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Figure 1.  Trends in Utilization Rates of Infertility and Assisted Reproductive Technology Services Among Commercially Insured US Women Aged 18 to 50 Years From February 2018 to December 2020
Trends in Utilization Rates of Infertility and Assisted Reproductive Technology Services Among Commercially Insured US Women Aged 18 to 50 Years From February 2018 to December 2020

ART indicates assisted reproductive technology; ASRM, American Society for Reproductive Medicine.

Figure 2.  Trends in Utilization Rates of Assisted Reproductive Technology Services Among Commercially Insured US Women by Age
Trends in Utilization Rates of Assisted Reproductive Technology Services Among Commercially Insured US Women by Age

ART indicates assisted reproductive technology; ASRM, American Society for Reproductive Medicine.

aP for interaction < .001 for ages 18 to 34 years and ages 43 to 50 years and P for interaction = .005 for ages 41 to 42 years compared with the recovery rate of the reference group (women ages 35-37).

1.
Hamilton  BE, Martin  JA, Osterman  MJK. Vital Statistics Rapid Release. Births: Provisional Data for 2020. Report No. 12. National Center for Health Statistics; 2021.
2.
Lopez  L  III, Hart  LH  III, Katz  MH.  Racial and ethnic health disparities related to COVID-19.   JAMA. 2021;325(8):719-720. doi:10.1001/jama.2020.26443 PubMedGoogle ScholarCrossref
3.
Quinn  M, Fujimoto  V.  Racial and ethnic disparities in assisted reproductive technology access and outcomes.   Fertil Steril. 2016;105(5):1119-1123. doi:10.1016/j.fertnstert.2016.03.007 PubMedGoogle ScholarCrossref
4.
Reed  NS, Altan  A, Deal  JA,  et al.  Trends in health care costs and utilization associated with untreated hearing loss over 10 years.   JAMA Otolaryngol Head Neck Surg. 2019;145(1):27-34. doi:10.1001/jamaoto.2018.2875 PubMedGoogle ScholarCrossref
5.
Bernal  JL, Cummins  S, Gasparrini  A.  Interrupted time series regression for the evaluation of public health interventions: a tutorial.   Int J Epidemiol. 2017;46(1):348-355.PubMedGoogle Scholar
6.
Stout  MJ, Van De Ven  CJM, Parekh  VI,  et al.  Use of electronic medical records to estimate changes in pregnancy and birth rates during the COVID-19 pandemic.   JAMA Netw Open. 2021;4(6):e2111621. doi:10.1001/jamanetworkopen.2021.11621 PubMedGoogle Scholar
1 Comment for this article
EXPAND ALL
Access to Services Through Insurance Expansion and Reform
Lee Collins, J.D. (1); Marcelle I. Cedars, M.D. (2) | (1) Board of Directors, ASRM and RESOLVE; (2) ASRM, UCSF
We read this Research Letter with great interest. Certainly, the uptick in use of fertility services suggests that people are giving increased priority to family building.

There may be an additional cause worth exploring: during the period in question, new state laws became effective that required new or improved commercial insurance coverage for fertility care. These laws, providing people with coverage for fertility diagnosis and treatment including IVF and for fertility preservation for iatrogenic infertility, make reproductive medicine far more affordable and are well documented to increase usage of IVF (1).

The American Society for Reproductive
Medicine (ASRM) formed a Collaboration with RESOLVE: The National Infertility Association, a nonprofit that supports and advocates for people trying to build a family. The Collaboration is a physician-patient partnership to combine decades of advocacy experience. As a result of this Collaboration, several states passed laws during the time in question to mandate that infertility benefits be added to insurance policies.

The timing of the new fertility coverage is as follows:

Oct. 2019 California passes coverage for fertility preservation (FP); all FP herein is for iatrogenic infertility (https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201920200SB600)

Jan. 2020 New York State covers IVF and FP (https://resolve.org/access-to-care-fertility-insurance-win-new-york/)

Jan. 2020 New Hampshire covers fertility treatment including IVF and FP (with RESOLVE New England) (https://www.gencourt.state.nh.us/rsa/html/XXXVII/417-G/417-G-mrg.htm)

April 2020 New Jersey covers FP (https://www.njleg.state.nj.us/2018/Bills/S2500/2133_I1.PDF)

Jan. 2021 Maryland shortens treatment waiting time; drops marriage requirement: https://resolve.org/get-involved/become-an-advocate/victories-and-achievements/

Feb. 2021 New York State allows gestational carrier contracts: https://nysba.org/new-surrogacy-law-brings-opportunities-but-practitioners-beware/

More coverage has or will soon become effective:

Jan. 2022 Colorado to cover IVF and FP (https://leg.colorado.gov/bills/hb20-1158)

Jan. 2022 Illinois to cover LGBTQ and single individuals; to shorten waiting time for people over 35 (https://www.illinois.gov/news/press-release.23629.html)

Based on data from the National Association of Insurance Commissioners, millions of people received new or more comprehensive coverage as a result of these laws, so it would be interesting to examine geographic data to see whether these states, and perhaps other mandated states, disproportionately contributed to the documented surge.

Changes in the insurance landscape may not come immediately to mind, but they are powerful mediators of access to care. A further analysis would be a great contribution to our understanding of access to the vital services of reproductive medicine and family building.

Respectfully submitted,
Lee Rubin Collins, J.D.
Board of Directors, ASRM and RESOLVE

Marcelle I. Cedars, M.D.
President, ASRM

[1] Jain T, Harlow BL, Hornstein MD. Insurance coverage and outcomes of in vitro fertilization. N Engl J Med 2002;347:661–6.

CONFLICT OF INTEREST: None Reported
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Research Letter
Obstetrics and Gynecology
October 6, 2021

Trends in Infertility Care Among Commercially Insured US Women During the COVID-19 Pandemic

Author Affiliations
  • 1Division of Reproductive Endocrinology and Infertility, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, La Jolla
  • 2Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, La Jolla
  • 3Division of Biostatistics and Bioinformatics, Department of Family Medicine and Public Health, University of California San Diego, La Jolla
  • 4Moores Cancer Center, University of California San Diego, La Jolla
  • 5Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla
  • 6Department of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts, Amherst
  • 7OptumLabs Visiting Fellow, Eden Prairie, Minnesota
JAMA Netw Open. 2021;4(10):e2128520. doi:10.1001/jamanetworkopen.2021.28520
Introduction

Early in the COVID-19 pandemic, the American Society for Reproductive Medicine (ASRM) advised clinicians in March 2020 to suspend infertility care despite the time-sensitive nature of fertility. In April 2020, the ASRM recommended cautious continuation of care. Although the US birth rate has decreased during the pandemic,1 the magnitude, direction, and duration of change in infertility care is unknown. We evaluated trends in infertility and assisted reproductive technology (ART) service utilization rates during the pandemic and whether patterns differed by age, income, or race and ethnicity, given the differential effects of COVID-19 on socioeconomic groups2 and known socioeconomic disparities in infertility care.3

Methods

For this cross-sectional study using an interrupted time series design, we used deidentified administrative claims data from the OptumLabs Data Warehouse to evaluate infertility service utilization rates among commercially insured US women aged 18 to 50 years between February 2018 to December 2020. The data warehouse contains information on more than 200 million patients covered by a US commercial health plan. Socioeconomic data were derived from public information for approximately 73% of enrollees.4 We used an interrupted time-series design5 with linear spline regression to evaluate the effects of the COVID-19 pandemic on infertility outcomes and estimated group effects overall and on rates of decline and recovery in the use of infertility and ART services, while accounting for time trends and confounding. We modeled claims for infertility (diagnosis or workup) and ART services (eTable in the Supplement) before the pandemic (February 2018 to February 2020), during care suspension (March to April 2020), and after care continuation (May to December 2020). Female age (18-34, 35-37, 38-40, 41-42, or 43-50 years), race and ethnicity (Asian, Black, Hispanic, White, or unknown), and household income (<$75 000, $75 000-$199 999, ≥$200 000, or unknown) were examined using interaction terms to assess differences in the decline and recovery in infertility and ART services utilization rates by group. Race and ethnicity were studied because of the differential effect of COVID-19 on racial and ethnic minority groups and known disparities in infertility care. The race and ethnicity data are derived from public information and estimates by a nationally recognized supplier of consumer marketing data.4 Statistical analysis was performed with R software (version 4.0.2; R Core Team), and P < .05 was the threshold for significance.

This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. The study was exempt from institutional review board review because the use of deidentified data from the OptumLabs data set falls under exemptions specificed by the Common Rule.

Results

The OptumLabs Data Warehouse claims data indicated that 8 755 271 women were eligible for this study. We observed incremental increases in infertility and ART service utilization rates before the pandemic (1.2 vs 0.72 per 10 000/y), sharp decreases during care suspension (−50.4 vs −21.6 per 10 000/y), and sharp recoveries after care continuation (96.0 vs 42.6 per 10 000/y) that were sustained through the end of the study (Figure 1). Patterns in infertility and ART services use were similar in all analyses. Before the pandemic, women aged 35 to 37 years had the highest ART utilization rate (29.8 per 10 000), followed by women aged 38 to 40 (24.0 per 10 000), 41 to 42 (16.8 per 10 000), 18 to 34 (6.4 per 10 000), and 43 to 50 (5.0 per 10 000) (Figure 2). The decline and recovery in utilization rates varied by age. Recovery rates adjusted for race and ethnicity and income were similar for women aged 35 to 37 and those aged 38 to 40 years (55.2 vs 46.8 per 10 000/y; P for interaction = .60), but they were significantly higher compared with women aged 18 to 34, 41 to 42, and 43 to 50 years (19.2, 28.8, and 8.4 per 10 000/y, respectively; P for interaction < .001 for ages 18 to 34 years and ages 43 to 50 years, P for interaction = .005 for ages 41 to 42 years). Before the COVID-19 pandemic, the ART utilization rate was highest among Asian women (19.1 per 10 000), followed by White, Black, and Hispanic women (9.2, 5.3, and 4.5 per 10 000, respectively; P < .001). The recovery rate after April 2020 was faster for Asian women compared with White women (105.6 vs 40.8 per 10 000/y; P for interaction < .001), whereas utilization rates were comparable among other racial and ethnic groups. The ART utilization rate before the COVID-19 pandemic was positively associated with income, but changes in utilization rates over time did not vary by group.

Discussion

The results of this study indicate a rapid and sustained increase in infertility care and use of ART services after April 2020 that surpasses prepandemic levels and seemingly exceeds an unfulfilled need from the March 2020 care suspension period. These findings support the high priority placed on family building across age, socioeconomic status, and racial and ethnic groups despite potential study limitations. These limitations include the generalizability of a commercially insured population, the inability to restrict the study population to enrollees with infertility care benefits or examine enrollees by geographic region, and the potential misclassification of race and ethnicity. If these findings are reflected in the general US population, the record-low birth rates in December 2020 (from conception early in the pandemic) may reverse1,6 and an increasing demand for fertility care may challenge current care capacity. Lower utilization rates and slower recovery rates of infertility care among women older than 40 years raises concerns attributable to age-dependent fertility declines. Persistent disparities with Black race, Hispanic ethnicity, and lower income were observed but were not associated with differential recovery. Studies on the sustainment of increased infertility care use are needed.

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Article Information

Accepted for Publication: August 5, 2021.

Published: October 6, 2021. doi:10.1001/jamanetworkopen.2021.28520

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Zhou B et al. JAMA Network Open.

Corresponding Authors: Brian W. Whitcomb, PhD, Department of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts Amherst, 715 N Pleasant St, Amherst, MA 01003 (bwhitcomb@schoolph.umass.edu); H. Irene Su, MD, MSCE, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, 3855 Health Sciences Dr, Department 0901, La Jolla, CA 92093-0901 (hisu@health.ucsd.edu).

Author Contributions: Drs Zhou and Su had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Zhou and Joudeh contributed equally to the work.

Concept and design: Zhou, Joudeh, Desai, Whitcomb, Su.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Zhou, Joudeh, Desai, Su.

Critical revision of the manuscript for important intellectual content: Joudeh, Kwan, Nalawade, Whitcomb, Su.

Statistical analysis: Zhou, Joudeh, Desai, Kwan, Nalawade, Whitcomb.

Obtained funding: Su.

Administrative, technical, or material support: Zhou, Desai, Su.

Supervision: Whitcomb, Su.

Conflict of Interest Disclosures: Dr Su reported receiving nonfinancial support from the OptumLabs research credit program, grants from the California Breast Cancer Research Program and the National Institutes of Health, and personal fees from Ferring Pharmaceuticals. No other disclosures were reported.

Funding/Support: This study was funded by a University of California and OptumLabs Research Award and by National Institutes of Health National Institute of Child Health and Human Development grant T32-5T32HD007203-37.

Role of the Funder/Sponsor: OptumLabs collected the data and reviewed the manuscript. The funders had no role in the design and conduct of the study; management, analysis, and interpretation of the data; preparation or approval of the manuscript; and decision to submit the manuscript for publication.

References
1.
Hamilton  BE, Martin  JA, Osterman  MJK. Vital Statistics Rapid Release. Births: Provisional Data for 2020. Report No. 12. National Center for Health Statistics; 2021.
2.
Lopez  L  III, Hart  LH  III, Katz  MH.  Racial and ethnic health disparities related to COVID-19.   JAMA. 2021;325(8):719-720. doi:10.1001/jama.2020.26443 PubMedGoogle ScholarCrossref
3.
Quinn  M, Fujimoto  V.  Racial and ethnic disparities in assisted reproductive technology access and outcomes.   Fertil Steril. 2016;105(5):1119-1123. doi:10.1016/j.fertnstert.2016.03.007 PubMedGoogle ScholarCrossref
4.
Reed  NS, Altan  A, Deal  JA,  et al.  Trends in health care costs and utilization associated with untreated hearing loss over 10 years.   JAMA Otolaryngol Head Neck Surg. 2019;145(1):27-34. doi:10.1001/jamaoto.2018.2875 PubMedGoogle ScholarCrossref
5.
Bernal  JL, Cummins  S, Gasparrini  A.  Interrupted time series regression for the evaluation of public health interventions: a tutorial.   Int J Epidemiol. 2017;46(1):348-355.PubMedGoogle Scholar
6.
Stout  MJ, Van De Ven  CJM, Parekh  VI,  et al.  Use of electronic medical records to estimate changes in pregnancy and birth rates during the COVID-19 pandemic.   JAMA Netw Open. 2021;4(6):e2111621. doi:10.1001/jamanetworkopen.2021.11621 PubMedGoogle Scholar
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