When we asked you how to improve Get Rich Slowly, you told us you’d like an article on “The horrible, terrible, no good, very bad reality of paying for fertility treatments.” We can’t fit all of that into one post, but we did ask Joanna Lahey, who gave us a series on health insurance, to give a broad overview of the issue in this guest post.

Joanna Lahey is an associate economics professor at the George H. W. Bush School of Government and Public Service and a faculty research fellow at the National Bureau of Economic Research. The opinions expressed in this post do not necessarily reflect those of the aforementioned institutions.

When I found out I suffered from infertility, I was lucky enough to be living in Massachusetts and was covered by a Massachusetts health insurance plan. Lucky because Massachusetts is one of the few states in the United States that mandates coverage of infertility treatment. Every test my husband and I went through and every treatment I underwent was completely covered by my insurance. After a year and a half of poking and prodding and medication and monitoring, I knew exactly what was wrong with me. My doctors were able to give the most conservative treatment options so I wouldn’t have to worry about risks with names like “overstimulation” or “rupture” or “triplets.” My only out-of-pocket costs were for HPT, OPK, and a fancy thermometer. [1]

That’s not the situation here in Texas, where it is mandated that infertility treatment be “offered” but not “covered.” What that means is that group insurers must offer at least one plan that has infertility treatment coverage as an option (at any price) and the employer may choose that plan or may choose another (usually less expensive) plan. What that almost always means is that insurers choose the less expensive plan that does not cover infertility. For the most part, people in Texas pay out of pocket for infertility treatment.

The Resolve website has a full listing of the states that mandate “coverage” or “offering” of infertility treatment for health insurance. Even if you live in one of the states that mandates coverage, you may still not be covered. State health insurance mandates do not cover firms that self-insure, so large companies (if they do not buy health insurance from an outside provider like Blue Cross/Blue Shield) don’t have to offer infertility coverage if they don’t want to. In some cases small firms are exempt from state mandates as well. Some states only require that HMOs cover infertility treatment. Some states put age limits on who can use the coverage or limit to specific treatments in their coverage. Even if you live in a covered state, the best thing to do is to check your employer’s plan to see what is and is not covered and what the rules are for that coverage before starting treatment.

How much does treatment cost?

As with all medical expenses, cost is going to vary tremendously with what the specific condition is, how intensive your treatment is, and where you live. In the case of infertility treatment, it also matters how much you can pay and who pays. That’s because if you can afford it or if someone else is paying, you may move to more intensive (read: expensive) treatments faster, whereas if you’re paying out of pocket and don’t have the money, you may wait and try less intensive treatments longer.

Sometimes insurance companies will cover parts of infertility treatments even if they don’t cover infertility. In general, if the diagnosis or treatment fixes a problem that’s not infertility, they are more likely to cover it, even if fertility is a side effect of the treatment. They may cover procedures that diagnose or treat endometriosis or amenorrhea. They may cover various surgeries. They may cover some medications but not others. They almost always cover medications related to thyroid, polycystic ovary syndrome (PCOS), or diabetes, even if those medications may result in your becoming pregnant. The important thing is that the doctor’s office codes the treatment with the non-infertility-related code if one is applicable (so coded as “amenorrhea” if the problem is you’re not cycling, rather than “infertility”). Most doctors’ offices are good about this, but it’s something to ask about just in case.

For ovulation stimulation, the first-line treatment is generally Clomid. Clomid itself is not very expensive — it’s generic and you can generally get it for under $30/prescription (note: all costs are for the U.S.). Doctors often recommend 4-D ultrasound (u/s) monitoring with Clomid, and monitoring costs can get up into the upper hundreds to low thousands, depending on how much your clinic charges for u/s. Another popular drug for ovulation stimulation is Femera (note that this is an off-label use of an anti-cancer drug). This drug is more expensive than Clomid. If your insurance covers it, you only pay your co-pay; but if not, the cost is usually somewhere in the lower hundreds of dollars. These medications are sometimes combined with Intrauterine Insemination (IUI), which can cost from a few hundred dollars to the low thousands of dollars.

The most expensive Artificial Reproductive Technology (ART) treatments are In Vitro Fertilization (IVF), Gamete Intrafallopian Transfer (GIFT) and Zygote Intrafallopian Transfer (ZIFT). Costs for these procedures are generally $10,000 to $15,000 or more. When discussing these costs with your doctor, it is important to ask whether the medications for ART are included in the transfer cost or if they are an additional $3,000 to 6,000 in expenses. Additional costs will occur if you need to move to using donor sperm, donor eggs, or donor embryos. Genetic testing adds additional layers of cost, though these are often covered by insurance.

The direct costs of fertility treatment aren’t the only costs that you should be considering. Estimates of the cost of infertility treatment per live birth range from $38,000 to $800,000. That top number includes the increased costs of birth complications and multiple births, both of which are more likely with fertility treatment. Once the baby has been conceived, most insurance will cover these costs — but you should look at your individual coverage to see what your out-of-pocket expenditures will be assuming these scenarios. Additionally, according to one study by Stanford University medical professor Michael Eisenberg and colleagues, infertile women seeking treatment spend a median of 51.5 hours on infertility-related activities over an 18-month period. Those hours aren’t consecutive, so you can’t just take a week-long vacation to get it over with. (Obviously, having a baby takes time too, but that’s true whether or not you use infertility treatment!)

Are there ways to lower the costs?

There are some ways that the costs of infertility treatment can be lowered. If your medical costs are more than 10 percent of your gross income, you can deduct the additional amounts on your taxes. That may also be something to think about as you time your more expensive treatments.

If you have to pay out of pocket, you can shop around for drug providers since different pharmacies often have widely varying costs. You can even shop around for sperm if you need it. Different reproductive clinics will also offer a variety of “deals” on fertility packages, but whether or not those are good deals is too complicated to address in this rather lengthy article. Another way to potentially save money is to get enrolled in a clinical trial. These trials will often pay for some or all of your expenses; but you generally don’t know if you’re in the treatment group or the control group — and if you’re in the treatment group, it could be the next amazing intervention or it may not work at all.

Is infertility treatment worth going into debt over?

Personally, having experienced the heartbreak of infertility and the joy of a much-desired child (or two!), I would lean toward “yes” in many cases. However, in an ideal world, you wouldn’t have to debt-finance infertility treatment even if insurance doesn’t pay for it.

When someone reaches that third stage of personal finance, doesn’t want to stop working, and wonders what’s the point of saving more, I always tell him or her to keep saving because unexpected expenses and opportunities will find you. Infertility treatment is one of those potential unexpected expenses. Being able to take the stress of debt-financing out of the equation because you’ve saved for a rainy day means one fewer stressor to deal with during a very stressful time. And it leaves you in a much better position if and when you bring home your bundle(s) of joy.

[1] For the uninitiated: HPT = pregnancy test and OPK = ovulation predictor test, which is kind of like a pregnancy test except there’s always two lines. The second line gets darker when you ovulate. Fun times.