Impact of Mandated Insurance Coverage on Utilization and Outcomes of In Vitro Fertilization

By Tarun Jain, MD

Since in vitro fertilization (IVF) was introduced in the U.S. in 1981, a number of states have passed laws requiring that insurance companies provide either partial or complete coverage of this beneficial treatment for patients with infertility.  In 2002, my colleagues and I undertook a study of the effects of these laws on IVF utilization and outcomes.  We used 1998 data reported to the Centers for Disease Control and Prevention (CDC) by 360 fertility clinics in the US and 2000 US Census data.  This study was published in The New England Journal of Medicine in August 2002. 

In 1998, of the states in which IVF services were available, three states (31 clinics) required complete insurance coverage,  five states (27 clinics) required partial coverage, and 37 states plus Puerto Rico and the District of Columbia (302 clinics) required no coverage.  We examined how frequently IVF treatment was utilized in each category of state and how the medical outcomes differed in terms of singleton/twin births versus triplets or more.  Our study found that clinics in states that required complete coverage performed more IVF cycles than clinics in states that required partial or no coverage (3.35 vs. 1.46 and 1.21 IVF cycles per 1000 women of reproductive age, respectively) and more transfers of frozen embryos (0.43 vs. 0.30 and 0.20 per 1000 women of reproductive age, respectively).  At the same time, we also found that treatment and outcomes were more conservative in states with complete insurance coverage than in those with no coverage:  physicians transferred fewer fresh embryos per cycle, the rate of live births was lower, and, importantly, the percentage of pregnancies with high-order multiples (triplets or more) was lower than in no-coverage states (9.7% vs. 11.2%, respectively). 

In summary, our study showed that state-mandated insurance coverage for IVF services is associated with increased utilization of these services but with decreases in the number of embryos transferred per cycle, the percentage of cycles resulting in live births, and the percentage of high-order multiple pregnancies, i.e., with three or more fetuses.

These findings suggest that in states that do not require insurance coverage, a substantial number of women who might benefit from IVF do not undergo it, probably because of financial constraints.  Furthermore, lack of such financial pressures in states with mandated insurance coverage likely results in couples opting for fewer embryos to transfer per IVF attempt.  Such practice leads to a lower chance of multiple births (especially triplets or more), which ultimately translates into having safer pregnancies and healthier children.

Tarun Jain, MD, is Assistant Professor & IVF Director, University of Illinois at Chicago.