BAY AREA FERTILITY CLINICS PROMISE BABIES OR REFUNDS.

Byline: Ann Wozencraft The New York Times

Using a strategy that has worked in the retail world to sell everything from Kodak film to Saturn cars, some fertility clinics are offering limited money-back guarantees to would-be parents desperate to have a baby.

At least two companies - Pacific Fertility Center, a chain of six in vitro fertilization clinics trying to expand beyond its California base, and Reproductive Health Associates, an in vitro clinic in St. Paul - are offering partial refunds to some patients who fail to become pregnant or who miscarry early in their pregnancies.

Such rebate programs are virtually unheard of anywhere else in medicine. Their champions say it is about time doctors in other fields tried them, too. Whether that happens will depend in part on how warmly the concept is embraced in the baby-making business.

Owners of the clinics call the plans an innovative way to reduce financial and emotional stress for would-be parents, who usually have no health insurance for fertility treatments. And some patients who have taken the offer speak highly of it. They say the money-back guarantee gives them more confidence in the clinic and helps offset the disappointment of an unsuccessful attempt to become pregnant.

But some people see the offer as troubling. They say the money-back guarantees are at best an eye-catching marketing gimmick and at worst a breach of medical ethics.

Critics fear that such programs could encourage doctors to practice risky medicine to increase success rates and avoid having to give rebates. They also fear treatment could be limited only to patients with the best chances of becoming pregnant.

And they are appalled by the idea of basing what the patient pays on whether the treatment is successful. Finally, they fear that such offers give infertile people false hope.

The American Medical Association has weighed in against the money-back guarantees, arguing in June that linking fees to outcomes violates its longstanding code of ethics.

``Such publicized guarantees manipulate and unfairly attract patients,'' says a report from an AMA task force.

In vitro fertilization, a $500 million-a-year business, generally involves mixing eggs harvested from a woman's ovaries with sperm in a petri dish, then transferring some of the resulting embryos into the woman's uterus.

On average, the method produces a baby about one in five times. The top clinics in the country have success rates near 30 percent. For women in their mid-30s and younger, the procedure usually costs $8,000 to $10,000 a try. The cost is often higher when patients are older or have complex fertility problems.

More than 35,000 babies have been born using in vitro in the United States since Louise Brown, the first test-tube baby, arrived 18 years ago last month.

The clinics that offer a money-back plan either charge a premium to participants or require advance payment for several attempts regardless of whether they are all needed. In essence, they are selling package deals of medical care and insurance that compensates women who fail to become pregnant.

Pacific offers participating patients a 90 percent refund if they do not become pregnant or if they miscarry within the first 12 weeks of pregnancy. That refund applies to the first attempt at in vitro fertilization, and it can be carried over for two subsequent attempts. Reproductive Health Associates promises to refund all but $2,000 of its fees if a patient fails, after three attempts within 18 months, to become pregnant and carry the fetus at least 26 weeks.

Peace of mind is not cheap. Pacific's money-back plan costs $12,500 and up, significantly more than the $7,725 it charges for its basic plan without guarantees. Reproductive's fee is at least $15,000 to cover as many as three attempts to become pregnant through in vitro fertilization regardless of whether all are needed.

Neither program offers refunds for extras like drugs and lab tests, which can add substantially to a patient's bill and also are not included in the price of the basic plan.

Dr. Geoffrey Sher, the founder and executive medical director of Pacific, explained the plan this way: ``We're sharing the risks with our patients. We're not guaranteeing a baby. All we're doing is indemnifying against failure and standing behind our success rates in the most ultimate way.

``We're saying to the consumer that we can guarantee you won't lose the farm in the process of trying to have a baby.''

Some patients say it is well worth it.

``We wanted peace of mind,'' said Grace Knopp, 32, of Vacaville, who paid $12,500 to be in the rebate program at Pacific's San Francisco clinic and became pregnant on her first try. She has since spent another $9,500 on incidentals.

``IVF is very straining emotionally and financially,'' she said about in vitro fertilization, ``and we wanted a guarantee if it didn't work. And you know what? I don't mind that we paid more, because we're having a baby after being infertile for years.''

But critics worry that money-back offers could lead doctors to take risks to increase the chances that their patients will get pregnant.

For instance, Pacific doctors have already been criticized by some peers for occasionally transferring too many fertilized eggs in older women. Sher said he has transferred as many as a dozen. Some doctors say transferring a high number of embryos is counterproductive and sharply raises the odds of high-risk pregnancies and multiple births. And they fear that under a money-back plan, this will happen even more often.

Dr. Zev Rosenwaks, a leading fertility specialist at New York Hospital-Cornell Medical Center, said if doctors have too much to lose when a patient fails to become pregnant, ``there might be a tendency to do certain things to improve the pregnancy rates.''

He declined, however, to comment specifically on other clinics' practices. His own clinic success rates consistently have been among the top few in the nation.

Consumer advocates, regulators and some doctors have other misgivings about the plans. Because the refund programs are so new, it is impossible to know whether the clinics will return fees cheerfully and promptly. Neither program puts fees in escrow. Reproductive, however, keeps the portion of the fees it might have to refund on deposit at a local bank in a separate account.

Some people also think it unfair that both programs limit entry to patients with the best chances of conceiving. Generally, that includes younger women or women who agree to use a young egg donor, as well as couples who have no identifiable fertility problem.

The clinics are selling expensive insurance to those who have the best chance of success while denying coverage to those most likely to go home without babies, critics say.

For instance, Pacific no longer admits women older than 40 into the money-back program unless they agree to use a young egg donor. Reproductive has a similar policy for women from 40 to 45.

Lastly, critics ask whether a money-back offer will attract patients who otherwise might have chosen a clinic with a higher success rate.

A comparison of success rates at the nation's infertility clinics can be ordered from the Society for Assisted Reproductive Technology, a self-regulatory group in Birmingham, Ala., by calling [phone]. SART is a subgroup of the American Society of Reproductive Medicine.

The society's data are far from perfect. Its 300 member clinics supply their own information, which is generally unaudited, and annual reports are issued a few years after the fact. But because the format forces clinics to report the data in a uniform way, consumers can use the reports to strip the puff from competing marketing claims.

Critics of the money-back offers say that even women who succeed in getting pregnant may be overpaying. Offered participation in the money-back plans, these consumers can easily decide they don't mind paying more for their medical care as long as they take home a biological child.

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Photo

Photo: Dr. Geoffrey Sher talks with a would-be mother at afertility clinic which offers money-back guarantees.

The New York Times