SUCCESS RATES weren't the only factor that brought Drew and Michelle Paras to Los Angeles. They also came because Pacific Fertility offers a sort of warranty: You get a baby, or your money back.

"How could you pass that up?" Drew asks, as he and Michelle wait in Pacific Fertility's elegant pink lobby.

Drew and Michelle Paras

The Parases asked their Las Vegas doctor to match the offer. He refused. "I never felt confident in my doctor there," Michelle says. "He could have just taken our money and said it didn't work."

Drew hopes money-back deals will spread throughout the medical world. But they are still virtually unheard of - except in the field of infertility. In the past few years, an estimated 60 infertility clinics - about 18 percent of all IVF clinics in the US - have begun offering patients some or all of their money back if they don't get pregnant. That horrifies some doctors. The American Medical Association explicitly opposes tying doctors' fees to outcomes. It says doctors should be paid for what they do, and the rest should be up to fate.

Dr. Sher responds that conventional standards shouldn't apply to in vitro fertilization. In other fields of medicine, he says, outcomes are ambiguous. At what point do you declare the cancer patient cured? IVF is "one of the very few, if not the only, field of medicine where the endpoint is clearly measureable," Sher says. "That's a baby."

Pacific Fertility medical director Dr. Geoffrey Sher explains his refund plan.
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Sher and other supporters of money-back plans say without such programs, some couples would be unable to afford in vitro fertilization. Sher's program and others allow patients to try IVF several times for a flat fee.

Dr. Michael Levy, an infertility specialist at Shady Grove Fertility Centers in Maryland, says his program began offering a partial refund to patients who don't get pregnant after a woman told him that if she tried IVF again, and the treatment failed, she wouldn't have any money left over to adopt. Levy says he feels more comfortable telling patients their treatment didn't work, "knowing that I haven't sabotaged their entire endeavor to have a family."

Pacific Fertility gives patients and prospective patients packets of information, videotapes about the center showing happy parents and babies at a reunion of PFC patients, and copies of Dr. Sher's book, The ART of Making Babies. A.R.T stands for "assisted reproductive technology."

Opponents argue that money-back (or "shared risk" or "outcome based reimbursement") plans aren't always as good as they look. They usually don't include the cost of diagnostic tests or drugs to stimulate a woman's ovaries, which can be quite expensive. Some programs require patients to undergo specific treatments before doing IVF -- treatments which also may not be included in the price. And some won't accept patients with poor prognoses.

See Evaluating Infertility Treatment Financing Plans
for samples of clinic guarantees and information from RESOLVE, a national infertility support group.

Diane Aronson, executive director of the consumer group Resolve, says her organization does not oppose money-back plans. But it does warn patients to be cautious about them. Aronson worries that patients may get caught in a bait-and-switch: they may start using a clinic because it offers a money-back deal and have all their initial tests done there. " After bonding with a physician," Aronson says, "they then may learn that they do not qualify" for the refund plan.

Aronson and other critics say doctors offering such programs have an incentive to try too hard, taking risks with patients to ensure pregnancy. For instance, doctors may transfer more embryos than usual to a woman's uterus if she's using a money-back plan. That may increase her chance of getting pregnant, but it also increases the chance that she'll have twins, triplets, or more. Multiple births are dangerous to the mother and babies, and they're expensive.

Ethicist Susan Wolf from the University of Minnesota is opposed to deals in which patients who don't get pregnant get their money back.
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Supporters of money-back plans argue that any payment system can be abused. Levy points out that if doctors are paid for each service they perform, they have an incentive to do unnecessary procedures. If they're managed by a company that pays them a flat fee, no matter how many services they provide, doctors have an incentive not to provide treatment, even if patients need it.

"This system like any other can be abused," Levy says, "and checks and balances should be in place."

Medical ethicist Ruth Macklin, co-chair of the National Advisory Board for Ethics in Reproduction, says doctors can ethically offer money back deals.
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Patients who do sign up for such plans are essentially gambling. For instance, at Pacific Fertility, a woman under 35 pays $13,400 for three attempts at IVF. If she bought each procedure separately, it would cost more like $25,000 (again, not counting drugs). If she takes three tries to get pregnant, she's saved a lot of money; if only one try, she's paid $13,400 for an $8,300 procedure.

Sher says he hasn't met a patient who calls his plan a bad idea. "I don't think anyone would characterize it as having lost if they have a baby the first try," Sher says.

After trying IVF twice at another clinic, Sarah signed up for the Full Refund Plan at Pacific Fertility Centers. She got pregnant on the first try, but she and her husband Ben aren't a bit sorry. They're delighted.

"It's incredibly awesome," says Sarah. "Even when you feel crappy it's great. You can't explain the feeling: I feel nauseous. Isn't that neat?"

Infertility patient Ben was glad to find a clinic that offered "a baby or your money back."
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Meanwhile, Michelle Paras learned in January that she did not get pregnant after her first IVF cycle at Pacific Fertility, so she's glad she and Drew signed up for the refund plan. They plan to try again this spring. "We both feel strongly about having our own biological child," Michelle says.

The Parases say they've known couples who kept going back for IVF after failing repeatedly to get pregnant. For them, Pacific Fertility's plan offers a stopping point. If they still don't have a baby after they've used up all three tries, they'll give up, and they'll use the money they get back to try to adopt.

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