Part two: Infertility treatments: Who will pay?

For most people, making a baby involves the right mate, the right mood and the right medley of hormones. For Heidi and Justin Dierking, it also required the right insurance. • Married for three years, the Dierkings of St. Paul have been trying to get pregnant. Several months ago, they began considering in-vitro fertilization. With IVF, as it's called, doctors coax egg and sperm together in a petri dish and implant the resulting embryo. It works about half of the time.

For the Dierkings, the stumbling block was price: IVF costs about $10,000 and their insurance didn't cover it. They talked about using credit cards, or taking out a home equity loan.

But Justin Dierking's employer had just been bought by a rival company. After his wife bugged him for weeks, he called to ask about benefit changes. He found out they now had a $20,000 maximum for infertility treatment. "He was on the phone, I was in the kitchen, and I said: 'What?!" recalled Heidi Dierking. "$20,000?!"

Suddenly, a baby was possible.

The Dierkings are one of thousands of infertile couples learning that the serendipity of their insurance coverage is the main factor making it possible to have a child.

For the one in 10 couples who are infertile, the quest for a child can become all-consuming, involving complex and expensive medical interventions. But fertility coverage right now is patchwork, depending on your employer's health plan and your level of coverage. As science continues to make advances in infertility and as the $3 billion industry grows, the question of who pays for treatment is becoming increasingly complicated.

Is infertility a disease? Should insurance cover treatment? And if so, which ones?

"It's murky," said Dr. Paul Karazija, medical director at Medica. "If you have a pituitary tumor and are infertile, clearly the pituitary tumor is an illness and a covered benefit. Then the condition is resolved and you are fertile." But when doctors can't find a medical reason for the infertility, the question of coverage becomes less clear.

Seven states have laws requiring IVF coverage, but Minnesota isn't one of them. Most health plans cover some treatments in the body -- such as fertility drugs or surgery -- but draw the line at anything that requires tinkering outside the body, such as IVF.

Now, the state's biggest insurer is considering extending coverage for IVF next year, which brings the issue to the forefront. Blue Cross and Blue Shield of Minnesota says it hopes to make IVF treatment a standard benefit for roughly half of its 2.9 million members -- those who are not in employer-sponsored or government plans. That may prod other insurers to follow suit, though they've been unwilling so far.

"It's not a life-and-death situation," said Dr. John Frederick, chief medical officer of PreferredOne. "It's a lifestyle issue."

Trying to avoid multiples

Most insurers cover a variety of hormonal pills and shots that jump-start a woman's ovaries, boosting the likelihood they'll release enough eggs so that one or two will be fertilized by a partner's sperm. Some insurers also will pay to inject the sperm right into the uterus.

If that doesn't work, there's in-vitro fertilization, a technique starting at about $10,000 that comes with about a 50-50 chance of success.

Patients typically pay out-of-pocket for the procedure, which may take several ovulation cycles to succeed. Those who have coverage are then reimbursed by their insurers, but seldom for the full amount. Minnesota clinics did slightly more than 2,000 cycles of IVF in 2005, the most recent numbers available.

As IVF success rates have risen over the years, some insurers are starting to think it may be the best option for some patients. Fertility drugs alone can lead to multiples -- triplets, or more. These babies often start life in intensive care, and can rack up medical bills of up to a million dollars each. Some die, or carry serious complications throughout their lives. Multiple births are also dangerous for the mother and extremely expensive for health plans, raising premiums for everyone.

Because IVF allows a doctor to implant a precise number of embryos, it can bring down the soaring number of multiple births.

"In a lot of cases, maybe going to IVF is the safest first choice," said Dr. Pat Courneya, a medical director at HealthPartners. "[Yet] there's a fear of unleashing an unpredictable expense at a time when we're already struggling with costs."

HealthPartners has discussed the issue internally, but couldn't get enough support from employer groups. Medica and PreferredOne say they simply can't justify paying for the full range of infertility treatments when there are diseases such as cancer and diabetes competing for money.

This ambivalence is reflected in coverage. Diagnostics are always covered. And in recent years, some employers have introduced dollar limits for infertility, allowing employees to decide how to spend that money.

PreferredOne underwriters estimate that covering IVF would add a half percent increase in premiums for a large company. But many employers don't understand the issue and worry that just one set of premature multiple births could instantly create a multimillion-dollar expense.

Saving for IVF treatments

Heidi Dierking is an event planner for Macy's. She is 35, the age when a woman's fertility begins to plummet.

Yet, according to her doctor, "I produce eggs like someone in their 20s," she says, with a flick of her red hair and an easy laugh. "So I'm hanging my hat on that one."

She met her husband at a wedding party in Fort Collins, Colo., where he was an Air Force officer. They married in the summer of 2004 and started trying to have a baby in the spring of 2005.

Every morning for a year and a half, Heidi Dierking said, she woke up and put a thermometer in her mouth, watching for the dip that signaled her most fertile period. "I now know I ovulate on Day 16," she said wryly.

But that knowledge didn't help her get pregnant.

Doctors conducted a battery of tests -- blood work, semen analysis and fluorescent dye shot through her Fallopian tubes to check for blockages -- but couldn't find anything wrong. So, like many couples with unexplained infertility, Dierking started taking the fertility drug Clomid. When that didn't work, her obstetrician sent her to the Center for Reproductive Medicine in Minneapolis in October 2006.

Since then, she's been through four rounds of drugs combined with intrauterine insemination, where doctors inject the sperm directly into the uterus. All failed.

Then fate intervened in the unlikely form of a corporate takeover. Justin Dierking's employer, Guidant Corp., was bought by Boston Scientific. His new health plan now included an unusually rich $20,000 lifetime limit for infertility.

In early July, Heidi and Justin Dierking decided to move on to in-vitro fertilization, which would raise their chances of success from 20 percent to 50 percent.

Without such benefits, a family's finances can literally revolve around paying the IVF doctor.

"We save for retirement, we save for college, and we save for this," said Michael Mark, whose wife, Stacy, has been through five cycles of IVF. Michael is 43 and Stacy is 37. They live in Minnetonka.

Mark, who works for Blue Cross, has a chromosomal abnormality that has caused multiple miscarriages for the couple. Their first round of IVF produced a son, Alex, born in October 2003.

But they kept trying. "You have a picture in your mind of your family and how many children there are," said Stacy Mason-Mark. "There have always been three in my picture."

The next three cycles failed. She underwent another in early August and is pregnant. Each time, the Marks paid between $15,000 and $18,000 in cash, which included genetic diagnosis to pick the most viable embryos.

Their health plan covered the diagnosis of infertility, but little else. Saving for IVF affects every spending decision they make. Meanwhile, Mason-Mark is working with a group to get legislation drafted that would require IVF coverage in Minnesota.

Dr. Richard Kopher, an ob/gyn with HealthPartners in St. Paul, treats many of these patients and refers some each year to the IVF clinics.

For these people, he said, the drive to reproduce is "up there with hunger and pain."

A right, or a privilege?

In early September, Heidi Dierking had 13 eggs removed. Five days later, doctors implanted two embryos.

She is now pregnant with twins.

She says she's still struck by the stroke of luck that made IVF an easy choice for them.

"I think about that a lot," she said. "Even if we had to pay for it, we could probably swing it. We're dual income, middle-class people. But what about all the people who would make wonderful parents but don't have the ability to finance a loan?"

She paused.

"Is that fair?"

mychen@startribune.com • 612-673-7434 marcotty@startribune.com 612-673-7394