Despite affecting 10-15% of couples in the United States, infertility—the inability to get pregnant after one year of regular, unprotected sexual intercourse—is often still treated as a taboo subject. This is especially true with male infertility, perhaps in part because women who are in a relationship with a man often bear the burden of being perceived as infertile. The reality is, roughly one-third of fertility issues can be attributed to women and one-third to men, while the remaining third are due to both male and female factors or lack an identifiable cause at all.
A widespread misconception about reproduction is that it’s a simple undertaking when, in reality, it’s a multifaceted process that can have setbacks and failures.
What factors can cause infertility in men?
Male factor infertility is often caused by issues with sperm:
- Oligospermia, or low sperm count, is defined as having less than 15 million sperm per milliliter of semen. The exact number of affected men is unknown.
- Azoospermia, or the complete absence of sperm, affects approximately 10% of infertile men, and 1% of all men.
- Asthenospermia, or impaired sperm motility, is typically diagnosed when less than 32% of sperm in a semen analysis are progressively motile.
These conditions can be the result of a problem with sperm creation in the testes or a blockage in the reproductive tract. Chromosomal disorders, like Klinefelter syndrome, can affect sperm production and are 10 times more prevalent in infertile men than fertile men. While sperm production can be negatively affected by prolonged exposure to high temperatures, there is little evidence supporting the pervasive misconception that heat generated by wearing tight briefs can cause infertility.
What factors can cause infertility in women?
Female factor infertility can be caused by:
- Structural issues or damage to the uterus, cervix or fallopian tubes
- Ovulation issues
Structural issues often result from abnormal tissue that blocks the movement of eggs and sperm through the fallopian tubes or prevents implantation in the uterus. These issues can be a result of inflammation in the pelvis, uterine fibroids, polyps or scar tissue within the uterus.
Ovulation issues can occur for a variety of reasons such as age, lifestyle factors, genetic disorders or hormonal problems. Polycystic ovary syndrome (PCOS), a hormonal condition marked by ovarian cysts, is a common reason for female infertility: up to 15% of women of reproductive age are afflicted with PCOS. While hormones play an important role in the female reproductive process, it’s a misconception that the use of hormonal birth control can cause infertility.
What are the leading causes of infertility for both genders?
There are many factors that affect fertility for both men and women:
- Age - While many people know that women are born with a finite number of eggs and thus become less fertile as their ovarian reserve is depleted, it’s a misconception that male fertility is unaffected by age: research shows that men’s sperm production begins to decline at around 34 years old.
- Hormonal issues - Hormonal imbalances or dysfunction may be acquired or caused by inherited disorders like Kallmann syndrome, a genetic condition marked by delayed or absent puberty.
- Lifestyle factors - This can include being severely underweight or overweight, or using tobacco, alcohol and certain prescription and recreational drugs.
- Environmental factors - Exposure to harsh chemicals, pollutants and radioactivity can affect fertility.
- Physical trauma - Surgical scarring and blunt force injuries can cause lasting damage to reproductive organ function.
- Sexually transmitted infections (STIs) - Untreated gonorrhea can affect sperm health, while gonorrhea and chlamydia can lead to pelvic inflammatory disease, causing scarring and structural damage to the fallopian tubes.
And while it’s still unclear if being infected with COVID-19 has any effect on fertility, there’s no evidence to support the misconception that COVID-19 vaccines, or any vaccines, can cause infertility.
Challenges faced by patients dealing with infertility
The costs of office visits, testing and treatment can create monumental financial strain, especially without adequate coverage. While infertility coverage is mandated on some level in 20 states, it is not widely covered otherwise. In vitro fertilization (IVF), a fertility treatment that involves retrieving eggs and then creating an embryo in a lab, is an effective route for some patients but can be prohibitively expensive: a single cycle of IVF can cost over $30,000 and patients may need to go through multiple rounds.
It can be difficult for patients to find an in-network fertility clinic and with the added emotional element of infertility treatment, it’s especially important to find the right care team. Complicating matters, when a heterosexual couple seeks fertility help they may focus on finding treatment for the woman without realizing the prevalence of male infertility. A semen analysis looking at sperm structure and quantity should be one of the first steps in an infertility diagnosis, but 18-27% of heterosexual couples dealing with infertility report skipping a male evaluation, possibly due to high out-of-pocket costs for men without benefit coverage.
People experiencing infertility may also suffer from depression, anxiety and grief, magnified by the fact that the loss can’t be tangibly seen by others. The diagnosis may cause intense shame as a result of societal expectations surrounding parenthood. Lasting struggles with infertility are often traumatic, and can be one of the most upsetting experiences in a patient’s life, even comparable to a cancer diagnosis. Counseling and mental health treatment are frequently important parts of a patient’s infertility journey, but add another layer of cost and time commitment.
A survey of 1,000 people dealing with infertility found that nearly half had not been open about their struggles at work and only 29% felt supported by their employers. It’s no surprise then, that when all of these factors are compounded with the physical stress of bloodwork, imaging, scopes and other fertility tests and treatments, patients dealing with infertility can experience decreased work performance, relationship strain and even violence between partners.
How plan sponsors should approach inclusive family planning benefits
Plan sponsors need to provide strong family planning benefits that transcend outdated notions about infertility. These benefits should include male fertility treatment as well as family-building coverage options for populations that may need access to fertility resources without ever being diagnosed as “infertile,” like single people and the lesbian, gay, bisexual, transgender and queer community. Doing so doesn’t just ensure vital coverage, but promotes strong mental health and attracts and retains talent.
“Fertility should be treated in the same way we cover all other complex medical conditions. This means adopting a benefit that has flexibility to be customized to the patient versus a one-size-fits-all model,” said Dr. Janet Choi, Progyny’s Chief Medical Officer. “I’ve worked with patients who have restrictive plans, and it often forces them to either delay the treatment they need or make decisions based on cost versus what’s recommended by physicians. Sadly, this negatively impacts their mental health and makes an already stressful situation even more so.
“When patients are financially constrained in their medical treatment options, they may feel compelled to make less optimal choices yielding lower pregnancy rates as well as higher rates of multiple pregnancies leading to more complications. This hurts employers who carry the burden of those downstream health care costs.”
Viewing a strong family planning benefit as a luxury or an avenue for increased costs is shortsighted and can lead to poor health outcomes for members and an increase in overall spend. As plan sponsors look to incorporate family planning benefit offerings, it’s essential to have a partner with specialized reproductive and family planning expertise to help navigate the complexities of the infertility landscape.
