How to Evaluate Fertility Centers with 7 Questions

Consider size, track record and management before success rates

A quite frequent question patients ask our center’s staff is, how do we know CHR is the right fertility center for us? Recognized by peers worldwide as one of the world’s leading fertility centers, the answer is usually not difficult for CHR’s staff members. The frequency of this question, however, convinced us that what many patients really are asking with this question is how to evaluate the quality of any given fertility center, whether in the U.S., Canada or overseas. We, therefore, decided to review this subject in organized fashion in the VOICE. Here are our recommendations:

1. Size matters: more than 200 but less than 1,000-1,500 cycles per year

Less than 200 cycles per year is too small an experience to maintain consistent quality control, especially in the embryology lab.
Over 1,000-1,500 cycles per year is usually too big to allow for individualized attention to patients and adequate communication between medical staff and patients.
Larger programs are often characterized by patients feeling like a number in a factory. Same rigid protocols are recommended for every patient regardless of individual history.

2. Established track record with low turnover of staff and reputation in the community

Watch out for newly established fertility centers.
Even with good physicians, nurses and embryologists, it takes years of working together to achieve optimal results.
Risk of problems in embryology decrease with years of continuous operation.
Passing inspections by federal and state health agencies for multiple years also helps.

3. Staff experience and qualifications

It matters whether a center’s physicians are subspecialty trained in Reproductive Endocrinology and Infertility or not.
It matters often even more whether embryologists are at doctoral (PhD or MD) level or primarily only technicians.
Finally, it does matter whether the staff has sufficient years of practice or just completed their training.

4. Who is in charge matters as well

Whether a fertility center is owned by its physicians, is investor-owned or within the confines of and academic institution and/or hospital will dictate priorities.
There is increasing evidence (especially from Australia where investor ownership is most advanced) that IVF cycle outcomes decline, and costs increase under such a management structure.
Many academic institutions offer excellent programs, but others prioritize teaching of students and residents over patient care. Infertility is one of the few areas in medicine where academic institutions, therefore, are not always the leading clinical providers in the community.

5. Does the program innovate and offer leadership in the field?

How well is the center and its leadership known in the infertility field and how well are they regarded?
Is the center conducting research and steadily publishing in well-regarded medical journals? Centers that do not participate in the research enterprise usually do not have access to the newest information and, therefore, lag behind centers that do.
Has the center contributed to the field? Are medical practices pioneered at the center now part of worldwide IVF practice? Do members of the center participate in postgraduate education of colleagues? Does the center offer participation in clinical trials? The more yeses a center offers to all of these questions, the more likely will it be able to offer state-of-the-art treatments.

6. What are a center’s IVF outcomes?

It may be surprising to many that we did not ask this question first, but there is logic to why we did not do that. In principle two reasons:

Pregnancy and live birth rates of centers are difficult to interpret since they depend on the centers’ patient populations. Like the best surgeons get the most difficult cases to operate on, the best IVF centers usually get the most difficult infertility patients to treat. So, for example, CHR serves the by far oldest patient population of any IVF center in the U.S. and probably, therefore, also the women with the lowest ovarian reserve. It would be foolish to expect that outcomes in such a population would be the same as at a center that, in principle, only serves women in their 20s and early 30s with tubal infertility.
A good number of IVF centers, unfortunately, take advantage of imprecise outcome reporting rules and manipulate those by often claiming highly exaggerated IVF cycle outcomes, which have nothing to do with reality [Kushnir et al., Fertil Steril 2013;100(3):736-741]. Remarkably, some of the most prominent centers are among the worst offenders!

Especially for lay people to get accurate data from the two national reporting data sets at the Centers for Disease Control and Prevention (CDC) and Society for Assisted Reproductive technology (SART) is, therefore, almost impossible. SART has made significant efforts in recent years to improve their reporting but is still lacking. It is for those reasons that both organizations strongly recommend against using their registry for comparing outcomes of IVF centers.

What is then to do? We recommend that the registries be used to compare outcomes between IVF centers in egg donation cycles. Here, patient populations are very similar at all centers (healthy highly selected young women in the 20s), numbers of transferred embryos are similar (though not always identical and, therefore, should be checked), and the same laboratories and physicians usually treat patients who use their own and/or donor eggs. One, therefore, can assume that an IVF center with good pregnancy and live birth rates in egg donation cycles will also have competent embryology for women working with their own eggs (Kushnir et al., Reprod Biol Endocrinol 2014;12:122). In good centers, live birth rates in egg donor cycles should exceed 45%.

Here are a few more clues on how to select IVF centers:

Even in good prognosis patients, live birth rates above 60% per IVF cycle start are probably too good to be true. The national average for all patients is about 30%, with median age of 36 years (by comparison CHR’s median age in 2017 was 43 years).
Watch out for centers that prematurely push for egg donation as a primary treatment option for women who have low ovarian reserve but are not yet in menopause. They, quite obviously, select good prognosis patients!
Watch out for centers that have a lot of add-on charges to standard IVF cycles, especially if they add those services to every cycle. Not every IVF cycle need assisted zona hatching (AZH), intracytoplasmic sperm injections (ICSI) and, certainly, not every IVF cycle needs preimplantation genetic testing for aneuploidy (PGT-A), which was until recently called preimplantation genetic screening (PGS).

7. Convenience and insurance

If you have insurance, it makes sense to use insurance first. It obviously also makes sense to stay in the neighborhood if there is a good-quality IVF center close by. However, remember that IVF centers, still, greatly vary in what they can offer and how they perform. Choosing the wrong center may, therefore, not only waste efforts and insurance coverage (because numbers of covered cycles is usually limited) but may also unnecessarily use up what, especially in older women, is the most valuable asset: time!
Many of the best IVF centers often accept only a limited number of insurances. At least in CHR’s case, the principal reason is that, when giving highly individualized patient care, resource costs per patient are much higher than in protocol-driven programs, where everybody, more or less, receives the same level of patient care. Insurance reimbursements offered by many insurance companies, therefore, frequently do not cover provider costs.
THIS IS IMPORTANT! A good number of IVF centers circumvent this fact by accepting reimbursement rates below a break-even point from insurance companies because they found a very profitable way to compensate for inadequate insurance reimbursements: By strongly recommending or, often, even mandating that their patients undergo add-ons to their IVF cycles, not covered by insurance, they end up receiving significant additional cycle revenue from out-of-pocket payments by patient for those add-ons. These payments, which often approximate insurance payments for whole IVF cycles from insurance companies, convert money-losing insurance cycles into highly profitable IVF cycles. Patients, however, incur significant out of pocket costs they never expected in otherwise fully insured cycles.
Likely the most blatant example for what CHR considers a rather coercive and even abusive approach to patient care, is PGT-A/PGS. In 2017, over 20% of all U.S. IVF cycles were accompanied by PGT-A/PGS, which only very recently was, once again by the ASRM defined as lacking clinical effectiveness (Practice Committees of the American Society for Reproductive Medicine and Society for Assisted Reproductive Technology. Fertil Steril 2018;36(4):442-449).

We hope that this brief guide to selecting IVF centers will help especially many first-time readers of the VOICE in not only making the right choice in selecting a fertility center but also in doing so in timely fashion. Most infertile patients do understand the importance of time in pursuing fertility treatments. Every treatment that can be offered will work better at younger than older ages. For this reason alone, it is not only important to find the right treatment center but to find it as early as possible.

Here at CHR, not a day passes when we do not hear from new patients, “we wish we had known about you earlier, when we ...”. Similarly, we here at CHR constantly wonder, considering how well we are currently doing with our patients (over 90% present to CHR after having failed usually multiple IVF cycles elsewhere), how much better we could do for them, were we given the opportunity to see and treat them earlier.

This is a part of the June 2018 CHR VOICE.

Norbert Gleicher, MD

Norbert Gleicher, MD, FACOG, FACS

Norbert Gleicher, MD, leads CHR’s clinical and research efforts as Medical Director and Chief Scientist. A world-renowned specialist in reproductive endocrinology, Dr. Gleicher has published hundreds of peer-reviewed papers and lectured globally while keeping an active clinical career focused on ovarian aging, immunological issues and other difficult cases of infertility.

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