For the purpose of this policy infertility is defined as a condition (an interruption, cessation, or disorder of body functions, systems, or organs) of the reproductive tract which prevents the conception of a child or the ability to carry a pregnancy to delivery. This is evidenced by the failure to achieve a successful pregnancy after twelve (12) months or more of appropriate, timed unprotected intercourse or therapeutic donor insemination. Earlier evaluation and treatment may be justified based on medical history and physical findings and is warranted after six (6) months for women over age 35 years.
Infertility may include:
- Absent or incompetent uterus;
- Damaged, blocked, or absent fallopian tubes;
- Damaged, blocked, or absent male reproductive tract;
- Damaged, diminished, or absent sperm;
- Damaged, diminished, or absent oocytes;
- Damaged, diminished, or absent ovarian function;
- Hereditary genetic disease, or condition that would be passed to offspring;
- Uterine fibroids;
- Sexual dysfunction impeding intercourse;
- Teratogens or idiopathic causes;
- Polycystic ovarian syndrome;
- Inability to become pregnant, or cause pregnancy of unknown etiology;
- Two or more pregnancy losses, including ectopic pregnancies; and
- Uterine congenital anomalies, including those caused by diethylstilbestrol (DES).
- Iatrogenic infertility is defined as an impairment of fertility due to surgery, radiation, chemotherapy, or other medical treatment.
Infertility for this policy does not include voluntary sterilization or reversal of voluntary sterilization.
Artificial Insemination is a procedure, also known as intrauterine insemination (IUI); or intracervical/intravaginal insemination (ICI), by which sperm is directly deposited into the vagina, cervix or uterus to achieve fertilization and pregnancy.
Assisted Reproductive Technology (ART) includes all treatments or procedures that involve the in vitro (i.e., outside of the living body) handling of both human oocytes (eggs) and sperm, or embryos, for the purpose of establishing a pregnancy. Treatments and procedures include, but are not limited to:
- In vitro fertilization (IVF) and embryo transfer
- Gamete intrafallopian transfer (GIFT)
- Zygote intrafallopian transfer (ZIFT)
- Tubal embryo transfer (TET)
- Peritoneal ovum sperm transfer
- Zona drilling
- Sperm microinjection
- Gamete and embryo cryopreservation (freezing)
- Oocyte and embryo donation
Gestational surrogacy or carrier
- Gestational surrogacy is an arrangement in which a woman carries and delivers a baby for another person or couple
ART does not include artificial insemination in which sperm are placed directly into the vagina, cervix or uterus.
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.