Guideline-recommended diagnostic evaluation and first-line treatment are frequently incomplete at the time in vitro fertilization (IVF) is initiated, and in several cases, the care being received before IVF begins is actively contraindicated by guideline care standards. Specifically:
- In most male and female infertility presentations examined, IVF was underway in the majority of patients before recommended evaluation or first-line treatment had been completed in even a third of cases.
- For the most basic diagnostic step in male infertility evaluation, semen analysis, nearly half of patients remained untested at six months following diagnosis.
- Among men with azoospermia, over half received testosterone treatment, which ASRM and AUA guidelines explicitly identify as contraindicated in men pursuing fertility.
- Among women with PCOS, more than a quarter had initiated IVF within the first month of diagnosis, before guideline-recommended first-line therapy had been attempted in the large majority of cases.
- Among women with hyperprolactinemia, a potentially reversible cause of infertility treatable with a well-tolerated oral medication, more than half had initiated IVF by month three while fewer than 34% had received any recommended first-line treatment.
These findings are drawn from an actuarial analysis of commercial insurance claims data conducted by Axene Health Partners (AHP). The analysis used the Merative MarketScan® Commercial Claims database covering approximately five million commercially insured members from 2021 through 2024. Guideline adherence was measured against ASRM and AUA/ASRM published recommendations, including the ASRM/AUA Joint Guidelines on male-factor infertility, the 2023 International Evidence-Based Guideline for Polycystic Ovary Syndrome, ASRM committee opinions on amenorrhea and endometriosis, and ASRM guidance on evaluation of infertile women. Because claims data reflects billing activity rather than clinical confirmation, adherence rates presented in this paper should be understood as reflecting services that were billed, not services that were clinically indicated — though population-level patterns of the magnitude documented here are not adequately explained by appropriate clinical variation alone.
The full white paper includes the complete analysis, with detailed adherence and IVF initiation rates by condition and guideline measure.
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