Access to Care and Why it Matters for Fertility
Roughly 6.7 million women in the U.S. have difficulty having children, but only about a quarter of people report that they are able to access the care they need to become pregnant (1). In fact, the percentage of births attributed to assisted reproductive technology (ART) is just 1.5% in the U.S., whereas ART accounts for almost 6% of births in countries that publicly fund IVF (2). Together, this information suggests that there is an unmet need for family-building services in the U.S.
The American Society for Reproductive Medicine (ASRM) believes that reproduction is a fundamental human right and that improving access to fertility services is an ethical imperative (3). Infertility is a disease that merits treatment, the same way that an ailment affecting the heart or lungs does. Unfortunately, as with many facets of healthcare in the U.S., issues such as underinsurance and geography pose challenges to accessing fertility services. Most of all, cost presents a significant barrier for people who could benefit from infertility treatment (4). The median cost of fertility treatment can range from just over $1,000 for medications to almost $20,000 for IVF with preimplantation genetic testing (PGT) and embryo transfer.
These barriers have exacerbated existing disparities in access to infertility treatment and even in outcomes. Some studies have shown that there are higher rates of infertility for Black and Hispanic people, and it often takes longer for people in all minority groups to reach fertility services (5). But there also have been reports of discrepancies in outcomes even after people access fertility treatment. According to one study, Black women had lower implantation and pregnancy rates than white women, even when women were the same age and underwent similar treatments (6). More research is needed to understand what generates these differences in access and outcomes, but it is thought that a combination of factors including bias, cultural stigma, and other comorbidities likely contribute. (7)
Fortunately, emerging legislation on a state level is mandating access to fertility services. As of 2021, nineteen states have laws that require private insurance companies to cover (or offer to cover) certain components of infertility diagnosis and treatment. (8) Still, among these states, the services that insurance companies cover are far from uniform. Here in New York, for instance, private health plans cover up to three cycles of IVF, while health plans in Hawaii cover just one (9,10). Additionally, these mandates may not always include people who are single, gender non-conforming, or in same-sex relationships, and state Medicaid programs include very limited offerings for fertility services, if at all (11). Increasing mandates for fertility services is important for improving disparities in reproduction: studies have shown that more people of all races and ethnicities have utilized fertility services in states that have mandates (12). Unsurprisingly, better coverage also leads to better outcomes overall. It is thought that when there is less financial pressure, physicians and patients are more likely to opt to transfer fewer embryos per cycle. As a result, there is a decreased chance of having twins or triplets after using ART in states with mandates, facilitating a healthier pregnancy for both parent and baby (13).
We in the fertility community still have a lot of work to do to address disparities in reproduction and to make fertility care more equitable. Non-profit organizations such as RESOLVE have been invaluable in connecting people with information and resources, and other programs offer a variety of grants and financing options to support fertility journeys. Here at RMA, we are aligned with ASRM’s view and are committed to ongoing research, advocacy, patient and provider education, and innovation that shed light on disparities in infertility and promote ways to mitigate them. We have also partnered with several programs, to help people navigate the financial challenges encountered during fertility treatment. Ultimately, advocacy aimed at improving access to care on both a state and national level is the key to ensuring that everyone has the opportunity to build their family.
(1) Ethics Committee of the American Society for Reproductive Medicine (2015). Disparities in access to effective treatment for infertility in the United States: an Ethics Committee opinion. Fertility and sterility, 104(5), 1104–1110. https://doi.org/10.1016/j.fertnstert.2015.07.1139
(2) Ethics Committee of the American Society for Reproductive Medicine (2015). Disparities in access to effective treatment for infertility in the United States: an Ethics Committee opinion. Fertility and sterility, 104(5), 1104–1110. https://doi.org/10.1016/j.fertnstert.2015.07.1139
(3) Ethics Committee of the American Society for Reproductive Medicine (2015). Disparities in access to effective treatment for infertility in the United States: an Ethics Committee opinion. Fertility and sterility, 104(5), 1104–1110. https://doi.org/10.1016/j.fertnstert.2015.07.1139 and https://www.who.int/news-room/fact-sheets/detail/infertility
(4) Quinn M, Fujimoto V. Racial and ethnic disparities in assisted reproductive technology access and outcomes. Fertil Steril. 2016 May;105(5):1119-1123. doi: 10.1016/j.fertnstert.2016.03.007. Epub 2016 Mar 30. PMID: 27054308.
(5) Insogna, I. G., & Ginsburg, E. S. (2018). Infertility, Inequality, and How Lack of Insurance Coverage Compromises Reproductive Autonomy. AMA journal of ethics, 20(12), E1152–E1159. https://doi.org/10.1001/amajethics.2018.1152
(6) https://www.fertstert.org/article/S0015-0282(16)30040-1/pdf
(7) Insogna, I. G., & Ginsburg, E. S. (2018). Infertility, Inequality, and How Lack of Insurance Coverage Compromises Reproductive Autonomy. AMA journal of ethics, 20(12), E1152–E1159. https://doi.org/10.1001/amajethics.2018.1152
(8) Kawwass, J. F., Penzias, A. S., & Adashi, E. Y. (2020). Fertility—a human right worthy of mandated insurance coverage: the evolution, limitations, and future of access to care. Fertility and sterility.
(9) https://www.dfs.ny.gov/apps_and_licensing/health_insurers/ivf_fertility_preservation_law_qa_guidance
(10) https://www.reproductivefacts.org/resources/state-infertility-insurance-laws/states/hawaii/
(11) Kawwass, J. F., Penzias, A. S., & Adashi, E. Y. (2020). Fertility—a human right worthy of mandated insurance coverage: the evolution, limitations, and future of access to care. Fertility and sterility.
(12) Dieke, A. C., Zhang, Y., Kissin, D. M., Barfield, W. D., & Boulet, S. L. (2017). Disparities in assisted reproductive technology utilization by race and ethnicity, United States, 2014: a commentary. Journal of Women's Health, 26(6), 605-608.
(13) Dieke, A. C., Zhang, Y., Kissin, D. M., Barfield, W. D., & Boulet, S. L. (2017). Disparities in assisted reproductive technology utilization by race and ethnicity, United States, 2014: a commentary. Journal of Women's Health, 26(6), 605-608. and Ethics Committee of the American Society for Reproductive Medicine (2015). Disparities in access to effective treatment for infertility in the United States: an Ethics Committee opinion. Fertility and sterility, 104(5), 1104–1110.