(FORTUNE Magazine) – LIKE ALL MY friends, I thought that when we started trying to have a baby it would just happen.'' So says Nancy Ameen today, four years after she and her husband, Toby Hoden, decided it was time to start a family. Ameen, now 35 and a lawyer with a large New York City firm, says that when she wasn't pregnant after seven months, ''I had the feeling that something was wrong. Most of my friends had gotten pregnant after about four months.'' So she and her husband sought the help of a fertility specialist at the highly regarded Center for Reproductive Medicine & Infertility at New York Hospital-Cornell Medical Center. After a year of unsuccessful drug treatments and inseminations with her husband's sperm, Ameen was despondent. ''Having a baby was all I could think about. I was finding it more and more difficult to concentrate at work. Toby felt so bad, because there was nothing he could do to make it better. Infertility is the kind of experience that you have to handle together, or else it will tear your marriage apart.'' In December 1992, Ameen's doctor suggested that the couple try in vitro fertilization (IVF), a process by which an egg is retrieved from the woman and fertilized with her husband's sperm, and the resulting embryo transferred back into her uterus. ''We immediately agreed to try IVF, but because there was such a long waiting list at Cornell, I couldn't do it until April,'' says Ameen. ''That was tough, because once you make up your mind to do it, you just want to get on with it.'' In the weeks leading up to the procedure, Ameen's husband had to inject daily doses of powerful hormone drugs into her hip. Along with the shots there were countless 7 A.M. trips to the hospital for blood tests and sonograms. ''If you didn't get there early, you'd wind up waiting forever,'' she recalls. ''Usually 30 or 40 women were waiting to have the same things done.'' Ten days after the IVF, Ameen went back to Cornell for a pregnancy test. ''Waiting for the results of that test was one of the most stressful things I have ever been through,'' she says. ''The hospital finally called at 6:30 that evening and told me I was pregnant, but said I had to go back for another pregnancy test a week later. That whole week I was depressed because here you are, completely elated by the news you are pregnant, but at the same time you're afraid you might lose it.'' The second test also came back positive. On January 22, 1994, Ameen gave birth to a daughter, Olivia. Though the potent mix of exhilaration and exhaustion that is parenthood has replaced the fear and uncertainty of the past three years, Ameen's struggle with infertility has left its mark. Says she: ''The most terrifying thing for ! me was thinking, 'What if I never get pregnant?' If someone had told me when we first started trying that it was going to take me ten years to conceive but that I would definitely get pregnant, that would have been easier for me to deal with than never knowing whether it would happen at all.'' There is a good chance that you may be familiar with what Ameen and her husband have gone through, or at least know someone who is. More than five million Americans -- or one out of every six couples of reproductive age -- experience some form of infertility. Contrary to popular perception, it's not just a woman's problem. The American Fertility Society (AFS) in Birmingham, Alabama, reports that nearly 40% of all cases of infertility are due to the male (low sperm count, poor sperm quality). Another 40% can be traced to a female condition (ovulation problems, fallopian tube damage or disease, or hormonal imbalances). In 20% of the cases, either both the man and the woman are infertile or doctors cannot determine where the problem lies. Based on these figures, and all the attention infertility has received, one might assume that it is epidemic. That is not the case. The National Center for Health Statistics (NCHS) points out that the infertility rate for women ages 15 to 44 has actually fallen since 1976. What has increased is the segment of the population most likely to have trouble conceiving: couples who have delayed childbearing and in which the woman is between the ages of 35 and 44. A 1990 study by the NCHS showed that among childless couples, 36% with a woman in that age bracket suffered from infertility, vs. 20% with a woman between 25 and 34, and just 8% with a woman 15 to 24. Says Dr. Zev Rosenwaks, head of Cornell's infertility program: ''There is no question that a woman's age is one of the contributing factors of infertility. When you delay childbearing, you have a higher chance of taking longer to conceive or not conceiving at all.'' THE INABILITY to have a baby can turn a couple's life upside down. Aside from the financial strain, the experience can be an emotionally charged ordeal that tests even the strongest marriages. Says Jim Gordon, 35, a Tupperware executive who for eight years has been trying with his wife, Kathy, to have a baby: ''Being around other people with kids really hadn't been that big an issue for me in the beginning. But now I'm starting to look at people with small children, and there's a feeling of envy, and that creates its own tension in the marriage.'' Patricia Saltzman, 28, who just finished her first IVF treatment, says bluntly, ''Your whole life is consumed by it.'' Dr. Linda Applegarth, a psychologist who counsels infertile couples at Cornell, says the lack of control over the outcome of infertility treatments is often the hardest thing to deal with. ''If these people were studying for an exam, they would know exactly how to get an A. But here they work and work and still don't get a payoff. I tell them it's normal to become frustrated or mad or obsessed by the whole process.'' Says Nancy Ameen: ''For the first time in my life, it didn't matter how hard I worked or how much I tried. Getting pregnant was beyond my control. Infertility is a very humbling experience.'' The men and women we spoke to for this story were remarkably open and intensely emotional in describing their experience with infertility. For some, just talking seemed to be a release. Others leaped at the chance to address the misconception that infertility is an ailment of selfish yuppies or one that could be cured if they would just relax. Says Kathy Gordon, 34, Jim's wife: ''We've been on cruises. We've been on vacations. That's not the answer.'' In several instances professionals with whom we spoke simply to gather statistical or financial information wound up coming forth with their own personal stories. Consider John Welch, 40, an executive with A. Foster Higgins & Co., the employee benefits consulting firm. When we called to request figures on how many companies cover employees' infertility treatments, he first offered details of the treatments he and his wife had been through in trying to conceive. The Welches endured five cycles of insemination with John's sperm and two IVF procedures. Several years ago, when they were beginning their first IVF treatment, Welch arrived at the hospital with his sperm sample, gave it to the nurse, and prepared to leave. ''She said, 'Wait, we have to see if this is enough,' '' recalls Welch. ''I just looked at her and said, 'Lady, it better be. I'm not 18 anymore.' My wife and I laughed about it later, but believe me, there really is no fun in any of this.'' There is now, though. The Welches have two children, including a baby boy born last month. Though some physicians bristle at the suggestion, infertility has become big business. Harley Earl, chief operating officer of the Pacific Fertility Medical Center in San Francisco, figures it to be a roughly $2-billion-a-year industry. That includes money spent on drugs, lab work, hospital tests, and surgeries, as well as IVF and other high-tech procedures. A single procedure -- or cycle -- of IVF, including drugs, averages $6,200, although it can cost up to $10,000 on the East and West coasts. Nearly 300 hospitals and clinics in the U.S. offer assisted reproductive technologies, up from 84 in 1985. But at a time when the baby-making business is booming, there are still sensitive issues that potential parents -- and society as a whole -- must address. Couples need to ask themselves how big a role they will allow science to play in their having a baby, and for how long. Who should pay for infertility treatments? Some insurance companies and corporations cover a portion of the bill, but most costs are borne by couples who can afford to pay, meaning that few lower-income couples have access to the treatment. Who should oversee programs that treat infertile couples? Clinics using any of the high-tech methods report their success rates on a strictly voluntary basis to the Society for Assisted Reproductive Technology (SART), which is an affiliate of the American Fertility Society. (Clinics that fail to report lose their membership in SART.) Patricia Saltzman and her husband, Ira, are just entering the world of high- tech reproduction. Patricia, a business systems analyst with Met Life Insurance in Bridgewater, New Jersey, began seeing an infertility specialist a year ago when, after nine months of trying, she and her husband were unable to conceive. ''I felt kind of foolish going to see my doctor for this because I was still pretty young,'' says Saltzman. ''But he told me my advantage was precisely that I was young.'' Since Saltzman menstruates irregularly, her doctor at Saint Barnabas Medical Center in Livingston, New Jersey, started her out on a series of hormones to help stimulate ovulation. Failure to ovulate is one of the primary reasons a woman is unable to conceive. At one point, Saltzman became pregnant, but she miscarried a week later. ''You tell yourself not to get too happy because you might lose it,'' she says. ''But I have to say, for that one week I was happy. When I miscarried, it was awful, just devastating.'' AFTER IT BECAME clear that drugs alone were not working, Saltzman had a laparoscopy. The procedure involves inserting a telescopelike instrument through a small incision in the naval, allowing the doctor to see if the fallopian tubes are blocked. In Saltzman's case, they weren't. Since doctors had already determined from earlier testing that the problem was not with her husband, IVF was the next logical step. Her procedure took place at the end of June. In one respect the Saltzmans are lucky. Patricia's employer will pay 90% of the costs for three IVF attempts. The drugs she must take cost roughly $2,000 a month, and they are 80% covered. Still, nothing can prepare a couple for the emotional and physical effects of IVF. Powerful hormone drugs such as Clomid, Pergonal, and Metrodin can cause severe mood swings. ''I'm usually a happy, up person,'' says Saltzman. ''But these drugs make you hysterical. I was crying all the time and found it difficult to concentrate at work.'' Some people also worry that the drugs might cause cancer later in life. ''The only studies done on this subject are inadequate,'' says Dr. Geoffrey Sher of the Pacific Fertility Medical Center in San Francisco. ''But right now there is no conclusive evidence showing a link between fertility drugs and ovarian cancer.'' Stress levels can soar when frequent doctor visits have to be juggled with a demanding schedule. Saltzman's workday starts at 7 A.M., which means that blood work and other tests have to be done at 6:15 A.M. ''I think I see my doctor more than my husband,'' she says with a small laugh. Saltzman wonders what she and her husband will do if the three IVF attempts her company pays for are unsuccessful. ''Do we start trying to save and pay for them ourselves?'' she asks. ''I don't know. People say, 'You're young, don't worry.' But what's the difference if you're young and going through hell or if you're old and going through hell? It's still hell, isn't it?'' PERHAPS the most misunderstood -- and misleading -- aspects of infertility treatment are just how successful any of these procedures actually are and how skillful individual clinics are in using them. According to the AFS, the average success rate for IVF, the most popular of the high-tech treatments, is 15.2%. That means, on average, that 15% of the couples completing one cycle of IVF will deliver a live baby. The odds seem pretty low -- until you consider what nature deals out. Dr. Benjamin Younger, medical director of AFS, says the chance that a reproductively normal couple will conceive in any one month is only between 20% and 25%. ''People look at that 15% average success rate for IVF and think it compares with a 100% chance of conceiving,'' he explains. ''That's just not how it works.'' Interpreting the success rates of individual clinics involves more than looking at the numbers. From the reports SART publishes, it is relatively easy to determine which programs far exceed, or fall far below, the average. But the picture gets murky when patients compare results among the majority of the clinics, which fall somewhere in the middle. That's because the data say nothing about the quality of the program or the type of patients the clinic is dealing with. Are the patients ones who have failed to become pregnant at other clinics and thus could be among the most difficult to treat? In that instance, an otherwise excellent clinic might not have the highest success rates. Conversely, if a program tends to deal with couples who are younger or who have relatively treatable forms of infertility, its results might be quite impressive. Says Dr. Joseph D. Schulman, head of the Genetics & IVF Institute in Fairfax, Virginia: ''A patient has to ask the doctor, 'What are the chances that a person of my age, with my particular medical background and problem, will get pregnant and deliver a baby?' That's what is meaningful.'' Equally meaningful is, who pays for the treatment? A 1992 survey by A. Foster Higgins & Co. showed that 34% of 1,695 large private and public companies with indemnity insurance offer some type of infertility coverage. Kenneth Sperling, a principal with the employee benefits consulting firm Hewitt Associates, says the companies that pay for treatment often see it as fitting in with their corporate culture and philosophy. ''They look upon infertility as something catastrophic that can seriously affect worker productivity,'' he says. ''Companies that don't cover it tend to believe they should only pay for treatments that correct a condition, not those that help achieve a condition, such as pregnancy.'' The flaw with that reasoning, say infertility experts, is that these same companies will pay for tubal surgery, a procedure done almost exclusively to help a woman become pregnant. However, tubal surgery costs nearly twice as much as a cycle of IVF, requires a longer hospital stay, and ultimately has a much lower success rate. Says Ellen Witman, a legislative consultant for Resolve, a national infertility education organization: ''Some women have two or three surgical attempts to repair blocked or damaged fallopian tubes because this treatment is covered by their insurance but IVF is not.'' President Clinton's health care reform proposal does little to clarify the issue. While his plan includes coverage for most infertility treatments, it specifically excludes IVF. Why? ''Because most insurance companies exclude it now,'' says Witman. Only ten states have mandates requiring insurance companies to cover or offer coverage of infertility treatment, some of which include IVF (companies that self-insure, as most large companies do, are exempt from the state mandates). If any national plan excludes IVF, residents of these states could lose benefits they already have. Resolve notes that since 1987, Massachusetts has required insurers to cover all infertility services, including unlimited cycles of IVF. The cost of this comprehensive coverage represents only 0.4% of the total monthly premium, or roughly $2.25 out of an average monthly premium of $562.50. The ability to help couples have babies has improved dramatically over the past 15 years, and there's no reason to believe the breakthroughs will not continue. For example, men who have low sperm counts or low-quality sperm can now be helped by a new procedure called intracytoplasmic sperm injection (ICSI), in which a single sperm is placed directly into an egg (see box). Cornell's Rosenwaks calls ICSI ''as big a breakthrough as IVF itself.'' BUT FOR EVERY new medical achievement there are potentially troubling issues. It is now possible through preimplantation genetic testing to screen for devastating hereditary diseases such as Tay-Sachs and cystic fibrosis. But what about someday screening for conditions like blindness or deafness, which are hardly life threatening but nevertheless affect the quality of life? Who determines whether embryos with genetic defects should be used or not? Is it wrong to allow only perfect babies to be born? How about screening for the ''right'' sex? Dr. Schulman of the Genetics & IVF Institute says his clinic does not offer gender selection. But he says he can see its application in ''family balancing.'' Says Schulman: ''If a family has three children of one sex, would it really be so wrong to help bring about the birth of the opposite sex?'' No doubt plenty of people would say yes. In the meantime, there are physicians such as Mark Sauer at the University of Southern California who believe all this talk of a brave new world overlooks one of the most basic benefits of IVF and other similar treatments. ( Says Sauer: ''The new technology gives us a great opportunity to bring children into families where they are truly wanted.'' Who could conceive of a better reason for using it?