The high cost of infertility

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.

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Brett
Brett
6 years ago

I would offer another alternative as this is a finance blog – fostering and adoption. Fertility treatments are not only expensive, but not in any way a sure thing. Even once pregnant, there can be miscarriages or difficult pregnancies. My wife had PCOS and other issues. After a surgery to remove cysts she was able to get pregnant, but was in triage once a week for blood pressure issues and delivered our son two months early. If the body is not cooperating on the getting pregnant part, you have to assume that the rest could have its difficulties and complications… Read more »

MomCents
MomCents
6 years ago
Reply to  Brett

Brett, I am in the same situation as you. I am currently fostering and our son is pre-adoptive…we are just waiting for finalization date (YAY). Like your wife, I have issues that would make conceiving highly improbable. I looked at IVF, FET etc…and if it were a SURE THING…I probably would have went in debt for it. Though I know nothing is a sure thing…not even natural birth. But for me (and I’m only talking about me)…there was too much at stake to create more debt. Our son came to us at 18 months with the GOAL of adoption…which is… Read more »

A
A
6 years ago

We ordered fertility drugs from overseas. The same drugs made by the same manufacturer cost $2K with a European label vs. $5K in the U.S. And the drugs were good — we have twins.

Prudence Debtfree
Prudence Debtfree
6 years ago

My husband and I are on a focused journey out of debt, and I don’t advocate for debt-financing for most things. But when it comes to infertility, I completely understand breaking the bank. 3 of my nephews and 2 of my nieces are in the world today thanks to fertility treatments. What a heart-breaking situation we’re in, with infertility rates seemingly higher that ever and abortion so frequently chosen when pregnancy is unwanted – a completely understandable choice. I personally know one young woman who made the choice to go through with her unplanned pregnancy and to give her child… Read more »

Jen From Boston
Jen From Boston
6 years ago

“This is a very sensitive issue, combining love, heart-ache, human rights, and politics. As such, I suspect that it can be taken advantage of for profit on many fronts.” Sadly, profit does work its way into the process and puts a shadow over many good intentions 🙁 I’m adopted (internationally from Korea), and after becoming involved with the Korean adoption community I began to learn more about adoption’s unsavory side. For anyone who’s considering adoption I strongly suggest that you do a lot of research. A good place to start is Ethica (http://ethicanet.sitesteaders.com/). Also Korean adoptee activist Jane Jeong Trenka… Read more »

Prudence Debtfree
Prudence Debtfree
6 years ago

I hope that in your own case, Jen, adoption has had a very happy outcome. It must be a fascinating experience to be part of the Korean adoption community in terms of the stories you hear and the insights you gain.

Jen From Boston
Jen From Boston
6 years ago

Yes, the family I was placed with turned out be a good match. I’m considerd a full member of my family, and the only time blood versus non-blood comes up is talking about how lucky I am NOT to share DNA with them! There’s a history of cancer and heart disease, as well as a troublesome “party gene” that has caused some to sow more than their share of wild oats 😉 It is great to be connected to other Korean adoptees, and many have found their birth families, and thus have learned about why they ended up being adopted.… Read more »

Mrs. GV
Mrs. GV
6 years ago

My husband and I did two rounds of IVF after three tries with Clomid. My meds were covered in part but everything else was out of pocket. We spent tens of thousands of dollars. I had an early miscarriage once and the rest did not work. We were fortunate enough to not go in debt for infertility treatment. We were able to use savings, combined with a small amount of money I had received as an inheritance. When nothing worked, and surrogacy with donor eggs or adoption were our only choices, we had to make a difficult decision. Start cashing… Read more »

Carrie
Carrie
6 years ago
Reply to  Mrs. GV

Your story sounds very similar to mine! Four clomid rounds, two IVF’s, all spectacular failures. 90% of it out of pocket, which we just managed to pay with cash (the amount would have exactly paid off the amount of debt we had left to snowball). We made the same decision as you after the last IVF failed. We just couldn’t stay in that place anymore. And thankfully we are now debt free! While some days are still difficult, it is getting easier all the time. And we are doing lots of exciting things we wouldn’t be doing if we had… Read more »

Chris
Chris
6 years ago

Maryland has a similar mandate where if you meet a bunch of conditions (infertile via disease, tried other less invasive treatments first, etc…) then they will cover IVF. My wife has endometriosis so they covered our IVF which is $10k plus. I believe we only pay 10%. Feel very blessed in that regard. Don’t know what I would have done if we had to pay this out of pocket. The article is right is regards that her obgyn performed the surgery to help her endometriosis, but since it was due to her being in pain and not fertility related it… Read more »

FindX
FindX
6 years ago

I had a hard time conceiving my second child. Heck, my kids are almost 8 years apart to almost the day. I did a couple of rounds of clomid and one of femara. I wasn’t happy doing it so I tried acupuncture. Lo and behold it happened! Anyway, I’m writing because the funny thing about my story is that three years later I’m super fertile. How is that? Well, I did an elimination diet because I just wasn’t feeling well. Long story short, I’m gluten intolerant and super sensitive to corn. Now I avoid those foods and eat whole foods.… Read more »

Joanna Lahey
Joanna Lahey
6 years ago
Reply to  FindX

I’m not a medical doctor, but it’s been my understanding that many women only find out about serious underlying chronic conditions (thyroid, PCOS, etc.) when they have trouble trying to conceive. They just thought their chronic problems were normal. Now that there’s more understanding of food sensitivities in the medical community, that’s another part of the tool-kit.

Brett
Brett
6 years ago
Reply to  FindX

Didn’t mention that in my original comment. My wife also suffered from celiac’s, though we didn’t discover it until just a few years ago. We have read and heard a lot about links with infertility issues and celiac’s.

Joanna Lahey
Joanna Lahey
6 years ago

One thing I should have mentioned– those out of pocket costs of HPTs and OPKs can be significantly reduced if you buy your HPTs and OPKs in bulk online. Instead of getting the fancy plastic POAS (Pee on a stick) that you get at the drugstore, you get little strips that you dip in a cup, like they have at the doctors office. If you’re in it for the long-haul, the difference in price is enormous. There used to be a great website called peeonastick.com that had comparison great tests of all the different products on the market, but last… Read more »

Midwest Jane
Midwest Jane
6 years ago
Reply to  Joanna Lahey

The dollar stores sell both pregnancy tests and ovulation tests. I was able to get a positive test for all four of my pregnancies very early on these. I don’t think the quality of these tests are any different from what you would buy in CVS or Walgreens.

Tom Murin
Tom Murin
6 years ago

What about the high cost of fertility? I have 2 children and they aren’t cheap!

Joanna Lahey
Joanna Lahey
6 years ago
Reply to  Tom Murin
Vanessa
Vanessa
6 years ago
Reply to  Tom Murin

I don’t have kids and I usually skip over the kid-themed articles, but I found your comment to be insensitive, even if you were only joking. Several posters have already used “heartbreak” and its variations to describe their pain, and you’re basically gloating how you have the opposite problem.

Ely
Ely
6 years ago

As a person who has never wanted children, I am baffled by this entire conversation. The trouble that people will go to, just to make another person in a world of 7.5 billion, when there are kids going without parents (Brett & MomCents you are heroes)strikes me as completely insane.

Of course I’m paying for chemotherapy for a dog, so I’m sure the feeling is mutual.

Midwest Jane
Midwest Jane
6 years ago
Reply to  Ely

“when there are kids going without parents ” Part of the problem is how fraught the adoption process is, not to mention the complications that can arise with open adoptions. You have to be willing to deal with relationships with birth parents and their families, as well as the possibility that at some point someone might challenge your adoption. International adoptions are extremely expensive, and many places have closed them off. There are many hurdles in place to taking home that needy child in an orphanage halfway across the world. Plus, we must not forget that many of these children… Read more »

Carla
Carla
6 years ago
Reply to  Midwest Jane

Though this topic does not apply to me (decided to be childless/free due to health problems and a past stillbirth), I must give my $.02 regarding adoption. I volunteer for and with children in the “system”, and even right out of the womb, many of the children I come across are born with mental and physical health problems due to FAS and and drug exposure while they were in in utero. Some of these issues are not always apparent until they are a few years old. When it comes to toddlers, many of them are diagnosed with PTSD and other… Read more »

Brett
Brett
6 years ago
Reply to  Carla

So true. I did not stress this in my original post on fostering and adoption. These kids often bring physical and emotional issues due to their circumstances. Having said that, our birth son was born two months early, had plagiocephaly, needed services for feeding issues, struggled with low muscle tone, and has asthma and peanut allergies. Our take was that natural-born kids can have issues too and you take kids as they are. For fostering, many times we can know at least some part of the issues that are present (or likely) and make a better informed decision to commit… Read more »

MomCents
MomCents
6 years ago
Reply to  Ely

Brett,

Thank you for your comment, but I’m not a hero because I chose to foster. If anyone is the hero…it is my son (in fact, one of the case workers called him little hero!) It is a hard decision, and it is filled with risk…but so is domestic adoption, international adoption, ART, and even natural birth for that matter.

Brett
Brett
6 years ago
Reply to  MomCents

MOMCENTS,

I think Ely made the hero comment. I agree, we are just people doing what we think is right and the kids are the ones that often times have heroic challenges they are trying to meet.

For those interested, I found this article a great read for those not fostering to relate to those families in their lives that are. Helps bring the conversation back to ground that foster parents are no more saints or heroes than any other parent.

http://scienceblogs.com/casaubonsbook/2013/03/12/what-foster-parents-wish-other-people-knew/

Ellen
Ellen
6 years ago

Having been through two rounds of IVF (one successful, one not) and multiple IUI’s, my advice is to be as on top of insurance and billing as you can possibly be. Call your insurance company before each round of treatment to ask what is covered and what is not. You may need prior approvals for some drugs or procedures. I was lucky to have my IVF partially covered by my insurance, but had to submit the claims myself. Despite having confirmed coverage two or three times, the company denied my claim the first time. Having good documentation of my prior… Read more »

Joanna Lahey
Joanna Lahey
6 years ago
Reply to  Ellen

Great advice! And something that applies to pretty much any expensive medical procedure.

Redstar
Redstar
6 years ago

We tried for a year and decided to eat healthy and use alternative treatment using traditional Chinese medicine (TCM) – specifically acupuncture. I found out my insurance covers acupuncture treatment up to 25x- known to also stimulate fertility. I am now 9 weeks pregnant after a month of treatment (and I continue to go), pay $50 a visit with partial insurance covered, did not have to resort to a specialist or drugs, but I do agree that it is a dilemma that trying to conceive can be costly and stressful. I am 40 yeas old, so I beat the odds.… Read more »

Joanna Lahey
Joanna Lahey
6 years ago
Reply to  Redstar

Interestingly, just like the infertility mandates, there are acupuncture mandates in some states and not in others. That is, acupuncture must be covered by group insurance plans in some states. So whether acupuncture is an out-of-pocket cost or covered by insurance also varies a lot!

Cath
Cath
6 years ago

It’s not practical for everyone, but if you’re open to a job change, you could look for a company that covers treatment. Chase covered my fertility treatments and eventual maternity leave.

Lauren
Lauren
6 years ago

Thank you so much for posting an article about this topic. Infertility affects many of us and is not talked about very openly, let alone talked about the cost of treatment (mentally or financially). I am lucky to say that I live in MA and have excellent health insurance and got pregnant after the first round of IUI. But after going through the whole process it was eye opening to see how many families are in the same or worse situation. My heart goes out to all of you who are actively trying to get pregnant and I wish you… Read more »

Jeff
Jeff
6 years ago

I worked a second job for three years to pay for infertility. Where there is a will there is a way. Who knows how many rounds of controlled overstimulation (clomid and Follistim) and one miscarriage on that. First round of IVF resulted in a miscarriage. Second round of IVF, nothing. Started the process of adoption before doing a frozen IVF cycle and DS #1! Next (and last) frozen IVF resulted in DS #2! Paid for it all with savings from second job. No insurance cost. Drug shopped many pharmacies to find the best prices. Probably spent clost to $45-50k all… Read more »

Joanna Lahey
Joanna Lahey
6 years ago
Reply to  Jeff

Congratulations!

NunnayaBiz
NunnayaBiz
6 years ago

An additional topic that this article doesn’t cover is male factor infertility. While I may (or may not – who really knows for sure?) be perfectly capable of getting pregnant naturally, my husband was born without either of his vas deferens and therefore we as a couple are currently persuing MESA/TESA with ICSI and IVF. Combine all of that with the fact that we have separate insurance plans (I am self-employed and he works for a small-ish business where adding me to his plan would be asininely cost prohibitive) and we’re in for tons of fun! I have a high… Read more »

Joanna Lahey
Joanna Lahey
6 years ago
Reply to  NunnayaBiz

The male factor problems they can fix can
be things like a vitamin deficiency or a blockage that requires surgery (and is often covered by insurance), or it’s something that leads to IUI and then more complicated and expensive ART (as in your situation). ICSI is included in some of those studies that give dollar figures of overall cost.

IIRC male and female factors explain about even amounts of explained fertility, at least according to fertility treatment site webpages. So not meant to say this is all female infertility because it isn’t!

phoenix1920
phoenix1920
6 years ago

I think another issue to consider on this topic is the timing of children. My dh initially wanted to wait until we were completely financially settled before we had kids, and then life threw us a curve ball. But it was probably for the better because who knows when we would have had kids when we were waiting for the “perfect time.” My doctor never discussed age and fertility and I was shocked when I learned how early some women experience fertility issues. In other words, sometimes waiting and trying to be financially ahead of the game can put one… Read more »

Meg
Meg
6 years ago

My heart goes out to anyone experiencing infertility. I want to highlight the fact that traditional methods of treating infertility rarely seek to find, and treat, the root cause. As other posters have noted, there is often an underlying health issue, sometimes it is related specifically to reproductive issues, but often it is not. There are a multitude of causes of infertility, which is a symptom of something else. More often than not (but not always), identifying and treating the “something else” is faster and cheaper than trying to go around the natural method of conception. Lifestyle changes, TCM, etc.… Read more »

Joanna Lahey
Joanna Lahey
6 years ago
Reply to  Meg

This is again outside of my technical expertise, but personally and anecdotally, there was an enormous difference between how OBgyn treat infertility compared to reproductive endocrinologists, with RE much more likely to get at the root cause and ob/gyn just medicating the symptoms. That’s probably not a blanket thing, but it does seem to be an experience a number of people have had.

Lori P
Lori P
6 years ago

My husband and I were lucky that he finally got a job that paid for all of the testing for both of us and any procedures/surgeries that were needed to help with fertility issues. All fertility drugs, artificial insemination, and sperm wash were all included. They also paid a portion for IVF. We went through treatments and procedures for 18 months with very little out of pocket cost except co-pays. We were unable to have a child, but thankful that we got the opportunity. I think that insurance companies should see fertility as a medical condition just like anything else.

Want a baby
Want a baby
6 years ago

This is a subject very dear to my heart. I have had one try with tablets only and two IUI with no success. I will be having a transfer in a couple of weeks using egg donation. Fortunately, my insurance foots costs up to three successful live births. I am hoping for the best!

Dianecy
Dianecy
6 years ago

Whoa, yesterday I stumbled on another website with an amazing first-hand article on this topic. I wrote about it here, included a link and posted as usual. Today, I see no comment. Perhaps the mods didn’t like the link to another blog, so I’ll try it this way: If you should happen to hop on over to “Go Curry Cracker”, you can read about how they got pregnant frugally.

Kristen
Kristen
6 years ago

Nice article! I’m a fertility doctor in a self-pay state. I just need to point out a few things: Femara may actually be cheaper than Clomid in self pay situations. GIFT and ZIFT are seldom done any more because IVF has become so much better. Although it’s not really kosher, many patients will donate their unused, unexpired fertility meds to their clinic to pass on to other patients. You can ask about that. Finally, it may be cheaper in the long run to do IVF earlier, rather than spend months or years on less successful treatments. Ask your doctor, and… Read more »

nicoleandmaggie
nicoleandmaggie
5 years ago

Here’s a post that has a lot of links to how to finance infertility: http://www.stirrup-queens.com/2014/10/dear-prudence-heres-what-you-should-have-said/

Lindsey
Lindsey
11 months ago

I am currently undergoing IVF and paying down debt. I don’t really believe in incurring debt, but this is the one exception I would make. Children are a light in your life. I see having children as a time limited investment in your old age. You have a limited amount of time when you can have them, and then you don’t have that opportunity anymore. I worked in a nursing home, and childless people nearing the end of their lives were often more depressed. People with children had better social support and were generally happier (of course there are exceptions).… Read more »

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