Insurance coverage and in vitro fertilization outcomes: a U.S. perspective

Reproductive outcome of women 43 years and beyond undergoing ART treatment with their own oocytes in two Connecticut university programs

PURPOSE

The aim of this study was to analyze the outcomes of IVF/ICSI cycles in women aged 43 and beyond.

METHODS

Retrospective analysis of clinical pregnancy and live birth rates in 168 fresh, non donor, ART cycles performed in two Connecticut university IVF programs.

RESULTS

In women of 43 and 44 years the overall clinical pregnancy and live birth rates were 8.3% and 5.3% per initiated cycle, respectively. There were no clinical pregnancies in women ≥45 years old. First cycle characteristics were not different from repeated cycles in terms of duration of ovulation induction, number of collected oocytes and transferred embryos (p > 0.05).

CONCLUSIONS

Pregnancies can still be achieved with IVF/ICSI up to the age of 44. Since most pregnancies occurred within the first 3 cycles, another attempt may be a reasonable option before resorting to oocyte donation for patients who failed two previous cycles. Women 45 years and beyond do not benefit from ART procedures using their own oocytes.

Diagnosis and treatment of diminished ovarian reserve in assisted reproductive technology cycles of women up to age 40 years: the role of insurance mandates

OBJECTIVE

To explore correlates of diminished ovarian reserve (DOR) and predictors of assisted reproductive technologies (ART) treatment outcome in DOR cycles using the Society for Assisted Reproductive Technologies-Clinical Outcomes Reporting System (SART-CORS) database; we hypothesized that mandated state insurance coverage for ART is associated with the prevalence of DOR diagnosis in ART cycles and with treatment outcomes in DOR cycles.

DESIGN

Cross-sectional study using ART cycles between 2004 and 2007.

SETTING

Not applicable.

PATIENT(S)

A total of 182,779 fresh, nondonor, initial ART cycles in women up to age 40 years.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Prevalence of DOR and elevated FSH, odds ratio of DOR and elevated FSH in ART mandated vs. nonmandated states, live birth rates.

RESULT(S)

Compared with cycles performed in states with mandated ART coverage, cycles in states with no ART mandate were more likely to have DOR (adjusted odds ratio 1.43, 95% confidence interval 1.37-1.5) or elevated FSH (adjusted odds ratio 1.69, 95% confidence interval 1.56-1.85) as the sole reason for treatment. Lack of mandated ART coverage was associated with increased live birth rates in cycles diagnosed as DOR, but not in cycles characterized only by an elevated FSH.

CONCLUSION(S)

A significant association was observed between lack of mandated insurance for ART and the proportion of cycles treating DOR or elevated FSH. The presence or absence of state-mandated ART coverage could impact access to care and the mix of patients that pursue and initiate ART cycles in ways that influence these proportions. Additional studies are needed that consider the coalescence of insurance mandates, patient and provider factors, and state-level variables on the odds of specific infertility diagnoses and treatment prognosis.

A reduction in public funding for fertility treatment--an econometric analysis of access to treatment and savings to government

BACKGROUND

Almost all assisted reproductive technology (ART) and intrauterine insemination (IUI) treatments performed in Australia are subsidized through the Australian Government's universal insurance scheme, Medicare. In 2010 restrictions on the amount Medicare paid in benefits for these treatments were introduced, increasing patient out-of-pocket payments for fresh and frozen embryo ART cycles and IUI. The aim of this study was to evaluate the impact of the policy on access to treatment, savings in Medicare benefits and the number of ART conceived children not born.

METHODS

Pooled quarterly cross-sectional Medicare data from 2007 and 2011 where used to construct a series of Ordinary Least Squares (OLS) regression models to evaluate the impact of the policy on access to treatment by women of different ages. Government savings in the 12 months after the policy was calculated as the difference between the predicted and observed Medicare benefits paid.

RESULTS

After controlling for underlying time trends and unobserved factors the policy change reduced the number of fresh embryo cycles by almost 8600 cycles over 12 months (a 16% reduction in cycles, p < 0.001). The policy effect was greatest on women aged 40 years and older (38% reduction in cycles, p < 0.001). Younger women engaged in relatively more anticipatory behaviour by bringing forward their fresh cycles to 2009. Frozen embryo cycles, which are approximately one quarter of the cost of a fresh cycle, were only marginally impacted by the policy. Utilisation of IUI cycles were not impacted by the policy. After adjusting for anticipatory behaviour, $76 million in Medicare benefits was saved in the 12 months after the policy change (0.47% of annual Medicare benefits). Between 1200 and 1500 ART conceived children were not born in 2010 as a consequence of the policy.

CONCLUSIONS

The introduction of the policy resulted in a significant reduction in fresh ART cycles in the first 15 months after its introduction. Further evaluation on the long-term impact of the policy with regard access to treatment and on clinical practice, particularly the number of embryos transferred, is crucial to ensuring equitable access to fertility treatment and the health and welfare of ART children.

The association between fertility clinic performance and cycle volume: implications for public reporting of provider performance data

OBJECTIVE

To quantitatively determine the relationship between fertility clinic performance and cycle volume, and to assess the implications for public reporting of provider performance data.

DESIGN

Retrospective longitudinal analysis.

SETTING

Clinic.

PATIENT(S)

The study population included 307 U.S. assisted reproductive technology (ART) clinics that continuously reported performance data to the Centers for Disease Control from 2003 to 2008.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Regression coefficients between pregnancy rate per cycle, live birth rate per cycle, or live birth rate per transfer and number of ART cycles performed.

RESULT(S)

Overall, there was no association found between a clinic's most recently reported success rate and its cycle volume. This finding was consistent across three time periods studied. Moreover, stratification analyses of clinics with greater than ±5%, ±10%, and ±20% change in success rates also found no association between clinic performance and cycle volume.

CONCLUSION(S)

As proxied by cycle volume data, patients seeking ART treatment do not seem to be influenced by positive or negative changes in a clinic's performance despite the public availability of this data. These results suggest that current public quality reporting encompassing success rates alone will not change patient behavior and therefore is insufficient to place salient competitive pressure on health care providers. Further research is necessary to define provider performance comprehensively and to determine the metrics, if any, to which patients respond.

The efficiency of a group-specific mandated benefit revisited: the effect of infertility mandates

This paper examines the labor market effects of state health insurance mandates that increase the cost of employing a demographically identifiable group. State mandates requiring that health insurance plans cover infertility treatment raise the relative cost of insuring older women of child-bearing age. Empirically, wages in this group are unaffected, but their total labor input decreases. Workers do not value infertility mandates at cost, and so will not take wage cuts in exchange, leading employers to decrease their demand for this affected and identifiable group. Differences in the empirical effects of mandates found in the literature are explained by a model including variations in the elasticity of demand, moral hazard, ability to identify a group, and adverse selection.