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7 reasons why fertility care is utterly broken

April 28, 2022, 11:26 AM UTC
In vitro fertilization (IVF) has come a long way since it was invented–but it costs too much, not enough people have access, and its outcomes are uncertain.
Ulrich Baumgarten - Getty Images

I am forever indebted to the doctors and scientists who enabled me to become a parent through In Vitro Fertilization (IVF). But it was not without heartbreak—including many failed cycles and 10 miscarriages.

In Vitro Fertilization has come a long way since the first IVF baby, Louise Joy Brown, was born in 1978. Thirty years ago, your chances of bringing home a baby with each IVF try was five percent. Today, around a third of attempts to procreate via IVF are successful, a rate that varies based on your condition.

While this is an impressive improvement, the fact is that the majority of patients will not go home with a baby after an invasive, emotional, and expensive round of IVF. There’s still much progress to be made.

But it goes beyond IVF, which is out of reach for many people facing infertility. The entire fertility care system is broken.

Fertility care fails on each point of the “Iron Triangle” of healthcare–access, cost, and quality. It’s not accessible, it costs too much, and the outcomes are dismal.

As an investor, founder, and most importantly, patient navigating fertility care in the United States, I think I know why:

1. Treatment for infertility is seen as elective, forcing patients to go into debt to have a baby

Unlike care for other medical conditions, infertility is seen as an elective treatment, and it is not universally covered by health insurance. Seventy percent of women who undergo IVF go into debt and about 80% have hardly any or no coverage–not an ideal, low-stress way to start a pregnancy.

Not only do patients often have to pay out of pocket, but they also don’t benefit from the lower rates that health plans typically negotiate. One report found that the average out-of-pocket cost per successful outcome of IVF was $61,377. That’s the going rate to have a child when you can’t.

2. Usually, treatment doesn’t work

Many patients start with the fertility treatment medications Clomid (Clomiphene citrate) or Femara (Letrozole). But the chances of a live birth from these drugs aren’t great; according to one study it’s just 23.3% for Clomid and 18.7% for Letrozole.

Once that fails, many move onto three or four cycles of intrauterine insemination (IUI), but the chances of this working are even lower: across all patients undergoing IUI, the live birth rates per cycle are around five to 15%. 

Then there’s IVF, if you can afford it. The chances that the first egg retrieval and transfer will result in a live birth are discouraging, ranging from 38.4% for women under 35 to 3.1% for women over 43.

3. There aren’t enough fertility specialists

With under 500 clinics across the country, an estimated 18 million women of reproductive age live in locations without access. Though one in eight women experience infertility, just 38% of American women with fertility problems, who hadn’t previously given birth to a live baby, have ever used infertility services.

There are simply not enough specialists to meet the demand for fertility treatments, resulting in long waitlists, inability to access care entirely, and unfulfilled dreams of a baby. In a field where every passing month and year matters, this shortage is failing many Americans.

4. There’s too much focus on women

Due to century-old stigmas and misconceptions about infertility, the woman is often the sole focus of fertility treatment despite the fact that males are equal contributors to infertility.

A quick search on PubMed shows 8,590 articles for “female fertility” and just 5,490 for “male fertility”–an imbalance indicative of how many of us patients feel at the clinic. 

The fact is, Reproductive Endocrinologists (REIs, aka fertility doctors) are trained OBGYNs first, as REI is a subspecialty within that field. More of their training is focused on treating women, which may be why it seems some doctors are more inclined to treat the female first, before acknowledging the male’s role in the issue.

5. Racial inequalities persist 

There is evidence that BIPOC patients are much less likely to seek care than white patients, despite having higher rates of infertility.

And like elsewhere in our healthcare system, the outcome disparities for Black patients are dismal and devastating. One study found that Black women had 33% lower chances of pregnancy and nearly double the miscarriage rates during IVF than white mothers. 

Researchers have concluded that extensive policy reform is needed to improve the fertility treatment process for everyone. It’s time to make actual changes—not just “highlight disparities.” 

6. The heteronormative framing makes it harder for LGBTQ+ family building

In addition to facing discrimination, LGBTQ+ parents face additional barriers in gaining fertility coverage because definitions often preclude them from qualifying.

For example, some states mandate coverage for “iatrogenic infertility,” meaning infertility caused by a medical procedure like chemotherapy, but it’s unclear if they will “count” fertility caused by gender-affirming care that results in infertility.

Other states mandate the couple’s own egg and sperm be used, which excludes same-sex couples from qualifying.

7. We totally ignore the mental health toll

Those going through infertility often call it the most trying time of their life. Research has shown that women with infertility have the same levels of anxiety and depression as women with cancer or HIV.

Yet mental healthcare is not part of the typical treatment path. Ironically, a low-stress environment is the optimal condition to conceive and carry a healthy pregnancy, and research connects lowering levels with higher chances of pregnancy. 

Halle Tecco, MBA, MPH is the Founder of Natalist (now part of the Everly Health family, where she serves as EVP of Women’s Health Strategy), a board member at Resolve: The National Infertility Association, and an investor/advisor in fertility companies KindBody, Conceive, Alife, and Poppyseed Health. She previously founded digital health VC firm Rock Health, and was an adjunct professor at Columbia Business School. She received her MBA from Harvard Business School and her MPH from Johns Hopkins University with a concentration in Women’s and Reproductive Health. 

The opinions expressed in Fortune.com Commentary pieces are solely the views of their authors, and do not reflect the opinions and beliefs of Fortune.

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