Characteristics of included studies

A total of 1529 studies were collected for this review research. The first stage involved removing 540 studies due to duplication. In the second stage, 938 studies were excluded based on their title and abstracts. In the third stage, 51 studies were further excluded after a detailed analysis of their contents. Finally, 11 studies were selected for this review research as they met the study’s objectives, which focused on investigating insurance policies in infertility services and their consequences. Figure 1 illustrates the process of searching for studies.

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Figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart for selecting studies.

Most studies (four) were conducted in the USA,17–20 while conducted in South Korea,21 Finland,22 Japan,23 China,24 Taiwan,25 Germany26 and Australia27, respectively. The studies were mainly retrospective and compared before and after the intervention, with analytical studies conducted on secondary data. The studies aimed to discuss making infertility services mandatory in insurance and investigate the consequences such as access, benefit rate, changes in infertility costs, socioeconomic dimensions, equitable allocation of resources and fertility. The studies’ data was collected mainly through the respective countries’ health insurance organisation’s data banks. Some studies also used national fertility census data, household population growth data and marriage and fertility data. Table 1 lists the characteristics of all the studies included in this review research.

Quality assessment results

For this systematic review, the quality of the included studies was evaluated using the JBI Critical Appraisal Checklist for Analytical Cross-Sectional Studies.16 This checklist was selected due to its suitability for assessing the methodological rigour of observational studies, which formed the majority of our included studies. Each study was assessed across eight key domains, including the clarity of sample inclusion criteria, validity of measurement methods, identification of confounding factors and appropriateness of statistical analysis. Each article was scored between 1 and 8, with a score of 3–4 or above indicating that the article met the qualitative standards (see online supplemental appendix 2).

The main findings of the studies

Table 2 presents the main findings of the included studies (see also online supplemental appendix 3). We have categorised the results into four sections.

Increased access to infertility services

Studies consistently demonstrate that comprehensive insurance policies enhance access to infertility services, with significant impacts observed in regions where public insurance provides or mandates coverage.

In the USA, studies by Vu et al and Bitler and Schmidt highlight that state-mandated Medicaid coverage and other state policies led to a 27% increase in first births among women over 35 and a marked rise in utilisation of ovulation-stimulating drugs and artificial insemination. These findings underscore the substantial influence of state-level policies on access and treatment utilisation.17 19

Taiwan experienced a 21.55% annual growth rate in ART-related births following policy changes that expanded ART coverage, as reported by Hsu et al, demonstrating that insurance coverage can directly increase treatment cycles and overall service usage.25

In South Korea, Lee et al found that national ART insurance coverage led to higher service utilisation rates, especially among older patients, indicating that national policies can drive broader service uptake when comprehensive insurance options are available.21

Disparities in insurance coverage and access to advanced treatments

Despite improvements in access in some countries, disparities in coverage remain a significant barrier to equitable infertility care. The extent and nature of these disparities often reflect national policies and economic conditions.

Japan and Germany present contrasting coverage models that highlight these disparities. Iba et al notes that Japan’s public insurance provides only basic treatments, omitting advanced infertility services such as in vitro fertilisation (IVF), which leaves higher-income individuals with better access due to their ability to pay out of pocket.23 In Germany, a shift from full to partial coverage (50% cost sharing) for ART in 2003 led to a 55% decrease in treatment usage and a 51% decline in ART births, as reported by Dietrich et al.26 This illustrates how policy changes can exacerbate financial barriers, especially for low-income groups.26

Australia experienced similar effects such as increased out-of pocket costs, implemented through Medicare copayments and restricted access to ART, impacting lower-income patients most significantly. Chambers et al27 emphasise the financial burden of these costs, noting that they created substantial barriers to access.

China, according to Wang et al, has limited insurance coverage, which partially supports ART costs but still relies on selective subsidies and commercial insurance to meet the needs of those requiring advanced care. This mixed model contributes to varied access levels, with advanced services more readily accessible to higher-income groups.24

Financial support mechanisms

The studies also reveal that the scope and design of financial support mechanisms—such as cost sharing, reimbursement and selective subsidies—play crucial roles in determining accessibility and affordability.

Finland has a partial coverage model where health insurance reimburses 50% of IVF-related drug costs, as found by Klemetti et al. While this alleviates some cost burden, the lack of full coverage still limits access for lower-income patients.22

In South Korea, national insurance covers comprehensive ART services, including inpatient and outpatient care, tests and fertility drugs, although older patients face higher out-of-pocket expenses due to more intensive intervention needs, per Lee et al.21

China’s insurance model, as Wang et al discusse, incorporates selective subsidies and emerging commercial insurance options to manage infertility treatment costs. While beneficial, this model underscores the need for a more standardised approach to ensure equitable access across socioeconomic groups.24

Impact on fertility outcomes

The findings further suggest that insurance coverage can influence fertility outcomes by affecting both the timing and frequency of infertility treatments.

Vu et al and Schmidt highlight that Medicaid and state-mandated coverage in the USA is linked with higher birth rates among older women, with Schmidt’s study noting a significant increase in first births among women over 35, particularly in specific demographic groups.17 20

Conversely, Machado and Sanz-de-Galdeano found that while insurance coverage in the USA improves birth rates for older women, it inadvertently delays motherhood among younger women, who may defer treatment, resulting in reduced fertility due to the natural age-related decline in fertility.18

In Australia, increased patient copayments for ART coverage, as documented by Chambers et al, correlate with reduced fertility outcomes, as financial barriers limit access to timely infertility treatments, ultimately impacting birth rates.27

Discussion

This systematic review examined the effects of health insurance coverage policies on infertility services. 11 studies, primarily from high-income countries, met the inclusion criteria.

The results of the studies suggest that coverage for infertility services through health insurance can increase access to and benefits from these services. However, as some studies have suggested, whether this coverage significantly improves the overall population or birth rate is still being determined. Of the 11 studies reviewed, six focused on access to services as an outcome,18 19 22–24 two examined the costs of infertility services coverage policies,22 23 two looked at birth rates20 25 and one focused on types of services.21 The studies reviewed four variables regarding the demographic groups covered: age, gender, marital status and education. The age range considered in most studies was between 20 and 49 years old.19 20 22 Four studies focused solely on women, while five examined services for couples with infertility problems.19 23 24 26 27 One study in China focused on single women,24 while another discussed the impact of education on access to services.19

Overall, the results of the studies indicate that insurance policies and the health system should aim to identify couples with infertility problems at a younger age. This is because success rates of infertility treatments decrease with age. For example, Klemetti et al’s study found that older women (40 years or older) received 1.4 times more IVF treatments than younger women (under 30 years old) but had a success rate of only six live births per 100 cycles, compared with 22 live births per 100 cycles among younger women.22 Another important finding was that infertility insurance policies can delay motherhood among relatively young women, which can make conception more difficult as fertility decreases with age.18

Studies have explored the impact of mandatory health insurance on access to infertility services, with a focus on ART and IVF. The findings suggest that coverage of infertility services has led to an increase in access to and receipt of medical services, drugs and costs.21 However, the lack of a single comprehensive policy has resulted in variations in access to services and affordability across different states, with some populations benefiting more than others.19 Access to infertility services has also led to inefficiencies, and coverage of infertility treatments alone may not improve the fertility rate in the long term.18

The cost of infertility services has also increased due to the increase in access to services, mainly the costly services of ART medical assistance technology. Studies have shown that insurance policies for covering the costs of infertility services vary across countries. For instance, in Japan, married women under 50 years of age can receive tests and essential infertility treatment services under public health insurance with a 30% payment.23 Meanwhile, in Australia, Medicare has significantly increased patient copayments for infertility services since 2010, leading to a general reduction in the use of services.27 In Finland, Social Security Health Insurance in both public and private sectors reimburses 50% of drug costs by the Social Security Organization.22 However, due to the high cost of infertility treatment services and the limitations of health system resources, it is only possible to cover some of the costs of infertility diagnosis and treatment. Selective reimbursement and subsidies for people in particular need, as well as the development of some commercial insurance, are available. Still, more comprehensive and constructive policies should be developed at the country level to standardise the market.24

Studies have found that implementing insurance policies covering infertility services can increase the birth rate. A study in the USA showed that Medicaid coverage of infertility services significantly increased the rate of first births among white women aged 35 years and older, with 24 out of every 88 births related to IVF treatment covered by insurance.20 A study in Taiwan reported a gradual increase in the number of births by ART, with an annual growth rate of 21.55%.21 However, another study showed that although infertility insurance coverage increases the birth rate among relatively older women and the prevalence of multiple births, it does not contribute to the long-term increase in fertility.18

Different countries have different health insurance policies for infertility services. For instance, Japan covers most of the diagnostic tests and essential treatments for infertility, but public health insurance does not cover IUI and ART treatments.25 In Australia, all courses of ART and IUI, IVF cycles and embryo transfers are covered by insurance, but patients must pay more through copayment.23 In South Korea, health insurance covers inpatient and outpatient services in specialised and subspecialised hospitals, clinics, tests and injections, pharmaceutical services, infertility treatment services and surgery, according to the guidelines, rules and instructions of insurance.21 However, most of these studies have been conducted in high-income countries, and there is a need for more studies in low-income and middle-income countries. Moreover, there are differences between healthcare systems in different countries, and the lack of sufficient evidence calls for more studies to determine the effectiveness of mandatory infertility care insurance in increasing the fertility rate and how health system policies can provide infertility services.

This review has limitations, including potential publication bias and the concentration of studies in high-income countries. Additionally, the quality of data reported in primary studies varied, which may affect the generalisability of our findings. Future research should focus on low-income and middle-income countries to better understand global disparities in access to infertility services.

Conclusion

Infertility imposes profound emotional and financial strains, with access to care remaining inequitable across regions. Our review reveals that comprehensive insurance policies for infertility services significantly impact fertility outcomes by increasing access to necessary treatments. However, disparities persist, particularly in access to advanced therapies, underscoring the need for more inclusive policies. Policymakers should recognise the critical role of insurance coverage in addressing both urgent healthcare access requirements and longer-term fertility outcomes, supporting equitable care that transcends socioeconomic and regional barriers.