1. NO. Should health insurers be forced to pay for infertility treatments? By Emily Shields CEP 541 – Dr. Shanahan November 6, 2012

2. What are infertility treatments? Medical interventions designed to increase the odds of conception and successful birth of a child Level I: thorough medical examination, initial ovarian stimulation with clomiphene citrate, hormone medications Level II: use of exogenous gonadotrophins (to stimulate ovulation) with or without intrauterine insemination (IUI), tubal surgeries Level III: assisted reproductive technologies such as in vitro fertilization (IVF)

3. Who needs infertility treatments? Approximately 12% of American women will receive infertility services of some kind during their lifetime.  1-2% will receive Assisted Reproductive Treatments (ART) such as IVF.  Many insurance plans do not cover the cost of infertility treatments.  Some states have mandated insurance companies to provide at least partial coverage of ART.  Only these 15 states have laws requiring at least partial coverage of infertility treatments:  Arkansas, California, Connecticut, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, Texas, and West Virginia.

4. Hormone therapy, IVF, surgery, delivery… Hormone therapy ~$200-3,ooo per cycle Tubal surgery ~$10,000-15,000 One cycle of IVF ~$12,400 Medications only, at least ~$5,000 (per successful outcome) Total cost per successful delivery through ART ~$41,000-133,000 (median $64,000)  Depending on the cause of infertility, specific treatment methods, mother’s age, and number of infants born from one pregnancy Range of Costs of Infertility Treatments

5. Treatment costs for successful outcomes: (successful = birth of child(ren))

6. Insurance State mandates increase total utilization of health care, which means higher premiums for families.  Most large employers self-insure under the Employee Retirement Income Security Act (ERISA). This is a federal law that supersedes state laws. Companies that operate under ERISA are exempt from state mandates. State insurance laws primarily affect small employers, individuals, and the self-employed. Milliman & Robertson’s cost analysis of mandated infertility treatment coverage:  Increase of 3-5% per year ($105-$175) for a basic health insurance policy with no other mandates included.  Total mandated costs add up, making health insurance prohibitively expensive.

7. Current facts and research… ~59,000 births in the United States in 2010 were the result of in vitro fertilization procedures (Society for Assisted Reproductive Technology) Interesting article on male sperm gene mutation: http://discovermagazine.com/2012/jan-feb/58 http://discovermagazine.com/2012/jan-feb/58  Sperm gene DEFB126 encodes a protein coating on sperm cells that help them reach the uterus and egg. Without the protein, sperm “get stuck,” causing problems in conception.

8. Social implications: Massachusetts example: The medicalization of childbirth and infertility has changed childlessness from a disappointing act of nature to an obstacle to be overcome. Social control around reproduction is still embedded. Higher insurance premiums for everyone, even low-income families who are not utilizing services. MA has mandated comprehensive insurance coverage. Despite increased access to ART through insurance coverage, it has been found that low SES parents are not utilizing them. Increases in use of ART have been seen in the upper middle class, predominately by white women. Is insurance coverage really a good thing?

9. Questions to consider: Should infertility be considered a disability? Is reproduction an inherent right that everyone should be able to enjoy? With the current state of health care (cost, accessibility, etc.) should infertility be a priority?

10. References Adler, N., Croughan, M.S., Eisenberg, M.L., Katz, P., Millstein, S.G., Nachtigall, R.D., Pasch, L.A., Showstack, J., Smith, J.F., Wing, H. (2011). Costs of infertility treatment: results from an 18-month prospective cohort study. Fertility and Sterility, 95, (3), 915– 921. http://dx.doi.org.gate.lib.buffalo.edu/10.1016/j.fertnstert.2010.11.026http://dx.doi.org.gate.lib.buffalo.edu/10.1016/j.fertnstert.2010.11.026 Adler, N., Cedars, M., Eisenberg, M.L., Glidden, D., Katz, P.P., Millstein, S.G., Pasch, L.A., Showstack, J., Smith, J.F., Walsh, T.J. (2011). Socioeconomic disparities in the use and success of fertility treatments: analysis of data from a prospective cohort in the United States. Fertility and Sterility, 96(1), 95–101. http://dx.doi.org.gate.lib.buffalo.edu/10.1016/j.fertnstert.2011.04.054 http://dx.doi.org.gate.lib.buffalo.edu/10.1016/j.fertnstert.2011.04.054 Bell, A. V. (2010). Beyond (financial) accessibility: inequalities within the medicalisation of infertility. Sociology Of Health & Illness, 32(4), 631-646. doi:10.1111/j.1467- 9566.2009.01235.x Bitler, M., & Schmidt, L. (2012). Utilization of infertility treatments: the effects of insurance mandates. Demography, 49(1), 125-149. doi:10.1007/s13524-011-0078-4 Matthews Jr., M. (1999). Should health insurers be forced to pay for infertility treatments? Insight on the News, February 8, 1999. Rice, J. Sperm gene points to infertility cure. Discover Magazine, January-February special issue; published online January 5, 2012.