By Neway Fertility on May 21, 2019
I am often asked, “What criteria should I use for when selecting a fertility center for my upcoming IVF cycle?” This is a critical decision that patients go through– Not just recognizing that they need help to achieve their fertility goals, but Where to go? Who to turn to for help? Surprisingly, the answer is not so straightforward. I have come up with six points to consider to help patients select a fertility center that is best suited to their needs.Size matters (look for centers which perform more than 200 but less than 2,000 cycles of IVF per year)
- <200 IVF cycles per year is just too small, there are not enough cases to maintain consistent quality control especially in the embryology lab
- >2,000 IVF cycles per year is just too big, loss of individual attention and communication
- Feels like a factory
- Patients report being treated like a number not a human being
Same rigid protocols recommended for every patient regardless of individual history
The first point to look for in an IVF center is its size. What I mean is that you want to pick an IVF center that has enough volume to perform IVF efficiently and have a good quality laboratory. A center needs to perform at least 200 cycles of IVF per year in order to maintain a good quality embryology laboratory. On the other hand, can a center be too big? Something I often hear from patients, when they go to centers that perform thousands of IVF cycles, many patients feel lost in that center. Patients don’t know who is taking care of them. They don’t see the same physician every time and many report that they feel like a number. When centers are so big, it can feel like a factory setting, with every patient getting treated the same way. For logistical reasons such large centers have limited ability to individualize care. Therefore, I advise patients to look for centers based on size first, ideally, a fertility center should perform somewhere between 200 and 2,000 IVF cycles per year.
Long track record
- A center should have good physicians, nurses, administrators and embryologists, who have been working together for years, this is important to achieve optimal results and smooth out the kinks inherent to complex operations of a fertility center.
- Risk of major problems occurring in embryology lab are mitigated by years of continuous operation.
- Has the center passed multiple inspections by federal and state health agencies?
The second most important point that patients should consider when selecting a fertility center is the track record of the center. How long has this center been operating and how many pregnancies have been achieved there? What is its reputation in the community? Ideally you want to look for a center that has an established track record. The reason for this is that in a relatively new fertility center there might be excellent doctors, embryologists, administrators, and nurses, but these people have not yet learned to work together and there might be breakdown in communication. Moreover, they have not gone through many years of inspections from the federal and state government health authorities. These inspections, over the course of many years, help fertility centers identify potential problems and correct them. A center that’s been around for a long time has had enough time to smooth out communications issues between the various departments within the center. Also the center has gone through inspections and been validated by outside agencies.
Who is in charge?
- Physician ownership vs. investors vs. academic institution: This will obviously dictate the priorities of the practice.
- If the physicians are employed at a practice which is owned by a group of investors the focus may be too much on profits over quality of patient care.
- Academic institutions may prioritize research and teaching of students and residents over patient care.
- Staff experience and qualifications
- Are the physicians’ subspecialty trained in Reproductive Endocrinology & Infertility or only in general OBGYN?
- Is there a doctoral (PhD) level embryologist on site or only technicians?
Does the staff have sufficient years of practice or did they just recently complete their training?
The third most important point that patients should ask before selecting a fertility center is a simple question, “who is in charge?” You want to really understand, -Is this a physician owned practice? Or - Is this a practice that’s owned by investors and the physicians are employed there? or Is this an academic practice that is owned by a hospital or a university? Depending on the ownership of the practice and who is making the decisions, the priorities may vary. While everybody wants to put patient care first, it’s obvious that when outside investors are involved in the ownership of a fertility center, the priorities of those investors may be over-represented at the expense of patient care. It’s also possible in large academic centers which provide great care in many different fields– including ours– but sometimes their priorities are not fully aligned with those of patients because these institutions also have responsibilities to train students and residents to perform research studies. So, the staff that work in large institutions may be pulled in many different directions while the patient’s interests can sometimes get left behind.
You should also look at the qualifications of the people that are that are going to be taking care of you. Is your physician subspecialty trained and board-certified in Reproductive Endocrinology & Infertility? Which means the doctor has attained the highest level of training within this subspecialty. Or is the physician only trained as a general OBGYN but has not had sub-specialty training, which is critically important to achieving the best outcomes in IVF. Also what are the qualifications of the embryologists? Because what happens in the embryology lab during the IVF process is very important! You want to be sure that the embryology lab is being run by an on-site PhD (doctoral) level laboratory director who is constantly overseeing the operations of that lab. If the lab director is not on-site, for example if it’s an off-site director, and the lab day-to-day operations are being run by technicians, obviously, this is a sub-optimal situation. Ask who is in charge and what are the qualifications of the people who are operating the fertility center before you commit to going there.
Innovation and leadership
- Is the practice and its leaders known and well regarded in the fertility field?
- Have they previously pioneered procedures which have since become mainstream in the field?
- Have they published their data in prominent medical journals?
The fourth point that patients should consider when selecting a fertility center is that center’s track record of innovation and leadership within the reproductive Endocrinology and infertility field and this is sometimes a difficult thing to ascertain because a lot of people claim that they’re leaders within the field but not so many actually are. One thing to look for is have there been peer-reviewed publications and scientific journals that have come out consistently over a course of years from the physicians and from from this fertility center? And have some of the publications that have come out of the center–have they changed the way that other people within the field practice? Have discoveries that have been made in the center been adopted elsewhere in the world? And have they really pioneered any new technique that is now more widely accepted? This is a very relevant thing to ask because if you’re dealing with physicians and a fertility center that’s sort of at the cutting edge of the field, you’re much more likely to have access to the types of treatments that are just recently coming out and all of the more recent technology that’s coming out than a center which is not involved in research and is not involved in innovation. So looking at those points, I think is important when selecting a fertility clinic –particularly for those people that maybe have not such a routine case of infertility but they have more complicated cases where newly developed techniques maybe very relevant to them.
Live birth rates (in context of patient population treated at that fertility center)
- Live birth rates reported to be above 60% per IVF cycle are probably too good to be true even in good prognosis patients (national average is about 30% per IVF cycle for all patients, with a median age of 36)
- Look at fresh donor egg live birth rates, these are more difficult to manipulate than rates with patients own eggs, in good centers these should exceed 45%
- Centers that treat “easy” cases and avoid “difficult” cases will have much higher pregnancy rates than centers that take on all patients regardless of prognosis.
- Is the center pushing for egg donation as a primary treatment option for women who have low ovarian reserve but are not in menopause?
The fifth point are the past pregnancy and live birth rates that have been achieved in that center. There are several reasons why I put this as the fifth point and not the first. The main reason is that you have to be able to understand what kind of patients have been treated in the center in the past and are currently being treated there. Many centers focus on treating “easy” good prognosis patients, while some centers focus on treating patients who have failed IVF elsewhere and have a poor prognosis due to more difficult underlying infertility issues. Obviously when treating a much more adversely selected patient population will produce lower pregnancy and live birth rates even in the best center. The most important question to ask before looking at pregnancy rate is, “What is the patient population that the center is treating?” Obviously, patients who are young and have mild underlying infertility will have better success rates than patients who are older and have more complicated underlying infertility problems.
Success rates published in national registries like those of CDC and SART should not be used to directly comparing fertility centers one to another because the underlying patient populations between different centers may vary. But these registries still provide data which is informative. I think that its especially relevant for patients to look at live birth rates within egg donation cycles. Because many things have been equalized in these cycles. The donors are usually selected from a carefully curated pool of women who have high fertility potential and there is a lot fewer ways for IVF centers to manipulate these data. Typically, live birth rates in fresh donor egg cycles exceed 45% and, in many centers, exceed 60%.
When you’re looking at live birth rates with patients who are using their own eggs, those can vary quite a bit. For all patients going through IVF in the United States, the live birth rate is around 30% and with the median age of patients being around 36. Now obviously younger patients will have higher live birth rates while older patients will have somewhat lower. I recommend looking at pregnancy rates and live birth rates in context of female age, and the difficulty of cases that the fertility center treats.
Cost, insurance, location, hours and days of operation, satellite offices
- While these issues are obviously important and should be considered they are secondary to points 1-5 listed above.
- Too many patients select a fertility center primarily based on convenience and later regret their decision after failed treatment.
The sixth point is again one that many patients use as their primary selection criteria for fertility centers, but in my mind, is actually one of the least important ones– And that is convenience, location, cost, and insurance. All of these issues are obviously important and it’s important to be able to have an affordable cost for your IVF. It’s important that you can use as much of your insurance benefit as possible. It’s important that the center is conveniently located to where you are, but if you’re selecting the center primarily based on these criteria, it’s not optimal because maybe the center is not ideally suited to your individual needs. Instead I recommend that patients use points one through five that I made above in selecting a fertility center. Only then consider logistics, cost, and insurance issues. But do not rely solely on these things when selecting a fertility center. I often see patients who have gone to local fertility centers, have failed treatment, and only later come for a second or third opinion and frequently say, “ I wish I had made the decision to come here much earlier in my treatment course.”
I hope this will help you select the best center for you.