Clinical Considerations in Managing Infertility and Expanding Fertility Benefits

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AJMC®: How has the clinical definition of infertility changed over the past few years, and what factors have contributed to this evolution?

ADAMSON: There are several reasons why the definition of infertility has changed. Historically, the definition of infertility has been the inability to get pregnant after a year of trying. And this definition applies only to heterosexual couples who are having intercourse. There’s been a sense for quite a while that, obviously, everyone has the right to found a family, and this definition did not include single people and those in the LGBTQ+ community. I’m actually very proud of my role as chair of the committee at the World Health Organization, which is actually a nonstate actor, an NGO [nongovernmental organization] called the International Committee for Monitoring Assisted Reproductive Technologies. We published a glossary in 2006 that had definitions surrounding reproductive medicine including a definition of infertility, which was the traditional definition of attempting to get pregnant for a year and not being successful. In 2017, we added a clause to this definition that said that infertility also included individuals who could not get pregnant when they wanted to have a family because of other reasons, and these could include disabilities or any type of reason. This expanded definition was accepted by many professional organizations around the world. It’s important to note [that] the World Health Organization, for many reasons, still uses the conventional definition of not getting pregnant in a year. But all the professional organizations and people providing fertility care around the world use the definition that infertility can affect anyone, heterosexuals with a classical definition, or the expanded definition that includes single people, women, men, those in the LGBTQ+ community, and [people of any gender]—it’s a very inclusive definition now.

AJMC: What role do cultural and demographic shifts play in shaping policies (eg, eligibility criteria) around infertility treatment coverage and employer-sponsored benefits?

ADAMSON: Cultural and demographic shifts over the past decade have significantly influenced policies on infertility treatment coverage and employer-sponsored benefits. Increased awareness of gender inequality highlighted social injustices in the workplace and beyond. The COVID-19 pandemic further shifted priorities, as many reassessed work-life balance and placed greater value on family time and personal well-being.

Generational changes have also played a role, with newer workforce entrants prioritizing flexible benefits including reproductive health options. Additionally, political developments around reproductive rights have amplified the call for equitable access to fertility services for both women and men. Combined, these factors have driven a growing recognition of infertility as a health issue and have motivated employers to address reproductive health more inclusively both [to retain talent] and to support diverse family-building paths. As a result, we’re seeing a notable increase in policies that support reproductive medicine and infertility benefits today.

AJMC: What barriers are there to reproductive care?

ADAMSON: There are a number of barriers to reproductive care. The primary one [involves] cost and affordability. Affordability is the out-of-pocket cost relative to net disposable income. In many of the more developed countries of the world and [in] Europe, when it comes to infertility treatment, there [are] government subsidies or national health plans that cover infertility. Because of the nature of the US health care system, subsidies or additional funding provided by government has by and large not been present in any meaningful way. About a decade ago, [up to] 20% to 25% of people who needed fertility care could access it, and when they could access it, the financial coverage for it through their health plans was very limited. The primary barrier has been affordability for patients who couldn’t get access to care.

In addition to that, there are other reasons that these benefits haven’t been brought in. When fertility care first developed and became more efficient, there was a high level of multiple-pregnancy rates with IVF [in vitro fertilization] and with fertility care. Multiple-pregnancy rates result in higher costs for pregnancy and for neonatal intensive care units. Perception among employers rapidly developed that infertility care was very expensive, and, as a result, they did not want to provide benefits. This is a primary reason for many years that employers did not want to provide these benefits. When you provide this care properly, the multiple-pregnancy rate, which used to be about 30% for twins, is now down to 5% or 6%, which is just a little over what the naturally occurring twin rate is. The twin rate has been brought down, and [that] reduced the cost, but the perception is still out there that this is a very expensive benefit when it is not.

The third reason [that] these benefits have not been brought in is because of traditional cultural perspectives around reproduction. The bottom line is people don’t talk about it much. I remember the days when people wouldn’t talk about breast cancer, HIV [infection], prostate cancer, erectile dysfunction, menopause, and periods. Those days are changing now. Our society has become more open about discussing reproductive issues, rights around reproduction, and gender inequity. We’re discussing social determinants of health [SDOH] that prevent many people in marginalized communities from getting access to care. This is a problem across all sectors of our health care system and all sectors of society, not just [in] reproductive medicine. The old perceptions of reproduction, gender, and marginalized communities have changed a lot, but those reasons prevented employers from being able to say, “We think this is something that’s good for our employees, and it’s good for our company, and so we’ll do it.” That’s changed, and we’re very grateful that these issues are changing.

AJMC: How can increased awareness and understanding of infertility contribute to better patient advocacy and support within health care systems?

ADAMSON: Increasing awareness and understanding of infertility is essential to improving patient advocacy and support within health care systems. Infertility remains a deeply private issue [that is] often shrouded in cultural myths and stigma, which [have] limited open discussions and access to fact-based information. Educating the public and patients with accurate, unbiased information can challenge outdated beliefs and promote gender equity in reproductive health.

When individuals gain factual knowledge, they are more likely to discuss these topics openly, advocate for reproductive rights, and support policy changes. This growing awareness shifts societal expectations, encouraging health care systems, insurers, and employers to recognize the importance of providing accessible fertility services. Ultimately, as awareness increases, it drives systemic changes including greater support from government and private insurers and improved employer-sponsored benefits, helping to ensure that all individuals have the right and opportunity to build a family if they choose.

AJMC: How are clinics and providers being impacted by the increase in employer-sponsored fertility benefits? What operational or patient-care adjustments do clinics have to make?

ADAMSON: The rise in employer-sponsored fertility benefits is driving significant demand at fertility clinics, creating operational and patient-care challenges. Clinics are facing a workforce shortage [that is] exacerbated by the growing number of patients accessing fertility services. This shortage spans all levels from reproductive endocrinologists and embryologists to nurses and support staff. For example, embryologists require extensive training including years of education and [laboratory] work, and [they] work under intense schedules, making it challenging to meet the increased patient volume.

This demand surge has pressured clinics to adjust their workflows and manage expectations for timely, personalized care. Although recent private equity investments have standardized processes within many clinics, they have also introduced financial pressures, which can affect the quality of care and increase patient wait times.

To address these challenges, the fertility sector is working to increase the pipeline of trained professionals, improve diversity, and explore digital solutions like AI [artificial intelligence] to boost operational efficiency. However, the adoption of digital tools in health care, such as electronic medical records, has often fallen short in improving provider quality of life and patient care. Concerns exist that AI’s primary focus might remain on profitability rather than enhancing patient care or provider support. Therefore, careful integration of technology is essential to retain the high-touch, empathetic care that patients facing sensitive reproductive issues require.

Finally, advancements in genetics, biomics, robotics, and other technologies could further improve efficiencies in the [laboratory], reducing manual work for embryologists. However, implementing these complex technologies in fertility care will require continued research and cautious application. The fertility field stands to benefit from both operational adjustments and careful technology integration to meet rising patient needs and improve overall care quality.

AJMC: What strategies can currently address the personnel shortage at fertility clinics?

ADAMSON: To address the personnel shortage at fertility clinics, several strategies can be implemented in the short term. First, increasing awareness and education is key. Patients who are better informed about lifestyle factors that impact fertility—such as avoiding smoking [and] excessive alcohol use and practicing safe sex—are more likely to make healthier decisions that can reduce the need for medical intervention. Preventive measures like these can not only decrease infertility rates but also improve patients’ chances of getting pregnant without requiring extensive medical care.

Second, by providing patients with better education and resources, [we make them] more likely to seek care earlier. Early intervention leads to faster diagnoses and more effective treatment plans, which ultimately reduces inefficiencies and waste in the system. This approach also eases the burden on providers by ensuring that patients receive the appropriate care at the right time, reducing unnecessary tests or treatments that do not contribute to better outcomes.

Technology plays a critical role in this process, particularly in streamlining communication and patient education. However, technology must be designed around the patient’s needs [and] not just cost-saving goals. Integrating tools like digital apps, AI, and virtual support into fertility care can improve the patient experience, but human interaction remains essential for emotional support and personalized care. An effective care navigator— supported by technology—can guide patients through their fertility journey, helping them make informed decisions and connecting them with the right providers sooner.

Fertility clinics should also optimize their use of ancillary providers such as nurse practitioners, medical assistants, and IVF coordinators. This can improve clinic efficiency by delegating tasks appropriately and creating a more integrated care system.

Ultimately, by focusing on efficiency, reducing waste, and enhancing patient and provider support, fertility clinics can better manage their workforce shortages and improve patient outcomes. Creating a more sustainable and rewarding work environment for providers with adequate compensation and reduced burnout will also help attract more professionals [to] the field. This comprehensive approach will benefit both the workforce and the patients [served].

AJMC: What new payer requirements or step therapy protocols have you encountered from employer-sponsored fertility benefits? How do these requirements impact your clinical decision-making and patient care strategies?

ADAMSON: The landscape of employer-sponsored fertility benefits has evolved significantly over the past few decades. Historically, most employers did not offer any fertility coverage and even basic diagnostic tests—like semen analysis for men—were often excluded. Early fertility benefits were limited to diagnostic tests and basic treatments like ovarian stimulation [clomiphene citrate] and intrauterine insemination [IUI], with IVF coverage rare and often minimal.

Around 10 years ago, IVF coverage began to expand, although it was still limited. Employers also started covering treatments for male infertility, which had been largely overlooked. In recent years, gender equity and [SDOH] have prompted employers to broaden coverage to include a wider range of fertility services. For example, egg freezing for women—whether for personal or medical reasons—became more commonly covered, and more employers also began offering coverage for sperm freezing.

The inclusion of the LGBTQ+ community in fertility benefit offerings has gained traction, reflecting a broader recognition of reproductive rights across all genders. Coverage caps today typically range from $20,000 to $25,000, [although] some employers now offer up to $100,000, while others remain limited to $1000 or $2000.

Over the last few years, employer-sponsored fertility benefits have become more comprehensive, expanding beyond traditional fertility treatments to include preconception genetic testing, pregnancy support, and postbirth services like lactation [consultation] and early childcare resources. Additionally, there has been growing recognition of the need for support throughout the reproductive life cycle including menopause care for women and andropause care for men. These trends reflect a broader shift toward inclusive, holistic health care benefits that [address not only] fertility but also reproductive health at all stages of life. For clinicians, these evolving employer requirements necessitate adjustments in clinical decision-making and patient care strategies. With increased coverage and more inclusive benefits, clinicians can better support diverse patient needs and navigate a broader range of fertility and reproductive health issues while ensuring [that] care aligns with the expanding scope of benefits offered by employers. These changes also provide an opportunity to enhance patient outcomes by reducing barriers to necessary treatments and offering a more personalized, patient-centered approach to fertility and reproductive care.

AJMC: How do step-therapy protocols in employer-sponsored fertility benefits impact patient care, and what strategies can clinicians use to address these challenges?

ADAMSON: Step-therapy protocols in infertility care present significant challenges for both clinicians and patients. These protocols, which have been in place for decades, often require patients to undergo a series of ineffective treatments—such as multiple cycles of ovarian stimulation and [IUI]—before progressing to more advanced options like [IVF]. Typically, patients may be required to complete as many as 3 to 6 cycles of IUI before moving on to other treatments, even when such treatments may not be appropriate for their specific needs.

This approach wastes valuable time, money, and emotional energy. Delaying access to the most effective treatments reduces the chances of a successful pregnancy, especially as time progresses. Additionally, patients are often required to stay with a generalist rather than seeing a fertility specialist, which can lead to misdiagnosis and unnecessary delays in treatment. The result is a cycle of ineffective care, prolonged emotional distress, and wasted financial resources—both for the patient and the health care system.

For patients, the financial burden is compounded by the out-of-pocket costs of treatments that are unlikely to succeed. With deductibles and co-pays attached to each cycle, patients may spend significant amounts on ineffective treatments, leaving them with less financial flexibility when more effective options like IVF become necessary. This financial strain combined with the emotional toll of failed treatments adds stress and further jeopardizes the patient’s chances of success.

From a clinical perspective, step-therapy protocols fail to align with evidence-based practices that prioritize individualized care. [Results of] research consistently [show] that early referral to a fertility specialist, with an accurate diagnosis and tailored treatment plan, is the most cost-effective way to achieve successful outcomes. Protocols that apply a one-size-fits-all approach ignore the reality that infertility is a complex, individualized condition. The best outcomes are achieved when treatment is personalized based on the unique needs of the patient.

To address these challenges, the key is to adopt a more flexible, patient-centered approach. Clinicians should have the freedom to make decisions based on individual patient needs rather than being constrained by rigid step-therapy protocols. Early access to specialists, accurate diagnosis, and personalized treatment plans should be prioritized to minimize delays, reduce unnecessary treatments, and improve both outcomes and patient satisfaction. This approach not only enhances care quality but also leads to better cost management, as it avoids the waste associated with prolonged, ineffective treatments.

Ultimately, while managed care protocols are intended to control costs, they should not come at the expense of patient outcomes. Evidence-based, individualized care offers the best solution for achieving both cost-effectiveness and high-quality fertility treatment.

AJMC: What does the typical patient journey look like for patients with infertility looking to get IVF? How has this journey evolved in terms of accessing treatments and services, particularly regarding the use of medical versus pharmacy benefits?

ADAMSON: The typical patient journey for those seeking IVF varies widely depending on individual circumstances, but [it] generally follows a predictable pattern. For many couples, conception is straightforward, with pregnancy occurring within the first 6 months of trying. However, about 1 in 5 couples faces infertility, and their journey is often marked by delays and emotional strain. Typically, couples will try to conceive for several months before seeking help, with most waiting around a year before seeking medical advice. However, it often takes 2 to [2.5] years before they consult a specialist.

Initially, many patients will see a generalist, who may recommend basic treatments such as ovulation induction with clomiphene IUI. These treatments are often trialed for 3 to 6 months, [although] 3 months is usually sufficient to determine if they will be effective. If [this is] unsuccessful, some patients may give up on treatment due to emotional stress, lack of insurance coverage, or financial barriers, while others may turn to adoption. Unfortunately, the emotional and financial toll often results in a significant number of patients discontinuing care before reaching more advanced options like IVF.

For those who persist, the journey becomes more specialized. Once referred to a fertility specialist, patients will receive a thorough evaluation, which could involve diagnostic testing and treatments such as reproductive surgery for conditions like endometriosis or fibroids. Many patients who eventually need IVF may not require the procedure immediately, as there are often other solutions such as treating male infertility or hormonal imbalances. However, in some cases, IVF is necessary, and, for certain patients, additional interventions like donor eggs, sperm, or embryos or even gestational carriers may be required.

The patient journey is further complicated by the evolving landscape of insurance and benefits. Historically, many patients faced challenges in accessing IVF and other fertility treatments due to limited insurance coverage. Today, the inclusion of fertility benefits including coverage for pharmaceuticals, diagnostics, and IVF is improving, [although] significant gaps remain especially regarding medication costs and coverage for procedures like egg retrieval. Many patients still face high out-of-pocket expenses especially for fertility medications, which can significantly impact their ability to continue treatment. In this context, the use of medical versus pharmacy benefits has also evolved. Increasingly, fertility medications are covered under pharmacy benefits, but many of these treatments are prohibitively expensive without insurance coverage. This can create a barrier for patients trying to access the medications needed to proceed with IVF or other assisted reproductive technologies. Navigating these benefits and understanding the insurance landscape is an important part of the patient journey, and having professional support—both medical and financial—is crucial.

In summary, the IVF journey is complex, emotionally taxing, and often delayed. Early consultation with a fertility specialist can lead to better outcomes, but patients face challenges related to insurance coverage, out-of-pocket expenses, and emotional stress. As fertility treatments become more accessible and comprehensive, personalized support from health care providers is essential to guide patients through the process, ensure [that] they receive appropriate care, and help them [to] navigate the financial aspects of treatment.

AJMC: In your experience, what does a good fertility protocol look like under the expanded benefits coverage?

ADAMSON: A good benefits package for infertility and reproductive benefits has several features. The first one is that it should be inclusive—every individual has the right to found a family. Regardless of whether they’re a heterosexual couple [or] single, LGBTQ+, or other gender, everyone should have access. There should be a special attention to those in marginalized communities who may have other barriers (eg, geographic, cultural)—a robust awareness and education program is needed. This will be digital these days with apps and web site information, but fact-based, patient-facing information is the first attribute of a really strong benefit, and it should be inclusive for everyone.

The second aspect is strong navigation and support. The health care system is complicated, especially when [there are] at least 2 patients—[such as] a woman and a man, 2 women or 2 men, a third party, a sperm or egg donor, embryo donation, [or] a surrogate. It’s a complex journey, and you need to have navigation from people who understand this. You need to have a program that also creates financial solutions, because affordability is such a huge issue. This often means a combined program where there’s some family-forming benefit from the employer but also an option to get additional funds (eg, direct-to-consumer lending with unsecured lending), because many employers want to make these benefits available but can’t afford $100,000 or $200,000 for gestational or surrogate [assistance] or $50,000 for egg donor’s cycles. They want to do something, but they can’t do everything that some patients might need. Many patients need far less, a couple [of] thousand dollars, but some might need a lot. Having the flexibility of an integrable financial solution, which involves unsecured lending for patients, can help address the affordability issues around access to care.

Finally, emotional support throughout is important. [Additionally,] for a good program, the employers want to look at the comprehensive reproductive health journey. This includes women’s, but also men’s, services around preconception for [genetic] testing, [home tests for women and men], and healthy lifestyle to prevent disease. There should be pregnancy support for leave benefits and referrals to doulas and postpregnancy/postpartum support with lactation, early childcare resources, and return to work. There should also be later-life support for the reproductive journey with menopause support, andropause support, and sexual health [information]. These are the attributes of a program that an employer will want to incorporate.

What’s important to point out is that employers who [initiate] these programs find out [that] there’s a high return on investment. The cost is not nearly as much as employers think it’s going to be, and, with the improved engagement and productivity of employees who are helped by this, there’s a net profitability for the company.

A good fertility protocol is also one that minimizes waste in the health care system by focusing on evidence-based treatments that avoid unnecessary interventions. This approach reduces the costs associated with ineffective reproductive care within the general medical plan, ultimately leading to better clinical outcomes, fewer multiple births, and less miscoding.

From a financial perspective, a well-designed fertility benefit offers a strong return on investment (ROI). Employers who provide comprehensive family-forming benefits see significant savings through reduced health care costs, improved employee productivity, and higher engagement. Moreover, offering these benefits enhances employee loyalty and satisfaction, making the company a more attractive place to work. It also demonstrates the company’s commitment to diversity, equity, and inclusion (DEI) by supporting reproductive rights alongside other essential health care services.

Employers who adopt family-forming benefits often find that the costs are minimal, with 97% reporting satisfaction with the financial and cultural returns. By offering comprehensive fertility benefits, companies not only meet profitability and DEI goals but also address critical [SDOH], ensuring [that] marginalized populations have access to high-quality care. This type of benefit is a win-win for both employees and employers, driving both individual and organizational success.

In summary, an effective fertility benefit protocol not only supports employees’ reproductive health needs but also contributes to a positive workplace culture, better employee retention, and improved business performance. With growing awareness and the availability of these programs, employers are increasingly recognizing their value.

AJMC: Have you noticed any gaps in patient or provider awareness of available pharmacy benefits or fertility treatments?

ADAMSON: The US pharmacy benefits landscape, particularly for fertility treatments, is incredibly complex, contributing to significant gaps in both patient and provider awareness of available options. The high cost of medications is one of the primary barriers, with the US consistently having the most expensive drugs globally. This is due to a combination of factors including the lack of government-negotiated drug pricing, extensive marketing costs, and the significant investments pharmaceutical companies make in research and development. Although the US leads in drug innovation, the financial burden of these developments is largely shouldered by American consumers and employers, further complicating access to care.

These complexities create substantial challenges for both patients and providers in understanding and accessing the most cost-effective treatment options, particularly in fertility care. Many patients may not fully understand the availability of pharmacy benefits for fertility medications, and providers may not always be equipped with up-to-date information on how to guide patients through these options.

To address these gaps, it’s crucial to improve both patient and provider education on pharmacy benefits and fertility treatment options. As part of this, I emphasize the importance of educating patients about available resources to lower the cost of medications; [these include] discount programs or pharmacy assistance programs. Providers also need to be equipped with clear, accessible information on how to navigate these benefits and help patients understand their options, especially when it comes to costly fertility medications like injectable hormones used in IVF.

From a provider standpoint, we are implementing initiatives to improve awareness of these pharmacy benefits. This includes collaborating with pharmacy benefits managers and insurance companies to ensure that clinicians are aware of the most current benefit structures and cost-saving programs available for fertility medications. Additionally, some programs focus on offering more transparency about the actual cost of treatments and medications, helping both patients and providers make more informed decisions.

Overall, improving awareness and education about pharmacy benefits is a shared responsibility among providers, insurers, and pharmaceutical companies. By providing better information and access to resources, we can help patients increase the affordability of fertility treatments, improve care delivery, and ultimately make fertility treatments more accessible for those in need.