Jon and Kate Plus Health Care

By Liza Mundy
Friday, June 26, 2009; 9:28 PM

Poor Jon and Kate. Their marriage is over, their show on hiatus, their domestic ordeal entering a new phase of acrimony. Possibly nothing could have saved this marriage, but one thing would have made it less fragile: a mandate for health insurance to cover in vitro fertilization.

If the Gosselins, whose efforts to raise eight kids have been chronicled over five seasons on cable television, had enjoyed, and availed themselves of, ready access to IVF -- the most sophisticated, controlled and expensive form of fertility treatment -- they almost certainly would not have had six children at once. "Just one more baby," is how Kate described their goal after twins. Without the added stress of sextuplets, they would have had a fighting chance at not fighting nearly as much as they did.

The price tag for health-care reform is already higher than anybody expected, so it's probably unreasonable to think that it could include better insurance coverage for the millions of Americans who suffer from infertility. But such coverage for women of childbearing age could lower the extraordinary health-care costs associated with the birth of triplets or more. And it would even the reproductive odds, giving middle-class and lower-income Americans access to treatment that is currently reserved for the well-off or the unusually well insured.

In the United States, an estimated one out of eight couples experiences infertility, which is defined as the inability to conceive within a year or to bring a pregnancy to term. Often seen, wrongly, as the self-inflicted punishment of working women who waited too long to have children, infertility is the result of a host of conditions -- age, yes, but also infections, hormonal imbalances, chromosomal abnormalities and physical blockage of reproductive passages.

It's nearly as common among men as among women, and possibly more common among the poor than among the rich, for the simple reason that the less money you have, the less likely you are to have had access to health care that could prevent serious consequences from relatively minor infections. Having less money doesn't keep you from seeking infertility treatment -- it just means that the treatment you get is more likely to saddle you with high-order multiples, whose care you are least likely to be able to afford.

In their best-selling book "Multiple Bles8ings," Kate describes pretty much that scenario. She and Jon met and married in their early 20s and soon were ready to start having children. She was a nurse and Jon was cycling in and out of jobs. They were hardly affluent, and Kate, who describes herself as having been "raised in an atmosphere of financial stress," was very money-conscious. While she doesn't detail what their health insurance covered, the couple lived in Pennsylvania, which like most states does not require insurers to cover IVF, a procedure in which egg and sperm are combined in a petri dish and the resulting embryos transferred into the uterus.

When Kate failed to get pregnant naturally, she sought out a doctor who confirmed that she had polycystic ovary syndrome, a condition in which a woman usually has problems ovulating. Kate writes that her treatment consisted of "painful injections" to stimulate her ovaries. That treatment produced twins. A year later, Kate started longing for another baby -- not uncommon among mothers of multiples, who sometimes feel cheated of an ordinary newborn experience and want to try again for a singleton, which is what Kate said she wanted. Jon was skeptical, but she prevailed. This time, she saw a different specialist. They told him they did not want multiples but would not selectively reduce, a procedure in which some fetuses are eliminated through injection of potassium chloride.

The doctor proceeded with treatment, which consisted of injections of fertility drugs, or gonadotropins, combined with intrauterine insemination (IUI), a form of artificial insemination in which the sperm is injected into the uterus. (Kate likely had IUI with her first treatment as well; her book does not make it clear.)

The good thing about this treatment is that it's relatively cheap, a couple thousand dollars compared to the more than $10,000 average cost for a single round of IVF. The bad thing is that it's notoriously hard to control how many eggs will be fertilized. The IUI/gonadotropin procedure carries, in the words of one recent study, "an increased risk of unpreventable high-order multiple births." And for a young woman like Kate Gosselin, the odds of having multiples with IUI only increase, according to Elizabeth Ginsburg, a physician and president of the Society for Assisted Reproductive Technology.

When the Gosselins went for an ultrasound during the treatment, they saw three, possibly four mature follicles, the cyst-like structures that cradle a developing egg. The doctor, Kate writes, told them that they would be unlikely to end up with three or four babies -- an odd claim, if he made it -- but said that they could forgo the insemination and try again later. They decided to go ahead. When the sonogram showed seven developing embryos (one would later disappear), Kate writes, Jon dropped to his knees.

The thing is, if they had gone straight to IVF, all of this would have been much less likely to happen. They might well have gotten twins, but they would have been highly unlikely to get six. It's true that in the early days of IVF -- the 1980s and '90s -- doctors often stuffed lots of IVF embryos into a woman's uterus, because little was known about how many might take. The result was plenty of multiple births. Largely because of IVF and fertility drug treatments, such births in this country have increased dramatically. In 1980, only 1,337 triplets or higher-order multiples were born in the United States; in 1998, that number rose to 7,625, according to the National Center for Health Statistics.

Babies born as multiples are far more likely to be premature, the health risks to infants and mother are much greater, and the toll on parents of triplets or more -- "severe physical and psychological exhaustion" as one study put it -- is immense. "Parents of multiples have triple the divorce rate," Kate Gosselin claimed in a recent episode of "Jon & Kate Plus 8." While some parents of multiples took issue with the idea that these marriages are unusually strained, even mothers of twins are more likely to experience emotional difficulties such as postpartum depression, points out Patricia Mendell, a psychotherapist and co-chair of the board of directors of the American Fertility Association. And sextuplets-plus-twins put strains of a whole new level of magnitude on parents.

In recent years, the rate of triplets and higher births has fallen slightly in the United States, thanks to the efforts of IVF doctors to reduce the number of embryos transferred. There are still outliers, such as the doctor who apparently transferred six embryos into "octomom" Nadya Suleman (two of those must have twinned, or split) but they really are, now, the exception. The American Society for Reproductive Medicine has developed voluntary guidelines saying that no more than two embryos should be transferred in the case of women under 35, and doctors should consider transferring only one. This is known as Single Embryo Transfer, and it's becoming increasingly common in European countries where IVF is often covered by national health insurance. In this country, only a small number of states mandate insurance coverage of IVF, and at least one, Connecticut, sensibly limits the number of embryos that may be transferred.

IVF is better for the mother and better for the resulting child, and it is increasingly cost-effective. Recently, a study in the journal Fertility and Sterility showed that it often makes sense to bypass IUI/injections and go straight to IVF. In this study, couples with unexplained infertility who failed to conceive with a low-level treatment were either given IUI followed by IVF, or were fast-tracked to IVF. The fast-tracked couples got pregnant more quickly, and the overall price tag for both treatment and delivery was thousands of dollars lower in the IVF-only group. The study also points out that IVF success rates have significantly improved over the past two decades, making it more effective than IUI.

And insurance coverage is hardly the big-ticket item you might think: In Massachusetts, which mandates coverage, a 2002 study argued that the rise in the annual premium is really a matter of just a few dollars. Yet replicating Massachusetts around the country is a tall order because of the persistent public view that infertility is somehow not a legitimate disease, or that infertility patients are to blame for their plight.

Last week, advocates descended upon Washington to make their long shot case for increased insurance coverage for infertility treatments. In Congress, Rep. Anthony Weiner (D-N.Y.) and Sen. Kirsten Gillibrand (D-N.Y.) have introduced a bill that would broaden insurance coverage for IVF. Advocates should work to make the long-term benefits clear: fewer high-order multiples, healthier children, less exhausted parents.

TLC has done a lot of the legwork for them. More than 10 million people tuned in to watch the televised implosion of the Gosselin family last week. Maybe no marriage could have survived that many Us Weekly covers or that many cameras. But really, it seems to have been the burden of being "plus 8," when all they wanted was "plus 3." If sweeping health-care reform includes more substantial IVF coverage, TLC will have fewer candidates for its carnival sideshow offerings, but that's a loss most of us could live with.

Liza Mundy, a reporter for The Washington Post magazine, is the author of "Everything Conceivable: How Assisted Reproduction is Changing Men, Women and the World." She'll be online to discuss this essay Monday at 11 a.m. ET. Submit your questions before or during the chat.

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