Fertility Solutions Medical Necessity Clinical Guideline Infertility

Clinical Performance Guideline Fertility Solutions Infertility

TABLE OF CONTENTS PURPOSE AND GOAL BACKGROUND GENERAL INDICATIONS TREATMENT CRITERIA

OVULATION INDUCTION CLOMID LETROZOLE TAMOXIFEN GONADOTROPINS

OVARIAN STIMULATION CLOMID LETROZOLE TAMOXIFEN GONADOTROPINS

THERAPEUTIC DONOR INSEMINATION INTRAUTERINE INSEMINATION

NATURAL CYCLE STIMULATED IUI ASSISTED REPRODUCTIVE TECHNOLOGIES IVF NATURAL CYCLE IVF ICSI IVF FRESH CYCLE NOT INDICATED ELECTIVE SINGLE EMBRYO TRANSFER MULTIPLE EMBRYO TRANSFER ADJUNCTS TO TREATMENT PREIMPLANTATION GENETIC TESTING GESTATIONAL CARRIER SURGERY TUBAL ENDOMETRIOSIS UTERINE MALE FACTOR INFERTILITY DEFINITIONS BIBLIOGRAPHY

Medical Necessity Guideline

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TABLE OF CONTENTS 1

Purpose: To provide an understanding of infertility treatment, issues surrounding infertility surgery, and issues surrounding multiple embryo transfers among individuals faced with the potential loss of fertility.

Goals: To provide an evidence-based approach to infertility management, infertility surgery, and the use of single embryo transfer in addition to describing the limitations of and recommendations for infertility treatment.

Background

I. Infertility

? Definition:

o A disease (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. It is defined by the failure to achieve a successful pregnancy after 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 6 months for women aged 35 years or older.

o The presence of an identified infertility factor should allow for immediate treatment, obviating the need for the waiting period to meet the definition of infertility when an individual is actively attempting to achieve a conception.

o Recurrent pregnancy loss is a disease distinct from infertility, defined by two or more failed pregnancies. When the cause is unknown, each pregnancy loss merits careful review to determine whether specific evaluation may be appropriate. (ASRM)

o For purposes of determining when evaluation and treatment for infertility or recurrent pregnancy loss are appropriate, pregnancy is defined as a clinical pregnancy documented by ultrasonography or histopathologic examination. (ASRM)

Artificial donor insemination may (refer to specific benefit language) be considered diagnostic in terms of meeting the definition of infertility for females without a male partner who do not otherwise have an identified infertility factor. Such artificial insemination is limited to not more than 12 inseminations for females ................
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