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.
Selective pronatalism refers to policies or cultural attitudes that encourage or discourage reproduction based on specific traits, such as race, nationality, or socioeconomic status. Historically, this has taken extreme forms, like Nazi Germany’s Lebensborn program, which promoted births among ‘racially valuable’ mothers while forcibly sterilizing or killing those deemed ‘genetically inferior.’ Today, selective pronatalism persists in subtler ways, such as insurance coverage rules or fertility clinic criteria that favor certain groups. For example, some countries or states restrict access to fertility treatments like in vitro fertilization (IVF) based on marital status, sexual orientation, or age. The article highlights how these biases can exclude individuals or couples who do not fit traditional norms, even when they desire to have children. The concept is contrasted with the Universal Declaration of Human Rights, which states that adults have the right to marry and found a family without discrimination.
The World Health Organization (WHO) classifies infertility as a disease of the reproductive system, defined as the inability to conceive after one year or more of regular, unprotected sexual intercourse. This definition is used to determine medical eligibility for treatments like intrauterine insemination (IUI) or IVF. However, the article questions the practicality of this definition, asking what constitutes ‘regular’ intercourse—frequency, timing, or even sexual position. The diagnosis is often required for insurance coverage in the U.S., but it excludes groups like queer couples or single individuals who may need fertility assistance due to social or physiological barriers. For instance, Mara Pellittieri and her spouse, a same-sex couple, faced higher hurdles because their insurance policy required six failed rounds of IUI before diagnosing infertility, while heterosexual couples needed only one year of unprotected sex. IUI costs between $500 and $4,000 per attempt and has a success rate of about 20%.
In 2023, the American Society for Reproductive Medicine (ASRM), a leading professional organization in fertility care, updated its definition of infertility to include the need for medical intervention, such as using donor eggs or embryos, to achieve pregnancy. This change acknowledges that infertility is not solely a physiological issue but can also stem from social factors, such as being in a same-sex relationship or lacking a partner. The ASRM’s update aligns with growing advocacy for ‘social infertility,’ a term describing situations where circumstances—not biology—prevent conception. For example, queer couples or single individuals may require fertility treatments to conceive, yet traditional definitions often exclude them. Some U.S. states with mandated insurance coverage for fertility treatments now recognize social infertility, treating it as a valid reason for medical assistance. However, this shift raises questions about the limits of such support, including who qualifies for assistance and what procedures are covered.
Legal scholars argue that denying fertility care based on sexual orientation or relationship status may violate constitutional principles of equality and liberty. In 2024, a married gay couple, Corey Briskin and Nicholas Maggipinto, filed a lawsuit against New York City, alleging discrimination in its health plan’s IVF benefits. While the city’s insurance covers IVF, it does not include costs for retrieving eggs from a donor, a procedure essential for gay male couples to conceive. Briskin and Maggipinto earn about $75,000 annually, yet they faced financial barriers due to the plan’s limitations. Their case highlights broader debates about whether governments or insurers should subsidize fertility treatments, especially when third parties like egg donors or surrogates are involved. The lawsuit challenges whether such restrictions infringe on the right to found a family, as outlined in international human rights declarations.
The U.S. has a *two-tiered system* for reproductive healthcare, where wealthy individuals receive substantial subsidies for fertility treatments like IVF—costing tens of thousands of dollars—while low-income individuals, such as Medicaid enrollees, receive limited or no assistance for conception. According to the nonprofit health policy organization KFF, Medicaid covers long-acting contraceptives like IUDs and sterilization in 41 states and Washington, D.C., but only a few states offer any fertility treatment coverage. Historian Laura Briggs argues that this system reflects a eugenic logic, where public benefits for the poor focus on preventing births, while private benefits for the rich enable planned pregnancies. For example, IVF can cost between $12,000 and $25,000 per cycle, while Medicaid may cover contraception but not the diagnostic or procedural costs needed to address infertility. This disparity raises ethical questions about equitable access to reproductive healthcare in America.
