The debate over in vitro fertilization (IVF) has become a hot-button policy and political issue, despite the medical procedure to help people become pregnant having been mainstream in the United States for nearly half a century.

The Alabama Supreme Court recently ruled that embryos are children under the law—prompting at least three fertility clinics in that state to halt treatment—and more than a dozen other states are considering IVF restrictions. In June, the Southern Baptist Convention, the nation’s largest Protestant denomination, voted to oppose IVF treatments, while the U.S. Senate blocked legislation that would have made it a nationwide right for women to access fertility treatments.

These developments beg the question: How would making IVF unavailable affect the many couples who are building their dreams of a family on the use of this technology?

A new Stanford study provides novel, concrete evidence on how these involuntarily infertile couples are affected: infertility leads to poorer mental health among both partners and a hefty hike in the likelihood of divorce.

Petra Persson, PhD, an assistant professor of economics and a faculty fellow at the Stanford Institute for Economic Policy Research (SIEPR), notes the findings point to the large costs that involuntary infertility have on society.

“Anyone who has an acquaintance who’s tried having a baby and failed would know, intuitively, that it can be a devastating journey,” said Persson. “But what we bring is the data and methods to be able to precisely estimate those personal costs; to go beyond personal accounts, no matter how profound, to a data-driven quantification.”

The study, released in May by the National Bureau of Economic Research, also examines the role that IVF affordability has on a couple's ability to use the technology. Fertility treatments can be expensive; in the U.S., a single cycle can cost as much as $30,000. So when health insurance doesn’t cover it, IVF is prohibitively expensive for many—especially among couples with lower incomes.

“Policies that affect the affordability of IVF have major impacts on the use of IVF treatments, especially at the lower end of the income spectrum,” says Maria Polyakova, PhD, an associate professor of health policy and a SIEPR senior fellow. “This, in turn, means that insurance coverage of IVF ultimately affects the distribution of children across the income spectrum.”

Infertility Treatments: Politically Charged

Infertility is diagnosed after a person has tried unsuccessfully for at least a year to get pregnant. During in vitro fertilization, mature eggs are collected from ovaries and fertilized by sperm in a lab, from either a couple’s own eggs and sperm or those collected by donors.

More than 86,000 infants (or 2.3% of all infants) were conceived in 2021 through the use of assisted reproductive technology (ART) in the United States, with this count primarily focusing on intensive IVF treatments.

But these treatments are controversial.

Throughout its history, infertility treatments have been at the center of many ethical, demographic and economic policy debates. Variation in policies that affect the availability and price of infertility treatments around the world is striking, reflecting the many differences in how societies think about infertility and assisted reproduction. At the most fundamental level, there is disagreement about the ethics of ART procedures altogether. And there are wide public policy differences around the world with regards to infertility and whether it’s a disease that should be covered by health insurance—or an elective treatment that must be paid for out of pocket.

“This remarkable variation in policy highlights the need for more evidence, yet systematic population-level evidence on the rate of infertility burden, its private and public costs, and families’ willingness to pay for treatment remains scant,” the researchers write.

Big Data on Infertility Treatments

This prompted Persson and Polyakova, along with their collaborators—Sarah Bogl, a former SIEPR predoctoral research fellow who is now a PhD student in economics, and Jasmin Moshfegh, a recent PhD graduate in health policy—to turn to administrative, population-wide data from Sweden to fill in some evidence gaps. They extracted data on the universe of fertility treatments in Sweden from 2005 through 2019, merged with information from income and health-care registries, one of the richest sources of population-wide administrative data in the world.

The research team first provided novel estimates of how common it is for women to encounter, and attempt to treat, infertility by looking at the prescription drug purchases for infertility treatments. They found that one out of eight women experience primary infertility (the inability to have the first child) over their lifetimes, making primary infertility as common as breast cancer.

“Many infertility stories have a happy ending, with nearly 75% of women bearing a child within eight years after staring their first infertility treatment,” the researchers write. Yet a quarter of the women who start infertility treatment will remain infertile.

Next, the researchers harness the power of these large-scale data on women who undergo fertility treatment to rigorously evaluate the extent to which involuntary infertility leads to changes in emotional and economic well-being. They identify a large sample of women who conceive after the use of fertility treatments, but where only a subset of these women ends up with a live birth. By following these women and their partners over a long period of time, they can quantify the impacts of persistent involuntary infertility among couples who are hoping to conceive a child using reproductive technologies.

“Our findings reveal large impacts on well-being of wanting to, but failing, to have a child,” Polyakova said. Women who remain infertile five years after their first unsuccessful conception are 48% more likely to fill a prescription for a mental health drug than women whose first conception succeeds, the researchers found.

“We also find an increase in the use of mental health medication among their partners,” said Polyakova. “Our estimates further reveal that couples who remain infertile are 6 percentage points more likely to get divorced in the long run, suggesting that infertility takes a toll on couple stability.”

Perhaps surprisingly, the study also found that persistent infertility has no impact on women’s long-run earnings, neither in absolute terms nor relative to their partners. This contrasts with the “child penalty” phenomenon that describes a commonly observed drop in long-run incomes among women who have children—a phenomenon that may be expected to imply a protective impact of infertility on women’s earnings.

“One interpretation of this result is that, while the arrival of a child causes a drop in women’s earnings, the longer-run toll of infertility on mental well-being among women who are involuntarily childless may have a countervailing (negative) impact,” they write.

Public Policy Remains Contentious

The researchers note that medical innovation in IVF treatments over the last few decades has been remarkable. But the costs remain high and prohibitive for many couples.

The U.S. Department of Health and Human Services estimates the cost for a single cycle of IVF to range from $15,000 to $20,000, and can exceed $30,000 if a donor egg is involved. While the number of employer health insurance plans that cover infertility treatment is growing, 29 states do not require private insurance to cover IVF treatment. States that do have some form of insurance mandate doesn’t apply to self-insured plans—or some 61% of workers. Public health insurance such as Medicaid offers none or very minimal coverage of any infertility services, with almost no coverage for the most expensive IVF procedure.

The researchers note that in Sweden, couples and single women 39 to 36 years and younger—depending on where they live—are entitled to three IVF cycles at basically no out-of-pocket costs. But once women turn 40, they are cut from the public insurance waitlist. These arbitrary age-based restrictions allow the researchers to study how insurance coverage of IVF affects utilization.

“Our estimate suggests that nearly 15 out of 25 childless women stop initiating treatments when they become ineligible for free IVF cycles,” the researchers write.

Money Talks

As is so often the case, it would appear to come down to money. When insurance is discontinued, lower-income households are more responsive to the change in coverage.

Higher-income couples are more willing and able to take the risk that paying more out of pocket will eventually lead to a desired child. The authors conclude that, as a result, “coverage of infertility treatments determines both the total number of additional children as well as their allocation across the socio-economic spectrum.”

Applying their estimates to the U.S. population, the authors conclude that subsidized IVF treatments could lead to 3.5% additional first births among 4.3 million childless women ages 30 to 39. The paper warns, however, that this does not directly mean that subsidizing IVF for everyone would be the best policy. 

“Arriving at the optimal design of public policies affecting the affordability of ARTs further requires understanding whether the most effective intervention would be subsidies or loans,” they write, “and in the case of subsidies whether the main goal is redistribution, in which case policy instruments other than public health insurance systems may be more efficient.”