Infertility

a common problem affecting 1 in 6 individuals worldwide

Infertility

Causes and coverage can vary greatly

April 24, 2025

Infertility is a common problem affecting 1 in 6 individuals worldwide. It is often stressful, frustrating, and even traumatic for those who find themselves unable to conceive. There are many reasons why someone may be struggling with infertility. Medication, surgery, and fertility treatment can all help resolve infertility but insurance coverage can vary greatly in scope and coverage descriptions. PBIRx guides our clients with strategic solutions that offer savings while ensuring appropriate access and utilization for members. 

PBIRx Intelligence

Learn how PBIRx helps our clients save while ensuring appropriate access to and utilization of fertility treatments - below

What is Infertility?

What is Infertility?

a common problem affecting 1 in 6 individuals worldwide

American Society for Reproductive Medicine (ASRM) defines infertility as:

    • The inability to achieve a successful pregnancy based on a patient’s medical, sexual, and reproductive history, age, physical findings, diagnostic testing, or any combination of those factors.
    • The need for medical intervention, including, but not limited to, the use of donor gametes or donor embryos in order to achieve a successful pregnancy either as an individual or with a partner.
    • In patients having regular, unprotected intercourse and without any known etiology for either partner suggestive of impaired reproductive ability, evaluation should be initiated at 12 months when the female partner is under 35 years of age and at 6 months when the female partner is 35 years of age or older.

Prevalence of Infertility

12% to 15% of couples are unable to conceive naturally

1 in 6 individuals worldwide experience infertility according to World Health Organization (WHO)

    • 12% to 15% of couples are unable to conceive naturally
    • Fertility declines with age in both men and women, but greater in women
    • Women’s chances of conception decline significantly after age 35
    • Male infertility accounts for 30% of all cases

Causes of Infertility

25% of infertile couples have more than one contributing factor

  • Female factors

    • Ovulation and tubal disorders
    • Endometriosis
    • Uterine or cervical causes

  • Male factors

    • Varicocele
    • Infections
    • Autoimmune causes
    • Sperm abnormalities
    • Undescended testicles
    • Hormone and structural abnormalities

  • Studies Show

    • 25% of infertile couples have more than one contributing factor leading to infertility
    • 20% of all cases are unexplained, fertility testing is unable to find a reason or cause a person or a couple is unable to get pregnant

Fertility Preservation

preserving reproductive potential for future use

National Institutes of Health (NIH) defines fertility preservation as follows:

    • The process of saving or protecting eggs, sperm, or reproductive tissue so that a person can use them to have biological children in the future

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Reasons for Fertility Preservation

    • Desire to delay parenthood
    • Prior to cancer treatment
    • Medical conditions that require reproductive surgeries
    • Prior to gender affirming surgery

Infertility Treatments and Procedures

medication, surgery, and fertility treatment options

Treatments and procedures include

    • Timed intercourse
    • Intrauterine insemination (IUI)
    • Assisted Reproductive technologies (ART)
      • In Vitro Fertilization (IVF) – most common form of ART
      • Egg freezing
      • Embryo transfer
      • Ovum donation
      • Gestational carriers

Common Fertility Medications

PBIRx clinicians continuously monitor latest treatments

Ovarian stimulation

    • Clomiphene (Clomid)
    • Letrozole (Femara)
    • Follistim AQ
    • Gonal-F
    • Menopur

Uterine support

    • Progesterone products
    • Estrogen products

Ovulation induction

    • Human Chorionic Gonadotropin (HCG)
    • Pregnyl
    • Novarel
    • Ovidrel

Premature ovulation prevention

    • Leuprolide (Lurpon)
    • Ganirelix
    • Cetrorelix (Cetrotide)

Fertility Costs

costs vary widely depending on treatment and insurance coverage

Clinic costs include

    • Diagnostic testing
    • Pre-treatment procedures (if needed)
    • The fertility procedure
    • Monitoring
    • Bloodwork
    • Pre-implantation genetic screening / diagnosis
    • Approx. $10K – $20K per cycle (one treatment)

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Medication costs for Assisted Reproductive Technologies (ART)

    • Approx. $5K – 20K (depending on procedure, amount of medication needed, pharmacy selection)

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Discount / financial assistance programs available for individuals with no fertility benefit

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Fertility benefits widely vary plan to plan, company to company

PBIRx Intelligence

PBIRx helps our clients ensure appropriate access and utilization

PBIRx PharmD Clinical Fertility Specialists monitor clients’ fertility drugs utilization and costs through monthly clinical and plan performance reports

    • PBIRx monitors fertility trends and provides recommendations to ensure proper utilization to prevent drug waste and abuse
    • PBIRx provides recommendations for fertility coverage based on the latest regulations, trends, and company culture and member demographics to ensure members have appropriate access to needed fertility treatments
    • PBIRx evaluates carve out fertility benefit vendors to provide clients with all available options for fertility coverage

Victoria Khavulya, Pharm D PBIRx Senior Clinical Specialist

Author:

Victoria Khavulya, PharmD

PBIRx SENIOR CLINICAL SPECIALIST

Fertility Organization and Resources

American Society for Reproductive Medicine (ASRM) – Professional multidisciplinary organization 

RESOLVE: The National Infertility Association – Patient advocacy organization 

Society for Assisted Reproductive Technology (SART) – Professional organization dedicated to Assisted Reproductive technologies (ART)

The HOPE for Fertility Foundation – Offers grants and financial assistance 

Baby Quest Foundation – Offers grants and financial assistance 

FertilityIQ – Provides comprehensive fertility patient education 

PBIRx Management Strategy:

PBIRx PharmD Clinical Fertility Specialists
monitor clients’ fertility drugs utilization
and costs through monthly clinical and
plan performance reports

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