In her late twenties, Asima Ahmad went looking for an explanation. Her cycles had never been regular. Everyone else’s in her family were. When she raised the problem with a physician, nothing happened.

"There was no workup done," Ahmad recalled. "I was just told some people have irregular cycles."

Ahmad went to medical school, learned the diagnostic criteria, and ordered the labs and ultrasound herself. "I actually diagnosed myself."

Today Ahmad is triple board-certified in obstetrics and gynecology, reproductive endocrinology, and obesity medicine. She is co-founder and chief medical officer of Carrot, a fertility and family care platform used by more than 1,000 employers. In May, the Department of Health and Human Services (HHS) Office on Women's Health named her a Women's Health Ambassador. Her story is the fertility system in miniature. The care that would have mattered most arrived years after the moment it was needed.

Better Testing Leads To Better Overall Health

What Ahmad missed was never only about fertility. Years of unpredictable bleeding carried an elevated uterine cancer risk nobody had flagged, alongside long-term cardiovascular and metabolic risk. "It’s much bigger than just fertility or reproductive health with some of these conditions," she explained.

Ahmad is blunt about what has to change in how clinicians are trained. She wants OB/GYNs to feel comfortable ordering a basic evaluation and talking a patient through the results: follicle-stimulating hormone and estradiol on cycle day two to four, anti-Müllerian hormone, an antral follicle count. None of it is exotic. Most of it is rarely offered before a patient is already struggling.

"The ‘don't worry, you're fine’ without looking at anything conversation needs to end," Ahmad argued. "You can't really tell them that everything's fine if they haven't looked at it."

What The PCOS Name Change Means For Fertility Care

Ahmad's condition got a new name this year. In May, from polycystic ovary syndrome to polyendocrine metabolic ovarian syndrome, or PMOS. It affects roughly one in eight women, more than 170 million worldwide. The old name implied ovarian cysts that many patients never had while burying the endocrine and metabolic features that actually drive risk.

The stakes show up in the data. Among U.S. women ages 20 to 49 , 45.2% of those diagnosed with PMOS report current fertility problems, about two and a half times the 17.1% rate among women without it. The pattern repeats for endometriosis, at 33.0% against 18.6%, and fibroids, at 25.4% against 19.0%. Melanie Cree, a pediatric endocrinologist at the University of Colorado Anschutz who worked on the renaming, framed the change plainly. "Renaming this condition is more than semantics," she observed. It moves the condition out of the gynecology lane and into metabolic medicine, which is precisely where Ahmad has been arguing fertility care belongs.

Most People Do Not Want IVF First

Here is where the conventional story about IVF breaks down. The assumption is that patients want it and the system obligingly delivers. Carrot's survey of 1,010 adults across four countries found close to the opposite: 89% know about IVF, but only 58% are willing to pursue it, and 83% would choose lower-cost options first.

The appetite for upstream care is there, and the clinical conversation is not. Some 84% would consider metabolic health support, while only 44% have ever discussed it with a provider. Nearly half learned their options only after they began trying to conceive or ran into trouble.

Carrot commissioned the research, and it finds demand for what Carrot sells. The finding is hard to dismiss because it matches what patients have been saying for years. Founder and CEO Tammy Sun described the distance between what people want and what they get as a gap that "is not subtle and it is not inevitable."

Ahmad, who still sees patients, is careful not to overcorrect. "I am a doctor who provides IVF, and I am not against it at all by any means," she said.

The Evidence For Upstream Care Is Not Settled

The business case for intervening earlier is documented. Carrot reports a 4:1 return on its fertility benefit. At SiriusXM, the company says 32% of members achieved pregnancy without IVF, cycles dropped 11%, there were zero multiple births, and savings passed $2.1 million.

They track how much treatment people used and what it cost, drawn from members who engaged at least 90 days before treatment. There is no comparison group, and fewer IVF cycles produce savings whether or not more babies arrive.

Does Losing Weight Before Pregnancy Improve Fertility

One randomized trial has tested a version of the premise that weight affects fertility. The NIH Reproductive Medicine Network's FIT-PLESE study assigned 379 women with obesity and unexplained infertility to 16 weeks of intensive weight loss or to exercise alone, then moved both groups to insemination. The intensive group lost about 7% of body weight and sharply reduced metabolic syndrome incidence. Healthy live births were 15.2% in the standard group and 12.2% in the intensive group, a gap that was not statistically significant. Better metabolic health, the authors concluded, "may not translate into improved female fecundity."

Richard Legro, who led the trial and chairs obstetrics and gynecology at Penn State Health Milton S. Hershey Medical Center, was more direct. Despite what standard practice recommends, " there’s just not enough evidence to recommend preconception weight loss" in these patients, he stated. Fertility clinics routinely counsel weight loss.

The trial is not a clean verdict on Carrot’s model. Its participants were already ovulating regularly, unlike the anovulatory population Carrot’s metabolic program targets. And the standard group exercised. FIT-PLESE tested whether intensive weight loss adds to exercise, not whether metabolic support beats none.

Ahmad makes that argument and adds one of her own. "We do track members who pursue upstream interventions and do not conceive," she said, describing outcomes that inform when a member should escalate to IVF. "A healthy pregnancy doesn't begin with a positive pregnancy test. It begins with the health of the woman before conception," she said, calling the trial's limits a reason "a study conclusion may not universally apply to every population."

Carrot is collecting metabolic outcomes data for a study comparing members who use the services with similar members who do not, measuring pregnancy rates, live births, preterm birth, and IVF avoidance. The company says it will publish outcomes for the full population, including members who never conceive, and intends to share the findings through peer-reviewed research once enough time has passed for birth outcomes to accumulate. It has done this before: Milliman, an independent actuarial firm, validated the methodology behind Carrot’s 2024 IVF outcomes study , which reported live birth rates 24% above the national average and multiple births 63% lower.

Until that research lands, employers are making coverage decisions on early evidence. That is true across the benefits market, not just at Carrot.

Who Pays Decides What Care Looks Like

Sun's argument for why the industry defaults to IVF is structural, not moral. "Incentives drive market behavior," she said. Tie revenue to embryology work and retrievals, and "It will drive people to the most expensive solution first."

There is also a hard ceiling nobody talks about. "There's actually not enough IVF doctors in this country to service every single person in this country," Sun noted. Roughly a thousand reproductive endocrinologists serve a country with some 300,000 primary care physicians.

Proposed federal guidance would allow employers to offer stand-alone fertility benefits outside their major medical plans, treating them as “excepted benefits” similar to dental and vision coverage. Employers would gain wide discretion over reproductive-care benefits.

The Fix Is A Conversation, Not A Procedure

Ahmad needed a medical degree to get an answer she should have received at 19. Her prescription for everyone else is less dramatic and harder to bill for—teach people what to look for and teach clinicians to run the test instead of offering reassurance.

"People know their bodies more than anyone," she said.

The intervention that would change the most is not a new technology. It is a conversation that currently happens years too late and, right now, the only institution funding it at scale is an employer.