One of the more sensitive issues that comes up in obstetrics, gynecology and Advanced Urology is patients having problems with infertility. We received some excellent didactic instruction on the medical elements of the topic, but I was struck by a key issue that came up during this discussion. It was the issue of how we, as a society and in the medical profession, classify infertility as a concept. This is important, because the classification influences reimbursement, which is a very big deal when it comes to the costs of medical treatment for fertility issues which can be astronomical.
Is fertility a key element of health? Is it a sort of privilege? Or is having babies/children a human right? Many people would lean that way. Is infertility a disease? Is it a condition?
Words are just words, but they matter a lot, both in how they influence how we think/feel about ourselves and others. There are certainly many things which we could clearly classify as a disease which can cause problems with fertility: e.g. infections or cancer. However, age is also a big factor, and most people would not classify that as a disease, the term “condition” seems a better fit. We don’t expect to cure aging, although medically we try to ameliorate some of its detrimental effects. However, fertility automatically involves two people, at least as we typically think about it, and that also makes it different from other “diseases”, so is the state of infertility is perhaps more of a “condition” on that front as well.
Suppose a young couple comes in to clinic, they’ve been trying to have children for 18 months, and I think most people would expect medical insurance to cover counseling and starting to look into issues of fertility through history, examination, labs and imaging. Then suppose a problem is discovered, what is reasonable for health insurance to cover as therapy? Just some things, or everything possible? Medications? Surgery? Donor sperm? Donor eggs? IVF? Surrogate mother fees?
Supposing the wife in a couple has had cancer and a hysterectomy and can’t have children but decides she wants to adopt. What about adoption fees? If we decide that infertility is a medical condition, and a patient wants children, perhaps adoption should be covered by health insurance. Most forms of health insurance cover contraception, abortion, and delivery. Why not cover transfer of a child to new parents? If so, when does this stop? Some couples might want to keep adopting and adopting. Is that a bad thing if there are kids that need homes? Should there be an age limit on parents? Would that be age discrimination?
However, what if there isn’t a couple, but just a single parent who wants a child. Is that patient in some sense infertile due to a “condition” namely that person’s life? Should health insurance help here? If that person is infertile, then a legally married gay couple is certainly infertile by the same measure. Should health insurance help here? Pay for sperm donation? Egg donation and a surrogate mother? Again, what about adoption?
As a society we have decided that eugenics is wrong. If we take it as fundamentally wrong to dictate who can have children, then deciding that some individuals have more rights to assisted reproduction than others, aren’t we violating that fundamental idea?
What do you think? What are the rights and how much does greater society (including in the form of healthcare payments or reimbursements) owe to the individual or family when it comes to fertility?
