I have been asked on my blog by different people why prices in fertility clinics are so different -I will give you an answer.
It concerns me that every day we receive more patients with previous reproductive treatments wrongly advised and badly performed. The reason for that is the proliferation of low cost fertility clinics. Some are new and others worked well but, faced by a recession, they lowered the prices and with it, the quality of care.
Today, as a doctor and also as general director of Institut Marquès, I will share with you my opinion on this subject, based on the data I have on financial management of medical centers.
The biggest expense in assisted reproduction clinics comes from the personnel. The best doctors and biologists are in the best centers. That happens in many other places: the best Formula 1 pilots are in the best teams, the best football and basketball players are in the first division teams. The best professionals look for the best salaries, the standing and security of a good brand.
We, as health professionals, are also looking for ethics, projection, innovation, working with the best technologies, participating in congresses in order to keep our knowledge up to date, being part of a team with specialists in all areas and having all the time we need to look after our patients.
That translates into a bigger financial cost, not only for the salaries, but clinics with teams of that caliber need more personnel in order for them to invest part of their time in scientific research, be part of congresses and seminars, projects, etc.
However, in low budget centers there are doctors and biologists with less experience or a lower professional capacity. They only assess the number of patients that they can visit per session and that they follow the administrative guidelines of the company. They do not demand anything else. In general, they are looking only for short-term profitability, as in many cases, the owners are investors from venture capital firms. They have profits and then they sell –quality, complaints and reports do not make any difference as the business will be closed within three o four years.
Other financial costs can receive more or less budget and the level of quality will depend on them. I am talking about facilities, the number of people dedicated to patient care, equipment, training, research, constant innovation and providing all services in the clinic itself even though they may not be profitable.
How all this has an impact on the patients?
The consequences affect the patients when it comes to advice the right treatment in their particular case, the results of the cycle, safety in the laboratory during the treatment and the matching of the egg or sperm donor.
Advising the right fertility treatment
In low budget centers, the doctors and biologists do their best and not always what is best for the patient.
We encounter cases in which an assessment by andrologists or geneticists would have been required, and it was not performed because the center in particular did not have the specialists in their team.
We see 40 year old patients that had and In Vitro Fertilization treatment, they had 8 embryos and 4 transfers of 2 embryos each, and on the last one a pregnancy that lead to an abortion due to a chromosomal anomaly that was detected at amniocentesis. That could have been avoided by performing a genetic test, but the center didn’t advice it because they didn’t have the facilities themselves. If they had requested an external laboratory their income would have been much lower, the center would have had to pay the external laboratory and they would have lost the income from all the frozen cycles.
The patients that come to us for the first time have, on average, four previous failed treatments. In many cases these cycles were well performed, but more and more frequently we come across treatments that had barely any chances of success, which made waste the time, hope and money of the couple. I.e. especially In Vitro Fertilization pick-ups with one single follicle and/or hormonal tests that show very poor egg quality.
The success of the cycle depends, in many cases, on other well assessed supplementary techniques (PGD, IMSI, Embryoscope, Polarized light, etc). The centers that don’t have them or don’t know how to perform them, they simply don’t advice them even thought the consequences.
In addition, in good centers there are medical sessions where the different specialists take part and each case is better assessed. The doctors do not have the pressure of having to perform a cycle regardless of the prognosis.
Fertility clinics and results
The results of each clinic depend on the expertise of the biologists and in the fact that there are biologists specialized in each technique. In low budget centers, the same biologist hast to do everything.
It also depends on the culture media and all the equipment used in the laboratory, as there is a wide range of prices.
The ovaries and embryos do not take into account bank holidays or good clinics either; their activity is the same every day. When a center tries to save money they avoid having doctors on duty and work in the laboratory at the weekends –to pay less extra hours–, and this has an effect on the end result, showing important oscillations. I know centers that they only retrieve eggs some particular days of the week!
The results depend also on the work load of each biologist. All processes with oocytes and embryos require precise times. If on one particular day there are many cases or, for instance, they retrieve many eggs during the puncture, they will need the help of more biologists. If there aren’t enough biologists, then there’ll be delays.
Another important factor is the quality of the laboratory equipment and the controls on its environmental conditions (temperature, gases, culture media, pH, etc). An IVF laboratory can be installed with very little money and you can make it work, but not at the same level as one with the best technology. The embryos don’t have the same good sleep in a one star hotel than in a five star hotel. This requires continuous investment and in economical terms is not profitable. In addition, patients don’t see that. That’s why, to offer quality standards, there is an Assisted Reproduction Laboratory certification, UNE-179007 which only a small number of laboratories have. It requires a big effort in terms of human and financial resources to put it in place, but is a guarantee of quality and that is the reason why our clinic has this certification.
Safety in the IVF Laboratory
Some people think that the worst that can happen is that the pregnancy test result will turn out negative. But this is not true, there are worst scenarios.
To make sure that we inseminate each oocyte with the right sperm or to transfer the embryos of each patient without any possible mistakes, in high standard centers we work in couples. Each biologist hast to monitor the other biologist. We don’t allow the biologist to do any task by him/herself, not even at the weekend –there is always another biologist supervising. This is very expensive but it minimizes the risk of error.
Embryos are very sensitive to environmental physical conditions around them. Although there are mandatory controls to detect contamination in the laboratory that have to be in place, many other control measures, in terms of air quality, temperature, humidity, etc., are also necessary. There can always be an inevitable accident, for instance, a water pipe leak or contaminated equipment that enters the facilities, but what differences one laboratory from another is the capacity to detect it, and solve it without affecting the embryos that are in culture on that particular day.
I remember that, at one stage, I had to confront some of my team colleagues when I decided that we should have two laboratories, separated by an armored door, because the investment and maintenance were twice as much –for instance, two external air renewal and filter systems instead of only one. Short after, we had a situation with the humidity levels in the air and, thanks to this measure, we were able to move the culture dishes containing the embryos into the spare laboratory right away and nothing happened. As you know, sometimes cheap turns out expensive.
The safety measures of the embryo and sperm tanks are highly valuable in order to avoid robbery, sabotage, misconduct, etc.
If you are sure that you are doing your job properly then you can be transparent (good restaurants show their kitchens). We came out with the idea of offering patients the option of seeing their embryos from home –they see a live video of the Embryoscope. This idea has not been followed by other centers, which cannot believe that we are offering this service. We are asked if we do not have medical-legal consequences. The answer is no. We didn’t have any, on the contrary, our patients value and appreciate it because is a way of showing transparency, of sharing information and enthusiasm and because we do not have anything to hide.
There is a very concerning statistic data, in cheaper centers they never cancel cycles due to bad response and there are always embryo transfers, even though these have bad quality.
Investment in safety is expensive and is proportional to the price of the cycle. All these extra safety measures are not mandatory. The situation I mentioned above can happen even when the requirements by the health authorities of a particular country are met.
Choosing Egg and Sperm donors
When a donor sperm is needed, the patient is told by the gynecologist that a donor with similar characteristics to her husband/partner will be chosen. In the case that the patient is a single woman the gynecologist will designate the one that she/he considers more suitable. If the center has its own bank, the gynecologist will see all the characteristics of a particular donor and she/he will have a big selection to choose from. A lot of care and resources have been needed to choose all these donors. Bear in mind that, for instance, at Biosperm –our Sperm Bank– only 4% of the candidates are accepted as donors! In the contrary, if a center hasn’t its own bank, the gynecologist won’t be able to choose the donor him/herself, and it will be requested to an external bank. In financial terms, a sperm bank is not profitable.
Egg donors prefer to go to centers that look better, more luxurious. Each center rejects more or less candidates depending on its own quality criteria; i.e. a person with myopia or very small, cultural level, drug consumption, etc. The rejected candidates will then go to another center where the selection criteria are less demanding.
Designating an egg donor can be done in different ways, but it will be done better if, as a doctor, you can choose from a big selection and, especially, if you can dedicate time and enthusiasm. And even better if your center allows you to choose two donors for each patient, in case one of them has to be cancelled (e.g. low response, flu, personal matters, etc).
Knowing how important the selection criteria of donors are, sometimes I ask myself, how come some people –even for this type of treatment– choose the cheapest center? What will you do after, if it doesn’t work? In my opinion, egg donation treatments have to be performed in a clinic you fully trust as –as you can see– there are many factors that you cannot control.
I think that medical centers should be well managed to be able to have the best professionals, the best facilities and equipment with the only goal of treating the patients. It shouldn’t be a business in which some groups invest in, with the only intention of making profit and, on top of that, in a short-term basis.
I am appalled to see how they try to draw people who have little resources to achieve their dreams –they do not have a second thought on giving deceiving results and costs. We often accept the fact that cheaper centers offer less quality but we should bear in mind that all the services will also have a lower quality. If you don’t have somebody who can look after you when you have a doubt or a problem, the same will happen to your embryos.
As a doctor I’m ashamed of all this.