By Dr. Joe Massey, MD
For those who have been trying to conceive without success, in vitro fertilization (IVF) can be a miraculous treatment. There are a variety of other reasons people need to go through IVF, including special medical situations or being in a same-sex relationship. IVF has been refined over the past four decades to a point that it is highly successful for most situations.
As everyone is generally aware, IVF involves substantial costs, including complex medical procedures, specifically designed space and sophisticated equipment (including an IVF laboratory), and medication costs.
To help you better understand IVF costs and the reasons for them, they can be broken down as follows:
- Screening procedures in the initial phase of considering IVF
- Baseline evaluation
- Case management
- Egg retrieval
- IVF lab
- Freezing embryos
- Embryo transfer
- IVF follow-up
There is a series of required steps in the intensive days leading up to and throughout an IVF cycle. Each of these involves imaging, blood tests, and checkups with your doctor to help make the best decisions for your family.
Screening before IVF
There are a number of necessary tests for patients who have never been evaluated by a fertility specialist to determine the cause of infertility. These include blood tests like AMH and imaging studies like the antral follicle count, which have individual costs. Some of them, like STD testing, are required for any reproductive procedures done.
The first step in an IVF procedure begins a day or two after a menstrual period begins. At the baseline appointment, a transvaginal ultrasound is done by the provider team, providing information such as antral follicle count, which becomes part of the decision-making tree used by the clinical team. Blood tests are also done. These endocrine tests require on-site testing in a dedicated lab with a lab technician working only on fertility patients. This allows the test results to be available the same day, making the information useful in deciding whether starting a treatment is appropriate, as well as which drugs and which regimen to use for treatment.
Once the drugs are initiated, patients must make frequent visits to the doctor’s office, generally four or five times in a treatment cycle. Each of these requires the use of transvaginal ultrasound equipment to visualize the developing follicles, which are measured by a highly experienced member of the clinical team. Blood tests using the on-site lab are also done to assess the endocrine response to the drugs.
Your clinical team meets daily to discuss the results of your monitoring to determine the next steps in the ovarian stimulation process. Once it is established that the follicles are ready, an egg retrieval is performed.
Up to one-third of IVF costs are not listed in clinic fees. The medications, which add most significantly to IVF cost, are gonadotropins (used to stimulate the ovaries to produce multiple follicles) and suppression drugs, which typically add $3,000 to $5,000 per cycle.
As the patient is monitored throughout her treatment cycle, the drug dose may be tailored. Clinicians consider the age of the patient and use ovarian reserve tests such as the AMH and the antral follicle count to adjust the dose of gonadotropin. Especially in the first treatment cycle, there continues to be some unpredictability. Increasing the dose to try to get more eggs increases the cost of an IVF cycle and, beyond a certain point, cannot produce more eggs than the patient has responsive follicles.
Most patients with diminished ovarian reserve want to try with their own eggs at least once. If there is poor ovarian response, often a discussion is engaged regarding the possibility of cycle cancellation.
In 15% of IVF cases, unpredictable costs can occur in the when things don’t go as planned during stimulation. The ovarian response may be too low with too few eggs, or too high, risking hyperstimulation. In these situations, drugs treatment stops after discussion of the situation, and with the patient’s consent, resulting in what’s known as cycle cancellation. It can happen after a few days or at the apparent end of the stimulation, and is a decision your IVF team does not take lightly.
However, this decision must be considered in the context of the overall plan of action. Starting over adds unexpected cost to an IVF treatment plan. However, when this decision is made, the idea is to ultimately improve the response by modifying the approach in a subsequent IVF cycle. Patients feel tremendous disappointment if the cycle is cancelled, but a negative pregnancy test is an even bigger disappointment.
The main elements of the actual IVF procedure come next: the egg retrieval and laboratory procedures. Overall, this critical phase accounts for roughly half the IVF cost. The egg retrieval involves expertise of the reproductive endocrinologist, a physician specialist who has training beyond medical school and OB/GYN training. The procedure is done in an operating or procedure room with a dedicated ultrasound machine, an anesthesia specialist, and a team of preoperative, intraoperative, and postoperative caregivers.
The eggs are retrieved under ultrasound guidance using a special guide, needle, aspirating tubing, and pump. Fluid is submitted to the laboratory, where the embryologist searches under the microscope in a sterile warm environment.
In vitro fertilization (IVF) lab
The next step is the actual IVF. As a general rule, the most critical part of the process of IVF occurs in the lab, once the eggs and sperm are provided. There are only a few hundred people in the US who are qualified to manage an IVF lab. This Ph.D.-level expert holds the title High-Complexity Clinical Lab Director (HCLD), which is awarded to people with special expertise who have passed stringent examinations. Often there is also a team of embryologists in the lab who have all trained for and dedicated their careers to IVF patients.
The IVF lab is a dedicated physical complex involving specialized microscopes, isolation hoods, air management systems, and incubators. Mature eggs are selected by the embryology staff. The sperm is washed and evaluated. Sperm and eggs are combined, either naturally or under the microscope through the micro-manipulation procedure called intracytoplasmic sperm injection (ICSI). Later, sometimes other micro-manipulation procedures are performed, like assisted hatching and embryo biopsies. These types of procedures involve a highly technical device called the micro-manipulator, which adds considerably to the cost of setting up an IVF lab.
The embryology team performs daily inspections on every egg and embryo, evaluating fertilization and development for up to seven days. The embryos are in small plastic dishes filled with special IVF media. The incubators must be tuned to perfection by staff and are checked daily to provide special medical-grade gases to ensure the proper temperature, humidity, and gas concentrations for embryo development and successful IVF.
Current practice allows for freezing of embryos, another time-intensive task for the team. The embryos are frozen through vitrification, a rapid freezing method that prevents ice crystals from forming. If preimplantation testing (PGT-A or PGT-M) is being done, the biopsy is done at this stage. The equipment and skill required for these tests are parallel to the micromanipulation procedures used in ICSI.
The embryo transfer is a fairly quick procedure, but requires the combined expertise of a sonographer, an IVF specialist physician, and a reproductive biologist or laboratory technician. Single embryo transfers are generally recommended to prevent the risk of twins. This means that if a patient has more frozen embryos that were not used for the first transfer, each new frozen embryo transfer (FET) adds another round of fees.
It’s not a large cost component, but of course pregnancy testing is required after IVF. Usually, the first pregnancy test is covered as part of the IVF cycle cost. Subsequent blood testing and early ultrasounds are usually not covered.
Expenses related to complications may not be covered in the IVF cycle cost. The most common complication is ovarian hyperstimulation syndrome. Others may involve bleeding or infection. The IVF informed consent document will explain these in detail.
Financial planning & multiple cycles
For purposes of financial planning, the reality is that to achieve a high level of success, two or three stimulation and retrieval IVF cycles are commonly needed. Discuss the likelihood of this with your fertility doctor, based on your specific situation, so that you can plan appropriately.
In considering the cost of IVF medications, once again, it’s important to realize that this may not be a one-time expense. For many patients, predicted IVF cycle success rates may be under 50% per stimulation cycle, meaning repeated cycles are commonly needed to conceive. They’re also more likely to be necessary in cases of diminished ovarian reserve. However, it’s good to remember that even patients with low ovarian reserve can succeed with IVF. It may take multiple tries, but in situations where patients are able to persist and do multiple cycles, approximately one-third of them can conceive successfully.
For some, there is the bonus of multiple healthy embryos and the option of additional frozen embryo transfer cycles after a failed IVF cycle. Those patients can use extra frozen embryos to achieve high cumulative success from one egg retrieval. This “one and done” happy outcome allows the second pregnancy to be achieved at low cost.
For those whose IVF fails the first time, persistence is a good attribute. The three resources that are primarily involved in decision-making for patients are time, emotional stress, and IVF cost. Because of the stress and cost of IVF, repeated cycles at some point may become unworkable.
In cases of diminished ovarian reserve, it becomes a question of when to move to egg donation, which is a serious and complex decision to make. This is an even more expensive plan, albeit with excellent outcomes.
Guaranteeing IVF Success
While we wish it were possible, there is no way to be 100% sure that IVF will succeed. Compare IVF success to the success rate of pregnancy with Mother Nature. Generally speaking, a young woman trying to conceive naturally with no fertility issues for herself or her husband/partner has about a 25% chance of a pregnancy in one month. Keep in mind that these numbers decline after about age 32. However, with the extensive drug treatment and sophisticated technology of IVF, the chances for conception for a woman in her mid-30s in one month can be 40%. This means a good strategy to guarantee IVF success is to be prepared to go through multiple cycles.
IVF & insurance
IVF is covered by insurance for the fortunate people who work for an enlightened employer. Employers have an option to choose to cover IVF for their employees. Unfortunately, often because of costs, infertility coverage, and specifically IVF, this coverage is left out. It has to compete with coverage for vision, dental, hearing, and other options.
At the time of this writing, 13 states have state-mandated requirements for coverage, but this does not always cover everyone. Before beginning IVF, the costs will be outlined for you and potentially submitted for preauthorization by your insurance company, if it is appropriate.
The wisdom of your IVF team incorporates the motto that in the case of infertility, it’s all about the final outcome, not about the journey. Persistence is key. While you are in the midst of the journey, it can be hard to remember that. Hopefully this overview of the many facets of IVF helps you understand more about the financial aspects of that journey.
As a well-known pioneer in IVF, Dr. Joe Massey loves to share in the joy of helping build families. Dr. Massey’s achievements in fertility medicine include involvement in the first pregnancy in the world following assisted hatching in 1988 and in the world’s first pregnancy following intracytoplasmic sperm injection (ICSI) in 1993. He has led a number of clinical trials and co-authored many articles published in medical journals.