that our patients are under terrible stress. I always encourage my patients to talk to me about what may be bothering them at a given moment. Unfortunately, many people are still quite shy and are unwilling to open up – even when they have known me for a long time.

In that best of all worlds, every infertility specialist would have a psychologist in the office at all times to help couples deal with the stress. Obviously, this is not practical but it is the ideal scenario.

Most people go to a physician when they are sick. Infertile couples are not sick in the usual sense of the term. However, the diagnostic procedures and treatments we put you through can make you sick. Laparoscopy is a surgical procedure. It is a low risk procedure but not a zero risk procedure.

Drugs used to stimulate ovulation have a low risk but not zero risk.

The procedures used to retrieve eggs for IVF and related procedures are low risk but not zero risk.

It is for this reason that I tell people over and over again that the most important thing in medicine, whether it is infertility or a respiratory infection, is to make the right diagnosis. Once the right diagnosis is made, the treatments are usually straightforward.

I recognize that in this brief section I have not said anything that you probably do not already know. Nonetheless, seeing it in black and white is often reassuring and it also helps to make you understand that I am constantly aware of the stress my patients are undergoing. Even if the therapies do not work and you never become pregnant, it is critically important that you maintain a healthy psychological attitude. There is now emerging evidence that the stress created by an infertility work-up turns around and actually may interfere with than woman’s ability to become pregnant. The information is new and the solutions are not yet apparent. Every infertility specialist has known for years that an infertile couple is under terrible stress. We simply did not have good enough data to recognize that the stress itself was another factor in infertility. Reducing your level of stress and maintaining a positive outlook is beneficial both in the infertility problem specifically and for the rest of your life in general.

One other piece of advice – IGNORE YOUR FAMILY AND FRIENDS. Once someone finds out you are trying to conceive, you will be immediately bombarded with tons of well intentioned advice, advice that is usually wrong. There are many myths concerning conception and infertility, many of them perpetuated by mothers who want to be grandmothers. You can’t stop them – just smile and ask me.

INTRODUCTION

Time was, not that many years ago, when physicians, be they Reproductive Endocrinologists or General OB-GYN’s, could do little to help an infertile couple. Diagnostic techniques were crude and inaccurate. Even if a diagnosis could be made, little could be done. Many couples either remained childless or chose adoption.

The last 25 years, and particularly the last 15, has seen an incredible revolution in the field of infertility. We now have highly sophisticated, very accurate techniques for both diagnosis and treatment. The term “normal infertile couple” should be relegated to the history books. The term “unexplained infertility” still has a valid place, but not in the way most people think of it. If a couple is willing to undergo the necessary testing, it is possible to determine the reason for a couple’s infertility in almost every instance.

Combined with the advances in diagnosis, there has been an equally phenomenal advance in our ability to treat those problems. Couples who formerly would not have achieved a pregnancy can now be helped to do so.

These advances have not been cheap. The technology necessary to make the diagnosis or treat the problems of an infertile couple is often quite expensive. The cost of health care in the United States is still escalating rapidly (a subject far too great to be covered here) – despite managed care. Because of the rising cost of medicine, many insurance companies have adopted the attitude that having a baby is a privilege – not a right.

Many insurance companies have adopted the attitude that treating infertility is not treating a disease even though, with only one exception, infertility is always the result of either the abnormal structure or function of some organ and is therefore a disease by the strict definition of the term. As a result, many infertile couples are finding, much to their dismay, that their insurance companies will not pay for the evaluation and treatment necessary for them to have a baby. It is an outrageous situation and one that will be corrected only if infertile couples write to their state and national representatives and demand that laws be passed requiring insurance companies to pay for infertility care. Unless those laws are passed, infertility treatment will end up the same way plastic surgery is today – it will be cash in advance and available to only those who can afford to pay for it. That would indeed be a tragic situation.

Some states mandate infertility coverage – unfortunately Pennsylvania is not one of them. You must complain loudly to your State representatives to correct this.

An infertile couple denied infertility benefits must also complain loudly to their employer – the person who selected the insurance benefits that denied them the coverage they should have. Many employers do not always appreciate how the insurance plan they choose impacts the welfare of their employees. Sometimes all it takes is asking for expanded benefits, something which ought not to be very expensive. In fact, it is quite cheap.

The purpose of this pamphlet is to acquaint you with what is considered “state of the art” for diagnosing the infertile couple. Treatment will be mentioned as necessary to also help explain the overall process. Also, treatment for most problems is now quite standardized once an accurate diagnosis is made. Making the right diagnosis is the basis of all good medical care.

This pamphlet will be updated when newer techniques become available. It is important for you to understand that every new advance in medicine is greeted with great fanfare. Every new idea is presented as the greatest thing since sliced bread. Many “wonderful” technologies and treatments are gathering dust in someone’s basement.

From the time a new technique is introduced until its proper role has been determined takes 5 or 10 years. I know that every infertile couple reads just about everything they can get their hands on and I am constantly bombarded with articles from various magazines, newspapers, the Internet, etc.

Please understand that I am fully knowledgeable about every technique available to the infertile couple – long before it hits the pages of Time Magazine. I certainly appreciate your input and certainly there may have been something I have overlooked. However, I pride myself on offering my patients the finest and most up to date infertility care available. If you have heard of something and have not found it being used in our practice, it is most likely for the reason that I do not consider it appropriate or effective enough to utilize.

More recently, women are coming in asking me about items they have seen on the “Web”. It is very important to understand that some physicians and other groups set up web sites strictly as a self-promotional gimmick. It is also important to understand that 50% of what is on the web is wrong and unless you are a physician, you have no hope of determining what is and what is not incorrect. Before you go jumping to any conclusions, please ask me.

Infertile men and women are not, with occasional exceptions, “sick” as most people would use the term. Nonetheless, couples with a fertility problem deserve the same level of attention as do people with bona fide illnesses. Infertility therapies are time consuming, often expensive, and carry some degree of risk. The time has long passed when therapies can be initiated without good reason. Very often I will see an infertile couple come in who have undergone various treatments without the cause of their infertility ever having been established!

I not infrequently see couples pushed prematurely into IVF before conventional, equally successful and sometimes even more successful infertility treatments have been tried. I freely admit that everyone eventually gets to the stage where “you throw it up against the wall to see if it sticks” if you are treating a couple and nothing seems to be working. However, I would suggest that this should be used less and less often. Infertile couples should be approached like any other medical problem – a full diagnostic evaluation should be undertaken and a proper diagnosis established before initiating therapy that might be useless and possibly counterproductive and counter-reproductive.

There are more than a few Reproductive Endocrinologists in the metropolitan Philadelphia area. Many infertile couples “make the rounds” – if Doctor A is not able to help you conceive, then maybe Doctor B can. If not, there is always Doctor C. Keep in mind that for basic infertility problems, the treatments are almost cook-book. Almost everyone will treat certain problems the same way. Other more complex problems will be treated differently by different physicians. One is not necessarily right and the other wrong. When no one knows with certainty what the best approach might be, each of us has his or her own biases. In this pamphlet, I have tried to present what I believe to be the most current information about infertility. I fully recognize that some of the statements I make are at odds with what many people believe to be true. I can back up everything I say with documentation from the medical literature. It does not mean that I am always right (no one is) but I believe that my years of experience has let me separate the important from the unimportant.

This pamphlet tries to summarize what is known and what is not. I can back up every statement I make with documented medical research. However, when something is as variable as infertility, putting a couple into a neat little package with an obvious diagnosis and a straightforward treatment may not always be possible. That is what makes medicine in general and infertility specifically an art as much as a science.

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