The Business of Miracles

January, 2003

Infertility: It is hotly debated in boardrooms, courtrooms and bedrooms. It is a condition on which some couples spend tens of thousands of dollars, in pursuit of medical miracles. And many couples don’t worry about it until it is simply too late.

One in every six couples of childbearing age has experienced the deeply personal heartbreak of infertility. “The number is stunning,” says Dot Shigemura, president of Resolve, the national infertility advocacy and support group. “When we applied that statistic to the data in Hawaii, we determined that 20,000 couples in our state, at any given time, are affected.”

Shigemura, who also is president of Resolve Hawaii, says some health care professionals find that number unbelievable. “Sometimes when we issue press releases, we cut that number in half, because it’s so staggering.”

Miracles and Millions

Is parenthood a right or a privilege? Though the U.S. Supreme Court recognizes reproduction as a human imperative, less than 1 percent of the couples that need treatment actually receive it. The Court in 1998 ruled that reproduction is a “major life activity,” and that people with physical or mental impairment that substantially limits reproduction are protected from discrimination. “Infertility has its own ICD (International Classification of Diseases) code in the American Medical Association’s code book, so the AMA identifies it as a disease,” says Dr. Philip McNamee, co-founder of Hawaii’s Pacific In Vitro Fertilization Institute.

McNamee was a major proponent of the 1987 law that requires certain Hawaii insurers to provide a one-time benefit for outpatient costs resulting from in vitro fertilization (IVF). “It’s been my passion for 17 years. Many Chamber of Commerce members have likened it to plastic surgery, as something that’s not an essential aspect of medicine. I think that family building is very, very important.”

A woman must meet several conditions to be eligible for coverage under the mandate. She or her spouse must have at least a five-year history of infertility; she must have unsuccessfully attempted to sustain a pregnancy through other treatments covered by insurance; and her infertility must be associated with endometriosis, exposure to DES, blocked or surgically removed fallopian tubes, and/or her spouse’s male factor infertility.

When the mandate was first introduced in the Legislature 15 years ago, the estimate from HMSA for the cost of coverage was outrageously high, “but it only turned out to be about $1 million,” recalls McNamee. On the Mainland, 13 states have passed similar laws; a half-dozen more have riders requiring coverage to be offered.

Though infertility coverage adds just a couple of dollars to the annual cost of each health care policy, the cost of treatment without it can devastate a couple’s finances. “For the small percentage of couples who go all the way to IVF,” Shigemura says, “that cost can be anywhere from $8,000 to $15,000.”

Moved by a Mandate

That mandate certainly made a difference for one Hawaii couple. In 1996, Britain Washburn Bozanic and her husband, Nick, who lived in Michigan at the time, began trying to conceive. “Nick was tested after six months of trying, because he’s older and hadn’t had children in his previous marriage. We got a diagnosis of male factor infertility. We proceeded to donor inseminations. After those were unsuccessful, they did a hysterosalpingogram on me.”

The 23-year-old woman was told she had blocked fallopian tubes. In 1999, Brit underwent her first IVF cycle, which resulted in miscarriage. Her physicians tried a frozen embryo transfer, also unsuccessful. Both were done with Nick’s sperm, extracted through ICSI. “In the process, they determined his sperm count wasn’t so bad. It had been a miscalculation the first time.”

In an attempt to repair Brit’s fallopian tubes, doctors performed a laparoscopy. “During that procedure, they discovered my tubes weren’t blocked!” After a year and a half of treatment, the Bozanics were given a clean bill of health. Between tests, diagnoses, donor cycles, IVF and a frozen embryo transfer, they had already spent more than $15,000, most of it charged to credit cards. Yet, they were back at square one.

Nick then was offered a job at Punahou School. Friends who were aware of the Bozanics’ struggle with infertility told them about Hawaii’s insurance mandate. “We hadn’t been considering moving; my husband had been teaching at Interlochen for 20 years,” Brit says. “But in Michigan, nothing is covered with respect to fertility treatment. We had certainly exhausted our resources.”

After moving to Hawaii, the Bozanics enrolled in HMSA’s PPO plan and began working with Dr. Kenneth Vu, then medical director at Pacific IVF. On Vu’s recommendation, they tried an IUI procedure, which added $400 to their expenses. (Though HMSA provides coverage for IVF as directed by the infertility mandate, it covers none of the lesser infertility treatments.) IUI was unsuccessful, so they proceeded with an IVF cycle. Even with coverage, their out-of-pocket cost was over $2,000.

The Bozanics’ son was born in November 2000. The happy ending gets happier: as this issue of Hawaii Business went to press in late November, Brit and Nick were awaiting the birth of their second child (conceived spontaneously, with only a wink from Mother Nature).

Time and Harsh Reality

Sometimes, the heartbreaking reality is that a woman has simply waited too long to start her family. “We believe our fertility belongs to us and will always be there when we choose to access it,” says Dr. Joyce Nakamura, chairman of the OB/GYN department at Kaiser Permanente. “This is not the case! Our fertility peaks at about 27, and it’s downhill from there.”

The chance that a woman will become pregnant spontaneously at 40 is probably less than 10 percent, Nakamura explains. “For infertile women who go through IVF at 44 or 45, it drops to less than 1 percent.”

Not surprisingly, professional women in their 40s, after taking care of their bodies with good diets, regular exercise and clean living, sometimes don’t even consider the possibility of infertility. “It’s really a difficult conversation when someone at 46 comes to me and says, ‘I’m ready to get started now!’” Nakamura says. “That’s happened to me at least three times in the past month: 45, 46 and yesterday, 47. I don’t want to talk these women out of giving it their best try, but the chance they’ll be successful is very small.”

Kenneth Vu, a reproductive endocrinologist who now runs the Hawaii Center for Reproductive Medicine and Surgery, concurs. “If you are 25 years old, you have a lot of time to waste. If you’re 38, you don’t have time. Shop around! Consult with a trained specialist, and do not waste time.”

Says Brit Bozanic, “Even things that seem obvious, like second opinions, are really vital. Yet I think we hesitate because we put such complete faith in medical professionals. I would emphasize being your own consumer advocate and making every effort to get as much information as you can, as quickly as you can.”

The bottom line, says Vu, is that precious fertile time should be saved. More than half his patients are over 38 years old. “I often see people who have been married for five or more years, [who] underwent the same treatments repeatedly without success. Cost isn’t a major issue as much as the ovarian reserve, which diminishes as a female gets older. You can have a million dollars but you cannot turn back the clock.”

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