In order to gain coverage for fertility treatment, patients historically have been required to receive a diagnosis for infertility. But here’s the catch: that medical diagnosis often means six to 12 months of unprotected, unsuccessful heterosexual intercourse, according to one industry executive. 

“That definition alone obviously prohibits any single parents by choice or LGBTQ+ from accessing the benefits,” said Ann Gaines, senior vice president of business development at Progyny, during a Wednesday interview at the Midwest Business Group on Health Conference in Chicago. Progyny is a fertility benefits management company.

There are vast disparities when it comes to fertility. One in five women struggle with infertility, and Black women are two times more likely to be affected. About 63% of LGBTQ+ individuals who are planning to build families expect to use assisted reproductive technology, foster care or adoption in order to become parents.

These disparities are due in part to benefit design, according to Gaines. It’s common for employers to offer a “dollar cap” benefit, in which employees have a limit on how much their employer covers for fertility services. This is inherently inequitable because different populations have different needs when it comes to fertility, Gaines said. For example, it’s more common for the Black community to carry the sickle cell trait. They require extra genetic testing of their embryos, which costs extra money. The LGBTQ+ community requires donor tissue, which also costs money.

“Those same dollars are not going to go as far in certain areas versus other different areas,” Gaines said.

Another traditional fertility benefits practice is step therapy, in which members have to go through a certain number of rounds of intrauterine insemination (IUI) before they move on to in vitro fertilization (IVF). IUI is “one of the least efficacious treatments in terms of pregnancy success,” and often leads to unnecessary costs, Gaines said. 

Instead of a dollar cap approach, Progyny offers fertility benefits through “smart cycles,” in which services, tests and medications are bundled together and are given a “cycle value.” For example, egg freezing will use up half of a smart cycle, while in vitro fertilization (IVF) will use up three-quarters of a cycle. Employers can decide how many cycles they want to cover. And instead of engaging in step therapy, the company just directs patients to the kind of treatment they need right away, Gaines said.

What’s the ROI on moving away from these more traditional fertility benefits? By not utilizing step therapy, savings are created by avoiding unnecessary treatments. Not having a dollar cap also reduces high-risk, high-cost pregnancies and twinning down the line. 

“What leads to twinning in this world is transferring more than one embryo,” Gaines stated. “With that cost-based idea, transferring multiple embryos — two or three embryos — in order to achieve pregnancy with fewer rounds of IVF, you’re going to see that uptick.”

One of Progyny’s clients is Abbott, a medical devices and healthcare company. But prior to working with Progyny, the company was providing a dollar cap fertility benefit, said Susana Pociejewski, manager of U.S. health plans at Abbott, during a panel at the conference. The company started noticing that a lot of its employees’ babies were going into the NICU after being born. After looking into the data, the company learned that it had 13 NICU babies as a result of its fertility treatments.

“Abbott had a great benefit: $50,000,” Pociejewski said. “But [there were] a lot of complexities. … We were determining what the right solution was for when folks were going to access care. You had to try for a year, had to have a diagnosis, couldn’t have a same-sex partner. There were a lot of limitations within our benefit plan that was leading to high-cost claimants: $17 million was what we had.”

Since changing its benefits, Abbott has had 278 babies, two sets of twins and no NICU babies, Pociejewski shared.

Other companies that provide fertility care include Maven Clinic, Kindbody and Carrot Fertility. Like Progyny, these companies also focus on inclusivity in their treatment.

Photo: Natali_Mis, Getty Images