‍In vitro fertilization (IVF) is a type of assisted reproductive technology (ART) where sperm and an egg are fertilized outside the body. In 2021, 2% of all infants born in the United States were conceived using ART. While there areother methods of ART, IVF is by far the most common, representing 99% of ART procedures performed.

Many different people may opt to grow their families via IVF, including those with infertility diagnoses or existing health conditions, LGBTQIA+ couples, those who have previously frozen their eggs and sperm, and single parents.

Including prescriptions, bloodwork, and genetic testing, a single cycle of IVF can cost up to $30,000 without health insurance coverage, and it takes the average person 2.5 cycles to achieve pregnancy. As such, insurance coverage for IVF treatments often determines if people needing fertility treatment are able to afford to grow their families or not.

Since federal law does not require any health plans to cover infertility treatments, these services are left up to individual states. Many states still consider in vitro fertilization treatments to be "boutique" or "elective"reproductive medicine, despite often being the only tenable option for LGBTQIA+ couples, single parents, and people with a diagnosis of infertility. Even if state insurance laws offer infertility coverage, IVF coverage can still vary greatly from state to state.

Understanding IVF and its impact on family building

What is IVF?

IVF involves retrieving eggs from ovaries and manually combining them with sperm in a lab for fertilization, after which the fertilized egg known as the embryo is placed inside the uterus. The process begins with suppressing the menstrual cycle and stimulating egg production before the egg retrieval, also known as oocyte retrieval. Once the eggs are collected, they are combined with sperm from either the partner or a donor and become embryos, which can then be transferred back to the uterus. Any additional suitable embryos can be frozen for future IVF attempts.

Medical conditions that may necessitate IVF include blocked fallopian tubes, low sperm count, endometriosis, and unexplained infertility.

IVF differs from intrauterine insemination (IUI), where sperm is injected directly into the uterus. Since IUI is less invasive and less expensive, many people opt to start there; however, due to its lower success rate, many people who try IUI first then go on to seek IVF treatment.

Many factors can affect IVF success rates. Since the quality of eggs and sperm deteriorates as people get older, reproductive age has a negative correlation with IVF success. Other important factors include prior successful pregnancies, a smooth embryo transfer, maintaining a healthy weight, and abstaining from smoking and alcohol.

In addition to the financial implications, IVF can often cause serious physical and emotional strain for families. The synthetic hormones in the ovulation-stimulating fertility drugs can cause intense PMS, weight changes, headaches, and nausea. Moreover, many of these drugs need to be injected, often for weeks at a time. Beyond physical discomfort, the process can be incredibly emotionally taxing and stressful.

The impact of these stressors seeps into all aspects of life, including the workplace. Nearly nine out of 10 employees feel their fertility challenges significantly impacted their productivity at work and 50% say it decreases their job satisfaction. Moreover, nearly one in five employees end up leaving their jobs because of the impact of fertility treatment.

The importance of IVF coverage

The cost of one IVF cycle ranges from $12,000 to $14,000, not including components of the process that clinics treat as add-ons to that base fee. While the clinic's base fee often includes monitoring appointments, bloodwork, and egg retrieval, it may not cover the injectable hormones, which can cost an additional $3,000 to $6,000. Other additional charges include genetic testing, trial transfers, cryostorage for unused embryos, donor sperm, or medical or hospital expenses.

Including these additional services—many of which may be necessary and required—the total bill for a single round of IVF typically ranges between $23,000 and $30,000. Considering that many people need more than one IVF cycle to achieve pregnancy, these costs quickly become prohibitive.

Infertility treatment coverage can make IVF more accessible and affordable, preventing people from going into debt or forgoing building their family altogether. As such, employers can play a key role in removing barriers to access. The business case for employers to support their employees as they start or grow their families is clear. While infertility insurance helps to improve diversity, equity, and inclusion in the workplace, other business advantages include better employee retention, recruiting better talent, and improved employee morale.

States with mandated IVF insurance coverage

Overview of state mandates

As of September 2023, 21 states and the District of Columbia have passed fertility insurance coverage laws. Only 15 of those laws include IVF coverage, and 17 laws cover fertility preservation services for iatrogenic, or medically-induced, infertility.

Even in these states, employers may not be required to cover infertility treatment and fertility preservation services if they’re self-insured, or if they have fewer than 50 employees and are not required to provide health insurance coverage. Religious organizations may also be exempt.

Another distinction between these state insurance laws is the difference between a mandate to cover and a mandate to offer. In mandated coverage laws, health insurance companies must provide coverage for infertility services in every policy, whereas mandated offer laws only require insurance companies to make this coverage available for purchase.

States with comprehensive IVF and infertility insurance coverage

Only 11 states require both IVF and fertility preservation coverage: Colorado, Connecticut, Delaware, Maryland, Maine, New Hampshire, New Jersey, New York, Rhode Island, Utah, and Washington D.C.

Massachusetts and Arkansas have mandated IVF coverage but not fertility preservation coverage, which would include freezing eggs, sperm, and embryos. California and Texas are mandate-to-offer states, meaning health insurance plans must have an infertility insurance option but are not required to provide it in any or all plans.

In Colorado, all large group (100+ employees) health benefit plans must cover up to three completed egg retrievals with unlimited embryo transfers. This Colorado law also specifies that fertility medications must be treated as all other prescription medications.

New York has similar legal requirements for all large group health plans to cover up to three IVF cycles and prescription medications, with an added clause that prohibits insurance coverage discrimination based on age, sex, sexual orientation, marital status, or gender identity.

Even the definition of what constitutes infertility varies significantly from state to state. For a comprehensive breakdown of fertility coverage laws by state, visit RESOLVE, the national infertility association.

States with limited or no IVF insurance coverage

Even among the 21 states and D.C. that have some sort of state-specific infertility treatment legislation, many of them are restrictive and discriminatory.

For example, Arkansas law stipulates that a patient's eggs must be fertilized with her partner's sperm, thus excluding LGBTQIA+ couples and single parents, a stipulation that persists in other states including Texas and Hawaii.

Further, these state laws often do not apply to self-insured plans, which cover 61% of workers in the U.S. The remaining 29 states do not require private insurance to cover any fertility services.