Infertility Clinics And The Insurance Billing Conundrum For Male Patients

Infertility treatments are expensive, and insurance coverage is often limited. In the US, only 15 states require insurance to cover in vitro fertilisation (IVF). Even when IVF is covered, patients can be left with huge bills, as insurers' lists of in-network providers are not always accurate. Infertility is defined as the inability to conceive after 12 months of regular, unprotected intercourse, and affects about 6% of married women aged 15-44. Male factor infertility contributes to about half of all cases, and the World Health Organisation and American Society of Reproductive Medicine define infertility as a disease. Despite this, coverage for male infertility is often excluded from health insurance laws. Excluding male infertility coverage places an undue burden on female partners, who may then have to undergo more invasive and costly procedures.

Male infertility insurance coverage varies across states

Male infertility care is expensive, with 16-20% of male patients' annual incomes spent on infertility-related expenses. Despite infertility being classified as a disease, with males contributing to almost half of all infertility cases, male infertility is frequently excluded from health insurance laws. Only eight out of 15 states with laws mandating coverage for female infertility care include any discussion of care for male infertility.

Some states, like California, Connecticut, Massachusetts, New Jersey, New York, and Ohio, have laws mandating some form of coverage for male infertility treatment. For example, in California, insurance companies must offer employers insurance plan options that include infertility coverage, but employers are not required to select these plans for their employees. In contrast, other states, like Montana and West Virginia, have laws mandating coverage for undefined infertility services in Health Maintenance Organisation (HMO) plans.

The variability in insurance coverage for male infertility across states highlights the importance of understanding the specifics of your insurance plan and applicable state laws. It is crucial to recognise that even when IVF is covered by insurance, high out-of-pocket costs and unexpected bills can still occur.

Male infertility evaluations can identify serious health conditions

Male infertility evaluations are important for both members of a couple trying to conceive. Male factor infertility contributes to about half of all infertility cases. Evaluations can help to identify and correct reversible causes of male infertility, as well as identify irreversible conditions that may be amenable to assisted reproductive techniques.

The evaluation process typically includes a semen analysis, which assesses the amount of sperm, the shape of the sperm, and the way that the sperm move. Blood tests may also be carried out to measure levels of male reproductive hormones, as too much or too little of these hormones can cause problems with making sperm or with having sex. In some cases, an ultrasound exam of the scrotum may be done to look for problems in the testicles.

Male infertility evaluations can also help to identify serious health conditions. For example, a retrospective study from two academic medical centres found that 6% of patients presenting for infertility evaluations had important medical pathology identified, such as 24 cases of cystic fibrosis mutations and two cases of cancer. Male infertility has also been associated with an increased risk of cardiovascular disease, testicular and prostate cancer, and early mortality.

IVF costs and insurance coverage

IVF Costs

The cost of IVF can vary depending on the patient's individual needs and the clinic they choose. A single IVF cycle can range from $15,000 to $30,000, with medications accounting for up to 35% of those charges. The base fee for IVF typically covers monitoring appointments, bloodwork, egg retrieval, and follow-up care, and can range from $12,000 to $14,000. However, this does not include the cost of injectable hormones, which can cost between $3,000 and $6,000. Additional clinic fees may include intracytoplasmic sperm injection, genetic testing of embryos, and cryostorage fees.

Insurance Coverage

Insurance coverage for IVF varies depending on the state and the employer's chosen plan. Only 15 states require insurance to cover IVF, and even in these states, there may be gaps in coverage. Large employers are more likely to offer fertility benefits, with about 27% of companies with 500 or more employees covering IVF in 2020. Insurance coverage for IVF generally depends on what coverage plans the employer has elected to offer, and where the patient lives. Nineteen states have laws that require employers to provide fertility benefits, but the specific treatments covered and eligibility criteria can vary. It's important to carefully review the insurance plan and understand what is and isn't covered before starting IVF treatment.

Infertility treatment options

Infertility treatment can be a long and anxious journey, but success rates are improving and procedures are safer than ever. There are three main types of fertility treatment: medication, surgery, and assisted conception. The treatment you have will depend on the reason for your infertility.

Medication

Drugs can be used to help with ovulation. Ovulation (releasing eggs) is the first step of the monthly reproductive cycle. If it doesn't happen, or if it happens very irregularly, it is very hard to conceive with regular sex alone. Problems with ovulation are the most common cause of infertility. Certain drugs can be used to bring on ovulation in women and birthing people who don't ovulate often or at all.

Surgery

Surgery is used to treat blockages or scarring on any of the organs in the reproductive system so that eggs can make their way to the womb more easily. Fallopian tube surgery can be used to remove blockages or scarring, allowing eggs to pass through. Laparoscopic (keyhole) surgery can be used to treat endometriosis, fibroids, and polycystic ovary syndrome (PCOS).

Assisted Conception

Assisted conception is the use of medical techniques to help with the process of becoming pregnant. Intrauterine insemination (IUI) is a popular procedure to treat many fertility problems. Doctors place sperm directly into the uterus, but not into the egg itself, while the patient ovulates. In vitro fertilisation (IVF) is the most widely known assisted conception technique. For IVF, patients take medicine to encourage their ovaries to produce more eggs than normal. The eggs are then taken out and fertilised with sperm in a lab.

Other Options

Cryopreservation (aka freezing your eggs, sperm, or embryos), egg or embryo donation, and gestational carriers (aka surrogacy) are also forms of assisted reproductive technology (ART). Donor sperm, donor eggs, and surrogates are often used by same-sex couples or single people who want to have a baby.

Infertility insurance coverage by state

Infertility treatment is expensive, and insurance coverage is often incomplete or non-existent. While some states have passed laws requiring insurance companies to cover IVF, the specifics of these laws vary, and many states do not have such laws.

States that Mandate IVF Coverage

As of 2024, 15 states require insurance companies to cover IVF:

• Arkansas
• Colorado
• Connecticut
• Delaware
• Hawaii
• Illinois
• Louisiana
• Maryland
• Massachusetts
• New Hampshire
• New Jersey
• New York
• Rhode Island
• Texas
• Utah

States with Fertility Preservation Laws

Additionally, 17 states have fertility preservation laws:

• Connecticut
• Delaware
• Illinois
• Maryland
• Massachusetts
• New Hampshire
• New Jersey
• New York
• Rhode Island
• Washington
• West Virginia

Other State-Specific Laws

Some states have laws that require insurance companies to offer infertility coverage to employers, who can then choose whether or not to include it in their employee benefit packages. These states include:

• California
• Texas

Some states have laws that require HMOs to cover infertility treatments when they are deemed "medically necessary". These states include:

• Ohio
• West Virginia

No State Mandate

Many states do not have a mandate to cover IVF. In these states, insurance coverage for infertility treatment is often limited or non-existent, and patients must pay out of pocket, which can amount to tens of thousands of dollars.

Frequently asked questions