A Baby, or Cash Back

But it wasn't easy.

Leanna didn't respond well to the medications that were supposed to trigger her egg production, so doctors had a very limited number of eggs to work with. Then the doctors found a tiny fibroid tumor in her uterus, which took two surgeries to correct -- but fortunately her health insurance covered that.

With each IVF try, the doctors altered the protocol a little, changing the sequence or dosage of drugs. But nothing worked -- after three cycles, Leanna still wasn't pregnant. The couple was devastated. The doctors offered to try one more time, for no additional cost. And the fourth attempt worked. Nine months later, Leanna delivered a healthy baby girl.

The whole experience was "a roller coaster of surprises," said Leanna. But she expressed relief that the financial aspects were taken care of upfront. "We cleared out our life savings, but at least we could get past that" and just concentrate on getting pregnant, she said.

"I'm sure they lost a boatload of money on us. . . . If we'd had to pay a la carte, we wouldn't have been able to fight so long to get the results. [The program] allowed us to endure the game. Each time, when we wouldn't get pregnant, we could just say, 'Oh. well, we have X number more tries.' "

A year after their daughter was born, the Currys decided to try again. Once more, they bought into the shared-risk program, braced this time for a long, hard road to pregnancy. Instead, Leanna got pregnant on the first cycle -- with twin girls. But they have no complaints: "It was a great return on the money," said Leanna. "We'd thought we'd be in for several cycles. We were thrilled not to have to go through all the treatments, all the highs and lows."

Playing the Odds

That's the nature of the gamble in shared-risk programs: Easy patients subsidize the tough ones. But not everyone agrees that the money-back plans are a boon to fertility-challenged couples. Shared-risk programs "have a lot of selection criteria and a lot of exclusion criteria -- they're cherry-picking the [women] most likely to get pregnant," said reproductive endocrinologist Rafat Abbasi of Mid-Atlantic Fertility Centers in Arlington, who is also a clinical consultant to the National Institutes of Health. Mid-Atlantic does not offer a shared-risk program.

"Most women get pregnant in one or two attempts . . . but among the cherry-picked ones," said Abbasi, "there's an even higher number who get pregnant the first time. But they're paying for three or four or five attempts. . . . The 28-year-old who pays $28,000 and gets pregnant in one try is subsidizing the 38-year-old who takes four times."

Another problem, said Abbasi: "In these programs, doctors tend to transfer higher numbers of embryos, increasing the risk of multiple pregnancies."

While that concern has been raised in the past, an investigation by the ethics committee of the American Society of Reproductive Medicine found no evidence of more embryos' being transferred in shared-risk patients, according to its 1998 position paper "Shared-Risk or Refund Programs in Assisted Reproduction."