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All fertility practices, therefore, need to wrestle with the commercial dilemmas that come from this gap in perception. If the clients of fertility services truly shop around for the clinic or doctor with the “best” statistics, then the clinics will be under implicit pressure to shape their practices toward particular statistical outcomes. Such manipulation is relatively easy. If clinics want to boost their pregnancy rates, they can refuse to treat women over a certain age, or women whose levels of FSH are higher than a certain level. They can encourage patients to withdraw from the program if they don’t get pregnant within a certain period of time, or they can skip less-expensive options in favor of IVF.

One could describe these tactics simply as good medicine: if a woman has reached a certain age and her hormone levels have dropped below a certain level, then perhaps doctors should encourage her either to withdraw from fertility treatments or to pursue only the most aggressive routes. But clearly, such tactics also reflect a commercial motive, for if patients choose fertility clinics by statistical rates of success, then clinics will be constantly tempted to discard those cases that damage their success rates. As one laboratory director asserts, “Fertility clinics are there to make money. You’re not going to pursue something that’s going to hurt you. And if your success rate drops, you’re going to lose patients.” [70] Columbia’s Sauer is even more direct. “Everybody,” he asserts, “knows how to inflate the numbers . . . If a program wants to maintain a very high success rate, they can and do literally select the best patients to treat.” [71]

When insurance enters the picture, the dilemmas become even more profound. Recall that in some states, coverage of fertility treatments is mandated by law: insurance companies in those states must include at least some IVF services in their basic insurance package. [72] As they do in other areas of health care, therefore, insurance companies have arrived over time at benchmarks for reimbursement. In Massachusetts, for example, a state with particularly generous coverage, insurance providers generally cover a prescribed course of treatment involving three rounds of Clomid, three rounds of the more powerful FSH, and then—and only then—IVF treatment. As a result, clinics based in Massachusetts operate under a fairly strict set of commercial constraints. They can’t recommend IVF (except in certain carefully defined cases) before the patient undergoes the prescribed rounds of Clomid. They can’t charge a forty-three-year-old woman much more than a twenty-eight-year-old. [73] If they are looking toward the bottom line, therefore, they will be drawn almost inevitably toward volume.