Financing Fertility

The idea of writing a piece on financing fertility was not on my radar map, but then three things happened. One, CBS news, which I watch most mornings, recently ran a three part series called “Facing Fertility” that caught my attention. Two, I attended an investment conference last month that included an entire session dedicated to fertility as an investment thesis. The speakers were fund managers who are investing in companies that are providing solutions to make fertility services more safe, effective, affordable, and accessible, and their presentation included a slide that mapped out the ecosystem for fertility related services. To say that it was big and complex would be an understatement. And finally, three, I was writing about one of our money moves, saving, and I wondered if saving for fertility related reasons should be something to consider. The fund managers had outlined the cost of accessing fertility services, and I thought to myself, most people would not budget for that. Therefore, given that I always dedicate my May newsletters to motherhood, I thought now would be the opportune time to write about this important topic: financing fertility.?

Mother’s Day is coming up soon, and in many countries it represents a joyful celebration of the many kinds of mothers in our lives. However, for many people who are struggling with fertility, Mother’s Day can be a painful reminder of their struggle to conceive. A struggle that is far more common than most people realize. The WHO estimates that fully one in six people worldwide will struggle with infertility in their lifetimes. In the US, the CDC estimates that 19% of all married women between the ages of 15 and 49 are unable to get pregnant after a year of trying, and 26% of married women between 15 and 49 will have difficulty getting pregnant or carrying the baby to term. That is an astonishingly high number for something that is talked about so little.

Thankfully, modern technology now offers some hopeful solutions for those women and their partners in the form of Assisted Reproductive Technology (ART). ART is defined as any fertility treatment where the egg and sperm are handled, with in vitro fertilization (IVF) being the most common technique. ART had its first success in 1978 with the birth of Louise Brown in England, and the technology has made a lot of progress since then. By the 1990s, the success rate of a live birth per IVF cycle was around 10-15%, but today that number has been reported as being as high as 54%. It’s important to note, however, that success rates vary widely depending on many factors, most notably the age of the woman. I should also note that infertility is often framed as a “women’s issue”, when research suggests that 40-50% of all infertility cases are due to “male factor” infertility.?I was shocked when I discovered that number, and I invite us all to check our assumptions when this issue is discussed in public and private spaces.?The fact that infertility is seen as a "woman's issue" is likely part of the reason why it has not received the attention it deserves.

It is estimated that over nine million people have been born from IVF treatments worldwide since 1978, with over a million of those births happening in the US. IVF is now responsible for 1.6% and 4.5% of all live births in the United States and Europe, respectively. However, these numbers only include the people who actually undertake these treatments, and does not include those who would want to but can't. And it cannot be overstated what an undertaking this can be. As I searched for information on the overall costs of IVF, I kept coming across terms like “mind-boggling undertaking” when it came to figuring out the full and true cost of having a baby through these methods. In the US, the cost ranges widely by clinic, but the average cost is estimated at $12,400 per cycle. Of course, that number can easily run much higher depending on the circumstances.

While researching this topic, I listened to so many podcasts of women sharing their stories, including one woman’s journey through six rounds of IVF and a gestational surrogacy (GS). Many celebrities, such as Kim Kardashian, Nicole Kidman and Tyra Banks, who had a child with GS, are public with their struggles. Curious what a surrogacy might cost? Over $100,000, with some estimates closer to $200,000. While the hard costs of treatments are high, they are also measurable. Harder to account for is the possible need to downsize one's work responsibilities and aspirations due to the physical and emotional toll of being on the fertility journey. For many women, trying to have a baby can become a multi-year, full-time effort. And remember, all of this is just the cost to trying to conceive and does not include the costs of actually raising a child in today’s world. A recent article in the Washington Post estimates that the average cost of raising a child from birth to the age of 18 is approximately $300,000.?

Unsurprisingly, all of this results in major gaps in terms of who undergoes IVF, with the primary issue being affordability, though geographic accessibility is also a huge issue since most clinics are located in larger cities. In the US, the majority of IVF patients come from white, college educated, high income households, meaning not everyone who may want to use IVF and other ART technologies are able to do so. Far from it in fact. In the US, up to 80% of women have limited or no access to financial assistance for ART treatments, and millions of women who may otherwise want to utilize this technology are unable to afford it. Yes, millions. It is estimated that one in seven couples in the US struggle with infertility, and that number is likely to grow over time as the average age of first time mothers (27.3 years) continues to rise.?In their presentation, the fund managers talked about the “addressable market” as it relates to their investment thesis, and to say that this market is huge would be an understatement.?Driving down the costs of various forms of treatments, while at the same time increasing accessibility and effectiveness, is therefore the goal.

I thought I knew a lot about this topic but the actual numbers were surprising, both in terms of how widespread the issue is and the costs associated with it. What I also didn’t expect was the rabbit hole of information I discovered about the emerging field of Fertility Preservation. The most common, and currently most talked about, procedure is the process of Vitrification-based oocyte freezing, or egg freezing. Fertility preservation is defined as the act of saving and protecting your embryos, eggs, sperm, and reproductive tissue in order to help you have a child in the future. And while many people who undergo fertility preservation techniques do so for medical and/or infertility reasons, there is a growing trend of elective fertility preservation.

While the US doesn’t collect national statistics on egg freezing procedures, many clinics have reported increases of up to 50% year over year of the number of women freezing their eggs. The reasons for these increases are complex and multifold, but one thing is clear. The COVID-19 pandemic has had an enormous impact on family planning. The pandemic gave many people the opportunity to reflect on and reevaluate their work, lives, and priorities. It set many people’s life plans back by several years due to lockdown and social distancing measures. At the same time, COVID also gave people the opportunity to undergo procedures that they may not have otherwise had time for prior to the pandemic. All of which, along with countless other factors, has led to a spike in the number of women looking to freeze their eggs.

This has also led to a spike in companies offering fertility preservation benefits, though not without controversy as it relates to the signaling of such an offering. The investment community has already taken notice that egg freezing is a big business, with costs averaging approximately $11,000 per cycle, not including medications and storage costs. It’s become so popular that many companies are now offering it as an employee benefit, including Facebook, Apple, and Google. And while it might be tempting to shout this as a victory for women to have this type of procedure covered, 40 percent of working women don’t even qualify for the Family Medical Leave Act (FMLA), which grants 12 weeks of protected job leave, unpaid, at the federal level. And only 12 percent of women in the private sector have access to any sort of paid maternity leave at all. Although it is likely that the same companies that have decent maternity leave also offer egg freezing as a benefit, it needs to be acknowledged that while we claim to be a country that values mothers and children, our private sector policies and practices say otherwise.?

It makes sense that science and technology will continue to advance and offer women more options than ever before when it comes to family planning. And I want to be clear. Giving women more control over their own bodies is always a good thing in my book. This is not an article on access to abortion services, but my mind could not help but consider the implications, financial included, of the state of access to these services. But this is not to say that this sudden boom in fertility preservation is not without its criticisms. Yes, many women are undertaking this procedure as a means to take control of their future and escape the so-called “ticking biological clock”. But there are others who point out that this industry of elective fertility preservation is simply capitalizing on fear and social pressure. Others point out that egg freezing is not a guarantee of future conception, and many clinics may oversell their success rate in order to bring in more customers. Ultimately, the choice to freeze your eggs or not is a very complex and individual one. And for all its skyrocketing popularity, I worry about the pressure that healthy young women may feel to do so, at great cost to them physically, emotionally, and financially. That’s why I so appreciate how Yale medicine frames this decision: “Deciding whether or not to freeze your eggs requires a long conversation between doctor and patient.”

So should you save for fertility preservation and/or possible fertility treatments? And when I say you, I mean any person who may want to be a parent one day, not just women. Like almost all questions about personal financial matters, the answer is personal. These procedures certainly cost a lot, and while we cannot always prepare for the expected, having money set aside, just in case, is not a bad idea. Extra savings can always be redirected for another purpose. When you really think about it, we plan and save for education, buying a house, retirement, and so many other things. Why would we not plan for how we are going to finance having a child, let alone raising one? All of this being said, it is important to fully acknowledge that for the vast majority of people, especially young people, simply making enough to cover life’s basic costs is a struggle. Delaying parenthood has perhaps become less of an issue of choice than an issue of necessity.?Unpacking privilege has to be a part of any robust discussion on this topic and I am certainly not doing it justice here.

It still feels like a "damned if you do, damned if you don't" type situation that working women frequently face. By this I mean if, as a woman, you pursue motherhood at a younger age when your eggs are likely healthier, it means time away from your career for which there remains a big motherhood penalty. If you work through those years, you risk a harder time getting pregnant and having a healthy and easy pregnancy, but you likely have a higher level of social, financial and career stability. I am having flashbacks to 2002 when Sylvia Ann Hewlett's book "Creating a Life: Professional Women And The Quest For Children" came out which sparked the "Opt-Out Revolution". And again, for the vast majority of women, opting out is not even an option. Making it work, navigating through, and, all too often, suffering in silence, is what happens. Though I am long past my childbearing and childrearing years, I truly hope that today's workplaces continue to evolve to offer more support and understanding for all their employees, including working mothers and parents.

There is so much more to be said about this topic, and I really need to stop making it a habit of biting off more than I can chew when it comes to writing a “financial newsletter with a gender lens.” There are so many longer form articles by real journalists, books, podcasts, and credible medical sites that are better places to go for deeper inquiry. The biggest takeaways for me from my research are the following: First, I am so much more knowledgeable about just how many people are on a fertility journey and what that might mean for them. I hope this means I will be more understanding and supportive going forward. Two, I have so much hope that investment capital can and will be there to help lower the costs and increase the effectiveness of protocols, so that more people can access these services if their dream is to have a child. Three, it is my core belief that knowledge is king, and if you are reading this as someone who wants to have a child one day, just thinking about your plan for how to do this is a very reasonable thing to do. I wrote about my motherhood journey a year ago, and I now realize just how fortunate I was to have two healthy children in my mid 30s without reproductive assistance.?

I want to close out this piece with a shout out to all the mothers out there, of all kinds, in honor of Mother’s Day. As I type this, my mother, Rose, is sitting across from me in front of a fire on a chilly Vancouver day, reading a romance novel with her feet up. She showed me the way and I am doing my best to follow her lead.