One of the largest issues facing the United States’ healthcare system is the cost of medical services. In a market system of healthcare in the United States, medical services are sometimes treated as a luxury product. Plastic surgeries for cosmetic purposes should fall under the luxury category, but many necessities, whether it is a hip replacement or child delivery, are priced as luxuries. This may seem like an over-exaggeration, but pick any type of surgery or drug, and the cost for that service is probably significantly higher in the United States than in other countries, such as France, where approval ratings are high for their healthcare systems (12). Unfortunately, in the United States, there is often not a “cheaper version” of these services available, and as a result, citizens have to pay the premium price for their health. In vitro fertilization (IVF) is a medical service that provides a different avenue of fertilization for couples with fertility issues. First, this paper will cover the basic science behind IVF while also providing this technology’s historical background. Looking at IVF through a biological lens will then justify it as a medical necessity. Throughout the paper, empirical data, such as rates of success and pricing of IVF, will aid in answering questions such as “Why is receiving IVF time sensitive?” and “How can couples struggle financially when choosing IVF?” Recommendations for insurance companies and fertility clinics will be made in addition to suggesting future research that can help project the future of IVF pricing in the United States.
IVF is an assistive reproductive technology (ART) that is used to treat infertility. It is regarded as one of the more expensive fertility treatments, as a successful pregnancy from using IVF can cost around $60,000 (15). However, in order to grasp the financial details of IVF, it is important to understand how the process works. The first step, which can take anywhere between 6-8 weeks, involves consultations with the fertility clinic, various tests, and receiving different hormone treatments to promote the maturation of eggs. This is followed by the retrieval of the mature eggs; the term in vitro translates to “in the glass,” which implies a biological process taking place outside of the body (10). After the retrieval, the eggs are fertilized, now called embryos, and are examined 16-18 hours post insemination to assess the embryos’ growth and development. After determining which embryos are of the highest quality in either the day 3 cleavage stage or day 5 blastocyte stage, the embryos are placed in the women’s body in the uterine cavity (9). In most cases, the couple will choose to either have one or two embryos placed into the women’s cavity (17). Overall, this process is considered one cycle; a term that will be used periodically throughout the remainder of this paper in order to provide perspective relating to the time and money that goes into these IVF treatments. According to the American Society for Reproductive Medicine, the average price for one cycle of IVF is $12,400 while the hormone treatments can cost an additional $3000-$5000 (17).
But first, how did we get to the point where IVF has helped treat infertility all over the world? One of the first ever recorded non-traditional methods of insemination occurred in 1770 when John Hunter of Scotland inseminated a woman with her husband’s sperm. A little over a hundred years later, in 1874, Dr. William Pancoast successfully inseminated a woman with a donor’s sperm. The next major development working toward IVF occurred in 1944 when Dr. John Rock and Miriam Menkin achieved the first ever in vitro fertilization of a human egg (6). Finally, the landmark event that ushered in the age of IVF as a form of ART occurred in England, July 1978, with the birth of Louise Brown. Her birth prompted other countries, ranging from Germany to Australia, to join this new ART movement. The United States had its first IVF birth in 1981 with the birth of Elizabeth Carr (7). Continued research on how to improve IVF eventually led to other ground breaking techniques, such as preimplantation genetic diagnosis (PGD), which allows pre-screening of embryos for certain genetic diseases and is often paired with IVF treatment (for additional $1800-$5000, of course!) (7). Despite all of the success that stems from IVF, it has caused controversy. In 2009, Nadya Suleman, also known as “Octomom,” birthed octuplets after twelve frozen embryos were transferred from her previous IVF cycles. Dr. Michael Kamrava, who oversaw the treatment, was stripped of his medical license for putting her life in grave danger (7). IVF has been a medical service available to the public for just 30 years. During those 30 years, however, debates over the price and coverage of IVF have persisted.
It is important to define the terms medical necessity and luxury. To clarify, while a wide range of meanings for medical necessity exists, the National Academy for State Health Policy’s definition for North Carolina (as well as many other states) is “medical or remedial care that is medically necessary to correct or ameliorate a defect, physical, or mental illness, or condition” (21). While it may be difficult to pin down a definition for medical luxury, it can be generally viewed as something that is not medically necessary; a procedure or other medical service that enhances some aspect of one’s well-being, such as plastic surgery for cosmetic purposes. Medical necessity’s vague definition could encompass any disease and we know very well that not all diseases are priced or covered as medical necessities. After all, isn’t the treatment for one person’s disease a medical necessity to that individual, even if that disease only affects a small portion to the population? By that logic and this definition, every procedure that covers a disease should be considered a medical necessity. This is not realistic, but one could make the same argument against IVF. Why should IVF be prioritized over millions of other physical or mental defects as a medical necessity?
Looking at this issue through a biological lens will exhibit why IVF should be either covered or priced as a medical necessity instead of a medical luxury. First, according to the American Society for Reproductive Medicine, IVF is in fact a “disease of the reproductive system” that “impairs the body’s ability to perform the basic function of reproduction.” On top of this, almost 11% of women in the United States have some sort of inability to have a child and 3% of that population opts for procedures such as IVF, while the other 90+% opt for other types of surgeries (23). However, it is important to acknowledge an issue with this argument; in a perfect world, everyone’s medical issues should be cared for. However, only 0.33% of the United States’ population opts to have this procedure in order to overcome infertility (23). Why prioritize a treatment that 0.33% of the population opts to have? I believe that the 0.33% statistic is misleading. A couple may not choose to undergo IVF treatment simply because a clinic is not in their area and they cannot afford to miss time from work to have a consultation. In addition, I believe the largest reason why this percentage is so low is because of the current price of IVF frightens couples away from pursuing this treatment. Does it make sense for a couple to hop on the IVF train if they can only afford one cycle, which has a poor success rate?
Second, it is possible to use Charles Darwin’s theory of “natural selection,” as presented in his 1859 work, On the Origin of Species, to provide evidence against the promotion of infertility in the population. One premise of his primary theory is that favorable traits that contribute to an organism’s survival, ranging from food foraging ability to having certain phenotypic traits that allow the organism to avoid predation, are selected for and are most prevalent in a population of that organism. Negative traits that affect an organism’s survival will be selected against in order to decrease that trait in a population (2). Most would consider infertility to be a negative trait. Women or men who suffered from infertility before procedures like IVF did not produce offspring and therefore were selected against, never having the chance to pass on these negative traits to their offspring. From a biological perspective, perhaps the best possible treatment option could be to allow infertility to be selected out of the population instead of asking insurance companies to cover a procedure that a small percentage of the population opts for.
However, this theory applied to IVF can also be countered as natural selection would not necessarily rid our population of infertility if left untreated. 12% of infertility is caused by obesity or even weighing too little while smoking has been estimated to cause almost 13% of infertility in women. In addition, untreated sexually transmitted diseases (STDs), such as chlamydia, can cause infertility (23). Environmental pressures may have caused individuals to pick up smoking habits or eat to the point of obesity (or not eat enough at all). Individuals may not have had sufficient sexual education, which could be the cause of contracting STDs. If the technology exists to fix this problem, why let individuals suffer from either natural selection from genetics or environmental pressures that may be out of their control, especially if the technology exists to fix the problem? On the flipside, genetic and environmental pressures are responsible for other diseases that are not necessarily priced as medical necessity. IVF is not a full proof solution, so why should IVF have higher priority over other treatments as a medical necessity?
The biological aspect that settles the score, categorizing IVF as a medical necessity, is that there is strong evidence supporting the notion of organisms having a biological desire to pass on their genes to offspring. The term “survival of the fittest” was first coined by Herbert Spencer in his The Variation of Plants and Animals under Domestication after reading Charles Darwin’s On the Origin of Species in 1868 (25). “Survival of the fittest” is often misunderstood by individuals and is often taken to mean that the physically strongest will survive. However, the term “fit” correlates with not necessarily muscles, but the ability to reproduce. An organism, by using “survival of the fittest” as a measure, is considered the most “fit” if the organism produces not only many offspring, but also if their many offspring live to produce another generation of offspring. While there have not been any theories that definitively connect “survival of the fittest” to humans, there is evidence that suggests this relationship exists (although it may not exist in everybody). “Baby fever” is a “physical and emotional phenomenon” defined as an “inexplicable urge to have a baby” while the “biological clock” theory occurs when women realize that their “biological baby-making window is closing” (24). Applying this theory to humans is speculative and it cannot be assumed that this “animal-like” urge exists in everyone. However, it must not be forgotten humans do share a large portion of our genome with other animals and humans do not understand our own genetics. Maybe there is something to “survival of the fittest” in humans that determines a person’s desire to have a child?
At $12,400 per cycle (closer to $20,000 if the hormone drugs are included), the price for IVF is high, as the median household income in the United States is about $59,000 (5). However, women often times will undergo quite a few cycles depending on their age and other factors, which can double, triple, or even quadruple that $12,400 price tag. The largest issue is that most states do not require insurance companies to include IVF to alleviate the costs of these pricey procedures, which I now accept as a medical necessity, as an accepted form of fertility treatment.
Of America’s 50+ states and territories, about 40 of them do not require any type of infertility coverage (26). While some states have taken steps forward over the past decade, such as California, some states still have odd provisions for when, after meeting a certain criterion, IVF is included (26). For example, in order for a couple to qualify for IVF procedures in Hawaii, the couple must show a documented history of “at least five years or prove that the infertility is a result of a specified medical condition” (26). The coverage is also a one-time benefit. This provision is an issue because when it comes to infertility, age can indicate the success rate of an IVF cycle. Texas also has a similar requirement.
Follow this hypothetical situation; A Hawaiian woman, who does not know that she or her husband (or both!) have infertility issues, is 27-years-old and wants to have a child a few years after marriage (26.9 is the median age of marriage in Hawaii) (27). By the time the woman is ready to start having a child, she may be 30-years-old. If this is the point where the couple start trying to have children and are not successful, it may take the couple a few years, based on a variety of factors such as education in general fertility as well as willingness to talk to each other as a couple that infertility could be the reason why the pregnancy is not working, to come to the realization that infertility may be the culprit. If the couple wishes to have IVF and cannot afford the $12,000 price tag for just one cycle of IVF, the couple, by law, may have to wait for 5 years to receive benefits for IVF. Now the woman is age 35, which according to the American Pregnancy Association, is a fringe age for IVF success rates. For any women under the age of 35, the success rate of a cycle of IVF is between 41-43%, meaning the average number of cycles until success is about 2.5 cycles. However, between ages 35-37, the success rate of a cycle decreases to 33-36% (3), meaning the average number of cycles for success is about 3. Given that only one cycle will be covered for the couple in Hawaii, the couple could end up having to pay close to $30,000 minimum out of pocket. Mind you, this is just to have one child! If the woman successfully undergoes child birth at age 35/36 and wants to have another child, the success rates of IVF for women between ages 38-40 is between 23-27%, which equates to almost 4 cycles (3).
The hardest question to answer is how do you decrease the price of IVF or require insurance companies to offer some type of coverage? Should insurance companies come up with better methods of coverage or should fertility clinics take it upon themselves to lower the prices of the services they offer? Focusing back on the insurance companies, the first step is for all states to offer some type of infertility coverage, including IVF. A state with an exemplary policy is Maryland, which asks for a two-year record of infertility and allows for up to three cycles of IVF per live birth. In addition, a couple may not exceed over $100,000 in a lifetime, which is equivalent to about eight cycles of IVF (26). If a woman is young enough when she realizes she has infertility issues, three cycles, which is often regarded to be the magic number for women under 35, seems reasonable. On top of this, depending on the age of the women, eight cycles of IVF may be enough to have two children. Maryland provides an excellent infertility structure that other states should adopt.
In a perfect world, an insurance system would be in place that could cover everyone’s needs. However, this is obviously impossible and I do not expect mass coverage of IVF to be a reasonable solution (even if I think it should be covered by all insurance companies!). Different states passing laws to regulate the inclusion of IVF in insurance policies is highly unlikely, and I am not so sure that this would be the correct solution. In defense of the insurance companies, it is hard to justify, from an economic perspective, covering a procedure that both covers a miniscule part of the population and has a very low success rate. In addition, many cases of infertility are caused by environmental issues such as obesity and STDs, which are both preventable and curable. Even further, why would insurance companies have any incentive to take on the risk of fertility clinics who could look to make a quick buck that abuse the technology and take on “older” patients (40+) for a few cycles that have a minimal chance of having a successful live birth?
While it is important to regulate medical necessities, not all issues can be solved through insurance companies. Instead, perhaps letting competition among fertility clinics set the market price is the best solution. Various fertility clinics have already begun this process. Some clinics, such as Shady Grove Fertility (located in MD, PA, and the District of Columbia), offer full refunds if a baby is not delivered (medicine and pre-screening fees not included) (11). Some clinics even offer mini-IVF, such as The Infertility Center of St. Louis, AK, which is a “dramatically lower-cost option with comparable results” (14). Elan Smickes in St. Louis has lowered the price of IVF services offered at Fertility Partnership at around $7,500 (4).
With fertility clinics across the United States making an effort to lower the cost of IVF not only for the positive PR, but also to compete with existing clinics, Smickes (who was a pioneer in decreasing the cost of IVF treatment) compared the eventual decline in IVF’s price to that of Lasik surgery in a 2010 interview. Costs for each eye used to be $6,000 a piece, but with a little competition, the price has decreased to as low as $1,500 for both eyes (4). One can hope that with increasing competition, the complexity behind state legislature requiring insurance companies to cover IVF can be avoided and instead of formally regulating IVF to be a medical necessity, competition will self-regulate the medical necessity and drive the price to an affordable level. The only difficulty has been trying to track down data that examines cost of IVF over a span of 15-20 years, which would be a valuable tool in determining the future trend of IVF pricing and could be the subject of future research. In addition, a stricter financial analysis should be used to determine what exactly is considered “affordable.” In the end, IVF clinics across the country are not going to wake up one morning and decide that IVF is a medical necessity and that they are charging too much. It is simply not the way the world works. Competition will drive down the price of IVF to resemble the price of a medical necessity. As stated by Smickes, “a woman’s right to have a chance to try to have a child should be available to all” (4). If the technology to solve infertility issues exists, then it should not be exclusive to those who can afford the procedure.