Clinical Review

2019 Update on fertility

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Progress is being made in recognizing infertility as a disease (thus meriting insurance coverage) and in improving embryo selection techniques for IVF treatment, but more work is needed. Plus, the SART's redesigned report includes a new feature for calculating a personalized prognosis that can aid in treatment decision making. Two fertility experts boil down these complex issues.



Professional societies, global organizations, and advocacy groups are continually working toward the goal of having the costs of infertility care covered by insurance carriers. Paramount to that effort is obtaining recognition of infertility as a burdensome disease. In this Update, we summarize national and international initiatives and societal trends that are helping to move us closer to that goal, and we encourage ObGyns to lead advocacy efforts.

Next, we detail several notable new features available in the annual report of the Society for Assisted Reproductive Technology (SART), an online interactive document that can be used to assist clinicians and patients in treatment decisions.

We also tackle the complexities of embryo selection for in vitro fertilization (IVF) and describe a potentially promising aneuploidy screening test, and explore its limitations.

Advances in recognizing infertility as a disease that merits insurance coverage

Article 16 of the United Nations Declaration of Human Rights states that "Men and women of full age, without any limitation due to race, nationality or religion, have the right to marry and to found a family. They are entitled to equal rights as to marriage, during marriage and at its dissolution."1 While few people value anything more than their family, the inability to have one because of infertility has long been in the shadows. Infertility is surrounded by myth, poorly understood by the public, rarely discussed in polite company, badly managed by physicians, and rarely covered by insurance. The current inadequacy of infertility insurance coverage denies the basic human right to found a family and perpetuates gender inequalities.

Major reproductive medicine organizations globally have endorsed the definition of infertility as a disease that "generates disability as an impairment of function" (TABLE 1).2 Fortunately, medical, societal, and judicial changes have resulted in progress for the 6.1 million women (and equivalent number of men) affected by infertility in the United States.3

Professional group advocacy efforts, and judicial rulings

The World Health Organization (WHO) has addressed infertility over the past several decades, with the organization's standards on semen analysis being the most recognized outcome. Progress has been limited, however, regarding global or national policy that recognizes the importance of infertility as a medical and public health problem.

In 2009, the glossary published by the WHO with the International Committee for Monitoring Assisted Reproductive Technology (ICMART) defined infertility as a disease.4 This recognition is important because it aids policy making, insurance coverage, and/or other payments for services.

The WHO also has begun the process of developing new infertility guidelines. Recently, the WHO held a summit on safety and access to fertility care, which was attended by many representatives of nation-state governments and international experts. It is hoped that a document from those proceedings will reinforce the public health importance of infertility and support the need to promote equality in access to safe fertility care. WHO initiatives matter because they apply to nation-states.

In the United States, the American Society for Reproductive Medicine (ASRM) for many years has recognized infertility as a disease. Only in 2017, however, did delegates at the American Medical Association's annual meeting vote to support the WHO's designation of infertility as a disease.

Continue to: Judicial views


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