- Many people require fertility assistance. this includes men and women with infertility, many lgbtq people, and single people who want to raise children. an estimated 10% of women report that they or their partners have ever received medical help to get pregnant.
- despite the need for fertility services, fertility care in the us. uu. it is inaccessible to many due to cost. Most of the time, fertility services are not covered by public or private insurers. Fifteen states require some private insurers to cover some fertility treatments, but significant gaps in coverage remain. only a state medicaid program covers any fertility treatment, and no medicaid program covers artificial insemination or in vitro fertilization.
- Most patients pay out-of-pocket for fertility treatment, which can be upwards of $10,000 depending on the services received. this means that in the absence of insurance coverage, fertility care is out of reach for many people.
- fewer black and Hispanic women report ever using medical services to get pregnant than white women. this is the result of many factors, including the lower incomes on average among black and Hispanic women, as well as barriers and misconceptions that may deter women from seeking fertility help.
- Lgbtq people also face greater barriers to accessing fertility care, as they often do not meet the definitions of “infertility” that would qualify them for covered services. Transgender people who undergo gender-affirming care may also not meet the criteria for “iatrogenic infertility” that would qualify them for covered fertility preservation.
- Laboratory tests (eg, progesterone, ovarian reserve, thyroid studies, prolactin)
- semen analysis
- imaging (eg, pelvic ultrasound, hysterosalpingography (hsg))
- diagnostic procedures (eg, laparoscopy, hysteroscopy)
- medications (for example, clomid/clomiphene citrate)
- surgery (eg, laparoscopy, hysteroscopy)
- intrauterine insemination (iui) [also known as “artificial insemination”]
- in vitro fertilization (ivf) [a type of assisted reproductive therapy (art)]
- cryopreservation [also known as “freezing” of eggs/sperm/embryos]
many people need fertility assistance to have children. this could be due to an infertility diagnosis or because they are in a same-sex relationship or are single and wish to have children. Although various forms of fertility assistance exist, many services are out of reach for most people due to cost. Fertility treatments are expensive and often not covered by insurance. while some private insurance plans cover diagnostic services, there is very little coverage for treatment services like iui and ivf, which are more expensive. most people who use fertility services must pay out of pocket, with costs often running into the thousands of dollars. very few states require private insurance plans to cover infertility services and only one state requires coverage under medicaid, the health coverage program for low-income people. this widens the gap for low-income people, even when they have health coverage. This brief examines how access to fertility services, both diagnostic and treatment, varies across the us. based on state regulations, insurance type, income level, and patient demographics.
diagnosis and treatment services
Infertility is most commonly defined1 as the inability to achieve pregnancy after 1 year of regular, unprotected heterosexual intercourse, and affects approximately 10-15% of heterosexual couples. Both male and female factors contribute to infertility, including problems with ovulation (when the ovary releases an egg), structural problems with the uterus or fallopian tubes, problems with sperm quality or motility, and hormonal factors (figure 1). About 25% of the time, infertility is caused by more than one factor, and in about 10% of cases, infertility is unexplained. However, infertility estimates do not take into account LGBTQ or single people who may also need fertility assistance to start a family. therefore, there are a variety of reasons that may prompt people to seek fertility care.
A wide range of diagnostic and treatment services may be required to aid in fertility (Table 1). Diagnoses typically include laboratory tests, a semen analysis, and imaging studies or procedures of the reproductive organs. If a probable cause of infertility is identified, treatment is often directed at addressing the source of the problem. For example, if someone has abnormal thyroid hormone levels, thyroid medications can help the patient achieve pregnancy. If a patient has large fibroids that distort the uterine cavity, surgical removal of these benign tumors may allow a future pregnancy. other times, other interventions are needed to help the patient achieve pregnancy. For example, if a semen analysis reveals poor sperm motility or if the fallopian tubes are blocked, the sperm will not be able to fertilize the egg and intrauterine insemination (IUI) or in vitro fertilization (IVF) may be necessary. These procedures also facilitate the formation of families for lgbtq and single people, with the use of donor eggs or sperm, with or without a gestational carrier (surrogacy).
use of fertility services
our analysis of the 2015-2017 national survey of family growth (nsfg) finds that 10% of women2 ages 18-49 say they or their partner have ever talked to a doctor about how to help them to become pregnant (data not shown).3 Among women aged 18 to 49 years, the most frequently reported service is fertility counseling (figure 2).
the cdc finds that the use of ivf has increased steadily since its first successful delivery in 1981. based on the most recent data, an estimated 1.8% of u.s. babies are conceived annually using assisted reproductive technology (art) (eg, IVF and related procedures).4 Proportions are highest in the Northeast (ma 4.7%, cn 3.9%, nj 3.9%) and lowest in the south and southwest (nm 0.4%, ar 0.6%, ms 0.6%).
Use of fertility services has dropped dramatically during the COVID-19 public health emergency. On March 17, 2020, the American Society for Reproductive Medicine (ASRM) issued guidelines to stop all new cycles of fertility treatment and non-urgent diagnostic procedures. Since then, ASRM has provided up-to-date guidance on the conditions that must be met and the steps that must be taken before fertility care can safely resume. During this time, a study conducted by Strata Decision Technology of 228 hospitals in 40 states found that patient encounters for infertility services were reduced by 83% from March 22 to April 4, 2020 compared to the previous year.
cost of services
Many patients do not have access to fertility services, largely due to their high cost and limited coverage by private insurance and Medicaid. As a result, many people who use fertility services must pay out of pocket, even if they are otherwise insured. out-of-pocket costs vary widely by patient, state of residence, provider, and insurance plan. In general, diagnostic laboratory tests, semen analysis, and ultrasound are less expensive than diagnostic procedures (eg, HSG) or surgery (eg, hysteroscopy, laparoscopy). Meanwhile, fertility drug treatment is less expensive than IUI and IVF, but even the least expensive treatments can result in thousands of dollars in out-of-pocket costs. many people must try multiple treatments before they or their partner can achieve a pregnancy (usually medication first, followed by surgery or fertility procedures if medications are unsuccessful). A study of nearly 400 women undergoing fertility care in Northern California demonstrates this general trend, with the lowest out-of-pocket costs for drug-only treatment and the highest costs for IVF services (figure 3). Previous research showed the cost of just one standard IVF cycle was about $12,500 in 2009, but is likely higher today due to rising health care costs overall. In addition, many patients require several rounds of treatment before achieving pregnancy, and the costs that accumulate in each cycle make these interventions economically unaffordable for many. In addition to actual treatment costs, patients may be charged out-of-pocket expenses for office visits, diagnostic tests/procedures, genetic testing, use of donor sperm/eggs, and storage fees and lost wages for time off from work. work.
Insurance coverage for fertility services varies depending on the state in which a person lives and, for people with employer-sponsored insurance, the size of their employer. Many fertility treatments are not considered “medically necessary” by insurance companies, so they are not typically covered by private insurance plans or Medicaid programs. When coverage is available, certain types of fertility services (eg, tests) are more likely to be covered than others (eg, IVF). a handful of states require fertility services coverage for some fully insured private plans, which are regulated by the state. These requirements, however, do not apply to health plans managed and funded directly by employers (self-funded plans) that cover six out of ten (61%) workers with employer-sponsored health insurance. States also have jurisdiction over the benefits covered by their Medicaid programs. The federal government has authority over benefit requirements in federal health coverage programs, including Medicare, Indian Health Service (IHS), and military health coverage.
Fifteen states have laws in place that require certain health plans to cover at least some infertility treatments (a “coverage mandate”) (figure 4). In addition, Colorado recently enacted a requirement for individual and group health benefit plans to cover infertility diagnosis, treatment, and fertility preservation for iatrogenic infertility, effective January 2022. Among states that do not have a mandate to cover, nine states5 and dc have a benchmark plan that includes coverage for at least some infertility services (diagnosis and/or treatment) for most individual and small group plans sold in that state.6 Two states (CA and TX7) require group health plans to offer at least one policy with infertility coverage (a “mandate to offer”), but employers are not required to choose these plans.
However, in states with “mandated to cover” laws, these only apply to certain insurers, for certain treatment services, and for certain patients, and some states have dollar limits on the costs they must cover ( appendix 1). for example, in oh and wv, the requirement to cover infertility services only applies to health maintenance organizations (hmos). In other states, almost all insurers and HMOS are included in the mandate. many states provide exemptions for small employers (<50 employees) or religious employers. In addition, state laws do not apply to self-funded (or self-insured) employer plans, which are regulated by federal law. Sixty-one percent of covered workers are enrolled in a self-funded plan.
Even in states with coverage laws, not all patients are eligible for infertility treatment. hello, someone with unexplained infertility only qualifies for ivf after five years of infertility. in others, patients are eligible after 1 year. Some states impose age limits on patients who can access these services (eg, ineligible if 46 or older in NJ or younger than 25 or older than 42 in RI). others impose restrictions based on marital status; For example, until May 2020, IVF benefits were only available to married women in MD. recently enacted legislation now extends coverage to single women. In addition, it is not always clear whether LGBTQ people meet the eligibility criteria for these benefits without a diagnosis of infertility. Additionally, many costs associated with surrogacy are often not covered by insurance.
States also vary in what treatment services they require plans to cover. Some states require insurers to cover cryopreservation for people with iatrogenic infertility, while others do not. Four states with insurance mandates do not cover IVF. eleven states do, but with a dollar limit on coverage (e.g., a lifetime maximum of $15,000 in ar and $100,000 in md and ri) or a limit on the number of cycles they will cover (e.g., (eg, one cycle of ivf in hi and three cycles in new york).
Do state mandates for IVF coverage affect use of services?
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Use of IVF appears to be higher in states with mandatory IVF coverage. CDC data from 2016 showed that in three of the four states that the CDC considers to have “comprehensive coverage”8 for IVF (IL, MA, NH), use of assisted reproductive technology was 1.5 times higher than the national rate. Similarly, a national study found IVF9 availability and utilization to be significantly higher in states with mandatory IVF coverage. A study in MA found that IVF utilization increased after the implementation of their IVF mandate, but no overuse by patients with a low chance of pregnancy success was found. State-level mandates can also help reduce disparities in access. For example, a recent bill proposed in the CA legislature would reverse existing limitations on fertility coverage and make the benefit available to single women and women in same-sex relationships.
how much does it cost to cover fertility benefits?
While the costs of fertility treatment can be very high for those without coverage, the cost of covering fertility benefits varies depending on covered services and utilization, which has implications for state budgets, employers and policy holders. For example, in 2019, New York passed a bill to require IVF and fertility preservation services for comprehensive private health insurance policies. the new york state department of financial services estimated that premiums would increase between 0.5% and 1.1% due to mandatory ivf coverage, and 0.02% due to mandatory asset preservation. fertility for iatrogenic infertility (caused by medical treatments).
An analysis of a proposed bill in CA to require private plans and Medi-Cal managed care plans to cover IVF services estimated that premiums per member per month would increase by approximately $5 in the private market and less than $1.00 for medi-cal cal plans. however, overall, out-of-pocket spending for people seeking services would drop substantially.
data from ma, ct and ri suggest that mandatory coverage does not appear to increase premiums significantly. All three states have been requiring infertility benefits for more than 30 years and estimate the cost of infertility coverage to be less than 1% of the total premium cost. In 2017, California was considering a more limited bill that would require fertility preservation for iatrogenic infertility in certain individual and group health plans. as the bill was introduced, it was estimated that it would result in a net annual increase of $2,197,000 in premium costs or 0.0015% for enrollees in mandated plans.
While these costs may be modest compared to the costs of paying out of pocket for these services, there are other costs to the coverage mandates. The ACA requires states to offset some of the costs of any state-mandated benefits beyond essential health benefits (EHBS) in the individual and small group market. This requirement was estimated to cost $59 to $69 million per year if one cycle was covered or $98 to $116 million per year if unlimited IVF cycles were covered.
what proportion of employers offer fertility benefits?
Large employers are more likely than small ones to include fertility benefits in their employer-sponsored health plans. According to Mercer’s 2017 National Survey of Employer-Sponsored Health Plans, 56% of employers with 500 or more employees cover some type of fertility service, but most do not cover treatment services such as IVF, IUI, or freezing. ovules. coverage is greater for diagnostic evaluations and fertility drugs. coverage is more common among larger employers and those offering higher wages (figure 5).
nsfg data show that significantly fewer women with medicaid have ever used medical services to get pregnant compared to women with private insurance. As of January 2020, our analysis of Medicaid policies and benefits reveals that only one state, New York, specifically requires its Medicaid program to cover fertility treatment (limited to 3 cycles of fertility drugs) (figure 6). however, some states may require medicaid to cover treatment for conditions that affect fertility, even though it is not directly stated in their policies. For example, states may cover thyroid medications or cover surgery for fibroids, endometriosis, or other gynecological abnormalities if they cause pelvic pain, abnormal bleeding, or another medical problem in addition to infertility. No state Medicaid programs currently cover artificial insemination (IUI), IVF, or cryopreservation (Appendix 2).
some states specifically cover infertility diagnostic services; ga, hi, ma, mi, mn, nh, nm and ny offer at least one medicaid plan with this benefit, but the range of covered diagnoses varies. For example, New York Medicaid specifically covers office visits, HSGs, pelvic ultrasounds, and blood tests for infertility. meanwhile, the infertility evaluation covered by georgia medicaid includes laboratory tests, but not imaging or procedural diagnostics. other states do not specifically cover infertility diagnoses or, more generally, do not cover “infertility services,” which likely include diagnoses. others do not mention the diagnosis of infertility in their medicaid policies, which means that the beneficiary will have to check with their medicaid program to see if these services are covered (appendix 2).
The Medicaid program’s lack of fertility assistance coverage has a disproportionate impact on women of color. among women of reproductive age, the program covers three in ten (30%) who are black and a quarter of Hispanics (26%), compared to 15% who are white. Because Medicaid eligibility is based on low income, people enrolled in the program may not be able to pay for services out of pocket.
The relative lack of Medicaid coverage for fertility services contrasts sharply with Medicaid coverage for maternity care and family planning services. nearly half of births in the us uu. They are funded by Medicaid, and the program funds most publicly funded family planning services. therefore, while there is wide coverage of many services for low-income people during pregnancy and to help prevent pregnancy, there is almost no access to help low-income people achieve pregnancy.
Although the majority of Medicare beneficiaries are over age 65, Medicare also provides health insurance to approximately 2.5 million adults of reproductive age with permanent disabilities. According to the Medicare Benefits Policy Manual, “Reasonable and necessary services associated with the treatment of infertility are covered by Medicare.” however, specific covered services are not listed and the definition of “reasonable and necessary” is not defined.
tricare: tricare, the insurance program for military families, will cover some infertility services, if it is deemed “medically necessary” and the pregnancy is achieved through “natural conception”, meaning that fertilization occurs through heterosexual intercourse. . diagnostic services are covered, including lab tests, genetic tests, and semen analysis. Treatments to correct the physical causes of infertility are also covered. however, iui, IVF, donor sperm/eggs, and cryopreservation are typically not covered, unless the service member sustained a serious injury while on active duty that resulted in infertility.
Veterans Affairs (VA): Infertility services are covered under the VA medical benefits package, if the infertility was the result of a service-connected condition. This includes infertility counseling, blood tests, genetic counseling, semen analysis, ultrasound imaging, surgery, medications, and IVF (as of 2017). however, the partner requesting services must be legally married and the egg and sperm must come from that partner (effectively excluding same-sex couples). donor eggs/sperm, surrogacy, or obstetric care for non-veteran spouses are not covered.
infertility services in publicly funded clinics
the cdc and office of population affairs (opa) quality family planning recommendations address the provision of basic infertility services. family planning providers are encouraged to provide, at a minimum, patient education on fertility and lifestyle changes, a complete medical history and physical examination, semen analysis, and, if indicated, referrals for laboratory tests of hormone levels, additional diagnostic tests (endometrial biopsy, ultrasound, hsg, laparoscopy) and prescription of drugs to promote fertility. however, studies of publicly funded family planning clinics suggest that the availability of infertility services is uneven. in a 2013-2014 study of 1,615 publicly funded clinics, a large proportion reported offering preconception care (94% for women and 69% for men), but fewer offered basic infertility services (66% for women and 45% for men). provision of any infertility treatment was uncommon (16% of clinics), likely requiring referrals to specialists who do not accept medicaid or patients without insurance.10 the majority of patients who rely on publicly funded clinics are from low income and likely could not afford infertility services and treatment once diagnosed.
according to the indian health service provider (ihs) manual, basic infertility diagnoses should be available for women and men at ihs facilities, including a history, physical examination, basal temperature chart (for predict ovulation), semen analysis, and progesterone tests. In facilities with obstetrics, HSG, endometrial biopsy, and diagnostic laparoscopy should also be available. however, it is not clear how accessible these services are in practice, and the provision of infertility treatment is not mentioned.
racial and ethnic minorities
The ability to have and care for the family you want is a fundamental tenet of reproductive justice. for those in need, this includes access to fertility services. the proportion of racial and ethnic minorities using medical services to get pregnant is lower than that of non-Hispanic white women, despite research that has found higher rates of infertility among black and American Indian/Native American women alaskan (ai/an ). Our analysis of 2015-2017 NSFG data shows that while 13% of non-Hispanic white women reported ever seeing a medical provider for help getting pregnant, only 6% of Hispanic women and 7% of non-Hispanic black women did (figure 7). A higher proportion of black and Hispanic women are covered by Medicaid or uninsured than white women, and more women with private insurance sought fertility help than those with Medicaid or without insurance. A variety of factors, including differences in coverage rates, service availability, income, and service-seeking behaviors, affect access to infertility care. In addition, other social factors also play a role. Misconceptions and stereotypes about fertility have often portrayed black women as not needing fertility assistance. Combined with the history of discriminatory reproductive care and the harm inflicted on many women of color over decades, some may delay seeking infertility care or may not seek it at all.
Other research has found that the use of fertility tests and treatments also varies by race. an analysis of nsfg data found that among women who reported using medical services to help them get pregnant, similar percentages of black (69%), hispanic (70%), and white (75%) women received fertility advice . however, less than half (47%) of African American and Hispanic women who used medical services to get pregnant reported having infertility tests, compared to 62% of white women, and even fewer women of color received services of treatment. According to an analysis of surveillance data from IVF services, use is highest among Asian and white women and lowest among American Indian/Alaskan Native (AI/AN) women. racial inequalities may also exist for fertility preservation; A study of women with cancer in New York found that disproportionately fewer black and Hispanic patients used egg cryopreservation compared to white patients. On average, more black, Hispanic, and Ai/an people live below the federal poverty level than white people or people of Asian/Pacific Islander descent. The high cost and limited coverage of infertility services make this care unaffordable for many people of color who may want fertility preservation but cannot afford it.
Iatrogenic, or medically induced, infertility refers to when a person becomes infertile because of a medical procedure done to treat another problem, usually chemotherapy or radiation for cancer. In these situations, people of reproductive age may desire future fertility and may choose to freeze their eggs or sperm (cryopreservation) for later use. The American Society for Reproductive Medicine (ASRM) encourages physicians to educate patients about fertility preservation options before undergoing treatment that is likely to cause iatrogenic infertility.
However, the cost of egg or sperm retrieval and subsequent cryopreservation can be prohibitive, especially if there is no insurance coverage. Only a handful of states (CT, Delaware, IL, MD, NH, NJ, NY, and RI) specifically require private insurers to cover fertility preservation in cases of iatrogenic infertility. no states currently require fertility preservation in their medicaid plans.
Lgbtq people may face greater barriers to fertility care and discrimination based on their gender identity or sexual orientation. Section 1557 of the Affordable Care Act (ACA) prohibits discrimination in the health care sector based on sex, but the Trump administration has removed these protections through regulatory changes. Without the explicit protections that have been removed in the current rules, LGBTQ patients may be denied health care, including fertility care, under religious freedom laws and proposed changes to the ACA. however, these changes are being challenged in court because they conflict with a recent Supreme Court decision that federal civil rights law prohibits discrimination based on sexual orientation and gender identity.
in a committee opinion, asrm concluded that it is an ethical duty of fertility programs to treat gay and lesbian couples and transgender people in the same way as heterosexual married couples. they write that assisted reproductive therapy should not be restricted based on sexual orientation or gender identity, and that fertility preservation should be offered to transgender people prior to gender transitions. this allows transgender people the ability to have biological children in the future if they choose. Despite this recommendation, in the aforementioned states with mandatory fertility preservation coverage for iatrogenic infertility, it is unclear whether this benefit extends to transgender people, whose gender-affirming care may result in infertility. In addition, many state laws regarding infertility treatment mandates contain provisions that may exclude LGBTQ patients. For example, in Arkansas, Hawaii, and Texas and in the VA, IVF services must use a couple’s own eggs and sperm (rather than a donor), effectively excluding same-sex couples. in other states, same-sex couples do not meet the definition of infertility and therefore may not qualify for these services. Data are lacking to fully capture the proportion of LGBTQ people who can use fertility services. Research studies on family formation are often not designed to include the fertility needs of LGBTQ respondents.
Single people are often excluded from access to infertility treatment. For example, the same IVF laws cited above that require a partner’s sperm and egg also effectively exclude single people, as they cannot use donors. Some grants and other funding options also stipulate that the funds must go to a married couple, excluding single and unmarried individuals. This runs counter to the ASRM committee’s opinion that fertility programs should offer their services to single parents and unmarried couples, without discrimination based on marital status.
At the federal level, efforts to pass laws requiring insurers to cover fertility services are largely stalled. The proposed Infertility Care and Treatment Access Act (HR 2803 and S 1461), which would require all health plans offered in group and individual markets (including Medicaid, EHBP, Tricare, VA) to provide infertility treatment, is still pending. in committee (and never left committee when it was proposed during the 115th congress). there has been some more movement at the state level. Some states require private insurers to cover infertility services, the most recent of which was NH in 2020. Today, NY remains the first and only state Medicaid program that covers any fertility treatment.
For those who want to have children, obtaining fertility care can be a stressful process. the stigma around infertility, intensive and sometimes lengthy or painful treatment regimens, and uncertainty about success can all take their toll. On top of that, in the absence of insurance coverage, infertility care is cost-prohibitive for most, particularly low-income people, and for more expensive services, such as IVF or fertility preservation. Significant disparities exist in access to infertility services based on residency status, insurance plan, income level, race/ethnicity, sexual orientation, and gender identity. achieving greater equity in access to fertility care will likely depend on addressing the needs faced by low-income people, people of color, and lgbtq people in fertility policy and coverage.