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. Author manuscript; available in PMC: 2015 Jul 1.
Published in final edited form as: Reprod Biomed Online. 2014 Mar 24;29(1):131–135. doi: 10.1016/j.rbmo.2014.03.007

State-mandated insurance coverage is associated with the approach to hydrosalpinges before IVF

Kenan Omurtag 1, Natalia M Grindler 1, Kimberly A Roehl 3, G Wright Bates 2, Angeline N Beltsos 4, Randall R Odem 1, Emily S Jungheim 1
PMCID: PMC4114072  NIHMSID: NIHMS579194  PMID: 24813751

Abstract

The aim of this study was to determine whether practice in states with infertility insurance mandates is associated with physician-reported practice patterns regarding hydrosalpinx management in assisted reproduction clinics. A cross-sectional, internet-based survey of 442 members of Society for Reproductive Endocrinology and Infertility or Society of Reproductive Surgeons was performed. Physicians practising in states without infertility insurance mandates were more likely to report performing diagnostic surgery after an inconclusive hysterosalpingogram than physicians practising in states with mandates (RR 1.2, 95% CI 1.1–1.3, P < 0.01). Additionally, respondents in states without mandates were more likely to report that, due to lack of infertility insurance coverage, they did not perform salpingectomy (SPX) or proximal tubal occlusion (PTO) before assisted reproduction treatment (RR 1.4, 95% CI 1.1–1.8, P = 0.01). Finally, respondents in states without mandates were less likely to report that the presence of assisted reproduction treatment coverage determined the urgency with which they pursued SPX or PTO before treatment (RR 0.7, 95% CI 0.5–1.0, NS). These results persisted after controlling for physician years in practice, age and clinic volume. In conclusion, self-reported physician practice interventions for hydrosalpinges before assisted reproduction treatment may be associated with state-mandated infertility insurance.

Keywords: assisted reproduction treatment, hydrosalpinx, insurance coverage, mandate, salpingectomy

Introduction

Tubal disease accounts for 25–35% of female-factor infertility (American Society of Reproductive Medicine, 2012, Honore et al., 1999). Tubal disease is most common in the form of a hydrosalpinx, which is an accumulation of serous fluid in the Fallopian tube that usually results from pelvic infection by gonorrhoea, chlamydia or both (Yoder and Hall, 1991) and ultimately leads to tubal occlusion. Although the toxic mechanisms of hydrosalpinges on fertility are not well understood (Strandell, 2007), it is clear that hydrosalpinges decrease the chances of pregnancy after IVF (Akman et al. 1996, Andersen et al. 1994, Blazar et al. 1997, Camus et al. 1999, de Wit et al. 1998, Fleming and Hull, 1996, Kassabji et al. 1994, Katz et al. 1996, Sharara et al. 1996, Shelton et al. 1996, Vandromme et al., 1995, Wainer et al., 1997, Zeyneloglu et al. 1998).

The ongoing pregnancy rate for patients with hydrosalpinges that are managed by laparoscopic salpingectomy (SPX) or proximal tubal occlusion (PTO) is over 2-fold higher than in the non-intervention controls (34% versus 17%) (American Society of Reproductive Medicine 2008, Jain and Gupta, 2007). As a result the American Society for Reproductive Medicine (ASRM), along with the Society of Reproductive Surgeons (SRS) recommend SPX or PTO before IVF in patients with hydrosalpinges (American Society of Reproductive Medicine 2008).

Associations between state mandates for infertility insurance coverage and increased utilization of assisted reproduction treatment have been demonstrated (Jain and Gupta, 2007, Jain et al., 2002), but it is not known how infertility insurance mandates may influence provider management of other interventions used to improve the chance of pregnancy. The current study group previously showed that Society for Reproductive Endocrinology and Infertility (SREI) and SRS members define a ‘clinically significant hydrosalpinx’ similarly and that practice reflects ASRM and SRS recommendations; however, variation in practice still exists and insurance coverage for assisted reproduction treatment may play a role (Omurtag et al., 2012). To better understand how particular health policies in a state may influence a physician's approach to hydrosalpinges, the current work surveyed practising SREI and SRS members regarding their evaluation and management of hydrosalpinges and stratified the responses on the basis of the presence or absence of mandated infertility insurance coverage in the state in which the respondents practice.

Materials and methods

This cross-sectional survey was approved by the Washington University Institutional Review Board (reference no. 201105156, approved 13 October 2011). The SREI member directory (www.socrei.org), which links to the ASRM member directory, was used to identify survey participants as previously described (Omurtag et al., 2012). Respondents were initially aggregated into three groups based on their primary practice location: (i) states with a comprehensive infertility insurance mandate (CIM): NJ, CT, IL, RI and MA; (ii) states with partial coverage: CA, TX, AR, MT, WV, OH, NY, HI, MD and LA; and (iii) states with no infertility insurance mandate (NoIM). Because initial analysis showed no difference in responses between CIM states and those with only partial coverage, responses from these two groups were combined to form the any insurance mandate (AIM) group: NJ, CT, IL, RI, MA, CA, TX, AR, MT, WV, OH, NY, HI, MD and LA.

Respondents were asked the following questions: (i) ‘If tubal status is inconclusive on hysterosalpingogram (HSG), what is your next step (diagnostic surgery versus repeat noninvasive imaging)?’; (ii) ‘Has lack of insurance coverage for salpingectomy/proximal tubal occlusion (SPX/PTO) prevented a patient from having this procedure prior to IVF?’; and (iii) ‘Does the presence of insurance coverage for IVF determine the urgency with which you will perform SPX/PTO?’

DatStat (DatStat, Seattle, WA, USA) was used to construct and implement the survey. Responses were analysed using Student's t-test and chi-squared analysis when comparing continuous, normally distributed variables and differences in proportions, respectively. Logistic regression was used to estimate associations between presence or absence of state-mandated infertility insurance and response to questions while controlling for respondent age and years in practice and reported clinic cycle volume. All analyses were performed in SPSS version 18 (SPSS, Chicago, IL, USA). The level of statistical significance was P < 0.05.

Results

This study collected 442 responses (41% response rate). Briefly, surveys were sent to 1078 SREI and SRS members between 25 October and 8 November 2011. Detailed methods and demographic information about the survey mailing and respondents, respectively, is described elsewhere (Omurtag et al., 2012). Respondents practising in AIM and CIM states both reported performing more IVF cycles per year than respondents practising in NoIM states. Respondents in AIM and CIM states were younger than those in NoIM states. There were no differences between respondents in NoIM and those in AIM or CIM states in terms of SREI membership, years of practice or practice setting (academic versus private) (Table 1).

Table 1.

Demographics of survey respondents.

CIM AIM NoIM
Practice setting
 Private practice 35 (51) 113 (53) 118 (53)
 Academic 32 (46) 91 (43) 102 (46)
 Other 2 (3) 8 (4) 4 (2)
Membership
 SREI only 50 (72) 138 (64) 107 (49)
 SREI and SRS 18 (26) 63 (29) 79 (36)
 SRS only 1 (1) 13 (6) 27 (12)
 Neither 0 (0) 3 (1) 5 (2)
Age (years) 47.5 ± 9.0 49.1 ± 10.4a 50.1 ± 10.0
IVF cycles per year 1000.7 ± 995.2b 836.0 ± 1087b 452.9 ± 677.1
Years in practice 15 ± 10 16 ± 11 18 ± 10
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Values are n (%) or mean ± SD. Students t-test and chi-squared analysis were used for comparing continuous variables and differences in proportions, respectively. None of the differences in practice setting or membership were significantly different between NoIM and AIM or CIM.

Also responses pertaining to AIM and CIM are not discrete because respondents in CIM are also counted in AIM.

a

P = 0.025.

b

P < 0.001, compared to NoIM.

AIM = states with any infertility insurance mandate; CIM = states with comprehensive infertility insurance mandate; NoIM = states with no infertility insurance mandate; SREI = Society for Reproductive Endocrinology and Infertility; SRS = Society of Reproductive Surgeons.

Providers in NoIM states were more likely to respond that they perform diagnostic surgery in the case of an inconclusive HSG than those in CIM or AIM states. Additionally, NoIM respondents were more likely to report not performing surgery for SPX or PTO before assisted reproduction treatment because of lack of infertility insurance coverage for the surgical procedure (Table 2). Finally, NoIM respondents were less likely than CIM or AIM respondents to report that the presence of IVF coverage determined the time course with which they managed hydrosalpinges before IVF. These trends in reporting persisted after controlling for years in practice, clinic volume and physician age (Table 2).

Table 2.

SREI/SRS members' approaches to hydrosalpinges before IVF, categorized by presence or absence of state insurance mandate.

Question Unadjusted Adjusted
RR (95% CI) P-value OR (95% CI) P-value
If tubal status is inconclusive on HSG, what is your next step? (diagnostic surgery versus repeat non-invasive imaging)
 NoIM versus CIM 1.4 (1.1–1.9) <0.01 3.0 (1.5–6.3) 0.003
 NoIM versus AIM 1.2 (1.1–1.3) <0.01 2.0 (1.1-3.6) 0.03
Has lack of insurance coverage of SPX/PTO prevented a patient from having this procedure prior to IVF?
 NoIM versus CIM 2.1 (1.2–3.4) <0.01 2.7 (1.4-5.4) 0.004
 NoIM versus AIM 1.4 (1.1–1.8) 0.01 1.6 (1.1–2.5) 0.03
Does the presence of insurance coverage for IVF determine the urgency with which you will perform SPX/PTO prior to IVF?
 NoIM versus CIM 0.5 (0.4–0.7) <0.01 0.4 (0.2-0.7) 0.002
 NoIM versus AIM 0.7 (0.5–1.0) NS 0.7 (0.5-1.1) NS
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AIM = states with any infertility insurance mandate; CIM = states with comprehensive infertility insurance mandate; HSG = hysterosalpingogram; NoIM = states with no infertility insurance mandate; NS = not significant; PTO = proximal tubal occlusion; SPX = salpingectomy.

Discussion

Although it is widely accepted that clinically significant hydrosalpinges negatively affect IVF success rates, Omurtag et al. (2012) previously demonstrated that physicians differ in their reported management practices. The current work provides three pieces of evidence suggesting that insurance coverage may be responsible for some of the variation in management. First, although most providers in this survey responded that they perform diagnostic surgery to determine tubal status when an HSG is inconclusive, providers in NoIM states were more likely to respond that they would do so than those in CIM or AIM states. This could be due to the fact that, in mandated states, counselling is more likely to be directed at attempting IVF before any tubal surgery. The patient would understand that if a cycle involving good-quality embryos fails, surgical intervention could then be performed to remedy damaged tubes before a subsequent treatment cycle. Second, respondents in NoIM states were less likely to perform tubal surgery before treatment when insurance coverage for the procedure was not available. A likely explanation is that providers in states with an infertility insurance mandate are less likely to encounter patients without coverage for SPX or PTO. Third, providers in NoIM states were less likely than those in CIM ir AIM states to report that coverage for IVF influenced the urgency with which they managed hydrosalpinges before IVF. This suggests that patients who have coverage for IVF might be offered the option of deferring surgery for hydrosalpinges with the caveat that, if there is a cycle failure, SPX or PTO could be performed before any subsequent embryo transfers.

Despite the evidence that the presence of hydrosalpinges can reduce the pregnancy rate by 50% in assisted reproduction cycles (Camus et al., 1999; American Society of Reproductive Medicine, 2008; Zeyneloglu et al., 1998), there are reasons a patient might elect not to undergo SPX or PTO. For example, patients recognize that tubal surgery for hydrosalpinges usually means relying on IVF for achieving future pregnancies, a management plan that can be hard for a patient to accept, perhaps mirroring the emotional responses well documented among young patients after tubal ligation (Hillis et al., 1999, Wilcox et al., 1991). Additionally, as previously pointed out, not all hydrosalpinges seen on HSG are equal; thus, some might elect to proceed with assisted reproduction treatment before surgical intervention when a hydrosalpinx is present, for example, on HSG but not on ultrasound. Nevertheless, this survey suggests that insurance coverage policies influence physician reporting in regard to practice patterns. Tracking first-cycle outcomes for those who do and do not have insurance coverage for SPX or PTO would provide insight into whether these insurance policies actually affect pregnancy outcomes.

The limitations of this study include possible variation in the respondents' interpretations of the survey questions and lack of information regarding respondents' qualifications beyond SREI or SRS membership (e.g. surgical volume, board certification). Furthermore, despite general recommendations to intervene, controversy regarding indiscriminate salpingectomy for hydrosalpinges lingers (Feinberg et al., 2008, Puttemans et al., 2000; Sabatini and Davis, 2005), making the findings from this study challenging to interpret. Most importantly, this study is limited in its ability to draw firm conclusions as it does not directly measure practice patterns or outcomes but instead relies on physicians' responses to a survey. Finally, because state infertility insurance mandates vary, those states that have comprehensive infertility insurance mandates (e.g. provide up to ‘x’ number of cycles) were separated from those states that have any mandate (e.g. lifetime caps that may only cover a portion of one cycle) to further delineate differences in reported hydrosalpinx intervention. Other authors have used this approach when investigating associations between IVF practice and state infertility insurance mandates (Jain and Gupta, 2007; Jain et al., 2002). This study observed a larger effect size between the NoIM and CIM groups than between the NoIM and AIM groups after adjustment for confounders, suggesting that reported practice patterns become more refined as the mandate becomes more comprehensive.

Prospectively examining outcomes among women in CIM states who have had IVF with or without intervention of hydrosalpinges may help to better inform practice and ultimately patient counselling. Complementing this with structured interviews could also help providers understand the emotional and psychological barriers that patients face when being told that ‘removing a part of the tube’ or ‘occluding it’ is part of optimizing their outcomes.

Although previous studies have examined how insurance benefits influence assisted reproduction treatment outcomes and provider behaviour in terms of number of embryos transferred (Jain et al., 2002), this study introduces findings that highlight another area of infertility treatment where insurance coverage may influence treatment approach. Ultimately, it is imperative that physicians continue to engage patients in the shared decision making that confronts them in the setting of hydrosalpinges before assisted reproduction treatment.

Acknowledgments

This work was supported by the National Institutes of Health, Bethesda, Maryland (grant nos. 5T32HD040135-10 to KO and K12HD063086 to ESJ).

Footnotes

Presentation: This work was presented in part at the 68th Annual Meeting of the American Society for Reproduction in San Diego, California.

Declaration: ANB notes involvement in speakers bureaus for Ferring, Merck and EMD Serono. The other authors report no financial or commercial conflicts of interest.

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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