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.”
—
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.
—
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.
When it came to going out, Ben and I had always been pretty far apart on the spectrum, but lately the divide had been causing problems. He almost always preferred staying out late and partied harder than I did. When I visited him in Houston, I’d often opt to stay in or leave the bar early, taking an Uber back to the apartment alone. This became a pattern, and it bothered me. There were times we simply did not enjoy doing things together the way we used to, as if the bitterness that built up after several small fights dulled the easy joy we were used to sharing. At our best, we fell naturally into what it is to be here now with a person you love. Once, burrowed in sleeping bags at the bottom of the Grand Canyon, he thanked me for being in the moment with him, living in the present as opposed to the future, where my thoughts often dwelled. Murmuring something in reply, I leaned up to kiss him and a bug with long legs bit me. I yelped, he promptly ushered the bug out of the tent, and we fell asleep spooning under the stars.
Lately, though, that levity and natural ease felt light-years away. The next night in New York, we lay in bed, tension between us. We’d been talking about moving in together for several weeks. “I’ve been having some doubts,” I said quietly into the dark. I asked him if he was sure he wanted me to move to Houston. “Ninety-five, ninety-eight percent sure, yeah,” he said, his voice low. A moment later: “Are you hesitant?”
“Yes,” I whispered. His arms were wrapped around me, but I felt far away.
Skip Notes
*1 EggBanxx, which was an arm of FertilityAuthority, was absorbed into Progyny when FertilityAuthority was acquired and became Progyny. Bartasi is no longer involved with Progyny.
*2 The company now thaws eggs as well as freezes them; it’s expanded to offer IVF and other standard fertility treatment services.
*3 The amount of medications an egg freezer needs varies depending on how aggressively her ovaries are stimulated—that is, the protocol determined by her doctor. So, the total amount spent on fertility drugs rises fast if a patient requires additional meds. Many egg freezers feel that the high and separate cost of the fertility medications is not explained well by clinics.
*4 And they’re going up; prices for egg, embryo, and sperm storage have risen sharply since 2019, largely due to inflation and supply chain pressures.
*5 In a preliminary national report from 2022, SART found that 43.1 percent of women under thirty-five had a live birth after a cycle of egg retrieval. The number was 3.2 percent for women over forty-two.
*6 For a few comprehensive resources pertaining to fertility insurance coverage laws, fertility treatment grants and financing programs, and getting fertility insurance coverage at work, see the top of chapter 9 in the Notes section at the back of this book.
*7 Infertility, a disease of the male or female reproductive system, affects roughly one in six adults worldwide and is defined by physicians as the inability to conceive despite having regular, unprotected sex for twelve months or more if you’re under thirty-five years old or for six months or more if you’re thirty-five or older.
*8 I spoke to a few women who, to get around this rule, were given an infertility diagnosis by the doctor they saw at the fertility clinic—even though they were not at the time actively trying to get pregnant—so that they could have egg freezing covered by their insurance.
*9 For a good resource on family-building coverage offered by employers, check out FertilityIQ’s Workplace Index. The report, which FertilityIQ publishes every year, analyzes industry trends and provides up-to-date employer fertility benefit information.
*10 I’d enrolled in an NYU-sponsored health insurance plan when I began graduate school, and when I called and asked them if and how I might have any kind of egg freezing coverage, I was told that without an infertility diagnosis I was out of luck.
*11 As I published more egg freezing pieces, I did receive offers of this nature from a couple of clinics and doctors. While the offers were enticing, journalism ethics make it clear that accepting free or discounted goods or services in exchange for press—even if, in this case, a fertility clinic doesn’t explicitly ask for it—isn’t okay.
*12 A different Valerie from the fertility doctor Valerie I mentioned earlier.
*13 After the Supreme Court ruling came down, fertility patients across the country immediately began contacting their clinics to arrange to move their eggs or embryos out of red states to avoid possible legal complications.
*14 In some states, this is already happening. One of many egregious examples: In 2022, public universities in Idaho stopped providing not just abortion referrals but contraception referrals, too—even going so far as stipulating that condoms are to be distributed only to prevent STIs, not to prevent pregnancy, and warning faculty members that they could face felony charges if they refer students to abortion services or “promote” abortion.
*15 Black women also suffer from higher rates of uterine fibroids—non-cancerous tumors in the uterus that typically develop during a woman’s childbearing years—and obesity, two conditions that can negatively impact fertility.
*16 The lack of ethnic diversity among donors leaves many intended parents without adequate options for building families that reflect their backgrounds.
