Fertility Preservation for Cancer Patients and Why Insurance Companies Should Provide Coverage

Because having cancer is already hard enough.

By Kendahl Servino

Receiving the news that you have cancer can put a slight damper on your day.
Last winter, I sat in a radiologist’s office as he motioned to two large screens in front of us.
They displayed the results from the mammogram I had just ten minutes prior. He gestured
to the left side, where a discernible mass dismantled symmetry from the otherwise identical
right side. There were tiny spikes emerging all around the perimeter of the tumor. Like a sea
urchin, the radiologist told me. My tumor was tiny, terrifying, and right in front of me. I had
been by myself. I was twenty years old.

Nothing about cancer is fair. As a young adult especially, the odds should have been well
within my favor. While the risk of breast cancer increases with age, the chances of a woman
being diagnosed with breast cancer in her twenties are 1 in 1,732 [1]. That’s 0.6%. And with
no family history either, the chances had been virtually zero. But again, nothing about
cancer is ever fair, and neither are all the changes in one’s life that accompany a diagnosis.
The effects of cancer in one’s life are seismic. Chemotherapy alone has a plethora of side
effects: alopecia, fatigue, nausea (and not to mention the many mental side effects that are
less discussed). But one unexpected side effect was the possibility of iatrogenic infertility.

Iatrogenic infertility is infertility induced by medical treatment. Chemotherapy has systemic
effects on the body, and reproductive organs unfortunately, cannot evade the cytotoxicity.
Many cancer patients turn to assisted reproductive technologies for fertility preservation
options prior to chemotherapy, which often include gamete and embryo freezing. In most
states, these types of procedures are considered elective and thus not covered by
insurance. For a cancer patient, this places an exorbitant financial burden on top of all the
other medical expenses. For many, being denied insurance coverage can feel like one more
unfair item added to the list of concomitant struggles of cancer.

Currently, seventeen states require insurance companies to offer some form of coverage for
infertility diagnosis and treatment. Of those, seven have legislature specifically for medically
induced infertility. The range of coverage varies by state: for example, Hawaii provides only
one cycle of infertility treatment, while Illinois offers four [2]. Here in Nevada however, there
are no insurance policies at all.

While insurance has thankfully covered the majority of my cancer treatment, fertility
preservation was something my family and I were left to on our own. After being advised to
look into fertility preservation options, I underwent oocyte cryopreservation, or colloquially,
egg freezing. This was a time sensitive process involving ovarian stimulation followed by
egg retrieval. For nearly two weeks, I gave myself a combination of subcutaneous injections
every evening when I got back from school. Thirty three oocytes were extracted for my
future use. I started chemotherapy two days later.

While breast cancer happens to be the most frequent cancer among reproductive age
women, less than 10% of those diagnosed decide on fertility preservation [5]. For some,
immediate treatment (whether chemotherapy or radiation) is critical and cannot be
postponed. Others may have already established their families. Yet for many, a lack of
insurance coverage leaves them no choice but to forgo preservation.

To put into perspective: according to the NovaRest 2017 Annual Mandate Report, egg
cryopreservation has an average price of $10,000-15,000 [6]. For estimates in Nevada,
Reno and Las Vegas are on the higher end with averages of $14,000 and $15,000,
respectively [7]. This excludes medications, which range from $2000-6000, and the annual
storage fees for the gametes, which costs about $300-500 a year. It is a colossal burden to
ensure the possibility of having children in the future following chemotherapy. Yet the ability
to have children in the future, should a cancer patient desire them, should not have to fall
contingent on his or her financial stability.

What’s interesting is that iatrogenic infertility is treated differently from other iatrogenic
conditions, which do often receive insurance coverage. The Women’s Health & Cancer
Rights Act of 1998 stipulated that if insurance companies were going to cover mastectomies
for breast cancer patients, they must also cover reconstruction surgeries [8]. If medically
necessary treatments are covered, so too must there be coverage for the sequelae that
follow. Analogously then, if insurance companies cover chemotherapy, they should also
cover the potential infertility. Yet, this isn’t the case. Providing coverage for other iatrogenic
conditions yet disregarding iatrogenic infertility seems little more than a stark moment of
cognitive dissonance.

Iatrogenic infertility coverage needs to be included in more states’ legislature. For the
seventeen states with existing legislature, the definition of “infertility” needs to be expanded
to support prophylactic procedures for cancer patients and others undergoing medically
necessary treatments. An alternative is to include fertility preservation as part of standard
cancer treatment, which is often already covered by insurance [5]. Currently, there are
independent programs, such as LiveStrong, which support cancer patients’ fertility
preservation finances. Thankfully, my family and I were able to receive partial financial
coverage from these types of programs. But there is still much more that can be done for
cancer patients. Because when we’re fighting for our lives, the potential inability to create a
family in the future adds one more unfair concern we’re forced to face.

Visit triagecancer.org/advocacy to learn how to be a cancer advocate.

References
[1] “Risk of Developing Breast Cancer,” Breastcancer.org, 20-Dec-2018. [Online]. Available:
https://www.breastcancer.org/symptoms/understand_bc/risk/understanding#:~:text=06%,
or 1 in 1,732,the next 10 years is . [Accessed: 07-Jun-2020].

[2] E. Skinner and A. Garcia, “State Laws Related to Insurance Coverage for Infertility
Treatment,” National Conference of State Legislatures, 12-Jun-2019. [Online]. Available:
https://www.ncsl.org/research/health/insurance-coverage-for-infertility-laws.aspx.
[Accessed: 07-Jun-2020].

[3] “Discover Infertility Treatment Coverage by U.S. State,” RESOLVE, 31-Oct-2019. [Online].
Available:
https://resolve.org/what-are-my-options/insurance-coverage/infertility-coverage-state/.
[Accessed: 07-Jun-2020].

[4] “State Laws & Legislation,” Fertility Preservation State Laws & Legislation | Alliance for
Fertility Preservation, 28-Apr-2020. [Online]. Available:
https://www.allianceforfertilitypreservation.org/advocacy/state-legislation. [Accessed:
07-Jun-2020].

[5] E. R. Cardozo, W. J. Huber, A. R. Stuckey, and R. J. Alvero, “Mandating Coverage for
Fertility Preservation — A Step in the Right Direction,” New England Journal of
Medicine, vol. 377, no. 17, pp. 1607–1609, Oct. 2017.

[6] D. Novak and K. Bender, “Annual Mandate Report: Coverage for Fertility Preservation …,”
16-Nov-2017. [Online]. Available:
http://mhcc.maryland.gov/mhcc/pages/plr/plr/documents/NovaRest_Evaluation_of_
Proposed_Mandated_Services_Iatrogenic_Infertility_FINAL_11-20-17.pdf. [Accessed:
07-Jun-2020].

[7] “How Much Does IVF Cost in Nevada? Average IVF Cost, Insurance & Financing,” IVF
Authority, 09-Jun-2019. [Online]. Available:
https://www.ivfauthority.com/ivf-cost-in-nevada/. [Accessed: 07-Jun-2020].

[8] L. Campo-Engelstein, “For the Sake of Consistency and Fairness: Why Insurance Companies
Should Cover Fertility Preservation Treatment for Iatrogenic Infertility,” Cancer
Treatment and Research Oncofertility, vol. 156, pp. 381–388, 2010.