From 2012 to 2019, the Nevada Fertility Center in Las Vegas put on a controversial contest. It put out a call for home videos from individuals or couples struggling with infertility, asking them to talk about their journey, and published a selection on its website. The public could vote for the most compelling videos. Of the top 10, a board from the clinic picked just one.
The winning video’s prize: a free round of in vitro fertilization (travel to Las Vegas and lodging not included).
The contest was the subject of the 2016 documentary Vegas Baby. While it’s easy to balk at the idea of a popularity contest for care intended to result in a child, the desperation suggested by the contest’s popularity—the clinic received thousands of submissions annually—is emblematic of the state of fertility care. In the United States, the average cost of a single IVF treatment is usually around $12,000; with medications needed to stimulate ovulation, costs can be as high as $20,000. Most people have to undergo a few treatments, so “successful” treatments resulting in a baby often cost around $64,000, one 2012 study estimated.
Most insurance companies don’t cover fertility care, which means these costs are largely paid out of pocket by patients in the US. The public healthcare systems of some European countries support a portion of fertility care for individuals up to a certain age—usually around the early 40s. But even then, many people turn to the private market, either to avoid long wait times (sometimes up to a year), or because they have exhausted their public options.
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Prospective parents can end up depleting their savings, borrowing money (either from loved ones or in a bank loan), or taking on credit card debt. Crowdfunding site GoFundMe has thousands of campaigns dedicated to fertility issues.
“Fertility impacts people who have the means to pay for it—and those that don’t,” says Jake Anderson, the co-founder of FertilityIQ, a website that provides free reviews of fertility clinics and educational information across the US. It’s unknown how many people can’t afford the fertility care they need: Not all of the estimated 48.5 million straight couples with some sort of medical infertility seek treatment (that global figure excludes people in same-sex relationships, or people wishing to become single parents). But given the out-of-pocket costs, it’s reasonable to assume that in many situations, fertility care is reserved for the wealthy.
Three things could lower the cost of fertility care for prospective parents. First, more access to information from third parties could help people make better decision about treatment options, potentially reducing the number of cycles they need. Second, businesses could increasingly offer fertility care as a benefit, making it part of their insurance coverage and sharply reducing costs for employees. And lastly, a push to reduce laboratory fees associated with fertility care could bring overall prices down significantly.
Information economy
Anderson and his wife, Deborah Bialis, created FertilityIQ in 2015 after they started seeking out their own fertility care. They discovered a maze of information and fertility clinics, each charging thousands of dollars for treatments that, at best, work about half the time. Given the uncertainty they faced—which clinic to choose, which treatments to start with—”it was certainly not worth the costs,” he says.
Their experience gets at one of the biggest problems with fertility care: the gamble. IVF, which involves extracting eggs from a person with ovaries and mixing them with sperm in a lab, has the highest success rate—about 50%, if the person with ovaries is younger than 35. That figure drops dramatically with age: Over age 43, the chance of having a successful birth with the parent’s own eggs drops to about 3%. It can be the right choice for individuals who are older, those who need to use donated eggs, or couples in which both partners have some kind of medical infertility.
But it’s also the most expensive.
The thousands of dollars paid for each cycle cover:
- medication to stimulate the ovaries,
- egg retrieval,
- fertilization,
- culturing embryos in the lab,
- and eventual transfer into the uterus
Some people’s costs only increase from there: If the eggs are coming from someone who is older than 38, the recipient may want to increase their odds of success by testing embryos for any chromosomal abnormalities that could result in a miscarriage, which costs another couple of thousand dollars.
Others can stand to do less. If a younger person or couple wants to have a baby and they have no other known health problems, they may want to elect a cheaper option, like intrauterine insemination (IUI), which follows up ovarian stimulation with an injection of sperm directly into the uterus. These procedures cost between $300 and $4,000. But if this less expensive option doesn’t work, a person may have to pay for IVF too.
Ideally, people seeking fertility care would be aware of the minimum amount of care needed for their situation. There’s lots of quality information available online through organizations like RESOLVE, the National Infertility Association in the US; the Society for Assisted Reproductive Technology; and the Human Fertilisation and Embryology Authority in the UK. But none of this is specific to individual couples. And unfortunately, almost all information about fertility clinics and the procedures they offer is designed to bring customers in, thwarting its objectivity.
And even though fertility clinics have to provide information about their success rates to the US Centers for Disease Control and Prevention every year, these data are always a few years old. Additionally, if a clinic is newer, and has treated less than 20 people in a certain age group, they don’t have to report it.
Recognizing the gap in information and the high desire for it, FertilityIQ provides Yelp-like reviews for doctors and clinics for a fee. “What we can do is say, let’s find a way for you to use the money you have efficiently,” says Anderson.
It also has online courses on several aspects of fertility care—from a breakdown of the procedures available for certain groups, like the LGBTQ+ community, to the details of different techniques. These courses are created with the help of researchers from places like Stanford, Northwestern, and Yale, independent of any clinic’s influence. Anderson estimates they could save users as much as $15,000.
Still, the courses themselves cost $95 each, with the option to buy all of them for $750. And information can only get you so far.
New life insurance
How much fertility coverage you get depends largely where you live. In Europe, many public healthcare systems help cover fertility care up to a point. Belgium covers six free rounds of IVF; Spain covers four, provided the person who hopes to become pregnant is under 42; Norway covers most public rounds of IVF, where people have to pay about $150 out of pocket, but it will also cover out-of-country IVF if couples are so inclined.
In the US, however, it’s a different ballgame. Only about 30% of people who need fertility care have some (but almost never all) costs covered by some form of private insurance. A lot of insurance companies offer several thousands of dollars toward fertility care, but even generous allowances like $10,000 only cover about 20% of average costs. In the US, no federally-funded health insurance—Medicaid, Veteran’s insurance, Children’s Health Insurance Program, or government employee’s insurance—covers fertility care.
Seventeen states mandate that privately insured people get some coverage for fertility care, but each state determines the details. Of those, only six states—Connecticut, Illinois, Maryland, Massachusetts, New Jersey, and Rhode Island—cover the majority of the costs of big-ticket treatments like IVF.
And those state mandates only cover about 36% of people who live there and work for a private employer, says Barbara Collura, the president of RESOLVE, the US National Infertility Association. Most companies bigger than 500 people are self-insured: They purchase insurance from larger insurance companies, which are exempt from these mandates.
The lack of coverage from most insurance inevitably leads to niche fertility plans.
Take Progyny, a tech company that originally focused on finding better ways to assess IVF embryo quality. In 2016 it pivoted to sell fertility care benefits to employers. In addition to these packages, the company provides each employee with a patient care advocate to help them navigate the field. Instead of having to go through certain treatments to get to IVF—which some insurance models require—patient care advocates help employees find the treatment that could work fastest for them.
Human resources executives say that they see fertility benefits like these as a retention and attraction tool, says Selena Yang, director of communications at Progyny, which went public late last year. At the moment, it only works with 137 companies—many of which are in the tech industry. There are a handful of other companies in this space, like WINFertility and Carrot, but it’s still a growing industry.
Some clinics are trying to help customers cut costs by offering package deals. Others offer a portion of the costs back if their services don’t work. Advanced Reproductive Care, a network of fertility care providers in the US, uses this model.
It’s good for patients—but it’s also good business. “It’s kind of like the clinic bets on your success, and you bet on your failure,” Sarah Burke, a Pittsburgh woman who became a parent after enrolling in such a program, told the New York Times in 2017. But these packages tend to select people who are likely to be successful early on, Anderson and Bialis told the Times—meaning that the clinic is more likely to pocket the extra cash. These could be cost-saving measures for some, but they won’t benefit everyone.
Lowering the cost of service
Making these services cheaper, without cutting quality, could have a significant impact on lowering costs.
“When you set up an IVF lab, it’s super expensive,” says Jonathan van Blerkom, a molecular biologist focusing on embryology at the University of Colorado. Embryos thrive in environments that are about 5% carbon dioxide, 5% oxygen, and 90% nitrogen—which is different from open air’s composition—and incubators that mimic the body’s temperature. There can’t be any contamination; usually air is blowing out so none comes in when the doors open. And they require microscopes and lasers that can manipulate cells just 15 micrometers wide—smaller than the finest strand of hair. He estimates a lab can take upwards of $100,000 in start-up costs alone.
Fertility clinics have to recoup the costs to set up these labs, where procedures like IVF take place along with egg freezing, storing, and supplementary processes.
Currently, the way these procedures are done, it’s impossible to lower costs. “It couldn’t and shouldn’t be made cheaper,” says David Adamson, a surgeon, endocrinologist, and founder of ARC Fertility, because that would likely mean taking shortcuts that would lower successful outcomes.
In the last five years, one of the biggest cost-cutting innovations has been the intravaginal culture system. Created by the Florida-based company INVO Bioscience, the device gained clearance from the US Food and Drug Administration in 2015. Instead of culturing embryos in a lab during IVF, up to seven eggs and 30,000 sperm sit in a tiny device that rests in the vaginal canal. Over the course of three days, up to seven embryos will develop. One can be transferred into the uterus, while the others are frozen (it’s best practice to only transfer one embryo at a time). The procedure isn’t offered everywhere, nor is it covered by insurance—but it is about half as expensive as traditional IVF.
Safely lowering costs even further, though, would require radically rethinking the process.
Van Blerkom is among a handful of scientists who believes that a $200 IVF process is already possible. He and his colleagues founded the non-profit Walking Egg Project in 2010 to deliver cheaper IVF treatment to childless families in developing countries. “If you understand the biology,” he says, “you can design a system where all the needs and atmospheres and conditions required can be done in a simpler manner.”
Van Blerkom has been working on his system for decades. He started in the ‘70s using pig embryos, which are surprisingly similar to those of humans. The Walking Egg method he developed in the early 2000s uses traditional egg-harvesting techniques in a local hospital, but replaces an incubator with a thermos. It uses a slow acid-base reaction to provide the balance of carbon dioxide and oxygen, and a powder-based media to grow the embryos instead of a pre-prepared one.
“Essentially, you just add water. And egg and sperm,” he says. “The lab part, which is the part that for most people makes a profit, that’s a little lunch box. Once you have materials and are ready to go, it’s not that difficult, and not that expensive.”
Telemedicine allows remote embryologists to identify the correct embryos to transfer later. It can’t treat complicated infertility—each ejaculate must have at least one million sperm, for example—but it could at least bring care to regions where reproductive health care has focused on access to contraception.
So far, the Walking Egg Group has done pilot studies in Belgium, where up to six rounds of IVF are reimbursed by the government (the experimental process was essentially a freebie for the participants; it didn’t count toward one of their government-covered cycles). To date, a few hundred healthy babies, including to a lab technician on the team, have been born this way for just about $200 each.
The solution wouldn’t be fitting for just resource-poor countries. It could work anywhere where families are struggling to have children. The reason we don’t already have it comes down to funding.
“To get it approved by the FDA, or the European agency, it takes a lot of money and time,” says Willem Ombelet, a reproductive health specialist consulting for the University of Hasselt and at the University of Ghent in Belgium. He and van Blerkom were among the scientists who founded the Walking Egg Project.
And right now, no one wants to fund it.
Ombelet believes the holdup isn’t because of the science, but the existing state of fertility care. Clinics have already built their expensive labs, he says. They want to make money through traditionally expensive procedures. But what they don’t understand is that by expanding their markets to serve millions of more people, they could ultimately end up making more money. “The three richest companies in Europe are Lidl, Aldi, and IKEA,” he says. “What they all have is a lot of sales that are very cheap, but good quality.”
Maybe the Walking Egg Project could do the same. Ombelet said the group’s next project is to apply for grants.
Correction (March 17): Courses on FertilityIQ are $95 each, and customers can purchase all of them for $750. A previous version stated that one course was $750.