The Fertility Center of Michigan

Dr. Shavell is very good about clearly communicating all the variables that play into IVF, and remembering the specifics of my situation. She has supported me and my partner with knowledge to help us make the most informed decisions at each step of the way. I appreciate her bedside manner. The only drawback is that she has a very busy schedule and sometimes it can be difficult to get time with her - but when you do get time together she is very attentive and a good listener.

Come prepared with your own questions and research - Dr. Shavell will help guide you along the way. Work to get on her schedule early as Dr. Shavell and her entire clinic are very busy.

Karyotype Testing Hysteroscopy Endosee 3 IUI cycles with Femara and Ovidrel Trigger Receptive DX Test (diagnosed Silent Endo) Egg Retrieval with PGT Testing FET #1 - with Orilissa, Lupron, PIO in lead up (dealing with Silent Endo and a specific blood clotting condition)

Our situation is unique in that we've chosen to do a fair amount of elective diagnostic testing. Over one year of working with the clinic our total costs for all testing, procedures, medications, cycle management and storage fees have totaled $33K.

She is always, kind, compassionate, takes her time with me, values what I have to say, and she never makes me feel stupid. (In comparison to her male counterparts at the office, it’s night and day difference).

Don’t be afraid to ask many questions!

She did a full evaluation of me and my partner. We got 2 diagnoses of septum uterus and mild male factor. I had surgical intervention, my husband was sent to a specialist (urologist). We then came up with a plan of a medicated cycle (letrozol, mid cycle ultrasound, and trigger shot). The first cycle resulted in a chemical pregnancy. We naturally conceived right after that miscarriage, she put me on progesterone, but that ended in a blighted ovum diagnosed at our first 6w ultrasound. After D&C and genetic testing that baby was found to have a genetic anomaly. We were advised to wait at least one cycle before we try again. We did a recurrent miscarriage blood panel, every thing was fine. She added baby aspirin to my daily vitamins. We did 3 more medicated cycles with the same dosage of letrozol for me because my body always responded well. This last cycle we conceived! We are 5 weeks today so hoping for our rainbow baby. We had met with Giuliani a few weeks ago to come up with a plan if this didn’t work, we had a plan in place to move onto IUI.

Oh who knows! In 2021 we met our deductible bc of costs associated with going there but luckily our insurance covered a good amount.

NA

Dr. Giuliani was very personable and took a thorough history from me. We have met 3 times via virtual appointments and she even called me personally after I had sent a patient portal message. Dr. Giuliani sent my husband to get checked out which led to us learning he had a pituitary tumor, no one else had even thought of this. Dr. Giuliani has been honest about next steps in treatment.

Take notes during the appointment and don’t be afraid to ask any questions.

Dr. Giuliani suggested we start with timed intercourse cycles with the option to add IUI at any time. We opted to do several timed intercourse cycles first. Dr. Giuliani suggest we try clomid as I had done several cycles with femara previously. She also suggested a mid cycle ultrasound and trigger shot with the timed cycle which I hadn’t done previously. When we were ready to add IUI Dr. Giuliani met with us to discuss that in further detail and answer any questions we had. She was also very honest that we may need to consider IVF and provided some information on that as well, since we have some male factor issues as well as PCOS.

My ultrasounds and office visits were billed to insurance, although I was not aware of the cost associated with speaking with the nurse after some of my ultrasounds so that was an extra cost. My portion of my first IUI was billed to insurance as I had asked, we did pay out of pocket for the semen was which was $375. Total cash price for each IUI is currently $800, up from $650 last year.

We have not reached this step in treatment.

Dr. Dodds is very caring and experienced. He founded the clinic, and I believe he has been a reproductive endocrinologist for approximately 30 years. In addition, he specializes in PCOS, my fertility issue. Therefore, I have a great deal of confidence in his ability to maximize my potential to be a parent. The only negative comment I have about Dr. Dodds is that I think is so knowledgeable that he sometimes forgets that I (as a patient) am not. He is always happy to clarify any confusion, but the first time he explains something, it is not always clear (e.g., certain details are missing or he mentions a term we had not previously discussed).

If you have any questions or need clarification, please ask. Dr. Dodds wants to ensure all his patients have a clear understanding of their treatment.

I did 4 IUI cycles. 3 were with Femara (5 mg for 5 days) and Estrace (vaginally) because of a thin uterine lining on ultrasound. Estrace was taken before and after IUI. For one of the cycles, I did a stepwise Femara cycle, as the first 5 days did not produce mature follicles. This resulted in the production of mature follicles after the stepwise administration. For the 4th IUI, I took Femara (5 mg for 5 days) and Gonal-F (75 IU) injections prior to IUI. For all IUIs, I did an Ovidrel injection 48 hours prior to the IUI.

Each IUI was ~$250.

Dr Young is very professional he has good knowledge of endometriosis and the paths to take to pregnancy. I am confidant I will get where I want to be with him as my doctor. He is dry and witty and has a way of making you feel comfortable

ask lots of questions

we started with famera and were going to move on to IUI. When an endometrioma was discovered before my first IUI cycle, we pivoted to egg retrieval. This proved difficult, as I needed higher and higher doses to get my follicles to develop. My first cycle i had 5 follicles, got one egg and one embryo. Thankfully, TFC has a multi egg retrieval program where for only 3 thousand dollars more than one cycle and transfer you can do 3 revivals, bank your eggs and do a transfer after your third retrieval. Eventually we got 6 embryos and froze them all. I then had endo surgery and had a transfer that failed. We tried for another transfer but canceled it due to a hormone producing ovarian cyst. We treated that with birth control, and while waiting we decided to do the recurrent pregnancy loss workup where we found polyps in my uterus. I had surgery scheduled to remove the polyps but that was canceled due to Corona virus.

17k plus meds so far

I asked to do one in our next transfer, he had no problem with it, but it was not offered

We met Dr. Thakur at our initial consultation, but since then I've only dealt with the nurses. I was surprised that she was not the one who performed my IUI's. The one time I met her I thought she was nice, but I felt rushed and did not have an opportunity to have all my questions answered.

Don't let her rush you and stay until all of your questions get answered.

Our diagnosis is male factor infertility. Dr. Thakur did one medicated cycle that was unsuccessful. Next I had an IUI that resulted in pregnancy, but the pregnancy was not viable so I miscarried. I did a second IUI that was unsuccessful. My third IUI was scheduled, but had to be cancelled due to illness.

Each IUI cost $600 out of pocket. My insurance does not cover anything dealing with infertility.

I don't have any experience with this yet.

Dr Young is very quiet but compassionate and caring. He called me after our second transfer didn't work just to see how I was doing and if I had any questions. He always asked us if we had any questions, shook our hands at the end and made us feel like he cared about what was going on with us.

Just be aware he is flat affected so if you're expecting an upbeat personality, you won't get that from him. It's not that he doesn't care, it's just not his personality

For egg retrieval, medications and 3 transfers, it was over $22,000

Dr. Shavell is very nice and soft spoken, easy to talk to. We were diagnosed with unexplained infertility though and given a packet of pre-determined steps with none ever working for us. Our care is really left in the hands of nurses, we never hear from the doctor or see her during/after procedures and ultrasounds unless we want to pay out of pocket for another consult.

You're just one of many. She is kind and knowledgeable but don't plan for her to actually be involved in your care unless you're doing IVF.

HSG that came back normal, 3 rounds of clomid, 4 rounds of Femara in attempt to see if any of these things would produce more follicles to increase chances of pregnancy. I was already ovulating on my own and ended up with multiple follicles twice. Also went on estrogen and progesterone to thicken lining when Femara thinned it. No success from any treatments.

Expensive, my insurance doesn't cover most of it. Ultrasounds are frequent and usually cost $175-250 depending on limited or complete (although even when charging for complete ultrasound the cervix isn't evaluated and a VERY fast sweep of the uterus is performed that's not very diagnostic). IUIs were around 700 each time, the HSG was probably closer to 1000 but I can't remember the exact numbers for sure. Consults are over 100, and then another 50 every time I talk to a nurse in the clinic after ultrasounds.

Not to that point yet

Dr. Shavell is so empathetic she almost comes off as meek in the consult room, which might be good for some people, but I prefer a doctor to be blunt and tell me like it is. She did perform surgery when I had an ectopic pregnancy and she's much more to the point in the operating room so I was happy with that and she did a great job.

I would suggest going into an appointment prepared with lots of questions to ask. I've done a lot of my own research and make lists of things I want to ask her about.

I've done 4 IUI's under Dr. Shavell's primary care. At the Fertility Center you basically see whichever doctor or nurse is available during your procedures though so a lot of these protocols were assigned by other providers. Each IUI cycle started with Clomid cycle days 3-5, midcycle ultrasound ~day 10-12, IUI ~day 13-15. The first two were negative. The third IUI was positive, but resulted in an ectopic pregnancy found at the 6 week ultrasound. Dr. Shavell recommended methotrexate to terminate the pregnancy. That was followed by two weeks of Beta HCG blood tests every few days and my numbers weren't going down. She recommended a second dose of methotrexate over surgery and that was also ineffective. Two weeks later I finally had surgery to remove the ectopic pregnancy and my fallopian tube. After methotrexate you have to wait 3 months to conceive so we did a 4th and final IUI that was negative. At that point we jumped into IVF and prepping for egg retrieval. I can't remember the protocol, but it involved Menopur and Ganirelix, etc. The ER was very successful with 18 eggs retrieved, 17 mature and fertilized, 14 made it to day 3. We did a 3 day fresh transfer with 2 embryos and froze the remaining 12. The result was negative. We waited a month or so and then began to prep for frozen embryo transfer. It was a long lupron protocol. We transferred 2 embryos, which resulted in miscarriage at ~5.5 weeks. We waited another month and began the same long lupron protocol again. We decided to thaw all frozen 10 embryos to grow them out to blastocyst with the goal of weeding out some that may be weaker. They all survived thaw and made it to blast. We transferred 2 and refroze the remaining 8. This cycle ended in a chemical pregnancy. We were getting ready to do some additional testing (hysteroscopy to check for fibroids, etc. and chromosome mapping) before moving forward with the next cycle, but everything is now on hold due to Covid-19. We will also do an ERA cycle prior to the next FET.

I would estimate that each IUI costs around $1500 including drugs, ultrasounds, and procedure. They don't bill insurance for the male portion, but they've billed my insurance for everything else and majority of it has been covered by Blue Care Network. We've paid 100% out of pocket for IVF as our insurance does not cover. We paid around $35K in 2019 for 1 IUI, 1 egg retrieval + fresh transfer, 2 FET's, meds, labs, etc., etc.

Dr. Shavell has had no problem transferring two embryos each time, but has made sure to ask that we are ok with the higher chance of having multiples.

Dr. Dodds was very well spoken and personable, he told me the findings of my blood work and what was normal or abnormal and what he thought we needed to work on. He have me several different options as to what my next steps should be, but also rated them as what he would "suggest if I were his own child" . He made it very clear that he wanted to get me to what my husband and my goal of having a child in the most cost effective and healthy way possible.

He is very open and will explain anything that you want/need.

Dr. Dodds wants to try two cycles of hybrid medications with IUI to increase my chances of conceiving. I will be using Femara 5.0, and Gonal F at 450iu at 75iu per injection for a few days days, and a trigger shot of Ovidrel at 250 mcg/.5 ml He also gave me the success rates for all of the options that he gave me (such as, I could try Laproscopic surgery to check for endo but it would only increase my chances of conceiving by about 20%, or I could do the hybrid and IUI which on average 60% conceive within 3 cycles, or IVF which is a 60% change on the first try no matter if I have endo or anything else, with the added bonus of having egg retrieval and FET at the age of 32 instead of later in life, especially with my low ovarian reserve.

with no insurance coverage, my consultation was around $240, ultrasound runs around $275, medication costs Femara $6, Ovidrel $100 Gonal-F $450, Initial consultation was $375, Blood work all together was around $600

N/A

Strengths-I do believe he truly wants to help his patients achieve the end goal of bringing home a baby Weakness-I believe he is a very busy man and I didn't feel as supported by him as I would have liked. I think he focuses the majority of his support on IVF patients

Speak up about your wants and if something doesn't sound right or applicable to your case

We did 2 rounds of IUI with femara and Ovidrel. The rationale was that due to my husband's lower sperm count and motility, having more eggs and putting the sperm closer to them would increase the chance of pregnancy. I had one negative cycle and one pregnancy that ended in a miscarriage/ possible ectopic

Each round of IUI ended up being around $800. IVF is expected to cost around $10,000 plus meds, anesthesia, etc.

N/A we did not do IVF

We had to cancel an egg retrieval which was so disheartening after finishing half of our shots/medications. She personally took time out of her day to call me and apologize for the situation even though it was not any fault of her own.

Be open minded through the process as things change often. Be more prepared to talk to all of the staff and nurses and ask many questions. You truly don't talk to the Dr often.

We decided to do a full IVF cycle. My body decided to produce one very large egg (many other small eggs that just would not be able to catch up) which resulted in having to postpone our IVF. After 3 failed IUI attempts and 2 additional rounds of femara that also failed, it was so heartbreaking! We just started our 2nd round of IVF. We will be doubling all of our dosages for injections and taking a stronger approach. Nothing like watching your dreams being crushed 6 different times. Still we remain positive and continue on. We are definitely praying for a healthy miracle.

We have personally spent over $25,000 and counting for fertility treatments. It is extremely overwhelming financially when you're constantly getting a bill for treatment plans and services. It hits harder after a failed attempt where you have to pay for more injections or medications. IVF and fertility are extremely expensive at this center. It is our closest option for being able to make appointments on a regular routine basis.

We thought it best to do a multiple embryo transfer after much discussion with our Dr. This next month feels like a standstill for time.

The first time I saw him was at the initial consult. He was very friendly and answered my questions, and went over my health history. I was concerned about being able to get pregnant due to losing a Fallopian tube a year and a half prior to this appointment along with having PCOS. He was very thorough and kind about everything.

Ask as many questions as possible, even write down questions before going in. You only see the Dr. once.

The first thing is Dr. Dodd’s gave me a list of speed donors to chose from. We decided to try doing the IUI first because I still have a good Fallopian tube. The first time we did the Clomid and Ovidril. A couple of ultrasounds and then the IUI. This did not work. The second time they changed the meds to Letrozole and Ovidril, a few ultrasounds and then the IUI. This attempt failed also. The third time they did the Letrozole, Gonal-f injections, Ovidril and progesterone, about 4 Ultrasounds and then the IUI. This attempt failed as well. They were hoping I would produce more eggs and I still only got about 2-3 each time.

Around $6000 for all 3 attempts including meds, ultrasounds, insemination and donor sorry.

Was very knowledgeable and seemed honest with us every time we spoke. He seemed to really want to help us with our family and offered different suggestions we could take. He left a lot up to us on how quickly we wanted to move forward and supported any decisions we made for our treatments.

Don't be afraid to ask questions.

We started with 3 rounds of femara resulted all negative pregnancy tests, had an HSG done results were normal. I started IVF procedures with injections in the morning and also in the evening. I don't remember every injection but was closely monitored by blood work and ultrasounds every other day. Once we got the okay I had a trigger shot and another injection. We had our egg retrieval and got 22 follicles 18 were mature, 14 were fertilized, 2 were implanted and 11 were frozen. We resulted in a positive pregnancy but at the 6 week ultrasound it wasn't looking good. I continued to take progesterone injections and at our follow up ultrasound we found both embryos implanted but we're not viable and I miscarried.

I was given a few options based on availability and I picked what I was able to do between my work schedule and office hours.

With our original insurance we had all of our procedures covered outside of a minor copay for each appointment. With our new insurance they do not work with so everything is now out of pocket even though our current insurance offers fertility treatments the same as our previous insurance it's just now out of network.

I think Dr. Shavell is knowledgable and realistic with fertility expectations and outcomes. She spent a significant amount of time with us at our initial consultation but did not actually perform any of my procedures herself. She was an overseer of my case. She did communicate well with me when she called on the phone and she did call to check up on me after our negative result.

Be prepared to communicate more with the Nurses and make sure you are given both your red and your green folders. Read everything they provide.

We did an egg retrieval with a long cycle. We did injectable hormones. We retrieved 13 eggs, 5 fertilized, 2 survived to freeze. We had to do a freeze-all cycle because I needed a polypectomy the following cycle. The cycle after the surgery, we did a frozen transfer with both embryos. They did not take.

The IVF procedures are expensive and they require payment for a deposit and then payment in full before the cycle. I was unprepared for this as my clinic in NJ billed me as we went along. This delayed us getting started since all the money was required up front.

In my age bracket, they recommended 2-3 embryos at a transfer. I understand the risks with that and opted to proceed with the multiple embryo transfer.

Dr. Shavell is very honest and gives me the facts - which I love. She is willing to try different things to get us where we need to be to have children. She is very intelligent and understands the fertility field. My only complaint is with the amount of testing she wanted done, we had to pay everything completely out of pocket, which got frustrating. But I was honest with her and told her we needed to save money, so she adjusted her plan.

Be honest about your financial needs up front.

So far we have done clomid cycles at 50mg per month days 5-9 with no luck.

$100 deposit for initial appointment which costs over $300. After that, we paid different amounts each appointment.

No strong opinion, it is up to us.

She's very warm and seems to treat her patients well as people. However, she really needs to be more assertive and guide the conversation as the physician. My wife and I felt like she wasn't forthcoming with information and basically waited for us to lead the conversation rather than sharing info upfront and using that to guide the conversation and treatment plan. She's too soft-spoken and needs to be able to tell it like it is, good or bad.

Do your research so that you know what questions to ask to get the information you need. If you rely on her to lead the conversation, you will likely not walk away with a good understanding of what's happening.

We're still early in the process, but at this point it's been mostly treating both my wife and myself with prescriptions for various things that seem to be contributing to our infertility (irregular cycles and hypothyroidism for her, prostatitis and low sperm count for me).

I saw all of the Doctors there. Dodds seemed to be the most experienced with all of the challenges that arose during my journey. I also saw Dr Thakur and really appreciated the fact that she took her time with me to answer any questions and side effects that I could expect.

Do your research and ask a lot of questions.

Unfortunately most of our costs were all out of pocket

She is very compassionate, answers all questions, and made sure we were comfortable with the plan. She ordered tests to try to find a cause for my recurrent miscarriage, but we didn’t find anything. I do wish she would’ve done further testing.

Don’t be scared to ask questions. She is very compassionate and willing to answer.

Femara followed by an ultrasound to monitor follicles and Ovidrel to stimulate ovulation. She added Estradiol due to thin lining and Crinone after ovulation. I did get pregnant that cycle but unfortunately miscarried.

We used oral medications with timed intercourse and insurance covered most of the cost but do not cover IVF.

I do not have experience.

Valerie is a very nice person but sometimes her tone can be taken the wrong way at first. She is very light spoken and sometimes I perceived her tone as patronizing. After getting to know her more I became use to it.

Ask questions.

The procedure used for IUI was the same each of the four times I did it. I am now starting my second round of IVF and she is changing the procedure to a flair protocol.

IUI's were around $500 for the procedure. IVF was around $8500.

I felt as though my provider listened to my concerns and looked into my medical record to get a full background so that my consultation wasn’t a waste of time. She also called me personally to discuss some of my lab results and went over the next steps with me which was very helpful.

Be honest and tell them what’s really on your mind.

Some costs that seemed to be optional ended up being costs that were required for successful treatment

I was given the option to either do a single or multiple embryo transfer

Dr. Dodds is willing to explore all avenues and alters your treatment as needed. I have noticed that amongst friends going through treatment, he does work through trends in the market (uterine scratch, embryogen, etc.). He is upbeat and has positive relations with his team at the clinic.

Do your research and go through every option that you have available to you. For example: ICSI, time lapsed photography, genetic testing. Decide what is right for you and ask the hard questions including success rates with each treatment.

For our IVF cycle we did ICSI (which is apparently used on 90% or so patients at TFC), time lapsed photography (differentiates between quality and keeps them in one enclosed space versus taking them out to check under a microscope), day 3 transfer (standard at this clinic), and freeze all cycle (I was at risk for hyper stimulation).

Shana, the ultrasound tech, is the best! She is so sweet and knowledgeable.

I became pregnant with twins after the first transfer (two embryos). We lost both of them at eight weeks. Therefore, knowing that pregnancy can occur, we opted for a single on the second transfer. Pregnancy did not occur, however.

Dr. Young is definitely very wise and I felt I could trust him with our treatments. Personally, I feel like his bedside manners could improve a little. He is very kind and thorough, but somewhat awkward at times. I felt like I had to push treatment changes when things didn't work but that's also largely a part of my personality. He always explained things in an easy-to-understand way.

Keep in mind that although he can come off a little quiet or awkward at times, I do believe he has plenty of wisdom and experience to handle direct treatment courses. I'm still undergoing treatment (more aggressive, I'll add) so I'm very curious to see how my thoughts on him will change, if at all!

I responded very well to Femara 5mg for my IUIs, so we stuck with that for 3 cycles. Although I was ready to change things up, I understood how he wanted to keep the course. I was also thankful to move on to Gonal-F for IUI #4, though my dose was small (75iu nightly). I actually responded with fewer follicles than on 5mg Femara. My 5th and final IUI, we tried a higher dose of Follistim (125iu) and I responded very well! Almost too well: 6 follicles. I'm very glad my clinic was upfront and honest with me about the risks and let me make that decision alongside of them. We still went for that IUI and it was a negative, but I feel very good about that last shot IUI: we tried our best and I feel much more comfortable moving forward with IVF, especially since I've gotten comfortable with injections.

I have zero fertility coverage besides 50% coverage for meds (which I realized was truly nothing since most pharmacies have an agreement and give women who are completely out of pocket a discount, so my med coverage didn't really do anything). Specifically with my clinic, a semen analysis was around $130. IUI including the sperm wash was $500. Most ultrasounds/appointments were in the $100 range, depending on your coverage, of course.

We are just about to start our first IVF cycle with Dr. Young, so I can't speak about embryo transfers yet. But, I did trigger and have an IUI with 6 follicles and they were very straightforward and honest with me about the risks. You could tell it was very important to them that I knew what I was doing.

I have only seen Dr. Dodds once, but he was pretty good when we met with him. He met with us in his office instead of an exam room. He took the time to review all of my previous tests and surgery. He asked us about our jobs. He had a connection to the place where my husband works and he told a long story about that. I appreciated that he waited until the end of the appointment to talk to us about that. I did feel like he was a little matter of fact and didn't explain things in great detail. He just laid out the plan and gave us the next step. I left a little bit confused and felt a little like we had been rushed into moving forward with an IUI.

Make sure you ask questions! We didn't really know what to ask at the time but we felt like we left with more questions than answers.

Dr. Dodds suggested that we start moving forward with an IUI. He put me on Femara, an ovidrel injection, and progesterone. He didn't really explain what each of these did or why I was taking them. After my husband and I discussed it, we weren't comfortable moving forward with the IUI right away. I called back and talked to a nurse about it. We decided to try timed intercourse first. So, she said to take the Femara and the progesterone, but I could wait on the Ovidrel. I went in for a mid-cycle ultrasound and the nurse told me when to have intercourse. After a negative pregnancy test that month, we decided to go forward with the IUI. Then it was back to the Femara, Ovidrel, and Progesterone. Then a mid-cycle ultrasound and the insemination. The Progesterone gave me really bad side effects so after I called and asked, my dosage was reduced by half and that seemed to help. I got another negative pregnancy test, so we started all over again. I am currently scheduled for another IUI later this week.

My initial appointment and ultrasounds are covered by insurance. The IUI procedure was $500. The meds were ordered through a pharmacy and were $100-$200 each cycle.

Dr. Shavell is very nice. She's a little too soft spoken at times; meaning her demeanor is almost too sympathetic. I want answers, I want to take comfort knowing you (the person I am trusting) has a plan of action specifically designed for me and that we aren't just going through the motions. There were times where I felt she was more focused on me thinking she cared than her actually trying to fix any issues. I also feel she is not very available when needed.

Ask her to give it to you straight. Also, request a full description of treatments with all the why's explained.

After my HSG, I had to have a polyp removed. Then we started on 50 mg clomid because that's the starting point, which I responded well to but nothing came of it. We did four cycles on this with the HCG (Ovidrel) shot. Then we moved onto letrozole and Gonal-F. I can't remember the specific dose of letrozole but the injections were 300. I did not respond as well to the letrozole as we had hoped. I am currently going to do one timed cylce of 100 mg of clomid (back to clomid after under-performance of letrozole) while we wait for insurance pre-authorization. If that is approved (different insurance company than the last round) I will have one last IUI cycle of 100 mg Clomid and Gonal-F 450 injections. IF this does not work, we will immediately be moving on to IVF.

Each IUI is $500 (sperm wash and procedure) plus the ultrasound and office visit. Each visit was a co-pay amount. Hybrid cycle had an extra ultrasound (echogram) which was more than the ultrasound. Medications were all based on what insurance would cover; most of it out of pocket.