Benefits Strategy

January 09, 2020

Employers have an important stake in helping employees and dependents who pursue fertility treatments find high-quality providers and utilize the most effective treatments. Technological advances in assisted reproductive technologies as well as other fertility preservation treatments have facilitated the increased demand for coverage of such treatments as well as fertility preservation services. As a result, more employers are partnering with specialty vendors to meet increased demand for comprehensive coverage for fertility treatments, whether through the expansion of population eligible to receive these services or tailoring their benefit design to promote evidence-based treatments rather than decisions based primarily on out-of-pocket cost. Coverage for evidence-based fertility treatments can improve maternal and child health quality outcomes and reduce employee and dependent medical costs.

Fertility Treatments: Background and Impact on Employers

The Centers for Disease Control and Prevention (CDC) estimates that 6% of married women and 9% of men struggle with some form of infertility. As a result, 12% of women aged 15 to 44 have experienced difficulty getting pregnant or carrying a pregnancy to term, regardless of marital status.¹ Clinical advances in fertility treatments have increased their efficacy and highlight the need for an innovative benefits package that gets them to the most efficient and cost-effective options available.

Employers have an important stake in helping employees and dependents who pursue fertility treatments find high-quality providers and utilize the most effective treatments. Coverage for evidence-based fertility treatments can improve maternal and child health quality outcomes and reduce employee and dependent medical costs.

Some companies that do not have a fertility benefit program in place cite cost as a barrier to implementation. They also may view fertility benefits beyond diagnosis and treatment of an underlying medical condition causing infertility as non-essential (i.e. not medically necessary). However, implementing an evidence-based fertility benefit or navigator program can prove to be cost effective for large employers. Offering little or no benefit for fertility treatments may save some money for the company up front, but employees fully paying out of pocket may be more likely to seek less expensive treatments that increase the likelihood of multiple gestations, which on average result in poorer maternal and child health outcomes and much higher medical costs.

Multiple gestations (i.e. twins or triplets) are associated with a host of serious health problems for both mothers and their babies. Mothers are at increased risk for preeclampsia (pregnancy-induced high blood pressure) and more often deliver before the pregnancy reaches full term. Preterm delivery often results in babies who are frail or have underdeveloped lungs. These problems are costly: in 2013, the total all-cause health care costs for delivery of a singleton was $21,458, compared to $104,831 for twins and $407,199 for higher-order multiples.² For these reasons, many employers are exploring programs and benefits that promote evidence-based fertility treatments, which strive to achieve a single, healthy gestation.

This guide discusses the range of fertility treatments and how to design plans to support evidence-based approaches to fertility treatment. The guide provides recommendations to employers looking to implement changes in their fertility coverage and align current or future benefit offerings with evidence.

Reasons Employers Should Consider Offering Fertility Benefits

Meeting the demands of the changing workforce

two people's silhouette For some companies, offering fertility benefits as part of the benefits package can help attract top talent. A growing number of large employers have chosen to implement or expand their fertility benefits in recent years both as a sign of goodwill towards their employees as well as a strategy to combat attrition rates among women as they progress in their careers. According to a survey of patients who received full coverage of their treatment cycles, many respondents reported feeling a greater sense of loyalty and commitment to their employers as a result.³

Some employers are providing benefits to employees to proactively help them conceive in the future. The market for egg freezing is projected to grow twenty-five percent annually until at least 2020.⁴ Offering coverage for fertility preservation services afford employees flexibility in building their careers before starting a family.⁵ Vendors are also beginning to offer men the option of freezing their sperm for fertility preservation, signaling potential growth in demand for such services.

Decreasing the rate of multiple births within their employee populations

lowering multiple births Multiple gestations pose risks to the mother and her babies compared to a singleton delivery. The rise of multiple birth rates has often been associated with expanded use of fertility therapies, such as ovulation-inducing drugs and assisted reproductive therapies (ART), with an estimated 1.6% of 2013 births being the result of ART alone.⁷ Between 1980 and 2011, the rate of twin births rose 76 percent.⁸ Triplet and higher-order multiple birthrates have declined in recent years, with the 2015 rate being the lowest in 21 years; changes in ART procedure that limit the number of embryos transferred have likely contributed to this decrease.

Many complications are associated with multiple births, which can result in an increased need for neonatal intensive care unit (NICU) treatment an added distress for the employee and his or her family

These complications include but are not limited to:

Preeclampsia: This serious complication is twice as likely to happen with a twin gestation than with a singleton. In some cases, babies of mothers with preeclampsia are delivered early to ward off complications.9
Increased risk for a Cesarean section (C-section): Almost 90% of twin deliveries and virtually all higherorder multiple deliveries are done via C-section.¹⁰ This method of delivery raises the risk of mortality and complications for the mother and babies. The recovery for the mother is prolonged as well.
Premature birth: 60% of twins, 90% of triplets and nearly all quadruplets are born prematurely.¹¹
Low birthweight: More than half of twins and virtually all higher-order multiples are born at a low birthweight, as it is generally related to preterm delivery.⁹
Gestational diabetes: Women carrying multiples are at a greater risk of having high blood sugar, possibly resulting in larger babies, which can cause danger to the mother and babies during birth.⁹

Course of Fertility Treatments

Diagnosis

84% of large employers provide coverage for evaluation by a specailist

Primary infertility is the inability to become pregnant or carry a pregnancy to a live birth after 12 months of timed intercourse or physician-supervised donor insemination.¹²Women aged 35 years and older are considered infertile after 6 months of trying to conceive. Secondary infertility applies to couples who have been able to have a child or children in the past but are now unable to conceive.¹³

Health plans generally adhere to these clinical definitions of infertility when determining eligibility for fertility treatment coverage. These definitions are predicated on achieving pregnancy through either heterosexual intercourse or therapeutic donor insemination, thereby including single parents by choice or LGBTQ couples. Self-insured employers can choose to alter the criteria for coverage, including entirely removing any time requirements.

The first step in treating infertility appropriately is determining the root cause. Before an employee can receive medical evaluation or treatment, they must complete a pre-authorization process through their health plan or third-party fertility benefit administrator to be directed to an infertility specialist. 84% of large employers provide coverage for evaluation by a specialist, making it the most common type of fertility benefit offered by large employers.³

While an OB/GYN or an OB/GYN with a subspecialty in infertility often initiates this evaluation and may begin some treatment, certain situations, such as a mechanical or hormonal problem, may warrant a referral to a board-certified/ eligible reproductive endocrinologist or urologist. This subspecialist can further coordinate care with other specialists if indicated.¹⁴

Emerging genetic technologies impact how infertility is diagnosed and treated, see the below section for Applications of Genetic Testing in Fertility Treatments.

Treatments

Once the cause of infertility is determined, the member can enter treatment. The efficacy of fertility treatments depends on what is being treated. For example, a medication can be effective for a woman with ovulatory issues but may have little effect on tubal problems. Therefore, it is challenging to identify which treatment is more effective than another on the aggregate level, although there is research/evidence that does take these nuances into account.
The next section explains the range of fertility treatments employers typically cover within their benefit:

Medication to treat the causes of infertility: This treatment option is covered by 81% of large employers.3 About 85 to 90% of infertility cases are treated with medication or surgery: when medications alone fail, they are often used in conjunction with other therapies.¹⁵ However, many of these medications have multiple indications or are prescribed off-label, meaning that an employer may be inadvertently covering the medication even though it was approved for another medical problem.

Surgery: If the root cause of infertility can be corrected by surgery, an employer’s medical plan may cover it regardless of fertility coverage levels.

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Intrauterine insemination (lUI): Sometimes referred to as artificial insemination, IUI involves the insertion of specially prepared sperm into the woman’s uterus. IUI is recommended for cervicalfactor infertility, male-factor infertility, as well as unexplained infertility in conjunction with certain medications (e.g. Clomid or Letrozole) for a limited number of cycles.¹⁶ IUI is covered by 69% of large employers.³ Success rates can be as high as 15% depending on the woman’s age, whether fertility medications are used, the underlying cause of infertility and other factors.17 This success rate, however, is associated with a much higher risk for a multiple gestation. Total cost of an IUI cycle (combined with Clomid) can be as high as $4,000.16 Many health plans require members to complete 6-12 rounds of IUI before qualifying for in vitro fertilization (IVF).

Assisted reproductive technology (ART): This approach is defined as fertility treatments in which both eggs and embryos are handled. ART does not include treatments where only sperm are handled, such as IUI.18 In 2016, the CDC reported the percent of cycles resulting in a live birth ranged from 3.2% for women aged 42 and older to 31% for women under age 35.19 Below are the most common forms of IVF:

In vitro fertilization (IVF): IVF involves combining the egg and sperm to create an embryo and then transferring the embryo into a woman’s uterus. 71% of large employers provide at least some coverage for IVF.³ It is important for employers to examine their existing benefits to ensure that not the initial consult is included, but subsequent visits and treatments as defined by the plan limits. On average, a basic IVF cycle (not including medication costs) is priced between $10,000 and $15,000 depending on plan design, patient characteristics and the site of care.²⁰
- Elective single embryo transfer (eSET) is the only recommended way to avoid the risk of multiple gestations after IVF.21 eSET is when a single embryo is transferred from a pool of multiple, viable embryos. Following eSET protocols directly influences the rate of multiple births: once requirements to only use eSET practices is put into place, the rate of multiple births decreases while the rate of pregnancy tends to remain the same. Approximately 27% of employers reported limiting the number of embryos transferred through ART to promote eSET usage.³
Less common ART procedures include:
- Intracytoplasmic sperm injection (ICSI)
- Zygote intrafallopian transfer (ZIFT)
- Gamete intrafallopian transfer (GIFT)

Applications of Genetic Testing in Fertility Treatments

Genetic Testing in Fertility Treatments Prenatal genetic testing is not exclusive to individuals using assisted reproductive technologies. However, expertise in genetic testing and counseling from fertility benefit partners, whether health plans or third-party vendors will be helpful in guiding employees through this complex area. Here are some examples for when genetic testing is applicable to fertility treatments:

Preimplantation genetic testing for aneuploidies (PGT-A) involves the assessment of embryonic cells to determine whether they have the correct amount of chromosomes: embryos with the incorrect number of embryos (known as aneuploid embryos) tend not to implant, resulting in miscarriages or the birth of children with genetic disorders. This type of genetic testing is widely used in IVF, as euploid embryos (embryos with the correct number of chromosomes) have a better chance of resulting in a successful pregnancy.²² The degree to which PGT-A is predictive of an embryo transfer leading to a live birth depends on the ability of the clinic to capture a useful sample and the laboratory’s ability to make an accurate determination.

PGT-A may be recommended for individuals/couples who: 1) have a history of inherited genetic disorders, 2) are known carriers of a chromosomal abnormality or 3) have experienced repeated miscarriages or recurrent failed IVF cycles. Advanced maternal age is also a determining factor. Identifying successful embryos for implantation has led to greater pregnancy rates in certain populations. Each test adds an additional $4,000 to $7,500 to the cost of each IVF cycle. Most major fertility clinics conduct these tests.

Preimplantation genetic testing for chromosomal structural rearrangements (PGT-SR) examines specific chromosomal abnormalities and preimplantation genetic testing for monogenic/single-gene disorders (PGT-M) looks for specific inherited conditions controlled by a single gene (e.g. Huntington’s disease or sickle cell disease). These types of genetic testing are used only in specific conditions where one or both parents are a carrier.²²

As procedures like embryo adoption and surrogacy become more common, employers should be aware of privacy concerns for egg/sperm donors, as the rise of genetic testing and sequencing may impact donors’ longterm anonymity.

Recommendations for Plan Design

In the past, employers that provided fertility benefits often placed a lifetime dollar limit. As an unintended consequence, employees have tried to get “the biggest bang for their buck” by selecting the lowest-cost provider or clinic and forgo tests or procedures like eSET that help drive success and healthy pregnancies. In 2018, 62% of employers reported placing a dollar limit for both medical and pharmacy or medical and treatment benefits. These employers reported a mean combined coverage amount of $20,000.

Supporting employees who experience infertility goes beyond paying for medical services. Employers can offer support programs to help guide employees through the conception journey. Health plans are increasingly offering their own fertility programs that coordinate with maternity support programs when the employee does in fact become pregnant. Employers should consider the use of navigational services through their health plan or a third-party vendor. Such services can not only steer employees to high-quality information and providers, but also ensure their enrollment in other applicable health care and well-being programs aimed to ease their transition into parenthood. Employers are increasingly partnering with third-party fertility benefit companies to administer their benefits either within or outside of the health plan.28

If an employer chooses to provide coverage for fertility medications and treatment, due diligence should be taken to ensure that employees have access to high-quality providers who follow evidence-based protocols, including eSET. Plan design, programs and communications are all levers employers can use to help employees access the best fertility services available.

1 | Reassess eligibility determinations for fertility treatments to reflect the diverse needs of your workforce. Company culture and workforce demographics may guide eligibility.

Age: Success rates for fertility treatments typically decrease when a woman is 40 years or older. If providing fertility benefits, particularly comprehensive coverage, employers may consider aligning their coverage limits with those set forth by the American Society for Reproductive Medicine.
Marital status: Some states that mandate fertility coverage place a caveat that the couple must be legally married, but it is unclear how they are being enforced. Employers should consider matching the eligibility for fertility treatment with the company’s policy on eligibility for health benefits.
Women without male partners: Large employers should consider expanding their eligibility criteria to include this cohort to improve employee satisfaction with benefits, reduce the likelihood of multiple gestations, and compete for talent.

2 | Steer members toward high-quality providers who follow evidence-based protocols and deliver superior clinical outcomes.

Consistent data on provider quality is available through the Society for Assisted Reproductive Technology (SART), which publishes an annual report on pregnancy success rates for ART fertility clinics nationwide, including details on patient diagnosis and the number of embryos transferred. Your health plan or third-party fertility benefits administrator can help determine which providers are high quality. Around 35% of large employers require employees seeking fertility treatments to use a center of excellence (COE) or high-performance network.24

3 | Re-examine limits to fertility treatment benefits to ensure they do not inadvertently drive employees to get the “biggest bang for their buck” and forgo use of latest technologies and best practices like single embryo transfers.

There is no restriction for placing a limit on the number of cycles, attempts or office visits. In fact, 27% of employers have taken this approach.3 Furthermore, evidence shows that the success rates of IVF begin to decline after four to six attempts – another reason to cap coverage after a certain number. Employers looking to offer fertility services but also keep their health care costs manageable should consider this approach. As employers consider this option, they should collaborate closely with their health plans and make their decisions based on evidence-based medical necessity.

4 | Ensure there are adequate connections between fertility benefits, maternity programs and other supplemental services and supports for new parents.

It is crucial that members can navigate from prenatal care, pregnancy visits and services to available postpartum and maternity programs.

5 | Educate employees about available fertility benefits and programs:

Provide clear, concise information about fertility benefits: Information should start with the pre-certification/medical evaluation stage found in benefit materials. Fertility benefits are complex and are often reviewed during an emotional time.
Use employee scenarios to illustrate coverage options: It may be easier for employees to grasp examples instead of basic text or a benefit coverage chart.
Consider a targeted approach: Women and men generally regard infertility in very different ways. Women with fertility issues are more likely to experience a greater loss in self-esteem and feel that having a baby is more important than men do. Men tend to want to support their partner instead of experiencing the emotions directly. Employers can better tailor their communications to these different cohorts by taking these factors into account.

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Adoption and Surrogacy

Unlike coverage for fertility treatments, which are administered as a pre-tax medical benefit, adoption and surrogacy benefits are typically post-tax reimbursement programs. Benefit managers looking to offer a comprehensive benefit package to help employees build their families should consider adding these options:

Adoption: Adoption benefits may include navigation services, financial assistance, as well as parental leave. More employers are beginning to offer some combination of these services, as they are relatively low cost and can substantially reduce the burden of going through the adoption process for employees and their families.³ Approximately 89% of large employers reported covering at least one adoption associated cost, with 79% covering agency fees, 75% covering legal fees, and 73% covering court fees.³

Surrogacy: This is often one of the last choices for couples trying to conceive, after they have exhausted other treatments. Traditional surrogacy involves inseminating the surrogate with the father’s sperm. The child is genetically related to the surrogate and the father. Traditional surrogacy is not legally permitted in many U.S. states. In gestational surrogacy, the mother provides the egg and the father provides the sperm, and the embryo is transferred to a third individual, who serves as the gestational carrier. The baby is genetically linked to the mother and father, not to the surrogate. The cost of surrogacy can range from $80,000 to $120,000: many determining factors, from legal fees and health insurance coverage for the surrogate (in the form of a lump sum) contribute to the bottom line. In 2018, 43% of employers reported covering some costs associated with surrogacy.³

Figure 1: Employer-Covered Surrogacy Costs or Benefits

Figure 1 details which services are covered. Due to eligibility rules, medical costs for surrogates are administered via lump sum instead of under the medical plan.

Fertility Preservation

Oocyte cryopreservation (egg freezing), embryo crypreservation (freezing a fertilized egg) and cryobanking (sperm banking) are available for two groups of employees: 1) employees who may become infertile as a result of medical treatmetn for a disease such as cancer and 2) those looking to preserve their fertility for options in the future. These cohorts differ considerably in terms of their needs, so employers should weight them separately when defining their coverage for these services.

1 | Iatrogenic infertility, or infertility as a result of a medical treatment for a serious condition like cancer, may warrant preservation coverage.
2 | Among the latter population, demand for customized and affordable egg freezing is spiking.⁵ For women pursuing these services, the average age has decreased to 35 years in 2018 from 28 in 2016.⁵ Increasingly, men are pursuing sperm freezing as well; vendors selling at-home sperm virility testing kits are rapidly entertaing the fertility preservation market.

Fertility Treatments for Transgender Employees

Depending on which stage of transition they are in, transgender employees may pursue either fertility preservation or treatment therapies. If an individual has not undergone gonadectomy (removal of testes or ovaries), and if an initial evaluation suggests the absence of ovulation or sperm production, the return of fertility may be possible after discontinuing hormone therapy for a period of time.²³ It is currently unknown whether long-term hormone exposure exposes the patient to unique medical risks when undergoing assisted reproduction procedures. Transgender patients who undergo fertility preservation or assisted reproduction should be informed of the lack of data on outcomes.

Conclusion

The demand for fertility treatments has grown considerably in recent years, reflecting a changing workforce and traetment landscape. Employers run the risk of their employees using affordability as the main criteria for provider and treatment selection instead of quality or overall health outcomes if the levels of coverage for thsi condition are not reviewed in the context of latest evidence and clinical advancements. Employers can design their benefit to help their employees find high-quality providers and the most effective treatment through a comprehensive fertility benefit while controlling their long-term cost trend associated with overall maternity care.

Additional Resources on Fertility

Societies

1 | Centers for Disease Control and Prevention (CDC). Infertility FAQs. Accessed on June 19, 2019. https://www.cdc.gov/reproductivehealth/infertility/index. htm
2 | Lemos EV, Zhang D, Van Voorhis BJ, Hu XH. Healthcare expenses associated with multiple vs singleton pregnancies in the United States. Am j Obstet Gynecol. Dec;209(6):586 e581-586 e511.
3 | Business Group on Health. Quick Survey Findings: Infertility, Surrogacy, and Adoption Benefits. October 2018. https://www.businessgrouphealth.org/resources/infertility-surrogacy-and-adoption-benefits-quick-survey
4 | FertilityIQ. The FertilityIQ Family Builder Workplace Index: 2019 – 2020.. Accessed on June 19, 2019. https://www.fertilityiq.com/topics/ivf/the-fertilityiqfamily-builder-workplace-index-2019-2020
5 | Mody S, Taylor H. Egg freezing has become the go-to for delayed parenthood – and companies are popping up to provide more cost-effective solutions. https://www.cnbc.com/2019/05/09/millennials-are-driving-down-the-cost-of-egg-freezing.html. Accessed June 19, 2019.
6 | Friedman D. Perk up: Facebook and Apple now pay for women to freeze eggs. https://www.nbcnews.com/news/us-news/perkfacebook-apple-now-pay-women-freeze-eggs-n225011. Accessed November 6, 2014.
7 | Multiples of America. Multiple Births Statistics. https://www.multiplesofamerica.org/. Accessed on June 19, 2019.
8 | March of Dimes. Multiple deliveries: United States, 1998-2008. Peristats. http://www.marchofdimes.org/peristats. Accessed September 26, 2014.
9 | American Society for Reproductive Medicine. Multiple pregnancy and birth: twins, triplets, and high-order multiples. http:// www.asrm.org/BOOKLET_Multiple_Pregnancy_and_Birth/. Accessed September 26, 2014.
10 | Barrett JFR, Hannah ME, Hutton EK, et al. A randomized trial of planned cesarean or vaginal delivery for twin pregnancy. New England Journal of Medicine. 369(14):1295-1305.
11 | American Pregnancy Association. Complications in a multiples pregnancy. http://americanpregnancy.org/multiples/complications/. Accessed September 26, 2014.
12 | World Health Organization (WHO). Multiple definitions of infertility. https://www.who.int/reproductivehealth/topics/infertility/multiple-definitions/en/. Accessed on June 19, 2019.
13 | U.S. National Library of Medicine. Medical Encyclopedia – Infertility. https://medlineplus.gov/ency/article/001191.htm. Accessed on June 19, 2019.
14 | Personal communications with Alexander Dlugi, MD. August 24, 2018.
15 | American Society for Reproductive Medicine. FAQs about Infertility. https://www.reproductivefacts.org/faqs/frequently-askedquestions-about-infertility/q04-how-is-infertility-treated/. Accessed May 13, 2019.
16 | The National Infertility Association. What is IUI? https://resolve.org/what-are-my-options/treatment-options/what-is-iui/. Accessed on June 19, 2019.
17 | FertilityIQ. IUI Birth Rate and Multiples in Context. https://www.fertilityiq.com/iui-or-artificial-insemination/how-well-iuiworks-by-patient-type#iui-birth-rate-and-multiples-in-context. Accessed on June 19, 2019.
18 | Centers for Disease Control and Prevention (CDC). What is Assisted Reproductive Technology? https://www.cdc.gov/art/whatis. html. Accessed on June 19, 2019.
19 | Centers for Disease Control and Prevention (CDC). 2016 Assisted Reproductive Technology National Summary Report. https:// www.cdc.gov/art/pdf/2016-report/ART-2016-National-Summary-Report.pdf. Accessed on June 19, 2019.
20 | University of Pennsylvania Medicine: Fertility Blog. IVF By the Numbers. https://www.pennmedicine.org/updates/blogs/fertility-blog/2018/march/ivf-by-the-numbers. Accessed on June 19, 2019.
21 | Centers for Disease Control and Prevention (CDC). Having Healthy Babies: One At A Time. https://www.cdc.gov/art/pdf/ patient-resources/Having-Healthy-Babies-handout-2_508tagged.pdf. Accessed on June 19, 2019.
22 | CooperGenomics. What Patients Need to Know about the New Names for PGS and PGD. https://www.coopergenomics.com/ blog/during-ivf/new_names_for_pgs_pgd/. Accessed on June 19, 2019.
23 | Amato P. Fertility Options for Transgender Persons. UCSF Center of Excellence for Transgender Health. http://transhealth.ucsf. edu/trans?page=guidelines-fertility. Accessed on June 19, 2019.
24 | Business Group on Health. 2019 Large Employers’ Health Care Strategy and Plan Design Survey. September 2018. https://www.businessgrouphealth.org/resources/2019-large-employers-health-care-strategy-and-plan-design-survey. Accessed on June 19, 2019.