Insurance coverage for male infertility care in the United States

The Ameliorative Impact of Cichorium intybus L. Distillate on Reproductive Parameters in Male Mice

Background

Cichorium intybus L. (Kasni) distillate is widely used in Eastern countries as a safe herbal drink to improve male fertility. However, the potential effects on fertility parameters and possible adverse effects have not been studied experimentally. The current study aims to evaluate the impact of Cichorium intybus L. distillate (CD) on male mice fertility.

Methods

In the present study (Shiraz, Iran), 30 male mice (30-35 g) were divided into three groups. 10 mice received distilled water (DW) for five weeks as the control group. Another 10 mice, named group CD1/2, received chicory distillate of 1/2 dilution, and the other 10 mice received chicory distillate of CD1/4 dilution as CD1/4 group, ad libitum for three weeks, and they received DW for two weeks afterward. Experimental mice were sacrificed on day 35, and sperm analysis and sera collection were performed for further investigation of FSH, LH, testosterone, and some liver and kidney function parameters. We used the left testis for stereological analysis, and the right one was excised to investigate the expression of the androgen receptor gene. For statistical analysis using SPSS 18.0, mean±SD values were analyzed by one-way analysis of variance (ANOVA) with Dunnett's analysis as post hoc to compare between groups. In stereological investigations, the Kruskal-Wallis method was used for pairwise comparisons to compare groups. The P value was considered statistically significant at P<0.05.

Results

Treatment with CD1/2 resulted in the elevation of serum FSH (P=0.002), LH (P=0.009), testosterone (P=0.034), seminiferous tubule epithelium volume (P=0.029) and length (P=0.028), and Leydig cells number (P=0.009) in comparison with the control group. Administrating CD1/2 (P=0.038) and CD1/4 (P=0.013) significantly increased sperm count compared to the control group.

Conclusion

The results revealed that using chicory distillate can improve hormone levels and sperm count in male mice.

Inequities in Medically Assisted Reproduction: a Scoping Review

Infertility has a high prevalence in the USA and health inequities play a large role in access to medically assisted reproduction (MAR). The aim of this study was to identify gaps in research pertaining to inequities in MAR and propose suggestions for future research directions. Searches were performed using MEDLINE and Ovid Embase. Articles that reported on MAR inequities, published between 2016 and 2021 in the USA, and written in English were included. The inequities investigated were adapted from the NIH-designated health disparities populations. Each article's inequity findings were extracted and reported, along with frequencies of inequities. Our sample included 66 studies. The majority of the studies investigated MAR outcomes by race/ethnicity and found that historically marginalized populations had poorer outcomes. LGBTQ + populations were less likely to use MAR or seek infertility care. Most studies found positive correlations with MAR use with income and education. The least commonly studied inequities in our sample were sex and/or gender and rural/under-resourced populations; findings showed that men and people from rural/under-resourced populations were less likely to access MAR. Studies that examined occupational status had varying findings. We suggest that future research be targeted toward: (1) standardizing and diversifying race/ethnicity reporting regarding MAR, (2) the use of community-based participatory research to increase data for LGBTQ + patients, and (3) increasing access to infertility care for men.

A better cost:benefit analysis yields better and fairer results: EPA's lead and copper rule revision

When conducted on a societal level, cost-benefit analysis (CBA) can indicate policies that best allocate scarce public resources. Done incompletely, CBA can produce spurious, biased results. To estimate the potential health benefits of EPA's recent Lead and Copper Drinking Water Rule Revision (LCRR), we used EPA's exposure, compliance, and effect coefficient estimates to monetize 16 of the health endpoints EPA has determined are causally related to lead exposure. In addition, we monetized one health endpoint that EPA has used elsewhere: preterm birth. We estimated that the total annual health benefits of the LCRR greatly exceed EPA's estimated annual costs: $9 billion vs $335 million (2016$). Our benefit estimates greatly exceed EPA's benefit estimates. There are also nonhealth benefits because lead generally contaminates drinking water through the corrosion of plumbing components that contain lead. The LCRR therefore has 2 components: reducing how corrosive the water is and limited replacement of lead pipes. Reducing corrosion damage to drinking water and wastewater infrastructure and residential appliances that use water yields significant annualized material benefits also: $2-8 billion (2016$). Effectively, the health benefits are free. Finally, while actual exposure data are limited, the available data on lead-contaminated drinking water exhibits known risk patterns, disproportionately burdening low-income and minority populations and women. This economic analysis demonstrates that to maximize national benefits and improve equity, the LCRR should be as rigorous as possible.

Temporal trends in sperm count: a systematic review and meta-regression analysis of samples collected globally in the 20th and 21st centuries

BACKGROUND

Numerous studies have reported declines in semen quality and other markers of male reproductive health. Our previous meta-analysis reported a significant decrease in sperm concentration (SC) and total sperm count (TSC) among men from North America-Europe-Australia (NEA) based on studies published during 1981-2013. At that time, there were too few studies with data from South/Central America-Asia-Africa (SAA) to reliably estimate trends among men from these continents.

OBJECTIVE AND RATIONALE

The aim of this study was to examine trends in sperm count among men from all continents. The broader implications of a global decline in sperm count, the knowledge gaps left unfilled by our prior analysis and the controversies surrounding this issue warranted an up-to-date meta-analysis.

SEARCH METHODS

We searched PubMed/MEDLINE and EMBASE to identify studies of human SC and TSC published during 2014-2019. After review of 2936 abstracts and 868 full articles, 44 estimates of SC and TSC from 38 studies met the protocol criteria. Data were extracted on semen parameters (SC, TSC, semen volume), collection year and covariates. Combining these new data with data from our previous meta-analysis, the current meta-analysis includes results from 223 studies, yielding 288 estimates based on semen samples collected 1973-2018. Slopes of SC and TSC were estimated as functions of sample collection year using simple linear regression as well as weighted meta-regression. The latter models were adjusted for predetermined covariates and examined for modification by fertility status (unselected by fertility versus fertile), and by two groups of continents: NEA and SAA. These analyses were repeated for data collected post-2000. Multiple sensitivity analyses were conducted to examine assumptions, including linearity.

OUTCOMES

Overall, SC declined appreciably between 1973 and 2018 (slope in the simple linear model: -0.87 million/ml/year, 95% CI: -0.89 to -0.86; P < 0.001). In an adjusted meta-regression model, which included two interaction terms [time × fertility group (P = 0.012) and time × continents (P = 0.058)], declines were seen among unselected men from NEA (-1.27; -1.78 to -0.77; P < 0.001) and unselected men from SAA (-0.65; -1.29 to -0.01; P = 0.045) and fertile men from NEA (-0.50; -1.00 to -0.01; P = 0.046). Among unselected men from all continents, the mean SC declined by 51.6% between 1973 and 2018 (-1.17: -1.66 to -0.68; P < 0.001). The slope for SC among unselected men was steeper in a model restricted to post-2000 data (-1.73: -3.23 to -0.24; P = 0.024) and the percent decline per year doubled, increasing from 1.16% post-1972 to 2.64% post-2000. Results were similar for TSC, with a 62.3% overall decline among unselected men (-4.70 million/year; -6.56 to -2.83; P < 0.001) in the adjusted meta-regression model. All results changed only minimally in multiple sensitivity analyses.

WIDER IMPLICATIONS

This analysis is the first to report a decline in sperm count among unselected men from South/Central America-Asia-Africa, in contrast to our previous meta-analysis that was underpowered to examine those continents. Furthermore, data suggest that this world-wide decline is continuing in the 21st century at an accelerated pace. Research on the causes of this continuing decline and actions to prevent further disruption of male reproductive health are urgently needed.

Estimating the effects of policies on infertility prevalence worldwide

Background

Infertility has troubled millions of people worldwide while always being an ignored issue. The high cost of treatment or lack of services placed a barrier to the alleviation of infertility status. Governments play a significant role to promote infertility-related policies for better access to infertility services and comprehensive supports for infertile people.

Methods

Data of infertility status indicators and infertility-related policies in ten representative countries were collected. An infertility-related policy system was established, then classification and quantification were processed according to specific criteria, and different policy implementation patterns were identified. The effectiveness of specific infertility-related policy and various patterns on infertility prevalence relief between 1990 and 2017 were evaluated via generalized linear models and analyses of covariance for the first time.

Results

Economic support policies would be less prioritized compared with social security policies, while economic support policy had a significant positive role in the decline of female infertility prevalence (β = -2·16, p = 0·042). In detail, insurance coverage and economic reward policies were crucial (β = -3·31, p = 0·031; β = -4·10, p = 0·025) with adjusted with covariates. The effect of economic support-oriented pattern was relatively better than other patterns for both male and female infertility prevalence relief. Nevertheless, the effectiveness of gradual-promotion pattern seemed preferable for male infertility prevalence relief while was similar with simultaneous-promotion pattern for females.

Conclusions

Our data-driven analysis revealed that insurance coverage and economic reward policies played the pivotal role in moderation of female infertility status. Economic support-oriented pattern and gradual-promotion pattern were preferable when promoting infertility-related policies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13802-9.

Does male fertility-related quality of life differ when undergoing evaluation by reproductive urologist versus reproductive endocrinologist?

The female infertility experience is well-described, but the male experience is less explored. We sought to understand if fertility motivations and quality of life differ for males undergoing fertility evaluation by a reproductive urologist (RU) versus a reproductive endocrinologist (RE). A cross-sectional study of 201 males undergoing fertility evaluation at an academic centre, by either a RU or RE, over a 2-year period, was performed. A survey was administered, with demographic, medical, and fertility motivations questions, and the validated Fertility Quality of Life (FertiQoL) questionnaire. Responses were compared by provider type using descriptive statistics, chi-square, and t-test. Most men (91.1%) pursued evaluation because of a mutual desire for children. RE evaluated males were older, earned higher incomes, and were more likely to pursue IVF versus those RU evaluated (p < 0.05). Men evaluated by RUs had lower FertiQoL scores, (p < 0.05), which correlated with having known male factor infertility (p < 0.05). Nearly all (96.2%) men evaluated by RUs indicated this was helpful for understanding their infertility. Our findings provide new insight into the male fertility evaluation experience. Despite the lower QoL seen by men seeing a RU, nearly all men reported that a RU evaluation was helpful for understanding their infertility experience.

Assisted reproductive technology cycles involving male factor infertility in the United States, 2017–2018: data from the National Assisted Reproductive Technology Surveillance System

Objective

To describe the prevalence and treatment characteristics of assisted reproductive technology (ART) cycles involving specific male factor infertility diagnoses in the United States.

Design

Cross-sectional analysis of ART cycles in the National ART Surveillance System (NASS).

Setting

Clinics that reported patient ART cycles performed in 2017 and 2018.

Patient(s)

Patients who visited an ART clinic and the cycles were reported in the NASS. The ART cycles included all autologous and donor cycles that used fresh or frozen embryos.

Intervention(s)

Not applicable.

Main Outcome Measures

Analyses used new, detailed reporting of male factor infertility subcategories, treatment characteristics, and male partner demographics available in the NASS.

Result(s)

Among 399,573 cycles started with intent to transfer an embryo, 30.4% (n = 121,287) included a male factor infertility diagnosis as a reason for using ART. Of these, male factor only was reported in 16.5% of cycles, and both male and female factors were reported in 13.9% of cycles; 21.8% of male factor cycles had >1 male factor. Abnormal sperm parameters were the most commonly reported diagnoses (79.7%), followed by medical condition (5.3%) and genetic or chromosomal abnormalities (1.0%).

Males aged ≤40 years comprised 59.6% of cycles with male factor infertility. Intracytoplasmic sperm injection was the primary method of fertilization (81.7%). Preimplantation genetic testing was used in 26.8%, and single embryo transfer was used in 66.8% of cycles with male factor infertility diagnosis.

Conclusion(s)

Male factor infertility is a substantial contributor to infertility treatments in the United States. Continued assessment of the prevalence and characteristics of ART cycles with male factor infertility may inform treatment options and improve ART outcomes. Future studies are necessary to further evaluate male factor infertility.

Feasibility analysis of incorporating infertility into medical insurance in China

In recent years, the incidence of infertility has been increasing gradually, while the natural rate of population growth is declining or even at zero growth. China is observed to enter a depth of aging society, leading to more severe infertility. Infertility patients face many predicaments, and many unreasonable behaviors existed in seeking medical diagnosis and treatment, of which the main influencing factor is economic condition. In China, Beijing has taken the lead in providing medical insurance for 16 assisted reproductive technology items. Assuming that all infertile couples with the option of assisted reproduction are treated, there would be a huge market gap. The reimbursement rate can be adjusted based on some factors within the affordable range of the medical insurance fund. Progress on infertility coverage in other countries was also reviewed. This paper cited the data of medical insurance funds in China in the recent 4 years as a reference. Based on the data, it is not currently able to cover all the costs of infertility diagnosis and treatment during the research period, but it is feasible to access selective reimbursement and subsidies for those in particular need as well as to develop some commercial insurances. There is a big gap in the application of assisted reproductive technology between China and developed countries. More comprehensive and constructive policies should be formulated countrywide to standardize the market. Assisted reproduction-related technologies and acceleration of the domestic medical apparatus and instrument replacement should be improved to reduce the cost.

Characterizing the Epidemiology and Provider Landscape of Male Infertility Care in the United States

OBJECTIVE

To characterize the epidemiology of male factor infertility and identify which types of providers are treating infertile men in the United States.

MATERIALS AND METHODS

The National Ambulatory Medical Care Survey was queried between 2006 and 2016 for all ambulatory care visits. Men with a diagnosis of infertility were identified by international classification of disease coding. Comorbidities, demographic and visit information were abstracted from the patients' medical record by a combination of trained surveyors and physicians. The survey data was weighted to create nationally representative estimates, and a combination of Chi-squared and Student's t-tests were utilized to determine significance.

RESULT(S)

Among the 8.7 billion patient visits between 2006 and 2016, there were 3,422,000 male encounters with a diagnosis of male factor infertility. The most common provider type for male factor infertility encounters was urology (42.12%) followed by primary care (39.79%), gynecology (7.05%) and all other provider types (11.01%). A significant number of men seen for infertility had comorbidities such as cancer (115,000 men, 3.36%) diabetes (267,000 men, 7.81%), depression (301,000 men, 8.8%), and active tobacco use (857,000 men, 30.3%).

CONCLUSION

In a nationally representative sample, more than 50% of ambulatory care visits for male factor infertility were not seen by urologists. These men also had a significant number of comorbidities for a relatively young cohort, emphasizing the importance of multidisciplinary care for men with a diagnosis of infertility.

Clinical Efficacy of Prodom-Assisted Urokinase in the Treatment of Male Infertility Caused by Impaired Semen Liquefaction

PURPOSE

To evaluate the clinical efficacy of prodom in the administration of urokinase in the vagina in couples with impaired semen liquefaction.

MATERIALS AND METHODS

Overall, 261 patients with impaired semen liquefaction were randomly divided into prodom-assisted urokinase treatment (PAUT) group (n = 91), syringe-assisted urokinase treatment (SAUT) group (n = 86), and traditional treatment (TT) group (n = 84) in the first stage. If the first stage of treatment failed, other treatment methods were initiated instead and the patients were grouped according to the newer treatment method in the second stage. The pregnancy rate, time-to-conception, and treatment costs were evaluated in each group.

RESULTS

In the first stage, the pregnancy rate in the PAUT, SAUT, and TT groups was 69.23%, 29.07%, and 22.62%, respectively; the time-to-conception was 2.66 ± 1.44, 3.69 ± 2.61, and 3.86 ± 3.00 months, respectively; the treatment costs were 658.18 ± 398.40, 666.67 ± 507.50, and 680.56 ± 480.94 $, respectively. The pregnancy rate and time-to-conception were different in the PAUT group compared with those in SAUT and TT groups (all P < 0.05). However, the difference in treatment costs was not significant (P = 0.717). In the second stage, 154 nonpregnant patients were divided into nine treatment groups, and the effects of changing TT to PAUT on the pregnancy rate, time-to-conception, and treatment costs were observed to be different from those of other treatments (all P < 0.05).

CONCLUSION

Prodom-assisted urokinase can effectively treat male infertility secondary to impaired semen liquefaction.

Lack of trusted diagnostic tools for undetermined male infertility

Semen analysis is the cornerstone of evaluating male infertility, but it is imperfect and insufficient to diagnose male infertility. As a result, about 20% of infertile males have undetermined infertility, a term encompassing male infertility with an unknown underlying cause. Undetermined male infertility includes two categories: (i) idiopathic male infertility-infertile males with abnormal semen analyses with an unknown cause for that abnormality and (ii) unexplained male infertility-males with "normal" semen analyses who are unable to impregnate due to unknown causes. The treatment of males with undetermined infertility is limited due to a lack of understanding the frequency of general sperm defects (e.g., number, motility, shape, viability). Furthermore, there is a lack of trusted, quantitative, and predictive diagnostic tests that look inside the sperm to quantify defects such as DNA damage, RNA abnormalities, centriole dysfunction, or reactive oxygen species to discover the underlying cause. To better treat undetermined male infertility, further research is needed on the frequency of sperm defects and reliable diagnostic tools that assess intracellular sperm components must be developed. The purpose of this review is to uniquely create a paradigm of thought regarding categories of male infertility based on intracellular and extracellular features of semen and sperm, explore the prevalence of the various categories of male factor infertility, call attention to the lack of standardization and universal application of advanced sperm testing techniques beyond semen analysis, and clarify the limitations of standard semen analysis. We also call attention to the variability in definitions and consider the benefits towards undetermined male infertility if these gaps in research are filled.

Cost burden of male infertility investigations and treatments: A survey study

PURPOSE

Male infertility represents 50% of all infertility problems. The management of male infertility is expensive, causing a huge burden on the patients. In this study, we aimed to calculate the cost burden of male infertility investigations and treatments.

METHODS

A total of 600 infertile male patients from a single center in Kuwait city were asked to fulfill an internet-based survey. The survey encompassed data about the cost of different investigations and treatments of male infertility. Patients were also asked about the preference of covering their condition either through government or by private insurance.

RESULTS

A total of 145 patients responded to the survey. Most of the patients earned 3295 United States Dollar (USD) to 6590 USD per month. The cost of the outpatient visit ranged from 131.7 to 263.4 USD. The cost of each hormonal test was 164.5 USD while the average cost of each imaging study was 131.8-164.7 USD. Most of the patients (62.8%) received medical therapy with an expense of >988.74 USD. Varicocelectomy cost ranged from 3295 to 6590 USD while the cost of testicular sperm extraction ranged from 1644 to 3294 USD. Most patients (96.3%) did not have health insurance coverage of infertility. On average, patients spent around 18% of their annual income on infertility care, excluding major surgeries.

CONCLUSION

Male infertility is a worrisome medical condition that causes a huge burden on the Kuwait community. Effective management necessitates insurance coverage and public health support owing to the huge financial burden on the patients and their partners. Thus, policymakers should re-evaluate their protocols of spending on male infertility care.

Evaluation, Treatment, and Insurance Coverage for Couples With Male Factor Infertility in the US: A Cross-Sectional Analysis of Survey Data

OBJECTIVE

To characterize the evaluation, treatment, and insurance coverage among couples with male factor infertility in the United States.

MATERIALS AND METHODS

A cohort of 969 couples undergoing fertility treatment with a diagnosis of male factor infertility were identified from an online survey. The proportion of men that were seen/not seen by a male were compared. Insurance coverage related to male factor was also assessed.

RESULTS

Overall, 98.0% of the men reported at least one abnormal semen parameter. Of these, 72.0% were referred to a male fertility specialist with the majority being referred by the gynecologist of their female partner. As part of the male evaluation, 72.2% had blood hormone testing. Of the 248 men who were not recommended to see a male fertility specialist, 96.0% had an abnormal semen analysis including 7.6% who had azoospermia. Referral to a male fertility specialist was largely driven by severity of male factor infertility rather than socioeconomic status. Insurance coverage related to male factor infertility was poor with low coverage for sperm extractions (72.9% reported 0-25% coverage) and sperm freezing (83.7% reported 0-25% coverage).

CONCLUSION

Although this cohort includes couples with abnormal semen parameters, 28% of the men were not evaluated by a male fertility specialist. In addition, insurance coverage for services related to male factor was low. These findings may be of concern as insufficient evaluation and coverage of the infertile man could lead to missed opportunities for identifying reversible causes of infertility/medical comorbidities and places an unfair burden on the female partner.

Demographics, Usage Patterns, and Safety of Male Users of Clomiphene in the United States

PURPOSE

The aim of this study was to characterize the demographics, usage patterns and complication rates of clomiphene use in male patients.

MATERIALS AND METHODS

We retrospectively analyzed male patients from ages 20 to 55 years old who were prescribed clomiphene citrate from 2001 to 2014 using the Truven Health MarketScan, a US claims database. We collected data regarding associated medical diagnoses, diagnostic testing, duration of use, and reported side effects including thrombotic events, vision problems, gynecomastia, mental disorders, liver disease, nausea, or skin problems.

RESULTS

In total, 12,318 men took clomiphene and represented the primary study cohort, with a mean age of 37.8 years. The percentage of men prescribed clomiphene increased over the study period, as did the average age of clomiphene users. Associated diagnoses included male infertility (52.0%), testicular hypofunction (13.5%), erectile dysfunction (2.4%), and low libido (0.4%). Associated testing included semen analysis (43.7%), testosterone (23.5%), luteinizing hormone (19.3%), and follicle-stimulating hormone (21.1%) levels. The median time of clomiphene use was 3.6 months, with 63% of men stopping within 6 months. No increased risk of reported clomiphene side effects were apparent in men taking the medication.

CONCLUSIONS

There is a rising prevalence of clomiphene usage without associated adverse side effects in the US. The variability in associated diagnoses, diagnostic testing, and duration of use suggest a need for greater awareness of the proper evaluation and treatment of the men who are prescribed clomiphene.

Gaps in male infertility health services research

The field of male infertility remains a niche specialty within urology. Although a male factor is implicated in at least 50% of all cases of infertility, and male infertility is thought to be associated with overall male health and longevity, this subspecialty comprises a relatively small proportion of urologic training. There remains a large knowledge gap with regards to prevalence of male factor infertility, as well as the need for health services for the diagnosis and treatment of male infertility. Health services research is a multidisciplinary approach that combines both qualitative and quantitative methodologies to improve patient care and outcomes pertaining to male infertility. This review summarizes the current literature pertaining to health services for male infertility and identifies opportunities for future research to improve access to and outcomes of male infertility care, including improvements in costs of care, patient education, and health policy.

The State of Men's Health Services in the Veterans Health Administration

PURPOSE OF REVIEW

For many diseases that place a large burden on our health care system, men often have worse health outcomes than women. As the largest single provider of health care to men in the USA, the Veterans Health Administration (VA) has the potential to serve as leader in the delivery of improved men's health care to address these disparities.

RECENT FINDINGS

The VA system has made recent strides in improving benefits for aspects of men's health that are traditionally poorly covered, such as treatment for male factor infertility. Despite this, review of Quality Enhancement Research Initiatives (QUERIs) within the VA system reveals few efforts to integrate disparate areas of care into a holistic men's health program. Policies to unify currently disparate aspects of men's health care will ensure that the VA remains a progressive model for other health care systems in the USA.