Address Line 1
Address Line 2
City, State/Province Postal Code
August 8, 2011
Complaint Review Committee
Address of Complaint Review Committee
Address line 2
City, State/Province Postal Code
Dear Complaint Review Committee,
My current medical insurance covers Gamete Intrafallopian Transfer (GIFT) infertility treatments,
yet provides no coverage for in-vitro fertilization (IVF). I am writing to request that coverage for
IVF be substituted for GIFT coverage.
I have prepared numerous reasons that IVF should be substituted for GIFT including
obsoleteness, efficacy, invasiveness, patient risk, diagnostic benefit, cost, precedence of
coverage, and patient rights. I elaborate on these reasons below.
Obsoleteness: GIFT is rarely performed. It is a widely accepted fact by the reproductive
medicine community that GIFT is an outdated form of treatment. Some physicians admit that
GIFT is performed so infrequently, that the standard of care is compromised. GIFT procedures
contributed to less than 1% of the 99,639 Assisted Reproductive Technology (ART) procedures
performed in 2000 reported to the Centers for Disease Control and Prevention (CDC) (see figure
1). A total of 383 clinics across the United States reported ART data to the CDC for their 2000
ART report. Please see Appendix A: Clinic Testmonials - Why IVF is performed in favor of
GIFT/ZIFT for more information.
Efficacy: IVF offers greater success rates than GIFT. GIFTs performed in 2000 resulted in a
success rate of 24.5%, as compared to the 31% success rate of IVF (see figure 2). It should be
noted that the percentages of successful IVF procedures are considered more reliable than the
GIFT percentage, statistically speaking, since the population of IVF procedures performed is
greater than the GIFT population (significantly more IVF procedures were performed than
Invasiveness: IVF is less invasive than GIFT. GIFT is performed in an operating room and
requires laparoscopic surgery involving two incisions. IVF, on the other hand, does not involve as
much as an incision. The first step of IVF includes transvaginal ultrasound guided egg retrieval.
The second step consists of trans-cervical embryo transfer which is a similar procedure to intra-
uterine insemination (IUI).
Patient Risk: GIFT subjects patients to greater risk than IVF. GIFT requires laparoscopic
surgery and thus carries substantial surgical risks. In contrast, IVF is performed under sedation
anesthesia. GIFT risks include:
1 Ectopic pregnancy
2 Multiple birth: Since eggs and sperm are transferred immediately into the fallopian tube in
GIFT, there is no way to observe fertilization nor is there a way to accurately control the
number of fertilized eggs which will implant. In 1998 multiple births occurred in 28% of
GIFT pregnancies and 20% of IVF pregnancies.
3 Accidental bowel injury: Patients who have had previous surgery (and this applies to
many requiring ART) may have bowel adhesions. This increases the risk of injury to the
bowel. Any injury must be repaired immediately to avoid peritonitis (infection of the
4 Superficial hemorrhage: Some bruising around the puncture marks or abdominal wall is
5 Retained "gas": The carbon dioxide gas which is placed into the abdomen during
laparoscopy may not all be expelled at the end of the operation; again this is more usual
in patients with adhesions. This may provide some discomfort under the ribs or in the
6 Risk of general anesthesia, including the possibility of death.
Figure 1: This diagram taken from the CDC 2005 ART report illustrates the infrequency of the
Figure 2: This diagram taken from the CDC 2000 ART report compares the live birth rates per
retrieval of GIFT and IVF.
Diagnostic Benefit: IVF offers diagnostic benefit while GIFT does not. Since the nature of
IVF allows observation of fertilization outside of the body, IVF provides a diagnostic benefit.
Fertilization may not occur. If fertilization is observed, it’s possible that implantation does not
Cost: IVF is less expensive than GIFT. GIFT is often more expensive than IVF since GIFT
requires the use of an operating room, laparoscopic surgery, and general anesthesia. IVF allows
for cryopreservation of unused embryos for subsequent pregnancy attempts, at a reduced cost.
Since IVF presents lower risk of multiple births than does IVF, cost of multiple birth delivery is
Precedence of Coverage: Precedent exists for substituting IVF for GIFT for <Name of
Insurance Company> subscribers. Based on my research, at least <number> other <Name of
Insurance Company> members were allowed to substitute IVF for GIFT coverage.
Patient Rights: Patients suffering from infertility are protected under the Americans with
Disabilities Act (ADA). On June 25, 1998 the U.S. Supreme Court ruled that infertility is a
disability in the Bragdon v. Abbot case, and that individuals diagnosed with the disease of
infertility are protected under the ADA. The ADA defines a disability as a "physical or mental
impairment that substantially limits one or more of the major life activities of such individual." To
be protected under the ADA, a person must have a physical or mental impairment that affects a
major life activity. Physical or mental impairment has been defined in the Code of Federal
Any physiological disorder, or condition, cosmetic disfigurement, or anatomical loss
affecting one or more of the following body systems: Neurological, musculoskeletal,
special sense organs, respiratory (including speech organs), cardiovascular,
reproductive, digestive, genital-urinary, hemic and lymphatic, skin, and endocrine; or …
It was the Bragdon v. Abbot case that ruled that infertility affects a Major Life Activity. According to
Resolve, The National Infertility Association, “employers, insurance companies, and legislators
should now take steps to follow the Supreme Court’s lead and recognize that reproduction is a
Major Life Activity.”
In 2001, New Jersey state government passed the Family Building Act which mandates infertility
coverage in the state of New Jersey and includes coverage for IVF procedures. I feel that the
factors that convinced New Jersey legislators to pass this legislation are applicable to my appeal.
Resolve of New Jersey supplied these factors:
1 Infertility does not discriminate.
2 Nationally, 6.1 million people – of every age, ethnicity and economic class – are
coping with the disease. They share a deep desire to have a family and the inability to
3 High-tech medical advances offer hope to many couples. However, decisions on
treatment too often are made for financial rather than medical reasons. Insurance
coverage is spotty; out-of-pocket expenses can climb into the thousands.
4 Some couples opt for procedures less likely to succeed because those procedures are
covered by insurance. Others are forced to choose between treatment and adoption
because, if treatment fails, they cannot afford both.
5 Surgically invasive treatments that are no longer the standard of care are often
covered by insurance. This results in women unnecessarily undergoing invasive
surgery with risk of complications, lower success rates, and greater expenses for
6 There is a correlation between lack of adequate insurance coverage and a higher
multiple birth rate. Infertility insurance coverage has been demonstrated to result in
fewer higher-order multiple births. This is cost-effective for insurers and promotes
quality of care for mothers and their babies.
7 Medical studies indicate that increased use of IVF could reduce the most costly,
controversial and harmful side effect of infertility treatment: having too many babies at
once. Multiple births increase the risks of death, injury or permanent handicap to
mothers and babies. Costs can soar. A triplet delivery can exceed $340,000.
Given the significant difference in regional success rates, I would like to undergo IVF at an out-of-
network provider, specifically at <Name of Preferred IVF Clinic>. My informed medical decision
was based on research published by the CDC. The clinic that I have selected, <Name of
Preferred IVF Clinic>, offers significantly higher success rates than the clinics in <Your Region>. I
examined the 2000 live birth rates per embryo transfer of three IVF clinics in my area. The
average live birth rate per embryo transfer for these clinics is <Number>%. As you can see, there
is a significant difference in this average success rate compared to the success rate at <Name of
Preferred IVF Clinic>, which is <Number>% (see table 1). By selecting a clinic with a relatively
high success rate, I subject myself to less risk and cost by reducing the probability of the need to
Table 1: The following chart lists live birth rates per embryo transfer for several clinics in my area
for patients under the age of <Number>. The average live birth rate in my area is <Number>%.
Clinic Name Location Live birth rate per embryo
<Clinic Name> <Location> <Number>
<Clinic Name> <Location> <Number>
<Clinic Name> <Location> <Number>
<Preferred Clinic Name> <Location> <Number>
Please feel free to contact me at any time if you require more information. Thank you for your time
and attention to this matter. I look forward to hearing from you.
<Your Name Here>
<YOUR CONTACT INFO>
Appendix A: Clinic Testmonials - Why IVF is performed in favor of GIFT/ZIFT
Clinic 1, City, State (Date)
We do GIFTS including for people who want in vivo (in the body) fertilization, and women over 40
who have failed regular IVF. We rarely if ever do ZIFTS- they have the lowest success rates and
always were an over-hyped option- combing tubal growth after proven fertilization- all to
compensate for poor labs- our coculture system is much better.
Clinic 2, City, State (Date)
We are one of the leading fertility Centers in the Cincinnati area. We do not do GIFT or ZIFT on a
regular basis. The reason why is that both are invasive operative procedures. If you don't become
pregnant with the GIFT procedures you do not gain any information about fertilization or egg
sperm interaction. These procedures become passé as the IVF laboratory techniques advanced
in technology. GIFT would be acceptable if the couple had religious beliefs that dictated that
fertilization occurred in the tubes.
Clinic 3, City, State (Date)
We no longer offer GIFT or ZIFT for two reasons: one, we were doing them so seldom it was very
hard for the staff to stay skilled at the procedures and they are both much more risky procedures
than simply an egg retrieval. Second, which applies to the first, the need for the procedure had
lessened due to better culturing conditions in the lab for the embryos over the years. Our IVF
pregnancy rate was equal to or better than that of GIFT or ZIFT, so there was no need to continue
offering the procedures. Many Centers have stopped offering them for the same reasons.
Clinic 4, City, State (Date)
We do not offer GIFT or ZIFT. These procedures are extremely expensive and not as successful
as IVF, which is half the cost.
Clinic 5, City, State (Date)
We do offer both GIFT and ZIFT, but, with IVF being as successful as it is, the indications for
doing GIFT and ZIFT with the extra surgical risk and cost are very few anymore.
Clinic 6, City, State (Date)
We do perform [GIFT and ZIFT], but there is really little indication for its use. Their success rates
are significantly lower in good IVF practices.
Additional information from [clinic website URL]: “[GIFT] has fell out of favor at most successful
IVF programs since IVF pregnancy rates in those programs are equal to or surpass those
resulting from GIFT. Additionally, GIFT requires an additional and more invasive procedure with
the addition of general anesthesia. We offer GIFT at [clinic name] to those patients who, for
religious reasons, are more comfortable with the more "natural" fertilization process that takes
place in the fallopian tubes.”
Clinic 7, City, State (Date)
The GIFT/ZIFT procedures require a laparoscopy surgery and IVF is less invasive. No surgery is
Clinic 8, City, State (Date)
I am sorry we do not offer [GIFT nor ZIFT] we strictly do In Vitro here there is a much better
success rate. The other procedures are an older way of doing it and In Vitro is much more
Clinic 9, City, State (Date)
[Doctor name] has asked me to respond to your e: mail. He states that we no longer offer GIFT
because the success rate for IVF is better, the cost is less and the IVF procedure is less invasive.
The ZIFT procedure is no longer used because of the great success with ICSI (intracytoplasmic
injection). We are able to achieve about an 80% fertilization rate with ICSI.
Clinic 10, City, State (Date)
[Clinic name] does not routinely perform Gift or Zift procedures. Our logic is that when gametes
are harvested, it makes not [sic] sense not to fertilize them in vitro to determine if the fertilization
process is a factor in the infertility diagnosis. Most of the cost of an infertility cycle have [sic] been
experienced with Gift or Zift, but you do not get the critical fertilization information. We therefore
prefer using the IVF procedure when compared to Gift or Zift. Gift or Zift procedures are common
among practices that do not have IVF capabilities.