The Problem of Choice

If freedom comes from having choices, well, I hate to say it, but it's a burden.  James and I are really struggling with the last-minute choice of which clinic to use. Our choices are Dominion Fertility, where we have had a failed IVF and IUI but are generally happy with the way we are treated; and Shady Grove Fertility, which is an enormous operation that treats around 25 times the number of patients Dominion does.  The reason I got the idea that Shady Grove might be better is that I saw that its statistics for pregnancies in my age group is twice as high as Dominion's.  So we started comparing. Yesterday we had an appointment at Dominion with Dr. Michael DiMattina.  He told me I looked cute in my little take-advantage-of-the-warm-day-during-the-winter outfit.  He said he was going to work really hard to make this time work.  He said they were going to pull out all the stops this time, like doing assisted hatching and ICSI.  James asked why they hadn't done it last time if that would have helped.  Dr. DiMattina looked at my chart and said, "oh, yes, they did do it that time."  But to his credit, he did have lots of recommendations to himself written on a post-it-note in the file, just in case we wanted to try again.  That included more stim meds to make more follicles, and then baking them in my oven for an extra day before they were harvested.  That's fair.  I believe that he really does want to make me pregnant, and that he's going to do his best.  I also believe that he has a good reputation and does a good job.   So we asked him why his statistics in my age group are not as good as Shady Grove's.  He said it was not "him" to bash his competitors, but that we should look at the stats differently.  He said instead of comparing statistics on the "trainwrecks" (yes, that's those of us like me, 35-37 and with documented infertility), we should look at the statistics relating to women who had used egg donors.  He said that's an even playing field: the clinics use consistently excellent eggs from 20-somethings, and the stats tell you how good the clinics are in general.  So we looked: Dominion's track record is about 70% at getting women pregnant with donor eggs in any given cycle.  Shady Grove's (or as he later referred to it, "Shady's") success rate is only 60%.  Okay, point taken.   He said also that Shady Grove was like a place he'd worked in London, where they treat women like they're in a meat market.  "That one's a frozen embryo transfer.  That one's a retrieval."  "Kay," he said, looking down into my file where my name was written, "They don't even know your name."  So at the end of the appointment (when he gave James some extra M&Ms from the jar on his desk), we thanked him for reassuring us, took the paperwork to get started, and left. Tomorrow is our appointment with Shady Grove, no doctor specified.  The women on DS have told me that the administration of Shady Grove has a terrible bedside manner, but some of the women have had good experiences with the doctors and nurses.  We want to go see what the excitement is all about.  We're going to a branch office; I think SG has about 8 offices in the D.C. area.  This one is 2 blocks from James's office, and about 10 from mine.  We'd go to it for all the monitoring, bloodwork, and ultrasounds.  We'd only have to go to their main office in Maryland for the retrieval and transfer.  James worried that there is no parking in downtown D.C., but I notice from the website that they give parking vouchers for the lot downstairs. From their 2005 statistics, as listed on the SART.org website, Shady Grove treated around 850 women in my age group, compared to about 30 at Dominion that year.  That's about 28 times as many.  Or 2,800 percent.  There are pros and cons that go along with the baby factory thing.  On the one hand, there are babies.  On the other, it's a factory.  How much do I mind that?  What does that really matter, anyway?  (I guess the answer will come when I'm on progesterone, walking that delicate line between holding it together and losing it). We wonder whether 30 is a big enough sample size to mean anything.  We wonder if the "terrible" doctors at Shady Grove would be more insensitive than a doctor that calls women in my situation "trainwrecks." And then there's the money.  We had decided to use the shared risk plan -- the one where we put a lot of money into their hands, and then if we don't get pregnant in 4 (at Domionion; 6 for Shady Grove) tries, we get that money back.  At Dominion it's $22,000.  At Shady Grove, it's $20,000.  First of all, Dr. D told me that we are no longer eligible for the Shared Risk plan at Dominion; they would have accepted me the first time, but since I "flunked" one IVF, I'm not eligible.  It's their policy.  He said we could ask at Shady Grove; they'd probably put us on their plan. Dr. D proceeded to tell us that he was not in favor of shared risk plans.  He only insituted one at his clinic because Shady Grove had one and he has to compete; it's a business, he explains.  But just as he'd told us the first time, when he DISCOURAGED us from using it, it's a bad system.  It's weighted in favor of the practice, so women usually end up overpaying for the services they get.  He can count on one hand the number of times that the clinic has lost money on this venture.  That makes sense since he only accepts people into it who have the most pristine infertile systems he sees.  Those of us who might actually use more than one or two cycles are kept out of it.  By the way, I calculated that unless you go on to a third or fourth cycle, you will be paying more for IVF than you would a la carte.  But, oh, the peace of mind! Dr. D said this time something that he hadn't said last time: risk sharing plans -- that is, gambling on patient success -- is unethical.  That's the AMA's official position.  He says that in most cases, it encourages women to overpay for their medical services, and don't care since they go home with a baby.  The clinics know that they will probably overcharge their patients, because they cherry pick the ones who are likely to be easy pregnancies.  The cynic in me points out that even though it's unethical and he condemns it, Dr. D does it.  He also selects the candidates who have the best chance of success -- certainly not me! -- which is something he accused Shady Grove of doing with their overall practice.  He said they only treat people who are likely to raise their statistics.  Really?  All 850 of my peers?  It looks to me like Shady Grove accepts everyone who is willing to pay! On the subject of ethics, Dr. D also points the finger at them by saying that they overcharge women for pre-implantation genetic testing ($5,000 a pop).  And what else?  There was another ethical violation he stuck in there as we were leaving in the hallway. We meet with Shady Grove tomorrow, as I've said.  We'll ask about their risk-sharing, about what they do that brings their statistics in my age group up so high.  We'll get the low-down on the emotional atmosphere of the place.  We'll see how easy or hard it is to park.  I hope to be able to bring in all of my medical records (waiting on a copy from Dominion actually).  We'll see what they say. Friday is Day 19 of my cycle.  I'm going to have to do this paperwork fast to get my drugs by Friday night.  That adds more pressure.  Why am I stalling, trying to get in all these visits and decisions?  I bet both clinics are fine, and both have good records of producing babies. But when this cycle doesn't work, I don't want to look back and wish I'd made the other choice.