Show Me the Money-Expenses Relating to ART by Jeffrey Kasky and Marla Neufeld

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Show Me the Money—Expenses Relating to ART

by Jeffrey Kasky and Marla Neufeld

It’s hard for anyone in the depths of assisted reproductive technology (ART) procedures to believe that having a child can actually be free for some people! A wide range of techniques are offered for ART pro- cedures and with that comes a range of fees for the medical procedures involved. Examples of variables that impact the cost depend on if an egg or sperm donor is required, if the cycle is a fresh IVF cycle or frozen IVF cycle, the medication protocol, and if there are any medical complications that arise during the process. The location where the ART procedures take place impacts fees as they vary depending on the city, state, or country. Studies show that in areas with fewer infertility clinics, the costs are actually higher for treatment; an area with a higher cost of living does not necessarily equate to higher ART costs.

Costs of Common ART Procedures

It is difficult to find an average for fees of ART procedures as many fertility clinics charge different amounts; most clinics do not publish the treatment rates or payment terms on their website. Patients should have a consultation with the clinic’s financial staff to formulate a budget and payment plan for the medical expenses.

The American Bar Association (ABA) Guide to Assisted Reproduction

Questions to Ask Fertility Clinics Relating to Costs

It is challenging to know what questions to ask a fertility clinic when you are new to the infertility world and don’t know the intricacies of ART finances. It is recommended that patients considering ART do their due diligence in the begin- ning and have a meeting with the fertility clinic’s financial department to have a detailed conversation about the costs involved, payment plans and financial assistance options. Some questions to guide you in talking to the financial depart- ment include:

1.  Does the clinic have a detailed list of procedures and corresponding costs? This list should include the common ART procedures like IVF and IUI, medical procedures associated with standard screening of new pa- tients, and should also include additional procedures that may be neces- sary such as ICSI, PGD, storage fees for frozen embryos, etc.

2.  Are medications, tests, lab work, ultrasounds, and consultations in- cluded in the cost of treatment?

3.  If necessary, what are the costs, including screening costs, involved when using an egg donor, sperm donor, or surrogate?

4.  What are the typical costs associated with medications?

5.  Does the fertility clinic provide financial counseling and psychological counseling? If so, are there fees for these services?

6.  Does my medical insurance cover any of the medications, testing, moni- toring, or procedures and does the fertility clinic verify coverage or is that the patient’s responsibility?

7.  When is payment due? Is payment required upfront? Is a payment plan available?

8.  Does the fertility clinic offer a reduced rate if you purchase an IVF package?

Surrogacy Costs

The expenses in surrogacy are multifaceted. Not only do you have to consider the costs associated with the ART medical procedures described above but you also have to factor in other expenses such as the “compensation” and/or “payments” to a surrogate, among other expenses.When doing your research on budgets, keep in mind that every state has different standards for costs associated with the process. For example, some states prohibit “compensation” to the surrogate. In these states, the concept of “altruistic surrogacy,” wherein the surrogate does not get paid a fee for her services, benefits the intended parents in that they can only pay the surrogate’s out-of-pocket expenses and medical expenses. However, surrogates looking to be compensated for their efforts will look outside such states, which can thus be a detriment for families in the prohibitive state trying to find a good surrogate match. It’s a “Catch-22.”

TIP: Part of ART is mastering the “art” of formulating a budget for each procedure taking place.

Financial Implications of ART

Compensation and Payments to the Surrogate

The notion of “compensation” and “payment” versus “reimbursement” to a surrogate is somewhat controversial. The language used may carry importance insofar as whether the financial portion of the arrangement could or should be considered “income” to the surrogate for taxation purposes.

A surrogacy contract sets out the financial responsibility, however it may be framed, and creates a payment plan that the intended parents will pay their surrogate. When working with a surrogacy agency, the agency establishes the payments made to the surrogate and there is little to no negotiation between the intended parents and surrogate as to what she will be receiving financially. When self-matching occurs and no agency is involved, the parties, either directly or through the lawyers, negotiate the payment terms to a surrogate. When using a surrogate, with an agency or self-matched, the amounts paid to a surrogate will be different depending on where the surrogacy is taking place.

A surrogacy budget can be broken down into three categories: (i) payments the surrogate should receive, (ii) payments the surrogate may receive depending on whether certain events occur, and (iii) payments to third parties involved in the process.

Payments the Surrogate Should Receive

As seen in most surrogacy contracts, from the moment a surrogate is selected until a determined time after the child is born, intended parents can be “on the hook” for payments to a surrogate for weeks or months post birth (depending on the contract). Below are the common payments made to a surrogate:

Surrogate’s compensation—Again, care must be paid to use of terms such as “compensation,”“payment,”“fee,” and the like. With that said, this is her “base fee” that typically begins once she is confirmed to be pregnant and continues to receive financial support every four (4) weeks thereafter until the child is born. Many surrogacy contracts require the surrogate to reach a certain week of pregnancy in order for her to receive her en- tire agreed amount (for example, thirty weeks, gestation for multiples, thirty-two weeks, gestation for a single child), and if she delivers prior to that determined week, then her compensation would be paid up to that point. A surrogate who has already successfully completed at least one surrogacy will typically be able to receive a higher amount of support than a first-timer.

Life insurance and disability insurance policy for the surrogate—The intended parents are usually required to take out a term life insurance policy and sometimes a disability insurance policy for the surrogate naming someone in the surrogate’s family as the beneficiary in case something happens to her during the pregnancy.

Medication start—The surrogate receives a payment at the start of her injectable hormone medications or other type of medication (not including birth control) to prepare her uterus for the embryo transfer.

Mock cycle—Surrogate may receive a payment should the fertility clinic perform a mock embryo cycle, which is essentially a dry run of preparing the surrogate’s body for the real embryo transfer.

Embryo transfer—The surrogate receives a payment on the day of the embryo transfer.

Monthly allowance—To cover the surrogate’s daily expenses for the pregnancy such as prenatal vitamins, local gas expenses, and groceries, the intended parents may choose to pay the surrogate a monthly allowance instead of the surrogate having to itemize and account for the incidental expense

Maternity clothes—The intended parents pay the surrogate an allowance for maternity clothes. The maternity clothing allowance should be higher if the surrogate is carrying twins.

Surrogate’s travel—Some surrogates live close to a fertility clinic and hospital, but some may live in different cities, states, or countries than the intended parents. In such cases, the intended parents are required to pay for the surrogate’s (and sometimes the surrogate’s partner or spouse) out-of-pocket travel expenses for all procedures involved including the initial screening, monitoring, embryo transfer, doctor appointments, and delivery of the child. The travel expenses may include gas, car rental, taxi, hotels, airfare, trains, and a per diem amount if the travel requires an overnight stay.

Typical Payments the Surrogate May Receive

Loss of reproductive organs—Pregnancy is risky; surrogates are compensated should something happen to any of her reproductive organs during the course of the pregnancy. There is a monetary value associated with the loss of the surrogate’s fallopian tubes, ovaries, or uterus.

Embryo transfer cancellation fee—Some surrogates receive a flat fee if the medications begin but the embryo transfer is cancelled whereby such cancellation is not a result of the surrogate’s intentional actions.

Selective reduction or elective termination—Should a selective reduction or elective termination of the pregnancy occur that is permissible under the contract (i.e., the surrogate did not do these procedures against the wishes of the intended parents), the surrogate receives a fee for having to undergo such procedures.

Invasive procedures—An invasive procedure resulting in a payment to the surrogate will include any procedure relating to the pregnancy requiring administration of IV fluids or an overnight stay at the hospital, with the exception of the birth of any child, such as amniocentesis. Invasive procedures should not include any standard procedures relating to the fertility treatments.

Ectopic pregnancy—Should an ectopic pregnancy occur, the surrogate is compensated.

Miscarriage—Should a miscarriage occur, the surrogate is compensated.

Cesarean section—Should the surrogate require a C-section, the surrogate is compensated.

Multiples—If the surrogate is carrying twins or multiples, she receives additional payments for each fetus.

Bed rest—If the surrogate is placed on physician-ordered bed rest (cannot be self-initiated), the surrogate receives her verifiable lost wages for the days she misses work. Some contracts pay surrogates her net lost wages while others pay gross lost wages. If a surrogate has a short-term disabil- ity (STD) policy, the intended parents will only be responsible for the lost wages that are not covered by the STD policy. The contract should establish how long the intended parents need to pay the surrogate’s lost wages once the child is born. Additionally, some contracts require the intended parents to pay limited lost wages to the surrogate’s partner or spouse for the days they accompany her to certain medical appointments or the delivery of the child.

Childcare and housekeeping—The intended parents may be responsible to pay for the surrogate’s reasonable childcare and housekeeping ex- penses during the pregnancy (this may be covered by the monthly allow- ance), delivery, postdelivery recovery, and if the surrogate is placed on physician-ordered bed rest.

Breast milk pumping—Should the surrogate agree to pump breast milk postbirth, the intended parents should pay either a weekly or monthly fee to the surrogate along with any expenses associated with pumping, such as equipment, milk bags, and shipping. It is important to discuss the parties’ rights and responsibilities insofar as the delivery of the breast milk is concerned. If the milk does not arrive at the par- ents’ home in usable condition, does the surrogate have to forego her payment for that period’s pumping? We believe that the responsibility should be on the parents to ensure (pun) that the milk arrives in useable condition.

Spoiling your surrogate—In an expression of gratitude towards a surro- gate, many intended parents voluntarily spoil their surrogate with tokens of their appreciation such as buying them food, prenatal massages, and gifts for the surrogate and her family. Before you undertake any course of action that is not contemplated in the contract, however, you should check with your attorney to make sure that what you’re planning to do is legal in your jurisdiction!

Payments to Third Parties Involved in the Surrogacy Process

Fertility doctors—The intended parents are required to pay any expenses associated with the fertility clinic for the surrogate and intended parents, which includes the screening of the surrogate, including FDA screening consultations, medications, the embryo transfer, monitoring, blood work, and ultrasounds.

Obstetrician—The intended parents are required to pay any expenses as- sociated with the obstetrician for the surrogate and whatever is not cov- ered by the health insurance of the surrogate.

Hospital—The intended parents are required to pay any expenses associ- ated with the hospital for labor and delivery, including the hospital stay for the surrogate and any complications relating to the surrogate and whatever is not covered by the health insurance of the surrogate. The surrogacy contract should provide how long the intended parents are re- sponsible to pay for the medical expenses of the surrogate once the child is born. Note that the hospital bills associated with the resulting child are charged to the insurance of the intended parents, not the surrogate’s insurance.

Medical insurance review—If the intended parents have the medical insur- ance of the surrogate reviewed by a professional to determine if any ex- clusion for surrogacy applies, they are responsible for any fees associated with this service.

ART lawyers—The intended parents are responsible to pay their attorney to draft the surrogacy contract and handle the court proceedings neces- sary to finalize their parental rights of the child. The intended parents also pay for a separate attorney to represent the surrogate. Other legal costs associated with this process may include court filing fees and certified copies.

Trusts and estates lawyers—It is recommended that the intended parents get their estate plan in order to prepare for the child and are responsible to pay for an attorney to draft any necessary wills, trusts, or other estate documents.

Immigration lawyer—When going abroad to use a surrogate or if the intended parents are from another country, an immigration lawyer is in- volved to ensure the proper citizenship of the child at the expense of the intended parents.

Escrow company—The intended parents pay for the escrow services to administer the payments to the surrogate throughout the surrogacy process.

Background information of surrogate—Usually these expenses are built into the agency costs, but intended parents may need to pay for a crimi- nal background check, home study, or other investigative research on a surrogate.

Surrogacy agency—If the intended parents require a surrogacy agency, they are required to pay the agency fee.

Egg donor agency—If the intended parents require an egg donor agency, they are required to pay the agency fee.

Sperm bank—If the intended parents require a sperm donor, they are re- quired to pay the sperm bank fee or fee to the sperm donor directly.

Psychologist—The intended parents pay for the psychological screening that is required when using a surrogate.

Nutritionist—If the surrogate requires the assistance of a nutritionist, it is at the expenses of the intended parents.

Acupuncturist—If the surrogate requires the assistance of an acupunctur- ist, it is at the expense of the intended parents.

Embryo storage facility—If the intended parents have frozen viable em- bryos, should they want to continue freezing the embryos for a length of time, they are required to pay storage facility fees.

Courier fee—If the intended parents want to have a pro- fessional transport the frozen embryos from one fertility clinic to another the fertility clinic (i.e., if the donor is in another location from where the embryo transfer occurs), they are required to pay for the proper trans- portation of the frozen genetic material.

CAUTION

Do you see a theme here? EVERYTHING is at the expense or at least the responsibility of the intended parent(s). The surrogate is responsible for NOTHING. Yes, hopeful parents, it’s expensive, and the entire burden of such expense is put on you.

Egg Donation Costs

The term donor is really a misnomer as egg “donors” are not generally donating their genetic material without being compensated. Leading ART organizations and ART professionals agree that donors of genetic material should be paid for their time, effort and inconvenience, and that the compensation received is not based according to the planned use of the eggs, the number or quality of eggs retrieved, the number or outcome of prior donation cycles, or the donor’s ethnic or other personal characteristics. The costs associated with egg donation can be separated into two main categories: (i) payments to the egg donor, and (ii) payments to third parties involved in the egg-donation process.

Payments to the Egg Donor

Egg Donor Fee—The egg donor receives compensation for providing her eggs. Such fee is commonly paid in two installments. One payment is required upon the start of injectable medications for the egg donor and the second is required upon the retrieval of the eggs (regardless if any eggs are retrieved and/or the quality of the eggs, unless it was the intentional fault of the egg donor). While compensation to egg donors varies, the American Society for Reproductive Medicine (ASRM) provides guidelines on compensation to donors in that total payments to donors in excess of $5,000 require justification and sums above $10,000 are not appropriate. In addition to limiting compensation, the nonbinding guidelines forbid paying additional money to egg donors for specific traits such as academic history, physical characterizes, or prior success as a donor.

Complications Insurance Plan for the Egg Donor—Intended parents may be required to purchase a complications policy for the egg donor to cover any major complications that may arise during the medical procedures for the egg donor.

Travel for the Egg Donor—The intended parents will pay for out of pocket travel expenses for the egg donor (and sometimes her partner or spouse) to attend any fertility doctor appointments such as the screening, monitoring, and egg retrieval. The intended parents may be required to pay any verifiable lost wages for the donor if she misses work because of the procedures.

Payments to Third Parties Involved in the Egg Donation

Fertility Doctors—The intended parents are required to pay any expenses associated with the fertility clinic for the egg donor, which includes the screening of the donor, including FDA and genetic screening, consulta- tions, medications, monitoring, blood work and ultrasounds, and the egg retrieval.

ART Lawyers—If the fertility clinic or egg donation program does not provide the proper legal documentation, the intended parents pay for their attorney to draft the egg donor contract. The intended parents also pay for a separate attorney to represent the egg donor.

Background Information of Egg Donor—Usually these expenses are built into the egg agency costs, but intended parents may need to pay for inves- tigative research on an egg donor.

Egg Donor Agency—If the intended parents require an egg donor agency, they are required to pay the agency fee. Many fertility clinics provide a database of fresh and sometimes frozen eggs; there are also frozen egg banks available to intended parents. Some egg donor clinics and providers offer shared egg donor cycles where multiple intended parents share in the eggs retrieved from one donor; this may reduce the expense of the eggs for the intended parents.

Psychologist—The intended parents pay for psychological screening that is required when using an egg donor.

Frozen Egg Storage Facility—If the intended parents have frozen eggs, should they want to continue freezing the eggs for a length of time, they are required to pay storage facility fees.

Courier Fee—If the intended parents want to have a professional trans- port the frozen egg from one fertility clinic to another the fertility clinic (i.e., if the donor is in another location from where the embryo transfer occurs), they pay for the proper transportation of the frozen genetic material

Sperm Donation Costs

Sperm donation may be the least expensive piece of the ART pie when compared to egg donation or using a surrogate. Sperm can be obtained from a known donor or through the use of a frozen sperm bank where the donors are usually anony- mous. The costs associated with sperm donation can be separated into two main categories: (i) payments to the sperm donor, and (ii) payments to third parties involved in the sperm donation process.

Payments to the Sperm Donor

Sperm Donor Fee—When a man donates his sperm to a sperm bank, he receives a fee typically per donated specimen, depending on various fac- tors such as the quality of the sperm provided. This fee is typically not paid to the donor directly by the intended parents as they pay a separate fee to the sperm bank to purchase the sperm. If intended parents are ob- taining sperm from a known donor, they may negotiate their own fee for the sperm directly with the donor.

Payments to Third Parties Involved in the Sperm Donation Process

Fertility Doctors—If the intended parents are not getting sperm from a sperm bank or require the assistance of a fertility clinic to screen a sperm donor, the intended parents are required to pay any expenses associated with the fertility clinic for the sperm donor, which includes screening the sperm donor, including the Food and Drug Administration and genetic screening, medications (if any), and consultations.

ART Lawyers—Typically a sperm bank provides the documentation for the sperm donor to sign off on and to relinquish any paternal rights to the donated sperm. However, as seen when using a known sperm donor (like family or a friend), it is imperative that the parties use an ART lawyer to draft the appropriate sperm donation contract. The intended parents also pay for a separate attorney to represent the sperm donor.

Background Information of Sperm Donor—Usually these expenses are built into the sperm bank’s costs, but intended parents may need to pay for investigative research on a sperm donor. Some sperm banks charge extra for an additional child or for adult photographs of the donor, other images or videos of the donor, and handwriting analyses of the donors.

Sperm Bank—If the intended parents require a sperm bank, they are required to pay the clinic’s fee to purchase the sperm. The cost for the sperm depends on factors such as whether the sperm is washed or not, if it is from an anonymous source, and if specifics regarding the background of the donor—such as whether he has a graduate degree, etc.—are requested.

Psychologist—The intended parents are strongly recommended to partici- pate in psychological counseling, at their expense, when considering the use of donated sperm.

Frozen Sperm Storage Facility—If the intended parents have frozen sperm and want to continue freezing the sperm for a length of time, they can ex- pect to pay storage facility fees.

Courier Fee—If the intended parents want to have a professional trans- port the frozen sperm to the fertility clinic or home, they are responsible for paying for the proper transportation of the frozen genetic material.

Estimated Expenses for Surrogacy and Egg Donation

As you see, there are variables that come into play when trying to determine the costs of ART procedures. This only gets more complicated as you add on addi- tional services such as surrogacy and egg donation.

Men Having Babies, Inc. (MHB) is a nonprofit organization that provides invaluable services such as educational and practical information to assist gay prospective parents achieve biological parent- ing, provide consumer feedback on reviews of fertility clinics, and promote the af- fordability of surrogacy-related services for gay men through financial assistance and the encouragement of transparency and customer feedback.

In order to help all people going through surrogacy and egg donation, MHB developed a Surrogacy Budgeting System. The goal was to decipher and harmonize the divergent cost structures involved in the entire surrogacy and egg donation procedure and develop a generic budget, as of 2015, with expected cost ranges per line item involved in the proces

The charts formulated by MHB pools data gathered from fourteen fertility clinics and sixteen surrogacy and egg donation agencies across the country. MHB continues to update these tables and asks that clinics and agencies provide current pricing sheets at least once a year.

While MHB does not publicize each provider’s cost sheet, the broad spectrum of data is used to create a generic budget. The comprehensive listing of all cost components in standardized categories is the first of its kind and provides pro- spective parents a definitive checklist of all possible costs. While many providers do not offer clear or full estimates to all possible cost components, MHB filled the omissions with data from independent experts and from their experience with the couples that have gone through the organization’s assistance program.

The budget is presented in two tables: one has all the nonmedical costs as- sociated with the surrogate: agency and legal costs, compensation, and expenses. The other table has the egg donation and IVF costs: donor matching, legal fees, compensation, and expenses; and medical screening of all parties, IVF treatment, lab fees, medications, monitoring, and other related costs.

Each table includes three columns: minimum estimated expenses, maximum estimated expenses, and the likely cost for each line item on the budget. Note that providers vary considerably in how they define, organize, and price various services. For instance, while most surrogacy agencies quote an “agency/retainer fee,” they vary in how inclusive that fee is. For some, it would include all the re- cruiting, screening, legal, and support functions associated with surrogacy. Others will quote separate fees for some of the items, even if they are not optional or provided by third parties.

In the table, Men Having Babies has listed all of the potential components of each general function or service and provided the minimum and maximum costs Men Having Babies has seen associated with these components when they are quoted separately. However in the “Likely cost” column Men Having Babies has only listed the costs associated with the components that are likely to be item- ized, and assumed all the other components should be included in the general agency fee.

The tables include estimated totals per stage or general grouping, such as medical screening or IVF treatment, which are shaded in gray. Each page is also totaled, and these numbers are highlighted in yellow. When considering these numbers, please keep in mind the following notes:

The totals of each category represent averages of the respective totals across the various providers, but are not always the arithmetic sum of all the itemized components (since not all of these items are necessary or quoted separately).

To arrive at cost estimates of the entire surrogacy and egg donation, you will need to add up the total of both tables. Currently that would amount to a minimum of $83,000, a likely cost of $122,000, and a typical $191,000 for the high end of the spectrum.

These totals include only a basic journey—namely they do not include costs associated with having twins, optional medical procedures (such as preimplantation genetic screening), or when more than one IVF cycle is needed (which is the case in about 30 percent of the times). The tables can allow you to calculated likely costs for these scenarios and others, and factor them in based on your circumstances and level of risk aversion.

While these tables were created by compiling the most up-to-date data from clinics and agencies around the United States, they are only offered as a budgeting aid. Anyone embarking upon a surrogacy and egg donation journey needs to formulate their own budget based on the specific services required and the actual providers being utilized.

In order to better understand the MHB tables, some abbreviations are used as follows:

 GC—gestational surrogate

 IP—intended parent

ED—egg donor (or sometimes: egg donation)

ACA—Affordable Care Act health insurance policy

LL—Lloyd’s of London health insurance policy

MMPI—Minnesota Multiphasic Personality Inventory test

 

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