Who Gets to Have a Baby in America? On the High Cost of Fertility in America

For as long as people have had children, some groups and individuals have had their procreation encouraged, subsidized, even prized—think of queens celebrated for bearing male heirs to their royal mates, or the “Better Baby” and “Fitter Family” contests of early twentieth century America. Others have experienced the opposite: discrimination, state neglect, or outright attacks on their capacity to reproduce.

Article continues after advertisement

What scholars call “selective pronatalism” has a long history. In its most extreme form, Nazi leadership implemented the Lebensborn program supporting the births of children to “racially valuable” mothers, while carrying out an extermination campaign of entire groups of people deemed genetically inferior, which included measures such as court ordered sterilizations. Selective pronatalism persists today, sometimes explicitly encoded in law, leaving people like Irena ineligible to get pregnant within their own borders. It embeds itself in our social and cultural messaging, and manifests in different tiers of insurance coverage, or in criteria and cutoffs established by fertility clinics or government bodies.

But she told me that their joy was tempered by the knowledge that, to have their second child, “We’ll have to go through this all over again.”

In the Universal Declaration of Human Rights, the closest thing we have to a global statement of shared values, Article 16 affirms that “Men and women of full age, without any limitation due to race, nationality or religion, have the right to marry and to found a family.” A UN report also cites a consensus that “where in vitro fertilization is available within a State, it must not be unduly restricted.” In 2012, the Inter-American Court of Human Rights ruled that a Costa Rican court’s ban on IVF violated the human right to private and family life and the human right to found and raise a family. Yet nowhere has it been established that fertility care, for the people who need it, is a right.

Some argue that fertility care is simply basic healthcare and should be universally accessible. In 2009, the WHO defined infertility as “a disease of the reproductive system” that could be diagnosed after a year or more of “regular unprotected sexual intercourse” had failed to produce a pregnancy. If infertility is a disease, it follows that procedures such as intrauterine insemination (IUI) and IVF are, if not exactly “cures” for that disease, then at least its best available treatments.

But any attempt to lasso the motley sex lives of millions of infertile couples into a clinical definition inevitably leaves questions in its wake. What is “regular” intercourse? Once a week? Twice? Missionary style? With artful mood lighting? Even if we could agree on a definition of “regular,” other questions follow. Who is eligible for these treatments? And on what basis? Who should pay? And how much? However one answers these questions, it is clear that hewing to a physiological definition of “infertility,” a diagnosis of which is typically necessary to obtain insurance coverage in the US, excludes queer and single people.

Mara Pellittieri, a communications professional based in Takoma Park, Maryland, ran up against this hurdle when she and her spouse, who was assigned female at birth, tried to access infertility coverage through her spouse’s employer, Stanley Black & Decker. According to their insurance policy at the time, heterosexual couples could receive an infertility diagnosis after “one year of unprotected inter-course” without conception, while queer couples could be diagnosed only after six failed rounds of IUI, which they would have to pay for out of pocket. Those rounds of IUI have, at best, a 20 percent chance of succeeding, and can cost between $500 to $4,000. Pellittieri and her spouse were daunted by the expense. “The person working at the insurance company felt really bad about it,” Pellittieri recalled. “They apologized for it.” But the policy, with its strictly physiological definition, was immovable.

In a 2018 paper, the bioethicist Lisa Campo-Engelstein and the physician Weei Lo proposed that an infertility diagnosis should be available to anyone who, during a twelve month period, possesses the “intent” to conceive but cannot “due to social or physiological limitations.” Pellittieri and her spouse dutifully underwent round after round of IUI as they strove to hit the half dozen they needed, and she unexpectedly became pregnant on the fifth try. But she told me that their joy was tempered by the knowledge that, to have their second child, “We’ll have to go through this all over again.”

But one might also ask whether there are limits to this help.

In recent years, legal scholars have taken the right to equality as the starting point for advocating for access to fertility care. Faren Tang, a former research scholar at Yale Law School, has written that “treating individuals differently based on whether they will have sexual intercourse with someone who can get them pregnant is un-constitutional,” citing Fourteenth Amendment principles of liberty and equal protection. Indeed, some US states that mandate insurance coverage for fertility treatments now recognize what scholars and advocates call “social infertility,” when it is someone’s circumstances, not their physiology, that is responsible for their inability to get pregnant.

In 2023, the American Society for Reproductive Medicine, the fertility sector’s main professional organization, updated its definition of infertility to include “The need for medical intervention, including, but not limited to, the use of donor gametes or donor embryos in order to achieve a successful pregnancy either as an individual or with a partner,” implicitly recognizing the social factors that leave couples like Talia and Maggie, or women like Arghavan, unable to get pregnant without assistance.

But one might also ask whether there are limits to this help. What if third parties—egg donors or surrogates, for example—are involved? Can a government requisition the necessary oocytes or commandeer a womb to guarantee a couple’s rights? In 2024, a married gay couple, Corey Briskin and Nicholas Maggipinto, filed a lawsuit against the city of New York alleging that the city discriminated against gay men based on sex and sexual orientation by categorically denying them from being eligible to receive IVF benefits through the city’s health plan. Briskin had worked for the city as an assistant district attorney, making about $75,000 a year, and though the city’s insurance covers IVF and other fertility procedures, when they read the fine print, they saw that it did not include coverage of, for example, the cost of retrieving eggs from an egg donor.

In the US, we have a situation in which some people’s reproduction is subsidized to the tune of one or two luxury cars, while others are offered highly effective contraceptive methods including long-acting reversible contraception, such as IUDs, which require a medical provider to insert and remove, or even sterilization, but little help getting pregnant. Enrollees of Medicaid, the health insurance program for low-income Americans, can get a long-acting contraceptive or sterilization covered by their insurance in all of the forty one states plus DC surveyed by the nonprofit health policy research organization KFF, but only a handful of states provide any assistance to someone on Medicaid who is struggling to get pregnant. Analyzing this two-tiered system, the historian Laura Briggs concludes that “the logic of public benefits and state-mandated private benefits is precisely eugenic: as a matter of law and regulation, insurers pay for the poor to get birth control and for the rich to get IVF.”

__________________________________

Excerpted from the book Inconceivable, provided courtesy of Dey Street Books, an imprint of HarperCollins Publishers. Copyright © 2026 by Sturdy Little Boss Enterprises, Inc. Reprinted by permission.