Purpose
The purpose of legislation for fertility preservation coverage is to provide cancer patients with access to standard medical treatments that will protect their capacity to have genetic children.
Background
In the United States, approximately 130,000 individuals between ages 0–44 are diagnosed with cancer each year.i As cancer survivorship improves, these patients face good odds; more than 85% will survive.ii Cancer treatments can directly or indirectly cause medically induced (iatrogenic) infertility. Chemotherapy, radiation, and surgery can damage gametes (eggs and sperm), reproductive organs, and/or endocrine functioning; they may also impact the ability to carry a pregnancy. Because this damage is caused by treatments and not the disease, it can affect patients with virtually any type of cancer.iii Patients with other conditions requiring similar therapies (e.g., sickle cell anemia, lupus, and thalassemia, etc.) are also at risk.iv
Costs
Cost is often cited as the most significant barrier to fertility preservation.v Costs can range from several hundred dollars for sperm banking, to approximately $15,000 for egg banking.vi Without insurance coverage, these treatments are unaffordable for many patients. These costs are exacerbated by the short window of opportunity that cancer patients have before starting potentially sterilizing cancer treatment. While the costs faced by an individual patient are high, the cost of implementing coverage across a population of insureds is very low. Independent analyses in states where coverage has been considered have shown costs ranging from one cent per member per month (PMPM) (California)vii; to $0.06 (Connecticut)viii; to $.10-$.24 PMPM (Maryland)ix.
Standard of Care
Patients facing iatrogenic infertility now have recognized, efficacious options for preserving their fertility prior to the initiation of their cancer treatments. Sperm, egg, embryo, and ovarian tissue banking are recognized as the current medical standard of care. These treatments are supported by all of the relevant medical associations, including the American Society of Clinical Oncology (ASCO), the American Society for Reproductive Medicine (ASRM), and the American Medical Association (AMA).x
Rationales for Coverage
- Medical Necessity. Fertility preservation for iatrogenic infertility is not “elective” or “experimental,” but rather a needed intervention to prevent potential sterility. Patients cannot defer or forego life-saving treatments to spare their fertility.
- Address direct side effect of cancer treatment. Remedies for other side effects of treatment, such as breast reconstruction, chemo-induced anemia, wigs, prostheses, etc., typically are covered by insurance.
- Prevent additional harms and associated costs.
- Recent studies show that significant numbers of patients make sub-optimal treatment decisions (e.g., stopping tamoxifen or choosing less gonadotoxic treatment) to minimize reproductive impact. These decisions may adversely affect both medical outcomes and treatment costs.
- Infertility causes distress, depression, anxiety; these have financial and medical consequences, and result in overall lower quality of life for survivors.
- Access disparities. The lack of insurance coverage disproportionately affects women and those of lower socioeconomic backgrounds.
- Fundamental life activity. Loss of fertility is not merely a medical complication; it permanently affects reproduction and parenthood – fundamental life functions worthy of the highest levels of protection.
Existing Fertility Preservation Coverage
Currently, eighteen states and the District of Columbia have enacted laws that require some insurers to provide coverage for medically-necessary fertility preservation.xi
i Center for Disease Control and Prevention. United States Cancer Statistics: Data Visualizations. USCS Data Visualizations – CDC. Accessed March 2, 2024. See Table: Rate of New Cancers by Age Groups (years), All Races and Ethnicities, Both Sexes
ii Barr RD, Ferrari A, Ries L, et al. Cancer in Adolescents and Young Adults: A Narrative Review of the Current Status and a View of the Future. JAMA Pediatr. 2016 May 1;170(5):495-501. doi: 10.1001/jamapediatrics.2015.4689
iii Estimating the percentage of newly-diagnosed cancer patients whose treatments will pose some fertility risk is difficult for several reasons: most studies attempting this have focused on individual cancer types; cancer treatments are ever-evolving;
and longitudinal data on fertility outcomes in survivors is sparse. The state of California estimates this to be approximately 70%. See California Health Benefits Review Program (CHBRP) Analysis of Senate Bill 600: Health Care Coverage: Fertility Preservation, A Report to the 2019–2020 California Legislature, April 17, 2019, p.9 Table 3, showing 5701 patients out of 8000 would be at risk for iatrogenic infertility.
iv Katsifis GE TA. Ovarian failure in systemic lupus erythematosus patients treated with pulsed intravenous cyclophosphamide. Lupus. 2004;13:673-678; Rovoa, T., Passweg J., Heim D., Meyer-Monard, S. HW. Spermatogenesis in long term survivors after allogenic hematopoietic stem cell transplantation is associated with age, time interval since transplantation, and apparently absence of chronic GVHD. Blood. 2006;108(3):1100
v Quinn, G.P., Vadaparampil, S.T., Bell-Ellison, B.A., Gwede, C.K., Albrecht TL. Patient–physician communication barriers regarding fertility preservation among newly diagnosed cancer patients. Soc Sci Med. 2008;66(3):784-789.
vi FertilityIQ. The Costs of Egg Freezing. https://www.fertilityiq.com/egg-freezing/the-costs-of-egg-freezing. Published 2017. Accessed July 14, 2018
viiCalifornia Health Benefits Review Program (CHBRP) Analysis of Assembly Bill 912: Health Care Coverage: Fertility Preservation, A Report to the 2013–2014 California Legislature, April 25, 2013.
viii UCONN Center for Public Health and Health Policy. “Review and Evaluation of Certain Health Benefit Mandates in Connecticut 2013.”
ix NovaRest Annual Mandate Report: Coverage for Fertility Preservation for Iatrogenic Infertility. Prepared for the Maryland Healthcare Commission, November 16, 2017. p. 27.
x Oktay, K., Harvey, B.E., Partridge, A. et al. Fertility Preservation in Patients With Cancer: ASCO Clinical Practice Guideline Update. J Clin Onocology. 2018. doi:10.1200/JCO.2018.78.1914; American Society of Reproductive Medicine. Fertility preservation and reproduction in patients facing gonadotoxic therapies: a committee opinion. Fertil Steril. 2013;100(5):1224-1231; Association AM. Oncofertility and Fertility Preservation Treatment. http://www.amaassn.org/ama/pub/news/news/2013/2013-06-17-new-ama-policies-annual-meeting.page. Published 2013.
xi State Laws & Legislation | Alliance for Fertility Preservation accessed September 2, 2024.
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