The Evolving US Fertility Care Landscape: Strategies for Addressing Increasing Demand

INFERTILITY IS A COMMON CONDITION that affects millions of individuals in the US. According to data from the National Survey of Family Growth, between 2015 and 2019, infertility, in some form, affected approximately 7.8% of married or cohabitating women (aged 15-49 years), whereas approximately 11.4% of men (aged 15-49 years) had some form of infertility, defined as sterility or subfertility, during the same time period.¹ One in 8 women (aged 15-49 years) will seek infertility services during her lifetime.² Same-sex couples and those who are single and desire to have a child also may require fertility assistance.

Key Trends in ART Use and Birth Rates

Assisted reproductive technology (ART) is one of several potential management strategies in infertility treatment. It includes fertility treatments during which eggs or embryos are handled ex vivo (outside the body).³ The most common form of ART is vitro fertilization (IVF), which accounts for more than 99% of ART procedures in the US.² Eggs are aspirated from the ovaries and combined with sperm to form embryos. These embryos may then be placed in a woman’s uterus, frozen for future use, or donated to others.³

In the US, the use of ART more than doubled between 2012 and 2021, and the number of infants born who were conceived through ART increased by 50%. Approximately 86,146 infant births (an estimated 2.3% of all infant births in the US) resulted through the use of ART in 2021. For women aged 40 to 45 years, 9% of live births were conceived through ART, and for women older than 45 years, nearly one-third of live births were conceived through ART.²

Mandated Coverage of Infertility Treatment

Many US states mandate coverage of at least some kind of infertility treatment (Figure 1)^4,5; however, individuals who subscribe to self-insured, employer-sponsored health insurance coverage are exempt from state mandates.^6-8 Furthermore, state Medicaid coverage of fertility services is often incomplete; some states may cover basic diagnostic services, but many do not provide treatment coverage.⁴ Some state mandates apply only to certain kinds of health insurance policies, for example, health maintenance organizations (HMOs), whereas others specify certain types of infertility treatment covered under the mandate.

Employer Considerations

The number of employees that a company has also may impact infertility coverage. In some states, an organization must have a set number of employees for that company to be mandated to provide infertility coverage. If an employer has fewer than that number, they may not offer coverage.⁵ The majority of employers offer infertility coverage that includes some type of treatment limit. The results of a national survey of small and large employers conducted by Mercer and RESOLVE: The National Infertility Association found that 88% of survey respondents placed limits on infertility coverage.⁹ The most common limit on infertility coverage (included by 60% of employer respondents) was stipulating a lifetime maximum benefit. As the Affordable Care Act (ACA) bans dollar caps on coverage, infertility coverage laws that have been passed since the ACA do not include dollar maximums. Instead, limits on employees’ infertility coverage include limiting the number of IVF cycles covered and a separate maximum number of drug therapies and limitations on egg preservation and storage.⁹

Definitions of infertility also can influence treatment coverage. Historically, infertility was defined as a lack of pregnancy despite 12 months of contraceptive-free intercourse with the same partner during each of those months.¹ In 2023, the American Society for Reproductive Medicine (ASRM) broadened the accepted definition of infertility to incorporate would-be parents beyond heterosexual couples, including those who cannot become pregnant for medical, sexual, or other reasons, as well as those who need medical interventions such as donor eggs or sperm to become pregnant.¹⁰ For example, in Delaware, intrauterine insemination (IUI) is required prior to receiving coverage for IVF, regardless of the appropriateness of this procedure for the given condition that led to infertility or the circumstance that led an employee to seek family expansion.¹¹

Considerations for LGBTQ+ Individuals

LGBTQ+ individuals may experience barriers and discrimination related to family planning and fertility care.¹² In some states, fertility coverage may require a diagnosis of infertility that is defined by a year of heterosexual intercourse before fertility benefits can even be triggered, or plans may limit coverage to iatrogenic infertility. Some states have additional stipulations stating that IVF services must use the couple’s own eggs and sperm, not gametes from a donor, which would only be possible for heterosexual couples with egg and sperm available for embryo formation.¹² The results of a recent survey administered by Progyny on the state of LGBTQ+ fertility and family building revealed that 68% of respondents said they could not access fertility care because of heteronormative definitions of infertility or diagnoses of infertility, even when their employer did offer a fertility benefit.¹³ Approximately 51% of respondents indicated that they attempted to expand their families, but that cost was a major barrier and source of worry.

Assessing the Financial Accessibility of Fertility/Infertility Care

Costs for infertility treatment vary widely depending on the required medications and procedures targeting the likely cause. If ART is needed, the cost for a single cycle of IVF is estimated to range between $15,000 to $20,000 and can exceed $30,000. With an average number of 2.5 cycles needed to achieve pregnancy using IVF, treatment costs can exceed $40,000.²

The results of a survey of Northern California fertility clinics found that the average out-of-pocket (OOP) cost per person for fertility care over 18 months was more than $24,000. In cases where fertility medication was the only intervention needed, the average cost for successful pregnancy outcome was about $5894 OOP. Because multiple cycles are often needed, the average OOP costs for IVF that led to a successful pregnancy outcome exceeded $61,000. The most costly OOP intervention was found to be IVF using a donor egg, in which the average OOP cost per person was $38,015 per cycle and $72,642 per successful outcome.¹²

These high costs can mean that, despite government insurance coverage, fertility care is inaccessible for many people in the US, particularly those in lower income brackets.¹² OOP expenses for fertility care vary considerably depending on the patient and their state of residence and insurance coverage. Beyond treatment costs, patients often face additional OOP expenses for office visits, diagnostic and genetic testing, gamete donation, and storage fees. These financial burdens are frequently exacerbated by lost wages due to time off for testing and treatment, with multiple treatment cycles often required to achieve pregnancy. For example, for those with New York Medicaid, the maximum annual income for a 2-person household is approximately $26,000 (US$ 2024). For individuals with very limited insurance coverage, the cost of IVF—averaging $30,000 per cycle and often exceeding $40,000 with multiple rounds— would be insurmountable.¹⁴

A Look to the Future: Why Are More Employers Covering Fertility Services?

Mercer and RESOLVE survey questions also assessed employers’ reasons for providing fertility benefits. The most common reasons cited were to ensure employees have access to quality, cost-effective care and to be able to competitively recruit top talent. Fifty percent of the respondents wanted to be recognized as a family-friendly employer. Additional reasons for providing fertility benefits included supporting equity, diversity, and inclusivity efforts; responding to employee requests; viewing infertility treatment coverage as commensurate with maternity benefits; mitigating the risk of high-risk pregnancies (such as in the case of multiple births); generating positive public relations; and complying with state laws. Of respondents, 47% stated that if they were aware that infertility coverage costs would be offset by cost savings from the elimination of other medical plan costs, they would be more likely to provide infertility coverage.⁹

When asked whether covering infertility benefits resulted in increases in medical plan costs, 97% of employers said that they had not experienced a significant cost increase. This included employers who cover IVF. Many employers stated that they were also interested in expanding to IVF coverage for their employees. Of survey respondents, 18% said it was very likely or somewhat likely that coverage for IVF would be added. In terms of other fertility planning elements, 12% of employers said it was very likely or somewhat likely that they would add egg preservation as a coverage benefit.⁹

In addition, the majority (two-thirds) of organizations stated they do not require a fertility diagnosis to have IVF covered. This means that same-sex couples and single parents have an increased likelihood of receiving coverage for IVF services from their plan. These considerations also extend to other fertility planning services including fertility preservation, which is defined as the process of collecting, freezing, and storing eggs to help people retain their ability to have children in the future.¹⁵

In 2023, $8.9 billion was spent at fertility clinics, and the demand is expected to continue to grow at a compounded annual growth rate of 13.6% until 2028, when projected spending will be $16.8 billion.¹⁶ In addition, recent data from the International Foundation of Employee Benefit Plans Employee Benefits Survey (which includes data from 625 organizations representing nearly 20 industries, ranging in size from fewer than 50 to more than 10,000 employees) show that, in 2024, 32% of organizations surveyed offered IVF coverage to their employees, demonstrating an upward trend from 13% in 2016 and 30% in 2022.¹⁷ When overall fertility benefits were evaluated in 2024, 42% of companies provided fertility coverage, trending upward from 30% in 2020 and 40% in 2022. Future projections suggest that 86% of companies plan to offer family-forming and reproductive support in 2025 (Figure 2).^17-19 A key driver of increased demand for fertility services includes increased awareness of services.

Strategies for Expanding Access to Fertility Services

Strategies for expanding access to fertility services are critical to providing equitable infertility care. Expansion in access to fertility services is also necessary to increase access to genetic carrier screening, IVF for genetic disease prevention, expanding options for the LGBTQ+ community, and offering additional family planning services such as fertility preservation. There is a deficiency of reproductive endocrinology, infertility, and ART services available to meet this demand. One strategy to meet this increasing demand is to recruit and train more reproductive endocrinology and infertility (REI) fellows and to utilize non-REI clinicians (eg, advanced practice providers, nurses, and ultrasonographers), who can perform clinical tasks consistent with their level of training to assist. The ASRM also recommends embracing validated technology (eg, medication management and patient communication applications, patient education and informed consent software, the use of AI to improve ovarian stimulation and embryo selection) to improve outcomes and decrease overall cost of care.²⁰

Another option is the use of specialty vendors to provide or administer fertility services. Specialty vendors focused exclusively on fertility services can offer targeted benefit packages with enhanced member services and are able to adapt quickly to technological advancements.^9,21 As many as 12% of large companies utilize specialty vendors to provide fertility care. Mercer and RESOLVE survey results found that the larger the company, the higher the likelihood of their using specialty vendor services for infertility (21% of survey respondents at companies with greater than 5000 employees used specialty vendors, compared with 14% of survey respondents at companies with 500 or more employees, and only 2% of survey respondents at companies with between 10 and 499 employees).⁹ Examples of specialty vendors include ARC Fertility, Carrot, Kindbody, Progyny, and WINFertility.

Models to Improve Comprehensive Family Planning and Fertility Services

Potential models that could provide more comprehensive and universal family planning coverage include following value-based care plans and the incorporation of specialty vendors.²¹ The strategy of the value-based care model for fertility outcomes, such as time to pregnancy (TTP), ongoing pregnancy rates (OPR), or live birth rates, has not yet been introduced in fertility care.²² By viewing fertility benefits through a value-based lens and the outcome as the rate of pregnancy, the focus can shift to prevention of infertility and interventions to aid in family planning.²¹ Results of a Netherlands-based study evaluating value-based care and the creation of realistic expectations that result in increased patient value show that the TTP and OPR as proxies for the outcome of live birth rate are relevant outcome measures to discuss with infertile couples.²² By developing a digital dashboard and using anonymized patient data to help illustrate to patients the possible outcomes for others who have similar fertility challenges, these individuals and their care providers can use a shared decision-making approach to fertility care; this helps patients have more realistic expectations for the infertility treatment process, likelihood of ongoing pregnancy rate, and the average time it takes to become pregnant. However, the authors noted that the results of this value-based care model need to be validated to provide more actionable results.

Conclusions

Infertility is a prevalent condition affecting diverse populations, necessitating equitable access to comprehensive fertility services. Advances in ART and broader coverage mandates have improved outcomes, but gaps remain, particularly for LGBTQ+ individuals, single parents, and those in lower income brackets. Strategies such as value-based care models, the inclusion of specialty vendors, and innovative technologies offer promising avenues for addressing unmet needs. By prioritizing accessible, cost-effective, and inclusive fertility care, stakeholders can support family-building goals while advancing equity and innovation in reproductive health services.

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