The Path to Family Formation: Understanding the Complexities and Challenges

For informed choices in fertility and family formation, employers seek to understand the complexities individuals face and offer supportive benefits.For informed choices in fertility and family formation, employers seek to understand the complexities individuals face and offer supportive benefits.


September 07, 2023

This guide aims to help employers understand the global landscape of fertility and family-forming benefits.

Infertility challenges continue to be prevalent and have a profound impact on individuals striving to start a family. Family formation and fertility care face limitations in terms of availability and accessibility worldwide. The prevalence of these challenges and their consequences on families may be overlooked, resulting in inadequate health coverage. Employers have an opportunity to make a difference by recognizing the significance of supporting employees' diverse journeys toward building families. By understanding the complexities and challenges involved in family formation, employers can develop comprehensive benefit strategies that encompass various pathways to family building.

Benefits for the Needs of Diverse Families

The journey toward starting a family comes with various hurdles impacting individuals differently. In heterosexual relationships, men increasingly may face infertility issues such as difficulties with ejaculation, low sperm levels or abnormalities in sperm shape and movement. For females, infertility can be caused by a range of factors affecting the ovaries, uterus, fallopian tubes and endocrine system.26 LGBTQ+ individuals and single parents by choice may encounter different challenges when starting a family. In addition to possible infertility challenges, they need to use alternative methods of conception and face legal complexities that heterosexual couples typically do not face.

Despite the challenges and obstacles, individuals seeking to form a family have various options available to them. In heterosexual relationships, couples can explore infertility treatment or decide to pursue adoption or surrogacy. In comparison, LGBTQ+ couples often find that the path to parenthood takes them directly to adoption, surrogacy and donor insemination. Meanwhile, single mothers by choice have a range of fertility options, including selecting donor sperm from banks or opting for surrogacy if pregnancy is not feasible. Similarly, men who aspire to become single fathers have the option to pursue adoption or seek an egg donor or surrogate.

Causes of Infertility and Benefits Offered

Infertility is a medical condition affecting the reproductive system of either males or females, and it can manifest as primary, secondary or unexplained. Click on each to learn more about them:

Primary infertility is the inability to become pregnant or carry a pregnancy to a live birth after 1 year of regular, unprotected heterosexual intercourse or physician-supervised donor insemination.27

Secondary infertility applies to couples who have been able to have a child or children in the past but are now unable to conceive.27

Unexplained infertility refers to a condition wherein comprehensive fertility evaluations fail to identify any specific cause underlying an individual or couple's inability to conceive.27

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 enabling single parents by choice or LGBTQ+ couples to have their treatments covered. In the U.S., self-insured employers have the flexibility to modify coverage criteria, which may include removing time requirements or eliminating the need for a medical diagnosis of infertility to access benefits. According to the Business Group’s 2024 Large Employer Health Care Strategy Survey, 75% of large employers will expand fertility benefits to cover all types of families in 2024 without the need for an infertility diagnosis. For plans outside the U.S., employers with a captive may have more flexibility to determine coverage beyond what is provided at the government level.


The first step in treating infertility appropriately is determining the root cause by an infertility specialist. While an OB/GYN (with or without 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 reproductive endocrinologist or urologist.28 Eighty-eight percent of large employers reportedly provide coverage for evidence-based medical evaluation of infertility.11

Treatment Options

Treatment begins once the cause of infertility is determined. Treatments may include medication, surgery, intrauterine insemination or assisted reproductive technology. Click on each to learn more about them:

This treatment option is covered by 92% of large employers.11 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.29

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

Sometimes referred to as artificial insemination, IUI involves the insertion of specially prepared sperm into the woman's uterus. IUI is recommended for cervical-factor infertility, LGBTQ+ families/couples, male-factor infertility as well as unexplained infertility in conjunction with ovulation stimulating medications (e.g., Clomid or Letrozole) for a limited number of cycles.30 IUI is covered by 96% of large employers.13 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. This success rate, however, is associated with a much higher risk for a multiple gestation. Some health plans require members to complete six to 12 rounds of IUI before qualifying for other treatment options.

ART refers to fertility treatments that deal with eggs or embryos. These treatments usually involve taking eggs out of a woman's ovaries, combining them with sperm in a lab and then putting them back in the woman's body or donating them to another woman. ART does not include treatments where only sperm are handled, such as IUI.32 Although ART has been accessible for over three decades, resulting in the birth of more than five million children worldwide, the issues with access and cost limit its use, particularly in low-and middle-income countries.26 One of the most common forms of ART is in vitro fertilization (IVF), where eggs and sperm are combined in a laboratory dish to form an embryo, which is then transferred to a woman's uterus. The success of IVF can be influenced by various factors, but the age of the woman using her own eggs is the most significant determinant. Women under the age of 35 have a greater than 20% chance of achieving a full-term, normal birth weight and singleton live birth per cycle.33 According to a Business Group on Health survey, 86% of large employers provide at least some coverage for IVF.11 Less common ART procedures include Intracytoplasmic sperm injection (ICSI), Zygote intrafallopian transfer (ZIFT) and Gamete intrafallopian transfer (GIFT).

Accessing safe, affordable and effective fertility care is a crucial aspect of ensuring reproductive health. Unfortunately, in countries where fertility treatments are legally permitted and culturally embraced, numerous individuals still encounter barriers that prevent them from obtaining these services. To gain a deeper understanding of the limitations present in specific countries, explore The Family Benefits Bundle Guide, review the interactive map provided by the European Society of Human Reproduction and Embryology and the European Atlas of Fertility Treatment Policies developed by the European Parliamentary Forum for Sexual & Reproductive Rights and Fertility Europe. These resources offer valuable insights into country-level regulations and funding related to fertility treatments.

Depending on an individual's employer insurance coverage or their geographical location and country of residence, the total cost of IUI and IVF cycles can vary significantly. This is because certain health plans and governments provide subsidies that can partially or fully reimburse a portion of the expenses. Specific to the U.S., the cost of fertility treatments can vary significantly based on patient characteristics and the site of care. An IUI cycle with medication, for example, can range from $4,000 to well over $20,000.34,35 In contrast, Belgium's mandatory public health insurance scheme ensures universal access to basic health care, including fertility services. Regardless of relationship status, women under the age of 43 are eligible for coverage, with expenses reimbursed for up to six IVF cycles. IVF is typically priced at $550 per cycle.36

While fertility treatments may indeed be more affordable in some countries outside the U.S., they can still present a significant financial barrier for the residents of the country. For example, in Brazil and Mexico, the cost of one fertility treatment can account for up to half of an employee’s annual disposable income.38 Although Brazil, among other countries, provides fertility treatment coverage within their public health system, accessibility remains restricted, and prolonged waiting periods are prevalent.38,39

In 2021, 59% of employers reported placing a dollar limit for fertility care.11

Among employers with dollar limits, 61% have a combined dollar limit (medical plus pharmacy), with a median dollar limit of $25,000. 11

39% of employers have a separate dollar limit for medical and pharmacy, with a median dollar limit of $25,000 for medical and $10,000 for pharmacy.11

In some other countries, there are caps on the number of covered cycles. Denmark covers the cost of up to three cycles for patients up to age 40 for a first child. Since evidence shows that the success rates of IVF begin to decline after four to six attempts, it makes sense to have a cap for coverage. Employers looking to offer fertility services but also keep their health care costs manageable may want to consider this option. In fact, 33% of employers have taken this approach.11

While there are no regulations with age restrictions for fertility treatment in the U.S. for self-insured employers, certain countries impose age caps. In Europe, age caps range from 37 (Latvia) to 55 (Cyprus). Notably, countries such as Poland and Turkey have opted not to impose any age restrictions.41 Moreover, age caps may differ between the public and private health care systems, leading to fluctuations in the availability of treatments.

Additional Family-forming Benefits

Employers seeking to offer inclusive and equitable family-forming benefits that support all paths to parenthood may want to consider offering benefits beyond fertility. These benefits can support a wide variety of people, including heterosexual couples, same-sex partners, individuals who are not in sexual relationships and those with certain medical conditions.

  • Adoption: Adoption benefits may include navigation services, financial assistance and parental leave. Employers 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. The average cost of adopting a child is between $20,000 and $50,000, depending on the country of adoption.
  • Surrogacy: This benefit is used by couples who have exhausted other treatments, someone with a medical issue that precludes them from carrying a pregnancy, a member of the LGBTQ+ community or a single parent. Surrogacy refers to the procedure in which a woman carries a baby on behalf of intended parent(s). Usually, the surrogate is not biologically related to the child. The intended parent(s) produce embryos by utilizing their own reproductive cells or opting for donated eggs and/or sperm. Subsequently, the developed embryo is transferred to the gestational carrier, who then carries the baby. The cost of surrogacy can range from $80,000 to $200,000; many determining factors, from legal fees and health insurance coverage for the surrogate, contribute to the bottom line.42

Approximately 85% of large employers reported covering at least one adoption associated cost, with agency fees covered by 98% of them and legal fees and court fees fully covered by all.11

Approximately 38% of employers reported covering some costs associated with surrogacy.11

Surrogacy laws and regulations vary widely across countries and even within different states or regions. In the U.S., surrogacy is legal, but the specific laws and requirements vary by state. While some countries permit surrogacy, others have restrictions or bans, such as China and most of the European Union.43 In India, for example, a restriction may be that the surrogate must be a female relative.43

Unlike coverage for fertility treatments, which are administered as a pre-tax medical benefit in the U.S., adoption and surrogacy benefits are typically post-tax reimbursement programs. Employers may want to seek input from their legal team on how to communicate potential tax implications to their employees.

Options for Transgender People

Depending on which stage of transition they are in, transgender people 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. Certain countries, such as Japan, mandate sterility procedures for transgender individuals during their gender affirmation process.44 In addition, it is currently unknown whether long-term hormone exposure exposes patients to unique medical risks when undergoing assisted reproduction procedures. Transgender patients who undergo fertility preservation or assisted reproduction may need to be informed of the lack of data on outcomes.

Employer Recommendations

  • 1 | Promote inclusion: Reassess eligibility determinations for fertility treatments to reflect the diverse needs of your workforce. For global workforces, work with a global fertility vendor partner to navigate country-specific regulations that can impact inclusive benefit guidelines.

Reassess eligibility determinations for fertility treatments to reflect the diverse needs of your workforce. For global workforces, work with a global fertility vendor partner to navigate country-specific regulations that can impact inclusive benefit guidelines.

  • Age: Align benefit coverage limits with those set forth by the American Society for Reproductive Medicine.
  • Marital status: Match the eligibility for fertility treatment with the company's policy on eligibility for health benefits.
  • Employees without partners: Consider expanding eligibility criteria to include employees without partners to improve employee satisfaction with benefits, reduce the likelihood of multiple gestations and compete for talent.
  • 2 | Engage effectively: Through consistent and culturally sensitive communications, educate employees about available benefits and programs.

Through consistent and culturally sensitive communications, educate employees about available benefits and programs.

  • Provide clear, concise information about fertility benefits: Fertility benefits are complex and are often reviewed during an emotional time. Information should start with the pre-certification/medical evaluation stage found in benefit materials.
  • 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: Recognizing the unique needs of individuals, partners and others struggling with infertility vary considerably, employers may want to consider personalization and personas when developing communication materials.
  • 3 | Ensure cultural competency: Assess whether there are culturally competent providers in the network that have the knowledge and experience to meet the unique needs of employees.
  • 4 | Uncover synergies: Look for connections among existing programs to support parents through family forming.
  • 5 | Financial flexibility: Take advantage of Health Reimbursement Accounts (HRA) or Lifestyle Spending Accounts (LSAs) for reimbursement. For key considerations for revitalizing incentive strategies and exploring LSAs, see Designing Incentives and Lifestyle Spending Accounts For a Modern Workforce.

This Guide is for Business Group on Health members only. It should not be reproduced, distributed or quoted without permission from Business Group on Health

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  1. Benefits for the Needs of Diverse Families
  2. Causes of Infertility and Benefits Offered
  3. Options for Transgender People
  4. Employer Recommendations