Fertility benefit coverage: Barriers and opportunities

Introduction

Infertility is a common disease: worldwide, an estimated 17.5% of couples experience infertility.^1-3 The definition of infertility, failure to achieve pregnancy after at least 12 months of sexual intercourse, is often used by insurance companies to determine fertility care coverage.^1,4,5 However, many people who do not meet this definition (e.g., LGBTQ+ couples, single parents) also seek medical care to conceive children.^5-7 Use of fertility treatments, which includes medications and procedures, is increasing: In 2023, 42% of U.S. adults in a Pew Research Center survey said they or someone they knew had used fertility treatments, up from 33% in 2018.^4,8,9 In 2018, 2% of all infants born in the United States were conceived with assisted reproductive technology (ART) procedures (i.e., any fertility treatments in which eggs or embryos are handled outside the body).^4,9 The importance of accessibility and affordability of fertility care is highlighted by data showing improved maternal and neonatal clinical outcomes, as well as a lower overall economic burden, when treatment selection isn’t impacted by cost and coverage considerations.^4,9-13

According to the results of a 2023 Pew Research Center survey, 61% of U.S. adults believe that health insurance should cover the costs of fertility care.⁸ However, U.S. insurers often do not consider infertility to be a disease, and thus fertility care may not be covered for affected patients.⁵ While an increasing number of states are implementing mandates for insurance coverage of fertility care, restrictions and limitations mean that many patients remain without comprehensive coverage, or do not have coverage at all.^5,10,14 An increasing trend toward coverage for specific fertility benefits among employer-sponsored health plans may be associated with positive outcomes and with minimal increases in plan cost.⁷

Background

Infertility is generally defined as the inability to conceive after at least 1 year of regular unprotected heterosexual sex.^1,4 In women, potential causes of infertility include disruption of ovarian function, fallopian tube obstruction or physical characteristics of the uterus (e.g., fibroids, endometrial polyps or congenital uterine abnormalities).⁴ Causes of infertility in men may include disruption of testicular or ejaculatory function, hormonal disorders, or genetic disorders that affect sperm quality or quantity.⁴ Healthcare surrounding fertility and infertility involves testing, treatment and fertility preservation (e.g., cryopreservation).^4,14 Patients may seek fertility testing (e.g., sperm analysis, physical examination, ultrasound, hormonal testing) as well as genetic counseling and screening.^4,15

Fertility treatments can include use of medications, surgery, intrauterine insemination (IUI; often referred to as artificial insemination) and ART.⁴ Pharmacologic treatments for male infertility may improve sperm concentration, motility and/or morphology.¹⁶ Medications used to treat infertility in women may act to induce ovulation, increase the number or stimulate development of mature eggs or help prepare the uterus for egg transfer.⁴ These medications are also associated with multiple births (e.g., twins, triplets), which carry an increased risk to the mother, as well as a higher risk of premature birth and health complications for the newborns.⁴ In vitro fertilization (IVF), intracytoplasmic sperm injection and zygote intrafallopian transfer are all methods of ART, and may involve use of donor eggs, donor sperm or both.⁴ Patients may require multiple rounds of treatment to become pregnant, and use of ART is also associated with the risk of multiple births.^4-6,14

Fertility Care Coverage

Infertility has been designated as a disease by the World Health Organization and the American Medical Association, yet insurance coverage of fertility care is mandated in fewer than half of U.S. states.^1,2,5,10 Mandated coverage is often restricted and may involve cost-sharing (e.g., deductibles, copayments, co-insurance), as well as formulary or prior authorization requirements; furthermore, employer self-funded health insurance coverage is exempt from state mandates.^14,17,18 More than 60% of employees with employer-sponsored health insurance have self-funded plans.¹⁴ Thus, mandated fertility coverage may not apply to many individuals living in states with mandates.^14,18

Medicaid coverage of fertility services is sparse, with some states covering diagnostic services but very few providing any treatment coverage.¹⁴ Furthermore, while patients of reproductive age who are on Medicare ostensibly have coverage for fertility care, there is a lack of clarity on what specific fertility services may be covered and under what circumstances.¹⁴

Accessibility of fertility treatment is an important consideration. While diagnostic testing for infertility may be covered, treatment may not be.^6,14 Indeed, in a retrospective analysis of 2010-2022 claims data from more than 10,000 U.S. women with an infertility diagnosis, approximately 30% did not have fertility treatment coverage.¹⁹

LGBTQ+ patients often do not meet the medical definition of “infertility,” and certain states exclude IVF services for couples using donor eggs or sperm.¹⁴ According to the National Survey of Family Growth (NSFG), between 2015 and 2019, 13.5% of women aged 25 to 49 years had impaired fecundity, while 8.9% had received medical help to get pregnant.²⁰ In particular, utilization of ART is low in the United States: according to the same NSFG data, only 0.5% of women have ever used ART.²⁰ A major barrier to fertility care access is the economic burden of treatment.^10,21

Costs of fertility care

The cost of fertility care varies widely, depending on what treatment modalities are used, as well as variations in treatment protocols and medication pricing/dosage.¹⁰ Treatment costs could range from a few hundred dollars (for ovulation induction) to tens of thousands of dollars (for IVF).¹⁰ Because patients often must pay out of pocket for treatment, fertility care may be out of reach for many.^10,14,22 In surveys of women with infertility, results highlight the increased financial burden associated with treatment, as well as the stress related to dealing with insurance companies and varying treatment coverage.^21,22

As previously stated, fertility treatment can increase the chances of becoming pregnant with multiples.⁴ The high cost of ART may lead patients to seek lower cost but less effective treatments that carry an increased risk for multiple births. Among patients using IVF, the high cost of each round may incentivize multiple embryo transfer over elective single embryo transfer (eSET), also increasing the risk of multiple pregnancy and related morbidity.^5,11 However, not only does pregnancy with multiples carry maternal and neonatal health risks, but it also is associated with substantially higher healthcare costs.^4,10,11 eSET carries a much lower risk of multiple pregnancy than does double embryo transfer (DET), and two sequential cycles of eSET is associated with similar live birth rates to DET, but with lower overall healthcare costs.^4,12,13

Outcomes associated with fertility care coverage

Fertility care coverage is associated with improved health outcomes. State-mandated coverage of fertility care is associated with fewer embryos transferred per IVF cycle and a lower rate of multiple births.^5,6,13

More employer health plans are starting to explicitly cover fertility care; however, there is still an unmet need for coverage of various treatments and procedures. A survey on employer-provided fertility benefits conducted by Mercer highlighted trends in coverage of fertility benefits between 2015 and 2020, as well as the reasons cited for that coverage. Among respondents in both 2015 and 2020, no coverage of fertility benefits was provided by approximately 40% of employers with 500 or more employees, and 23% of employers with 20,000 or more employees. However, over the same period, coverage of specific benefits, including evaluation by a reproductive endocrinologist or infertility specialist, drug therapy, IUI, IVF and egg freezing, increased markedly. Among respondents that added coverage within the previous two years, 61% cited supporting diversity, equity and inclusion (DEI) as a primary objective for the change. Offering fertility coverage was noted to have achieved several outcomes, including “ensuring employees have access to quality, cost-effective care” (71%), “satisfying employee requests” (64%), and “staying competitive in attracting and retaining talent” (62%) (Figure). Notably, satisfying employee requests and helping advance DEI efforts were reported as much more successful among companies that cover IVF (81% and 89%, respectively) as compared with those that do not cover IVF (44% and 27%, respectively). Furthermore, 35% of respondents that covered IUI or IVF stated that they designed the benefit to be available for LGBTQ+ and single employees. However, only 12% of respondents placed no limitations on coverage. The two most common limitations were a lifetime maximum benefit (60% of companies; median, $16,250) and limit on the number of IVF cycles covered (13% of companies; median, 3 cycles). While 55% of respondents who did not provide coverage cited cost concerns as a reason, 97% of respondents who offered benefits (including IVF) said it did not result in a significant medical plan cost increase.⁷

The trend toward increased coverage of fertility care among employers is promising, but gaps in coverage remain. For example, in 2020, only about half of large employers and a third of small employers covered drug therapy, while coverage of IVF was even less common.⁷ Employers seeking to prioritize access to care, satisfy employees and attract and retain talent may consider providing or expanding fertility care coverage.

Conclusion

Despite the recognition of infertility as a disease, its high prevalence and the increasing trend in use of fertility care in the U.S., many insurance companies provide limited or no coverage for diagnosis or treatment. Individuals looking to start or expand their families face the potential for high out-of-pocket costs that may influence treatment choices and lead to worse health outcomes and higher long-term healthcare costs. Comprehensive fertility care coverage may allow for increased access, equity and satisfaction for enrollees.

References

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