Kerry-Ann Hamilton and her wife have long wanted children. “Early in our relationship, we had conversations about having a family,” says Hamilton, a communications consultant in Washington, DC. “My wife comes from a family with five siblings. She loves them, and always wanted to have a large family.” Hamilton herself was adopted—a transformative gift, she says. She was excited to pass that love on.
Hamilton’s enthusiasm carried easily over the phone when we spoke in early February. Last year, she and her wife, LJ, had finally decided they were ready to create a family of their own. The couple decided to explore adoption, and Hamilton, who is in her late 30s, would also try to become pregnant using her own eggs.
They had all the love in the world—“the most essential in starting a family,” says Hamilton.
There was just one key ingredient they couldn’t get on their own: sperm. In 2019, the couple sought a donor to help them achieve their dream, and found a friend who was willing to provide his genetic material. They’ll use his sperm in Kerry-Ann’s fertility treatments—intrauterine insemination or in vitro fertilization—until she becomes pregnant.
For Kerry-Ann and LJ, fertility care affords them the opportunity to expand their family in ways that weren’t possible 40 years ago. The US Centers for Disease Control and Prevention (CDC) estimates that 12.7% of women in the US aged 15 to 49—over 7 million women—sought medical help for infertility between 2015 and 2017. According to the World Health Organization, about 50 million couples worldwide experience some kind of infertility, although the actual rate may be higher.
Yet for many people, there’s some stigma around being unable to have children without medical intervention, even as social circumstances—including more diverse family structures, career pressures, lower marriage rates, and access to abortion and contraception lowering adoption rates—have made it more common to have children later in life.
In 2018, the average age of people who gave birth for the first time in the US was nearly 27 years old, with first-time parenthood increasing among 30 to 44 year olds. In 1980, just a half a generation earlier, it hovered around 22. While these slightly older new parents may be more financially and professionally stable, it’s a biological tradeoff, particularly for people with ovaries. Eggs are a limited resource, and they don’t always age gracefully, making it harder to become or stay pregnant. And on top of that, there are other medical reasons—including sperm that are unable to reach the egg, endometriosis, polycystic ovarian syndrome, or blocked fallopian tubes—that can make it hard for people to become pregnant.
Enter fertility care. The first baby to come from in vitro fertilization—fertilization “in glass”—was born in 1978. Since then, developments in ovulation-stimulating medications, egg and embryo freezing, and embryo-growing cultures have boosted IVF success rates from less than 10% to nearly 50% for people under 35. Globally, that translated to a $13.6 billion industry in 2018. Estimates from Berkshire Hathaway’s Business Wire suggest that by 2026, it will more than double to $27 billion.
This industry is a reflection of our economic times. A lot of fertility care is aimed at women who want to delay having children in order to maximize their early-stage career growth. For a number of reasons, these individuals may also be more likely to be able to pay for fertility care.
But infertility can happen at any age, and any socioeconomic status.
Which presents a frustrating problem: Advances in fertility care mean that, theoretically, more people can have children if they want to. But high costs and lack of insurance coverage limit access. In the US, women of color—who are disproportionately more likely to be poorer than white women—wait longer to seek out fertility care, and ultimately have poorer outcomes. Globally, nearly half of the world’s fertility clinics are in European countries, while over half of African countries have none at all. Fertility care is reflective of a widening socioeconomic gap.
“Reproductive rights should include the right to reproduce,” says Jonathan Van Blerkom, a molecular biologist at the University of Colorado who specializes in embryology. But right now, it’s impossible for everyone who wants to have a child to do so. Scientists and policy makers are going to have to team up to figure out how to lower these costs—or else, fertility care will remain a luxury for only the wealthy.
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A baby for a buck
Despite its increasing prominence, fertility medicine cannot guarantee success (read: a baby). According to the CDC, which has required fertility centers to report their success rates since 1995, the average success rate is about 24% (pdf). That rate is highly dependent on the age of the person with ovaries, with younger people having more success. Over 50% of people under 35 using ART had a baby in 2016 in the US, but only about 3% of individuals 43 and older did.
Still, fertility care provides hopeful parents with a chance at conception they wouldn’t otherwise have. It has made parents out of LGBTQ+ couples, straight couples dealing with infertility or sterility, people who elect to become parents while not partnered, or those with more than one partner. There are gamete donation services for people who need additional eggs, sperm, or entire embryos, and surrogacy programs for those who need a person with a uterus to carry their child. Virtually anyone can become a parent without adopting, if they want to.
Provided they have the funds, of course.
Fertility care is expensive. Initial visits to doctors’ offices may be hundreds of dollars, and costs quickly reach the tens of thousands with more advanced procedures like IVF. Add-on procedures, like injecting sperm directly into an egg to guarantee fertilization, or preimplantation genetic testing, are usually thousands more.
In some parts of the world, like many European countries, the UK, and Israel, fertility care is partially covered by public health care. These plans offer at least a few rounds of IVF for free, or at highly subsidized rates, to those under the age of 43. But that may not be enough for individuals who are having extreme trouble getting and staying pregnant. Because so much of fertility care depends on the age of the eggs, people may want to be seen quicker than public plans allow. All of these factors may push customers into the private market, where they pay full price.
In the US, fertility care largely remains in the private sector. It isn’t covered by public insurance, like Medicaid, the Affordable Care Act, or even the insurance provided to federal employees and members of the military. Although some private insurance plans cover pieces of fertility care, most don’t. And while 17 states have mandated some kind of fertility coverage through private insurance, those laws end up covering far fewer people than you’d expect.
So people pay out of pocket however they can. Some take out personal loans. Some buy bundle packages from clinics, which ultimately discount procedures even if they pay more up front. And some turn to benefit management companies, which are rushing to fill the coverage gaps where employers aren’t. The glaring question: why is this care so expensive anyway?
An egg and a sperm cell meet in a petri dish
The phrase “fertility care” is a broad one, covering all healthcare for infertility—which itself has a very specific definition. As opposed to being sterile, infertility describes a person with a uterus failing to get pregnant or having miscarriages after a year of trying. (Sterility describes when someone is completely unable to have children, including people who undergo vasectomies, tubal ligation to block fallopian tubes, or gender confirmation surgery such as a vaginoplasty or phalloplasty.)
Most people think of fertility care as IVF—and it’s true that procedure put the field on the map. In 1976, a UK couple named Lesley and John Brown went to obstetrician-gynecologist Patrick Steptoe after struggling for nearly a decade with infertility. Both of Lesley’s fallopian tubes were blocked; even though her eggs were perfectly healthy, her husband’s healthy sperm couldn’t reach them.
A few years prior, Steptoe and his colleague, Robert Edwards, had figured out that eggs could be fertilized outside of the fallopian tube in a glass jar. They partnered with the world’s first embryologist, Jean Purdy, to collect eggs from hundreds of people with infertility, and mixed them with sperm in the lab. Five got pregnant—but there were no live births.
Lesley Brown was willing to give them a chance. She consented to have Steptoe laparoscopically retrieve a single mature egg, which was fertilized with John’s sperm in the lab. Purdy carefully tended to the embryo in the lab, and after it had grown hundreds of cells big, Steptoe inserted it into Lesley’s uterus. The embryo implanted properly—and nine months later, Louise Brown was born.
The concept behind today’s IVF is essentially the same as that for which Edwards won the Nobel Prize in Medicine in 2010. (Steptoe was already deceased, and Purdy was excluded from the award. Sigh.) But fertility care today is composed of a number of interventions, including IVF, under the umbrella of assisted reproductive technology (ART).
Clinicians will try different strategies, in order of least to most invasive and technical, to get someone pregnant. Broadly, the first step is taking medication to regulate ovulation or “superovulation”—tricking the ovaries into coaxing more than one egg into maturity at once. Next comes intrauterine insemination—when sperm is injected directly into the uterus—followed by IVF. But treatments vary widely depending on patients’ unique situations.
There isn’t an overarching regulatory body keeping track of fertility treatments globally, but the best estimates suggest that there has been a global uptick in recent years. Japan, which has a shrinking population, performed just over 100,000 ART cycles in 2004, and more than 300,000 in 2013. In 2011, Europe had the highest rates of ART, with over 350,000 cycles. ART is less common in the US, the UK, Latin America, Canada, and Australia and New Zealand, but they’ve also seen a slow uptick in the number of cycles used. In the US, those figures are the highest, with an increase from just over 100,000 cycles in 2004 to 150,000 cycles in 2013.
Providing those services isn’t cheap. The majority of a clinic’s costs come from the lab setup itself; they require a sterile environment, microscopes, and lasers for conducting precise procedures on cells just a handful of microns wide. They also need facilities to incubate and freeze various gametes. These startup costs can easily hit $100,000, say Van Blerkom, and clinics have to make sure they can make them up quickly. On top of that, there are medication costs, which are an additional couple thousand dollars, and the personnel, which include reproductive endocrinologists, nurses, embryologists, and perhaps even a social worker or two on staff.
But it’s pretty easy for most clinics to make up the costs of setting up a lab quickly, considering that most procedures cost several thousand dollars.
As a result, fertility clinics are highly profitable. Most aspects of fertility care are technically elective—no one person needs a child to survive themselves—which is why in the US, most fertility care is not covered by insurance, and countries with public fertility care also have private markets. But the desire to reproduce is a major part of being human. “The disease state of fertility is completely dissimilar from all others,” says Jake Anderson, the founder of the fertility care rating website FertilityIQ. “You have the emergency of a gunshot victim, the cost of plastic surgery, and the difficulty of interpretation of cancer.”
So the people who show up seeking help for infertility are particularly vulnerable to price gouging. Clinics know this. And where there’s demand, industries will come up with a supply—in this case, what fertility care specialists call “add-ons.” In theory, this means that would-be parents are leaving no stone unturned. In reality, there’s limited evidence that these add-ons actually increase the likelihood of having a healthy baby. But that’s not stopping business from booming even more.
Business beyond the basics
The business of fertility care can grow in two ways: the number of people seeking it can increase, or the amount they’re spending each cycle of treatment can, says Ben Mol, a gynecologist at Monash University in Australia. “If your cycles stabilize, using more tech per cycle can still increase business.”
Even in countries where some parts of fertility care are covered by public health, including cycles of IVF, these tech-driven add-ons are not. In the US, where most people do not have insurance coverage for fertility care, the industry is almost entirely out-of-pocket. “That’s a great business if you’re in health care,” says Anderson. Instead of waiting for insurance companies to pay costs to the clinics, fertility companies get paid at the point of sale.
The field is therefore awash in capital—either from private equity groups looking to make big returns on investments in large fertility chains, or from venture capital-backed startups trying to get in on the action.
Consider gamete freezing. Today, it’s possible to freeze both sperm and eggs and use them at a later time. This could be helpful when someone has an underlying medical issue, like cancer, whose treatment may have lasting effects on fertility. It could also be an option for adults who are considering taking gender-confirming hormones and don’t want to discontinue them when they want to have children.
But the market for this add-on has surged primarily in response to women who are choosing to delay having children. Eggs are a finite resource: By the time a person with ovaries hits their late 30s, they’re likely to have more eggs with chromosomal abnormalities that make it harder to become pregnant and carry a healthy baby to term. (Some younger people can experience diminished ovarian reserve by their early 30s, but this is less common.) Egg freezing can stop that clock. And though not every frozen egg can be successfully fertilized and implanted, if a person 35 or younger freezes their eggs, they have about a 70% to 90% chance of having a healthy baby.
To freeze eggs, they’re first retrieved like they would be for IVF. But instead of fertilizing those eggs, technicians remove water from the cell and replace it with a sort of cellular anti-freeze. Then, the eggs are flash-frozen in liquid nitrogen. This vitrification process, which took off in the early 2000s, preserves about 95% of eggs—theoretically indefinitely. In 2012, when the American Society of Reproductive Medicine removed the “experimental” label from medically necessary egg-freezing, it became essentially mainstream—with a price tag of about $7,500. (“Elective” egg-freezing, which is the term for when an otherwise healthy person freezes their eggs to use later, is still experimental.)
“The best years [to have children] are your late 20s and early 30s, but that’s also the time when you’re having the most productive years of your career,” says Gina Bartasi, the founder of Kindbody, a fertility startup based in New York. And so while “social cryopreservation”—health care speak for “not medically necessary”—isn’t covered by most insurance, it’s becoming an increasingly popular work perk at major companies, like Alphabet, Netflix, Microsoft, and Uber.
Another common add-on is preimplantation genetic testing, or PGT, which theoretically enables couples to choose only the healthiest embryos to transfer. Whether PGT definitively improves pregnancy rates, however, is less clear.
In the 1990s, the fields of embryology and genetics merged to begin to test embryos for certain heritable conditions before they were implanted into a person’s uterus. The first tests detected the presence of a mutation on the X-chromosome that led to severe intellectual disabilities; now, PGT tests for some 300 conditions, including cystic fibrosis, some intestinal cancers, and hemophilia.
In the late 1990s and early 2000s researchers started looking at another way PGT could help people stay pregnant. Aneuploidy, or having more or fewer chromosomes than the 46 that should be in an embryo, is the leading cause of miscarriages. It’s also common in eggs that come from people 38 or older. Genetic testing for aneuploidy allows a person to implant only those embryos that have a normal amount of chromosomes, increasing the chance of a healthy pregnancy.
These tests cost thousands of dollars, but they’re rudimentary. They have a high rate of both false positives and false negatives, which can lead to the discarding of healthy embryos or pregnancies that fail. Using PGT doesn’t guarantee more healthy babies. Instead, those who don’t get the procedure may be able to afford more rounds of IVF in general—but the outcome is still the same.
And then there’s a whole crop of add-ons with even less data to back them up.
This group includes procedures like “endometrial scratching,” in which a tiny plastic tube tickles the lining of the uterus to promote better attachment, or “artificial hatching” to open a tiny hole in the protective layer of proteins around the egg to make way for sperm. There are other techniques that essentially add embryonic nutrients to coax the embryo to develop, or implant on the uterine wall. Expectant parents can even undergo immunosuppression to try to stop the body from rejecting the embryo as a foreign body (which doesn’t often happen). These procedures cost hundreds of dollars, which can leap into the thousands very quickly if performed multiple times or on multiple eggs.
Their efficacy is based on shaky evidence. While there are anecdotal success stories, there isn’t clear evidence of how these techniques worked for parents who successfully gave birth, and if they’re effective for everyone. Late last year, the American Society of Reproductive Medicine published a review of all these procedures, based on the current scientific evidence, and found that none of them actually improved the chances of someone having a live baby. Similarly, the Human Fertilization and Embryology Authority, the UK’s regulatory body, published a rating of all these procedures, and said none were unambiguously helpful.
But they’re all legal—at least for now.
What’s legal where?
In the US, there’s minimal regulation of fertility clinics, let alone the procedures they perform. The nearly 500 fertility clinics in the US, most of which are private, are only required to report their success rates to the CDC. They can be accredited by the CDC, but they don’t have to be.
In other countries, national laws dictate what can and cannot be done to the embryo for ethical reasons—Germany doesn’t allow PGT for anything beyond life-threatening diseases, for example, and countries like China, Japan, and Saudi Arabia don’t allow surrogates to carry a child for someone who cannot.
Scientists are broadly concerned about the implications of federal regulation for fertility care, says Antonio Rosario Gargiulo, a reproductive endocrinologist and infertility specialist at Brigham and Women’s Hospital and Harvard University. The fear is that religious or conservative governments may make it harder for individuals to receive any kind of fertility care. They could do this by disallowing preimplantation genetic tests, or even the creation of several embryos at once for fear that some of them have to be discarded.
This happened in Italy in 2004, when the Catholic government essentially regulated embryos as humans. “That law said you can’t freeze embryos, you can’t biopsy them, you can’t take cells from them,” said Gargiulo. “Egg donation and surrogacy was made a crime with a penalty of two years in jail.” Although part of the law was eventually overturned in 2016, it made IVF cumbersome for straight couples, and impossible for same sex couples. Single women are still prohibited from pursuing IVF, and surrogacy is still illegal.
For this reason, there is a big market for so-called fertility tourism, or “cross-border reproductive care.” People may choose to go to other countries to access fertility care either because it’s cheaper, or because their home country doesn’t allow certain procedures. There isn’t great data on how common this kind of medical tourism is, but one 2010 assessment based on data from 46 fertility clinics across Europe estimated that between 11,000 and 14,000 people went abroad for fertility care.
Despite the risks, Gargiulo believes there is value in regulation from professional societies to ensure that people who are desperate aren’t being taken advantage of.
Norbert Gleicher, the medical director for the Center for Human Reproduction in New York, worries that because most fertility clinics are for-profit businesses, they’ll want to sell these dubious add-ons in order to keep making money. In his opinion, more scientific groups like the American Society of Reproductive Medicine should be issuing official statements on add-ons to stop clinics from charging individuals who won’t likely benefit until randomized controlled trials back them up.
“I am very disappointed by our professional organizations because they’re really being subverted by commercial interest,” he says.
Reproductive equality for all
The power of being able to choose when to have a child is relatively new for women. It first started with the contraception revolution in the 1960s, which allowed women to choose not to become pregnant. This was huge: It meant that women could have careers, their own wealth, and autonomy over their own bodies. Unintended pregnancies, including teenage pregnancies, have fallen dramatically. Adoption rates have fallen dramatically, too.
Globally, the effects of that revolution are clear. Women are choosing to have fewer children, and fertility rates are falling, which will shrink countries’ populations. In the 1960s, globally women had four children on average; now that figure hovers just around two.
Fertility care has the potential close the circle: It allows women to come back to having children when they want to. But, as with contraception, it’s not always accessible—particularly because of the costs associated with it.
At the moment, there are far more people suffering from infertility than can access care. “We just hear heartbreaking stories of people who have tried everything,” says Barbara Collura, the president of RESOLVE, the US National Infertility Association. People have maxed out credit cards, taken out loans, and refinanced homes in their bid to become parents. Sometimes, they’ll even pressure physicians to transfer more than one embryo in at a time to increase the chance of having a child at all, which is risky for both the parent and the fetuses. And still, not everyone who needs care can get it.
For fertility care to be accessible to all, either costs have to come down, or coverage has to increase.
Scientists are trying to find ways to cut the price tag. About half of the costs in fertility care come from the lab equipment needed to carry out procedures involved in fertility care, says Meir Olcha, a reproductive endocrinologist and infertility specialist at New Hope Fertility in New York. INVOcell Bioscience, a company based in Saratoga, Florida, has come up with a way for harvested embryos to mature in the vaginal canal—eliminating the need for lab embryo incubators and lowering costs to about half of a traditional IVF cycle. Other researchers, like Joaquín Llácer at the Reproductive Medicine Department at Instituto Bernabeu in Spain, are working on genetically profiling fertility care recipients to come up with personally targeted drugs and treatments, so they’ll have to go through as few failed rounds as possible. But these techniques are just getting started.
There is also an increasing movement for employees to get fertility coverage from their employers—but because the market is so new, most insurance companies don’t want to take it on. Businesses can work with a growing market of third-party fertility benefits management companies, but it’s not a mainstream perk yet.
Fertility medicine runs into the same problems with providing equitable care as the larger health care industry. The future of family-building will depend on how companies and countries choose to build access into their products and policies. If they don’t, fertility care will be another wedge widening the global socioeconomic gap.
Correction (March 17): Medical egg-freezing is no longer experimental as of 2012, but elective egg-freezing still is, according to the American Society of Reproductive Medicine.