# Association of State Insurance Mandates for Fertility Treatment With Multiple Embryo Transfer After Preimplantation Genetic Testing for Aneuploidy

## TL;DR

States requiring insurance coverage for IVF see fewer multiple embryo transfers after genetic testing, reducing multiple pregnancy risks.

## Contribution

Shows that state insurance mandates for IVF are linked to reduced multiple embryo transfers after preimplantation genetic testing.

## Key findings

- MET after PGT-A was 24% less common in states with fertility mandates.
- MET increased live birth odds by 70% but quintupled multiple birth risk.
- Despite PGT-A, MET remained common in states without insurance mandates.

## Abstract

This cohort study investigates the association of state-mandated insurance coverage for in vitro fertilization with rates of multiple embryo transfer after preimplanation genetic testing for aneuploidy.

Is state-mandated insurance coverage for in vitro fertilization associated with decreased use of multiple embryo transfer (MET) after preimplantation genetic testing for aneuploidy (PGT-A)?

In this cohort study of 110 843 embryo transfers, the odds of MET were 24% lower in cycles with PGT-A in states with fertility mandates than in states without these mandates. While the odds of live birth were 70% higher with MET vs single embryo transfer after PGT-A, the risk of multiples was 5 times higher.

This study found that MET after PGT-A was more common in states without fertility insurance mandates and was associated with increased risk of multiples.

Multiple gestation is one of the biggest risks after in vitro fertilization (IVF), largely due to multiple embryo transfer (MET). Single embryo transfer (SET) uptake has increased over time and has been attributed to various factors, such as mandated insurance coverage for IVF and preimplantation genetic testing for aneuploidy (PGT-A).

To investigate whether mandates for IVF insurance coverage are associated with decreased use of MET after PGT-A.

This cohort study was conducted using data on embryo transfers reported to the Society for Assisted Reproductive Technology between 2014 and 2016. Data were analyzed from January to October 2021.

State-mandated coverage for fertility treatment and type of cycle transfer performed (PGT-A, untested fresh, and untested frozen).

Use of MET compared with SET, live birth, and live birth of multiples.

There were 110 843 embryo transfers (mean [SD] patient age, 34.0 [4.5] years; 5520 individuals identified as African American [5.0%], 10 035 as Asian [9.0%], 5425 as Hispanic [4.9%], 45 561 as White [41.1%], and 44 302 as other or unknown race or ethnicity [40.0%]); 17 650 transfers used embryos that underwent PGT-A. Overall, among transferred embryos that had PGT-A, there were 9712 live births (55.0%). The odds of live birth were 70% higher with MET vs SET after frozen embryo transfer with PGT-A (OR, 1.70; 95% CI, 1.61-1.78), but the risk of multiples was 5 times higher (OR, 5.33; 95% CI, 5.22-5.44). The odds of MET in cycles with PGT-A in states with insurance mandates were 24% lower than in states without mandates (OR, 0.76; 95% CI, 0.68-0.85).

This study found that despite the promise of using SET with PGT-A, MET after PGT-A was not uncommon. This practice was more common in states without insurance mandates and was associated with a high risk of multiples.