969 - Access to In Vitro Fertilization, 2025

Welcome to Public Health On Call, a podcast from the Johns Hopkins Bloomberg School of Public Health, where we bring evidence, experience, and perspective to make sense of today's leading health challenges. If you have questions or ideas for us, please send an email to [email protected]. That's [email protected] for future podcast episodes. Hi listeners, it's Lindsay Smith Rogers. Today, access to in vitro fertilization, otherwise known as IVF. Sean Tipton is the Chief Advocacy and Policy Officer of the American Society of Reproductive Medicine. He joins Dr. Josh Sharsteen to talk about the recent White House announcement on IVF and how much of a step forward in access to care it represents. Let's listen. Sean Tipton, thank you so much for joining me here on Public Health On Call. Could you tell me a little bit about the American Society for Reproductive Medicine? Sure, so the acronym we use is ASRM. It was founded in 1944. We've got about 7,000 members around the world who are not only physician to work primarily in reproductive health, including infertility care, but actually all members of the cross-disciplinary team. So our membership includes nurses, advanced practice nurses, genetic counselors, and mental health people, and practice managers, and even highly unusual for a medical group. We even have lawyers in our membership. And what is their common goal? Well, I mean, they are all about advancing reproductive care. So in the broad spectrum, that's any aspect of people's reproductive lives. You know, we talk about going contraception, infertility, menopause, all those kind of things are the subjects of the research and care that our members provide. Today we're going to talk about assisted fertility. Tell me about that technology and a little bit maybe about how it's changed over the years. So for fertility care, you know, the big breakthrough announced sort of the baseline foundational sort of technique is called in vitro fertilization. That was first done in 1978. We are now millions of babies, 40 years in a Nobel Prize into the use of IVF to help people build their families. What makes it when people talk about assisted reproductive technologies, what the criteria means that definition are the really the egg coming out of the body. And so in an IVF procedure, the physician takes over the woman's menstrual cycle, kind of shuts it down and then uses other medicine to ramp it up. So in a natural cycle, a woman will ovulate one egg at a time. Under medical assistance, you want to get more than that because human beings are actually notoriously inefficient at reproducing. And so it often takes more than one egg. So the physician provides medication that is monitored over a couple of weeks. The woman that ovulates and the physician retrieves the eggs, takes those out of the woman's body, puts them in a culture media or a dish with sperm. You see which embryos, which eggs fertilize, turning embryos begin to grow and develop. And the best one of those then is transferred back into the woman in hopes that it will implant and establish a pregnancy and lead to a healthy baby. And that now happens about how often in the United States? Well, it's a little over 2% of all births in the United States are the result of in vitro fertilization procedures. So it is becoming increasingly common. And in order to go through that, there's medicines, there's procedures, all that costs money. Yeah, it is a arduous, complicated and resource-intensive medical procedure. Now, it has reputation as being an expensive procedure, but that is primarily because so many insurance companies don't provide coverage for it. So if you're looking at sort of actual cost, I mean, it's about this. It's almost exactly the same as the hip replacement that I recently had. It is pretty much the same cost as the cesarean section for delivery. People just don't talk about those being expensive because they don't typically write the checks to pay for those their insurance companies do. So that's a really important point. Insurance coverage is not as routine for this technology compared to other things out there in medicine. That's correct. And it's hard to quantify exactly, but we can safely say that a majority of Americans do not have coverage for IVF. Now, that is because, you know, that may be people without any kind of insurance. That includes people on Medicaid and Medicare. That includes people who are serving in the military. None of those people have coverage. But I think the sad and disheartening fact is just how many people who think they have good typically normal employer-provided health insurance, that all too often that insurance also does not provide adequate coverage for fertility care. And so as a result, people who are interested in this wind up paying a lot of their own money they weren't expecting to pay if they're going to have this at all. Correct. So this became an issue in the last presidential campaign. Could you explain the context for that? Yeah, 2024 really was the IVF campaign. I've been working in this field of policy for a very long time. It is without question the most visible it's ever been in a campaign. That came about for a couple reasons. The fundamental part of that was the Dobs abortion decision in 2022, which said no longer is there a guaranteed constitutional right to reproductive autonomy in this country. That then allowed the Alabama Supreme Court in February of 2024 to issue a decision that said a plaintiff could bring a wrongful death case against a medical facility because that facility lost their embryos. It was a very unfortunate incident. But that's the bottom line is the the Alabama Supreme Court said, just as you could bring a wrongful death case for the death of a child, so too you can bring a wrongful death case for the demise of a fertilized egg in a freezer. And that really put all of IVF at risk because part of IVF is the loss of some of the embryos as other embryos are then implanted. Absolutely. So human beings are inefficient reproducers. So the IVF process requires more than one egg and you want to get more than one embryo because oftentimes just one is going to be insufficient. And I recall when that started to happen, you heard a lot about the importance of IVF to a lot of Americans. Well, it was really interesting. I mean, so that decision shut IVF down in Alabama within 48 hours. The decision came down on a Friday afternoon because in American politics, that's when you put out bad announcements that you think are going to be controversial. By Tuesday morning, really, IVF was shut down in the state of Alabama. Now, that created what I've come to describe as an unprecedented outpouring of outrage, both mostly within Alabama but really throughout the country. The Alabama legislature, one of the most conservative, the most anti-choice legislative bodies in this country within three weeks, passed a law to shield IVF providers from any of these legal implications. That was a testament to the popularity of IVF and just how dangerous that court decision was. When you get that kind of reaction from the public, and that leads to that kind of reaction in a state legislator, elected officials and candidates who want to be elected officials pay attention. So fast forward to the presidential election. I think what you saw was many Republicans, particularly Donald Trump, recognized or figured they had a vulnerability on women's health issue based largely on abortion politics. And so, they were looking for a way to triangulate that, to a way to say, "No, no, we still like medicine." So President Trump very clearly came out in favor of IVF, in fact, talking about that he pledged to provide free universal access to IVF during the campaign and early in his presidency. That trickled down throughout the Republican Party. So it became, which presented a little bit of a dilemma for some Republicans, many of whom had built their careers on taking very strong anti-choice stances. For parts of the anti-choice community who put a lot of emphasis on life begins at conception and every fertilized egg needs to be the legal and is the ethical and should be the legal equivalent of a born human being, IVF creates a problem for them, particularly if it's popular. Because people come to understand what the scientific reality is that fertilized egg is. Which is, most fertilized eggs and human beings are not going to become babies. There are tremendous obstacles along the way and they often are not overcome. And so, the more, I think the anti-choice folks understood the danger that the popularity of IVF and a better understanding of IVF and human biology that result from this discussion posed a real political threat to them. Facing that dilemma, how did politicians respond? Did they stick to their original approach of saying a fertilized egg is a human life and we can't have any loss or did their positions evolve? There was a lot of but. So there's a lot of I am right to life, but I like IVF or I am pro IVF, but I'm also right to life. From a policy standpoint, there is absolutely no reason you can't take that stance, right? For example, sin stops of the abortion restrictions that have been passed in many states in this country have not forced any IVF provider to change how they practice. They've had to change how they do their informed consent procedures because the implications may be different. But the abortion restrictions have been pretty clear in law that they are dealing with an established pregnancy. And so the legal question is what is the status of this fertilized egg in a petri dish in a clinic is very different from what is a gestating fetus in a woman's body? Those are different questions. So from a policy perspective, there wasn't as much tension as there might be, say, from a philosophical or ethical. I'd say that's true for now. I mean, there clearly are elements of the anti-choice community who would very much like to ban IVF. So let's go back to President Trump and his pledge to make IVF a free benefit. How is that going? Well, he hasn't delivered on that promise just yet. The announcement last week made some progress towards that, but it clearly was not what he said he was going to shoot for in the campaign. It's not really what even in the executive order that he announced in February set as the goal. So tell me about the executive order in February. So the executive order in February essentially task what's called the Domestic Policy Council, which is a part of the White House operation, which their function really is to try to coordinate on policy questions that may cross between different cabinet agencies. So he tasked the Domestic Policy Council with giving me a policy recommendation that we can use to make sure that IVF is affordable and available for people and give it to me by May. They reportedly had it done, but there was no announcement about that. Really, between February and October, you didn't hear anything from the White House. There were no public developments. They clearly were working behind the scenes. So there's an announcement in February, you don't hear much, and then October, what happens? So in October, the White House had an event in the Oval Office, I believe. They announced really, the policy they announced was really too prompt. One had to do with medications, so pharmaceutical products. They announced an arrangement they had made with one particular pharmaceutical company. EMD Serono, who agreed to make their fertility drug portfolio available through the coming TrumpRX exchange at a lower cost. They're saying $3,200 for a product that typically was more like $5,000 or $6,000. In exchange for that, EMD Serono also got some promises about a sort of rapider approach for approval of a new drug that they had been seeking approval for, which has been available in Europe for a long time, and we certainly support its being available here. And then the second part of the announcement? The second piece was an insurance piece where they're going to say they're going to change policy to allow employers to offer a fertility benefit outside of the traditional health insurance benefits in the same kind of way that people get access to vision and dental care, which is not part of a normal health insurance plan. Now, that leaves a lot of room open for how that's going to work. My concern with that is that those dental and vision plans typically are not really insurance plans. And the insurance plan as a concept is you spread the risk around a lot of people, and that reduces the cost for everybody, and we all sort of help each other. The dental vision model tends to be more of a discount plan, right? Not really a normal insurance thing. And so where $100 could be a significant discount on getting, say, a filling, $100 on a $15,000 IVF cycle is not really a very big deal. So I think it remains to be seen how helpful that's going to be. What we do know is that this will now be available to consumers using their pre-tax dollars, which can be a big deal. So between the two, I mean, it moves the needle. It does not move the needle all the way to universal access to fertility care. I wonder with the insurance benefits structured this way, your concern that the only people who will sign up for it are people who know they need IVF, and that could make it pretty expensive. Well, I do think that most people are probably not as a matter of course. And the way that, yeah, of course, I'm going to use dental care. Of course, I'm going to need vision care. They probably won't check a fertility care box unless they have some reason to think they're going to utilize it. And so you get that adverse selection as the term in the insurance business, which means the only people who are paying for it are going to be the ones who are going to need it. And it's hard to make that model work economically for anybody. Doesn't work for the insurance providers. Doesn't work for the employers. Doesn't work for the patients. And so I think that's a real concern and a real limitation of using that approach. So progress, it's still a long way to go. I think that's exactly right. How do you remember as the people who are out there working with individuals, hoping to have children to IVF, feel about where things stand right now? Well, I think right now they have a lot of questions because we don't know. We don't know even for sure how the implementation of the reduced price for products is going to occur, let alone knowing if other manufacturers will feel the need to match that pricing. And that could be a significant development as well. And I was saying on the insurance front, we really don't know what that's going to mean in terms of dollars. So I think there's some cautious optimism amongst the physicians who want to provide this care to patients who get frustrated because every day they see patients and they know there's a technology available that can help them, but those people can't access it for economic reasons. And that's a real frustration for physicians. But I do think that there's also some concern. We saw patients even during the campaign put off care because they were sure that pretty soon IVF was going to be free. And IVF has a very time-sensitive medical procedure. It matters how quickly you get to it. If a woman attempts an IVF procedure at 32, it is very different than it will be for her at 40. And so time is not on the side of the IVF patient. And so there's a concern that either, A, patients are getting their hopes up about how good this benefit is going to be or delaying that care. But the other thing is going to be good. And then they're going to delay care and the benefit is not going to be that helpful anyway. So there is some concern there. Sean Tipton, thank you so much for such a fascinating discussion and really appreciate you joining me today. Of course. Any time. Public Health On Call is a podcast from the Johns Hopkins Bloomberg School of Public Health, produced by Joshua Sharfstein, Lindsay Smith Rogers, and Stephanie Desmond. Audio production by J.B. Arbogast, Michael Bonfills, Spencer Greer, Matthew Martin, and Phillip Porter, with support from Chip Hickey. Distribution by Nick Moran. Production Coordination by Catherine Ricardo. Analytics by Alisa Rosen. If you have questions or ideas for us, please send an email to [email protected]. That's [email protected] for future podcast episodes. Thank you for listening. [Music]