Creating life is one of humanity's most valuable abilities, but women alone can give birth. As women increasingly delay motherhood for careers and education, infertility and the inability to conceive naturally becomes more common. New technologies like IVF, IUI, and egg freezing can help women conceive later in life, but they are very expensive and often not covered by health insurance. While some states require coverage for infertility treatments, the Affordable Care Act did not mandate such coverage nationally. As women's reproductive years decrease with age, technologies may help preserve fertility longer but also raise ethical issues.

1. Creating life is one of the most valuable resources known to man, and, so far, giving birth can
only be procured by a woman.
In order for societies to thrive and grow, populations need to multiply, expand, and new generations
arise. In the 21st century times have changed dramatically and as marriages decline, or happen later in
life, women are also choosing to hold off on motherhood—sometimes when their biological clocks are
winding down. “The average age of first-time mothers increased by 3.6 years, from 21.4 years in 1970
to 25.0 years in 2006. While the average age for first births increased from 1970 to 2006, the increases
were more dramatic during the first two decades, from 1970 to 1990” (see figure 2)6. In fact, in recent
years, more and more women are attempting to become pregnant after the age of forty, and unless we
have had the foresight to freeze our eggs a decade earlier, getting pregnant is highly unlikely; there is
only a five percent chance.
“Infertility is the result of a disease (an interruption, cessation, or disorder of body functions, systems, or organs) of
the male or female reproductive tract which prevents the conception of a child or the ability to carry a pregnancy
to delivery. The duration of unprotected intercourse with failure to conceive should be about 12 months before an
infertility evaluation is undertaken, unless medical history, age, or physical findings dictate earlier evaluation and
treatment1”.
 From 1970 to 2006 the proportion of first births to women aged 35 years and over increased nearly eight times.13
 In 2006, about 1 out of 12 first births were to women aged 35 years and over compared with 1 out of 100 in 1970.13
 Women are choosing advanced degrees and a higher education and in turn are delaying marriage and children.
 The pursuant of a long-lasting career, is a financial coup for women, in order to contribute into a dual-income home.
 Today, women realize they can have children on their own, especially when financially and emotionally comfortable.
 First time mother’s ages are rising; women in their forties, even over fifty, are diving into the idea of becoming a
parent later in life.10
 As progressive and advanced as women have become, waiting for motherhood can have dire consequences..
What happens then, when the female population is not reproducing as much as centuries ago?
How can their biological livelihoods be kept intact, if they choose to delay procreation until later in life?
Are there technological advancements available that can banish the fears of being permanently childless?
There are promising and extraordinary remedies today.
IVF (in-vitro fertilization)
IUI (intrauterine insemination)
Egg freezing
These technological wonderments can help women bring a baby into existence, but the caveats can be multi-faceted, including deep
financial commitment, emotional hardships, and moral ambiguities. The desperate need for these new technologies is clear;
preserving a woman’s ability to bare children, especially at an advanced reproductive age, is ever present today and some clinics are
even resorting to money-back guarantees. This “new normal” can offer a small piece of mind, as utilizing these treatments can be an
astronomical financial burden. “Accompanying each IVF (in vitro fertilization) cycle’s uncertain outcome is a substantial cost, typically in
the range of $7,000 to $10,000. Couples often pursue multiple IVF cycles if needed, so a total cost in the range of $10,000-$30,000 is
common”22.
Unfortunately, the ACA does not provide any measures for women that have fertility issues.
Those who are having difficulty conceiving a child have no recourse, but to pay out of pocket, unless they live in a
state that has passed mandates. The mandates require health insurance companies to offer plans that offer or
include certain aids in trying to becoming pregnant, but many do not include advanced techniques like IUI and
IVF. A step in the right direction, however, is the inclusion of EHB’s; essential health benefits. (see figure 6)
Biological Boundaries
It is a devastating reality, but when we are born, we have all of the eggs, to reproduce, that we will
possess in a lifetime, and every year, they decrease with our chronological age. When we reach
puberty, we have well over a quarter of a million eggs “in reserve” but as each decade passes, the
number decreases. The problem then lies, within the reality of child bearing and what can be done, if
there are fertility issues at hand, or the moral dilemma of how to help a woman of an advanced age
become biologically pregnant.
Ethical Echoes
References
“With insurance coverage such a barrier to infertility treatment, the
question is, will the Affordable Care Act mandate that insurers cover
it? The answer is no. Mandated coverage for infertility treatment is
not explicitly spelled out under the ACA. The law only outlines ten
“essential health benefits” categories that must be included in all the
health plans sold through the state health insurance marketplaces.
While the ACA does not require insurers nationwide to cover specific
treatments and procedures, states were given the responsibility to
choose their own essential health benefits plan and can decide to
include infertility treatment as part of their state’s essential health
benefits (EHB) of its ‘benchmark plan’ ”3.
There is no question that women are waiting longer to have families, whether it is a tenacious focus toward one’s
career, or the maternal instinct has not surfaced during the best childbearing years. Whatever the case, fertility
issues have become a major tenant in a woman’s life, but with new and innovative scientific and technological
advances, options are becoming more readily available to those wanting to start a family.
One caveat is the issue of the costs of treatments and, “…these technologies are expensive, and only 25% of
health insurance plans in the United States cover infertility treatment”2. Fortunately, this conundrum was being
noticed and, currently, fifteen states have passed legislation that allows mandates to exist, for coverage of infertility,
in private insurance plans. Many questions remain however, including the debate about whether the infertility issue
may or may not be a medical condition. Furthermore, even if insurance companies do employ these mandates, will
it make a difference to a woman who is infertile? What part of the female population is affected more than the
other?
Although the Affordable Care Act (ACA) does not directly address the crucial area of fertility, as of 2013, fifteen
states have brought individual legislation and mandates to their residents. The mandates vary, but the ACA does
include essential health benefits, (EHB’s), see figure 8.
“…the goal of the ACA is to expand coverage to the uninsured by improving affordability. Any services that may be
seen to undermine that mission, not surprisingly, will be met with resistance. As technology improves and infertility
treatments become more efficient, it is imperative that we, as providers, continue to be aware of the evolving policy
landscape to help our patients achieve their family building goals”18.
“Some mandates are mandates ‘to cover’, and require that health insurance companies provide coverage of
infertility treatment as a benefit included in every policy. Less commonly, states have enacted mandates ‘to offer’
and require only that health insurance companies make available for purchase policies that cover infertility
treatment”2. The laws become more complex from state-to-state, and many mandates exclude coverage of IVF, or
In-Vitro Fertilization, as it is questioned whether that specific type of fertility treatment is preventative, or a luxurious
benefit.
Cultivating Creatures
Promising Parenthood 1American Society for Reproductive Medicine. (2013). Infertility. Reproductive Facts. Retrieved from http://www.reproductivefacts.org/topics/detail.aspx?id=36
2Bitler, M., & Schmidt, L. (2012). Utilization of Infertility Treatments: The Effects of Insurance Mandates. Demography, 49(1), 125-149. doi:10.1007/s13524-011-0078-4
3Cahill, M. (2013, July 23). What the affordability act does when it comes to infertility treatment. Resolve. Retrieved on November 15, 2013 from http://www.resolve.org/get-involved/legislative-issues/blog/what-the-affordable-care-act-does-wrong.html
4Center for Disease Control and Prevention. (2013). Reproductive health: Infertility. CDC. Retrieved from http://www.cdc.gov/reproductivehealth/Infertility/
5Center for Disease Control and Prevention. (2013, September 10). Most recent art data. CDC. Retrieved from http://www.cdc.gov/art/
6Center for Disease Control and Prevention. (2009, August). Delayed childbearing: More women are having their first child later in life. CDC. Retrieved from http://www.cdc.gov/nchs/data/databriefs/db21.pdf
7Cheney, A. (2002). When science comes home. My Generation, (6), 30.
8Eggsurance. (2012, October 3). Amazing facts on egg freezing: Infographic. Eggsurance. Retrieved on November 23, 2013 from http://www.eggsurance.com/Blog/ViewList.aspx?pageid=2&mid=1&pagenumber=4#.UpLABI1yn4g
10Inside E. Street. (2012, January 30). Having babies at 50 and beyond. AARP. . Retrieved on November 22, 2013 from http://www.aarp.org/health/conditions-treatments/info-01-2012/babies-after-age-50-inside-estreet.html
11Kurland, N. B. (2001). Impact of legal age discrimination on women in professional occupations. Business Ethics Quarterly, 11(2), 331-348.
12Lee, N. C., & Woods, C. M. (2013). The Affordable Care Act: Addressing the unique health needs of women. Journal Of Women's Health, 22(10), 803-806. doi:10.1089/jwh.2013.4549
13Matthews, T.J. & Hamilton, E. (2009, August). Delayed childbearing: More women are having their first child later in life. CDC. Retrieved on November 22, 2013 from www.cdc.gov/nchs/data/databriefs/db21.pdf
14Mneimneh, A. S., Boulet, S. L., Sunderam, S., Zhang, Y., Jamieson, D. J., Crawford, S., & ... Kissin for the States Monitoring ART (SMART) Collaborative, D. M. (2013). States Monitoring Assisted Reproductive Technology (SMART) Collaborative:
Data Collection, Linkage, Dissemination, and Use. Journal Of Women's Health (15409996), 22(7), 571-577. doi:10.1089/jwh.2013.4452
15Ms. Fit. (2012, April 4). Top 10 fertility myths debunked-image. Fithology. Retrieved on November 15, 2013 from http://fithology.blogspot.com/
16Neumann, P. (1997). Should health insurance cover IVF? Issues and options. Journal Of Health Politics, Policy And Law, 22(5), 1215-1239.
17Nurses Professional Group. (2013). Infertility is not an inconvenience; it’s a disease: Infographic. NPG. Retrieved on November 20, 2013 from http://www.npg-asrm.org/Infographic_InfertilityIsNotAnInconvenience/
18Omurtag, K., & Adamson, G.D. (2013). The Affordable Care Act's impact on fertility care. Fertility & Sterility, 99(3), 652-655. doi:10.1016/j.fertnstert.2012.10.001
19Pintrest. (2013). Family infographics. Pintrest. Retrieved from, http://www.pinterest.com/thebabyquestion/family-infographics/
20Prafulla. (2013, May 5). Infertility by the numbers: infographic. Prafulla. Retrieved on November 20, 2013 from http://prafulla.net/medical-and-health/fertility-by-the-numbers-infographic/
21Rochman, B. (2013, October 14). 5 million babies born through IVF in past 35 years, researchers say. NBC News. Retrieved on November 24, 2013 from http://www.nbcnews.com/health/5-million-babies-born-through-ivf-past-35-years-researchers-8C11390532
22Schmittlein, D. C., & Morrison, D. G. (2003). A Live Baby or Your Money Back: The Marketing of In Vitro Fertilization Procedures. Management Science, 49(12), 1617-1635.
23Waters, A. (n.d.). Infographic: IVF use in america. Fertility Nation. Retrieved on November 24, 2013 from http://www.fertilitynation.com/united-states-of-ivf-state-ivf-rates-rankings-map-infographic/#.UpLUho1yn4g
24Women’s Health. (n.d.). Infographic: The affordable care act-addressing the unique health needs of women. Women’s Health. Retrieved on November 20, 2013 from www.womenshealth.gov/news/highlights/aca-infographic.html
Affordable Care Act Accountability
Artful Answers
Figure 18
Mastering Mandates
Rippling Ramifications
Background Basics
Figure 58
Figure 38
Figure 213
Figure 95
Figure 9
Figure
319
“…the goal of the ACA is to expand coverage to the
uninsured by improving affordability. Any services
that may be seen to undermine that mission, not
surprisingly, will be met with resistance. As
technology improves and infertility treatments
become more efficient, it is imperative that we, as
providers, continue to be aware of the evolving
policy landscape to help our patients achieve their
family building goals”.18
The most recent statistics are quite alarming and in 2011, close to 7 million women were diagnosed with some form
of infertility4. This alarming number may be only increasing, as the female population is deciding postpone
motherhood for a variety of reasons and some are even opting out all together. The emotional and physical
commitment once a drastic step is taken (like tube-tying), can have ramifications in the future, especially for those
women that feel they may have made a mistake in giving up the chance at parenthood. Along those lines, some
facet of health insurance should have clear options if the time has past to become biologically pregnant, or if
surgical methodologies can be taken to reverse past procedures, and the new founded desire to bare a child.
“As a result of the Affordable Care Act, more than 47 million women are now eligible to receive preventative services with cost-sharing.
In addition women will no longer need a referral from a primary care provider to obtain obstetrical or gynecological
services”15.
Even though some of these conundrums are inflating later in life, there is still reason to argue that insurance
providers should have some available options even if they may be a bit more costly. An easy ideology to follow is a
solution I developed called, Q.U.A.R.C. Care: Quality, Utilization, Access, Reliability, and Change. Within my
model, each branch would include specialized subsets, including prevention (under utilization), flexibility (under
access), and cost (under reliability AND change). This is my ultimate vision in attempting to jumpstart and stimulate
health care; crucial preventative measures must be followed but medicines and invasive surgeries, should be used
only as a last resort. As new technologies are being developed and discovered, the hope that cures that ail us will
also arise, but as knowledge is power, educating ourselves about all sides of an issue, especially as complex as
fertility, is imperative. We need to be vigilant, in understanding the concept that health needs differ vastly, for each
and every one of us, in particular the differences between men and women. Distinguishing not only between
genders, but every individual’s history is unique is the key to protecting our health for today and tomorrow.
The Q.U.A.R.C. Model
Quality: Specialized physicians who know their trade.
Utilization: Prevention in any and all areas, to eradiate disease before it arrives;
Opportunities to make our own choices without pressure.
Access: Flexibility to get many opinions without penalties.
Reliability: Trustworthiness in care received and in fair costs.
Change: This facet is not mutually exclusive to all others and can be uniquely
intertwined with all of the other objectives; the main premise being
that
the medical industry and business is never static and is constantly
shifting
and changing—which must be a conscious awareness in all of us.
(Fisher, 2013)
What are the options for a woman who was born without
enough egg reserve or is simply past her prime?
Can we push the limits of our biological clocks, and if
so, where is the line then drawn?
The issue of infertility is such a loaded one from the onset, but when factoring in the idiosyncratic nature of some
of the facets of the process, it becomes even more philosophically puzzling. Even more complex, is what a
woman, or the couple, decides to do with their unused frozen eggs or embryos. Shockingly, many of these unborn
“fetuses” exist, which is especially true for those who have passed the age in which they can biologically produce
offspring.
• The question remains then, what happens to these embryos?
• Should they be destroyed? Sold? Adopted?
• There are so many moral questions and very little answers, even thought there are thousands of eggs, fertilized
and not, being held in frozen states, all over the Western world.
“Experts estimate that there are tens of thousands of frozen embryos in the United States, many belonging to
couples in their late 40s and 50s, who are far removed from the time when they froze them. For infertility doctors,
these forgotten embryos represent a legal nightmare: the same people who have not come forward to tell them
what to do with their embryos could sue for destruction of property if the doctors destroy them.”7
The reality of the complex and idiosyncratic nature of fertility issues and the high cost of treating problems remains
and , the question still remains, what aspects should be covered, and those, if any should be paid for, out-of-pocket.
Figure 618
Ironically, some of the states that use
these methods the most, are not
mandated via insurance companies to
include some type of reimbursement or
deductible to help pay for the exorbitant
amount of infertility treatments. California
being one of the higher states, in the use
of IVF, although the state has not
deemed insurers to include fertility issues
in a health care plan. This mean that the
majority of participants are paying for
these services out of pocket and more
than likely driving themselves into deep
debt—to have a baby.
Fascinating ideologies are rising about
how as females look for more and more
ways to overcome infertility, the
technologies and methodologies may
harm the possibility to become pregnant
versus help them, and in turn cause
severe emotional damages. Key issues
that would be a consequence of adding
measures to aid in increased fertility are
the following: the impact of insurance
coverage; the cost-effectiveness of IVF;
valuing the benefit of IVF; and adoption
as an alternative.
Figure 815
Using advanced technological methods to get pregnant is becoming
commonplace and many agencies want and need to record and
gather data, in order to allow for new ideologies and methodologies to
develop. “Assisted reproductive technology (ART) refers to fertility
treatments in which both eggs and sperm are handled outside the
body. The Centers for Disease Control and Prevention (CDC)
oversees the National ART Surveillance System (NASS), which
collects data on all ART procedures performed in the United States.
The NASS, while a comprehensive source of data on ART patient
demographics and clinical procedures, includes limited information on
outcomes related to women's and children's health”14. Having limited
information makes continued research harder to obtain and in order to
provide a plethora of smart, advanced and developing options,
carefully monitored subjects should be studied and recorded, if made
permissible.
Finding methods, that might be less invasive to the female body and more natural, could be discovered by
unleashing new insights from the data and information found amongst ART patients. Preventing low birth rate
and safe multiple births, as these are at high risk, in ART. SMART (State Monitored Assisted Reproductive
Technology) Collaborative is quickly becoming the premier foresight into how to improve and perfect
technologies.
“A wide breadth of applied research within the Collaborative is planned or ongoing, including examinations of the impact of
insurance mandates on ART use as well as the relationships between ART and birth defects and cancer, among others”14.
The debate of whether health insurance should cover assisted reproductive technologies (ART) methodologies that aid in
procuring women to have children, is both an economic and moral dilemma. Today, women are having children later in life and
infertility is becoming a topic of deep concern, with 6.7 million women with impaired fecundity—those who are unable to carry a
baby to term or cannot get pregnant at all.5
“…IVF is clearly distinctive in certain dimensions: it is not a treatment for a life-threatening illness, and it raises profound ethical
and social questions regarding reproduction and family. Thus, even if one maintains that health care should not be considered a
private matter, it might still be argued that IVF is not health care, and thus that the ordinary rules do not apply. On the other hand,
given the centrality of parenting for the "normal functioning" of human beings (Daniels 1985), as well as the fact that it is a
medical solution for a medical problem, perhaps
IVF is not that dissimilar from other medical technologies”16.
The question remains whether or not it is a facet of health that health insurance should define as a standard benefit, and if so,
how feasible would it be to take on this added burden.
As a clarification, these numbers only apply to women in the age range of fifteen to forty-four. For women at the age of forty-five
or older, other studies and statistics will need to be procured in order to decipher exactly the methodologies involving infertility,
especially as the onset of menopause sets into a woman’s lifecycle.
The moral of the story in life is to never give up hope, and be
thankful and grateful, that we live in a society, with an ever-changing
and warp-speed technological state of wonderment. I
cannot believe that any of the five million babies born through IVF21
would consider themselves anything less than a human being—no
matter how they were conceived—and frankly all of these children,
are extraordinarily special gifts, deeply wanted to be brought forth
into the our phenomenal universe.