In America today, one in eight couples struggle with infertility, and that number is expected to increase. Another metric that's rising? Inequality rates. Since 1970, the gap between the rich and poor has widened steadily. When it comes to race, the sizable income gap between Black Americans and white Americans has closed only slightly in the past decades, and poorer Hispanic Americans are falling further behind. Overall, the rich are getting richer and the poor are getting poorer. What does inequality have to do with infertility? Although people of all incomes and races struggle to conceive, effective fertility treatments are prohibitively expensive for many and thus not equally available to all. And for people hoping to expand their families via adoption, the steep price can keep them from realizing their dreams, too. As a result, we can add parenthood to the list of things often decided by demographic privilege.
Infertility Is a Growing Problem
Experts predict that the rate of infertility will continue to rise as people delay having children. Dr. Isiah Harris, a reproductive endocrinologist at the Spring Fertility clinic in San Francisco, explained, "2016 was the first time ever in the US that the CDC reported more women having babies in their 30s than in their 20s." As more people try to conceive at older ages, more might need help getting pregnant with treatments like intrauterine insemination (IUI) or in vitro fertilization (IVF). These treatments come at a price that puts the goal out of reach for many. Let's break down just how much fertility treatments can cost on average per attempt.
Average Price of Fertility Treatments Per Cycle in the US:
- Medication only: $636
- IUI with clomiphene: $1,453
- IUI with gonadotropins: $3,841
- IVF: $14,402
- IVF with donor egg: $21,771
For women under 35, IUI results in a live birth about 12 percent of the time, while the IVF success rate is about 40 to 50 percent. Given these rates, women are often unsuccessful the first time and may have to do multiple rounds of various treatments, depending on their exact infertility diagnosis. The likelihood of success for each of these treatments goes down as women get older. Since results can vary based on the doctor or patient, the CDC reports success rates by specific clinics and age of patient.
In a 2012 study, participating women received an average of 3.6 fertility treatments over 18 months and spent an average of $19,690. Only 30 percent of these women found success with treatment, which meant many patients spent tens of thousands of dollars without having a baby. On average, the cost per successful pregnancy was $48,242.
How People Pay For Fertility Treatments
Many employer-sponsored insurance plans specifically exclude fertility treatment from their coverage. I spoke to one woman, who preferred to remain anonymous, and she described how it felt to find out her insurance was worthless when it came to treating infertility.
"I had been working for the same company for years and barely went to the doctor," she recounted. "When I actually needed to get medical tests done to help explain our trouble conceiving, I was told everything would be out of pocket — including an HSG test that was quoted as $10,000. I left my doctor's office in tears. It seemed cruel that my potential medical issue was being treated differently than someone else's. It made me feel like, what's the point of insurance if it won't even cover a test, let alone IVF if I needed it?" While this particular woman was able to get the HSG test (which evaluates the state of your fallopian tubes) for about $1,500 as an out-of-pocket patient, that was just a first step in figuring out what treatment might work.
Some employers do cover fertility treatments via their insurance plans. Famously, Facebook and other Silicon Valley companies will also pay for egg freezing. But should you be able to become a parent just because you work at Facebook?
Not surprisingly, many people find themselves depleting their savings or putting off other goals like buying a home in order to afford treatment. Others go into debt. "The understandable desperation to have a child leads some lenders to take advantage of patients by offering high-interest loans to patients desperate for treatment," Dr. Harris told me. He's heard of patients with no debt and good jobs being offered loans with a staggering 12 percent interest rate to pay for egg freezing, for example.
Should you be able to become a parent just because you work at Facebook?
When loans or savings aren't available, some ask their social networks for financial assistance. Just look at GoFundMe, and you'll find countless stories of couples looking for some extra help to make their parenthood dreams a reality. The crowdfunding site has a dedicated page for IVF fundraising. The stories have common themes, while being uniquely heartbreaking. One woman wrote: "I didn't realize infertility would rob me of the joy of celebrating pregnancies and milestones with friends and their children, because while I was happy for them it was just too painful for me . . . I never thought financial constraints would come into the discussion about having a family." She successfully raised $7,000 to put toward the $20,000 cost of one round of IVF. Other couples turn to GoFundMe hoping to try IVF after paying for numerous unsuccessful tries with IUI. After reaching the limits of their savings or credit cards, they need help to continue the journey to parenthood.
Spring Fertility, which opened in 2016, has tried to make this path more accessible by offering 0 percent interest payment plans for egg freezing with no down payment, as well as discounts that range from $1,000 to $2,500 off IVF for teachers, civil servants, veterans, and members of the military. But it's still a steep price.
White Women Are the Most Likely Group to Get Treatment
Money alone doesn't determine who can access medical treatment for infertility. Race also comes into play. A 2015 study published in the Pediatric and Perinatal Epidemiology medical journal noted that white women are the most likely group to receive fertility treatment overall, although reports of infertility were the same across all races. The study found that even in states that mandate insurance cover the cost of fertility treatment, disparities by race and education persist. So it's not just about who can afford it.
The study concluded that better targeting of online resources could improve access to information across demographics. It continued: "Additional targeted outreach by organizations already in existence to fight stigma and improve knowledge about fertility problems . . . could be beneficial."
Even in states that mandate insurance cover the cost of fertility treatment, disparities by race and education persist.
Unfortunately, the current state of this outreach isn't all that inclusive. Another study from 2012 found that 97 percent of fertility clinics included photographs of white babies on their website and advertising materials, and 62 percent only featured photographs of white babies. The image of an older, professional white woman as the typical IVF patient might have the effect of excluding others from accessing this reproductive technology, even when their insurance will pay for it. Public figures like Michelle Obama and Gabrielle Union are helping break down that stereotype by talking about their own journeys. The medical industry should catch up.
Our medical system is full of racial bias and discrimination, and in general, Black women are less likely to visit a doctor than white women. The same is true for infertility: Black women are less likely than white women to get medical treatment. When they do seek help for infertility, Black women wait twice as long to do so. Because of this delay, Black women could miss out on low-cost solutions for infertility. As the study pointed out, simple counseling can often help optimize chances of natural conception or provide and increase awareness of less invasive treatment options.
New Fertility Startups Aim For Inclusiveness
As they try to appeal to patients, newcomers to the fertility industry could be part of the answer to disrupting the current situation. Look at the website for Spring Fertility, and you'll see diverse imagery. "We are an ethnically and racially diverse organization, so it's natural for us to be inclusive," Dr. Harris explained. Currently, Spring Fertility employs five different providers that include a first-generation immigrant from Vietnam, a Hispanic woman, an African-American man (Dr. Harris), an African-American woman, and a "token white guy," as they put it with some humor. "Our mission is to help everyone have the family of their dreams, irrespective of gender, race, or sexual orientation," Dr. Harris said.
Other direct-to-consumer fertility startups are trying to expand who can access fertility services. This could help people in diverse demographics seek treatment earlier. Modern Fertility is one such startup that wants to help women get the same basic tests you would get at a fertility clinic without ever having to go to one. You simply go to the Modern Fertility website and purchase a test for $150. A doctor then reviews the order and assigns a personalized test you can take at home or at your local Quest Diagnostics lab. If you take it at home, you can send the test back via mail. Then, a doctor will review your results before posting them online. After that, you have access to a doctor and online community to discuss your results and the best next steps. The main thing the Modern Fertility test looks for is your AMH levels, which can give you an idea of how many eggs you have left. They'll also provide a Fertility Measurement Index (FEMI), with the hope of giving you a better sense of your fertility than your age alone can.
"We think education is for everyone," explained Dr. Nataki Douglas MD, PhD, and chair of the Modern Fertility Medical Advisory Board. "All women should be able to get access to this basic and important information about their body so they can be their own best personal health advocates," she said. By giving women a more personalized and specific look into their own fertility picture, Modern Fertility could help women avoid expensive fertility treatments down the road. For example, a woman in her late 20s who shows a low number of eggs for her age may decide to start trying to conceive naturally now.
Dadi is another company trying to remove barriers for fertility services, but for men. It's created a $99 at-home male fertility test kit that is easier and cheaper than traditional options. For $99 more per year it will store your sperm, too. "Since launch, we've shipped Dadi kits all throughout the US and we're going to continue to spread awareness and education about male infertility," Dadi cofounder and CEO Tom Smith told me. Affordable tests like the ones offered by Modern Fertility and Dadi could reduce the barrier to entry for fertility treatment and help close the information and access gap. Earlier interventions may lead to more affordable and fewer treatments.
Adoption Is an Expensive Option
For many people hoping to expand their families, adoption is the preferred choice for various reasons. But it's important to note that regardless of the personal considerations, adoption is also expensive. Adopting through a private agency can range from $20,000 to $40,000 on average and can climb much higher depending on specific circumstances. Costs can include a home study, legal expenses, counseling, training, and supervision until the adoption is finalized. Adopting a child from the foster care system is often more affordable, since government assistance programs try to minimize expense and encourage adoption of children with special needs or circumstances, like older kids, siblings groups, or children with health issues. But it also takes a lot of resources.
As with fertility treatment, the majority of adoptive parents are white. They also tend to be better educated and more financially well-off. Sadly, many people who want to welcome a child via adoption might not be able to afford the upfront cost.
How We Can Address the Inequality
With infertility on the rise, we know that the "old-fashioned" way of making a baby won't work for many. More people will turn to assistive reproduction technology and adoption to create their families. But if we don't find ways to address the costs and general inequality in this country, your socioeconomic status could decide whether or not you become a parent.
We can look to other developed countries for ideas. Many cover fertility treatments under universal healthcare programs. The French healthcare system will cover up to six IUIs and four rounds of IVF before a woman's 43rd birthday, as one American expat who shared her experience going through IVF in France explained. And you still get the standard reimbursement if you go to a private clinic. A good friend of mine who lives in Australia was able to complete a round of IVF there for about $5,000 out of pocket, after the Australian national system covered half of the total cost. She didn't have to file any paperwork, and the rebate was paid directly to the private clinic she went to. In the United Kingdom, the National Health Service (NHS) will cover three rounds of IVF for women under 40 if they haven't been able to conceive after two years and meet other requirements. These systems aren't always perfect. Waiting times in the UK often encourage people to seek private treatment (which costs much less than in the US, at £5,000, or about $6,500). But while some are better than others, these systems do offer options for those who can't afford the total cost.
The desire to have a child is an essential part of the human experience for many. Yet, the American healthcare system has long considered pregnancy and childbirth as a luxury. Insurance companies commonly treated pregnancy as a pre-existing condition and would deny women coverage based on that until the Affordable Care Act (ACA) passed in 2010. Before the Pregnancy Discrimination Act became law in 1978, many employer-sponsored insurance plans did not even cover labor and delivery, requiring new parents to pay for it out of pocket. Even after that, a 2009 study found that only 13 percent of the insurance plans available to a 30-year-old woman on the individual market covered maternity care. It took the ACA to change that. We have a long history of marginalizing "women's" health conditions, and the lack of support for fertility treatments is another example.
If we want to make parenthood accessible to all, we need to increase access to treatments that cure a medical condition.
The first baby was born from IVF more than 40 years ago. Fertility treatments are no longer experimental, but a medical necessity for a large portion of Americans. Infertility doesn't just impact working older white women who can afford IVF, as the stereotype might suggest. It stretches across income and racial demographics. If we want to make parenthood accessible to all, regardless of their privilege, we need to increase access to treatments that cure a medical condition. Otherwise money will help decide who gets to be a parent in America.