Babies Are Bottom Line for Clinics
For Dr. Mark Sauer, being a fertility specialist is not unlike coaching the University of Oklahoma football team: a blistering hot seat where winning is the only means of keeping the job--and the glory.
In the big money baby-making business, like football, scoring is everything.
Patients pay anywhere from $8,000 to hundreds of thousands of dollars to get pregnant at centers such as UC Irvine’s fertility clinic. They are desperate, usually well-educated and willing to do just about anything to have a baby. And they will take their cash to the clinic with the highest winning percentage.
The pressure to succeed is enormous, medical ethicists and fertility experts say, sometimes causing doctors to tiptoe across ethical and legal lines. Sometimes, as alleged in the case of Dr. Ricardo H. Asch, to disregard them altogether.
Asch, one of the nation’s foremost fertility experts, resigned from UC Irvine Friday amid allegations that he took eggs from patients without their consent and, in at least one case, used the eggs of one woman without her knowledge to impregnate another patient.
He has denied knowingly violating the wishes of his patients, saying that, if any administrative mistakes were made at his clinic, the university must share the blame.
“There’s a tremendous pressure to keep building the big statistics,” said Sauer, associate professor in the Department of Obstetrics and Gynecology at USC. “You can practice this field in a totally responsible manner, and if you don’t have great success, it counts for nothing.”
Now with this latest controversy in the fertility industry, some doctors, medical ethicists and fertility experts are calling for tougher controls on their booming, largely unregulated business of making babies.
“There’s less regulation here than there would be probably in the animal-breeding industry,” said Dr. Arthur Caplan, director of biomedical ethics at University of Pennsylvania. “It’s basically a market free-for-all with very little oversight over who offers services, what they do, how much they charge.
“If, as alleged, people did use embryos without the consent of the donors, it’s just absolutely a breach of trust and it’s a breach that will reverberate through the whole practice of assisted reproduction,” Caplan said.
While most of the doctors interviewed for this story were shocked at the allegations against Asch, many said it was not hard to believe that something of this nature could occur.
“Things are done in this field that would never, ever be done in any other field of medicine without review or without big studies that look at efficacy or safety,” said Jonathan Van Blerkom, co-director of the Reproductive Genetics In Vitro, a Denver clinic.
The reason? Money. Lots of it. At Asch’s Center for Reproductive Health, the doctor and his associates reported earnings of $4.5 million from January, 1992, to August, 1994, according to UC Irvine’s College of Medicine.
Ten years ago there were five fertility clinics in Southern California; today there are more than 30, according to local fertility experts; Van Blerkom, who consulted for the National Institutes of Health panel that set the guidelines for human embryo research, said the competition for clients sometimes pushes doctors to “cut moral corners.”
“This has always come up when you have one woman who has a disproportionate number of eggs and another woman who is very nice and very deserving and doesn’t have enough eggs,” Van Blerkom said. “Wouldn’t it be nice to give her a few?”
Van Blerkom also said that some doctors have been known to put 12 or 15 embryos back into a patient instead of the standard three or four to get the highest chance of fertility, then selectively abort if there are multiple fetuses.
Much of the pressure comes from the patients.
“There are programs that I know of that do [in-vitro fertilization] on patients that are not infertile,” he said “A woman comes in that can afford it and who wants to get it over with it at a certain time. . . . The woman is not infertile, but her pregnancy goes into the clinic’s success rate.”
Dr. Joseph Gambone, director of the fertility program at the UCLA School of Medicine, describes the “average” fertility patient as a professional who in no other aspect of life knows what it means to fail.
They are, he said, highly motivated achievers, “or overachievers,” who believe that hard work and the right amount of money can produce almost anything--namely, results.
Namely, a baby.
“When they come to us, they are, for lack of a better term, emotionally desperate,” Gambone said. “Because there’s a threat to their self-esteem when infertility arises, they’re highly motivated to seek out the best clinic, the best person, the best method, the most sure-fire success rate.”
Dr. George Tagatz, professor of obstetrics and gynecology at the University of Minnesota, said that some patients spend upward of $50,000, with one treatment cycle costing $8,00 to $10,000.
Dr. Robert E. Anderson, director of the Southern California Center for Reproductive Medicine in Newport Beach, said many couples do “comparison shopping” when they seek an infertility doctor.
“I frequently get calls from patients who just want to know: ‘What is your success rate?’ Period,” Anderson said. “As if there’s some magical number I can pick out that would tell them how likely they are to succeed.”
But Anderson and others expressed concerns that the allegations involving Asch and his partners at UC Irvine would give the public the “impression that they have something to fear. That does a tremendous disservice to the profession.”
“I hope the public doesn’t think that an incident like this is commonplace,” he said. “I know that isn’t the case.”
But some doctors say that in their efforts to lure patients, some of their colleagues promise more than they can deliver.
A disturbing trend, in Sauer’s view, is the tendency of some physicians and clinics to quote, not delivery rates, but rather pregnancy rates under the misleading umbrella term, “success rate.”
“I would say that women over 40 going through in-vitro fertilization have a 15% pregnancy rate, but I also know that ‘pregnancy rate’ is not the appropriate term here,” he said. “A lot of patients hear the pregnancy rate quoted, and they automatically, think, ‘Baby!’ But one-third to half of the women [in that 15%] over 40 will also miscarry after they’re pregnant.”
No other field of medicine offers such philosophical dilemmas, Sauer said, adding, “Patients generally go to doctors for care, but in this case, you go to doctors for only one reason: Results. Nothing short of a baby will satisfy the consumer. You may spend innumerable hours and give it your best effort, but there’s no guarantee of success.”
Gambone said he is troubled by the allegations against Asch, saying that, if proven true, “It makes what we do less of a profession. Because one of the key definitions of a profession is that we police ourselves.”
He said there’s a lack of oversight clouding the work itself, but that oversight “represents a delicate balance. It’s really difficult to report every single procedure--the paperwork slows down the process tremendously, and the one thing these patients want is fast action. And again, results.”
For physicians linked to cash-strapped universities and hospitals, the push for success is not just about money.
“The pressure to have a successful program are somewhere between enormous and unimaginable,” Caplan said. “You got a school like Irvine in tough financial straits, trying to make a name for itself. It recruits in these specialists. . . . They’re expected to both bring in patients, capture grants, publish research--put the school on the map.”
Caplan and others say that success also has the capacity to make some fertility doctors feel above the rules: They’re making life so nothing they do is wrong.
Others in the field cited the tendency for some doctors to elevate themselves, spurred on by adoring patients.
“Oh, you walk on water,” said Van Blerkom. “It’s just putting sperm and egg in proximity” in a woman’s body.
Times staff writer Quyen Do contributed to this report.
* DOCTOR’S ADVOCATE: Former patient praises Dr. Ricardo H. Asch. B1
