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individual and small-group policies were required to offer. 56 VOL. 116 NO. 1 / JULY 2021 ASRM PAGES There has been progress, although. In the past, most state insurance laws incorporated a definition of infertility that relied on 6–12 months of unprotected heterosexual intercourse, thus excluding same-sex couples and single individuals from mandated coverage. In 2018, New Jersey remedied this problem in part, amending its law to include women who are single or in same-sex relationships once they prove unable to conceive after a course of intrauterine inseminations. Fertility preservation also has gained ground. Between 2017 and 2019, 7 states (Connecticut, Delaware, Illinois, Maryland, New Hampshire, New York, and Rhode Island) passed laws requiring insurers to cover fertility preservation for patients facing gonadotoxic therapy. Apart from state or federal laws, employers may voluntarily choose to include fertility coverage in the benefits they provide to employees. This is, to be sure, a stopgap measure until infertility becomes covered universally, but it often can be achieved far more quickly than a statewide law. Estimates of the percentage of employers that provide such a benefit appear mainly in industry surveys. Two recent surveys of human-resources departments reported that just over onequarter of responding employers offered some degree of infertility or IVF coverage, with companies of >500 employees more likely to offer it compared with smaller companies (55, 56). A third survey focused on large employers with R20,000 people; the percentage of such employers offering an infertility benefit rose from 29% in 2016 to 44% in 2018 (57). However, the actual content of benefits varies widely, ranging from meaningful coverage to low monetary caps. OTHER DISPARITIES IN ACCESS TO INFERTILITY TREATMENT Economic barriers are not the only impediments to accessing infertility care. Chief among the noneconomic barriers are cultural and societal factors. Researchers who have studied African-American, Hispanic, Muslim, and Asian populations in the United States have noted that communication differences, cultural stigmas (including male and female aversion to being labeled infertile), cultural emphasis on privacy, and unfamiliarity or prior bad experiences with the US medical system can dissuade members of certain racial, ethnic, or religious groups from seeking care for infertility (58–62). Language differences also may discourage non–Englishspeaking patients from seeking care. Physicians may consciously or unconsciously make assumptions or possess biases about who deserves to be a parent and who wants or deserves treatment (63, 64). Women of color, for example, have reported that some physicians brush off their fertility concerns, assume they can get pregnant easily, emphasize birth control over procreation, and may dissuade them from having children (59). Another obstacle is the burden of pursuing infertility treatment, particularly cycle-based treatments like IVF. In addition to being able to afford treatment, the patient must be able to take substantial time off from work for office visits and be able to travel to medical facilities that may be geographically distant (65–67). Many treatments require repeated visits and the ability to follow complex medical instructions (68). Geographically, the distribution of obstetriciangynecologists and IVF centers varies widely among states and locales, and there is growing public health awareness that these services are inaccessible in many communities (69–71). As of 2017, 13 US states had %5 reproductive endocrinologists in practices accredited by the Society for Assisted Reproductive Technology (SART) (71). The highest concentrations of IVF centers and male reproductive specialists are found in states with mandated IVF insurance and high median income (72, 73). An estimated 18 million women of reproductive age live in locations with no ART clinics (74). Thus, geographic unavailability may impede many from seeking or obtaining treatment. Patients may be denied access to effective care if the institution at which they seek treatment does not inform them of treatment options, such as IVF, because they conflict with the religious affiliation of the institution. Fair access also is impaired by providers who refuse to treat unpartnered individuals and same-sex couples, a practice that this Committee rejects (75). DISPARITIES IN OUTCOMES OF INFERTILITY TREATMENT As recently summarized, the research on IVF outcomes and race/ethnicity, including 3 studies using data collected from the SART database, suggests that when African-American, Asian, and Hispanic women attain access to ART, they experience lower success rates compared with non-Hispanic white women (58). The findings include evidence of lower implantation and clinical-pregnancy rates as well as increased miscarriage rates among certain minority women. These differences in treatment success are concerning; they are poorly understood and insufficiently studied, with explanations ranging from biologic factors to modifiable behavioral factors (40, 76, 77). Their rectification is critical to achieving reproductive health equity among women and men of different racial and ethnic backgrounds. More research is urgently needed to identify the causes and the remedies for
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