Try and Try Again

Nona Grayson never imagined that having a family would be this difficult. After a first in-vitro fertilization attempt failed, she became pregnant on her second try, although serious complications kept her in the hospital for 10 days and required months of constant bed rest. She finally gave birth to a healthy son, John. That was two years ago.

Now she and her husband, Curt, are trying to have a second child. Two IVF procedures failed in the last year, but the couple plan to undergo additional procedures in the next year. “We have a huge ache in our hearts for another child,” says Nona, 41, of Aliso Viejo. “We just have to keep trying.”

One of the most agonizing questions for couples having difficulty getting pregnant is whether and when to give up and begin exploring other options. Traditionally, that happens after early fertility treatments fail and a couple has gone through three or four advanced fertility treatments, like IVF, or other, much less common options. It is by then that up to 90% of successful procedures are believed to occur.

Even so, fertility doctors and experts across the country say more couples like the Graysons are refusing to give up and are pushing the limits of fertility treatment. It’s not unusual, they say, to see women undergo six, eight or even more IVF cycles now. (One doctor in San Francisco said he recently helped a women get pregnant on her 23rd cycle.) Although a few women end up successful, the overwhelming majority do not. And that’s causing a debate among doctors and health experts about if and when it’s appropriate to stop trying to help a couple have a baby and steer them to other options like adoption. It’s an especially delicate dilemma with women older than 40, whose chance of getting pregnant with fertility treatments is about a quarter that of younger women, no matter how often they try.

One key concern is that some doctors aren’t being candid with patients over 40 about how low their chances are for getting pregnant--and how severely the odds diminish after several failed cycles. Some experts also worry that some physicians are underselling the emotional, financial and medical risks that may result from multiple unsuccessful procedures. To help, the American Society for Reproductive Medicine plans to introduce physician guidelines for multiple fertility treatments later this year, although officials say the guidelines are unlikely to include specific recommendations on the overall number of treatments doctors should provide.

“People are more willing and confident today to spend longer on the fertility treadmill,” says Dr. Paul Zarutskie, a fertility specialist in Laguna Niguel, who says he rarely allows a patient to undergo more than four cycles. But “it’s not clear if that’s a good thing. At some point, physicians have an ethical responsibility to help people get off the treadmill and consider other options.”

The Demand Is Strong

Overall, the $2-billion-a-year fertility industry is booming, even in the current down economy. According to the Centers for Disease Control and Prevention, the number of procedures rose almost 40% between 1995 and 1999, the last year for which information is available.

There are three stages of fertility treatment that women can undergo. The first stage involves a host of different pills and injections meant to stimulate a woman’s ovaries. That includes drugs like Clomid, Pergonal and Gonal-F and costs $1,000 to $2,000 per try. The next step, which is more invasive and costs twice as much as the first stage, includes artificial insemination, where semen is placed inside the woman’s reproductive organs. Finally, when all else fails, women move on to advanced treatments like IVF or other more invasive options, in which eggs are retrieved, fertilized with sperm in a lab and inserted into the uterus after three to five days. In some cases, one cycle can run as much $15,000. If that doesn’t work, the only other options are to use donated eggs or sperm or adoption, so many patients keep trying as long as they can emotionally and financially afford it.

And that’s exactly what’s worrying folks. Although IVF procedures are commonplace, they are not without downsides or risks. For one, the emotional toll and daily grind can be brutal. Studies have found that depression rates among women who fail fertility treatments can be higher than those with cancer or HIV. Moreover, a life filled with seemingly endless shots, doctor appointments and failed cycles can severely strain marriages, some of which don’t survive the ordeal. And considering that most fertility treatments aren’t covered by insurance, many couples experience financial hardship, putting another strain on a relationship.

There’s also relatively little research about the long-term health effects of ovulation-inducing drugs. Indeed, most women undergoing IVF procedures can take up to 15 medications and have hormone levels 10 times higher than normal for weeks or months. About a decade ago, two separate studies at the University of Washington and Stanford University found that women who stayed on the drugs for only several months had a significantly higher risk of ovarian cancer. After those alarming findings, however, several subsequent studies reached contradictory conclusions. Today many doctors simply tell patients that the risk is unclear. (One problem is that few of the studies have looked at women who have undergone multiple fertility treatments and stayed on fertility drugs for long periods of time.)

Why They Keep Trying

Jennifer Gammelgard says she isn’t thinking about the long-term health effects right now. She and her husband, Erik, have been trying to have a baby for years. She underwent six procedures in five years, and finally, after the last procedure just a few weeks ago, she got pregnant. Although she admits it wasn’t easy, she says it was worth it. “I went through hell and back and then back again,” says the 31-year-old San Diego human resources executive. But “I still feel like it’s a God-given right to have a child.”

While that may explain why so many couples turn to fertility treatments in the first place, experts say there are a host of reasons more couples aren’t giving up earlier and are willing to undergo multiple procedures today. For one, improved technology has led to higher success rates in recent years. According to the latest annual report from the CDC, 33% of women 35 or younger undergoing advanced fertility treatments had a baby in 1999, compared with about 25% four years earlier. Women older than 40 also are having more success, though their odds of conceiving a child--about 10%--are still comparatively low.

Congress, too, is playing a role. In 1992 it passed a law setting up a system for nearly 400 clinics nationwide to report annual success rates and other data. (The data are on the CDC’s Web site, www.cdc.gov.) Not surprisingly, those statistics have become influential in women’s choices about where to seek treatment.

The Role of Doctors

One drawback of the federal reporting system, however, is that clinics report only an overall success rate--not how many attempts it took to achieve success. Some fear that’s pushing aggressive doctors to just keep trying. “It’s hard not to think some doctors are going a bit further than they would without [the reporting system],” says Ruth Fretts, a fertility researcher at Harvard Medical School in Cambridge, Mass.

And some doctors may be providing a financial incentive for patients to continue trying. Many clinics now offer “cost containment” packages, which usually charge a higher fee for the first IVF treatment but then give steep discounts on the next two cycles if the first doesn’t work. That can save a couple thousand dollars but may also encourage repeated attempts.

Why some doctors allow patients to continue having procedure after procedure is difficult to say. Many infertile couples desperately want a child, and doctors may have difficulty saying no if a patient insists on continuing. Plus, although some couples may spend more than $100,000 for repeated IVF treatments, many clinics say that these patients tend to be financially well-off. “There are definitely sacrifices,” says Dr. Jackson Wu, a UCLA fertility specialist and professor. But “overall, many couples are happy to keep trying, even if they don’t end up successful.”

What’s more, there may be some help on the way, at least for those who are suffering from financial problems as a result of their treatments, something many fertility advocacy groups say is a growing problem. In the last several years, 15 states have begun to require employers or health insurers to offer at least partial coverage of fertility treatments. More states may follow suit, although prospects are dimming because of the still-soft economy.

California’s legislature has explored mandating employer coverage of fertility treatment, but current state law only requires insurance companies to offer the plans to companies. Individual employers are not required to provide fertility treatment as an employee benefit. The result is that few California employers cover fertility treatment. People can buy individual policies that cover at least part of the procedures, although those plans tend to have high deductibles. Some advocacy groups are lobbying Congress to force more insurance coverage nationally.

Meantime, the number of multiple treatments is unlikely to slow down because, for many people, the desire to have a baby is worth any hardship. “It’s a gerbil wheel,” Nona Grayson says. “But it’s all we’ve got.”

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Improving Odds

Succes rates for in-vitro fertilization and other advanced fertility treatments are climbing, one of the reasons many individuals are undergoing multiple procedures.

Total procedures:

1995 -- 45,906

1999* -- 63,123

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Success rates**:

1995

Age 34 and under -- 25.3%

35-39 -- 18.2%

40 and over -- 39.8%

1999

Age 34 and under -- 32.2%

35-37 -- 26.2%

38-40 -- 18.5%

41-42 -- 9.7%

* Latest year available

** The 1995 and 1999 figures include different age groupings because the Centers for Disease Control and Prevention changed the way it reported statistics.

Sources: Department of Health and Human Services; Centers for Disease Control and Prevention