Financial Barriers

Numerous studies have shown one of the most common barriers to accessing fertility care is the cost of treatment. At the time this chapter was written, the United States has some of the most expensive ART in the world. The average cost of a single IVF cycle in the United States in 2014 was $12 400 USD. That same year the average cost of a cycle in Europe was $5000 USD[2]. Infertility care is often excluded from health insurance plans in the United States; therefore, most patients are required to pay out of pocket for the majority of their treatments. The cost of an IVF cycle can be prohibitive and limits the treatment options available to those who require infertility services. Even non-IVF treatments, such as intrauterine insemination (IUI), may be cost-prohibitive as the required hormonal medications alone can cost several thousand dollars[3].

Decreased patient costs have been shown to increase the utilization rates of fertility services. These costs are different around the world due to the variety of healthcare systems. Comparative analysis of different countries has demonstrated a correlation between affordability of ART and utilization rates. Scandinavian countries have some of the most comprehensive government funding for infertility treatment. These countries show significantly higher rates of utilization despite rates of infertility comparable to the United States[4]. It is suspected that, by alleviating some of the financial burden from the individual patient, more people are willing to seek treatment.

State-mandated insurance coverage for IVF has been proposed and implemented in several states as a way to increase access to care within the United States. At the time of publishing, there are 16 states with some form of infertility insurance coverage laws. The degree of coverage and requirements for eligibility vary widely by state. Similar to what has been observed comparing different countries, studies within the United States have demonstrated higher utilization rates of infertility treatment in states with comprehensive mandates compared to those without. While the larger political debate surrounding government-mandated insurance is beyond the scope of this chapter, these studies highlight that more affordable treatment is correlated with increased access to care and utilization. There may be other unexpected benefits to decreasing patient costs. Some studies have noted a possible association with fewer embryos transferred per cycle in states with mandated insurance coverage and countries with more affordable care. It is suspected that couples may feel less pressured to transfer more than one embryo in a single cycle if the financial burden is lifted[5,6].

Drivers of High Cost of Fertility Treatment

IVF has evolved to be a complex process, which requires an expensive infrastructure. The cost to the patient comes not only from the medications and procedures but also the general overhead cost of running a fertility clinic. The process of stimulating the ovaries to prepare for egg retrieval generally involves many visits for hormonal testing and ultrasound evaluations of the ovary. Patients are often required to learn how to self-inject hormonal medications. Not only do these medications come at a high cost to the patients (often thousands of dollars per cycle), but the complexity of the medication schedules also requires the clinics to provide teaching on how to administer appropriately. As much of the stimulation process relies on the patient’s ability to properly give these medications at home, the clinic needs highly trained staff to communicate results and instructions effectively.

IVF facilities and the required embryology laboratories are costly, due to both the high infrastructure cost and the requirement for constant monitoring for safe storage of oocytes and embryos. The proper environment for managing and storing human embryos must be highly controlled. Human embryos lack organs such as lungs, kidneys, or livers to filter or remove toxins. Ambient air contains volatile organic compounds (VOCs) that impede embryonic development. Therefore, good IVF laboratories will have sophisticated heating, ventilation, and air conditioning systems designed to remove not only particles, but also these VOCs. Specialized incubators are required to provide the appropriate temperature, low oxygen, and high carbon dioxide concentrations. Because these are complex electromechanical devices, they need quality control checks each day. Achieving good quality control requires special instruments to undergo periodic calibration. Additionally, the incubators and embryo storage units can fail completely. Because this equipment houses something as precious as human embryos, the devices must be monitored at all times with a reliable alarm system.

Geographic Barriers

Physical access to infertility care is another potential obstacle to obtaining treatment. While many general obstetrics-gynecology practitioners may provide basic medical and surgical therapies to treat infertility, many patients require specific services provided only by fertility clinics. This may include diagnostic procedures, such as hysteroscopies and hysterosalpingograms, or treatment therapies such as IVF, ICSI, and preimplantation genetic testing (PGT). The evaluation and treatment course may span several months, requiring frequent visits for monitoring and procedures.

The United States lacks adequate distribution of infertility providers. There are approximately 1300 board-certified reproductive endocrinologists practicing in the United States, with about 50 graduating from fellowship programs every year. There are many women across the United States who may not live in an area that provides fertility treatment. Reproductive endocrinologists are primarily centered in dense urban areas. Geographic analysis has identified that IVF clinics are generally not available in cities with a population less than 250 000. This leaves those living in more rural areas without easily accessible resources. It has been estimated that 18 million women of reproductive age live in regions without access to ART providers, while another seven million live in a region with only a single ART provider[7]. While few patients may have the ability to travel great distances to reach appropriately trained providers, many do not have the resources required to seek out care.

Even those who live in close proximity to an IVF clinic may struggle with the time required for treatments. Many individualized protocols within the United States require multiple clinic visits for sonographic and laboratory hormone monitoring for a single cycle. Patients may face difficulty getting the required time off work as many people prefer to keep infertility treatments a private matter.

Social and Cultural Barriers

Given social and economic factors are often closely intertwined, it appears improvement in access to care is affected by more than decreasing cost. Similar rates of infertility are found among women of all races, socioeconomic status, and education levels. A study in 2005 surveyed women in the state of Massachusetts who underwent evaluation of infertility and found that there were significant educational and racial disparities. Despite the implementation of a broad mandate of six IVF cycles covered per pregnancy, African-American and Hispanic women, as well as those with less than a high-school degree, were underrepresented among those who were receiving treatment[8].

Different cultures may have stigmas surrounding the concept of infertility and may not be aware of the appropriate time to seek help. Nor may they know how to seek assistance. In many developing countries, particularly sub-Saharan Africa and South Asia, misinformation regarding infertility can cause significant social consequences for women. Some cultures do not recognize male factor infertility and, as a consequence, women are often blamed and even ostracized for the inability to conceive a child. The social repercussions of childlessness are often overlooked as these resource-poor countries are battling numerous health crises.

Members of the lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ) community may encounter barriers to accessing treatment that heterosexual couples would not experience. Same-sex couples often experience greater costs for treatment, whether that be for gamete donation or a gestational surrogate. Same-sex couples, transgender patients, and unmarried persons may be denied treatment by clinics. While many states provide protection for these individuals, not all states have such laws to prevent discrimination. The American Society for Reproductive Medicine (ASRM) has published strong ethics committee opinion statements emphasizing the responsibility of fertility providers to offer evaluation and treatment to all people of the previously mentioned groups[9,10].