I first learned of fertility financing companies when I read a Forbes article topped by the headline “Meet Prelude Fertility, the $200 Million Startup That Wants to Stop the Biological Clock.” Prelude is a lucrative private-equity-backed start-up created in 2016 by Argentine serial entrepreneur Martin Varsavsky. Soon after it launched, Prelude began aggressively acquiring fertility clinics around the United States, and is now one of the largest networks of fertility centers in North America. Varsavsky “envisioned a new norm for reproduction, one that would anticipate infertility rather than simply react to it. Young people in their reproductive prime could freeze their sperm or eggs in their twenties, live their lives, pursue careers, and then, when they finally met the right person, thaw their frozen gametes,” a New Yorker article described. Varsavsky, who often touted the line “Sex is great, but not to make babies” while raising funds for the company, called his vision the Prelude Method. The aim was to own every step of a fertility patient’s journey, starting with egg freezing in their twenties and ending with a baby in their thirties or forties.

Initially, the Prelude Method started at $199 a month for the four-step process: egg freezing, embryo creation, genetic screening, and embryo transfer. A patient could choose between two product plans and, after plunking down several thousands of dollars up front, pay a couple of hundreds of dollars each month, sort of like a car layaway plan. Now, the company directs potential clients to a fertility clinic in its network, then provides financing options via third-party companies for services a patient will undergo. In 2019, Varsavsky joined forces with T. J. Farnsworth, a healthcare entrepreneur, who was building a similar chain of fertility practices in Texas and Georgia. Prelude, which now owns more than eighty clinics in the United States and Canada, offers its fertility treatment packages via Bundl, the company Farnsworth started, which combines ART procedures and charges customers a package price. Bundl also promises patients a baby or their money back.

When I finished reading the Forbes article, I felt a little sick to my stomach. I was still coming to terms with egg freezing’s high price tag; who has a spare $30,000 lying around to pay for this? Not me. I found myself calculating the cost of the egg freezing packages over the years one would need them, and getting a little panicky thinking about a near future where egg freezing and storage is just one of a young professional woman’s usual fixed costs, like rent or car insurance. Which, it turns out, is exactly how Prelude wants women like me to think about reproduction—and that was another aspect that made me queasy. It was the “commanding every aspect of a woman’s fertility” bit that bothered me about Prelude’s business model and mission to dominate the market, along with its subliminal messaging: Invest in your fertility now so you don’t have to resort to buying your way out of infertility later. “We are now targeting women in their 20s and early 30s,” Susan Herzberg, then Prelude’s president, told The New York Times in 2018. It’s smart from a business perspective, of course: The earlier a woman freezes her eggs, the more money she’ll shell out to keep them on ice until she’s ready to use them. A convenient omission by companies like Prelude, however, is the fact that the vast majority of women who have frozen eggs to date haven’t returned to thaw them.

The goal of helping people finance fertility treatment the way they might pay for a car, though, makes sense—even if it sounds icky—especially for millennials and Gen Zers who need help affording what for many of them is the largest out-of-pocket health expense they’ve ever encountered. That’s what led Claire Tomkins to co-found Future Family, which offers sixty-month loan plans for IVF or egg freezing, including discounted lab work and medications, and a “fertility coach” to field questions and help patients navigate their treatment. Other fertility entrepreneurs have expanded into financial products to address cost barriers and appeal to the “buy now, pay later” mindset; their companies partner with fertility clinics to attract customers and offer payment plans similar to Future Family’s to help patients finance treatment.

Fertility clinics now extend all sorts of finance options on their own to both entice patients and ease their minds. Some clinics offer egg freezing discounts for women with a medical diagnosis, for transgender men, and for women in the military. Some offer “freeze with friends” deals: Southern California Reproductive Center ran a promotion saying if three friends freeze eggs together, each receives 30 percent off; Ova, a clinic in Chicago, advertises on its website, “The more friends in your circle who freeze together, the bigger the discount!” There’s an increasingly popular “freeze and share” hybrid model, where a woman can freeze eggs for free or at a discount when she donates half of her retrieved eggs to an egg donor program or to prospective parents who can’t otherwise conceive. There are also package or “shared risk” programs for when patients return to use their frozen eggs—this offsets the high risk of IVF cycle failure.[*5] Shady Grove Fertility, which has dozens of clinics nationwide, offers a more-or-less “satisfaction guaranteed” program in which qualifying egg freezing patients pay a flat amount for unlimited attempts to get pregnant with their frozen eggs. At Spring Fertility, where Mandy froze eggs, if a patient freezes at least twenty eggs before age thirty-five or thirty eggs before age thirty-eight at one of the company’s clinics and doesn’t get pregnant when she returns to use them, she is refunded all of the money she paid to Spring for freezing and attempting to use her eggs.

Fertility clinics and for-profit companies they partner with are financially incentivized to sell egg freezing and IVF. They pitch programs and packages that go like hotcakes; many patients end up losing money on them, while others save. That’s the reality of fertility treatment’s capitalistic backdrop. The way I see it: Fertility financing companies aren’t the enemy, and many do a good service helping people pay for incredibly expensive procedures. But while efforts to make egg freezing more affordable are one thing, aggressively targeting young women to sell them on a procedure they may not need, or that may not pan out, is another. It’s an aspect of egg freezing’s bigger picture I would come to be increasingly troubled by.

The fertility financing scene is…a lot. But onward to the pragmatics of paying. In lieu of or in addition to leveraging a shared risk program or fertility treatment loan, many women turn to other avenues to help them afford egg freezing, particularly their health insurance or employer.

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When it comes to paying for egg freezing, we need to talk about three things: state insurance regulations, employer-offered fertility benefits, and self-pay.[*6]

The short answer to the question Does health insurance cover egg freezing? is that it depends. In the United States, private health insurance, which includes employer-sponsored plans (known as group plans), is regulated at the federal level and more heavily at the state level, and laws often address which healthcare services must be covered by group and individual plans. As of September 2023, twenty-one states and Washington, D.C., have laws requiring insurance companies to cover or offer some variation of fertility testing, diagnosis, or treatment. But each of these states can define “fertility coverage” however it sees fit, and they vary considerably in their entitlements, including how long a person has struggled with infertility before qualifying for treatment, what sort of treatment is covered, whether same-sex couples and unmarried individuals are covered, and more.

The list of states that offer fertility treatment coverage has been growing steadily since the 1980s, though benefits vary widely. Here are a few state-specific examples (accurate as of this writing). Massachusetts, which has one of the most generous laws, requires insurers that provide pregnancy-related benefits to also cover infertility diagnosis and treatment, which includes IVF and egg freezing, among other procedures. Delaware, New Hampshire, and New Jersey have comprehensive infertility coverage, including for the pricey fertility meds. In New York and Colorado, certain patients are eligible for up to three rounds of IVF and are covered for medically necessary fertility preservation procedures, such as freezing eggs or sperm before undergoing cancer treatment. California does not require insurers to cover fertility treatment; if employers choose to offer it as part of their employee health benefit package, IVF isn’t included. The opposite is the case in Texas, where insurers must offer IVF, and if employers elect to extend the benefit, patients must have a history of five continuous years of infertility or meet a long list of criteria to qualify for coverage. Also, the patient’s eggs must be fertilized only with her spouse’s sperm, rather than a donor’s. The spouse’s-sperm-only stipulation is also the case in Hawaii and Arkansas, once again effectively excluding same-sex couples and single people. Finally, some states place age limits on female patients who can access fertility benefits—a woman in New Jersey, for example, must be under the age of forty-six to be eligible; in Rhode Island, she must be between the ages of twenty-five and forty-two—and others place restrictions on marital status.

To put it bluntly, the United States has never considered any sort of fertility treatment worthy of widespread subsidized healthcare coverage. Most of the mandates stipulating that private insurers cover some fertility treatments are geared toward infertility, and in the majority of cases, as I’ve said, a person must have a diagnosis of infertility from a doctor in order to qualify for coverage.[*7] This is problematic in that it doesn’t apply to same-sex couples who aren’t infertile; they’re just not in a situation where they can achieve pregnancy via sex (more on ART access issues and how these laws affect LGBTQ+ people shortly). It also doesn’t apply to healthy women wanting to proactively freeze eggs.[*8] While some insurance mandates include at least partial coverage for fertility preservation due to medical conditions, there is no coverage for egg freezing without a medical reason or for proactive fertility testing (discussed in chapter 6) without an infertility diagnosis.

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Employer coverage for fertility is a different story. Many private sector companies have changed their healthcare coverage plans to include ART for less limited reasons. Apple and Facebook, back in 2014, were among the first large firms to announce that their insurance plans would cover egg freezing for employees for non-medical reasons. By 2017, egg freezing was the hot new perk in Silicon Valley. At first it was mainly tech and finance companies that covered it; then new media companies, start-ups, and universities began extending the benefit, too. As of 2021, 19 percent of large U.S. employers offered egg freezing, compared to just 6 percent in 2015. No longer a nice-to-have perk, fertility treatment coverage in general has become a staple in many employers’ healthcare packages: More than 42 percent of large U.S. employers, and 27 percent of smaller companies, offer IVF benefits.[*9]

Back to Progyny, one of the largest publicly traded femtech companies, which partners with companies to manage fertility benefits for employees. An employer decides to offer fertility benefits to its employees; Progyny then manages all aspects of those benefits, connecting members to its network of more than 950 fertility specialists, covering fertility medications under Progyny Rx, and overseeing treatment. Each member receives access to a “patient care advocate,” who helps the patient coordinate appointments, connects the patient to an on-demand nurse for help with fertility meds, and even offers emotional support. (Um, wow.) Progyny’s more than 370 clients include Amazon, Google, Meta, and Microsoft.

Becca, while working at Google, froze twenty eggs thanks to the company’s Progyny benefit, and doubts she would’ve frozen her eggs without it. When she froze, she was thirty-seven and single and didn’t know if she wanted kids. “But I wouldn’t want my fertility to be the reason I couldn’t be with someone I fell in love with, if kids were very important to him,” she told me when we spoke on the phone a few days after the procedure. To Becca’s relief, the week of her egg retrieval was a relatively calm one at work. Becca’s boss, who was male, knew she was freezing her eggs, but her colleagues—also mostly men—didn’t. “There was a part of me that didn’t want to make people feel uncomfortable,” she said, adding that she also didn’t want to draw attention to the fact that she was thirty-seven and unpartnered. “Almost everyone I know at work that’s my age is married and has kids,” she said. “The fact that I’m single at my age feels a little bit like a failure, like I’ve done something wrong. And so it’s not something I like to highlight to the people I’m trying to instill confidence with.” A year later, Becca told me that freezing her eggs helped her realize that having a kid isn’t critical to her being happy in life. She also more confidently pursued things she wanted—a new job, a location change, and a partner. “There’s so much more to life than whether or not you’re fertile,” she said, with a satisfied sigh.

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How do people without insurance benefits or employer coverage afford egg freezing? Since I fell into that boat, I’d been mulling for months over how I would manage to pay for the procedure. Dr. Noyes had offered me a medical discount for freezing, since in the clinic’s view my having one ovary was a sort of “condition,” but I was having trouble getting my health insurance to agree.[*10] After I published my first story about egg freezing, my mother emailed me: Great article! Maybe an egg freezing place will contact you to freeze your eggs at no cost![*11] Women often freeze their eggs in their mid-thirties, just as they enter prime wealth-building years. For some, that means depleting their savings, going into debt, and/or delaying goals such as homeownership in order to self-finance egg freezing. They take out loans, mortgage their houses, borrow from 401(k) accounts, start GoFundMe campaigns, or take on second jobs in order to afford one or more cycles. Increasingly, many women travel abroad for a better deal; egg freezing is a fraction of the cost in countries like Spain and the Czech Republic. I would need to look into every possible way to get the dollar signs down, because the more I scrutinized egg freezing costs, the more clearly I saw it as a financial impossibility.

Remy paid for egg freezing by taking out a $20,000 personal loan and charging the meds to a credit card. She also sold her engagement ring—“extra cash for the eggs,” she told me—and took on additional shifts at the hospital. Sometimes alimony can finance egg freezing; I read about cases in which women fought hard for egg freezing to be paid for by their ex-husbands as part of their divorce settlements—and won. There are nonprofit organizations that provide fertility treatment scholarships and grants. Often, families help, as Mandy’s offered to. A few years ago, Valerie,[*12] a Chicago woman who froze her eggs in her early thirties, began documenting her experience on a blog and a weekly podcast. When she started her project, her respondents were mostly in their late thirties. Now she hears from women in their mid-twenties whose grandparents want to help finance the procedure, as they might a down payment for a house. She also gets calls from parents with teenagers and college-age daughters, who see egg freezing as a future gift and are willing to foot the bill—the return on investment coming in the form of a grandchild down the road. Danielle, a thirty-nine-year-old in Dallas who did two rounds of IVF before getting pregnant, echoed this, telling me: “My husband and I are not going to pay for our daughters’ weddings one day, but we will pay for them to have their eggs frozen when they’re in their twenties.”

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“We pay too much for the things we think are precious, but we also start to believe things are precious if someone makes us pay too much,” writes Jia Tolentino in her essay collection Trick Mirror. She was referring to the wedding industry and trendy workouts like barre and the world of beauty and wellness in general, but when I read that sentence I immediately thought about a woman’s eggs. A modern-day young woman learns her eggs are precious upon discovering they are something of a commodity. Her eggs are fragile, and every moment brings them closer to expiration. It makes sense, then, at least on an emotional level, that it costs thousands of dollars to freeze them, and thousands more down the road to use them. For many women, egg freezing is both exorbitantly expensive and the easiest money they’ve ever spent.

Dr. Lora Shahine, a reproductive endocrinologist in Seattle, summed it up to me like this: “I think of egg freezing as this incredible opportunity. It’s very empowering, it’s wonderful, but the way it’s sold as insurance and a guarantee is really scary.” If a woman works at a company like Amazon or Google, she went on, “egg freezing is a no-brainer. For them, the financial pressure is really eased. So that’s a real win. It shouldn’t change someone’s family goals. But it can relieve a large burden and allow people to feel a little bit more free.”

The people benefitting from egg freezing and being courted by fertility clinics, though, are a specific subset: predominantly white middle- to upper-middle-class professionals in their thirties. Prohibitively high costs make egg freezing and IVF impractical, if not impossible, for many people, especially those with lower incomes. And so, I realized, it isn’t just that egg freezing is a new and complicated technology. Or that it’s really expensive. When I began to learn more about the inequalities in access to treatment, I realized it was more about the ways in which fertility is a privilege, not a right.

Embryo Destruction Meets Anti-Abortion

A revolution of sorts might have been taking place in the femtech world, but elsewhere, the opposite was happening. In 2017, Donald Trump’s administration, with evangelical Mike Pence at the helm as vice president, began to dismantle reproductive freedoms—and many other civil liberties—on its first days in office. Although the landscape changed under President Biden, reproductive rights remain fragile, and the abortion battleground is particularly inflamed. The year 2021 was an especially dark time for abortion access, with more than a hundred new restrictions passed. Americans gained a constitutional right to abortion in 1973. In 2022 they lost it when the U.S. Supreme Court, in its Dobbs v. Jackson Women’s Health Organization ruling, delivered the most consequential abortion decision in five decades by overturning Roe v. Wade and striking down the nationwide right to abortion. The modern climate with regard to abortion access is anxiety-inducing, to say the least, but the more terrifying reality is that the laws in development threaten anyone with a uterus, and have implications beyond a woman’s ability to not remain pregnant if she doesn’t want to.

Women’s judgment about our own bodies and futures cannot be trusted, politicians insist, so our reproductive systems must be controlled by lawmakers—overwhelmingly, older white men. The Court’s ruling leaves it up to states to dictate abortion access, without requiring state bans to include exceptions of any kind. While some states are trying to make abortion access more robust, other states are aggressively pushing to limit the scope of when abortions can be performed. As of December 2023, twenty-one states now ban abortion or restrict the procedure earlier in pregnancy than the standard set by Roe v. Wade. Several states ban abortion after six weeks of pregnancy—which is before many women know they are pregnant.

The new abortion bans have had a less recognized effect—namely, creating confusion and legal questions about the practice of discarding embryos, which is a normal part of IVF. That’s the nature of the technology; creating multiple embryos is the point. Those with the greatest chance of developing into a healthy baby are used first, and the excess embryos are typically frozen, until the person or people who made them decide to use or discard them. As long as IVF is here to stay, so too is the reality of leftover unused embryos on ice. But IVF and related fertility treatments may not, in fact, be here to stay.

The current configuration of the Supreme Court has already begun to impact the state of reproductive rights in the United States for decades to come; it has also called into question the status of legal rights for women undergoing fertility treatment, as well as their doctors. “The United States has a political debate about abortion that has spilled over into everything that has to do with embryos,” Alta Charo, a retired professor of law and bioethics at the University of Wisconsin–Madison, told The New Yorker in 2023. The abortion bans could mean impaired access to ART. The concern is that as some states rush to pass fetal personhood bills, they may inadvertently or purposely ban IVF. Some states specifically exempt IVF from their abortion bans, but in others, restrictive “personhood laws” have been passed that use murkier language—such as specifying that life begins at fertilization, when an egg becomes an embryo, as opposed to the implantation of an embryo or a fetus being viable—and leave several stages of the fertility treatment process vulnerable to government interference, opening up the legal terrain for states to interfere with IVF and curtail patients’ access to care. If the bans are interpreted as granting embryos legal rights and protections, a fertilized egg would have the same rights as a child. Yet even if the two are deemed legally equivalent, they are decidedly not biologically equivalent, and giving an embryo “personhood” status raises all sorts of questions about what can be done with embryos created outside the body.

Experts have been worried about the impact of abortion bans on IVF for years. Many anti-abortion activists object to embryos being destroyed due to genetic screening results or because people have finished building their families. Legal experts predict that the new state abortion bans could make it easier to place controls on genetic testing, storage, and disposal of embryos. Parts of the IVF process could become illegal; in some states, it could be banned altogether. In states where the law dictates that life begins at fertilization, frozen embryos could be defined as unborn children under law, and discarding unused or frozen embryos could be criminalized (although it’s worth noting that even within the anti-abortion movement, this view of IVF and what’s created through ART is considered extreme).

What could it mean practically if laws banning embryo destruction were to pass? Fertility clinics might choose to limit the number of embryos created per cycle to try to avoid having any “extra,” but that could mean more expensive and invasive cycles until someone successfully gets pregnant. Doctors who perform IVF and discard unused frozen embryos in accordance with their patients’ wishes may be prosecuted. Fertility patients in states where the use of ART is questionable might find it necessary to have their eggs and sperm collected in-state, then shipped to a clinic in a state where the legal climate is less volatile and their eggs or embryos won’t exist in limbo—a workaround that adds another cost and burden to the already burdensome process of fertility treatment.[*13]

So the Dobbs ruling not only threatens the health of pregnant people but also, ironically, may lead to fewer healthy babies being born to parents who want them. The downstream effects are unclear. Ensuing state policies could affect everything from how miscarriages are managed to how certain birth control is provided.[*14] The impact of restrictive abortion laws on fertility treatment will likely come down to the legislation’s language and the tenacity of individual prosecutors who are interpreting it. Time will tell how the impact of Roe v. Wade’s reversal on the U.S. fertility industry will play out—and if going after embryos will become the next frontier of the anti-abortion movement—but the operational and legal implications could be enormous.

In the meantime, as fertility technology forges ahead, reproductive rights are in many ways regressing. It’s a disconcerting juxtaposition: We may soon live in a country where abortion is heavily restricted or illegal in most states but IVF and egg freezing are a guaranteed benefit at many private companies; where across America abortion providers are forced to shutter their doors while fertility clinics host “Cocktails and Cryo” egg freezing parties to drum up new business. That is, at least, if access to ART remains intact and until the legal definition of viability and the reproductive medical view that life does not begin at fertilization come to a head.

It’s enough to make anyone’s ovaries tremble. I had spent so much time thinking and asking questions about a woman’s ability to get pregnant that, some days, it was easy to forget about the legal and political forces at work to, one, make her stay pregnant against her wishes and, two, not adequately help her if her pregnancy went wrong. The stark reminder that, in today’s world, women’s fertility, sexuality, and overall health are politicized in ways that men’s are not prompted me to take a harder look at the systemic barriers and socioeconomic disparities blocking people from accessing reproductive technologies.

Access Denied

Despite the incredible technological advancements surrounding reproductive technology in recent decades, there are still substantial roadblocks to having children for many people—infertile or not. Since the first IVF program opened in the United States in 1980, stigmatizing laws and entrenched social and cultural attitudes have contributed to significant disparities—dictated by state of residence, insurance plan, income level, race and ethnicity, and sexual orientation and gender identity—that have made ART difficult to access. The result is that today systemic barriers prevent many people who are not white, cis, heterosexual, and upper-middle-class from pursuing fertility services.

Let’s start with race. How race affects maternal and reproductive health in a more general sense is a larger conversation, but in essence: The reasons that Black women, overall, have poorer pregnancy outcomes and face more obstacles in accessing fundamentals such as affordable housing, healthy food, transportation, and good prenatal care are embedded in broader social disparities, a complicated matrix of external forces—including structural racism and income inequality—at play. This context is important to understand why, compared to white women, so few BIPOC women pursue fertility treatment, and the ways in which race in America gravely affects many Black women’s fertility journeys, from both medical and emotional standpoints.

In the United States, about 12 percent of women ages fifteen to forty-four have trouble getting pregnant, and Black women are twice as likely to experience infertility as white women.[*15] Despite these higher rates of infertility, Black women are less likely to access medical help to get pregnant, and if they do, they may wait twice as long before seeking treatment. Many women experiencing infertility face an uphill battle in getting care, but Black women face additional challenges, such as a lack of Black sperm and egg donors and prejudice from physicians in a medical space that is overwhelmingly white.[*16] Several factors, including income, differences in coverage rates, and availability of services, affect access to infertility care. So does the history of discriminatory reproductive care and harm inflicted upon BIPOC women over decades.

Studies have shown that doctors may consciously or unconsciously make assumptions or possess biases about who deserves to be a parent or deserves treatment. Black women, for example, have reported that some providers brush off their fertility concerns, emphasize birth control over procreation, and dissuade them from having children. Or doctors assume they can get pregnant easily; misconceptions and stereotypes about fertility have often portrayed Black women as not needing medical help to get pregnant. Feelings of shame and isolation are particularly pervasive among BIPOC women with infertility: In a survey of more than one thousand women of a variety of races, Black women were more than twice as likely as white women to say that they wouldn’t feel comfortable talking about their fertility issues with friends, family, a partner, their doctor, or even a support group. This is one reason it was a big deal when Michelle Obama, in her memoir Becoming, told the world about her miscarriage and undergoing IVF.

The egg freezing employer benefit discussed earlier raises deeper questions about race and class inequality regarding fertility care. The benefit affects employees at largely white-collar companies, who tend to be highly educated, higher-income, and predominantly white—meaning the policy helps alleviate the financial burden for those already at an advantage. Historically, fertility treatments have been mostly marketed to and used disproportionately by white women of high socioeconomic and educational backgrounds, which is one reason Black women have been largely left out of the conversation around egg freezing. A few years ago, SART analyzed nearly thirty thousand egg retrievals and found that only 4 percent of women who undergo the procedure identify as Hispanic, while just 7 percent are Black. As it stands now, egg freezing is available to those (relatively few) who are aware enough to seek it out and can afford it. As reproductive freedoms continue to get chipped away at throughout the country, it is the lower-income, often BIPOC women who will end up the least able to attempt to buy back some of that reproductive autonomy with fertility preservation.

There is at least one aspect of access to ART that America does well—in theory, at least, if not always in practice. In the United States, egg freezing and IVF play a pivotal role in making the LGBTQ+-parent family as viable as any other family. This is important, given that availability of ART for LGBTQ+ and unmarried people is restricted in many places worldwide. In most countries, only married heterosexual couples with a diagnosis of infertility can access fertility treatment; it was only in the last few years that social egg freezing became legal for lesbians and single women in countries like France and Norway.[*17] In the United States, virtually anyone who can afford ART can use it—a rare example of America being more progressive than its European peers.

For many in the LGBTQ+ community, especially lesbian couples, egg freezing can be, in some cases, a no-brainer. If a queer or bisexual woman or a nonbinary or AFAB (assigned female at birth) person wants to use their or their partner’s eggs, as opposed to donor eggs, to create embryos, having eggs already frozen puts them a step ahead. Egg freezing is also an option for transgender men; freezing their eggs before beginning gender-affirming medical care leaves open the possibility of having biological children someday.

But hurdles to receiving insurance coverage make it difficult for two groups of people in the United States in particular to undergo fertility treatment: LGBTQ+ couples and solo parents by choice.[*18] Some states have revised language in their legislation in recent years to feature a definition of infertility that includes LGBTQ+ and unpartnered people. But most state insurance laws incorporate a definition of infertility similar to the one mentioned above: six to twelve months of unprotected heterosexual intercourse. And, again, some states only cover IVF if the couple’s own eggs and sperm are used, stipulations that exclude same-sex couples and would-be solo parents. If it seems unfair that queer couples often cannot qualify for insurance coverage in order to have a biological child—and are discriminated against because they cannot “prove” infertility the way heterosexual couples having sex can—that’s because it is.

Lack of fertility preservation coverage is also a major inequity issue for the expanding transgender population seeking hormonal therapies. While pursuing reproductive services is not the most pressing problem that patients seeking gender transitions currently face—that would be states restricting gender-affirming care for adolescents—it matters. Fertility preservation for transgender youth is, for the most part, understudied and underreported. Professional societies have published guidelines highlighting the need to establish standardized protocols for primary care doctors when counseling transgender patients as they consider sex reassignment, to discuss the potential risk of fertility impairment as well as fertility preservation options before a transgender person begins hormonal or surgical therapies. But it will be a while until such discussions become the standard of care.

If transgender youth do happen to receive counseling about egg or sperm freezing prior to undergoing hormonal interventions, the decision about whether to pursue it isn’t an easy one. Similar to BIPOC people, transgender individuals face barriers such as discrimination and refusal of services. And even if they overcome the hurdles and decide yes, the issue remains: How to pay? Few can afford the substantial out-of-pocket costs of fertility preservation of eggs for transgender men or—less expensive but still not inconsequential—fertility preservation of sperm for transgender women. And, of course, those price tags don’t include use of the frozen eggs or sperm if and when the person wants to have children. As with cancer patients, the onus is often on transgender patients to prove to insurance companies that fertility preservation is medically necessary. It’s hard to say for certain how insurance coverage would change the current low rate of transgender people who preserve their reproductive cells, but as Devin O’Brien Coon, medical director for the Johns Hopkins Center for Transgender Health, has said, “There’s no question that transgender patients would preserve their fertility if insurance covered it.”

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There isn’t a one-size-fits-all solution to overcome these limitations and make it easier for BIPOC and LGBTQ+ people to use ART to build biological families. A major step in the direction of progress would be including fertility treatment in all health insurance coverage, as with other health conditions and diseases affecting other major bodily systems, which would help address needs faced by low-income persons. Another would be to expand insurance companies’ definition of infertility to ensure that same-sex, single, and transgender individuals are not precluded from coverage. Femtech’s ability to help improve racial equity in reproductive healthcare offers some hope; solutions tailored for delivering culturally sensitive care to subpopulations are emerging. One, the digital platform Health in Her HUE, connects Black women and women of color to culturally sensitive healthcare providers, evidence-based health content, and community support. Another, FOLX Health, is the first major queer and trans venture-backed company to offer virtual care and prescriptions for hormone replacement therapy and sexual health. Still, until better policies are in place to help combat the economic, cultural, and social barriers at play, many people who need fertility services will remain unable to benefit from them, and egg freezing will remain a far cry from an equal-opportunity venture. Inequitable access to reproductive opportunity has plagued the fertility industry from its earliest days, but it doesn’t have to define its future—something to keep in mind as the landscape of reproduction continues to quickly evolve before our eyes.

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I finished graduate school with strong grades and several bylines to my name. The week of graduation was a happy time. I celebrated with my professors and fellow journalism grads, as well as my parents, best friends, and Ben. But I was beyond burned out. Somewhere between finishing my thesis and yet another internship and figuring out what I was doing after that final semester, I had lost fifteen pounds on my already petite frame and had dropped the ball helping a mentor complete research for her next book. I’d spent two years hustling, and I had published pieces and professional connections to show for it. I’d also acquired significant credit card debt and what seemed like permanent dark circles under my eyes.

Two days after graduation, I flew to Berlin for a journalism fellowship in Germany and Poland. Then I taught a high school creative writing program in the Czech Republic. Ben had taken a new job in Houston, and I’d decided it was time to leave New York for a while, mostly because I couldn’t fathom how to afford continuing to live there as a freelance writer. In August, Ben and I packed up my Brooklyn apartment in a flurry of boxes and sweat. He went back to Houston and I went to Colorado, where my parents had bought a house in the mountains and where I had decided to catch my breath. When I arrived, my father took one look at me and said, “You look about twenty years older than when I last saw you. Please go eat something and rest.” I slept for what felt like a week.

A few months later, I flew back to New York to meet Ben for a weekend; it was his birthday, and he wanted to celebrate in the city. We stayed at an Airbnb in Williamsburg. The morning of his birthday, Ben went out to get us food. “Hunting and gathering,” we called it: his love for bringing back breakfast on weekend mornings and my love for starting the day slowly and anticipating his walking in the door with delicious treats. We spent the day on the Lower East Side: drinks at McSorley’s, a movie, a walk through Union Square. That evening, he wanted to stay out late, but I was tired and not up for the night he wanted to have. The cab dropped me off at the apartment and took him back across the bridge. When he crawled into bed hours later, I pretended to be asleep.