Infertility/Decreased Fertility: Significant Positive Changes in the Last 30-40 Years

Julia V. Johnson, MD

Since Louise Brown was born in 1978, the first child conceived through IVF, there has been marked improvement in the diagnosis and treatment of infertility for men and women. Although insurance companies in many states do not recognize this common disease, it effects at least 12% of women and 15% of married men in the U.S. Fortunately, the awareness of this disease, and the effectiveness of treatment, has increased. In 2017, the American Medical Association joined the World Health Organization in recognizing decreased fertility/infertility as a common disease of reproductive aged women and men. Now, 15 states offer some coverage for this disease with Massachusetts being one of the first to mandate private insurance coverage for infertility.

The causes of infertility are complex, yet the evaluation has been simplified significantly during my years as a Reproductive Endocrinologist/Infertility (REI) Subspecialist. The causes of infertility include low sperm count or motility or ‘male factor’ (35%). ‘Female factor’ (45%) includes the most common cause, tubal or uterine disease (30%) with the next most common as ovulatory dysfunction (15%). The remaining causes are unexplained (20%). In the early years, testing was complex, involving cervical mucus testing, endometrial biopsy, specialized sperm testing and repeat hormonal testing. Currently, a doctor obtains a simple set of tests to confirm multiple factors, including: ovulation (ovulation predictor kit or progesterone level in the luteal phase), assurance of a normal uterus and fallopian tubes (ultrasound or hysterosalpingogram), hormonal tests to evaluate ovulatory disorders or rule out premature ovarian dysfunction, and a semen analysis. All testing can be done in a month at modest cost by an experienced REI at UMass Memorial.

And treatment is now also straight forward. In the past, complex surgery was done to fix scarred fallopian tubes with poor success and ovulation induction was overused with the risk of multiple gestation. There was no treatment for male infertility except trying intrauterine inseminations (with limited success) or donor sperm. Now, the only reason for surgery is severe pain (endometriosis), to clip fallopian tubes (and increase pregnancy rates) or remove lesions from the uterine cavity (polyps and fibroids). Only oligoovulatory and unexplained infertility patients use ovulation medications and then only in limited amounts. For women with ovulation dysfunction (such as PCOS), 50% become pregnant within six months; if very mild, male factor is added and an intrauterine insemination can be considered. For other causes, if surgery is not indicated first, then IVF may be the best treatment with pregnancy rates per cycle of 40-50% for women under age 35. The success with IVF treatment has increased from 8-10% per cycle when I started in 1988 to 40-plus percent per cycle currently. IVF treatment is highly successful for male factor, tubal factor, uterine factor, ovulatory dysfunction and unex- 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.