The Impact of Insurance Mandates on Multiple Birth Rates Following in Vitro Fertilization

To determine whether mandated insurance coverage for in vitro fertilization (IVF) has influenced changes in embryo transfer practices and multiple birth rates over time. Retrospective cohort study. We utilized the Society for Assisted Reproductive Technologies-Clinical Outcomes Reporting System (SART-CORS) database to identify fresh, autologous IVF cycles performed between 2007 and 2011 in women aged 20-42 years. Only first IVF cycles performed in each woman’s state of residence were included in the analysis. Cycles were excluded if the indication for IVF was “non-infertile” or “preimplantation genetic diagnosis,” if they were performed in a state with only one reporting clinic, or if embryo transfer occurred on days other than 3 or 5. Among the 40 states with more than one clinic, 6 have legislation requiring insurance coverage for at least one IVF cycle and were designated “mandated:” CT, HI, IL, MA, MD, and NJ. The remaining 34 states were designated “non-mandated.” Regression models with a mandate*year of cycle interaction term were used to examine the effect of mandate status on changes in multiple birth rate per live birth, the proportion of transfers with elective single embryo transfer (eSET), and the mean number of embryos transferred over time. A total of 173,968 cycles were included in the analysis. The multiple birth rate was lower in mandated than non-mandated states (P < 0.001) and decreased over time in both groups (P < 0.001). Similarly, the proportion of transfers with eSET was higher in mandated than non-mandated states (P < 0.001), and increased over time in both groups (P < 0.001). The mean number of embryos transferred was lower in mandated than non-mandated states (P < 0.001), and decreased along a similar trajectory over time when embryo transfer was performed on day 5 (P < 0.001). Conversely, there was a significant interaction between mandate status and time among cycles with day-3 embryo transfer (P < 0.001). The mean number of embryos transferred decreased over time in both groups (P < 0.001), but the trajectory of decline was steeper for non-mandated states between 2007 and 2009 (P < 0.001). Between 2010 and 2011, the trajectory of decline was similar between the groups (P = NS). Multiple birth rates have decreased over time in both mandated and non-mandated states. Although the gap between these two groups has narrowed with respect to the mean number of embryos transferred on day 3, providers in mandated states still transfer fewer day-5 embryos and are more likely to perform eSET.