Fixed medical fee arrangement in fertility treatment: some pertinent ethical concerns

The high costs, coupled with the uncertain outcome, of clinically assisted reproduction have led to the introduction of a fixed medical fee arrangement for multiple fertility treatment cycles until reproductive success is attained by the patient. Nevertheless, it must be noted that experienced fertility practitioners are well-versed in the statistics and likelihood of reproductive success for different patient age-groups and subfertility indications. Hence, there is a risk that they might misuse this knowledge to discreetly and discriminately limit any fixed medical fee package only to good-prognosis patients with high chances of reproductive success. Poor-prognosis patients would probably be excluded from such a scheme. Hence, the net result is that good-prognosis patients would end up paying more medical fees, while poor-prognosis patients would not benefit at all from such a fixed medical fee arrangement. A higher profit margin is thus achieved for the fertility doctor and clinic in question, with little or no benefit to patients. This would obviously be a breach of professional ethics and medical deontology.

The high medical fees associated with human clinical assisted reproduction are a result of several factors:

•	Expensive overheads arising from the purchase and maintenance of technologically sophisticated medical and laboratory instruments (i.e., micromanipulators, incubators, programmable freezers and ultrasound machines);
•	High costs of fertility hormones used in superovulation (i.e., purified recombinant gonadotrophins);
•	Heavy investment in the training and education of highly skilled clinical and laboratory personnel.

In the majority of countries worldwide, the state does not subsidize fertility treatment generally and the high medical fees impose a heavy economic burden [1] on patients, who often deplete their entire life savings and can also put themselves heavily in debt by seeking fertility treatment. Even in countries where state subsidies are available for clinically assisted reproduction treatment, this often applies only to government-funded hospitals and clinics (where there are usually long patient waiting lists) and not to privately run fertility practices.

Besides expensive medical fees, patients also face psychological and emotional pressure from the highly uncertain outcome of fertility treatment. For example, the average national success rate per fertility treatment cycle in both the UK and USA is 25–30% [101,102], whereas, in Singapore, the success rate ranges from 16 to 28% at different fertility centers [103]. Under such trying circumstances of high medical fees and uncertain treatment outcome, some patients may find it advantageous to take up a fixed medical fee package to undergo as many treatment cycles as possible until reproductive success is attained. In fact, such an arrangement in medical fee payment is gradually gaining in popularity, not only among patients but also among fertility doctors and clinics, particularly those in private practice. Hence, it is imperative to critically examine some of the potential ethical pitfalls in such an arrangement for medical fee payment.

On the surface, such a scheme would appear to be highly reassuring and comforting to patients. For a fixed medical fee, they would receive as many treatment cycles as possible until reproductive success is attained. Nevertheless, it is likely that fertility doctors and clinics would discreetly and discriminately limit any fixed medical fee package to only good-prognosis patients with high chances of reproductive success after one or two treatment cycles (i.e., younger women with tubal blockage, mild male-factor subfertility that can be rectified easily by intracytoplasmic sperm injection). Poor-prognosis patients (i.e., older women with polycystic ovarian syndrome, endometriosis and severe male factor subfertility) would probably be excluded from such a fixed medical fee package. They may not even be aware that such a scheme exists at the fertility clinic in which they are receiving treatment.

To make the entire package more attractive to patients, payment of fixed medical fees can be made by a number of installments and, if reproductive success is attained before the entire sum is paid, then the remaining fees may be waived. Suppose that the price of a single in vitro fertilization cycle is US$10,000, whereas the fixed medical fee package is US$45,000 for multiple IVF cycles until reproductive success is attained. An arrangement can then be made for the patient to pay three US$15,000 installments for each of the first three cycles. If she attains reproductive success on the second cycle after paying US$30,000, then the remaining US$15,000 can be waived. Otherwise, if there is no successful conception after three paid attempts, the patient can receive as many treatment cycles as possible without further payment, until reproductive success is finally attained. In another variation, the fixed medical fee scheme can also incorporate antenatal care and delivery of the newborn as an added bonus, to make the entire package appear even more attractive and worthwhile to patients. Hence, it would deceptively appear that good-prognosis patients could end up paying reduced medical fees, whereas poor-prognosis patients would benefit from such a fixed medical fee arrangement as there would be a cap on the maximum cost payable.

However, in reality the net result is that good-prognosis patients would end up paying more medical fees, whereas poor-prognosis patients would not benefit at all from such a fixed medical fee arrangement. In contrast to the lack of benefit to the patients, a higher profit margin is thus achieved for the fertility doctor and clinic in question. It must be noted that experienced fertility practitioners are well-versed in the statistics and likelihood of reproductive success for different patient age-groups and subfertility indications and it would be a breach of professional ethics and medical deontology if they were to misuse this knowledge to selectively encourage or even ‘hard-sell’ their fixed medical fee package to patients whom they already know have high chances of reproductive success in fertility treatment.