Multiple Choice: The Consequences of FSH/IUI Fertility Treatments

In our crazy healthcare system, insurance companies often decide which infertility treatments a woman can use. And that, as our correspondent discovered firsthand, can lead to troubling consequences.

By | Boston Magazine |

fsh iui treatment multiple choice

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Last fall, my husband and I breezed into an early-morning appointment at our doctor’s office, in western Massachusetts. I’d recently taken several home pregnancy tests, all of which had turned out positive, so we arrived feeling triumphant and giddy. Soon, we’d be able to see our much-anticipated little nipper on a sonogram. Take that, infertility!

A short while later, I was flat on my back, straining to see the computer as a technician maneuvered the ultrasound wand. But she didn’t turn the screen toward us. Instead, she took my hand and said, “I see more than one.” Long pause. “I see more than two.” An even longer pause. “I see more than three.” Finally, she tilted the monitor toward us. Our favorite nurse, who had been uncharacteristically quiet, put her head in her hands and nearly burst into tears before walking out into the hall.

After a few minutes, she returned with the Envelope. Gently, she told us that it contained an overview of “selective reduction,” an option for parents of way more babies than expected that eliminates some of the fetuses. She explained that the fertility treatment we’d used—something called FSH/IUI, which involves injecting sperm into a woman’s uterus after she takes a regimen of hormones—had put us at risk for multiples (a fact we’d been unaware of). The nurse then recommended that we take our time before opening the Envelope.

We never did.

Some things about infertility are pretty hilarious. Appointments can be filled with sublimely ridiculous moments, like when a lab tech hands you a test tube filled with your husband’s sperm and says, in all seriousness, “Better put it in your bra while you wait for the insemination, dear. It’s better for the baby not to get cold.” Other procedures just beg for levity. During a blood test, a nurse noticed me going pale and said, “Aw, it’s just a little prick. Turn your head, close your eyes, and it’ll be over soon.” To which my husband couldn’t resist interjecting: “It’s our wedding night all over again!”

But there wasn’t much funny about the Envelope—or the alternative, for that matter. Picturing my 5-foot-3, 95-pound frame cartoonishly bulging with a quartet of babies had me worried about my own health. But the world also seemed to have an infinite number of calamities in store for these fetuses, no matter what decision we made. Trying to give birth to all of them would put them at risk for lifelong complications, because they would inevitably be born prematurely. Even imagining what it might be like to “eat for five” failed to lift the gloom. The conversation on the ride home from the doctor’s office that day was barren. “Four,” my husband said. “Four,” I repeated. “Impossible,” he said. “Impossible.”

“But did you see their hearts beating?”



After being handed the Envelope, I realized that I wasn’t the first person to have been unnerved by the unexpected results of an FSH/IUI treatment. The mommy blogosphere is teeming with moms admitting—no, loudly proclaiming—that juggling twins (or more) had never been part of their plans. Mark Twain said it best: “Sufficient unto the day is one baby. As long as you are in your right mind, don’t you ever pray for twins. Twins amount to a permanent riot. And there ain’t any real difference between triplets and an insurrection.”

Just how many couples enter the world of FSH/IUI (which stands for follicle-stimulating hormone/intrauterine insemination) and end up staring at Envelopes is impossible to say. And that, as I found out, is because nobody is recording the treatment’s rates and outcomes. Massachusetts, like all states, isn’t required to report incidences of the procedure, the way it must with in vitro fertilization (IVF). Anecdotally, physicians nationwide report that FSH/IUI is often mandated by cost-conscious insurance companies as the step women must take before the more-expensive IVF. It’s also widely understood—and I found this out the hard way—that the procedure makes it incredibly difficult to control how many fetuses you’ll end up with, whereas women undergoing IVF know exactly how many embryos are transferred during each procedure. My doctors told me that it was highly unusual to have wound up in my quadruplet situation, but they acknowledged that the process is as much an art as a science.

According to Howard Jones, the perennially forward-thinking, 102-year-old father of IVF in the U.S. (he oversaw the birth of the first baby in the country conceived that way), FSH/IUI produces three and a half times more twins deliveries in the U.S. each year than does IVF. And, overall, the number of deliveries involving multiples is growing rapidly. According to a 2012 report from the National Center for Health Statistics, one out of every 53 babies was born a twin in 1980; in 2009 it was one out of every 30. Eli Adashi, a professor of medical science at Brown University, says this “multiple-births epidemic” is a significant contributor to the dramatic spike in preterm babies, as about 60 percent of twins and about 90 percent of triplets are born prematurely. In all, 12 percent of all children born in the U.S. are now preemies. According to the March of Dimes, these babies often arrive with a whole Pack ’n Play’s worth of medical issues, including cerebral palsy, chronic lung disease, intellectual disabilities, and a heightened risk of early childhood death.

Which is why Jones and some of his colleagues are engaged in a heated but little-noticed medical debate—one taking place outside the mainstream reproductive-technology conversation—about limiting or phasing out FSH/IUI. “It’s just an out-of-date concept,” Jones says. “In an ideal world, I think it wouldn’t be used at all.” Adashi, for his part, says that “Virtually all selective-reduction cases can be attributed not to IVF but to FSH/IUI.”

So why is it used at all? In a nutshell, whether a woman must go through FSH/IUI is dependent not on what her doctor thinks will work, or what she herself wants, but almost wholly on what her health insurance dictates. That’s because the procedure is more often covered by insurance than is IVF. The reason is simple: IVF can cost up to $10,000 per cycle, whereas the typical round of FSH/IUI is about $2,000.

The smaller price tag for FSH/IUI does put fertility treatment within the reach of more women—hence its awkward sobriquet, “a poor person’s IVF”—but not without drawbacks. In addition to being more likely to produce multiples, it’s much less successful than IVF. Doctors say that FSH/IUI has about a 10 percent success rate in younger patients, whereas IVF’s rate is four times higher. (For older women, the success rate is lower for both methods.) The truth, though, is that FSH/IUI is not as inexpensive as it might seem on paper, because the cost of the treatment doesn’t include caring for the high-needs preemies that it tends to produce.

We’re lucky to live in one of the few states where infertility is covered by insurance, as 70 percent of American women don’t have any kind of infertility coverage at all. Yet the treatments still aren’t available to every woman in Massachusetts. Medicaid doesn’t pay for them, and certain self-insured employers don’t, either. Some insurers, meanwhile, are willing to cover FSH/IUI but not IVF. Still, we’re ahead of most states. In the past few years, a handful of insurance companies here have begun letting women (especially those with unexplained infertility) bypass FSH/IUI treatments and go right to IVF.

Massachusetts insurers are in the position of setting an example for the country. They should allow women to choose between FSH/IUI and IVF (some women do select FSH/IUI for religious reasons). They should listen to experts like Jones, who say far more FSH/IUI research is required. And they should start tracking instances of selective reduction. But because infertility treatments account for just one percent of claims, insurance companies have not made reforming the system a priority. They must start.

Another change that’s needed: Honest accounting of infertility treatments should factor in the cost of caring for all those preemie multiples. Jones, for one, is taking up the cause, making his case in the language insurance companies understand best—money. He’s finishing a paper arguing that the additional medical costs associated with FSH/IUI—which can include both the intensive care of premature babies and complications from multiple births—could pay for IVF (that is, a single embryo transfer) several times over.


I admit my share of culpability in my receiving FSH/IUI treatments. Did I delay having kids until I was nearing my baby-making expiration date? Yes. Did I blindly accept insurance-mandated protocols and fail to press for details? Guilty. But I also believe that women should be able to have some control over—and full information about—how many babies each infertility treatment is likely to give them. When it comes to facing selective reduction, we shouldn’t be put in the position of having to choose in the first place.

In the end, nature did the reduction for my husband and me. And though I experienced conflicting emotions, there was also a psychic weight lifted at not having to consider selective reduction and agonize over which babies would be lost.

And as the weeks went on, we arrived at the point when we could find out the gender of our progeny. Not wanting to learn this secret in a sterile exam room, we asked a nurse to write the information down so we could do the big reveal later—on our own time. This time, with a smile and well wishes, she handed us a big envelope.

We didn’t open that one, either.

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