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To achieve this result, fertility centers employ a large and growing bundle of techniques: physical examinations, batteries of tests, and sometimes counseling sessions. If the problem can be identified (as in roughly 90 percent of cases), then specialists at the center lay out a suggested course of treatment. Because of the uncertainties involved, however, the treatments are in many ways more like options; patients try a particular method, check monthly for results, try a few more rounds, try another method or another, and move on. In the tougher cases, the doctors function almost as engineers. They tinker with the production process, trying different combinations and techniques. Patients, meanwhile, also tinker—at least initially—with the clinics they select and the procedures they pursue. Once they have settled on a particular practice, however, patients rarely leave. Instead, they tend to become involved in an increasingly personal relationship, relying on their doctor, their clinic to provide the product they desperately want.

Consider, for example, the case of David and Vivian, a professional couple in their early thirties who were unable, for unexplained reasons, to conceive. [39] Vivian had hormone treatments and intrauterine insemination (IUI) at Massachusetts General Hospital, and became pregnant with twins. But the twins died during the third trimester, leaving Vivian desperate to try again. In sixteen months she had five more rounds of hormones and three more IUIs. Then she switched to IVF, got pregnant on the second try, and miscarried. Frustrated, she and her husband finally left MGH for Saint Barnabas, a New Jersey clinic that Vivian believed to have “the highest success rate.” At Saint Barnabas, Vivian and David paid $379 for each test, compared with a $10 copayment in Massachusetts. But they didn’t care. The couple spent more than $100,000 on further treatments before adopting their son, Dmitri, in Russia.