Op-Med is a collection of original articles contributed by Doximity members.
The 2020 American Society for Reproductive Medicine (ASRM) annual conference was innovative, virtual, and educational. While we did not get to enjoy the Pacific Northwest in Portland and physically see our colleagues, the scientific quality remained rigorous. ASRM pivoted with the times and held a virtual conference attended globally by thousands of scientists, embryologists, and clinicians. This year’s conference delved into topics ranging from social issues, including access to care for diverse and underserved populations, to cellular and molecular issues, involving the implantation potential of embryos identified on the next generation to be mosaic. It delved into the use of microfluidics, deep learning algorithms, and artificial intelligence to increase efficiency in the laboratory and regenerative and restorative biology.
However, beyond these impressive scientific studies, one topic that inspired many projects and highlighted throughout the conference was identifying issues and possible solutions related to access to care and addressing the disparities that exist amongst our patients. In fact, ASRM’s Access to Care movement has been a critical call to action leaders in our field to collaborate on innovative ways to overcome this important issue. This is even more relevant in today’s climate. While we have seen advances in programs such as cost assistance for fertility preservation, diversity and inclusion, and LGBTQ care, many gaps in care persist.
We know that infertility affects 15% of couples in the United States, and an estimated quarter of these infertile couples have sufficient access to infertility care. This is not a problem solely in the United States and is even more profound globally. Without even considering the financial implications of fertility treatments, many patients around the world do not have physical access to an IVF center with a functioning embryology lab. This global challenge was highlighted by Dr. Angelique Rwiyereka, the director of the Rwanda Infertility Initiative, which exemplified in her plenary lecture the determination and commitment needed to establish a reliable and self-sustaining IVF center in resource-limited settings such as Rwanda.
Many factors are tied to disparities and access to reproductive healthcare, including but not limited to: socioeconomic status, geography, race, ethnicity, sexual orientation, and gender identity. Unsurprisingly, financial factors are the major contributor to the lack of access to fertility care. At this year’s conference, an interactive session was held to educate participants about three models that have been established to try to bridge the financial gaps that exist today. In the United States, ASRM estimates that a single cycle of IVF costs around $12,400, which is cost-prohibitive for many patients. Experts including Dr. Paula Amato and Dr. Jennifer Hirshfeld-Cytron discussed the importance of advocacy in the passage of legislation for increased insurance coverage, the development of non-profit foundations to allow grant applications for individual patients and implementation of affordable fertility care programs for employees.
An oral presentation by Dr. Benjamin Peipert and his colleagues at Duke focused on characterizing the landscape of state-mandated insurance coverage for infertility treatment and fertility preservation in the United States. Unfortunately, significant heterogeneity was found among the states with fertility mandates. There are currently only 19 states (or 38%) that have passed legislation mandating insurers to cover or offer coverage for the diagnosis and treatment of infertility or conditions resulting in infertility. Of these, only 12 states (or 63%) mandate IVF coverage. The eligibility for infertility coverage varies significantly, and patients are often met with lifetime limits or exemptions for various reasons. Their study highlights the need for future fertility legislation while also investigating new and innovative solutions to the problem.
While there has been progress in some states on fertility coverage, there is room for improvement in the inclusivity of these mandates across the country. For example, we were reminded at the conference of the disparities that exist in infertility care by race, sexual orientation, and gender identity. Not only is there a disparity in the access to care amongst minorities, but there is also a disparity in the efficacy of our fertility treatments. One study showed that Black women wait for longer periods of time and are thus older at the time of treatment, likely due to lack of knowledge regarding infertility and treatment options. Further, Dr. Makhijani and colleagues from the University of Connecticut presented a retrospective study investigating whether racial disparities in IVF pregnancy outcomes persist in frozen embryo transfer (FET) cycles on a national level. Their research found that Black patients remain an independent predictor of reduced live-birth rates in frozen embryo transfer cycles, likely due to higher clinical loss rates and lower implantation rates. Dr. Quinton Katler and his colleagues from Emory looked at the SART database to investigate whether ethnicity impacted oocyte cryopreservation outcomes. In this time period, oocyte cryopreservation was predominantly utilized by non-Hispanic white women, and the data showed that trends in cancellation and increased gonadotropin dosing are disproportionately seen for minority ethnic groups.
Beyond race, the health disparities in access to care are also evident in the LGBTQ community. Not only are these patients excluded from many insurance mandates, but there are many psychosocial aspects of family building in these increasingly diverse families that must be addressed. Dr. Pearson and her colleagues at Northwell investigated how the quality of life impacted transgender patients who desired to pursue fertility counseling and preservation. Even with improved access to care, they found that a majority of transgender patients were not offered adequate fertility counseling. Careful attention must be given to the principle of social justice that includes access to fertility services for each and every individual.
This year’s conference made it clear that, as a medical society, ASRM maintains a strong commitment towards furthering access to care. The few studies mentioned here highlight the many unique factors that are a part of this issue but leave a lot of opportunity for further investigation. As a community of dedicated clinicians and scientists, we must continue to collaborate and find innovative solutions to providing equitable access to fertility care.