WORCESTER MEDICINE
Infertility
Infertility/Decreased Fertility Continued
plained infertility. The standard of care for infertility treatment is clearly established. The only remaining issue is decreased fertility based on advanced maternal age, which continues to be a challenge. Fertility rates naturally drop for women as they age with a decrease in pregnancy rates and increase in miscarriage rates beginning in the mid-30s. If couples ‘save’ their money for infertility coverage, they may miss a critical window for optimal treatment. The sad story is that the evaluation is brief and simple, and the treatment is highly successful for younger women/couples The issue for those with infertility is routine insurance coverage. The typical argument made against an insurance mandate for evaluation and treatment of decreased fertility/infertility is the cost. Indeed, in countries such as Denmark and Belgium, which cover treatment, the IVF rate is high – 12,500 IVF cases per 1 million women aged 15-45. However, studies have demonstrated the relative cost of infertility coverage is relatively modest. New York state estimated insurance premiums went up by 0.5% when infertility treatment, including IVF, was included in private insurance. For individuals without coverage, the cost can be problematic, with the average cost for an IVF cycle costing $12,000 (with more than one-third of the cost being medications). It is a positive factor that Massachusetts was one of the first states to mandate infertility coverage, recognizing this disease as requiring private insurance coverage. Although, the insurance companies put up many barriers (such as excessive testing) to delay treatment, the services are available throughout our state. Although infertility evaluation and basic treatment has been available at the University of Massachusetts Medical Center for many years, the institution now has the only IVF program in Central Massachusetts. Even in Massachusetts, however, there are limitations to covering the disease of decreased fertility/infertility. There remains inequity in covering the costs of this standard evaluation and treatment. Government insurance has no coverage for public or federal employees, although there is limited coverage for veterans whose injuries resulted in infertility. State insurance programs, such as Medicaid, may cover infertility testing but does not cover treatment. This leads to a significant disparity of treatment for those who are economically disadvantaged, many of whom may come from Black, Chinese and Hispanic communities. Often, these individuals have several jobs yet elect not to obtain private insurance due to the cost or lack of availability by the employers. I encountered this frequently at UMass and encouraged patients to obtain private insurance leading to coverage of infertility treatment as a modest cost. This allows the underserved in our community the right to have their disease treated and the family they desire. In summary, infertility is clearly a common disease of reproductive aged men and women and the current evaluation is straight forward and the treatment is effective. Encourage your patients to see an REI specialist, including those at UMASS in our IVF program, to discuss their circumstances, take a brief evaluation and consider the best treatment for their disease. We are most fortunate to live in a state that respects the reproductive rights of women and men. + Julia V. Johnson, MD, is a Professor Emerita and Former Chair of OB-GYN at the UMass Chan Medical School and UMass Memorial Medical Center. Following retirement in 2020, she is now at the University of Vermont College of Medicine/UVM Health Care as a Professor and member of the Faculty Training Residents and Fellows in Reproductive Endocrinology and Infertility.
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JANUARY / FEBRUARY 2022
An Infertility Story: One Woman’s Experience Marianne E. Felice, MD
J
ohn and i married late; we were both
35. In our 20s, when most people marry, we were starting our careers. John was career Navy and I was in medical school. When I was a pediatric intern in Harrisburg, Penn., he was assigned to Harrisburg for recruiting duty. He tried to recruit me into the Navy. I declined, but agreed to go on a date. One date led to another and, after seven years of dating, we were married in San Diego, Calif.. There, I accepted a position at University of California San Diego as chief of adolescent medicine and he was assigned duty at the naval base. We presumed we would have children, never thinking it would be difficult. I began looking for au pairs and day care options. John balked and stated he would retire from the Navy and become a stay-at-home dad. I was aghast. “Why?” he asked. I said, “Because this baby will be smoking cigars and playing poker and cussing like a sailor before it reaches its third birthday!” He laughed. “Yes, and that is if it’s a girl. Imagine what I will do if it is a boy!” We tried with no success. Two years later, we had an appointment with a fertility expert. We did everything he said to do. tracked my temperature daily with that special thermometer to hone in on ovulation. I did not think John was paying attention to my daily ritual until one evening, when he was in the shower, I turned down the bed and a note was pinned to my pillow: “Signal, when ready!” John booked us on cruises so I would be away from work and relaxed. The cruises were great, but a pregnancy did not happen. We were both evaluated for infertility with no causes found. One procedure was memorable. We were scheduled for an in vivo fertilization at the time of ovulation. At the doctor’s
