June 16, 2014 | Posted By Lisa Campo-Engelstein, PhD

In a recent blog, I asserted that assisted reproductive technology (ART) should be a higher priority for the global South because of the severe health, social, and economic effects infertility can have on women there. The most common response to this claim is that resources should first be devoted to treating and preventing life-threatening conditions, such as malaria and HIV/AIDS, rather than conditions that are perceived as merely social and/or psychological. The same response is often used when people suggest that ART should receive higher priority in the global North. Whereas many global North countries provide national health coverage for ART, the US does not. However, there has been movement toward coverage for ART in the US in the last couple of decades and currently 14 states require health insurance companies to cover ART (though there is a wide range of what is covered and under what circumstances). Unfortunately, oncofertility (fertility preservation for cancer patients) is not covered in any of these state laws.

While I understand the argument that limited healthcare resources should be dedicated to the most "pressing" conditions, it is also important to recognize the potential side effects of choosing not to provide coverage for oncofertility and other types of ART. One concern with the lack of coverage for ART is that it reinforces socioeconomic inequalities. The primary users of ART are white, educated, middle- and upper-class not because this group is the most likely to be infertile, but because they are the most likely to be able to afford the high cost of ART out-of-pocket expenses. Cancer patients from lower socioeconomic backgrounds are unlikely to have the large amount of disposable funds (the average cost for one cycle of IVF is around $12,400) for fertility preservation treatment. While “traditional” infertility patients can save their money over a period of time in order to be able to afford ART, cancer patients need to preserve their fertility before their cancer treatment commences and thus they need to be able to immediately provide the cash for fertility preservation treatment in order for it to occur. 

There is some anecdotal evidence that patients have been able to get their private insurance companies to cover their fertility preservation treatment.  These successes generally depend upon being knowledgeable about the medical system and/or having a patient navigator offering assistance. Cancer patients from lower socioeconomic backgrounds typically do not have the time, resources, education, and connections to facilitate convincing their insurance companies to cover oncofertility. Some patients may not even realize that oncofertility is an option since oncologists do not always discuss it with their patients. The lack of insurance coverage for oncofertility treatment, as well as its high cost, is a reason oncologists frequently give for why they do not bring up oncofertility as an option with their patients. Insurance coverage of oncofertility would make it much more likely that oncologists discuss it with all their patients, regardless of socioeconomic status.

The lack of insurance coverage for oncofertility disadvantages those of lower socioeconomic status.  It is important to recognize how health policy decisions affect people from different backgrounds differently, though the fact that one group is disadvantaged does not necessarily mean we should change our policies. In the case of insurance coverage for oncofertility, and ART more broadly, many other good arguments have already been put for forth (see, for example the hyperlinks in this blog). 

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BIOETHICS TODAY is the blog of the Alden March Bioethics Institute, presenting topical and timely commentary on issues, trends, and breaking news in the broad arena of bioethics. BIOETHICS TODAY presents interviews, opinion pieces, and ongoing articles on health care policy, end-of-life decision making, emerging issues in genetics and genomics, procreative liberty and reproductive health, ethics in clinical trials, medicine and the media, distributive justice and health care delivery in developing nations, and the intersection of environmental conservation and bioethics.