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The Fertility Divide

Policy loopholes are leaving same-sex couples without coverage for infertility treatment, and many are calling it discrimination

Hayley MacMillen
Sep 13, 2018 · 5 min read
Credit: winterbee/iStock/Getty

After eight rounds of DIY artificial insemination over nine months, including the use of a friend’s sperm and a syringe, Ash Blair’s wife was finally pregnant. The couple (only Blair agreed to be quoted for this story) had been waiting almost a year for a positive pregnancy test — a result that cost them nearly $4,000. As a same-sex female couple, they knew a baby wouldn’t come cheap. When they began exploring their options three years ago, however, they didn’t anticipate just how expensive the process of conception would be for them.

At the time, Blair, now 30, and her wife, now 33, were insured by UnitedHealthcare through Blair’s job as an office coordinator. But before their plan would help cover any fertility treatments, such as ovulation drug therapy or clinical insemination, they learned that the insurance company would require proof of Blair’s wife’s infertility. That’s where things got tricky, and the costs started adding up.

“We immediately realized that we didn’t have enough money, and that we weren’t going to be able to get our health insurance to cover any of the costs of fertility treatments,” Blair says.

Getting pregnant can be a pricey endeavor for any couple, but for same-sex relationships like Blair’s, getting coverage for necessary assistive treatments is especially difficult. That’s in part because health authorities such as the Centers for Disease Control and Prevention, the World Health Organization, and the American Society for Reproductive Medicine define infertility as the inability to get pregnant after one year of unprotected sex. This interpretation, of course, doesn’t apply to a woman in a same-sex partnership — or, for that matter, any woman who is interested in fertility benefits but not in unprotected penile-vaginal sex.

Some insurance companies have taken advantage of this convenient clinical definition, declining to cover fertility treatments for women in same-sex partnerships on the grounds that they cannot “prove” their infertility. In recent years, states including New York and New Jersey have moved to ban this “loophole,” framing it as discrimination on the basis of sexual orientation. These state initiatives to level the fertility playing field have been hailed as civil rights wins, but the changes have been slow. New Jersey passed its law to include women who rely on donor sperm on its infertility treatment coverage mandate in 2017. The legislation was introduced in 2013 and picked up steam in 2016 after a same-sex female couple and two other women sued the state for denying them coverage.

Many insurance companies, UnitedHealthcare included, are careful to define infertility as the inability to conceive after a year of unprotected sex or therapeutic donor insemination. This part of UnitedHealthcare’s definition “has remained consistent since 2014,” said company spokesperson Tracey Lempner in an emailed statement. Aetna — the insurance provider Blair and her wife have today — says the company changed its policy to allow infertility benefit coverage for women without male partners back in 2002. Spokesperson Shelly Bendit told Medium in an emailed statement that “the definition of infertility may vary due to state mandates and plan customization.”

These changes are not enough to help couples like Blair and her wife, who say they would have struggled to afford the 12 cycles of in-clinic intrauterine insemination (IUI) that Aetna requires to be paid out of pocket before fertility treatment coverage kicks in. This common 12-cycle requirement flies in the face of research suggesting that couples who successfully conceive with IUI typically do so after an average of three cycles. Some fertility physicians, like Heather Huddleston, MD, a reproductive endocrinologist at the Center for Reproductive Health at the University of California at San Francisco, also question the need for 12 cycles of IUI as a baseline. Though Huddleston’s recommendations can vary person to person, the number of IUI cycles she recommends women undergo before trying other options like in vitro fertilization (IVF) is typically much closer to six, she says.

“Even though we’ve been trying for close to a year now, none of that counts.”

“It’s one thing if a heterosexual couple is having intercourse at home for 12 months,” Huddleston says. “You can ask them to [try] a couple more months before they come in, but for same-sex couples, each month [of IUI] is an expensive month.”

Depending on a person’s insurance, health provider, and location, a single round of intrauterine insemination with donor sperm can cost $1,500 or more, most of which typically goes to cover the cost of the sperm. Blair and her wife, who live in New York City, opted for the more affordable but often less effective method of at-home insemination with a friend’s sperm, using a syringe or cervical cup. The $4,000 they spent went to fertility treatments such as tubal flushing; transportation for the friend providing his live sperm; sperm analysis; and fees for the lawyer who drafted a contract for the couple and their donor to sign, clarifying all three parties’ parental rights.

The couple’s pregnancy was hard-won, but their joy was short-lived. “The fetus was alive with a heartbeat, then died at about nine weeks,” Blair says. And since their eight attempts to conceive weren’t performed in a clinic, the couple is no closer to insurance coverage than they were before: “Even though we’ve been trying for close to a year now, none of that counts.”

Shannon Minter, legal director of the National Center for Lesbian Rights in San Francisco, says he often stresses to women in same-sex relationships that trying to conceive comes with financial burdens and legal stumbling blocks, especially when sourcing their own sperm. If a woman has an infertile male partner, Minter explains, then insurance companies that cover fertility treatments will generally pay for the sperm and the cost of artificial insemination. “A woman who is with another woman is functionally in the same situation, and so it seems it would only be fair for the insurance companies to pay for the cost of artificial insemination in that circumstance,” he says.

Minter points to employers as a possible lever for change: “If enough good companies start saying to the insurance companies, ‘Hey, we want policies that provide equal coverage for same-sex couples who need to have children,’ that could really make a big difference.”

Stacey Sullivan and her wife, Lauren Steblen, have employer-sponsored insurance to thank for the conception of their two children. First, though, the Maine-based couple shelled out a total of about $20,000 for seven in-clinic IUI cycles for Sullivan and six for Steblen, none of which were covered. But once Sullivan, now 40, and then Steblen, now 38, respectively hit the six-cycle mark without conceiving, they had a new option: At that point, Steblen’s insurance — a UnitedHealthcare plan offered by her employer, Pfizer Pharmaceuticals — would cover IVF for both women, up to $40,000 per person.

“We don’t know anybody that has that type of benefit,” Sullivan says. “It just helped alleviate the financial stress that we were having.” The procedure was ultimately successful for both women: The couple’s son, whose biological mother is Sullivan, is now three and a half, while their daughter, whose biological mother is Steblen, is nearly a year old. The documented cost of IVF treatments for both women, all covered by insurance, came close to $65,000.

Blair and her wife, meanwhile, are exhausted but determined. Three weeks after the miscarriage, they invited their sperm donor over for another round of insemination. “It’s really emotionally trying,” Blair says. “We’re hoping for the best in the next few months… but it’s still like, fuck, here we go again.”

Hayley MacMillen

Written by

Health and sexuality writer and law student living in Berkeley, California.

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