But help came through a call to Dr. Sanford Rosenberg, a fertility specialist in Richmond, Va., who had started a program capitalizing on lower medical costs overseas. By using an egg donor from Romania and having the eggs fertilized in Bucharest and shipped back to the United States, the Butuceanus cut their costs to $18,000, including enough fertilized eggs for repeated efforts.
For the newlyweds it was worth it, with the embryos blossoming into an easy pregnancy on the first try.
‘I have two beautiful little boys, they’re the love of my life,’ Ms. Butuceanu said of her six-month-old twins, Cristian Joseph and Nicolae Alexandru, who happened to be conceived in Romania, her husband’s native country. ‘I used to think that the only people who could go through in vitro were doctors and lawyers and their wives, people with a ton of money.’
The vast majority of Americans who are infertile look for help close to home. A small number, though – no one keeps an official count – are seeking help in places like South Africa, Israel, Italy, Germany and Canada, where the costs can be much lower, becoming in essence fertility tourists.
‘For the price of one I.V.F. cycle in the U.S.A. the patient can come to South Africa, have the treatment done here in Cape Town and have a lovely holiday at the same time and still take some cash home,’ said Dr. S. Sulaiman Heylen, a fertility specialist at the Cape Fertility Clinic in Cape Town.
The National Center for Health Statistics estimates that about 10 percent of the childbearing population (or six million couples) suffers from infertility, a number that could increase if women continue to delay childbirth until later ages, as Ms. Butuceanu did.
While fertility specialists say that only about 10 percent of infertile couples could make use of high-tech treatment like in vitro fertilization and that in vitro and similar services account for less than 3 percent of infertility services, that percentage still translates into more than 100,000 in vitro efforts a year, according to the latest figures from the Centers for Disease Control and Prevention.
In the United States, the average cost of a single in vitro effort is $12,400, and insurance usually does not cover the procedure. For some, cutting costs by booking a flight and spending a week or more abroad for treatment seems like an easy step in the desperate quest for a baby.
‘There’s a network of people, and lot of information is on the Internet now,’ said Shannon Abbey of Woodbine, Ga., a 35-year-old Navy wife who had her son Noah Michael Chase last June, after two in vitro cycles at a clinic in Naples. ‘People are more willing to tell you where they went, how they got there, the name, the address.’
Ms. Abbey, for instance, learned that several Navy wives on herhusband Kevin’s ship, the La Salle, had gone to Italy for helpconceiving. She moved there while her husband was mostly deployed at sea, in the Persian Gulf and elsewhere. The prices in Italy ranged from $2,500 to $4,000 for treatments, and a few hundred dollars for medications that cost thousands in the United States.
Now, she is in touch with Navy wives and other couples who are flocking everywhere for in vitro fertilization: Colombia, France, Belgium, South Africa, Malaysia, Singapore.
‘I believe it’s just about money,’ said Pamela Madsen, executive director and founder of the American Fertility Association, an advocacy group for fertility patients. ‘It’s not about the availability of technology. We have approximately 355 I.V.F. centers in the U.S., so no matter where you live there’s at least one I.V.F. center.’
‘But we have many couples who travel to Israel. I hear about it in Belgium,’ she said, adding that she had just been approached by an Israeli group opening a center in the Dominican Republic to attract American women.
‘Isn’t it a travesty that American couples are forced to leave our great nation because only 14 or so states require insurance companies to treat infertility? Less-developed countries, nations struggling with war, understand the importance of family. What does it say about the value we put on families and children?’
But many fertility specialists cast a more critical eye on going abroad. Even Ms. Madsen cautioned that some foreign clinics might offend American sensibilities when it came to waiting time or levels of pain medication.
Others raised substantive concerns about regulation of overseas clinics, genetic testing, standards for egg donors and language barriers, not to mention the difficulty in comparing pregnancy rates in American clinics with those abroad. Much depends on the woman’s age and the reasons for the couple’s infertility.
‘It’s a mixed bag,’ said Richard T. Scott, director of the Assisted Reproduction Program at Reproductive Medicine Associates of New Jersey, one of the largest programs in the country, with 4,000 new patients a year. ‘Pregnancy rates are substantially less in Europe than in the U.S. and have been for 10 years. You pay less, but have less chance of taking home a baby.’
As for fertility tourism, ‘I think people are talking about it more,’ Dr. Scott said, adding that it remains rare. ‘If there’s anything we see, it’s people going home for a donor of particular ethnicity. We have Jewish couples who go to Israel for a Jewish egg donor. People have gone to Taiwan and Korea for those reasons.’
Dr. Scott and others speculated that new Food and Drug Administration guidelines on tissue donation that will take effect in May could mean more stringent oversight, as well as higher costs for sperm donation or frozen embryo transfer – which could hinder efforts like Dr. Rosenberg’s or push more people out of the United States.
Sean Tipton, a spokesman for the American Society for Reproductive Medicine, said that anecdotal information suggested that many more people came here for fertility treatment than Americans who went abroad.
Many factors make fertility treatments more expensive in the United States, Mr. Tipton said. They include higher overhead, lack of insurance coverage and the absence of government financing for research involving human embryos.
Some clinics in the United States are trying to reduce costs. The steps they have taken include guarantees that for a set fee, they will continue fertility treatments for as many as six times until a woman becomes pregnant. But typically, clinics offer such options largely to women under 35, who are more likely to succeed on fewer tries.
So people shop around.
While Dr. Rosenberg has a partnership with a fertility center in Romania, other women and couples go directly to other countries. Often, the way is paved because the husband is overseas on military duty or one of the potential parents is a native of the country in question. It makes an already fraught situation easier.
Monica Chwojdak, 32, whose husband, Brian, is an Army officer stationed in Hohenfels, Germany, will try her third in vitro cycle in Germany next month, even though her research suggests that the Germans do less genetic testing and implant less-developed embryos than Americans do, she said.
But her last cycle cost less than $5,800, compared with the $10,000 to $12,000 Ms. Chwojdak was quoted by civilian clinics in the United States and $6,000 to $8,000 by a program affiliated with Walter Reed Army Medical Center. After learning that one of her tubes was blocked (‘I was devastated’) and that in vitro was her best option, she was determined to keep trying.
‘We’re still working off savings,’ Ms. Chwojdak said. ‘We couldn’t do that if we had to pay for it in the U.S.’
A 42-year-old Detroit woman, who did not want her name used to maintain her privacy, returned to her native Johannesburg for two cycles of in vitro because it was cheaper than at home, even with airfare. The procedures did not work, and even though she eventually became pregnant without intervention, she fumes that she had to go abroad.
Some Jewish women go to Israel because it is easier to make certain there that in vitro is performed in accordance with Jewish law. The country has about 30 major fertility centers. All over Israel, the Puah Institute offers counseling and referrals and other assistance to couples with fertility problems, fielding 150 calls a day. For Israeli citizens, in vitro is free. It costs others about $6,500 a cycle, with much cheaper medication on average than in the United States.
‘There are more Americans for sure as time goes on,’ said Rabbi Yonatan Adler, the director of Puah’s public relations.
One reason is religious, the other is cost. Older women are more likely to be accepted, too. Rabbi Gideon Weitzman, who heads the institute’s English-speaking section, said, ‘People are exploring the possibilities.’
Like Ms. Abbey. She recalled methodically pricing Thailand at $3,000 but deciding that the medicine was too primitive, ruling out London at $7,000 a cycle, and dismissing Germany for low success rates. But everything was better than the upwards of $18,000 for a doctor and treatment that she was quoted when they lived in Modesto, Calif. The total cost for her two in vitro efforts in Naples was less than $8,500, she said.
‘People will do anything for a baby,’ Ms. Abbey said. ‘There’re women out there who’ve hocked the house. So what’s the big deal about taking your passport and leaving the country?’