An Overview of Temporal Trends in Multiple Births After Assisted Reproductive Technology in the USA

Judy E Stern


Expert Rev of Obstet Gynecol. 2013;8(4):357-368. 

In This Article

Insurance Coverage: The Elephant in the Room

As of 2011, the highest multiple birth rate in developed countries was found in the USA with Canada a close second.[91] Some of this is the absence of legislation in the USA. However, another factor making it difficult both to legislate the number of embryos transferred and to convince patients to transfer fewer is the absence of adequate insurance coverage for ART in most states. In the USA, insurance companies have historically paid little for infertility treatment. As of this writing, only 14 states have laws requiring some form of coverage for ART but only five have 'mandated' coverage for ART cycles.[203] Other states mandate that ART coverage be 'offered' to employers by insurance companies, but there is no mandate for the employer to choose that option and actually offer it to employees. Even in those states that have mandated insurance coverage, the only required coverage is that provided by private sector employers and this does not cover government employees, students and unemployed persons. US healthcare coverage is thus very different from that found through much of Europe where fertility treatment is covered.

Several studies have shown an association between mandated coverage in US states and embryo transfer number.[95–97] Both Jain et al.[95] and Martin et al.[97] suggested that mandated coverage is associated with fewer embryos transferred, although Reynolds et al. suggested that this association holds for Massachusetts only.[96] Having ART covered by insurance may directly influence the decisions that patients make about the number of embryos they will transfer. In one Canadian study, investigators found that 81% of patients believed that insurance coverage had or would have an effect on the number of embryos they would choose to transfer.[98] Another study found that while insurance coverage predisposed more patients to SET, patients with no coverage could still be encouraged to transfer one embryo with the help of improved education.[99] An additional study found that use of elective SET was 16% for cycles not covered by insurance or a shared risk program (in which money paid for treatment is given back to the patient who does not achieve a live birth) that helped defray payment compared with 25% for patients with insurance coverage.[100]

Given the incredibly high cost of multiple birth,[101] it is curious that insurance companies do not take up the fight to reduce the number of embryos transferred. A policy that required SET in good prognosis patients in order for ART to be covered could make sense if it reduced the overall cost per delivered baby. Nevertheless, the insurance industry has not generally been a partner in this debate. This has been the case with regard to number of embryos transferred, but it can also been seen in insurance coverage of ART versus treatments such as gonadotropin therapy and intrauterine insemination (IUI) which many companies require prior to providing coverage for ART even though the treatments frequently result in higher multiple birth rates. In a recent study, Reindollar et al. performed a prospective trial to look at the effectiveness and cost of using IUI rather than ART as the first line of treatment for patients with unexplained infertility.[102] This study clearly demonstrated that the live birth rate was lower and the cost higher when IUI rather than ART was performed as the first line of treatment. The higher cost correlated with the higher multiple birth rate for IUI, where number of embryos cannot be controlled. Despite such evidence, many insurance companies still require three to six cycles of IUI before they will cover ART, if they cover ART at all. Reasons for this intransigence are hard to fathom. Understandably, patient advocacy groups have been hesitant to take up this fight since once a debate on legislation is begun, it could result in insurance companies requiring SET for every patient whether they are good candidates for this or not. A bill or policy on insurance could also be transformed into a law or insurance requirement advised by aspects of the ethical debates discussed above and resulting in limits on the number of oocytes inseminated or discarded and this could result in reductions in live birthrates. Retaining the discussion of number to transfer within the doctor patient relationship has distinct advantages.