Access barriers create worse IVF outcomes for Black parents
Even when they do pursue infertility treatments, like intrauterine insemination (IUI) or in vitro fertilization (IVF), treatment is less likely to succeed: Black women have lower pregnancy rates, higher rates of clinical pregnancy loss and lower live birth rates. It’s a double-edged issue: Black women are using IVF and assisted reproductive technologies less and later. The racial disparities are staggering among people who use assisted reproductive technology. Of 40,545 patients included in a 2021 study on disparate outcomes for Black women undergoing IVF, a whopping 62 percent were white, while 15 percent were Asian, 7.3 percent were Hispanic/Latino, and just 6.4 percent were Black.
Stigmas and stereotypes remain
Sonhara Eastman spent seven years going through fertility treatments to have her children, a daughter born in August 2019 and a son born in September 2023. She began with IUI and then switched to IVF. She had gone through three failed rounds of IVF before getting pregnant on the fourth round.
“Throughout that time span, into the sixth year of going through fertility treatments, no one knew,” Eastman said. “I was embarrassed and didn’t tell anyone.” I didn’t know anyone who was talking about it. She found out after visiting a fertility expert that she could carry but her egg reserves were too low. It was difficult for her to talk about. It was difficult for Hendricks to discuss the topic. It’s a longstanding, racist myth that can be traced back to forced reproduction under slavery.
“Sometimes I think we actually believe what people say about people from the African diaspora: That we’re just overly fertile and that it’s going to happen naturally for us,” said Leah Jones, director of maternal health and birth equity initiatives at SisterSong Women of Color Reproductive Justice Collective. We’ve been conditioned to believe this, even though it isn’t true. Other barriers to entry
Aside from harmful stereotypes, there are significant barriers for assisted reproductive care. The biggest barrier is its cost. A single IVF cycle (defined as ovarian stimulation, egg retrieval, sperm retrieval, fertilization, and embryo transfer) can range from $15,000 to $30,000.
Other methods of extending fertility, like freezing eggs and storing embryos, come with their own price tag. Egg freezing tends to cost between $8,000 and $15,000 per cycle, with storage fees costing between $500 and $1,000 annually.
These procedures are not always covered by insurance, which makes them totally out of reach for a large portion of the U.S. population, including many people of color.
“So much of who gets fertility treatment is based on insurance coverage,” said Dr. Erinma Ukoha, a maternal fetal medicine fellow at Physicians for Reproductive Health who works with high-risk obstetric patients, said. “We have to consider what’s covered by public insurance versus private insurance, what states mandate fertility coverage, what kinds of jobs give people good insurance.”
Plus, she pointed out, patients need to be able to get time off work to access care, especially given fertility treatment can be extremely intensive both physically and mentally.
Hendricks considered herself “extremely lucky” to have a job that would have covered up to three rounds of IVF. She only managed to complete one round of IVF before deciding on adoption, which is a costly undertaking. Hendricks’ adoption of her son, in May 2016, was a private domestic one. The cost can be anywhere between $20,000 and $45,000. Hendricks explained that “the system is set up in such a way that if you are unable to have children naturally, then it’s very difficult for you to even have them.” Both IVF and adoption can be very expensive, let alone the cost of raising a child. The lack of diversity among providers is also a problem. According to the Association of American Medical Colleges only 5.7 percent of U.S. doctors are Black compared to 13.7 percent of Black Americans. However, Black patients treated by Black doctors have better outcomes due to higher levels of care and trust. Eastman called her “the best thing for me and for my fertility journey.”
“There were cultural things, like every time we would do a treatment, she would say let’s pray,” Eastman said. “There were certain things I felt like I could talk to her about on a deeper level, because I knew she would understand.”
Though she emphasized she wouldn’t have gone out of her way to find a Black doctor, and that all she cared about was having a doctor who would be able to help her conceive, Eastman’s experience is a testament to the importance of increasing diversity in the medical field.
Barriers to entry lead to worse outcomes
The stigma around infertility, as well as concrete barriers to entry like high costs and lack of insurance coverage, means Black women pursue infertility treatment not only less often, but also later in life.
For women in their early to mid-20s, there is a 25 to 30 percent chance of getting pregnant every month. By age 40, that probability falls to about 5 percent.
White women are most likely to start fertility treatment before the age of 35, though Black women are most likely to start at 41 or older, according to a 2020 study. The neonatal mortality rate for Black mothers using fertility treatments was four times higher than the rate for white mothers.
Ukoha ascribed that delay to provider bias, as well as the aforementioned economic factors.
“There’s the question of who gets referred and when they get referred,” Ukoha said. “How long does it take to even begin to access that care, to get an appointment and feel comfortable in that space?”
Making strides toward the future
Eastman, who once believed she couldn’t even share her journey with her family members, developed a web series and a podcast about the silence around Black infertility.
“My family would always ask us about when we were going to have kids and what was taking so long,” Eastman said. Everyone asked me about it when we went to New York after my grandmother died. I was overwhelmed because we had just had another failed IUI at the time, and my husband came out and told everyone.”
Although she was initially “livid, it turned out to be a really good thing, because people were so supportive.” The positive reaction from her family led her to post about it on social media. She posted a Facebook message urging people not to ask about people’s plans for children. She was told to check her Facebook account by her sister later that evening.
“A lot of people, Black people in particular, were messaging me saying, ‘I am struggling with infertility and no one knows about it’,” Eastman said. There were so many messages, I felt overwhelmed by trying to respond to them all. It made me feel that I wasn’t the only one.”
The sheer number of people who were willing to share their feelings with a stranger online than even their families was a powerful message to Eastman. She was inspired to create a web series Black Girls Guide to Fertility to highlight the struggle of dealing with infertility in silence. Eastman met a woman who said she had gone through infertility but quit. When I asked why, she replied that it was just too overwhelming. She said that after two IVF failed attempts, not being able talk to anyone about it and having to deal with it alone was too much. That was so devastating to me.”
SisterSong, the largest national multiethnic reproductive justice collective, is making strides to get people of color talking about fertility. The organization held its first Black (in-) Fertility Awareness week earlier this year. It was aimed at raising awareness, fostering dialog, and advocating the human rights for Black communities who are facing infertility. SisterSong’s Jones, who organized the week, called it a great success.
“There were people who learned something they didn’t know before, there were people who left considering their fertility very differently than they did before they came,” Jones said. The more we talk about it in Black and Brown spaces, the more people will realize that this is a topic we need to be talking about. She had an ectopic pregnancies in her early 20s and required a medication-induced abortion. “They’re still frozen right now, and I’m not sure what I want to do with them.” “They’re still frozen right now, and I’m not sure what I want to do with them.”
She added that another racial disparity in fertility is the lack of donated Black sperm and eggs available for people who are considering surrogacy or needing donated eggs or sperm.
SisterSong, which is based in the South, is working alongside SPARK Reproductive Justice NOW and the Center for Reproductive Rights on a state campaign to create a bill for insurance mandates, which would make fertility health care and assisted reproductive technology covered in the state of Georgia. The group will also examine outdated parental laws that could be causing problems for LGBTQ+ families, and develop a toolkit other states can use. The bill would have prohibited state restrictions on the procedure, and required insurance coverage. Who is given priority to build their families the way they want to, and who does not? Ukoha suggested that in order to achieve equity in these health-care systems, we have to ensure policies are truly antiracist and in line with the goal of allowing patients to make decisions for themselves.
“Contraception, abortion, pregnancy care, and fertility care are all related, and they all function within this system of white supremacy,” Ukoha said. We need to ensure that all people have access to these options and that they don’t face unnecessary barriers in receiving care.
