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Notice, too, the loyalty that each of the clients retained for the provider. Even when they were spending considerable sums of money, for example, Vivian and David didn’t take their case to a different center. Even after five years of complex and frustrating treatment, Patricia was only beginning to consider other options, such as egg donation or adoption, or other potential providers. In this regard, the fertility trade functions very much like the medical trade in general. That is, the people who purchase fertility services don’t see themselves as participating in a commercial relationship. They switch providers only reluctantly; they don’t argue about price; and they generally don’t blame the doctors when treatment fails. [42] Such tendencies are further reinforced when insurance is paying the bill for fertility treatments, as happens now across Europe and in several U.S. states. [43]

The view from the clinics, by contrast, is more commercial. Although nearly all fertility centers tout their medical expertise and their patient-focused environments, they also reveal a distinctly financial bent. To begin with the obvious, in the United States, at least, fertility is emphatically a for-profit endeavor. Nearly all the major sperm banks are for-profit, as are all the hormone providers and most of the egg banks. The fertility clinics themselves occupy a more mixed landscape, because many remain linked with major research universities and their affiliated teaching hospitals. All the doctors at Boston IVF, for example, are on staff at Boston’s Beth Israel Hospital and hold teaching appointments at Harvard Medical School. All the doctors at Manhattan’s Center for Women’s Reproductive Care are affiliated with Columbia University. Similar connections link Yale Medical School and the Yale Center for Reproductive Medicine and Infertility.

Yet in many of these cases, the fertility centers are not themselves bundled into the hospitals’ nonprofit status. Boston IVF is a stand-alone, professionally managed private corporation, as is the Center for Women’s Reproductive Care. The doctors, therefore, wear at least two hats: clinicians or researchers at major teaching hospitals, and employees of for-profit fertility centers. Some then multiply these hats even further. Boston’s Berger, for example, along with some of his colleagues, has additional financial interests in an egg donation firm (Dream Donations), an embryo testing laboratory (Embryonics), and a consulting business (IVF Performance). Dr. Cappy Rothman, who teaches at the UCLA School of Medicine, is also a cofounder of the IVF Center at Century City Hospital and medical director of California Cryobank, one of the world’s largest sperm banks. Generally, the rationale for these overlapping structures is in part scientific synergy, and in part pure profit. “I was dismayed,” recalls Berger, “that physicians could only make money from what they do with their hands.” [44]