Fewer than 150,000 IVF procedures (out of a pool of more than 1.5 million women/couples that are believed to be in need of IVF) are currently performed yearly in the United States. In other words, fewer than 10% of patients who need IVF gain access to this treatment. The number of procedures performed barely scratches the surface of the demand. At the same time most of the more than 360 programs in this country are grossly underutilized.

One half of all the IVF procedures in the United States are probably performed in fewer than 40 programs, with the remainder divided among the rest of the clinics. Since some larger programs are doing more than 1,000 procedures a year that means that others are performing far fewer than 100. Yet no one can gain optimal expertise doing so few procedures per year. Nor can smaller programs afford to incorporate many important technologic advances in the field. It is also impossible to develop meaningful statistics, let alone confidently report them, when they are based on such small numbers of cases per clinic.

The fact that only about one in ten women who need IVF actually undergo the treatment bears is largely due to two factors: First, most women/couples who are in need of IVF often find themselves being prescribed other lesser such as reproductive surgery and intrauterine insemination that do not offer them a reasonable prospect of success. Second, since only about 20% of American women/couples have insurance that covers IVF, such expensive treatment often represents an out of pocket expense that is unaffordable to most.

The fact that even in this the “era of Viagra” many insurance companies still reimburse for procedures such as penile implants done in cases of male impotence, and yet the same providers refuse to cover infertility, is an embarrassment. Perhaps, the predominantly older male executives of these insurance companies view male impotence as a life‑endangering condition and a couple’s desire to have a baby, as a vanity….Talk about a “double standard!” Also, many insurance companies cover relatively ineffectual surgeries to unblock Fallopian tubes, and in some cases for fertility hormone therapy and intrauterine insemination, but not IVF procedures. They do so either through ignorance, naivety or in the hope of avoiding or deferring IVF, probably as a cost-cutting strategy …yet another example of a “double standard”. After all, if they recognize the need for infertility treatment and are willing to pay for some forms of therapy, the only plausible explanation for denying coverage for IVF which is far more likely to be successful, is to cut their expenses and bolster profit. Americans deserve better.

Insurance companies would no doubt argue that they are reluctant to pay for IVF treatment for two basic reasons. The first is the unacceptably high cost associated with caring for mothers and babies compromised as a result of the very high incidence of IVF-multiple pregnancies (especially triplets or greater). The second is that IVF statistics currently reported annually by the Society for Assisted Reproductive Technology are delivered unaudited and unaccredited. While most IVF programs are honest in the reporting of there statistics, this not true for all, giving some credence to the claim by insurance providers that without access to valid outcome statistics they are unable to determine the cost of doing business.

So should Federal or State government mandate that insurance companies pay for all IVF? Some states already do, but this has led to internal cost-cutting trends that can prejudice standards of care. So, I personally do not favor mandatory regulation. I do, however, strongly advocate independent accreditation of all IVF programs. All United States IVF programs should submit their statistics on quality of service for review by an impartial accrediting agency. There are strong incentives for IVF programs to participate in such accreditation, including the argument that, (provided accreditation is accompanied by a forced limitation in the number of embryos transferred so as to reduce the incidence of multiple births), insurance companies should start stepping up to the plate when it cones to covering IVF .

I believe that until IVF programs become accountable and submit to a full and transparent accreditation process that verifies their IVF success rates, we will not achieve universal insurance reimbursement for IVF. As a result, the remaining 90% of couples who need this treatment will continue to be left out in the cold. And why should the size of the pocket book determine the ability to have a family?

I firmly believe that accountability and legislation should go hand in hand. Neither approach would be entirely successful alone. But it will not be easy to accomplish these changes. Convincing insurance companies that it is in their own best interests to fund IVF performed by accredited programs will be a long, slow process. And until there is more accountability by individual IVF programs, insurance companies forced to fund procedures with widely varying outcomes might be expected to lobby for repeal of mandatory reimbursement laws.
Under such a system, IVF programs might submit to an ongoing process of peer review. Participating programs would register each prospective patient with the accrediting body prior to initiation of treatment. A patient code number could ensure confidentiality, and registration of the patient with the society would guarantee proper data interpretation. New programs that initially submit themselves for accreditation could have 12 months to demonstrate an ability to meet “acceptable” operational and outcome standards. Programs wishing to apply for accreditation after the first year could submit to a similar prospective evaluation or may elect to undergo a detailed retrospective audit according to the standards set forth by the accrediting body’s peer‑review committee. Instead of eliminating marginal IVF programs (which might otherwise occur under government‑mandated regulation), such an accrediting body would set an example and would even help struggling programs upgrade their standards and performance in the area of high‑tech infertility treatments. Each accredited program would undergo an annual peer review to become re-accredited. This would provide an ongoing assurance of proficiency to the consumer and to the referring doctor, and would also give each program important feedback regarding its own performance.

I further anticipate that participation in such an accrediting process would snowball as IVF programs become convinced that accreditation would be in their own best interest for the sake of insurance reimbursement, and to forestall mandatory regulation by federal or state governments.

Ultimately, consumers can control the debate. They may have to band together to make their voices heard against the forces of the marketplace, but they can bring about change. Now is the time for IVF consumers to be outspoken. If they don’t participate in the campaign to put the IVF house in order, they will have only themselves to blame if progress towards insurance reimbursement comes slowly. One of the most promising lobbying avenues would be to join one of the infertility support groups, both to become more informed, and to speak with a louder voice before the medical profession, legislative groups, and the insurance industry.

It is time for consumers to marshal their buying power to demand that these “Four A’s” in the field of high‑tech infertility management are met:

Accreditation of IVF programs

Accountability by the medical profession with regard to providing validated statistics or a track record, and instilling rational expectations in infertile couples who seek their advice.

Availability and access to the consumer of state‑of‑the‑art standards of care.

Affordability of services to all those in whom they are indicated.