In the Weeds with Infertility (n.): Why Definitions Matter

As of May 2022, the median age of women giving birth in the U.S. has reached an all time high of 30 years old. Meanwhile, the American birth rate fell by 4% in 2020, marking the largest single-year decrease in almost 50 years, and it hasn’t improved much since. This decline in birth rate follows a trend that saw its genesis during the Great Recession in 2007; since then, the U.S. birth rate has fallen by a staggering 20%. In simple terms, as the New York Times reported last year, “American women are having fewer children and having them later than ever before…” 

The good news is these changing rates are not necessarily something to be overly worried about when Assisted Reproductive Technology (ART) is taken into account. IVF and gestational surrogacy in particular have made it so that parenthood is, theoretically, more accessible than ever before.  Not only can IVF help heterosexual couples combat infertility, but it also opens the door of biological parenthood to those previously unable to conceive within their partnerships — such as gay, lesbian, and non-binary couples— and to single Americans hoping to have children without a partner. 

So why exactly is ART not part of our mainstream healthcare? Why does it only account for only 1-2% of American births per year, when our birth rate is so quickly declining? 

The answer lies largely in the way the American medical system defines infertility. The current definition fails to include any American who wishes to have children, but is not in a long-term, heterosexual, cisgender relationship in which neither party has a pre-existing health condition that could also prevent a safe pregnancy. 

For example, the Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), and several American insurance companies define medical infertility as the failure to conceive after one year of unprotected sexual intercourse. This definition represents a massive failure of reproductive justice, as it ignores the fact that a fertilized embryo only requires a successful combination of egg and sperm— something which can now be successfully achieved without intercourse.

Then, that embryo can be carried to term by anyone with a healthy womb, which could mean a biological mother, a gestational carrier, or a traditional surrogate, none of whom need to necessarily identify as a woman. In fact, pregnancy has not required sexual intercourse between a man and a woman since the 1970s, but the medical community and insurance companies still define infertility in this dated way, to devastating effects for many.  

Here is an example: a heterosexual couple has regular unprotected sex for a year as do their neighbors, a lesbian couple. Neither couple gets pregnant, yet one couple is able to receive a formal diagnosis of infertility, potentially making them eligible for insurance coverage for fertility treatments. The other is simply out of luck, forced to spend the money out of pocket in order to achieve the same end goal of having a baby.  Though both couples were unable to conceive naturally, the lesbian couple is not currently awarded the same benefit as the heterosexual one, just because they do not fall into the narrow definition of medical infertility. 

Just this year in April, a same-sex married couple in New York was denied IVF services for this very reason. The city’s insurance policy defined infertility as the inability to conceive “after 12 months of unprotected intercourse,” only applying to intercourse between a man and a woman. Even for heterosexual, cisgender couples, this definition leaves many behind. In reality, infertility can be a result of a number of things that affect the egg, sperm, or the bodies of the involved parties. For example, medical infertility can be caused due to dysfunctions in hormones, the uterus, the ovaries, tubes, sperm or reproductive tract. It can also be a result of exposure to toxins or previous medical treatment such as radiation therapy. Additionally, cancer, heart disease, and many autoimmune diseases, in which a womb may work but a body cannot handle a pregnancy, can prevent a safe pregnancy.

However, many people still think infertility only refers to when a woman cannot achieve pregnancy because she does not produce eggs, ignoring the myriad other social or medical conditions that can complicate natural conception. Even clicking through the comments section of stories on infertility can illustrate the prevalence of this misconception; for example, in this Financial Times piece detailing the author’s own journey with surrogacy, one commenter wrote the author was really not infertile as she produced eggs, disregarding how many additional factors truly fall under the umbrella of infertility. In reality, many people, including older couples, non-heterosexual couples, and those with HIV, are unable to achieve a safe and/or natural pregnancy. However, very few of these people would be considered infertile by current definition. 

Social infertility, on the other hand, encompasses the inability to have children without medical assistance due to non-biological factors. For example, this can include the previously mentioned lesbian couple, who is unable to get pregnant without some form of ART. This also includes all sorts of couples that fall under the LGBTQ+ umbrella that don’t have the egg and sperm combination to naturally conceive. Social infertility also includes single people who wish to become parents. This term encompasses the people who are infertile not because of their bodies, but because traditional, natural conception doesn’t apply to their lives. This is a very real form of infertility that affects individuals on a daily basis. 

Operating with a narrow definition of infertility is detrimental to many prospective parents because, for the few states that require insurance companies to cover infertility treatment, most insurance companies require a diagnosis of infertility to cover any sort of fertility treatment. Additionally, like Michigan, many states don’t provide insurance coverage for infertility at all, which can be the deciding factor for if a person is able to have a child or not. Fertility treatments are incredibly expensive in the United States and are unaffordable for many families. One cycle of in-vitro fertilization (IVF) can cost $12,000 to $14,000, and that doesn’t include any additional fees such as genetic testing, a mock embryo transfer, and injectable hormones. All-in, an IVF treatments is upwards of $20,000. Michigan’s two earner median household income is $66,198. And for most patients, one cycle of IVF does not result in pregnancy. 

This is why broadening the definition of infertility is so vital. Once we begin to recognize infertility in a broader context, we can improve upon the coverage options available and begin to provide equal care to all infertile individuals. Doing so would not only benefit the American birth rate, but also simply make the dream of parenthood accessible to the countless Americans who still today find it utterly unattainable.

—Caitlin Fagel and Sabrina Nash