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  Seeking treatment a matter of cash and culture By Gary Rotstein, Post-Gazette Staff Writer Infertility treatment is a significant part of practicing medicine for many obstetrician-gynecologists, but Dr. Robert Kisner isn't one of them. His East Liberty office receives a high proportion of low- to moderate-income women, and infertility problems are seldom their reason for seeing him. "They are pursuing pregnancy at a younger age when they have less problems conceiving," Kisner said. "People of lower income . . . they're usually not delayed, which is a problem for professional couples." And, he noted, if his patients do have problems conceiving, they typically move on with their lives, "more likely to let Mother Nature take its course." The doctor's observations from practicing medicine in the city for 25 years point to one seldom-discussed aspect of modern infertility treatment: the distinction between how affluent, well-educated couples approach the issue compared to those with fewer advantages. A monthly cycle of fertility drugs alone can easily run $2,000. If an extreme remedy like in vitro fertilization is pursued along with the medications, the costs for one gamble on a baby may reach $10,000. Such figures leave most of the playing field of infertility treatment -- especially more advanced methods -- to those with either sizable income or the type of job that carries attractive insurance coverage. And because many insurers balk at covering infertility treatment, it helps patients if they're savvy enough to fight through bureaucratic roadblocks to obtain coverage of services. "You hear about this being a yuppie disease, which it clearly is not, but it may be that well-educated, high socioeconomic status families know best how to work the system, and they have the necessary resources," said Shawn Pipton, spokesman for the American Society for Reproductive Medicine. The 1995 National Survey of Family Growth found that more than 20 percent of women with middle incomes or higher had obtained infertility services at some point in their lives, compared to 14.2 percent of those below the poverty line. That's probably due to a combination of the more affluent women both having access to treatment and the need for it from postponing childbirth attempts. In 1995, 49 percent of female college graduates 22 to 44 years old had no children, compared to just 8 percent of those without a high school diploma. Like income and education, a couple's race can also influence the likelihood they'll pursue infertility treatment. The 1995 national survey showed whites were 2 1/2 times as likely as blacks to have used fertility drugs, and four times as likely to have used assisted reproductive technologies such as in vitro. Black income levels are generally not as high as those of whites, but Dr. Lori-Linell Hall, a black reproductive endocrinologist who practices in Wexford, believes the distinctions go beyond those disparities. "There's a cultural thing where the African-American community is somewhat wary of the technology," she said. "I think there's a cultural bias against it." Monthly meetings of the Resolve infertility support group at UPMC Shadyside rarely draw more than one black face among the 20 to 30 visitors, and often not even that. Couples are more likely to drive there from 50 minutes away in Westmoreland County than five minutes away in Garfield or Homewood. When the issue of increasing access to infertility treatment is debated, it still largely ignores those with low incomes. Lobbying efforts nationally and in state legislatures focus on proposals to mandate that insurers cover infertility treatment. Eight states currently require that in some form. But to have insurance, one usually must have a decent job. Medical assistance in Pennsylvania provides no coverage of infertility treatment. State resources aren't even available to low-income couples in Massachusetts, which has the nation's toughest law forcing private insurance providers to pay for the treatment. Professor Alan Meisel, director of the University of Pittsburgh's Center for Medical Ethics, doesn't see the disparity in access to infertility services as much different from how America treats the poor in various essentials of life. "In fact, one could argue that one's own health is more crucial than the possibility of creating more people," Meisel said. "The failure to provide [poor people with quality] health care, food, clothing, housing, transportation -- those strike me as worse affronts to human dignity because they interfere more with becoming a full human being." Kisner said that if any of his patients feel exploited or cheated out of infertility services, he hasn't heard of it, and he doesn't see any injustice himself. "I don't know of any better way of doing it," the doctor said.
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