Diagnosis and treatment of diminished ovarian reserve in assisted reproductive technology cycles of women up to age 40 years: The role of insurance mandates

Objective: To explore correlates of diminished ovarian reserve (DOR) and predictors of assisted reproductive technologies (ART) treatment outcome in DOR cycles using the Society for Assisted Reproductive Technologies-Clinical Outcomes Reporting System (SART-CORS) database; we hypothesized that mandated state insurance coverage for ART is associated with the prevalence of DOR diagnosis in ART cycles and with treatment outcomes in DOR cycles. Design: Cross-sectional study using ART cycles between 2004 and 2007. Setting: Not applicable. Patient(s): A total of 182,779 fresh, nondonor, initial ART cycles in women up to age 40 years. Intervention(s): None. Main Outcome Measure(s): Prevalence of DOR and elevated FSH, odds ratio of DOR and elevated FSH in ART mandated vs. nonmandated states, live birth rates. Result(s): Compared with cycles performed in states with mandated ART coverage, cycles in states with no ART mandate were more likely to have DOR (adjusted odds ratio 1.43, 95% confidence interval 1.37-1.5) or elevated FSH (adjusted odds ratio 1.69, 95% confidence interval 1.56-1.85) as the sole reason for treatment. Lack of mandated ART coverage was associated with increased live birth rates in cycles diagnosed as DOR, but not in cycles characterized only by an elevated FSH. Conclusion(s): A significant association was observed between lack of mandated insurance for ART and the proportion of cycles treating DOR or elevated FSH. The presence or absence of state-mandated ART coverage could impact access to care and the mix of patients that pursue and initiate ART cycles in ways that influence these proportions. Additional studies are needed that consider the coalescence of insurance mandates, patient and provider factors, and state-level variables on the odds of specific infertility diagnoses and treatment prognosis.