The Costs of Infertility

Arielle Bogorad: We often spend many years trying not to get pregnant. And then we finally decide, okay, I'm ready. And then it doesn't happen quickly. And it's almost shocking, because all our lives we've been told how easy it is to get pregnant. So it's, what do you mean I can't get pregnant? I thought it would be easy. 

Katie: Welcome back to The Money with Katie Show, Rich Girls and Boys. Today we're talking about the costs of infertility. Now, it's no surprise to anyone, I imagine, that having a child is expensive. Not to mention the costs of birthing a child, which we discussed in our blog post this week on moneywithkatie.com. We will link that in the show notes for you. But when nearly one in six people globally is affected by infertility, the expensive reality is that merely getting pregnant is not always free, either. As of 2023, the majority of healthcare plans do not include fertility treatments in their coverage, as they are not deemed, quote, “medically necessary.” This means that people struggling with infertility have to pay for these types of services themselves. And surprise, surprise: A baby don't come cheap.

And as we dug into the research for this episode, we realized there are a lot of thorny elements to this topic around the ethics of things like surrogacy, or destroying or donating unused embryos, adoption, donor-conceived children, and more. All that to say, this is not just a financial topic, but a complex human rights topic too. And so we're gonna highlight some of those concerns throughout the episode where appropriate. According to 2022 data, 80% of patients who have undergone fertility treatments say it has negatively impacted their finances. And while treatments have become more affordable in recent years, the out-of-pocket cost can be upwards of $40,000 when it's all said and done.

So we'll dive into the actual math shortly, but before we do, let's cover a few reasons why I think this is becoming an increasingly relevant financial consideration, especially for millennials and Gen Z. First, we've talked about this on the show before. Giving birth to and rearing future generations is, I don't know, kind of a necessary component of a thriving society and economy. I think there's a fundamental financial element or economic element of birth. Second, when nearly 20% of the population deals with infertility and the out-of-pocket costs can equal nearly an entire year of the median take-home pay in the US, the decision to have children, if you experience infertility, means a massive up-front financial commitment that likely requires a considerable amount of planning in the years before you are ready.

And lastly, and perhaps this one is a bit slippery, but stick with me. As it takes longer and longer to feel financially stable, aka average age of marriage and home ownership growing increasingly older over time, I think it stands to reason that the number of people requiring some sort of fertility treatment in order to successfully conceive a baby will rise over time. 

Furthermore, there's the perspective of the child that needs to be honored in these conversations. We so often consider the desire of the parent to have babies, whether through medical intervention or adoption, but don't always lend as much consideration to the ethical ramifications of these types of choices for the other humans involved. One listener of this show reached out to share her experience, and she basically said that being adopted from one country to another has left her with intense feelings of cultural loss, that these are the types of non-financial considerations that need to be weighed, too. 

So without further ado, let's talk about the price of infertility. We'll go over ways you can budget and plans for treatments in the future, the average costs for each of the main options available, and insights from Arielle Bogorad, SVP of employer market strategy at Progyny, the first fertility benefits provider to go public, and an organization offering comprehensive fertility and family building benefits to more than 5 million people across the US. She actually went through this experience firsthand, so she's gonna share her own infertility story too. We will get into all of the numbers after a quick message from the sponsors of today's episode.

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Katie: Arielle's fertility journey was a long and winding road.

Arielle Bogorad: My personal story actually intersects with my professional journey, so I'll actually start there. So for 10 years I had executive responsibilities for worldwide benefits and well-being programs at a Fortune 500 company. So what does that mean? I had responsibilities for the strategy and design of benefits across 25 countries. This included the US medical plan, which at its peak had about $250 million in total paid spend. Prior to 2017, the medical plan didn't cover any fertility treatments. It only covered the underlying diagnosis, which is like basically nothing. So in 2016, my benefits team vetted Progyny and saw that it really aligned to our overall benefits, philosophy, and guiding principles.

So we were always looking for progressive partners who put an emphasis on highest quality and an exemplary member experience. So now fast forward to June of '17, and that's when my personal infertility journey began. So we had been trying to conceive at that point for six months or so, and nothing was happening. And I attempted to get an appointment with my OB initially, but she had a long wait. And then I remembered, hey, what about that fertility benefit that I put in place? And I ended up having a very difficult journey. I ended up being diagnosed with unexplained infertility, and it turned out that I was also considered what they call a “poor responder” to the IVF medications.

So I ended up having four egg retrievals, two canceled stimulation cycles at three IVF clinics. And out of all of that, I only obtained two chromosomally normal embryos, one of which was chromosomally inconclusive initially, but miraculously came back chromosomally normal upon retest. And that embryo is my three-and-a-half-year-old daughter today. So through that journey, I became passionate about improving access to care for fertility and family building. So much so that I made a career pivot to join Progyny as an employee last year, and really to continue to advance the cause. And I firmly believe that without my prior employer's coverage, my daughter, she wouldn't be here today. I very simply would've been priced out, especially because my daughter's embryo came from that fourth egg retrieval. That's really pretty inspiring and motivating to me, because I'm not alone. I know I'm not alone. Infertility is so common. 

Katie: For today's purposes, we're gonna look at the three most popular ways to address infertility: IVF, IUI, and adoption. Now, I am no Sex Ed 101 teacher and I went to Catholic school, so the extent of the sex ed that I received was “Don't have sex,” but here is a quick recap of IUI and IVF. IUI is intrauterine insemination, where sperm is placed directly into the uterus during a fertile window. And when IUI doesn't work, medical professionals often recommend IVF. Now, IVF is short for in vitro fertilization, where a fertilized egg is implanted into the uterus. IVF might also be recommended because of blocked fallopian tubes or low sperm count or severe endometriosis. 

In both cases, here is the unfortunate headline: There is no guarantee that these processes will work, but they can significantly increase the chance of a positive result. During one of the first comprehensive studies on fertility costs that happened back in 2011, researchers heard from approximately 400 women who were dealing with infertility. And at the time, the median per person costs ranged from $1,182 for medications only, to $24,373 for IVF and $38,015 for IVF using donor eggs. For those who had successful outcomes that involved IVF followed by the birth of a child or pregnancy that reached 20 weeks within 18 months, that average skyrocketed to $61,377. Keep those numbers in mind as we dive into the averages today, because like I said, these treatments are more affordable than they've ever been, but they are by no means cheap. 

So IUI is typically the most affordable of the three options. So we'll start there. According to FertilityIQ, a typical cycle ranges from $500 to $4,000 based on three major factors: medications, monitoring, and blood work, and the actual insemination process. Keep in mind that most people usually require multiple cycles of IUI. 88% of successful IUIs take place in the first three cycles, and 95.5% within the first four. So on the low end, we're looking at $500 for a single cycle or upwards of $4,000, four separate times, which amounts to roughly $16,000 total. Whether or not your insurance will cover IUI differs by region, plan type, sex of the patient or patients, and even the drugs that are prescribed to you. 

Now on to IVF. Per the New York Times, the average cycle costs between $12,000 and $17,000, not including medication. With medication, the cost rises closer to $25,000. And according to Forbes Health, your base cost will be between $12,000 and 14,000. But add-ons will bring the bill to between $15,000 and $20,000. That'll get you monitoring, egg retrieval, embryo creation, and the embryo transfer. But there are other costs to consider too, like the ovulation-stimulating medications (similar to IUI), semen analysis, and a fertility assessment. I have to say, I never thought I'd be saying the words “semen analysis” on The Money with Katie Show, but here we are. This is the world we live in. 

The process is up to 40 times more expensive than IUI, but it does experience a higher success rate overall. The Forbes piece outlines the majority of the costs for embryo creation and transfer, frozen embryo transfers, and more. So we will link it for you in the show notes. Many patients, like Arielle, go through several rounds of IVF, though as a semi-questionable silver lining, some clinics will offer discounted pricing on second or third cycles. We stan markets of scale (hashtag #capitalism). But Arielle's IVF experience was a winding road, indicative of the way that it's not always gonna be straightforward even if some of your costs are covered.

Arielle Bogorad: So I had the four egg retrievals that I needed, and a typical egg retrieval is comprised of both medical costs as well as pharmacy costs. So there's two components, and I would estimate that a typical cycle costs between $20,000 to $25,000. But know that this number can vary depending on the medications that you specifically need if you require other tests or procedures. So for instance, if you and your partner are carriers for a monogenic disorder like sickle cell or Tay-Sachs, then you might require additional genetic testing called PGT-M. And the prices also have regional differences. So it's going to be more expensive if you live on the coast than if you live in the Midwest, where I live.

So all in all, my care was likely in the $100,000 to $120,000 range for the four egg retrievals, plus the two canceled cycles and two frozen embryo transfers that I endured in order to have my daughter. So much. It's mind-boggling, right? And for that much money, sometimes you don't get anything in return. And I have a few examples of that too. So I had two stimulation cycles where my estrogen didn't increase. So the first time it happened, my doctor called off that cycle on the 10th day of stimulation. So that's like after 10 days of giving myself injections, going to the clinic, and doing blood work and them doing ultrasound to see how my growth was.

And the second time it happened, my cycle was canceled on the fifth day of stimulation. So all of the medical and drug spend up until that point, and just ends up being sunk costs for those two cycles. So I really had six stem cycles: two that were canceled, four that went through to retrieval. And so I also had two egg retrievals where I was able to complete the full cycle. I made some blastocyst embryos, which is once they retrieve your eggs and fertilize them, then they have to grow to day five to seven, and then they have to reach a certain stage, which is like, you want it to get to blastocyst, which is like the cellular stage. But upon genetic screening, those blastocyst embryos that I had in two of my egg retrieval cycles, all of them came back as being chromosomally abnormal.

So I went through all of that and I didn't have anything to show for it. Had I been cash pay, I would've nothing to show for like a $40,000 to $50,000 investment. And it's really hard to verbalize how traumatizing it is both physically and emotionally to go through an IVF cycle and then to have nothing to show for it. People who are cash pay, they are either completely priced out and unable to even try IVF, or they're tapping into their savings or taking on substantial debt, like sometimes taking out second mortgages on their homes in order to achieve their dream of building a family. 

And I think what upsets me the most about that is infertility is a disease, like a really complex medical condition. And I just believe it should be covered by medical plans just as we cover treatments for, say, asthma or diabetes. 

Katie: And it's worth addressing the moral or philosophical angle. When you create embryos that you do not use, you have a few options: You can destroy them, you can donate them to science, or you can donate them to other people. And everyone feels differently about the ethics of these choices for themselves. 

And then there are the issues for the embryos that you do use, or around donated sperm or eggs. For example, if you were conceived using donated sperm or a donor egg, if that donation was anonymous, you do not currently have a legal right as a child to know your biological parents, though many clinics will now share that knowledge once you turn 18. In some countries, anonymous donation is considered a human rights violation and is illegal. And this has been the subject of recent legislation in the United States, too. Beginning in 2025, Colorado will become the first state to ban anonymous sperm and egg donation, giving donor-conceived adults the legal right to request information about their donor's identity and medical history. And in the era of at-home DNA testing, it's kind of impossible to guarantee secrecy anymore anyway. So these are just considerations to weigh when you're going down this path, beyond the obvious financial ones, and you will have to judge your own comfort level with them.

Now, I wanna note, these are all big numbers and big choices that impact you and your future offspring, but I don't mean to deter you. I think planning ahead and having these conversations with yourself or your partner openly before going down this path can help ensure that you feel empowered and good about the choices that you're making along the way. 

Lastly, let's talk about adoption. According to the Department of Health and Human Services, in 2021, on any given day, 113,000 children are eligible for adoption, and most wait an average of almost three years to find an adoptive family. Costs run the gamut from $0 to $60,000. So let's break that down. Adopting a child from the foster care system in the United States can range from free to a few thousand dollars, but some of that cost may be offset by the federal adoption tax credit, which was $14,440 in 2022. Now, if you plan to adopt from a domestic licensed private agency, that cost usually runs between $30,000 and $60,000. If you plan to set up an arrangement with the birth parents independently with an attorney, you can prepare for $35,000 to $40,000 in expenses.

The most expensive path is international or inter-country adoption, which can run you $50,000 or higher. This is because there are a number of expenses to plan for, from working with professionals like doctors and lawyers and social workers, medical expenses for the pregnancy, home studies and background checks, and search fees and travel. And of course, the process can take place over a few months to over a few years. So while the costs can add up, there's sometimes also a good amount of time to budget for them as they arise. 

As our listener who is an adoptee who reached out said, quote, “Adoption wasn't about money to me; it was about my whole life.” End quote. So, adoption trauma, you can look it up. This is a real thing. It's a well-documented psychological phenomenon that highlights how complex and multifaceted starting a family through non-traditional means can be for everyone involved, from the adoptive parents to the birth parents to the adoptees themselves. We'll be right back after a message from the sponsors of today's episode. 

So when it comes to all the paths for parenthood, there are ways that we can financially plan. Now, ideally, you're able to listen to this episode ahead of planning for children, so you can start to save, budget, plan accordingly. More on that soon. But we're gonna start with action item number one, which is healthcare. 

So in the US, step number one is exploring your employer-sponsored healthcare coverage. I love it here. As of this recording, 20 states mandate providing or offering fertility coverage and benefits, including New York, California, Colorado, Maryland, Illinois, and more. Because my primary employer, Morning Brew, is based in New York, all healthcare plan options do include mandated coverage for fertility benefits. So we did a little bit of sleuthing and Henah reached out to our healthcare team to see what was covered. It included IUI, IVF, and artificial insemination, as well as diagnostic tests and procedures like blood tests and biopsies and ultrasounds. But in order to be eligible, providers must submit pre-authorization. So you essentially have to prove that you have been trying to conceive for long enough before they will deem it medically necessary. 

If you're not sure if you'd be covered, call your insurance provider directly, or ask your HR department, or speak with your primary physician, your referring doctor. In the event that it is covered by your employer, you may find that it's actually relatively affordable. And here are a few questions to ask them, and then jot down the answers. 

Number one, is my initial consultation covered? Number two, which medications are covered? Number three, what is the waiting period before qualifying for IVF? Number four, is there a cap on the coverage, and is it a dollar amount or a cycle limit? That one's a biggie. And because we live in the good old US of A, make sure you write down who you speak to at the insurance company. So if the bills you receive later are incorrect, you will have a tangible paper trail. Yep, like I said, we love it here. You can also check out our upcoming episode on fighting medical bills. That's gonna be a fun one. Anyway, here are a few other questions that Arielle says you may want to ask when you're starting this process. 

Arielle Bogorad: Some key questions for your insurance provider. This could be a good place to get started. Do you require proof of medical diagnosis of infertility in order to access coverage? That's a big one that's discriminatory to our LGBTQ+ and single parents by choice. It's often a gate written into a summary plan document, the official document of a medical plan, that basically dictates that you have to try to have heterosexual intercourse for six to 12 months prior to coverage commencing. And so that will automatically eliminate some people from even starting the process. 

Another question: Is surrogacy and adoption a covered benefit? Is the purchase of donor tissue, which is sperm and eggs, covered? Are prescription medications associated with the fertility treatments covered, or is just the medical treatment itself? What are the typical out-of-pocket costs like we just spoke about, like is acupuncture a covered benefit, for instance? Is fertility coverage subject to the deductible and co-insurance? And quite honestly, for many people this is their first big medical event, and so it's their first time dealing with their health insurance and so forth. So asking, how does my deductible and co-insurance work? Does our plan have a network of reproductive endocrinologists and/or reproductive urologists that I can or need to leverage? Like it might be a requirement. How do I find out more about my benefit? Is there a member support component to the coverage? Are there training materials on how to administer the medications? There are lots of questions, but hopefully this is a good list to help get someone started. 

Katie: And if your employer doesn't offer fertility benefits, you can try to champion them within your organization. Resolve.org from the National Infertility Association offers a number of ways to take action, including a running list of state bills fighting for IVF coverage, and Arielle had a few thoughts to share about the best way to take action to fight for fertility benefits at your employer or at the state or federal policy level.

Arielle Bogorad: I'd like to say first of all, your voice matters. Take it from me. As a former benefits professional, it makes a difference when benefits teams hear from their employees. It makes a big difference when a benefits team can substantiate their strategy proposals. Every year we take proposals to the C-suite and if we have employee testimonials to back that up, that makes a big impact in terms of getting that approval. If your company does not offer an inclusive fertility benefit, then I would encourage you to go to your HR department today. 65% of employers who offer fertility benefits, they only do so because their employees have asked for it. So please be empowered by that.

And when evaluating benefits, you should look for a plan that does not discriminate or limit treatment based on your need for an infertility diagnosis. That's a big one that I just spoke about. And that summary plan document, that formal document, they oftentimes have that discriminatory language. I would review that and ensure, because that's a clear barrier for LGBTQ+ individuals. Some benefit plans also have a dollar cap design. This forces individuals to choose treatment options based on a price tag, and you might run out of money mid-cycle, which is also like, there's no other type of specialty in healthcare where you might run out of coverage during treatment. It's also inequitable, those types of dollar caps for those living in states with high cost of care and for individuals who need additional treatments to start their families, like their money's not gonna go as far as someone else that lives in a place with a lower cost of care.

So shifting to the policy side, it's actually incredibly powerful to advocate at both the state and federal level for our fertility and family-building rights. For the past five years, I have personally advocated on Capitol Hill for the expansion of fertility coverage, for research funding, and for adoption equality. I've done that with Resolve. Every year, Resolve hosts an advocacy day. You come together with others from your state and you speak to your senators and congressmen and women, and it is incredibly empowering to speak to your legislators. I would highly recommend that to people. And at the state level. So currently, 'cause it's different from federal and state at the state level, currently there are only 20 states that mandate coverage of fertility treatments. They all mandate coverage at varying levels. And these state mandates only apply to medical plans that are considered fully insured. So companies that are self-insured, which are those typically that have a thousand or more employees, those plans are not required to comply with the state mandates. So to sum up this answer, yes, you can absolutely make a difference at your employer and at the state and federal policy level. I cannot underscore that enough. 

Katie: And to highlight the experience of the other people involved, adoptees and donor-conceived people have rights that are worth advocating for too. Open adoptions have become much more common in the US, and as we mentioned before, donor-conceived people have been pushing to abolish anonymity for sperm and egg donation, and some countries have made anonymous donation illegal.

This is not to dissuade you from pursuing an alternative path to becoming a parent, but just to say that it is a complex issue for adoptees and donor-conceived children, even if they are aware of their origins from the start. There are a lot of resources that share the voices of adoptees and donor-conceived people, and I encourage you to explore them if you're gonna go down this path, because the more that you know going in, I think the better equipped you will be. 

Let's move on to budgeting for this, and the reality of debt when you are trying to conceive. Because if healthcare coverage isn't an option at all, and maybe you can't switch jobs to a new employer that does offer it, which we're gonna talk a little bit more about later, what options do you have? So you can apply for grants online—we're gonna link a resource for that. You can enter lotteries—we'll also link some for free IVF cycles. And you can find financing programs like family-building loans. There's even something called a Shared Risk IVF plan, which can refund you some or all of your expenses if you do not get pregnant. If you're interested in adoption, there are also a number of grants of up to $5,000 or low-interest loans of up to $10,000 that you can find online. 

And when it comes to the conflicted feelings around debt in the personal finance world, I think it's important to acknowledge that debt might be the reality for a decision this large and expensive. But my personal view is that if you know that you wanna become a parent more than anything, and there is a viable solution for doing so that may require you to engage in some creative financing, it's really hard, I think, to put a price on having a baby. Of course that desire does introduce some perverse incentives in the marketplace. We know that companies can charge whatever they want because they know it's likely the biggest decision you're ever going to make. You're gonna spend accordingly. But I don't think there should be shame associated with needing to take out loans to amortize the cost of something this large and important over time. And that said, and Arielle is gonna touch on this further, the most sensible and low-cost option if you don't have fertility benefits at your current employer might actually be to change employers to a company that does offer fertility benefits.

Aura Finance, a money management platform, collaborated recently with Noula, a hormonal health company, to chat through the costs of pregnancy and fertility. And in that conversation, they recommended interviewing multiple clinics to inquire about payment plan options and sliding scale costs. If you know that you want to try to conceive soon, you can also schedule preconception visits with your doctor six months to one year in advance. So we're gonna link to that conversation in the show notes. If you have decided to budget for these costs out of pocket, you can work backward to find out what you need based on the approximations that we covered above. 

So for example, let's say my husband and I wanna have a child in five years, and we would prefer to try IVF one to two times if we need to go that route. That means I will need to set aside, say, $50,000 over the next 60 months, or approximately $800 per month for treatments. And if you're curious about saving for medium-term goals or how to make the most of it, we have an episode on that which we will link in the show notes. 

Arielle Bogorad: We often spend many years trying not to get pregnant, you know. And then we finally decide, okay, I'm ready. And then it doesn't happen quickly. And it's almost shocking, because all our lives we've been told how easy it is to get pregnant. So it's, what do you mean I can't get pregnant? I thought it would be easy. So I think because of that, there's a few things to think about. Firstly, it's important to talk to your healthcare provider. Try to be educated and have a plan. No matter if you're a way out from wanting to start a family or you're actively trying to conceive. Early detection of conditions such as endometriosis and PCOS, polycystic ovarian syndrome, that can cause infertility, is key. It can help you down the line if you can detect that earlier on. Electing to freeze your eggs when you are younger is really akin to taking out an insurance policy for yourself. It can cost around $16,000 for treatment, medication, and storage. Freezing your eggs is a way for you to kind of future-proof yourself and have a stash of eggs that you could leverage in the future. 

So then if you're in the throes of trying to conceive, it's good to arm yourself with information. Dig into that medical plan document to understand, do you have fertility coverage? What limitations may exist? And then you need to start understanding what out-of-pocket expenses might look like, and how to budget. And honestly, you might even need to make a job pivot. Many individuals who do not have access to fertility benefits, they might be priced out before they can even begin their journey. And I have known some people who will seek out employers who offer fertility benefits and change jobs just for this type of coverage because it's so cost-prohibitive and it's so life-changing. So depending on your situation, it might make sense to consider finding a new job with a company that offers comprehensive benefits. 

And then lastly, I would just say on the emotional side, this is a journey with high highs and low lows. You have to consistently prioritize your mental health, and seeking therapy is a great option, as is having conversations with friends and family. At Progyny, we have a clinical psychologist on staff, Dr. Georgia Witkin. She specializes in infertility and she reminds individuals how to reframe the narrative of infertility into thinking of yourself in a pre-parenthood stage rather than in a stage of infertility. Basically, keep it positive and then focus on the future. The diagnosis of infertility, when you get that from your doctor, that's just the beginning of what could be a really long journey. So trying to be positive is good. I mean, that's always our goal, right? But it's not always easy. And having professional support is important. 

Katie: The future of family planning is evolving really rapidly, and hopefully there will be more and more financial help for prospective parents in the future. 

Arielle Bogorad: The good news is that more and more people do have access to fertility and family-building treatment than they did 10 years ago. And while we have a significant way to go to have fertility and family-building treated as all other medical conditions, I've seen that the stigma of infertility has really been shrinking over the last few years. Additionally, LGBTQ+ family-building has come to the forefront of the fertility conversation. Many employers are realizing that inclusive family-building benefits are just really a must. And infertility is no longer a women's issue. More and more men are coming forward to share their struggles with male factor infertility, and at Progyny, we feel that everyone deserves a chance to build a family. And the more people that talk about infertility, the more we can normalize it. And I just believe that it's up to us to continue advocating and knowing that our voices really, truly matter. 

Katie: Because it's clear that this is a common issue and one that really deserves more support overall. And if this is something that you have personally experienced, we would love to hear from you. So shoot us an email at moneywithkatie@morningbrew.com. All, right y'all. That is all for this week. I will see you next week, same time, same place, on The Money with Katie Show. Our show is a production of Morning Brew and is produced by Henah Velez and me, Katie Gatti Tassin, with our audio engineering and sound design from Nick Torres. Devin Emery is our chief content officer, and additional fact checking comes from Kate Brandt.