To Build a Family

Is reproductive technology a privilege or a right?

Keith Negley
Add to Briefcase
Nora Caplan Bricker
Dec. 4, 2015, 5 a.m.

Rachel Vorkink and her wife re­cently ac­quired a puppy. They’d planned to have a baby first, but plans change, and now they have sleek, brindle-coated Sasha—who, while we sit in their liv­ing room on a re­cent Thursday even­ing, watches Vorkink in taut but obed­i­ent si­lence from in­side her ken­nel, oc­ca­sion­ally nip­ping at the bars in protest, as two cats wander free around the house. Vorkink jokes that her home is a zoo. If so, it’s a very tidy one: a beau­ti­fully main­tained house in Biller­ica, a sub­urb of Bo­ston, where the backs of couches bear woolen blankets, and the tops of tables are crowded with fam­ily pho­tos.

Vorkink, a school psy­cho­lo­gist who works with dis­abled kids, and her wife, Mar­tina Sna­jder, who’s study­ing to be­come a li­censed men­tal-health coun­selor and who works with drug ad­dicts, moved in­to this house last year. It rep­res­ents a life they wer­en’t sure they would ever have to­geth­er. They met 13 years ago, when Vorkink’s fath­er spent some time in Croa­tia on busi­ness. Vorkink was 23 when she went to vis­it her par­ents in Zagreb and met Sna­jder, then 21; she moved to Croa­tia a year later, and they re­lo­cated to the United States as a couple in 2004.

This is the point at which Vorkink and Sna­jder’s story di­verges from the fairy-tale het­ero­sexu­al ver­sion. Had they been straight, they could have got­ten mar­ried to se­cure Sna­jder leg­al status. But, un­til the Su­preme Court struck down the De­fense of Mar­riage Act in 2013, same-sex mar­riages that were re­cog­nized at the state level had no bear­ing on fed­er­al im­mig­ra­tion law. In fact, even though Vorkink and Sna­jder lived in a state where they could get mar­ried—Mas­sachu­setts—law­yers ad­vised them not to: If Sna­jder showed in­tent to stay in the United States, the coun­try could re­voke her stu­dent visa. She also couldn’t leg­ally work. The couple spent the bet­ter part of a dec­ade in a fin­an­cial and emo­tion­al hold­ing pat­tern. Someday, they knew, they wanted to save money, buy prop­erty, get mar­ried, have chil­dren. But for years, the only thing they seemed to be able to do without jeop­ard­iz­ing that fu­ture was wait.

“We thought of mov­ing to Canada, we thought of mov­ing to Europe,” Vorkink says. “We didn’t buy a house un­til we knew that DOMA was struck down.” They did, however, have a wed­ding, minus the pa­per­work, in 2009, and get leg­ally mar­ried, des­pite the risk, in 2011, urged on by pre­dic­tions of DOMA’s de­mise—and the de­sire to start hav­ing chil­dren. Vorkink, in par­tic­u­lar, had felt her whole life that preg­nancy and moth­er­hood would be de­fin­ing ex­per­i­ences for her. “You get to a point where you’re wait­ing around for laws to change that are really un­fair, and some­body else is mak­ing de­cisions for you about your life, and you stop caring,” she says. “I have to live my life.”

VORKINK AND Sna­jder were pre­pared for the fact that, as les­bi­ans, they’d be fa­cing steep out-of-pock­et costs: Donor sperm usu­ally costs around $800 per sample, and the simplest ver­sion of in­trauter­ine in­sem­in­a­tion also runs sev­er­al hun­dred dol­lars per vis­it. (Though the like­li­hood of get­ting preg­nant from a single cycle of IUI de­pends on a range of in­di­vidu­al factors, it’s of­ten es­tim­ated at around 20 per­cent for wo­men un­der 35, mean­ing that this meth­od can ul­ti­mately cost thou­sands of dol­lars.) But after months of at­tempts, Vorkink star­ted to sus­pect something she hadn’t planned for: that she was hav­ing prob­lems with in­fer­til­ity. “Bar­ri­ers to fam­ily-mak­ing,” she says. “That’s what I feel like my adult life has been.” When she got the dia­gnos­is, she says, one of her first thoughts was, “We already fought for 10 years.”

For people who need to avail them­selves of as­sisted re­pro­duct­ive tech­no­logy—be they single wo­men, les­bi­ans, fam­il­ies strug­gling with med­ic­al in­fer­til­ity, or, like Vorkink and Sna­jder, some com­bin­a­tion—the U.S. health care sys­tem can be ex­tremely dif­fi­cult. For one thing, re­pro­duct­ive as­sist­ance costs more here than any­where else in the world: A cycle of in vitro fer­til­iz­a­tion—the most com­mon op­tion for wo­men who can’t con­ceive through het­ero­sexu­al sex or a simple in­sem­in­a­tion—usu­ally costs between $12,000 and $20,000 in the United States versus more like $4,000 in much of Europe. This is in line with the fact that health care in Amer­ica costs more in gen­er­al than in oth­er wealthy na­tions. But where­as in­sur­ance or na­tion­al health care sys­tems in many European coun­tries, along with Is­rael, will cov­er at least one round of IVF, cov­er­age in the United States is a patch­work. Only 15 states have man­dates on the books re­quir­ing any in­fer­til­ity cov­er­age, and only eight re­quire any cov­er­age of IVF. Many of these stat­utes only ap­ply to het­ero­sexu­al, mar­ried couples; even with a med­ic­al dia­gnos­is, single wo­men and les­bi­ans are of­ten ex­cluded. Of course, com­pan­ies have the op­tion of cov­er­ing IVF with or without a man­date; however, in the es­tim­a­tion of Eli Adashi, a pro­fess­or of med­ic­al sci­ence at Brown, only about a third of the na­tion’s private em­ploy­ers do. It’s also the case that, even in man­date states, self-in­sured em­ploy­ers—and, in many cases, re­li­gious em­ploy­ers—aren’t forced to com­ply.

This situ­ation leads to pre­dict­able res­ults. “It’s the high­er-in­come, primar­ily white, urb­an people that are fig­ur­ing this out and avail­ing them­selves of the ser­vices be­cause they can af­ford it,” says Bar­bara Col­lura, pres­id­ent and CEO of RE­SOLVE, a na­tion­al ad­vocacy or­gan­iz­a­tion for people with in­fer­til­ity. “People that are middle-in­come, dif­fer­ent eth­ni­cit­ies, not in the urb­an set­ting, are shut out of care.”

The is­sue of ac­cess to re­pro­duct­ive help is closely linked to many of the biggest con­ver­sa­tions about civil rights that have con­sumed Amer­ica in the last dec­ade. It fol­lows nat­ur­ally from the ar­gu­ments about a right to health care that ac­com­pan­ied the pas­sage of the Af­ford­able Care Act in 2010 and from the ad­vent of na­tion­wide same-sex mar­riage earli­er this year. Most of all, though, it has a clear link to our coun­try’s on­go­ing de­bate about re­pro­duct­ive choice—ex­cept that this is­sue re­verses the terms of that de­bate by fo­cus­ing on the right to re­pro­duce, rather than the right not to re­pro­duce. “If you look at the people talk­ing about ‘re­pro­duct­ive justice,’ in­fer­til­ity is al­most nev­er part of the con­ver­sa­tion,” says Col­lura. “Whenev­er we see groups that say, ‘We do re­pro­duct­ive health,’ … when you look at it, it’s a code word for fam­ily plan­ning or abor­tion. To me, in­fer­til­ity and the need and de­sire to build a fam­ily ab­so­lutely falls un­der re­pro­duct­ive health.” The ques­tion, in short, is wheth­er re­pro­du­cing is a priv­ilege or a right. We’ve yet to have a real na­tion­al con­ver­sa­tion about this is­sue, but it’s one that the coun­try is, in many ways, over­due to face.

Vorkink and Sna­jder—who I met through RE­SOLVE—are for­tu­nate: They live in Mas­sachu­setts, which has the most com­pre­hens­ive man­date in the coun­try—and which is one of only five states (the oth­ers are Con­necti­c­ut, Illinois, New Jer­sey, and Mary­land) where IVF cov­er­age, if avail­able, isn’t lim­ited to het­ero­sexu­al, mar­ried couples. (In states that only re­quire het­ero­sexu­al, mar­ried couples to be covered for IVF, the man­dates con­tain lan­guage—such as “The pa­tient and her spouse must have at least a two-year his­tory” of in­fer­til­ity or “The pa­tient’s eggs must be fer­til­ized with her spouse’s sperm”—that ef­fect­ively ex­cludes single wo­men and les­bi­ans.)

And so it’s strik­ing that, even in the strongest corner of the coun­try’s safety net, for people strug­gling to have a fam­ily, ac­cess­ing those be­ne­fits has been far from straight­for­ward. For a het­ero­sexu­al couple in Mas­sachu­setts, cov­er­age kicks in if you simply at­test that you’ve been try­ing un­suc­cess­fully to con­ceive for a year or more; at that point, both IUI and IVF will be covered. But les­bi­an couples have to pay for a year of IUI out-of-pock­et be­fore they can qual­i­fy as in­fer­tile and gain ac­cess to the same be­ne­fits. Thus, Vorkink had to pay about $1,000 monthly (in­clud­ing the sperm) to be in­sem­in­ated in a doc­tor’s of­fice once a month for a year—and her cov­er­age, when it even­tu­ally came, didn’t in­clude ret­ro­act­ive re­im­burse­ment. Be­cause of this ex­tra fin­an­cial bar­ri­er for LGBT people, says Liz Coolidge, who co­ordin­ates the in­sem­in­a­tion pro­gram at the Bo­ston LGBT clin­ic Fen­way Health, “most of the wo­men I see have some kind of pro­fes­sion­al de­gree.”

Late in that first year, Vorkink star­ted to sus­pect something was wrong. Once her cov­er­age kicked in, her in­sur­ance paid for a test that con­firmed her fears—but it also came with the good news that, thanks to her geo­graph­ic luck, her in­sur­ance com­pany would cov­er six “fresh” cycles of IVF (in which doc­tors stim­u­late the ovar­ies and fer­til­ize the em­bry­os) plus any ad­di­tion­al “frozen” cycles (in which doc­tors trans­fer frozen em­bry­os that wer­en’t ori­gin­ally used). She hoped that the worst was be­hind her.

Most of the laws that re­quire in­sur­ance to cov­er in­fer­til­ity passed state le­gis­latures in the late 1980s and early 1990s, though the last one to pass, Con­necti­c­ut’s, came as re­cently as 2005. The polit­ic­al cli­mate has changed since then. “You had the eco­nom­ic down­turn, and then the be­gin­nings of the Af­ford­able Care Act, and a lot of un­cer­tainty around that,” says Col­lura. “Even in states that seemed ‘man­date friendly,’ they were gun-shy about adding new man­dates for any­thing.” For ex­ample, a meas­ure passed the Cali­for­nia le­gis­lature in 2013, but Demo­crat­ic Gov­ernor Jerry Brown ve­toed it, say­ing he wanted to see how the ACA en­act­ment went first. Many fer­til­ity ad­voc­ates had hoped that the ACA would en­shrine as­sisted re­pro­duct­ive tech­no­logy as one of its “es­sen­tial be­ne­fits” (or would oth­er­wise man­date its cov­er­age, as the ad­min­is­tra­tion did with birth con­trol), says Cathy Sakimura, deputy dir­ect­or and fam­ily law dir­ect­or at the Na­tion­al Cen­ter for Les­bi­an Rights. But the ACA didn’t men­tion the is­sue, leav­ing it de facto in the hands of the states.

The rise of the tea party, and the grow­ing po­lar­iz­a­tion around re­pro­duct­ive rights—for ex­ample, the idea that a fer­til­ized em­bryo has per­son­hood—hasn’t helped the cause, either. (IVF can lead to the dis­card­ing of un­used em­bry­os.) “We see lots of anti-choice state le­gis­lat­ors who don’t like non­tra­di­tion­al re­pro­duc­tion, and some­times they do things to go after it,” says Sean Tipton, head of ad­vocacy and policy at the Amer­ic­an So­ci­ety for Re­pro­duct­ive Medi­cine, which rep­res­ents doc­tors. As for ex­pand­ing cov­er­age in the United States: “We’d like to be more pro­act­ive, but un­for­tu­nately, we spend a lot of time pro­tect­ing the leg­al­ity” of what’s already avail­able.

There is at least one per­son, however, who’s try­ing to fig­ure out what in­fer­til­ity cov­er­age should ideally look like. Susan Crockin helped write and lobby for the Mas­sachu­setts man­date, which was among the first in the coun­try, in 1987. She’s a law­yer who teaches at Geor­getown Uni­versity’s O’Neill In­sti­tute for Na­tion­al and Glob­al Health Law, and she has de­voted most of her ca­reer to the sub­ject of re­pro­duct­ive law. “My very prac­tic­al hope over the next couple of years, and where I’m try­ing to put my en­ergy, is in­to try­ing to get to­geth­er an in­ter­dis­cip­lin­ary ar­gu­ment,” she says. This means “bring­ing to­geth­er the leg­al chal­lenges, the eco­nom­ic per­suas­ive­ness, and the eth­ic­al is­sues”—in oth­er words, amass­ing a case that treat­ing fer­til­ity cov­er­age as a civil right is not only the eth­ic­al thing to do, but, from the per­spect­ive of our coun­try’s health sys­tem, the eco­nom­ic­ally sound thing, too.

The eco­nom­ic piece of that ar­gu­ment rests on the idea that cov­er­ing IVF could ac­tu­ally save money. In re­cent years, doc­tors have in­creas­ingly been en­cour­aging wo­men who un­der­go IVF to have just one fer­til­ized em­bryo trans­ferred in­to the uter­us—but, since the vast ma­jor­ity have scraped and sac­ri­ficed to pay for the pro­ced­ure without help from in­sur­ance, many opt to trans­fer mul­tiple em­bry­os, to raise the odds that at least one will sur­vive. The prob­lem with this ap­proach is ex­em­pli­fied by Nadya Sule­man, the Cali­for­nia wo­man who be­came known as “Oc­to­mom” when she gave birth to oc­tup­lets in 2009 via IVF. Mul­tiple births—in­clud­ing bio­lo­gic­ally nat­ur­al twins and triplets—tend to cre­ate risks for both moth­er and in­fant, as well as ex­tra costs. All of this taxes our med­ic­al sys­tem.

A trio of re­search­ers, in­clud­ing Adashi, the Brown pro­fess­or, wanted to know just how much money the United States would save if wo­men only had single-em­bryo trans­fers. “One of the thoughts was that if it be­comes ap­par­ent that IVF is not as ex­pens­ive as it’s made out to be, and if you can ac­tu­ally save money in the pro­cess,” maybe that would bol­ster the case for cov­er­age, says Adashi. “We had a hunch that the sav­ings would be sub­stan­tial”—but even they were sur­prised when they crunched the num­bers and found that elim­in­at­ing mul­tiple births from IVF would save the United States roughly $6.3 bil­lion a year. “It means we could cov­er IVF with the cost sav­ings and have health­i­er ba­bies,” Crockin points out. In fact, cov­er­ing IVF might be the only way to make those sav­ings a real­ity: Fam­il­ies whose in­sur­ance is pay­ing for the pro­ced­ure have proved more amen­able to single-em­bryo trans­fers. To go a step fur­ther, new laws could make single trans­fers a re­quis­ite of cov­er­age—a pop­u­lar meas­ure in European coun­tries that pay for IVF, such as Bel­gi­um and Sweden.

Wheth­er these sav­ings would ac­tu­ally ma­ter­i­al­ize in the real world is an­oth­er mat­ter en­tirely, however. In Que­bec—which un­til re­cently paid for IVF—pro­ponents were also op­tim­ist­ic that their pro­gram would pay for it­self by re­du­cing twins, triplets, and oth­er “mul­tiples.” Ex­cept in cases of severe in­fer­til­ity, Que­bec doc­tors were only per­mit­ted to im­plant one em­bryo. But though the pro­por­tion of mul­tiples did go down, from 30 per­cent of IVF births to around 8 per­cent, the cost did not. That’s be­cause, says Neal Mahutte, med­ic­al dir­ect­or of the Montreal Fer­til­ity Cen­ter, the total num­ber of ba­bies born via IVF went up so much that the num­ber of twins stayed about the same, and so did the ex­tra ex­penses that twins tend to en­tail.

Mahutte led a team of re­search­ers in an ef­fort to fig­ure out what could be done about the pro­gram’s $70 mil­lion a year price tag. They found that the province was spend­ing an av­er­age of $17,919 per baby born to a wo­man un­der 35, but that the cost climbed dra­mat­ic­ally from there: For 40-year-old wo­men, the av­er­age was $43,153, and for 43-year-old wo­men, it was $104,000. For older wo­men in par­tic­u­lar, he says, “We saw a situ­ation where the prob­ab­il­ity of suc­cess of the cycle was rarely a factor in de­cision-mak­ing about wheth­er to start the treat­ment. People would say, ‘I have everything to gain and al­most noth­ing to lose.’ It’s like if some­body of­fers you a lot­tery tick­et for free.” Per­haps, he sug­ges­ted, phys­i­cians should have to de­term­ine that a cycle has at least a cer­tain chance of suc­cess (he threw out 5 per­cent as a pos­sib­il­ity) be­fore the pub­lic should be re­quired to pay for it.

Al­tern­at­ively, Mahutte and his team cal­cu­lated that Que­bec could save half the money it was spend­ing on the pro­gram—while only re­du­cing the num­ber of births from IVF by 10 per­cent—by in­sti­tut­ing a few lim­its: an age cap of 41; a ceil­ing of two cycles per wo­man; a stricter defin­i­tion of what con­sti­tuted “one cycle” of IVF; the ex­clu­sion of pa­tients who had pre­vi­ously had an elect­ive tubal lig­a­tion or vas­ec­tomy. The team presen­ted this pro­pos­al to the gov­ern­ment in the hopes of sav­ing the pro­gram. But it was cut any­way last month, re­placed with a mod­est tax cred­it.

For Mahutte, the struggles with cost in Que­bec don’t un­der­mine the idea that free IVF is po­ten­tially eco­nom­ic­al; fur­ther re­stric­tions could have trimmed the cost of the pro­gram even more while main­tain­ing it for the ma­jor­ity of wo­men. Adashi, too, ar­gues that even if the Que­bec pro­gram may have been “too gen­er­ous,” the fun­da­ment­al lo­gic that re­du­cing mul­tiples saves money while pro­du­cing bet­ter health out­comes is sol­id. “If one were to design such a plan, one would have to look at the Que­bec pro­gram and make sure we’re not re­peat­ing mis­takes they might have made,” he says. He is con­fid­ent that in­vest­ing in IVF to re­duce mul­tiples “is not only the right thing to do but the smart thing.”

STILL, THE POS­SIB­IL­ITY re­mains that ex­pan­ded IVF cov­er­age would res­ult in net ex­penses rather than net sav­ings—in which case it would rep­res­ent a trade-off, per­haps one that would be dif­fi­cult to jus­ti­fy. Jef­frey Kahn, a pro­fess­or of bioeth­ics and pub­lic policy at Johns Hop­kins Uni­versity, says that in an ideal world, he’d like to see bet­ter ac­cess to fer­til­ity care. But, he asks, “How do you value the out­come of hav­ing a bio­lo­gic­ally re­lated child against the out­come of someone who got a kid­ney trans­plant?” Plus, the eth­ic­al ques­tion of wheth­er hav­ing chil­dren is a right or a priv­ilege is fur­ther com­plic­ated by the fact that, al­though ad­op­tion, too, is ex­pens­ive and com­plex, it is pos­sible to build a fam­ily out­side the con­fines of bio­logy.

In the coun­tries that do cov­er in­fer­til­ity (many of which do not re­quire re­cip­i­ents to be straight or mar­ried), there’s of­ten a pro-na­t­al­ist in­cent­ive at work, says Geneva-based health care eco­nom­ist Mark Con­nolly. For Is­rael, which has the world’s most gen­er­ous IVF cov­er­age—two ba­bies for any wo­man, re­gard­less of how many cycles it takes to get there—a grow­ing pop­u­la­tion pro­tects against a con­stant ex­ist­en­tial threat, while “places like South Korea and Es­to­nia are start­ing to fund [IVF] be­cause they have a de­clin­ing pop­u­la­tion,” Con­nolly says. In Europe more gen­er­ally, Con­nolly pos­its a link between coun­tries where there’s ex­tens­ive ac­cess to re­pro­duct­ive as­sist­ance and na­tion­al cul­tures that are more gen­er­ally pro-fam­ily, with good na­tion­al day care, par­ent­al leave, and so on. In France, for ex­ample, he says, IVF is looked at as “part of that pack­age.” “Amer­ica doesn’t have a lot of fam­ily-friendly policies,” he points out. “We don’t do much ma­ter­nity leave. We’re not Sweden. Are we a fam­ily-friendly coun­try?”

Crockin, for one, hopes we can be more so. She sees a strong eth­ic­al and leg­al case for cov­er­ing re­pro­duct­ive as­sist­ance, and she thinks that the Su­preme Court’s re­cent de­cision on mar­riage equal­ity has bolstered that case—not just for same-sex couples, but for every­body. “The basis of [Oberge­fell v. Hodges] is that we should not de­prive any­one of the right to be and have a fam­ily,” she says. Un­der her lo­gic, this has cre­ated a leg­al pre­ced­ent that can be ap­plied to all as­pects of fam­ily-mak­ing, in­clud­ing re­pro­duc­tion. Says Crockin, “I think you can take some of those state­ments and say, ‘But we now have people who have a right that they can’t ex­er­cise ex­cept in a way that is in­cred­ibly bur­den­some and ex­pens­ive—and, for some, pro­hib­it­ively ex­pens­ive.’ ”

In Crockin’s view, tak­ing this rights-based ar­gu­ment to its lo­gic­al con­clu­sion would mean cov­er­ing re­pro­duct­ive as­sist­ance for any­one who needed it in the child­bear­ing years (con­ven­tion­ally capped in the early 40s for wo­men). That would in­clude cov­er­age of IUI for people who are not med­ic­ally but “so­cially in­fer­tile”: same-sex couples and single people. “We are a so­ci­ety that has moved quickly to em­brace and re­cog­nize same-sex mar­riage, and it seems to me fun­da­ment­ally at odds with that to say, ‘OK, pay out of pock­et if you want to have a child,’ when every­one else doesn’t have to,” she says.

The economic argument rests on the idea that covering IVF could actually save money. 

Even Crockin’s ex­pans­ive vis­ion of the right to re­pro­duce does con­tain prac­tic­al lim­its, though. She ac­know­ledges, for in­stance, that it’s tough to ima­gine U.S. in­sur­ance pay­ing for the pur­chase of sperm samples or donor eggs, or for a sur­rog­ate to carry a preg­nancy, which is not only ex­pens­ive, but also harder to clas­si­fy as “med­ic­al” care. (This means, among oth­er things, that it would re­main cheap­er for les­bi­ans and single wo­men to re­pro­duce than gay men.) But Crockin can ima­gine a world where IUI and IVF are covered for any­one: To put it crudely, if someone brings all the pieces to the table—egg, sperm, uter­us—yet still needs help, then the med­ic­al mojo that puts it all to­geth­er would be avail­able.

Crockin thinks her ar­gu­ment could gain a mor­al mo­mentum that the nar­row­er push for med­ic­al in­fer­til­ity cov­er­age in the 1980s and 1990s nev­er achieved. “It’s fun­da­ment­ally more eth­ic­al, and I don’t think it’s sig­ni­fic­antly more ex­pens­ive,” she says. Un­der the cur­rent sys­tem, when people who can’t have chil­dren without med­ic­al help buy in­sur­ance, they pay in­to a pool that cov­ers con­tra­cept­ive care, ma­ter­nity care, and pe­di­at­ric care. Why, she asks, shouldn’t they get the care they need covered in re­turn?

If Crockin can con­struct the per­fect ar­gu­ment, the ques­tion re­mains: Where to bring it? She ad­voc­ates go­ing straight to the in­sur­ance com­pan­ies and to large em­ploy­ers, show­ing them the eco­nom­ic ar­gu­ment (car­rot) and the leg­al ar­gu­ment (stick) to en­cour­age them to avoid end­ing up on the wrong side of a case. There have been a few small signs that get­ting the in­sur­ance com­pan­ies on­board is the best way to get this is­sue back on le­gis­lat­ors’ agen­das. In Cali­for­nia, the meas­ure that passed the le­gis­lature in 2013 (though it was later ve­toed by the gov­ernor) wasn’t op­posed by the in­sur­ance sec­tor. It would have man­dated in­sur­ance cov­er­age of fer­til­ity pre­ser­va­tion, such as sperm and egg freez­ing, for people who had been dia­gnosed with can­cer and were about to lose their fer­til­ity to treat­ment. The com­pan­ies saw an­ec­dot­al evid­ence that can­cer pa­tients were delay­ing chemo­ther­apy un­til they could fig­ure out some means of pre­serving their fer­til­ity, lead­ing to worse out­comes and high­er costs in the long run.

In Mary­land, in­sur­ance com­pan­ies backed an en­tirely dif­fer­ent ex­pan­sion of IVF cov­er­age: This year, in the wake of mar­riage equal­ity, a num­ber of les­bi­an couples filed law­suits ar­guing that the state’s man­date, which only ap­plied to straight couples, was dis­crim­in­at­ory. “The in­sur­ance in­dustry, the gov­ernor’s of­fice, and oth­ers were nervous about pending lit­ig­a­tion, and that helped al­low for bi­par­tis­an sup­port,” says state Sen­at­or Cheryl Kagan, the bill’s primary spon­sor. The meas­ure be­came law last spring, and the Na­tion­al Con­fer­ence of State Le­gis­latures will be sug­gest­ing it as a mod­el for oth­er states whose man­dates put them in the same leg­al bind. (When I reached out to the or­gan­iz­a­tion that rep­res­ents in­surers, Amer­ica’s Health In­sur­ance Plans, for a stance on wheth­er plans should ex­pand their fer­til­ity cov­er­age, a spokes­per­son wrote back that “it’s pos­sible in the fu­ture, state man­dates could add that type of cov­er­age to es­sen­tial health be­ne­fits pack­ages” but ad­ded that “AHIP doesn’t is­sue re­com­mend­a­tions or take po­s­i­tions on cov­er­age de­cisions.”)

There are ways to make fer­til­ity care more avail­able—at least to some ex­tent—without wad­ing in­to the bur­eau­crat­ic labyrinth of in­sur­ance. For ex­ample, says Char­is Thompson, chair of gender and wo­men’s stud­ies at the Uni­versity of Cali­for­nia, Berke­ley, some clin­ics are try­ing to open their doors to a broad­er range of cus­tom­ers (a busi­ness pro­pos­al that is, of course, fin­an­cially as well as mor­ally ap­peal­ing) by “of­fer­ing low-cost loans, or shel­ter­ing their pa­tients from hav­ing their cred­it scores too im­pacted by those loans.” Oth­ers, Thompson notes, are pi­on­eer­ing a tech­nique that’s of­ten called “mini-IVF” or “mi­cro-IVF,” in which young­er pa­tients or those with a good pro­gnos­is can opt to buy “lower doses of fer­til­ity drugs, less mon­it­or­ing and lab ma­nip­u­la­tion” in the hopes that the barer ba­sics will still pro­duce a baby.

But the fact re­mains that “there aren’t really any policy think tanks do­ing fer­til­ity in the U.S.,” ac­cord­ing to Con­nolly. In­deed, the heavy hit­ters in both the re­pro­duct­ive-rights and the LGBT-ad­vocacy worlds ap­pear not to be pri­or­it­iz­ing the is­sue: Both Gay & Les­bi­an Ad­voc­ates & De­fend­ers and NARAL Pro-Choice Amer­ica re­ferred me to oth­er ex­perts in the field when I con­tac­ted them; the Hu­man Rights Cam­paign, the coun­try’s most prom­in­ent LGBT group, nev­er got back to me. The de­bate around this is­sue “seems to move for­ward a little bit and then stop,” says Con­nolly. He him­self has largely moved onto oth­er top­ics after fo­cus­ing for years on this one. “There’s no money in it for me to do re­search,” he told me.

RACHEL VORKINK DIDN’T get preg­nant from her first round of IVF. But her fer­til­ity clin­ic had frozen one of the fer­til­ized em­bry­os, and when they did a “frozen trans­fer,” it worked. Nine weeks later, she mis­car­ried. “The not get­ting preg­nant for so long was really dif­fi­cult, but it’s cruel and un­usu­al pun­ish­ment to get preg­nant, fi­nally,” she says. “We went to the ul­tra­sound, we had a heart­beat.” An­oth­er stress on her emo­tion­al state: the IVF cycles them­selves, which in­volve daily hor­mone shots that make wo­men feel naus­eous and achy, and, in Vorkink’s words, “nutty and ter­rible.” Still, Vorkink was de­term­ined. Last sum­mer, after her fifth cycle, she learned she’d again got­ten preg­nant with a frozen em­bryo. But once again, she mis­car­ried after a few weeks.

At this point, with one cycle left through her in­sur­ance, “emo­tion­ally, I feel like I need to do something dif­fer­ent,” she says. She and her wife de­cided to try us­ing Sna­jder’s eggs to cre­ate a preg­nancy that Vorkink would carry, as she’d al­ways wanted to. “It’s an iden­tity thing for me,” she says. “I don’t know who I’ll be if I can’t have chil­dren.” She used to feel like it was es­sen­tial to her self-concept that she have a bio­lo­gic­al child, but over four years of cyc­lic­al grief, she has had to al­ter her defin­i­tion. “I still have a lot of hope that I can bear a child,” she says.

The prac­tice of us­ing one part­ner’s eggs and the oth­er’s womb, of­ten called “re­cip­roc­al IVF,” is pop­u­lar with les­bi­an couples, since it gives both wo­men a bio­lo­gic­al con­nec­tion to their child. But there was a prob­lem: When Vorkink and Sna­jder brought the plan to their doc­tor, she warned them that re­cip­roc­al IVF is nev­er covered by in­sur­ance. To Vorkink, this seemed non­sensic­al and un­fair—a clear sign that IVF cov­er­age is de­signed with straight couples in mind. Re­cip­roc­al IVF doesn’t cre­ate sig­ni­fic­ant ex­tra costs for doc­tors or in­surers; it es­sen­tially means di­vid­ing the cycle in half, giv­ing the fer­til­ity drugs that stim­u­late the ovar­ies to the part­ner whose eggs will be used, then per­form­ing the trans­fer sur­gery on the part­ner who will carry. “We’re a fam­ily, shar­ing tis­sue to make a baby,” she ar­gues, “just like a straight couple. … We don’t fit with­in the con­fines of this box they’re try­ing to put us in.”

That Vorkink and Sna­jder hit this lim­it even in Mas­sachu­setts shows just how many bar­ri­ers re­main for those who are not in het­ero­sexu­al re­la­tion­ships. Col­lura says she could ima­gine mo­mentum on this cause com­ing from gay rights groups, whose con­stitu­en­cies are primed to care about the avail­ab­il­ity of fer­til­ity medi­cine. “They tell me ac­cess to IVF and fam­ily-build­ing is one of their top three con­cerns,” she says. Even if the is­sue turns out to be a bit lower on groups’ lists than that, it’s not too hard to ima­gine that if it rises up a slot or two, it could be­come a big part of the na­tion­al con­ver­sa­tion.

So far, that con­ver­sa­tion is per­col­at­ing slowly. There are reas­ons for this: It’s hard to ima­gine the fer­til­ity land­scape chan­ging through the kind of big class-ac­tion suit that’s of­ten used to tackle civil rights is­sues, be­cause that type of re­lief comes too slowly to help wo­men whose child­bear­ing hopes are acutely time-sens­it­ive. And it’s dif­fi­cult for RE­SOLVE and sim­il­ar or­gan­iz­a­tions to build big net­works of sup­port­ers. Says Col­lura: “Un­like can­cer, or some of these oth­er things where people sort of hang onto it and want to give back, people are very quiet about their in­fer­til­ity. Once they build their fam­ily and per­haps have re­solved their in­fer­til­ity, frankly, they close that door and they want to move on.”

Col­lura is hop­ing to spend the next few years fo­cus­ing on “on­cofer­til­ity” meas­ures—those that would help can­cer pa­tients, like the one that nar­rowly missed be­com­ing law in Cali­for­nia two years ago. Though suc­cess in this area wouldn’t help the vast ma­jor­ity of people who need ac­cess to re­pro­duct­ive as­sist­ance, “I do think that it could lead the way,” Col­lura says. “I think you have to sort of find your beach­head and fig­ure out what comes next.” Along sim­il­ar lines, Tipton says that AS­RM’s top pri­or­it­ies in­clude a pair of bills—cur­rently lan­guish­ing in Con­gress—to make the Vet­er­ans Health Ad­min­is­tra­tion pay to treat ser­vice-mem­bers who were rendered in­fer­tile by in­jur­ies in the line of duty.

The bright­est spots of hope at the mo­ment are elite private com­pan­ies, like Face­book and Apple, which are start­ing to of­fer egg freez­ing as a be­ne­fit, in or­der to at­tract and re­tain top-notch fe­male em­ploy­ees. This Oc­to­ber, the tech com­pany In­tel quad­rupled its fer­til­ity be­ne­fits: Em­ploy­ees now have up to $40,000 they can spend on fer­til­ity treat­ment, plus $20,000 to spend on as­so­ci­ated pre­scrip­tion med­ic­a­tions—and same-sex couples can ac­cess the be­ne­fits without a med­ic­al dia­gnos­is. (In­tel also tripled its ad­op­tion policy, to $15,000 per ad­op­tion with no cap on the num­ber of times it can be used.)

None of that, of course, will help Vorkink and Sna­jder, whose next steps now rest wholly on their eco­nom­ic status. When the in­sur­ance com­pany con­firmed that there would be no as­sist­ance if Vorkink and Sna­jder chose to do re­cip­roc­al IVF, Vorkink’s par­ents offered to help. They didn’t want her to sub­ject her­self to a sixth, identic­al cycle that seemed un­likely to pro­duce a happy out­come. In Oc­to­ber, Vorkink and Sna­jder paid $13,000 out of pock­et to start the pro­cess of re­cip­roc­al IVF; a mem­ber of Vorkink’s fam­ily will be the sperm donor, giv­ing her an­oth­er lay­er of con­nec­tion. Vorkink is ap­peal­ing the in­sur­ance com­pany’s de­cision, hop­ing to get re­im­bursed—though the chances are small, she says that she’ll see it through “on prin­ciple.” In the mean­time, she feels grate­ful to her par­ents. “Thank God for them,” she says, “be­cause I know that this pro­cess re­quires a level of priv­ilege that we don’t have as a couple.” She knows many people would nev­er have been able to take this shot at cre­at­ing the fam­ily of their dreams.

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