Two Steps Forward but Miles to Go: Examining “Improved but Insufficient” Legislation to Mandate Insurance Coverage for Medical Fertility Preservation

In 2017, the first state-level legislation was introduced (in Connecticut and Rhode Island) to mandate insurance coverage for medically indicated fertility preservation. Since then, 18 states have passed legislation to cover fertility preservation for iatrogenic infertility. At the time of writing, 19 states currently have active legislation, 3 states have inactive legislation, and 10 remaining states have no insurance mandate to cover fertility preservation for iatrogenic infertility. ¹ Impaired fertility arising from gonadotoxic medical treatments is one of the most distressing aspects of cancer for reproductive-aged patients (i.e., adolescents and young adults, “AYAs,” 15–39 years). Oncofertility-related concerns are linked to higher rates of mental health disorders in AYA survivors, with financial toxicity surrounding fertility preservation being a leading source of distress. ^2,3 Legislation to mandate coverage for medical fertility preservation stands to provide critical relief from financial burden and associated distress for AYA cancer patients.

In this important study, Komorowski et al. retrospectively evaluated whether the enactment of state-level legislation in Illinois (HB 2617) to cover medical fertility preservation (MFP) was linked to a change in relative socioeconomic conditions of individuals accessing fertility preservation services. The authors hypothesized that median area deprivation index (ADI) of patients initiating ovarian stimulation for MFP would increase post-legislation.

Findings of the authors' analyses reveal an increase in frequency of referrals and an increase in initiation of ovarian stimulation, as well as more patients with Medicaid insurance coverage seen for MFP consultation and initiation. However, the predicted median ADI of patients initiating stimulation—while higher post-legislation, therefore representing increased neighborhood disadvantage—did not reach statistical significance when compared to the pre-HB 2617 landscape of MFP. Rightly so, the authors conclude that, while a statute mandating MFP coverage appears to mitigate barriers to entry to fertility preservation services, legislation alone may not be enough to expand access to patients living in the most disadvantaged areas.

Importantly, Komorowski et al. observe that while HB 2617 provides more coverage than was previously accessible for MFP, the allotted coverage is not comprehensive. The bill guarantees gamete or embryo cryopreservation as well as the necessary medications for this process. It does not, however, provide for long-term storage costs for gametes or embryos, nor does it cover the costs of future use of gametes or embryos (for example, egg warming, egg insemination, or embryo transfer). Additional potential costs associated with in vitro fertilization (IVF) may not be covered either, such as mock embryo transfer, pre-implementation genetic testing, donor gametes, intracytoplasmic sperm injection, ultrasounds, blood work, or additional medications and doctor’s visits. With a single IVF cycle averaging between $15,000 and $20,000, ⁴ the price of services outside the purview of HB 2617 is likely prohibitive to achieve a live birth (or multiple live births) for cancer patients living in lower-ADI areas.

Limitations to the bill’s coverage for services may contribute to the authors’ findings that the median ADI of service users did not increase significantly after enactment. HB 2617 effectively lowers the barrier to entry to the initial phases of technologically assisted reproduction (e.g., cryopreservation). Even so, the costs of pursuing assisted reproductive technology through to a live birth likely outsize the financial issuance afforded by the mandate. Future advocacy would be wise to target an expansion of coverage toward broadly encompassing more of the necessary components of fertility preservation along the assisted reproduction trajectory.

Previous work has highlighted AYA cancer survivors’ need for integration of discussions of fertility services and financial hardship into long-term care programs. ⁵ Consequently, the development, implementation, and evaluation of holistic supportive services to navigate the long-term financial realities of and resources for impaired fertility is a critical priority area for research. Furthermore, lobbying for insurance coverage to provide comprehensive, ongoing supportive services is a priority area for advocacy in the field of women’s health.

Finally, Komorowski et al. make impactful use of geospatial mapping to illustrate changes in pre- and post-legislation ADI via service users’ census tracts. The maps (Figs. 1A and 1B) visually signify how comparatively more individuals residing in more disadvantaged neighborhoods in the Chicagoland area initiated MFP stimulation post-legislation. The fact that access to fertility preservation services is so intrinsically linked to legislative infrastructure harkens the notion of “stratified reproduction.” First introduced to social science discourse by anthropologist Shellee Colen in 1995, ⁶ stratified reproduction attends to the ways in which reproductive possibilities fall along socioeconomic, racialized, and political fault lines.

Komorowski et al.’s innovative use of mapping to visually render an account of stratified reproduction reinforces the central project of their article, which is a call to action to regard insurance coverage for medical fertility preservation as integral to the broader fight for reproductive justice.