Experience:

Egg Freezing

Fertility doctors, clinics and laboratories have an enormous range of experience. For instance, while nearly every fertility clinic in the US markets their ability to do egg freezing, less than half have ever thawed a single egg. The freezing and thawing of eggs are delicate processes and you’ll want to choose a clinic that can prove to you they do it regularly, and successfully.

Egg freezers should also pay attention to whether this clinic is competent at performing IVF. The reality is that if you need to use the eggs you froze, you’ll have them thawed, inseminated, and transferred at the clinic where they are stored. That is IVF, and it’s a much more involved process than egg freezing.

Trying To Conceive

For patients trying to conceive now, you will want to go to a clinic that has a sufficient amount of practice. Our data shows that clinics that do more than 150 – 200 IVF cycles per year tend to have slightly higher rates of success. On the other hand, we did not find an upper end of the range whereby a clinic can do too many cycles. There are some perfectly good clinics that do less than the average number of annual cycles, but you should make doubly sure that they are exceptional for their size.

How Aggressive Are The Doctors:

Fertility doctors, and clinics, tend to have their biases around how aggressively they want to treat patients. What your clinic’s stance is will likely influence how much time and money you invest in the process.

Hormone Therapy

For instance, there are clinics that practice “mini-IVF”, where the doctor employs a “minimal stimulation” protocol that subjects the patient to less hormone therapy, but likely delivers fewer eggs per retrieval. Conversely, there are clinics that are very comfortable pushing the envelope, and plenty of clinics that fall somewhere in between.

Clomid vs. IUI vs. IVF

To some extent, there is a continuum of infertility treatments, and many doctors have different opinions on which level of treatment is the right place to start, and when to advance to a more intensive approach. One example might be when a patient should advance from IUI to IVF. While IVF is often 3 – 5x more effective on a per cycle basis, it is also 8 – 10x more costly. We speak with plenty of women who felt like their doctor “automatically wanted to jump to IVF”, and just as many who felt that their clinician “wasted precious time on IUIs that weren’t working”. As you can see below, there is no specific number of IUIs patients undergo before moving to IVF.

Do They Specialize In What You Have

There are many underlying reasons why a woman, or couple, cannot have a child. Often the underlying causes are incredibly complex, and require a fair amount of specialization to address the issue. Thus there are clinicians who are especially good at treating diminished ovarian reserve, PCOS, endometriosis, and the 10 to 20 other conditions that cause infertility. Getting to a doctor who knows how to treat what you have is key. So is avoiding doctors who will determine you have the only thing they know how to treat. Patients who suffer from male factor infertility, should be seen at a clinic with a reproductive urologist on staff. Those who are dealing with recurrent pregnancy loss, and for whom “getting pregnant” is not the issue, probably don’t want to be seen by a doctor whose only answer is: “Just do more IVF”.

Bias and Behavior Around Multiple Embryo Transfer

Patients and doctors need to determine how many embryos to transfer. This decision has numerous implications, including the likelihood the transfer will lead to a live birth, as well the likelihood twins will be born, with the associated risks to both the carrier, and the offspring. You can see some of the associated risks below.

While many doctors and clinics say they insist upon transferring a single embryo at a time, the reality is that 50 – 70% of transfers still involve multiple embryos. There are compelling reasons to choose either a single (lower risks) or multiple (higher success rates) embryo transfer, but you will want to understand how your doctor has approached such questions in the past, how they may guide you, and what they are opposed to.

Bias and Behavior Around Egg Donation

For most patients, success rates using donor eggs are higher than using a patient’s own eggs. For instance, in the case of a woman in her early 40s, her odds of success using donor eggs are often 10x higher than using her own eggs. That said, many patients are reluctant to consider donor egg until the time feels right. Doctors will certainly have a perspective on this, and some will refuse to continue to cycle a patient if she insists on trying with her own eggs. There are many reasons a doctor could take such a stance, ranging from wanting to use the patient’s time and money wisely, to protecting their own publicly-available rates of success. As a patient, you will want to understand at what point a doctor typically insists on guiding the patient to donor eggs, and what will happen if you are not ready for that.

Will Your Doctor Adapt Treatment

Many fertility doctors will tell you, “IVF is both a diagnostic, and a treatment”, meaning something is learned from each cycle, even those that “fail”. Implicit in this is the understanding that after each failed cycle, the doctor will deploy a new approach. That does not always happen, and it is common for patients to lose faith that their doctor is adapting treatment in a meaningful way with successive rounds. As you can see, when patients believe their doctor is adapting treatment, they are inclined to stay. When they are less sure, they are inclined to leave.

Clinic Size and Affiliation

Fertility clinics vary dramatically, and two parameters of real differentiation are both the size of the clinic, and whether the clinic is run as a standalone business, or is part of a larger academic institution. There are trade-offs in all scenarios, and to overgeneralize here are a few:

Larger versus Smaller Clinics

Larger clinics typically have more resources for patients, and often have laboratories that do more cycles and thus have more data to use to fix their processes. On the other hand, a higher percentage of patients (69% vs 61%) at small clinics feel like they are treated with greater care and decency. Finally, we notice larger clinics tend to make more mistakes, until they reach the “mega clinic” level of 1,000 or more annual cycles.

Private Practice versus Academic Affiliation:

Our data shows that patients are more likely to consider private practices better run than academic medical center clinics, and after controlling for a number of factors, possibly see higher rates of success. Patients who see doctors in a private practice are nearly twice as likely to have their doctor perform all of their medical procedures, including the transfer (here is why that matters). On the other hand, doctors within an academic medical center often have no financial interest in steering a patient in one direction or another.

Does Your Clinic Make Errors, And What Type

The fertility treatment process has many moving parts, and, as a result, errors get made. Nearly 30% of all fertility patients will experience a clinical or clerical error at any given center, and you can see a breakout of these below. We notice a tight correlation between patients who report errors and success rates (which could be coincidental, and not causal). You can research each doctor and clinic’s frequency and type of errors at FertilityIQ.

How Good Is The Laboratory

Most embryologists tell us a superb laboratory can double your likelihood of success, and yet patients have almost no way to ascertain if their clinic’s laboratory is any good. We’ve done an entire piece devoted specifically to this subject, but there are a few things to keep in mind. Find out the laboratory's fertilization rate (70% is respectable) and blastocsyst conversion rate (40 – 50% by Day 5 is solid) to get a sense for their ability to take eggs and sperm and deliver promising embryos. Also, have a close look at the experience of the embryologists working in the laboratory, and the culture conditions they keep: are their incubators state-of-the-art (“desktop” are better than “big box”), and are the atmospheric temperatures in those incubators at the recommended 5% levels? To give you a sense for how lab quality can differ, here are the outcomes from two highly-regarded clinics when they use (presumably consistently good) donor eggs with their patients.

How Good Is The Billing Department

The average IVF patient will spend $40,000 - $50,000 on treatment, and most patients will pay in cash. Billing mistakes are incredibly commonplace, and a billing department that is disorganized can cost you thousands of dollars and weeks of aggravation — if you ever discover the issue, which you probably won’t. On the other hand, a superb financial coordinator can appeal to the clinic administrators to get you discounts, knows how to properly lobby insurance on your behalf, and continually looks for ways to save you money. To be certain, an excellent billing department may not change your result, but it will partially dictate your perception of the experience.