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1 Student name Center: USxxx school name goes here! Candidate Number xxxx June 2023 Exam Series 9239 Component 2 Essay Word Count: 1987 Should infertility treatment coverage by health insurance plans be expanded? Infertility is a disease of the reproductive systems in which conception isn’t achieved after a year. About 48 million couples worldwide suffer from infertility (World Health Organization, 2020). Various hormonal, metabolic, and physical disorders can cause female and male factor infertility, for instance endometriosis and low sperm count (Flyckt, R., & Falcone Cleveland Clinic, 2019). However, increased developments in medicine and biotechnology, have caused the development of infertility treatments. Infertility treatments involve any hormonal therapies, assistive reproductive technologies (ART), or medical procedures used to conceive (World Health Organization, 2020). In vitro fertilization (IVF) and intrauterine insemination (IUI) are examples. Although available, treatments are expensive and not fully covered by insurance plans around the world, including private models seen in the United States and universalized models seen in Switzerland (Giezendanner, S. et al., 2020). The expense of such treatments limits access for couples in need. It is suggested that insurance coverage of infertility should expand to make treatments more affordable. But with other options, like

2 adoption, and laws put in place for insurance coverage in this sector, it can be argued whether infertility treatments require more healthcare coverage at all. The problem is that infertility treatments are expensive making them unaffordable for many of those that seek it. This occurs because treatments can cost upwards of $20,000 USD, making it difficult to pay out-of-pocket without acquiring excessive debt (Ethics Committee of the American Society for Reproductive Medicine, 2021). The uninsured and even those enjoying comfortable insurance coverage can struggle with finances. Every day, couples around the world plan to start a family only to find themselves unable to conceive without medical intervention and unfortunately not all can afford to treat their infertility. Long-term effects of this problem can be felt by many families as they are unable to conceive their own biological children due to the expense of treatment, which can cripple them economically. It is important that this problem is resolved because having children is a human right to be enjoyed by everyone despite any health problems they face. Infertility has long been an issue but not until recently were doctors able to develop advanced infertility treatments. Great success did not occur until the 1900’s with In Vitro Fertilization, defined by a cycle of hormonal shots, egg retrieval, and embryo transfer. The first IVF live birth, Louise Brown, born in 1978, signaled success (Cambridge University Press, 2018). However, with success came expenses, since the first treatment rounds in the 90’s the average cost has been $6,000 per cycle. So, many families were not able to afford treatment (National Library of Medicine, 2018). Affordability of infertility treatments has always been a struggle for couples since the possibility of treatment began but is it justifiable to invest more into the healthcare system for a disease can be seen as less imperative, should there be expanded healthcare coverage for infertility?

3 For such reasons, there has been great debate on whether infertility treatments should receive more or if any financial assistance from insurance, encompassing all models. Some believe there should be no modifications to the existing coverage as even legislative measures have been made, and instead money should be put in other areas in medicine and family planning. Others might instead believe that the financial aid in place is not enough. During the course this research paper, I will be discussing and analyzing these two opposing perspectives to conclude whether infertility treatment coverage should be expanded by health insurance plans. To begin, the first perspective being considered is that fertility treatment should be covered by health insurance and coverage should expand. Infertility treatments are expensive, even for those receiving insurance coverage. As seen in the US, most insurance companies require out of pocket payment. United Healthcare, one of the top-rated plans, has an out-of- pocket payment of $10,000 USD and doesn’t cover IVF, which is the most successful of all treatments (Very Well Family, 2022). But the expenses really become a burden for those that do not have coverage. In Ireland, for example, it was written by local journalist Enright, governmental policies opted for no state funded ART coverage, leaving those who suffer from the disease to pay with their own income (The Ireland Times, 2021). As a result, people have to choose between an ethical dilemma, saving money or having their children.. A source that explores the problem economically is a peer reviewed journal with a study conducted in Kuwait titled “ Cost burden of male infertility investigations and treatments ” by Ahmed Al-Kandari and Ahmad Alenezi (2020). This source is highly credible as it is a peer reviewed journal verified by experts in the field of infertility as well as economics. In addition, it is authored by two Doctors of Medicine, Al-Kandari a consultant urologist and professor in Kuwait University, and Alenezi a urologist at Mubark Hospital in Kuwait, both professionals in

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4 the field of male infertility as urologists are the doctors treating the urinary system and male fertility. The study examined 154 infertile males, a large sample size showing a balanced and representative study, and the costs of their infertility treatments collecting data from those using governmental insurance or private insurance in the process of treating their infertility (Al- Kandari, A. M., & Alenezi, A., 2020). It should be noted that the study only examines male factor fertility, which is often socially overlooked due to the common place of blame on the woman. Still, as it is not representative of the other 50% of people that suffer from infertility, women, and can be seen as a weakness of the study. It was seen that out of the total, 96.3% of patients did not have health insurance coverage on fertility and leading them to spend 18% of their annual income on treatments (Al-Kandari, A. M., & Alenezi, A., 2020). This amount only included the outpatient visits, hormonal tests, and specific procedures. Without including the cost of surgeries, it amounts to 7,000 – 14,000 USD per patient per cycle. Even if you are insured it doesn’t mean that infertility treatments are adequately covered. Thus, the statistics and numerical estimates, in addition to being a strength to the journal, show concrete evidence that an expansion of coverage would be beneficial. It is important to note that Kuwait is a developing country so citizens may not have the economic capabilities warranted to pay for these expensive treatments, putting those less economically fortunate at a disadvantage. But this dilemma is also seen in developed countries. In France, a country with a Statutory Health Care Insurance providing universal healthcare, women suffering from infertility spend on average €70,000 before a successful pregnancy, an amount unattainable for many (Bourrion et. al., 2022). But not only does not having access to treatment hurt their finances it can also hurt their mental health. According to WHO, a reliable global organization of experts in health, women suffering from infertility are more likely to

5 become depressed, anxious, and victims of violence (2021). Such a negative effect can be brought about culturally as majority of times women are blamed for not being able to fall pregnant (2021). With such effects, it can be reasoned as to why people want insurance coverage for infertility treatments and its expansion. On the other hand, the second perspective on this debate is that insurance coverage for fertility treatments should not be expanded. It is argued because of other options like adoption, that there shouldn’t be more expansion as adopting also provides a child. Adoption is the social and legal process by which children become members of a new family (Child Welfare, n.d.). Although adoption is expensive, for example, in China it may cost up to $30,000 USD, the cost is seen more justifiable because it seems a more ethical option to expanding a family as it aids the orphans (Considering Adoption, 2021). According to Wagstaff and Therivel (2017), using well-founded UNICEF statistics, around 13 million children worldwide are waiting for adoption. Thus, spending large sums of money on multiple rounds of treatment when there are orphans waiting for families. This is further studied in a peer reviewed journal from India called “ A Phenomenological Approach to Understand the Concept of Child Adoption with Adoptive and Non-Adoptive Couples” written by Gayathri Nagarajan and K.P. Naachimuthu certified psychologists, which examined the effects of adoptions on children and parents. To strengthen its claim and validity, in addition to being approved by other experts, it included a well-planned out descriptive study with a good sample size, providing for firsthand accounts from participants. However, the study only takes place in India, a valuable global context, but does not take account other countries, and thus is a weakness. The study found that adoption was a great for women that still didn’t bear children with ART or IVF. A case of an adoptive mother was seen in which she had 6

6 miscarriages using infertility treatments and only through adoption was she able to have her child (Nagarajan, G., & Naachimuthu, K. P., 2017). Despite having many rounds of infertility treatments, amounting to $30,000-$40,000, a child may not be conceived and as a result it is believed that expansion in healthcare coverage for infertility should be limited because of options like adoption. Furthermore, countries already have legal and political initiatives in place to help infertile couples. Canada for example has one round of IVF covered (Olympia Benefits Inc, n.d.). In a peer reviewed article, “ Survey on ART and IUI: legislation, regulation, funding and registries in European countries ” written by the European Society of Human Reproduction and Embryology, a renowned organization, countries have even introduced tax deductions for those that have received ART, including countries like Germany and Italy (Calhaz-Jorge, et. al., 2020). In another peer-reviewed journal, “ A collaborative approach to adopting/adapting guidelines” Australia is seen to be using its finances to help the adoption process to aid those suffering from infertility. This is something that is impactful to the lives of the parents and orphans in the systems and shows a way that the money that could be invested into the healthcare system to expand infertility coverage could be reallocated. In addition, counties like the United States have passed legislation to deal with this problem. Congress’s official website posted about the Access to Infertility Treatment and Care Act, which allows for coverage of one treatment (U.S. Congress, 2020). This should be enough for parents to realize that there are other options to growing a family, like adoption and some government already have laws in place that could make the monetary expansion of healthcare for infertility unnecessary. After evaluating the sources and arguments on each side of the problem of whether infertility treatment should receive more health care coverage, I concluded that infertility

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7 treatment coverage should be expanded. Before beginning my research, I knew that infertility treatments were expensive and that patients should receive more coverage. Although I still concur with this side of the debate, I have become more empathetic to the countering side and recognize that there are valid points. It is evident that ART and infertility treatments are expensive, and millions suffer from infertility but, it should be noted that there are other options which could be of greater benefit, such as adoption. In addition, several countries have already put certain laws into place to help these families and thus there is some mobilization to battle infertility coverage. One view suggests that capital and the economy of parents to be is to be an important factor when considering the expansion of the coverage of treatments and could certainly make for greater accessibility. The other brings up just as valuable points that ethically there should be more incentives to the option of adoption and politically there have been actions to aid these groups suffering from infertility. Yet, there would need to be more research on my part to strengthen my stance and credit my position on this argument. It would be beneficial to see more research done on the budgeting and economics of health insurance plans if more ART were to be financed into already existing healthcare systems to better gage the results of the expansion of coverage. But knowing how important it is to be able to have children in our society, I find it difficult to deny people from coverage that can allow them to expand their families. Even those less economically fortunate and lacking proper health care coverage should have the same access to conceiving their children. (Word Count: 1987)

8 References Al-Kandari, A. M., & Alenezi, A. (2020). Cost burden of male infertility investigations and treatments: A survey study. Urology annals , 12 (4), 314–318. https://doi.org/10.4103/UA.UA_48_20 . Accessed on January 3, 2023. Best Fertility Insurance Companies . (2022, June 9). Verywell Family. https://www.verywellfamily.com/best-fertility-insurance-5113266 . Accessed on January 3, 2023. Biggers, J. D., & Racowsky, C. (2018). A brief outline of the history of human in-vitro fertilization. In-Vitro Fertilization: The Pioneers History, Cambridge University Press, Cambridge UK . Accessed on January 3, 2023. Bourrion, B., Panjo, H., Bithorel, P. L., de La Rochebrochard, E., François, M., & Pelletier- Fleury, N. (2022). The economic burden of infertility treatment and distribution of expenditures overtime in France: a self-controlled pre-post study. BMC Health Services Research , 22 (1), NA. Accessed on January 3, 2023. B, O., & Benefits, O. (n.d.). 5 Things You Need to Know About IVF Cost in Canada . https://www.olympiabenefits.com/blog/5-things-you-need-to-know-about-ivf- costs-in-canada. Accessed on January 3, 2023. Calhaz-Jorge, C., de Geyter, C., Kupka, M. S., Wyns, C., Mocanu, E., Motrenko, T., Scaravelli, G., Smeenk, J., Vidakovic, S., & Goossens, V. (2020). Survey on ART and IUI: legislation, regulation, funding and registries in European countries: The European IVF-

9 monitoring Consortium (EIM)forthe European Society of Human Reproduction and Embryology (ESHRE). Human Reproduction Open , 2020 (1) Accessed on January 3, 2023. Considering Adoption. (2022, December 19). How Much Does International Adoption Cost? | Considering Adoption . Considering Adoption |. https://consideringadoption.com/adopting/adoption- costs/international-adoption-costs/ Accessed on January 3, 2023. Enright, L. (2021, January 16). Infertility treatment: When will free IVF be introduced in Ireland? The Irish Times. https://www.irishtimes.com/life-and-style/health-family/infertility-treatment- when-will-free-ivf-be-introduced-in-ireland-1.4451397 Accessed on January 3, 2023. Flyckt, R., & Falcone, T. (2019). Infertility: A practical framework. Cleve Clin J Med , 86 (7), 473-482. Accessed on January 3, 2023. John Hunter (1728–1793) | The Embryo Project Encyclopedia . (n.d.b). https://embryo.asu.edu/pages/john-hunter-1728-1793 Accessed on January 3, 2023. Nagarajan, G., & Naachimuthu, K. P. (2017). A Phenomenological Approach to Understand the Concept of Child Adoption with Adoptive and Non-Adoptive Couples. Indian Journal of Community Psychology , 13 (2), 229+ Accessed on January 3, 2023. Okely, A. D., Ghersi, D., Hesketh, K. D., Santos, R., Loughran, S. P., Cliff, D. P., Shilton, T.,

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10 Grant, D., Jones, R. A., Stanley, R. M., Sherring, J., Hinkley, T., Trost, S. G., McHugh, C., Eckermann, S., Thorpe, K., Waters, K., Olds, T. S., Mackey, T., . . . Tremblay, M. S. (2017). A collaborative approach to adopting/adapting guidelines - The Australian 24- Hour Movement Guidelines for the early years (Birth to 5 years): an integration of physical activity, sedentary behavior, and sleep. BMC Public Health , 17 (S5). https://doi.org/10.1186/s12889-017-4867-6 Accessed on January 3, 2023. U.S.Congress. (2021). Access to Infertility Treatment and Care Act. https://www.congress.gov/bill/117th-congress/house-bill/4450 Accessed in January 3 , 2023. Wagstaff, J., & Therivel, J. (2017). Orphans: Foster care and adoption; Global Perspective. Cinahl in Accessed on January 3, 2023. World Health Organization. (2019, December 10). Infertility . https://www.who.int/health-topics/infertility Accessed on January 3, 2023.

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