Background
Previous studies have demonstrated that state mandated coverage of in vitro fertilization
may be associated with increased utilization, fewer embryos per transfer, and lower
multiple birth rates, but also lower overall live birth rates. Given new legislation
and the delay between enactment and effect, a revisit of this analysis is warranted.
Objective
This study aimed to characterize the current impact of comprehensive state in vitro
fertilization insurance mandates on in vitro fertilization utilization, live birth
rates, multiple birth rates, and embryo transfer practices.
Study Design
We conducted a retrospective cohort study of in vitro fertilization cycles reported
by the 2018 Centers for Disease Control and Prevention Assisted Reproductive Technology
Fertility Clinic Success Rates Report in the United States. In vitro fertilization
cycles were stratified according to state mandate as follows: comprehensive (providing
coverage for in vitro fertilization with minimal restrictions) and noncomprehensive.
The United States census estimates for 2018 were used to calculate the number of reproductive-aged
women in each state. Outcomes of interest (stratified by state mandate status) included
utilization rate of in vitro fertilization per 1000 women aged 25 to 44 years, live
birth rate, multiple birth rate, number of embryo transfer procedures (overall and
subdivided by fresh vs frozen cycles), and percentage of transfers performed with
frozen embryos. Additional subanalyzes were performed with stratification of outcomes
by patient age group.
Results
In 2018, 134,997 in vitro fertilization cycles from 456 clinics were reported. Six
states had comprehensive mandates; 32,029 and 102,968 cycles were performed in states
with and without comprehensive in vitro fertilization mandates, respectively. In vitro
fertilization utilization in states with comprehensive mandates was 132% higher than
in noncomprehensive states after age adjustment; increased utilization was observed
regardless of age stratification. Live birth rate per cycle was significantly higher
in states with comprehensive mandates (35.4% vs 33.4%; P<.001), especially among older age groups. Multiple birth rate as a percentage of
all births was significantly lower in states with comprehensive mandates (10.2% vs
13.8%; P<.001), especially among younger patients. Mean number of embryos per transfer was
significantly lower in states with comprehensive mandates (1.30 vs 1.36; P<.001). Significantly fewer frozen transfers were performed as a percentage of all
embryo transfers in states with comprehensive mandates (66.1% vs 76.3%; P<.001). Among fresh embryo transfers, significantly fewer embryos were transferred
in comprehensive states among all patients (1.55 vs 1.67; P<.001).
Conclusion
Comprehensive state mandated insurance coverage for in vitro fertilization services
is associated with greater utilization of these services, fewer embryos per transfer,
fewer frozen embryo transfers, lower multiple birth rates, and higher live birth rates.
These findings have important public health implications for reproductive-aged individuals
in the United States and present notable opportunities for research on access to fertility
care.
Key words
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Article Info
Publication History
Published online: March 10, 2022
Accepted:
March 2,
2022
Received in revised form:
March 1,
2022
Received:
October 10,
2021
Footnotes
The authors report no conflict of interest.
This study received no funding.
Cite this article as: Peipert BJ, Chung EH, Harris BS, et al. Impact of comprehensive state insurance mandates on in vitro fertilization utilization, embryo transfer practices, and outcomes in the United States. Am J Obstet Gynecol 2022;227:64.e1-8.
Identification
Copyright
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