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In retrospect, I wish we had gone with IVF first. You have the same emotional investment, and if your insurance covers it, why not go where your odds are the highest? Over time, as patients reevaluate their thresholds concerning the costs and odds of success, their perspectives, and the amounts they are willing to spend, can fluctuate. I drew lines, erased them, drew them again, erased them and drew them yet again.

I wound up doing six! You were born!

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Not surprisingly, members of a couple can disagree over these issues—how much a child is worth to each of them. One member of a couple, but not the other, may want to go to extreme measures, causing personal and marital strains.


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Some people will do anything and not stop: Take out loans, do strange things. I thought he was going to break down in my office! People have different values. These financial burdens can significantly strain a relationship in multiple ways.

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The number one thing that will tear up a marriage in a heartbeat: finances. These cost constraints raise larger public policy questions as well. When asked if they thought more regulations might be needed, most providers and patients argued for government policies to mandate or increase insurance coverage, but were wary of other government regulations concerning ART.

Heightened insurance coverage could aid not only patient finances, but yield other benefits as well, such as reducing an incentive for twin or higher multiple births.

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Due to finances, many patients who want eventually to have more than one child will seek to have twins, rather than a singleton pregnancy, even though twins have higher rates of medical complications [ 41 ]. Legislation feels dangerous. But if insurance were available, people would take fewer risks in terms of the number of embryos transferred. I have seen disasters, with being pregnant with a higher order of fetuses. Several patients think government money spent on other programs can be better used for ART. Yet patients and providers were frequently aware that if the government or private insurers ended up covering more IVF expenses, someone would ultimately have to bear the costs.

Nonetheless, most patients and providers felt that coverage for infertility should be mandated, feeling that it is for serious disease. It should be part of the health plan.

If you have infertility, it may or may not be covered. Providers tended to be more aware than patients of additional specific challenges that existed to government mandates to increase coverage. Mandated coverage can help many patients, but poses conundrums given limited resources, rising health care costs overall, and competing public health needs, of how much to provide to everyone, and who should receive coverage—whether insurance should cover only patients with medical causes of infertility, or single and gay and lesbian patients as well.

Unfortunately, money drives a lot of this, as well as changing social mores. The world is changing. Families can be put together in different ways. We need reasonable limits. But clearly tensions persist, concerning who should draw those limits, and where, and what kind of evaluative process to use.

Two children per family is reasonable not like [certain groups] with That could be federally mandated. Nonetheless, many providers are not optimistic about insurance coverage increasing anytime soon. To mandate would not be very in favor politically. The rest? In part, infertility treatment may be considered elective—unlike procedures in other medical specialties that aim to eliminate life-threatening disease.

Here, procedures may all be considered elective. Many providers assumed that insurers may also not see childlessness as a priority or relatively important problem. If a health plan has so much money, how far down the list are you going to fund?

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Preventative care for pregnant women, and treating all the diabetics and related diseases, ends up on top of the list. These data, the first to explore how providers and patients view, respond, and make decisions regarding limited insurance and resources for ART, raise several critical ethical and policy concerns. Current policies force many patients and providers to struggle with complex medical, financial and ethical strains regarding the cause, length, cost and outcome of infertility treatment and the odds that insurers will cover these expenses.

Most of these patients were employed full-time and had a certain amount of resources or insurance for infertility treatment, but these amounts ultimately proved limited, forcing difficult choices. These data suggest several key findings that have not previously reported in the literature. Firstly, insurers cause stress because of not only what they decline to cover [ 10 ], but how they make and communicate these decisions. Commonly, insurers will not commit to coverage in advance, and instead decide only afterwards, and on case-by-case bases.

Consequentially, patients must often pay first, and later struggle to get reimbursed, which can take months. These data highlight how patients and providers then face uncertainties, unable to predict in advance how best to allocate limited coverage amounts, causing strain. Secondly, while prior data have suggested that costs cause anxiety and lead many patients to stop treatments or rely on savings [ 6 , 7 , 10 ], the current data suggest how patients may respond in other ways as well, adopting several strategies—e.

Thirdly, while the prior literature has examined how women may feel stress and stop treatment because of expenses, the present data highlight how members of a couple often make these decisions jointly, but can disagree, impacting relationships.

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Fourthly, while prior research has shown that limited insurance coverage impedes many patients from seeking IVF treatment [ 6 — 8 ], the present data suggest that patients do not perceive and respond to resource limitations as fixed phenomena—i. Fifthly, while prior research has suggested that costs affect patient decision-making [ 6 , 7 ] and cause anxiety [ 10 ], the present data highlight how these effects are in fact worsened, exacerbated by other factors and strains patients confront.

Though these clinicians may not have actually wholly fit these descriptions, patients felt that these providers did so, which is itself worth noting. These data thus indicate how choices about paying for infertility treatment are commonly not one-time decisions, and how several specific variables, related to numbers of past failures, resources and opportunity costs, can shift over time.

Eighthly, these findings shed light on ways of developing a rational choice model concerning selection of possible approaches in infertility treatment, but also several challenges in doing so. The health belief model, applied to many areas of patient decision making, similarly theorizes, in part, that patients weigh the risks and benefits of a particular procedure [ 42 ]. These data provide vital insights for the development of rational choice models, identifying, clarifying and framing specific decision points concerning various treatment options and criteria.

Future research and efforts to develop and test how such models might focus on just one or more of the decisions in these multi-stage journeys——e. Yet the present data also underscore how patients may confront multiple complex economic, social, psychological and ethical decisions, involving deeply personal, subjective dreams and values, made in the contexts of intricate relationships among individual members of couples, and with providers, insurers and others, and potentially shifting over time.

Creating a child can have profound psychological, social, cultural, moral, and even religious value, providing ultimate personal meaning and purpose that is not wholly measurable. Individuals seek sources of symbolic immortality—connections to provide senses of ultimate meaning, often through offspring or religion [ 43 ]. Arguably, for many individuals, in no other area of economic life is the potential value of the goal as high. Doctors may provide overly optimistic estimates e. Insurance companies may fail to communicate in advance whether they will reimburse costs, and if so, how much, and based on what criteria.

Yet though standard models of rational decision-making thus face considerable challenges and may apply here only with difficulty, these data suggest ways, as discussed above, of helping to develop such models as much as possible—by trying to quantify these various specific types of uncertainty and incorporate them into a model. These data have several critical implications for future policy, practice, research and education.

Specifically, these interviewees highlight stresses and other consequences of current limitations that have not heretofore been empirically probed, concerning not only what insurance companies decide, but how they do so and communicate these decisions to patients. Efforts to increase insurance coverage generally should continue, but hurtles remain, and countless patients will doubtlessly continue to confront limitations.

Such organizational entities could issue guidelines that providers make full costs clear to patients, ensuring that patients are aware beforehand of all hidden or excess expenses.