Fertility and Family Building Education

Fertility and Family Building Toolkit

Modern Fertility and Family Building Education

Fertility Facts

  • Infertility is recognized as a disease by the American Medical Association and the World Health Organization.
  • Infertility is common. 1 in 6 people, regardless of gender, experience infertility. More will require assistance to build their families based on health circumstances and family compositions.
  • Infertility impacts men and women equally. Male-factor infertility is often overlooked and impacts nearly half of cases, either alone or as a contributing factor.

Workforce desires today encompass support and coverage for fertility and family building care that’s inclusive of individualized health scenarios. Traditionally, infertility was defined simply as an inability to conceive after six months to one year of unprotected heterosexual intercourse. This definition prevented many singles by choice and LBGTQIA+ couples from being eligible for the benefit due to age, sexual orientation, marital status, and more, creating a major equity gap.

In 2023, the American Society of Reproductive Medicine, ASRM, released an updated, more inclusive definition of infertility that is not restricted by gender, sexual orientation, or marital status.

“Infertility” is a disease, condition, or status characterized by any of the following:

  • 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 six months when the female partner is 35 years of age or older.

Americans are starting families later in life, which can make it harder to conceive. U.S. Census Bureau and National Center for Health Statistics data shows that fertility rates among women ages 20-24 declined by 43% between 1990 and 2019, while rates for women ages 35-39 increased by 67% in that same period. A 2023 National Health Statistics report indicates that reasons for delayed childbearing include the pursuit of higher education and increased labor force participation, where “having a first child at older ages has been associated with a positive impact on women’s wages and career paths.”

First pregnancies beyond the mid-30s are associated with a higher risk of pregnancy complications and underlying conditions like gestational diabetes or preeclampsia, highlighting the desire for fertility and family building care that is comprehensive and considers the whole health of the patient. There is a clear opportunity to support employees as they are building and growing their families with robust fertility, family building, and maternal/paternal health support.


The New World of Family Building: Growing Demand and Common Pathways

Fertility and family building assistance comes in many forms, including preconception care, fertility treatments, pregnancy support, surrogacy, and adoption. Comprehensive benefits will factor in proactive support and expert navigation for all of the fertility and family building pathways – including maternity support that can have a major impact on high-risk pregnancies – while guiding employers through the nuances of offering in a compliant, clinically effective, and member-centric fashion.

Because fertility treatment is often a patient’s first complex interaction with the health care system, benefits that offer access to the highest-quality providers and advocate-supported navigation can offer employees the best chance at growing their families in a healthy, effective, and financially responsible way.

Removing infertility diagnosis requirements can also offer access to a wider population. Sixty-three percent of LGBTQIA+ individuals planning to build their families say they will rely on assisted reproductive technology (ART), foster care, surrogacy, or adoption to become parents. Single parents by choice rely on the same pathways for starting or building families.

Employers who want to close equity gaps for the LGBTQIA+ and singles by choice employees and their dependents planning to build their families may find it helpful to partner with a vendor with specific expertise. There may be compliance and tax considerations associated with offering services that don’t meet infertility diagnosis requirements, so look for benefits that can guide employees through the process.


Assisted Reproductive Technology (ART)

Assisted reproductive technology is the most common family building pathway and represents roughly 2.3% of babies born each year. Since 1978 there have been 9 million babies born using assisted reproductive technologies worldwide – and this number continues to grow thanks to innovative technologies and payers providing coverage. See “Fertility Terminology” for more information on ART.

More about ART



Many individuals choose to build their families through adoption. One-third of Americans have considered adoption as their pathway to parenthood, leading to approximately 135,000 adoptions in the United States each year.

Adoption can be a complicated, lengthy, and a costly process, depending on the type of adoption (e.g., private, domestic, international). According to Child Welfare Information Gateway, independent or agency-based adoptions can cost anywhere from $30,000 to $60,000 per child. Fees typically cover a birth mother’s medical expenses, legal representation for adoptive and birth parents, court fees, social workers, and more. Singles and couples who pursue adoption will need to navigate state laws that may factor in age, marital status, and sexual orientation of the adoptive parents.

More About Adoption



Surrogacy is the process where an individual serves as a gestational carrier for the prospective parent(s). Singles or couples might consider surrogacy if they have struggled with infertility, have a medical issue that precludes them from carrying a child, or are a member of the LGBTQIA+ community.

Typically, the child is not genetically related to the gestational carrier. The prospective parent(s) undergo IVF to create embryos using their own egg and sperm or donor egg and/or donor sperm. The embryo is then transferred to the gestational carrier.

The surrogacy process can be costly and lengthy. Costs can range from $100,000 to $150,000, which covers surrogacy agency fees, matching services, psychological screening, legal services, medical expenses for the surrogate as well as the prospective parents (creation of the embryo), surrogate compensation, and surrogacy services.

More About Surrogacy


Foster Care

Foster care is a system in which a minor is placed into a ward or group home (residential childcare community or treatment center), the private home of a state-certified caregiver (referred to as a "foster parent"), or with a family member approved by the state. The placement of a foster child is normally arranged through a government or social service agency. The institution, group home, or foster parent is compensated for expenses - family members are not. In some states, relative (or "kinship") caregivers are provided with a financial stipend.

More About Foster Care


Barriers to Fertility Care

As employers look to new or expanded fertility and family building benefits, it is important to first understand some common barriers employees may face.

Infertility can be challenging as it is often associated with a sense of shame, secrecy, or stigma. Without a benefit to cover fertility and family building care, employees are left to navigate a complex, disconnected, and often expensive process that can leave them frustrated, unsuccessful in their attempt, or in poor financial shape.

Coverage or benefit models that treat infertility differently than other chronic diseases, such as with a dollar cap benefit model, can inadvertently perpetuate this stigma and impede clinical efficacy by not covering care in a timely, streamlined fashion. Employers can play a pivotal role in breaking this stigma and member friction by championing a flexible, individualized approach for fertility care.

Very few states mandate fertility offerings, and even in those that do, that benefit is minimal. Traditional plans often include the dollar cap benefit model, which establishes a finite dollar amount for coverage and care. This can impact a patient’s decision-making as they try to cut costs to maximize their benefit (such as choosing to skip certain tests to save money). Others use a “step therapy” approach, requiring patients to try specific treatments first before pursuing more clinically appropriate treatments based on their unique situation.

Race-related disparities in fertility and maternal health, especially among black women, are another factor at play in the fertility landscape. Black, Indigenous, and People of Color (BIPOC) populations continue to have higher rates of infertility and a higher risk of maternal mortality. Despite higher rates of infertility, Black women are less likely to access treatment when compared to white women and, if they do, may wait twice as long before seeking care. Treatment models that remove barriers found in traditional plans, focus on the member, offer culturally competent care, and can do much to address disparities. For example, offering genetic testing for Sickle Cell Disease (1 in 13 Black or African American babies is born with sickle cell trait) as part of an inclusive episode of care can support Black reproductive health without forcing members of this community to use up their dollar cap more quickly than their white counterparts.

Look for vendors who offer benefits for an entire episode of care and follow best practices in medicine for complex care conditions. Ask to see how the vendor’s model works when it comes to member support and finding culturally sensitive care from a provider and care management team. These factors allow the benefit to address disparities in care for better outcomes and member experience.


Be in the Know: Fertility Terminology

Common Fertility Treatment and Procedures


Assisted Reproductive Technology (ART)

ART is defined by the CDC as fertility treatments involving surgically removing eggs from a woman’s ovaries, combining them with sperm in the laboratory, and returning them to the woman’s body or donating them to another woman. ART does NOT include treatments in which only sperm is handled (i.e., intrauterine insemination) or procedures in which a woman takes medicine to stimulate egg production without the intention of having eggs retrieved.


In Vitro Fertilization (IVF)

IVF is a technique where an egg and sperm are combined in a special laboratory to create an embryo. Depending on the diagnosis and age of the prospective mother, a single embryo or multiple embryos are transferred to the woman’s uterus to enhance the chances of pregnancy.

Note: Implanting a single embryo (elective single embryo transfer, or “eSET”) is a best practice in most cases. During this procedure, one embryo is selected from a larger number of available embryos and is placed in the uterus. eSET helps families achieve success while preventing associated risks with multiple births (two or more children born at the same time), which can lead to pregnancy complications, pre-term births, and costly NICU stays. There are some cases where multiple embryo transfer is appropriate. Vendors who manage utilization to authorize fertility procedures where appropriate will offer the population the safest and most effective care.

Success rates vary based on age, medical history, infertility diagnosis, history of previous births, miscarriages, and previous experience with IVF cycles.

The process typically involves tests designed to avoid potential complications:

  • Preimplantation Genetic Testing for Aneuploidy (PGT-A): This test may be performed in conjunction with IVF treatment and involves testing embryos for chromosomal abnormalities. PGT-A testing supports single embryo transfer, reduces the risk of miscarriage, and increases the probability of a successful pregnancy.
  • Preimplantation Genetic Testing for Monogenic/Single Gene Diseases (PGT-M): This test is used prior to embryo transfer to help identify possible genetic defects and is intended to prevent specific genetic diseases or disorders from being passed to the child. Coverage of PGT-M is especially important for certain ethnic groups at higher risk for genetic disorders, such as Sickle Cell Disease, Tay-Sachs disease, and cystic fibrosis.


In Vitro Fertilization (IVF) - Fresh

An IVF fresh cycle starts by stimulating the ovaries with a course of medications. Following stimulation, the doctor retrieves the eggs, which are then taken to the lab and fertilized. After three to five days, an embryo is transferred into the uterus with a goal of achieving pregnancy. Any remaining embryos may be biopsied to be tested for aneuploidy (PGT-A) before being frozen using vitrification (“flash freezing”) for later use. IVF fresh can also be used with a donor egg and/or sperm.


In Vitro Fertilization (IVF) – Frozen/Freeze-All

An IVF freeze-all starts by stimulating the ovaries with a course of medication, followed by egg retrieval and fertilization. On day 5, the developing embryos are biopsied before being frozen using vitrification. The biopsied tissue undergoes (PGT-A), allowing the fertility specialist to ensure the most viable embryo is chosen for transfer. The embryos remain frozen while the PGT-A testing takes place, allowing the prospective mother’s body to rest and return to a pre-treatment state before a frozen embryo is transferred. IVF freeze-all can also be used with a donor egg(s) and/or sperm and has a higher successful pregnancy rate, compared to IVF fresh.


Frozen Embryo Transfer

Embryos that have been frozen during an IVF freeze-all, fertility preservation (egg freezing) or previous IVF fresh cycle are available to be thawed and transferred into the uterus. A frozen embryo transfer is commonly performed following an IVF freeze-all cycle to allow for (PGT-A) on the resultant embryos. PGT-A testing ensures only a genetically or chromosomally normal embryo is chosen for transfer.


Other Common Fertility Treatments and Procedures

Timed Intercourse

This entails timing intercourse for the most optimal window of fertility.

The two core types include:

  1. Unmedicated: couples track their own ovulation or track through ultrasounds with their doctor and/or an app-based intervention with preconception counseling.
  2. Medicated: fertility medications assist ovary stimulation to produce more eggs; this process often requires hormone-stimulating medication for 13 to 17 days before attempting conception. During this time, physicians monitor follicle growth and prescribe a trigger shot, which induces ovulation.

Once ovulation has been triggered, couples are instructed to have intercourse every other day for three days. Two weeks later, a pregnancy test is taken. The average success rate of timed intercourse is between 9% and 33%. Success rates decline as people age and can also be impacted by other factors, such as smoking, excessive alcohol consumption, stress, being overweight, using recreational drugs, and having other chronic conditions (such as diabetes or high blood pressure), STDs, or hormonal disorders.


Intrauterine Insemination (IUI)

Also called “artificial insemination,” this process involves directly inserting prepped sperm into the uterus using a catheter. This is done either with or without a course of medication.

The CDC and the Society for Assisted Reproductive Technology (SART) do not currently require fertility clinics to report IUI, but success rates have been reported to vary from 5-15% with a rate of multiples ranging from 8-30%. Success rates vary based on a patient’s age and response to medication.

It is important to note that IUI is not for everyone. IUI is not an effective treatment for those with blocked or damaged fallopian tubes, problems with pelvic adhesion, diminished ovarian reserves, severe endometriosis, male-factor fertility issues, or a history of poor IUI response. When these conditions are present, other treatments are often a better course of action.


Reciprocal IVF

This process includes same-sex female partners providing one of their eggs, which is then combined with donor sperm. The resulting embryo is placed in the uterus of the other partner.


Fertility Preservation (egg/sperm/embryo freezing)

Fertility preservation, also known as tissue cryopreservation or egg/sperm/embryo freezing, allows singles or couples to preserve their fertility for future attempts at pregnancy. This treatment may be appropriate for women with health issues such as endometriosis, fibroids, diminished ovarian reserve/low egg supply, a family history of early menopause or cancer, and for those who choose to delay childbearing. Men may be advised to consider sperm freezing due to low sperm count or other medical conditions. Fertility preservation is also an important treatment option for trans individuals prior to transitioning to preserve their ability to have children at a future date.


Sperm Washing

This process increases the chance of a successful pregnancy by washing sperm with a special solution to remove low-quality sperm and potential disease-carrying material. Sperm washing is a standard component of many fertility procedures and is especially critical for serodifferent couples.

What does serodifferent mean?

When a couple is serodifferent (or "serodiscordant"), it means one person is living with HIV and the other person is HIV-negative.

Understanding the Data

Fertility Treatment Data

When working with fertility and family building benefits, reliable, high-quality data is important. This allows for benchmarking results and outcomes against national averages to ensure quality care and shows how a benefit stacks up when it comes to a return on investment.

Fertility treatment is unique in health care in that a national database of outcome data is publicly available. In compliance with a 1992 congressional mandate, fertility clinics in the U.S. are required to report data on ART cycles annually. Since 1995, this data has been collected via the National ART Surveillance System (NASS). Reports are published annually and include the percentage of ART procedures and transfers resulting in pregnancy, live births, and multiple births (e.g., twins and triplets). As employers explore fertility and family building benefits, this data can play a vital role in ensuring access to high-performing fertility clinics.


Key fertility data points (as of November 2023)

Pregnancy rate per IVF transfer (national average: 53.8%)

  • A high IVF pregnancy rate indicates treatment processes used by providers are working. Providers adhering to best practices and using the latest technologies will boast a higher rate.

Miscarriage rate (national average: 18.4%)

  • Miscarriage rates that are lower than the national average indicate best practices are being used and providers are working with their patients to mitigate risks. Miscarriages are unavoidable, but quality providers will work to keep the miscarriage rate as low as possible.

Retrievals per live birth (national average: 3.5)

  • Retrieval per live birth rate indicates how many rounds of treatment a patient goes through on average before achieving a full-term pregnancy and live birth. The lower the number, the fewer treatments the patient must go through (and the less expensive it is for the employer).

Live birth rate (national average: 41.6%)

  • A high live birth rate is a surefire sign of successful treatments and practices that ensure healthier, full-term pregnancies. The higher this statistic, the better.

Single Embryo Transfer (SET) rate (national average: 75.5%)

  • The SET rate indicates providers are using best practices (implanting one embryo) to reduce the risk of multiples. Implanting multiple embryos, which can be beneficial in limited situations, can lead to high-risk pregnancies and costly NICU stays.

IVF multiples rate (national average: 6.9%)

  • Implanting multiple embryos can be beneficial in limited situations, but best practice is to reduce high-risk pregnancies and encourage healthy, singleton pregnancies by implanting a single embryo in the majority of cases.

IUI success rate (national average: not collected)

  • IUI data is not collected at the national level. Reported success rates range between 5-15%.


Work chart: Evaluating/Calculating clinical outcomes

To understand a solution’s outcomes, it’s important to first understand how the numbers are calculated. Here is an easy-to-use chart to help evaluate solutions.

Employers can include the following chart of questions in a Request for Proposal (RFP) or Request for Information (RFI) to solicit their direct.

For a downloadable version of this chart, click here.

Question Why is this important? Answer
What is the vendor’s network model? A vendor’s network model gives insight into whether or not the vendor is able to receive outcomes directly from providers and the level of clinical oversight the vendor has.
How was the data collected? For ex: claims, self-reported, direct from providers, from clinic-reported data? Understanding how a vendor receives data is critical as it can tell how complete and accurate the data is and whether it is for the employer’s specific members or for other patients at that clinic.
Does this data represent the vendor’s entire book of business or is it a smaller sample? Having a clear understanding of the population size used to calculate the outcomes is important to understanding its validity. Meaningful cycle volume and high reporting compliance are critical in ensuring outcomes are representative of patients’ results and not due to random chance.
How does the vendor calculate the outcomes? What is the calculation behind each metric? Fertility is very complex. A single success outcome can be calculated in many ways. For example, when a vendor says they have a pregnancy rate of X, is it pregnancy rate per retrieval, pregnancy rate per transfer, or pregnancy rate per transfer for those <35, etc. Consistency is required for accurate aggregations and comparisons.
Has the data been validated by an independent third-party? A third-party, independent verification can ensure a trustworthy methodology for calculating outcomes.
Does the vendor report outcomes every year? For what years does the vendor report outcomes? What are they benchmarking against? A consistent trend of superior outcomes is key to understanding the value and impact of a solution. CDC and SART release data on a delayed timeline to allow for analysis; the most current CDC is delayed by 3 years and SART data is delayed by 2. Fertility solutions should be clear about the CDC/SART data they are benchmarking against and they should be using their most up to date outcomes so employers can evaluate the most recent impact of the solution.
When can the next update of outcomes be expected? Knowing the vendor’s process for updating data and outcomes is important to understanding if data is old or may be cherry-picked, and when to expect updated outcomes.

Work chart: Calculating clinical outcomes

To understand a solution’s outcomes, it’s important to first understand how the numbers are calculated. Here is an easy-to-use chart to help evaluate solutions.


Work Chart: Data-Specific Questions

Below are the clinical metrics essential to understanding the effectiveness of a fertility benefit solution. Remember: higher numerators indicate a larger data pool for the outcomes.

An employer can ask for the numerators, denominators, and vendor outcomes from a prospective benefit. Employers can also include this chart in a Request for Information or Request for Proposal project with the vendor to solicit their direct input.

For a downloadable version of this chart, click here.

Outcome Numerator Numerator Definition Denominator Denominator Definition Vendor Outcome Nat’l Avg.**
Pregnancy rate per IVF transfer IVF treatments in which a transfer occurred within the respective date range AND clinical pregnancy was confirmed IVF treatments in which a transfer occurred within the respective date range
Miscarriage rate IVF treatments within the respective date range with confirmed clinical pregnancy and confirmed miscarriage (loss of pregnancy) IVF treatments within the respective date range with confirmed clinical pregnancy
Retrievals per live birth Count of all attempted retrievals where an attempted retrieval is followed by an attempted transfer within a 12 month period at the same clinic Count of positive clinical pregnancy confirmation for IVF in which a transfer occurred with a service date within the report date range) minus the count of IVF treatments with a confirmed positive pregnancy with a service date within the report date range that had a miscarriage
Live birth rate Live births for IVF treatments in which a transfer occurred within the respective date range IVF treatments in which a transfer occurred within the respective date range.
Single Embryo Transfer (SET) rate Count of all IVF treatments in which a transfer occurred with a service date within the report date range AND where SET was performed. Count of all covered IVF treatments in which a transfer occurred with a service date within the report date range.
IVF multiples rate Multiple live births for IVF treatments in which a transfer occurred within the respective date range. All live births for IVF treatment in which a transfer occurred within the respective date range.
IUI success rate The total number of IUI treatments that resulted in a successful pregnancy. The total number of IUI procedures that were performed, including both successful and unsuccessful attempts. 5 – 15%*

*IUI data not collected at the national level.

** National averages are as of MM/DD/CCYY.


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