Disparities in infertility workup costs across the United States

Abstract

Objective

To investigate cost disparities of infertility diagnostic tests across the United States.

Design

Cross-sectional study analyzing costs for recommended infertility diagnostic tests, including hormone tests (follicle stimulating hormone, luteinizing hormone, estradiol, and progesterone), semen analysis, transvaginal ultrasound, and hysterosalpingogram. Data were sourced from consumer cost claims repositories for five most populous cities per state, categorized into four regions (Midwest, South, West, and Northeast) as per US Census Bureau classifications. Descriptive statistics and analysis of variance with Tukey’s post hoc tests evaluated cost variations across states and regions.

Setting

Not applicable.

Patient(s)

No individual subject data.

Exposure

Not applicable.

Main Outcome Measure(s)

Average costs for infertility diagnostic tests by states/regions, correlated with median household income, race, poverty, uninsured rate, and insurance mandates.

Result(s)

Alaska had highest total cost at $2,986, with Oregon the lowest at $835. Costs for all tests, except follicle stimulating hormone, varied significantly across states. Regional variations were noted, with luteinizing hormone, estradiol, transvaginal ultrasound, and hysterosalpingogram showing significant differences. Total workup costs varied by region, with Midwest having the highest average at $1,651, positively correlated with median household income, followed by Northeast, West, and South. States with insurance mandates for fertility coverage had lower uninsured rates. No correlation was found between state insurance mandates and costs.

Conclusion(s)

The study highlights significant regional cost disparities in infertility care, emphasizing complexities of access and affordability in the United States. Further research is needed to assess the out-of-pocket financial burden on patients and identify strategies to reduce these costs.

Infertility represents a prominent health challenge impacting a significant percentage of women in the United States, with 7.4 million women of reproductive age, or 12.1%, experiencing difficulty having children (1, 2). Approximately 12% of women will receive infertility services at some point during their lifetime (3). Infertility is a condition that is impactful in patients’ lives—couples and individuals suffering from infertility often grapple from a significant amount of emotional strain (4, 5). Adding to the complexity of emotional burden is the substantial cost associated with infertility treatment in the United States. The expenses associated with addressing infertility, particularly through assisted reproductive technology such as in vitro fertilization (IVF), has been extensively explored over the last few decades (6, 7). One study places the financial commitment for each cycle of IVF per couple or individual estimated to approximately $19,200 (8).

Against this backdrop of financial burden associated with infertility treatment, the challenges truly begin in the diagnostic phase that individuals and couples must first navigate. Recent literature has predominantly concentrated on the costs entailed in treating infertility postdiagnosis, but there exists a notable gap in understanding the potential financial hurdles associated with the diagnostic process (9, 10). When a patient initially seeks consultation with an infertility specialist, an assortment of preliminary tests and imaging studies are typically ordered. It is at this juncture that costs begin accruing for patients, adding an additional layer of financial strain even before the commencement of actual treatment. For some, the expenses accrued at this phase may be too burdensome to proceed with treatment.

Insurance coverage for infertility can range from no coverage to coverage only for diagnostic testing, to full coverage—and this variation often depends on the type of insurance the patient holds as well as the state of residence. Many insurance companies do not consider infertility a “disease” and often exclude the testing involved and treatment from coverage. Only 21 of 50 states in the United States have passed fertility coverage laws, but many of these mandates still do not include complete coverage (11, 12). Despite persistent advocacy efforts to mitigate these financial challenges for individuals and couples, this movement does not have a clear resolution in sight. In the current political landscape, it becomes imperative to truly understand the financial burden that patients face when they first engage with a physician to address infertility concerns.

This study seeks to attain a comprehensive understanding of the costs associated with infertility by examining the costs of the initial tests and imaging studies that may be ordered by physicians. To do so, this study reviews the costs of these diagnostic tests across the United States and analyze whether there are differences regionally. The costs of these tests are also analyzed against whether a particular state has an insurance mandate for infertility. This is in effort to determine if state mandates influence costs, hypothesizing that nonmandated states might exhibit higher and more variable costs because of reduced regulation and coverage. Previous research has delineated regional deficiencies in access to infertility services, raising concerns about potential disparities in costs of IVF treatments across different regions in the United States (13, 14, 15). Therefore, one of the aims was to observe whether discernible trends are apparent in the costs of infertility diagnostic workups, particularly in areas where access to care may be limited. This investigation also seeks to evaluate the equity of these costs on a national scale.

Materials and methods

Study design

Cross-sectional study Data components

To identify which tests are commonly employed during initial diagnosis of infertility, this study considered the Committee Opinions from the American College of Obstetricians and the American Society for Reproductive Medicine (16, 17). This study’s primary focus was to obtain price data of the following tests: antimüllerian hormone levels (AMH), gonadotropin levels (follicle stimulating hormone [FSH] and luteinizing hormone [LH]), estradiol levels, progesterone levels, semen analysis, transvaginal ultrasound (TVUS), and hysterosalpingogram (HSG). The selection of data components was guided by recommendations from American College of Obstetricians and American Society for Reproductive Medicine, which outline key tests for infertility evaluation. However, the choices were also constrained by the limited range of tests available to analyze on the consumer repository websites. For example, saline infusion sonography is commonly used in an infertility workup; however, the cost data for this were not available in publicly available consumer repositories. Demographic variables including median household income, race/ethnicity makeup of White and Black population, poverty level, and uninsured rate were collected. Other secondary variables that were collected included insurance mandates for infertility coverage in the 50 states.

Data collection

This study employed the 2022 Census data to identify the five most populous cities in each state. This approach allowed us to provide a representative sample size per state, while working within practical limitations, such as the search constraints imposed by the websites used to gather cost data. In the case that one city did not have cost information, the next most populous city was used to obtain a total of five per state. States were divided into four regions (Midwest, South, West, and Northeast) as recognized by the US Census Bureau (18). Price data for infertility workup components were collected from fairhealthconsumer.org and hfcostlookup.org (19, 20). A preliminary analysis was conducted in two states to compare costs listed on both websites and found no discrepancies. Both websites were used interchangeably to gather cost data for this study. The costs were systematically gathered for five cities in all 50 states except for Hawaii, which only had one geographic area listed as an incorporated place (Urban Honolulu CDP). Demographic variables were collected for each state using the 2022 Census data (21, 22). Information about insurance mandates was collected from RESOLVE, the national infertility organization (12). Insurance coverage ranged from minimal to full coverage; however, the extent of coverage was not studied in this project, only whether coverage was present.

Medical codes

Current Procedural Terminology codes were used to obtain cost information from the above websites. The same codes were used for all states and across the two websites to ensure consistency as there were often several codes that could be used for any of the tests.

• •AMH—82166
• •FSH—83001
• •LH—83002
• •Estradiol—82670
• •Progesterone—84144
• •Semen analysis—89320
• •TVUS—76830
• •HSG—58340

Statistical analysis

Descriptive statistics, including means and SDs, were computed for each infertility workup component per state and per region. All hormone tests (i.e., AMH, FSH, LH, estradiol, and progesterone) were grouped during analysis. One-way analysis of variance tests were conducted to compute mean costs across states and regions for each test and imaging study. Post hoc tests using Tukey’s honest significant difference were performed for comparison of means for states and regions. Independent sample t tests were used to analyze comparison between costs and insurance mandate status per state. Secondary variables, such as the demographic variables, were analyzed in the context of regional costs. Nonparametric median tests were used to analyze the secondary variables (i.e., the demographic variables) based on regions. Nonparametric t test was used to compare states with and without insurance mandates to the uninsured rate per state. Median household income was correlated with the total laboratories and total workup costs per region using Spearman’s rho. Statistical significance for all tests was set at P≤.05.

Ethical consideration

This study was reviewed and approved by our institution’s institutional review board and was determined to involve nonhuman subjects (IRB-2024-538)

Results

Variations in costs per state

Costs of the various components of infertility workup are noted in Table 1 based on state. Alaska had the highest total costs of diagnostic tests, whereas Oregon had the lowest total cost. When analyzed across states with one-way analysis of variance tests, costs of all tests and imaging studies except for FSH (P=.06) varied considerably (P<.001). For example, the cost of LH ranged from $64 to $227, whereas the cost of TVUS ranged from $108 to $375. Figure 1 represents a heatmap indicating total costs.

Table 1.

Average costs for infertility workup tests by state.

States	FSH ($)	LH ($)	Estradiol ($)	Progesterone ($)	AMH ($)	Semen analysis ($)	TVUS ($)	HSG ($)	Total cost ($)	Insurance mandate	Uninsured rate (%)
Alabama	71.20	100.60	106.40	93.20	120.40	105.00	140.00	417.40	1,154.20	No	8.8
Alaska	179.60	214.00	198.00	176.40	310.00	322.00	364.00	1,532.60	3,296.60	No	11.0
Arizona	122.60	125.20	190.80	146.60	216.80	134.80	375.80	531.00	1,843.60	No	10.3
Arkansas	131.60	119.60	182.80	116.40	170.40	163.60	124.00	601.00	1,609.40	Yes	8.4
California	110.60	100.60	199.20	128.20	131.60	231.60	201.40	724.00	1,827.20	Yes	6.5
Colorado	164.80	111.20	146.60	113.00	204.80	151.80	154.60	1,131.60	2,178.40	Yes	7.1
Connecticut	150.40	125.00	214.00	157.20	200.20	214.60	230.80	1,316.00	2,608.20	Yes	5.2
Delaware	94.00	98.00	150.00	110.00	131.20	186.68	132.28	179.28	1,081.40	Yes	5.6
Florida	122.40	118.60	191.20	124.20	175.80	178.52	124.96	189.66	1,225.30	No	11.2
Georgia	130.20	122.60	190.40	146.40	176.20	180.20	126.52	192.64	1,265.20	No	11.7
Hawaii	64.00	64.00	97.00	90.00	127.00	125.00	142.00	650.00	1,359.00	Yes	3.5
Idaho	75.60	95.00	95.20	77.60	204.80	133.20	180.40	265.40	1,127.20	No	8.2
Illinois	169.20	179.20	170.80	108.20	200.40	148.00	293.40	854.20	2,123.40	Yes	6.6
Indiana	115.40	105.40	155.60	149.00	139.20	209.00	139.20	766.00	1,778.80	No	7.0
Iowa	97.40	120.40	131.80	84.60	151.20	129.40	153.60	738.60	1,607.00	No	4.2
Kansas	122.20	123.40	154.40	119.00	179.60	148.60	126.60	498.60	1,472.40	No	8.6
Kentucky	139.00	95.60	133.20	110.40	137.00	141.56	107.68	153.64	1,018.10	Yes	5.7
Louisiana	125.80	124.60	192.00	104.80	165.00	149.16	114.24	155.31	1,130.90	Yes	6.9
Maine	89.80	151.40	269.00	147.60	155.20	161.60	108.20	798.60	1,881.40	Yes	6.6
Maryland	92.60	92.20	149.40	96.40	157.20	176.08	113.28	146.06	1,023.20	Yes	6.1
Massachusetts	117.00	135.00	185.80	139.80	161.80	206.40	146.20	893.00	1,985.00	Yes	2.4
Michigan	90.20	91.40	128.20	94.40	123.20	106.20	171.20	508.00	1,312.80	No	4.5
Minnesota	102.80	130.00	144.40	136.00	187.80	157.80	172.40	1,047.80	2,079.00	No	4.5
Mississippi	99.60	98.40	128.00	104.40	162.20	175.36	122.84	161.62	1,052.40	No	10.8
Missouri	121.80	110.60	165.20	180.20	192.60	186.40	143	728	1,827.80	No	8.6
Montana	197.80	88.20	125.20	221.40	140.40	134.20	185.00	417.60	1,509.80	Yes	8.3
Nebraska	154.80	130.20	167.60	100.00	120.60	196.60	163.00	520.00	1,552.80	No	6.7
Nevada	136.20	134.60	213.60	150.20	177.60	167.40	330.80	620.80	1,931.20	No	11.1
New Hampshire	151.80	148.60	177.60	165.00	241.80	159.92	151.24	171.99	1,368.00	Yes	4.9
New Jersey	123.80	120.80	172.40	88.20	182.80	166.30	160.61	171.32	1,186.20	Yes	6.8
New Mexico	89.00	108.20	125.60	109.40	144.40	161.20	178.80	623.60	1,540.20	Yes	8.2
New York	112.40	130.80	158.80	116.00	153.40	201.60	235.60	1,060.20	2,168.80	Yes	4.9
North Carolina	111.60	131.60	184.40	129.00	142.00	169.60	125.76	171.28	1,165.20	No	9.3
North Dakota	120.00	125.20	131.00	117.00	242.20	239.60	131.40	630.80	1,737.20	No	6.4
Ohio	130.40	128.40	199.80	128.00	138.80	177.00	180.20	690.40	1,773.00	Yes	5.9
Oklahoma	123.80	128.00	149.00	126.80	163.80	159.92	119.88	189.80	1,161.00	No	11,7
Oregon	71.60	118.60	107.80	78.80	1,320	160.14	116.34	182.17	967.50	No	6.0
Pennsylvania	106.20	126.20	160.60	108.20	185.60	154.40	115.92	181.25	1,138.40	No	5.3
Rhode Island	85.20	126.20	142.00	107.20	156.80	149.64	111.76	178.21	1,057.00	Yes	4.2
South Carolina	98.40	102.60	157.00	120.60	86.40	148.36	111.00	173.45	997.80	No	9.1
South Dakota	127.00	127.00	179.40	700.00	185.60	187.40	158.00	491.00	2,155.40	No	8.1
Tennessee	103.60	104.20	138.00	115.60	135.40	149.30	206.93	159.98	1,113.00	No	9.3
Texas	113.80	122.20	156.80	125.20	167.20	194.00	172.40	826.20	1,877.80	Yes	16.6
Utah	66.00	85.60	73.80	73.40	104.60	136.80	118.00	351.00	1,009.20	Yes	8.1
Vermont	109.00	129.40	179.60	145.00	179.20	141.00	226.96	163.17	1,273.30	No	3.9
Virginia	58.60	70.00	82.80	137.20	121.00	145.52	231.84	161.70	1,008.70	No	6.5
Washington	99.80	98.20	151.80	132.80	142.00	132.00	190.20	567.20	1,514.00	Yes	6.1
West Virginia	134.60	128.60	206.60	132.40	167.80	146.60	204.20	155.10	1,266.80	Yes	5.9
Wisconsin	151.20	146.20	183.80	165.80	210.80	198.80	308.00	1,101.80	2,466.40	No	5.2
Wyoming	130.00	227.00	197.00	142.00	205.00	204.00	237.00	814.00	2,156.00	No	11.5

Note: The prices listed represent the averages from the five most populous cities in each state, except for Hawaii, where only one listed price was available for all components. AMH = antimüllerian hormone; FSH = follicle stimulating hormone; HSG = hysterosalpingogram; LH = luteinizing hormone; TVUS = transvaginal ultrasound.

Figure 1.

Heatmap of total cost.

Variations in total costs per region

Comparisons of average costs of each of the infertility workup components are listed in Table 2. Significant variation in costs across regions was identified in LH (P=.007), estradiol (P=.03), and AMH (P<.001) costs; however, this was not significant when all hormone tests were grouped (P=.26). Transvaginal ultrasound and HSG costs were also found to be significantly different (P=.02 and P=.002, respectively). The costs of FSH, progesterone, and semen analysis did not vary considerably across regions (P=.93, P=.38, and P=.58, respectively). Overall, total workup costs varied considerably across regions when all regions were compared with each other (P=.004), except for the comparison between Midwest and West as identified by Tukey’s post hoc test. Midwest has the highest average total cost of infertility diagnostic tests, followed by Northeast, West, and South regions.

Table 2.

Average costs for infertility workup tests per region.

Regions	Hormone tests ($)	Semen analysis ($)	TVUS ($)	HSG ($)	Total cost ($)	Uninsured rate (%)	Median household income ($)	Racial makeup (%)	Average poverty level (%)
Midwest	151.40	173.73	178.33	714.6	1,823.80	6.36	71,570	White, 83.8; Black, 8.4	11.9
South	124.50	160.59	142.36	252.7	1,196.90	8.79	67,271	White, 71.6; Black, 21.1	14.4
Northeast	148.70	163.45	165.25	1,382.6	1,629.660	4.91	83,267	White, 82.3; Black, 9.1	10.6
West	136.60	168.78	213.41	647	1,712.30	8.15	78,452	White, 77.5; Black, 3.7	11.6

Note: HSG = hysterosalpingogram; TVUS = transvaginal ultrasound.

Demographic distribution across regions

Demographic information across regions, including median household income, racial makeup, average poverty level, and uninsured rate is included in Table 2. The median household income was highest in the Northeast ($83,267) and lowest in the South ($67,271) (P=.005). Percentage of White population was highest in the Midwest (83.8%) and lowest in the South (71.6%) (P=.002) and concurrently, the percentage of Black population was highest in the South (21.1%) and lowest in the West regions (3.7%) (P<.001). Poverty level was highest in the South (14.4%) and lowest in the Northeast regions (10.6%) (P=.007). The uninsured rate had a range of 2.4%–16.6%, with a mean and SD of 7.5% ± 2.7%. Uninsured rate was highest in the South (8.79%) and lowest in the Northeast (4.91%) (P<.001). Hormone test costs were found to be significantly correlated with uninsured rate (P=.046), however not with total workup costs. Total workup costs were found to be significantly correlated with median household income (P<.001). However, when compared regionally, only the Midwest had a significant correlation (P=.01).

Insurance mandates

Twenty-one states in the United States have mandates for insurance companies to include infertility coverage. If a state has any level of insurance coverage, a “yes” was included in the “Insurance” column in Table 1. No significant differences were found for workup costs between states with and without insurance mandates. The uninsured rate varied significantly between states with and without insurance mandates (P<.001), with states having mandates averaging a 6.57% uninsured rate compared with 8.39% in states without mandates.

Cost distribution per test

Figure 2 shows the distribution of average costs per test in the United States. Hysterosalpingogram encompasses, by far, the largest percentage of the infertility workup at 52%, followed by TVUS, semen analysis, and the average of the five hormone tests.

Figure 2.

Composition of total costs per test in the United States. HSG = hysterosalpingogram; TVUS = transvaginal ultrasound.

Discussion

This study reveals an analysis of the average costs of infertility diagnostic tests across states and regions in the United States reveal significant variations. Across the states, there is a noticeable variation in the costs of individual tests, with some states exhibiting notably higher or lower costs compared with others. Alaska stood out as having substantially higher costs across all tests. Regionally, the Midwest and Northeast generally demonstrated higher average costs for most tests, with the South tending to have lower costs. These regional differences could be attributed to various factors including differences in healthcare infrastructure and market competition. Individual tests in the infertility workup revealed that the HSG is the costliest. This information can guide a cost-effective sequence for infertility workups. Prioritizing less expensive tests, such as hormonal assays (e.g., AMH and estradiol) and semen analysis, before reserving HSG for cases where it is clinically warranted, may be more advantageous for a potential cost-reducing algorithm.

As far as costs in relation to demographic variables, this study showed significant differences between regions. Regions with higher median household incomes, such as the Northeast, tended to exhibit higher average costs although regions with lower median household incomes such as the South, tended to exhibit lower average costs for infertility tests. The South also held the status for highest poverty level, lowest percentage of White population, the greatest percentage of Black population, and the highest uninsured rate. These trends suggest a potential alignment between the socioeconomic status of a region and the affordability of infertility diagnostic tests. It is important to note, however, that these relationships are not always consistent across regions and tests. Moreover, although there are variations in poverty levels across regions, these differences do not consistently align with variations in infertility tests costs. Reducing test costs in high-cost areas could alleviate financial burdens on patients; however, expanding insurance coverage to all patients may be a more equitable solution to mitigate disparities and improve access to fertility care regardless of location.

Analyzing the total costs of an infertility workup across states and regions is important to assess disparities and outliers. However, 21 states in the United States have passed insurance mandates as of September 2023 (12). These mandates can range anywhere from full infertility coverage encompassing fertility preservation to IVF treatment, whereas some states only have minimal coverage. Although we expected that nonmandated states may experience higher costs than mandated states because of lack of regulation, this study revealed no differences when comparing whether states had insurance mandates with the various infertility workup component costs. It is important to note, however, that most mandates do not apply to federally based insurance options, so patients with such coverage might not benefit from state-level fertility treatment mandates, potentially leading to higher out-of-pocket costs. Moreover, although insurance mandates may not directly affect the cost of the tests themselves, the presence of insurance can significantly influence out-of-pocket expenses for patients. Further research is needed to explore the impact of insurance coverage on the out-of-pocket costs associated with fertility diagnostics. This study revealed a significantly lower uninsured rate in states with insurance mandates, compared with states without mandates. This may suggest that states with insurance mandates not only increase access to fertility care but reflect broader health coverage policies that help lower overall uninsured rates.

The findings should be interpreted within the context of several limitations. First, the data collected are based on average costs obtained from specific sources and may not fully represent the actual costs incurred by individuals, especially after insurance contributions that were not studied here. Costs were obtained from the most populous cities in each state, without accounting for the potential impact of population density on cost disparities. This also limited the ability to capture the range of economic and demographic variations present in less populous areas. The study focuses solely on diagnostic tests and does not consider other aspects of infertility evaluation such as consultations, medications, surgical procedures, or treatment. The insurance information also does not delineate between minimal to full coverage, and only studies whether there is a mandate present in that state. Future research could delve into the correlations between prices of diagnostic workups in concordance with the treatments of infertility and examine whether the impact of insurance coverage increases the utilization of diagnostic tests. Moreover, longitudinal studies tracking changes in costs over time to assess the impact of policy interventions could provide valuable insights. Evaluation of the relationship between costs and patient outcomes and satisfaction would also be useful.

Overall, this study emphasizes the significant financial burden that infertility workup imposes on patients, which must be addressed to promote equity. The average total workup costs across all states were found to be approximately $1,559. However, this varied notably based on region (ranging from $1,000 to over $1,800), as well as between states (ranging from $800 to $3,000). Interestingly, our study revealed observed considerable variation in costs among specific laboratory tests. For instance, although FSH and LH tests may seem similar, they sometimes exhibited vast cost differences (i.e., FSH in Wyoming costs $130, whereas LH costs $227). The evidence presented here highlights the need for policy interventions that can guarantee equitable access to fertility care, particularly for marginalized communities, to ensure that all individuals receive fair reproductive health services. Furthermore, this study sheds light on the potential disparities among clinics, laboratories, and hospitals within regions for an infertility workup. This is important to inform insurance companies and other third-party payers to reassess coverage policies to ensure fairness of costs to patients. This information is also invaluable for patients seeking cost-effective options and healthcare providers striving to establish more equitable pricing structures.

Conclusion

This study analysis highlights significant variations in the costs of infertility diagnostic tests across states and regions in the United States, emphasizing the complexity and challenges associated with accessing and affording infertility care. Future research is necessary to comprehensively evaluate the out-of-pocket financial burden of infertility diagnostic workups and explore potential strategies for mitigating these costs.

CRediT Authorship Contribution Statement

Naveena R. Daram: Writing – review & editing, Writing – original draft, Project administration, Methodology, Investigation, Data curation, Conceptualization. Malika L. Day: Writing – review & editing, Methodology, Investigation, Data curation. Rose A. Maxwell: Writing – review & editing, Supervision, Methodology, Formal analysis. Meghan C. Ozcan: Writing – review & editing, Validation, Supervision, Methodology, Conceptualization.

Declaration of Interests

N.R.D. has nothing to disclose. M.L.D. has nothing to disclose. R.A.M. has nothing to disclose. M.C.O. has nothing to disclose.