Health insurance coverage for infertility treatments varies widely. Some plans cover advanced assisted reproductive technologies (ART). Others only pay for basic evaluations. This article will explore why infertility treatments should be covered by insurance.
According to the WHO’s 2020 Infertility Fact Sheet, infertility affects millions of people of reproductive age worldwide. It impacts not only individuals but also families and communities. Estimates suggest that “between 48 million couples and 186 million individuals live with infertility globally.” Inequities and disparities in access to fertility care services adversely affect the poor, unmarried, uneducated, unemployed, and other marginalized populations.
A wide variety of people, including heterosexual couples, same-sex partners, older persons, individuals who are not in sexual relationships may required infertility services. Some circumstances, such as HIV serodiscordant couples and cancer survivors, may require highly personalized approaches to care.
Although both women and men can experience infertility, women in a relationship with a man are often perceived to suffer from infertility, regardless of whether they are infertile or not. Further, infertility has significant negative social impacts on the lives of infertile couples. Women are more often suffer negative consequences of infertility such as partner violence, divorce, social stigma, emotional stress, depression, anxiety, and low self-esteem. Addressing infertility can mitigate gender inequality.
The evolving definition of infertility (we’ve come a long way, baby)
–The landmark 1993 ASRM definition
As far back as 1993, the American Society for Reproductive Medicine (ASRM) – the professional society for reproductive medicine physicians and providers – declared:
“Infertility is a disease of the reproductive system that impairs the body’s ability to perform the basic function of reproduction.”
Despite this statement by professional experts, it took many more years for other major health groups to formally agree.
–The 2009 WHO and ICMART definition
In 2009, long after ASRM’s initial declaration, the World Health Organization (WHO) and the International Committee for Monitoring Assisted Reproductive Technology (ICMART) decided to define infertility as:
“a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.”
These organizations are important because they influence the perspectives and practices in the international health community. This definition became a part of the WHO-ICMART glossary that was published in 2009.
–International Glossary on Infertility and Fertility Care
The 2009 International Glossary on Infertility and Fertility Care was updated in 2017  This effort was led by ICMART in partnership with all the major international fertility societies. An important change in the definition of infertility occurred at that time:
“A disease characterized by the failure to establish a clinical pregnancy after 12 months of regular, unprotected sexual intercourse or due to an impairment of a person’s capacity to reproduce either as an individual or with his/her partner. …”
This definition acknowledges the rights of individuals with a desire to parent in a non-traditional manner, including having access to fertility care.
–The AMA joins in
In the same year, the American Medical Association (AMA) joined WHO/ICMART in declaring that infertility is a disease. Persuaded by the ASRM, the AMA House of Delegates adopted a resolution during their 2017 annual meeting that described infertility
“as a disease state with multiple etiologies requiring a range of interventions to advance fertility treatment and prevention.”
In a summary of their decision, the AMA stated their hope that the new designation would remove some of the stigmas and importantly, “promote insurance coverage and payment.”
Lobbying the AMA and others has been part of a strategic effort by ASRM to ensure that more Americans have access to reproductive medicine. According to past president Richard Paulson, MD,
“We all feel this way and realized it was time to put our efforts behind it,” adding infertility doctors have become “increasingly sensitive to the fact that much of the American population simply can’t afford infertility treatment.”
–A major advance in billing codes
The presence or absence of a specific code to bill for a service is a key factor in payment for those services. A notable advance in this area occurred when the International Classification of Diseases (ICD) which governs billing codes added “infertility” to the list of ICD-9 codes. It is now a part of the ICD-10 codes currently being used in the US.
Being “covered” is not enough, the coverage must be robust
Financial constraints are an important determinant of whether or not infertility treatments are covered. They also influence the extent of the coverage. In other words, which procedures and drugs are covered as well as the magnitude of the patient’s cost-sharing.
The benefit’s design has significant clinical implications. Infertility professionals express concern that some patients make suboptimal decisions about treatment. For example, they may choose to transfer multiple embryos to the uterus at once, instead of the now-recommended single embryo transfer. The driver of this decision is to avoid paying for more procedures. This leads to a higher risk of complications for mother and child and higher long-term health care costs for insurance companies.
Despite several major health groups declaring that infertility is a disease, complex and varied factors, including those just described, determine what is covered and how much is paid for as part of healthcare coverage. Employers purchase health insurance for their employees and have a say in the type of infertility coverage they want to be included in their plans. Insurance companies must respond to their wishes as well as comply with state and federal regulations as well as a factor in their own financial considerations.
Perceptions of infertility care play a role in coverage
Major factors that determine coverage include cost, prevalence, and politics/external pressures (including state advocacy and internal pressure from employees on employers). In writing about the politics and culture of parenthood for CNN Health, Elissa Strauss has her own perspective as to why insurance companies still do not sufficiently cover treatments such as in vitro fertilization (IVF). She sums it up as follows:
“economics, ignorance and sexism.”
There’s widespread agreement on the role of economics and the influence it has on covering infertility treatment. For years the label “experimental” was problematic. However, now – forty years after the successful birth of Louise Brown, the awarding of the Nobel prize to Sir Bob Edwards for its creation, and the birth of almost 10 million babies worldwide – it’s impossible to continue to call the procedures experimental.
Two other factors have led to low coverage rates for infertility treatment according to Strauss: sexism and the perception of who needs IVF. She points to insurers’ treatment of women’s issues as a “niche” health issue, starting with the fact that 30 years ago childbirth was not covered by insurance and had to be paid out-of-pocket. This attitude, she says, continues to play a role in the denial of coverage. She also notes the irony of treating infertility as a “female” issue when half of the infertility cases are associated with male factor infertility.
The other issue Strauss believes has interfered with gaining wider insurance coverage is the perception that procedures like IVF are only needed/used by wealthy women who require the procedure because they delayed having children until too late while they pursued careers. The demographics of who is affected by infertility and needs treatment definitively show otherwise.
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The trend for coverage of infertility is improving
The trend for coverage of infertility is definitely improving but the most active sectors embracing this change are technology firms, banking, and other highly compensated industry sectors as described in this New York Times article . There is also wide variation in what is covered, how much is paid, and even whether pre-authorization is required before receiving treatment.
The article cites an analysis of infertility coverage by broad industry sectors and the top 250 employers for the 2017/2018 benefit year. A survey of a subset of 10,000 verified IVF patients who had complete IVF coverage in 2017 found that employees who had their IVF covered reported the following:
- Those with coverage were more likely to remain in their job for a longer period (62%),
- They were more willing to overlook shortcomings of their employer (53%)
- Covered individuals were more likely to work harder (22%)
- And, the vast majority (88%) of women who had their IVF fully paid by their employer decided to return back to that employer after maternity leave
There is also a higher rate of employee satisfaction with their employer if fertility benefits are offered compared to employers that do not offer a benefit:
- 4 times more believe their employer is meeting the needs of today’s families
- 5 times more believe their employer listens to their needs
- 5 times more believe their employer cares about their well-being
–Comments from the survey
Comments from survey respondents also revealed stark differences in how employees felt about their employers based on whether or not they offered a fertility benefit. One woman stated that because her employer offered such coverage “I’m loyal – it’s the reason I stay.”
Those employers who did not offer coverage earned negative comments from employees including: “behind the times in health coverage,” “makes me feel undervalued,” “discriminated against this disease,” and “must be a better place to work, I’m looking for a better job with better benefits, better understanding.”
There is still room for improvement
Coverage of infertility has improved over the years, largely from competitive pressures among companies looking to attract and retain the best employees. However, there is definite room for improvement since only about a quarter of current IVF costs are covered nationally. The current need for infertility services is not being met largely because of a lack of affordability.
So, how does a disease like infertility garner inclusion as a covered benefit? External pressure can drive decision-making by employers who determine benefit coverage with insurers and with state and federal legislators to enact mandates to ensure appropriate coverage for needed treatment. RESOLVE: The National Infertility Association serves as a valuable resource and advocates on both counts.
- The RESOLVE Coverage at Work Initiative has materials to help individuals advocate on their own behalf with their employer to add fertility coverage to benefit packages. This includes talking points to use with your Human Resources department and/or benefits manager and a template letter you can customize. The letter provides the type of information employers need including studies that show there actually are minimal net costs involved in adding coverage because improved health outcomes result in lower employer maternity expenses. You can download the template “Insurance Coverage Request Letter” by clicking here.
- RESOLVE plays an active advocacy role working to secure state legislative mandates requiring insurance coverage for infertility treatment. To learn more about what your state does – or doesn’t do – when it comes to requiring insurance coverage of infertility treatment, you can click on the RESOLVE list.
- The organization also produces a Fertility Scorecard that ranks each state on how well they’re doing on the issue. You can learn more about RESOLVE’s current state advocacy issues here and find out how to become involved.
Some really big questions remain
Whatever varied factors you believe may influence whether infertility is considered a disease with coverage for needed treatment, CNN Health’s Strauss notes there are “thornier” issues to consider: is having a baby a privilege or a right?
Such questions parallel the discussion of whether or not access to health care is a right. While most countries consider it to be so, this position is not universally held in the US. Kara N. Goldman, MD, assistant professor of reproductive endocrinology and infertility at New York University has advocated for comprehensive infertility coverage. She states
“I think of reproduction as a basic human right. Patients should be able to have families, and we have the medical care to make that possible.” 
The view that reproductive rights include the right to diagnosis and treatment of infertility is increasingly becoming the international norm. 
The bottom line
This article has reviewed why it is important to provide access to infertility and fertility care for all who want a family. Since the major barrier to access is affordability, it is imperative that health insurers, particularly employer-sponsored health plans, include this care as a covered benefit.
With a healthy economy and a desire for healthy babies, employees facing infertility have every reason to expect that employers can and should offer a fertility benefit. Surveys and studies show it makes companies more competitive, increases their ability to attract and retain the best employees, enhances employee morale and productivity, and improves health outcomes.
- WHO. Infertility. 2020 Sept 14, https://www.who.int/news-room/fact-sheets/detail/infertility (Accessed 2/27/21)
- Zegers-Hochschild F, Adamson D, Dyer S, et al. The International Glossary on Infertility and Fertility Care, 2017 July 28, ASRM FertStert, DOI:https://doi.org/10.1016/j.fertnstert.2017.06.005
- Strauss E. 40 years later, why is IVF still not covered by insurance? Economics, ignorance and sexism. CNN Health, 2018 July 25, https://www.cnn.com/2018/07/25/health/ivf-insurance-parenting-strauss/index.html (Accessed 2/27/21)
- Carrns A. Tech Companies Get High Marks for Covering Infertility Treatments. New York Times. 2017 Nov 15. https://www.nytimes.com/2017/11/15/your-money/infertility-treatment-coverage.html. (Accessed 2/27/21)
- Starrs A, Ezeh A, Barker G, et al. Accelerate progress: Sexual and Reproductive Health and Rights for All. Report of the Guttmacher-Lancet Commission. 2018 May 9. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30293-9/fulltext
Published 10/29/18. Updated and republished 2/27/21.
Financial disclosure: Dr. Adamson is a part of ARC Fertility. TDWI, however, did not receive any compensation to publish this story. Rather, it was published because of the important nature of its content.