[1]Anjani Chandra and Elizabeth Hervey Stephen, “Infertility and Medical Care for Infertility: Trends and Differentials in National Self-Reported Data,” presented at the NIH Conference on Health Disparities and Infertility, March 10–11, 2005, slide 14. Conveyed directly to author.
[2]Chandra and Stephen, “Infertility and Medical Care for Infertility,” slide 15. This figure refers to the total number of women in the United States who reported in 2002 that they had ever sought infertility services.
[3]There are no formal estimates. The figure of $41 million comes from a representative of the American Society for Reproductive Medicine, conversation with author, January 2005.
[4]See Michael Gold, “Franchising Test Tube Babies,” Science 7, no. 3 (April 1986): 16.
[5]This calculation was done using inflation rates in medical care, where prices have risen sharply over the past decade. If one uses the basic rate of inflation, the adjusted price would be only $8,394.
[6]Indeed, between 1976 and 2000, prices in the personal computer industry fell an average of 27 percent each year. See Ernst R. Berndt and Neal Rappaport, “Price and Quality of Desktop and Mobile Personal Computers: A Quarter Century of History,” presented at National Bureau of Economic Research Summer Institute, Cambridge, MA, July 31, 2000.
[7]In some states, negotiated contracts with insurance companies did exert significant downward pressure on prices. Yet prices still rose on average across the United States.
[8]See for example, Kimberly A. Johns, “Reproductive Rights of Women: Construction and Reality in International and United States Law,” Cardozo Women’s Law Journal 5, no. 1 (1998); Berta E. Hernandez, “To Bear or Not to Bear: Reproductive Freedom as an International Human Right,” Brooklyn Journal of International Law 17, no. 2 (1991); and Meredith Marshall, “United Nations Conference on Population and Development: The Road to a New Reality for Reproductive Health,” Emory International Law Review 10, no. 1 (1996): 441, 471.
[9]Douglass C. North, “Institutions,” Journal of Economic Perspectives 5, no. 1 (Winter 1991): 97–112.
[10]Anne Taylor Fleming, “New Frontiers in Conception,” New York Times Magazine, July 20, 1980, 14.
[11]Ibid., 14.
[12]See Aminatta Forna, “Wanted: The Perfect Baby,” Independent, July 19, 1998, 5; and David Plotz, “The Rise of the Smart Sperm Shopper,” Slate, April 20, 2001.
[13]See U.S. Congress, Office of Technology Assessment, Artificial Insemination: Practice in the United States: Summary of a 1987 Survey—Background Paper, OTA-13P-BA-48 (Washington, DC: U.S. Government Printing Office, August 1988), 8, 33.
[14]Leslie Milk, “Looking for Mr. Good Genes,” Washingtonian, May 1999, 65.
[15]Pascal Zachary, “Family Planning: Welcome to the Global Sperm Trade,” Wall Street Journal, January 6, 2000, B1.
[16]Interview with author, New York, February 9, 2004.
[17]According to Schou, the contribution margin had fallen to 70 percent by 2005. This decline was due to the increased cost of hiring donors.
[18]Interview with author, Fairfax, VA, March 2004.
[20]Data provided by banks to the author.
[21]Conversation with author, February 18, 2005.
[22]Naomi Pfeffer, The Stork and the Syringe: A Political History of Reproductive Medicine (Cambridge: Polity Press, 1993); “They Are the Egg Men,” Economist, September 3, 1994, 79.
[23]For many years, Serono’s best protection was the inherent barriers that potential competitors faced. To produce its drugs, it relied on twice-daily urine collections from one hundred thousand postmenopausal donors. Few other companies were willing to establish a similar base of supply. See Alison Leigh Cowan, “A Swiss Firm Makes Babies Its Bet,” NewYork Times, April 19, 1992, section 3, 13.
[24]Andrea Adelson, “A Fertility Drug Grows Scarce,” NewYork Times, February 26, 1995, 26.
[25]Della De Lafuente, “Infertility Drugs Growing Scarce: Shortage Alarms Couples, Jeopardizes Treatments,” Chicago Sun-Times, February 26, 1995, 6.
[26]Quoted in Adelson, “A Fertility Drug Grows Scarce,” 26.
[27]Interview with author, New York, February, 2004.
[28]Alan Trounson et al., “In Vitro Maturation and the Fertilization and Developmental Competence of Oocytes Recovered from Untreated Polycystic Ovarian Patients,” Fertility and Sterility 62, no. 2 (August 1994): 353–362; and “They Are the Egg Men,” Economist, September 3, 1994, 79.
[29]“Biotech Babies,” Economist, March 13, 1993, 78.
[30]Fiona Fleck, “Switzerland: Profit at Biotech Concern,” New York Times, February 4, 2004, W1; and Doug Bailey, “Is It Business or Is It Revenge?” Boston Globe, May 24, 1992, 29.
[31]Quoted in Liat Collins, “A Labor of Love,” Jerusalem Post, September 14, 2001, 7.
[32]For one particularly painful story, see Joan O’C. Hamilton, “What Are the Costs?” Stanford Magazine, November–December 2001.
[33]For some studies of potential effects, see Roberta B. Ness et al., “Infertility, Fertility Drugs, and Ovarian Cancer: A Pooled Analysis of Case-Control Studies,” American Journal of Epidemiology 155, no. 3 (February 2002): 217–224; and Louise A. Brinton et al., “Ovulation Induction and Cancer Risk,” Fertility and Sterility 83, no. 2 (February 2005): 261–274.
[34]The sale of human organs is illegal in virtually every country. Iran appears to be the only exception. There is, however, a thriving black market for many organs. For a fascinating report on this market, see Michael Finkel, “Complications,” New York Times Magazine, May 27, 2001, 26–33, 40, 52, 59. For the black market in cadavers, see John M. Broder et al., “In Science’s Name, Lucrative Trade in Body Parts,” New York Times, March 12, 2004, A1, A19.
[35]Because there is no central reporting of donor fees in the United States, no precise data is available. These are estimates provided, via e-mail correspondence, by the ASRM. For confirmation of the $8,000 figure, see also Mark V. Sauer, “Further HFEA Restrictions on Egg Donation in the UK: Two Strikes and You’re Out!” Reproductive Biomedicine Online 10, no. 4 (2005): 432.
[36]See Joan O’C. Hamilton, “What Are the Costs?” and James Herbert, “Donation Dilemmas: Selling of Eggs Gives Birth to Controversy,” San Diego Union-Tribune, September 3, 2000, E1.
[38]Interview with author, Boston, November 2003.
[39]The details of this story are true. The names, however, have been changed. From interview with author, Boston, March 2004.
[40]Interview with author, March 2005. The names have been changed.
[41]Interview with author, March 2005. The names have been changed.
[42]Instead, patients—and particularly women—tend to blame themselves for failing to become pregnant.
[43]As of 2005, nine U.S. states have laws that require insurance companies to cover infertility treatment. Five states have laws that require insurance companies to offer coverage for infertility treatment. The broader questions surrounding insurance coverage are discussed in chapter 7.
[44]Interview with author, Boston, November 2003.
[45]Interviews with author, November and December 2003.
[46]Interview with author, November 2003. For a story of one clinic’s efforts to compete, see Gina Kolata, “Fertility Inc.: Clinics Race to Lure Clients,” NewYork Times, January 1, 2002, F1.
[47]Similar payment options are described in Ann Wozencraft, “It’s a Baby, or It’s Your Money Back,” New York Times, August 25, 1996, section 3, 1; and Joan O’C. Hamilton, “A Pregnant Clause,” BusinessWeek, March 25, 1996, 46.
[49]Interview with author, November 2003.
[50]Quoted in Michael Selz, “Birth Business: Industry Races to Aid Infertile,” Wall Street Journal, November 26, 1997, B1.
[51]The Fertility Clinic Success Rate and Certification Act of 1992 states that “each assisted reproductive technology program shall annually report to the Secretary through the Centers for Disease Control.” Critics, however, are quick to note that this law has no teeth, because the Centers for Disease Control (CDC) has no enforcement power, and the only sanction under the 1992 law is for the CDC to publish the names of programs that do not report. See Fertility Clinic Success Rate and Certification Act of 1002, Public Law 102-493 (H.R. 4773); Keith Alan Byers, “Infertility and In Vitro Fertilization: A Growing Need for Consumer-Oriented Regulation of the In Vitro Fertilization Industry,” Journal of Legal Medicine 18 (1997): 265–313; and Jennifer L. Rosato, “The Children of ART (Assisted Reproductive Technology): Should the Law Protect them from Harm?” Utah Law Review 57 (2004): 57–110.
[52]Interview with author, February 2004.
[53]For more data on cost, see Gary W. DeVane, “Optimal Pregnancy Outcome in a Minimal-Stimulation In Vitro Fertilization Program,” American Journal of Obstetrics and Gynecology 183, no. 2 (August 2000): 309–315; and Bradley Van Voorhis et al., “Cost-Effectiveness of Infertility Treatments: A Cohort Study,” Fertility and Sterility 67, no. 5 (May 1997): 830–836.
[54]Interviews with author, New Haven, CT, December 2003.
[55]According to one recent study, for example, 39 percent of women believe that a woman in her forties can conceive and have a baby as easily as a woman in her twenties. Reported in “Women’s Health: Survey Shows Women not Informed on the Latest Feminine Health Information,” Women’s Health Weekly, May 22, 2003, 54. Likewise, a 2001 survey conducted by the American Infertility Association found that nearly 90 percent of women overestimated the period when fertility begins declining by five to ten years. See “Fertility Survey Finds Astonishing Results: Only one of 12,382 Women Answered Correctly,” American Infertility Association, reproduced at http://www.americaninfertility.org/media/aia_survey_results.html. For commentary, see Michael Hanlon, “The Last Egg Race,” Scotsman, October 24, 2002, 8.
[56]2001 data from the Centers for Disease Control.
[57]Centers for Disease Control, 2001 Assisted Reproductive Technology Success Rates, section 2. Available at www.cdc.gov/reproductivehealth/art.htm.
[58]Ibid.
[59]See Michele Hansen et al., “The Risk of Major Birth Defects After Intracytoplasmic Sperm Injection and In Vitro Fertilization,” New England Journal of Medicine 346, no. 10 (March 7, 2002): 725–730. For evidence that suggests a more equitable level of birth defects, see “Test-Tube Kids Develop Normally,” Wall Street Journal, July 3, 2003, D5; Kerryn Saunders et al., “Growth and Physical Outcome of Children Conceived by In Vitro Fertilisation” Pediatrics 97, no. 5 (May 1996): 688–692; and Jennifer R. Bowen et al., “Medical and Developmental Outcome at 1 Year for Children Conceived by Intracytoplasmic Sperm Injection,” Lancet 351 (May 23, 1998): 1529–1534.
[60]See Laura A. Schieve et al., “Low and Very Low Birth Weight in Infants Conceived with the Use of Assisted Reproductive Technology,” New England Journal of Medicine 346, no. 10 (March 7, 2002): 731–737; Michael R. DeBraun et al., “Association of In Vitro Fertilization with Beckwith-Wiedemann Syndrome and Epigenetic Alterations of LIT1 and H19,” American Journal of Human Genetics 72 ( January 2003): 156–160; and Brian Vastag, “Possible IVF-Birth Defect Link,” Journal of the American Medical Association 288, no. 23 (December 18, 2002): 2959.
[61]See Centers for Disease Control, 1995 Assisted Reproductive Technology Success Rates, Figure 8B. Nearly identical figures appear in the 2001 Centers for Disease Control report. See also Nanette Elster et al., “Less is More: The Risks of Multiple Births,” Fertility and Sterility 74, no. 4 (October 2000): 617–632.
[62]See “Virginia Clinic is Mum on ‘Success’ Rate,” Washington Post, December 4, 2001, F6.
[63]ASRM guidelines are periodically published in Fertility and Sterility. See, for example, The Practice Committee of the American Society for Reproductive Medicine and The Society for Assisted Reproductive Technology, “Revised Minimum Standards for Practices Offering Assisted Reproductive Technologies,” Fertility and Sterility 82, supplement 1 (September 2004): S7.
[64]According to the director of the NICHHD (National Institute for Child Health and Human Development), the demand for fertility treatments is so pressing that many women choose to undergo therapies that haven’t been fully tested by clinical trials. See “NICHD Network Identifies Most Effective of a Series of Infertility Treatments,” National Institutes of Health, NIH News Alert, January 21, 1999.
[65]Interview with author, New Haven, CT, December 10, 2003.
[66]Quoted in Gina Kolata, “Harrowing Choices Accompany Advancements in Fertility,” NewYork Times, March 10, 1998, F3.
[67]Quoted in ibid.
[68]For a discussion of this dynamic and its implications, see Ezekiel J. Emanuel, “Eight is Too Many,” New Republic, January 25, 1999, 8–11.
[69]One powerful exception is Ellen Hopkins, “Tales from the Baby Factory,” New York Times Sunday Magazine, March 15, 1992.
[70]Interview with author, December 2003.
[71]From a PBS Frontline interview. Accessed at http://www.pbs.org/wgbh/pages/ frontline/shows/fertility/interviews/sauer.html.
[72]States with either a “mandate to cover” or a “mandate to offer” include Arkansas, California, Connecticut, Hawaii, Illinois, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, Texas, and West Virginia. Several of these states cover only specific types of infertility; several others exempt health maintenance organizations from providing coverage. See States Mandating Insurance Coverage for Infertility and Pregnancy Loss, International Council on Infertility Information Dissemination, available at http://www.inciid.org/insurance.html. See also Saul Spiegel, “Infertility— Causes, Treatment, Insurance and Disability Status,” OLR Research Report, February 3, 2005, available at http://www.cga.ct.gov/2005/rpt/2005-R-0145.htm.
[73]In practice, though, older women typically purchase more services, such as assisted hatching and preimplantation genetic diagnosis, and a greater number of additional tests. They are also charged higher fees if they choose to participate in shared risk programs.
[74]In a related analysis, Hamilton and McManus find that insurance mandates tend to increase the size of fertility clinics in the given state. See Barton H. Hamilton and Brian McManus, “Infertility Treatment Markets: The Effects of Competition and Policy,” mimeo, Washington University at St. Louis, September 2004.
[75]For a full analysis of the implications of insurance in Massachusetts, see Martha Griffen and William F. Panak, “The Economic Cost of Infertility-Related Services: An Examination of the Massachusetts Infertility Insurance Mandate,” Fertility and Sterility 70, issue 1 ( July 1998): 22–29.
[76]Both California and New York require most insurers to cover infertility treatment. But they explicitly exclude IVF from the coverage. For the specific provisions, see National Conference of State Legislatures, “50 State Summary of Laws Related to Insurance Coverage for Infertility Therapy,” available at http://www.ncsl.org/programs/ health/50infert.htm.
[77]Communication with author, May 2005.
[78]Bette Harrison, “Focus on In Vitro Fertilization: Frozen-Egg Birth Brings Fame to Doctor,” Atlanta Constitution, October 18, 1997, 5E; and Elizabeth Heathcote, “Stop the Clock,” Independent, May 31, 1998, Features, 1.
[79]See Aileen Ballantyne, “Egg Timers,” The Times (London), December 1, 2001.
[80]Quoted in Sarah Boseley, “Frozen Egg Baby Hailed as Fertility Milestone,” Guardian, October 11, 2002, 1.
[81]Quoted in Harrison, “Frozen-Egg Birth Brings Fame to Doctor.”
[82]Quoted in Elizabeth Heathcote, “Stop the Clock.” See also Gina Kolata, “Fertility Advances Leave Trail of Ethical Questions,” NewYork Times, June 5, 1992, A10.
[83]Amy Dockser Marcus, “Fertility Clinic Set to Open First Commercial Egg Bank,” Wall Street Journal, April 17, 2002, D1.
[84]Interview with author, January 2004.
[85]Interview with author, January 2004.
[86]The egg always contains an X chromosome, the sperm either an X or a Y. It is the sperm’s chromosomes, therefore, that determine the sex of a child.
[87]See Claudia Kalb, “Brave New Babies,” Newsweek, January 26, 2004, 45–53; and Meredith Wadman, “So You Want a Girl?” Fortune, February 19, 2001, 174–182.
[88]Centers for Disease Control, 2002 Assisted Reproductive Technology Success Rates. Available at www.cdc.gov/reproductivehealth/art.htm.
[89]Matthew G. Retzloff and Mark D. Hornstein, “Is Intracytoplasmic Sperm Injection Safe?” Fertility & Sterility 80 (2003): 851–858; and “Infertility and Inheritance,” Economist, June 10, 2000, 87–88.
[90]“Infertility and Inheritance,” Economist.
[91]Melissa Healy, “Fertility’s New Frontier: Advanced Genetic Screening Could Help Lead to the Birth of a Healthy Baby,” Los Angeles Times, July 21, 2003, 1; and Cary Goldberg, “Screening of Embryos Helps Avert Miscarriage,” Boston Globe, June 13, 2003, A1.
[92]Anjani Chandra and Elizabeth Hervey Stephen, “Infertility and Medical Care for Infertility: Trends and Differentials in National Self-Reported Data,” presented at NIH Conference on Health Disparities and Infertility, March 10–11, 2005, slide 23. Note that the total percentage of married women who suffer from infertility and seek some form of treatment is 36 percent, higher than these numbers indicate. Yet treatment in many of these cases includes only a consultation or some other basic service.
[93]Chandra and Stephen, “Infertility and Medical Care for Infertility”; and Chandra et al., “Fertility, Family Planning and Reproductive Health: Data from the 2002 National Survey of Family Growth,” Vital Health Statistics 23 (forthcoming, 2005). See also Suzanne Wymelenberg, Science and Babies: Private Decisions, Public Dilemmas (Washington, DC: National Academy Press, 1990), 14.
[94]Chandra and Stephen, “Infertility and Medical Care for Infertility,” slide 23.
[95]See Martha Griffen and William F. Panak, “The Economic Cost of Infertility-Related Services: An Examination of the Massachusetts Infertility Mandate,” Fertility and Sterility 70, no. 1 ( July 1998): 22–29; Tarun Jain et al., “Insurance Coverage and Outcomes of In Vitro Fertilization,” New England Journal of Medicine 347, no. 9 (August 29, 2002): 661–666; and John A. Collins, “An International Survey of the Health Economics of IVF and ICSI,” Human Reproduction Update 8, no. 3 (2002): 265–277.
[96]A. Nyboe Anderson et al., “Assisted Reproductive Technology in Europe, 2001: Results Generated from European Registers by ESHRE,” Human Reproduction 20, no. 5 (2005): 1160.
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