When I was 36, I got a phone call from my doctor's office: If I wanted to have children, they said I should do it right away.
I was single and, coincidentally, had been considering having a child on my own; I'd even been browsing around for donors and talking to adoption agencies. Starting the process seemed both expensive and irreversible. Yet I thought back to the call with my doctor, and it seemed like a sign to move ahead and try to have a baby via fertility treatments.
I thought it would be easy to waltz into a clinic and make this happen—it always seems so easy in the movies. Little did I know the financial and logistical quagmire the next few years would become. I wish someone had given me a manual.
The manual I wish I'd had
Luckily, over the last 10 years, I've become a part of a community of so many different types of parents, many of whom have gone to great lengths to get where they are: parents of children through donors; parents who used surrogates; LGBTQ+ families; single parents; friends facing infertility. We saved and called our insurance companies and paid and paid again.
What I wish I'd known falls into a few categories: potential costs, ways to save, and ways to pay. Within each of those categories are nuances based on circumstances like your insurance coverage, your state's mandatory coverage, and how you are classified by your insurance company.
Untangling your (and/or your partner's) classification by the insurance company can be complicated. It generally means whether or not you have a partner with whom you can (biologically) conceive, whether or not you have the ability to carry a child, and whether or not your partner has the ability to carry a child. Health insurance pays for services based on gender of the parents—but it generally pays differently based on sex assigned at birth as well as current gender. For example, two women won't get the same coverage as a heterosexual (cisgender or transgender) couple.
Keeping all of that in mind, remember that to your insurance company, medical intervention for having a child is considered a way to treat infertility, which isn't always the same thing as helping you have a baby, and many insurance companies require a certain order of operations of procedures for approval, which is often based on how you are classified in their system.
Additionally, the minimum your insurance company must cover varies by state, as does what they cover. The maximum they will pay varies wildly and it can be inconsistent.
Note: All costs are estimates based on the national average in 2021.* Please check with your medical provider and insurance company for specific costs.
Initial testing and evaluation
Before doing any procedures, there is generally a handful of office visits and tests to set a baseline and determine a plan of action.
- Consultations: Meeting with the fertility specialists and doctors is generally several visits and several hundred dollars per visit.
- Diagnostic testing: This can include bloodwork, hormone testing, semen analysis, and a common test where dye is run through the fallopian tubes. These can be several hundred to several thousand dollars each.
Where is your insurance company in all of this? It depends on how they classify you, but most of the time this part of the process is covered in part or full, particularly if you have been trying to get pregnant with a partner. However, it's more complicated if you're using a donor, so make sure to check with your insurance company.
Intrauterine insemination (IUI)
IUI is often the first procedure many of us try. Most insurance companies require a certain number of IUI treatments (often assisted by medications) before you can move on to anything more aggressive, and how many you have to try (generally 3–6) will vary based on your age, health, and whether or not you have a partner to provide sperm.
- Donor sperm: This varies based on donor and company, but it can be approximately $1,000 per vial. Some insurance companies/states will pay for this and some do not. There is more to consider about donor sperm, such as whether you want to purchase several vials (in case you need it for multiple attempts) and whether you want some available later for siblings, in which case you'll have to pay for storage (several hundred dollars per year). Additionally, there's often a cost for access to the profiles of the donors (~$50–$100), genetic consultations, and later, connecting into the sibling registry (~$150). I also spent several thousand dollars on expedited shipping because it was hard to coordinate between the sperm bank and my doctor's office. Every round needs new sperm.
- Sperm preparation/washing: Whether the clinic is preparing your donor sperm or sperm from a partner, they will have to prepare it for use. This varies in cost but can be a few hundred dollars.
- Fertility drugs: This varies based on your insurance. Oral drugs can be a few hundred dollars, but the heavy-duty injectables can be in the thousands.
- Monitoring: Ultrasounds and other testing could be several hundred dollars.
- Embryo transfer: This also varies based on insurance but can be approximately few hundred to a thousand dollars.
Where is your insurance company in all of this? It depends on approval from your insurance company, their specific policy, and mandatory state coverage. For me, most of the actual medical procedures and medications I had were covered (beyond the deductible), but the donor sperm wasn't (some states/polices cover the donor sperm but require you to pay it out-of-pocket and then reimburse you). I did 5 (failed) rounds of IUI, for a total out-of-pocket cost of about $4,000.
In vitro insemination (IVF)
I then moved on to IVF: There are drugs that stimulate your eggs, which are then removed, combined with the sperm, and then hopefully returned to you as an embryo.
- Donor sperm: Same considerations and costs as IUI, though note that some sperm banks have higher costs of sperm prepared specifically for IVF (it's more concentrated).
- Sperm preparation/washing: Same considerations and costs as IUI.
- Fertility drugs: The drugs used for IVF are more involved than IUI and it's important to check with your insurance to understand what they cover. When I did it, my insurance had a $7,000 cap even though my total benefit was $25,000—so I had to pay for all drugs above and beyond $7,000. The cost of IVF drugs can vary based on insurance, whether or not you're doing an egg retrieval with a fresh transfer or transferring a frozen embryo, and where you get medications. The range can be anywhere from $5,000–$10,000.
- Monitoring: This can be frequent and extensive—bloodwork and ultrasounds with increasing frequency both before and after the procedure. These can be several thousand dollars.
- Egg retrieval: This is a surgical procedure that requires anesthesia, so the price reflects the complexity and necessary staff. This can cost around $10,000–$15,000 (and generally includes the embryo creation and transfer).
- Egg donor: If you use an egg donor (or a partner's eggs), many of the costs above are transferred to them. However, you will still need to pay for medications for the person planning to carry the baby (to allow their body to prepare for pregnancy) as well as compensation for the donor's pain and suffering. This cost can vary dramatically but can be anywhere from $15,000–$40,000.
- Embryo creation: Someone in a lab takes the eggs, mixes them in a dish with the sperm, and then sees what happens and gives any potential embryos a grade. You can also do something called "assisted embryo hatching" (ICSI) which involves directly inserting the sperm into the egg. The addition of ICSI can be another $2,000.
- Embryo freezing: If you have extra embryos and want to save them for potential use in the future, you can save them in cold storage. This is generally a few hundred dollars a year.
- Embryo transfer: This is when the embryo is transferred. Note that this cost varies based on whether you are doing a fresh transfer (with an egg retrieval) or a frozen transfer (from an embryo from a previous retrieval). If you're doing a fresh transfer, this cost is generally bundled with the other procedures; if you are doing a frozen transfer, it could cost several thousand dollars.
Where is your insurance company in all of this? It depends. Look carefully at your coverage and deductible, as well as your medication cap. Anything that isn't a medical procedure (like storage or compensation to a donor) is unlikely to be covered. With my insurance, I paid about $9,000 in medication and about $7,000 in other costs for one (successful) round of IVF.
Freezing your eggs might seem like a financial gamble, but it can save costs because it can be faster and easier to get a higher volume of healthy eggs with fewer drugs or procedures.
The cost of freezing your eggs varies (mainly based on location) from about $5,000–$10,000, and that generally includes the cost of the drugs as well as storage. Additionally, many workplaces are offering a benefit (outside of what's covered by insurance) to help reduce the cost.
If you use a gestational carrier (surrogate)—which several of my friends have done—there might be some sticker shock. The cost varies based on where the surrogate lives (in the United States or internationally), but it can still range from $100K–$150K.
- Egg donation: The costs are similar to using an egg donor for IVF, though because it's generally a different person than the gestational carrier, there is an entirely separate set of fees.
- IVF: The clinic will have to prepare the embryo and the surrogate will have to go through a version of IVF (medication, embryo transfer) similarly to how it would happen for one person.
- Fees: There can be many of these—agency fees, legal fees, extra fees for multiple babies or needed medical procedures, pain and suffering for each person (for example, added fees if the surrogate has a cesarean section), and potential living expenses if the surrogate has to go on bed rest.
Where is your insurance company in all of this? Again, it depends on how you are classified medically and whether or not it's considered a fertility treatment. If it is, some might be covered by insurance, assuming the approved order of operations is followed—though many of the costs (fees, storage, etc.) likely won't be covered.
How to save and pay
When I look back on my experience, I don't remember exactly how I paid for everything, but I know I wasn't well-informed at the time and I wish I'd done things differently. Here are some ways to potentially ease the financial load:
- Using an HSA: First, consider using a health savings account (HSA) if you are enrolled in an HSA-eligible health plan. With an HSA, you can often split your contributions into invested money (for example, if you know you want it there for a few years and want to give it the potential to grow) and cash (so you can pay for your qualified medical expenses directly from your account). You can get tax benefits for contributions, and there are no taxes on potential earnings or when you use the money for qualified medical expenses. (Note that even though many fertility-related procedures will be considered qualified medical expenses, the expenses for a third party, such as a surrogate or egg donor, may not qualify—so be sure to confirm.)
- Investing ahead of time: If you aren't eligible for an HSA but have some time to plan ahead, you can still save in a way that has potential to grow: for example, in a digital investing account, mutual fund, or managed account that is appropriate for your level of risk and timeline.
- Financing: If you need to consider financing your fertility treatments, many clinics will work with you directly on payment plans or packages (for example, you buy a certain number of rounds of IVF and get money back if unsuccessful). Additionally, many banks have personal loans or lines of credit specifically for fertility treatments or adoption.
- Accessing cash: There are several ways you might be able to tap into cash if you need it. For example, you might be considering a second mortgage, a 401(k) loan, or using your credit cards—but there is a hierarchy of considerations, including, but not limited to, taxes, penalties, and interest.
- Getting to know your insurance policy and workplace benefits: There is variation from state-to-state, policy-to-policy, and company-to-company. Read your benefits ahead of time because knowing what you're eligible for can help maximize your claims.
- Talking to a tax professional: Once you spend a certain amount per year on qualified medical expenses, you can itemize and deduct them from your taxes. So keep track of what you spend and talk to a qualified tax professional to understand your eligibility.
Now, my son loves to tell people that he "cost $20,000 to make." Considering how much it could have been and how grateful I am to have him, I consider him a bargain.