What are the biggest disconnects between insurance-mandated fertility treatment protocols and evidence-based care?

Why does our health insurance not actually cover health care? Why are they allowed to get away with this when it comes to reproductive medicine? Why do we have to pass laws to force insurance companies to do what they purportedly exist to do: provide health care insurance.

We are also seeing insurance companies actively promoting and forcing people to undergo many IUIs and use injectables plus IUI. IUI used to be the number one cause of multiple births in the United States. Multiple births cause enormous morbidity and mortality for both mothers and babies. Yet insurance companies have forced, and are still forcing, people to undergo IUI—even in cases where it is not indicated, not effective, or potentially dangerous—instead of allowing IVF.

This doesn’t make sense from a population-level cost perspective. The cost of IVF per baby is much less than IUI because IVF is far more effective: it may be only twice as expensive per cycle but about ten times more effective, so the cost per baby is lower. It’s unclear why insurance companies think they’re saving money this way. Maybe they assume people change insurance every year and try to deny as much as possible. You see many policies that require six or twelve IUI cycles before allowing access to IVF benefits—these are people who actually have IVF benefits, yet the insurer still finds ways to say no.

We are at a stage of technology where we can safely and effectively help people struggling with infertility to do proactive family planning—not just address infertility, but also plan for a desired family size. Many people want two children; replacing yourselves as a couple often means having two kids. Insurance companies creatively and aggressively erect barriers to care in many ways.

We also see discrimination: people who are single or LGBTQ may be denied coverage because they don’t fit a narrow definition of infertility that presumes heterosexual sex for six to twelve months without conception. The ASRM guidelines have worked to eliminate that barrier—as of 2022 (maybe 2023 or 2024; I’d have to check), people who are single or LGBTQ do meet the definition of infertility and should be covered. Insurance should not discriminate based on partner status, sexual orientation, or gender identity, but many companies still do.

Even when people have infertility coverage or IVF benefits, insurers often restrict embryo banking. Embryo banking is currently the best way to do family planning. A good program in the United States should be able to achieve about a 60 percent (maybe higher) live birth rate from a single euploid embryo. If you follow the standard of care and ASRM guidelines—performing single embryo transfers—that translates to roughly three euploid embryos per live birth. Three euploid embryos with a 60 percent live birth rate each yields approximately a 95 percent chance of achieving one live birth from those three embryos.

Of course you could get zero successes, or three successes, and if one embryo splits you could have more than one child from a single embryo. But that’s where the numbers come from. Theoretically, if you want two children, you would like to have six euploid embryos. Most people cannot produce six euploid embryos in one cycle—not even donors. Studies show that donor embryos still have a very high rate of aneuploidy: 30 to 50 percent of donor embryos will be aneuploid. That’s just nature—meiosis is complicated and error-prone.

It’s almost miraculous that most of the time we end up with 46 chromosomes. Meiosis involves complex exchanges to increase genetic diversity, and then chromosomes must be divided evenly so every egg and sperm receives 23 chromosomes. Given how intricate that process is, it’s surprising it works as often as it does.

I think insurance-based IVF protocols and evidence-based care are largely aligned. Much of the evidence about IVF protocols focuses on achieving a healthy singleton live birth, which is the ultimate goal because it is the lowest-risk pregnancy for both mothers and babies. So there is generally alignment with insurers on that point.

In some cases, insurance plans may require older testing modalities for ovarian reserve. We might need to do tests we don't rely on as much anymore, such as a basal FSH level, even though we are more likely to use anti-Müllerian hormone and antral follicle count in modern fertility practice.

Sometimes a patient has a clear indication for IVF, but the insurer recommends trying intrauterine insemination two or three times first as part of their usual practice. These decisions can generally be appealed, but appeals take time, which can be a deterrent for patients.

There is a real benefit to broader system oversight of medical practice. The entities paying for care are ultimately responsible for the outcome of the baby, so I understand their role in setting guidelines and trying to keep care safe. Fortunately, apart from whether IVF is covered at all, I haven’t largely seen insurers dictate physician practice in ways that are solely financially driven. It seems they focus on patient safety and following general practice guidelines, and safe outcomes tend to be less costly for insurers.

In terms of altering how I care for patients, I don’t feel that insurers are meddling. I hear those frustrations in other areas of medicine, but in fertility it’s usually a straightforward question of whether coverage exists. It’s uncommon that insurers’ requirements don’t align with how we would practice anyway.