In an interview with "Good Morning America"'s Robin Roberts for her new memoir "Becoming," Michelle Obama revealed that her two daughters, Malia and Sasha, were conceived using in-vitro fertilization (IVF). Malia, Obama's eldest daughter, was born in 1998, 20 years after the birth of the first IVF baby, Louise Brown, in a hospital in Oldham, England. In 1998, according to the Centers for Disease Control and Prevention, slightly over 80,000 assisted reproductive technology procedures (ARTs) were performed in the United States. Two decades later, that figure has more than tripled. Nearly 2% of live births in the US are the result of IVF and other ARTs (including intrauterine transfer and intracytoplasmic sperm injection, or ICSI, in which the sperm is injected directly into the egg to effect fertilization). Over eight million children have been born via IVF worldwide. A recent survey by the Pew Research Center found that 9% of women aged 35 to 44 reported that they or their partner had undergone fertility treatment.
Obama's disclosure that their children were the product of IVF is a welcome addition to this public conversation about infertility, one which will hopefully prompt some women and men to reconsider whether it could be a solution for them. It is inevitable that Obama's star power will help demystify this medical process. But what greater public familiarity with IVF won't do is help the many women and couples struggling with infertility for whom the principal obstacle to parenthood is financial, not psychological. For too many, the price of IVF places the procedure out of reach. The spiraling costs associated with the "infertility industry" mean that the benefits of new assisted reproductive technologies (ARTs) are not equally available to all.
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Professional women like Michelle Obama remain most likely to pursue IVF, not just because they have put their careers before childbirth and left it too late to have babies the natural way, as the common cultural myth goes, but because they can afford to. (According to the CDC's most recent report, less than one-third of ART treatments result from a diagnosis of diminished ovarian reserve, which tends to correlate with advanced maternal age, lower than the number of treatments performed as a result of male-factor infertility.)
IVF's high price tag, combined with an uneven insurance coverage has created an entrenched social division between IVF haves and have nots. When the Pew Research Center's figure of 9% of women or couples who have undergone infertility treatment is broken down by race, the discrepancies are stark. While 12% of white women report that they or their partners have undergone treatment, only 3% of black women, and 5% of Hispanic women report the same. This is despite the fact that, as Ann V. Bell recently wrote in "Misconception," women of color are in fact more likely to suffer from infertility. The education gap is equally stark. While 56% of adults with a postgraduate degree say that they have either undergone infertility treatment or know someone who has, only 20% of those with a high school degree or less report experience or knowledge of infertility treatment.
There is, to a certain extent, a chicken and egg aspect to the lower instance of IVF amongst women of color. Because they encounter fewer friends and family who have undergone IVF, they are less likely to consider it as an option. Obama's speaking out about her own infertility will hopefully show African-American and other minority women that IVF is not exclusively a white woman's solution. But while Obama's revelation may inspire a greater interest in the procedure, it does nothing to lower the financial barriers to infertility treatment.
In her recent "Conceivability: What I Learned Exploring the Frontiers of Fertility," Elizabeth Katkin describes spending nearly $200,000 in pursuit of a baby. Katkin's experience is exceptional, and involved eight IVF cycles in America, England, and Russia. More typical is the case of Nurse Frankie, the featured patient on the episode of ABC's long-running medical drama "Grey's Anatomy," which aired the night before Michelle Obama's "Good Morning America" interview. Frankie, described on the show as "skating towards 40," paid "$41,632 for three rounds of IVF and a miscarriage." An IVF cycle costs, on average, $17,000 for drugs and treatment, with additional costs of several thousands of dollars if a patient uses ICSI to increase the chances of success in cases of male-factor infertility; freezes her embryos; or opts to submit her embryos to preimplantation genetic screening (PGS). A bill of $41,632 for three rounds of treatment would be about par for the course for someone whose health insurance partially covered the IVF medication protocol but not the treatment itself.
Sixty-three percent of American women pay for IVF treatment entirely out-of-pocket. Patients who meet strict age and health criteria can potentially hedge against the costs of multiple rounds of IVF by opting for one of the myriad "baby or your money back" programs, first pioneered by Maryland-based Shady Grove Fertility in 1993, which cap the costs for multiple rounds of IVF between $20,000 and $40,000 dollars (often excluding the cost of necessary drugs), with the promise of a refund if the treatments are not ultimately successful. The schemes are essentially shared risk pools for women pursuing infertility treatment without insurance, as those who become pregnant on the first round do not receive a partial refund and effectively cross-subsidize patients requiring multiple rounds of treatment.
A handful of states, including most recently Delaware, require health insurance companies to provide at least limited IVF coverage. Texas requires health insurers to offer policies that cover IVF but do not compel employers to select those policies for their employees. Even in states where some form of IVF coverage is mandatory, out-of-pocket costs can run into the thousands of dollars. According to Fertility IQ, a private organization founded by former infertility patients which collates information on US patients' experience of infertility treatment, the technology, consulting and accounting, and banking and finance sectors rank highest in terms of fertility benefits offered, while the industrial and retail sectors rank lowest.
IVF came of age in the wake of the second-wave feminist movement and campaigns for abortion rights, which both argued that biology was not destiny and that a woman's reproductive choices were her own to make, without interference from the state. Together these two convictions have, up to now, also largely stymied any united campaign by women to ensure that IVF was covered by health insurance or, in countries with national health systems, financed by the state. The result is that IVF has grown up largely within the private marketplace, with prices determined by what the market will bear. While an ever-growing number of professional women are finding the resources to conquer infertility through IVF and other assisted reproductive technologies, the treatment's high price tag means that many are effectively priced out of motherhood.
The recent shift in the abortion wars towards a focus on accessibility and affordability, as embodied in the landmark 2016 Whole Woman's Health v. Hellerstedt case, or Congressional efforts to limit access to abortion services by defunding Planned Parenthood, underscore the reality that a woman's reproductive choices are not her own to make if practical and financial realities limit her ability to pursue some choices. Michelle Obama has done a great service to infertile women and couples in sharing her own IVF journey. Her status as a role model for many women across the racial and social spectrum makes her ideally positioned to take the conversation further, and push women, doctors, and legislators to re-evaluate whether the comparatively unregulated expansion of the IVF industry in America has actually increased the average woman's ability to control her own fertility.
This article was updated to reflect more exact price information provided directly by Shady Grove Fertility.