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Vanessa Ikwuazom

Dr. Shannon Stettner

Arts 130 (Reproductive Justice)

22nd March, 2020

Assisted Reproductive Technologies

    The World Health Organization clinically defines infertility as “the inability of a

sexually active, non-contracepting couple to achieve pregnancy in one year” (World Health

Organization, 2009). One way this issue is resolved is through the use of Assisted Reproductive

Technology (ART), which consists of various optional medical procedures for people dealing

with infertility. Multiple studies discussing highlight success stories of pregnancy via the use of 

ARTs such as: vitro fertilization, intracytoplasmic sperm injection, gametes cryopreservation,

and the use of fertility drugs. However, some people still struggle with infertility and do not have

access to health care services due to numerous barriers. This struggle relates to the concept of

reproductive justice, which is defined by the Sister Song organization as “ the human right to

maintain personal bodily autonomy, have children, not have children, and parent the children we

have in safe and sustainable communities”(Rodriguez, 1997). There are people who find it

challenging to obtain treatment involving reproductive technology due to a number of factors,

such as: cost of fertility service, race, stigma, location, sexual orientation, age and HIV. By

examining how these various factors have an impact on accessing Assisted Reproductive

Technologies in the US, this paper will illustrate how these factors pose as a barrier in preventing

people from receiving their respective treatments thereby preventing reproductive justice.

            The current health care system in the US provides the option of either public or private

healthcare. The public health care system consists of  “plans provided by the government for
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low-income individuals or families, the elderly, and other individuals that qualify for special

subsidies”( Chan, Anthony 2020). This means that public healthcare is funded and provided

through the government. The private healthcare system entails “plans provided by private

companies and are often provided by an employer or other organizations with which the

policyholder is affiliated” (Chan, Anthony 2020). This type of healthcare is provided by profit-

making hospitals and free-lancing practitioners. Although these healthcare options are made

available, the US has no “universal health coverage” (Barrows 2016). This means the

government does not provide healthcare to its residents or tourists, therefore the medical

treatment received has to be paid for. Furthermore, to gain access to these options one has to

have insurance, according to an article by Sameer Kumar, Neha S Ghildayal and Ronak N

Shah the U.S. healthcare system is “characterized as the world's most expensive yet least

effective compared with other nations” (Kumar, Sameer et al. 2011). To elaborate, The U.S.

healthcare system is seen as expensive because not all citizens have the means to pay for health

insurance due to low level income. This disparity also results in the U.S healthcare system being

less effective because it is only accessible to those who can afford insurance.

        Infertility being a well-known issue in the US, the display of an unfair distribution of access

to healthcare makes matters much worse for women struggling with infertility due to the inability

of most women being able to afford  insurance. This what? then leads to a restrictive access

towards to medical treatments such as Assisted Reproductive treatment. In the US fertility

services are not available to all women, according to an article under the women’s health policy,

there are “fifteen states in the US that require some private insurers to cover some fertility

treatment, but significant gaps in coverage remain” (Ranji & Weigel, 2020). This means that in
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order to access these reproductive technology treatments most people have to pay large sums of

money out of their pocket.

    The American Society for Reproductive Medicine (ASRM) holds the position that all

“Assisted Reproductive Technology(ART) Centre’s and insurance providers, should address and

lessen existing barriers to infertility care”(Quinn et al. 1120). This means that the ASRM is of

the opinion that various ARTs clinics and insurance providers across the US need to address and

reduce the prevailing barriers centered around infertility care. A good example of an existing

barrier in obtaining infertility care is the cost involved in making use of Assisted Reproductive

Technology treatments. Based on an article discussing  access and use of infertility services in

the US, it was stated that the “access to general infertility and ART services is very much in the

crosshairs of an economic barrier”(Adashi et al. 2016).This means that obtaining access to

general infertility and ART treatment is limited due to financial barriers.

    In an article discussing the health disparities to procreation in the US , as of 2012 

Kissil  stated that the “average fee involved in a single distribution of In-Vitro Fertilization falls

between $10,000-$25,000” (Kissil et al. 199). However, in a more recent article, Gurevich stated

that the “average fee involved in a single cycle of IVF falls between $12,000-

$15,000”( Gurevich, Rachel 2020). In-Vitro Fertilization being a type of ARTs, a woman can

need up to 3 cycles of IVF to become pregnant and with a single cycle of IVF costing this much,

it may be tasking for all women to pay for up to 3 cycles. The findings of both Kissil and

Gurevich showcases how the cost of an ART treatment reveals what class in society can easily

access and make use of this treatment. As stated in paragraph two, both public and private

healthcare can only be accessed through paid health insurance. This means those who are able to

pay for insurance can more easily access ART treatment. Based on Kissil’s statement,
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“individuals who have access to health insurance are more likely to be employed and living in a

higher socioeconomic level than the general U.S. population” (Kissil et al. 200). The particular

reason for this circumstance is that women in a higher socioeconomic class can more easily

access these treatments because of their wealth, allowing them to pay for insurance to access

ART treatment. Though, women in a lower socioeconomic class may struggle with the cost of

paying for ARTs treatment due to their low-level incomes.

            A factor that the American Society for Reproductive Medicine would advise Assisted

Reproductive centres and insurance providers to address as a barrier towards infertility would be

race, whereby women are restricted access to Assisted Reproductive Technology due to the

colour of their skin. A study that suggests that the reason why black women do not seek ARTs

services is because “medical providers are more likely to have a variety of negative stereotypes

about African American patients” (Kissil et al. 200). These negative stereotypes towards black

women may cause them to fear the kind of service and treatment that they may receive from

providers. In addition to the negative stereotypes ofto minority women in ART services, a

research study explored possible reasons as to why those in serious need of infertility did not

seek ART. One reason as stated in the research result was that “African-American and Hispanic

women found it more difficult to find a physician with whom they felt more comfortable, to get

an appointment with a physician “(Missmer, Stacey A., et al 2011). Another study that

researched the outcome of IVF in relation to race and ethnicity suggested that “when African

American, Asian, and Hispanic women attain access to ART, they experience lower success rates

compared with non-Hispanic white women”(Ethics Committee of the ASRM,1106). The

suggestion of low success rates of ARTs among minority women showcases how not enough

research on ARTs has been conducted among minority women. It also displays how the
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“differences in treatment success rate is very concerning as well demonstrates poorly understood

and insufficiently studied, with explanations ranging from biol-ogical factors to modifiable

behavioral factors” (Ethics Committee of the ASRM,1107). In some case’s minority women may

also face quite a struggle surrounding ART treatment. In Missmer's research study, it was

explained that “compared to white women, African-American women were more likely

concerned about failure to conceive, using science to conceive, the social stigma of infertility,

and disappointing their spouse “(Missmer, Stacey A., et al 2011). Thus, the high success rate in

non-Hispanic white women may be a reason as to why they are less concerned about failure to

conceive with or without science involved, face social stigma from others and disappoint their

spouses.

       Alongside the struggles faced by minority women while trying to access ART treatment, as

mentioned above, the factor stigma can be viewed as a barrier while seeking access to ART

treatment. Women may fear to disclose that they areir making use of ART treatment because

they fear that they may be stigmatized for their choice. In a blog discussing infertility stigma  it

was stated  how “ individuals wanting to have kids is seen as a social norm , which means people

who don’t conform to this norm are potentially at risk of experiencing stigma.”( Talia Shirazi

2019). This conveys how there’s a non-avoidable stigma surroundinged by those who struggle

with infertility. In an article by Navjotpal Kaur and Rosemary Ricciardelli it was stated that

“mothers who have made use of the ART treatment face a dilemma of disclosure, they are then

faced with the question on if they are to re-veal or not that they underwent ART to achieve

pregnancy?” (Navjotpal Kaur and Rosemary Ricciardelli ,237). In an article discussing the

stigma attached to infertility, it was stated that infertility is usually seen as a” stamp of

shame”( Diaz, David, 215). This means some people are of the opinion that women who makes
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use of assisted reproduction are seen as shameful for not being able to conceive naturally.

However, the reproductive justice agenda states that one should have the right to “to all

reproductive alternatives and the right to choose the size of our families” (Ross, 2017). Hence,

meaning that women should be able to decide what reproductive alternative to use in achieving

pregnancy.        

           Location could also be another factor for ART centres and insurance providers to address

as barriers to infertility care. Geographically, people may struggle to access ARTs treatment due

to the lack of fertility centres in their area. Location could be a barrier because those who live in

the outskirts of cities, like urban areas, have smaller populations and are not well equipped with

all the healthcare services needed. An article discussing the use of infertility services mentions

how “the maldistribution of ART clinics gives rise to a circumstance that favors mandated states,

high median income states, and urban over rural locales”( Adashi et al.2016). The unequal

distribution of ART clinics in the US creates a condition that benefits mandated states, states

with a high household salary, and urban over rural areas. As a result, there would be  extra costs

attached to ARTs treatment , this is because people who live in rural areas would have to

consider the expenses of travelling towards the city to receive treatment. For instance, people

who live in rural areas would have to pay fees for essentials, such as gas and hotel expenses, and

some may have to pay for ARTs appointments because they are placed under the private

healthcare system. In other case’s women end up choosing between going to work to earn

income or going to seek ART treatment. To support this claim, a research study exploring the

reasons why people do not seek ART explained that “women without a graduate degree found it

to be more difficult to get time off from work to see the physician”(Missmer, Stacey A., et al

2011).
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         An individual’s sexual orientation is a factor that could be considered as a barrier to

accessing ART treatment. This may be because most people believe the common roles needed

when raising children are the mother and father figures. In an article discussing the welfare of a

child in a heterosexual family, it was stated that “as an outcome when children are in a

nonstandard group (bisexual family), those families are automatically classified as inferior and

disqualified” (De Wert, G., et al 2014). In other case’s same-sex couples may be discriminated

against by their ART physicians. To support the above claim an article by the ethics committee

of the American Ssociety for Rreproductive Mmedicine stated that “providers have expressed

doubts about whether transgender individuals are suitable candidates for parenthood” (Ethics

Committee of the American Society for Reproductive Medicine,2015). This finding reflects how

that there are physicians in the ART service that are still very narrow-minded towards various

changes like; same sex unions that have taken place in different parts of the world.

       The factor of age could also be a barrier to accessing ART treatment. In an article discussing

the IVF age restriction in America, the author Heather stated that “Most fertility clinics set an

age limit, often between 42 and 45 years old, for a woman to use her own eggs''( R. Huhman,

Heather2020). The reason being that physicians may be concerned for women who are above

forty and reaching the stage of menopause. In an article attempting to answer the question on the

establishment of age restriction in Art, an explanation was given that “many practitioners

indicated that they were making age limit decisions based on personal feelings and beliefs as

well as on perceptions of public opinion”. (Zweifel, Julianne E, et al,2019). Consequently, some

physicians made choices to restrict the access of ART to women close to the stage of menopause,

based on personal opinions and public perception. It is a well-known fact that most women lose

the ability to conceive children after the age of 35. However, this restrictive access to ARTs for
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women who are still able to conceive in their early 40s results in them being less hopeful of

having children. In a clinical study researching on the live birth rate of over 313 women between

the age of 40 to 46, the overall result stated a “clinical pregnancy rate of 3.8% per cycle and

chance of live birth rates was 3.2% that most of them occurred in women aged lower than 42

years.” (Aflatoonian, Abbas, et al.2011). In addition, an article discussing reproduction at an

advanced age stated that the “Maternal mortality rates are significantly increased in women older

than 35 years, and even more pronounced after age 40 years” (Sauer, Mark V,2015).

           Human immunodeficiency virus being a well-known and common disease in the US, in

which those who live with this disease also struggle with infertility. In the US there are

approximately 1.2 million people in. who are living with HIV today” (HIV.gov 2021). The factor

on transmittable diseases could also be a barrier that ART Centre’s and insurance providers

should address to increase fertility care in the US. .However, with a transmittable disease like

HIV there may be restricted access to ART treatment towards HIV carriers . In an article about

HIV and fertility, it was stated that “Fewer than 3% of US ART practices registered with the

Society for ART provides service to couples in whom one or both partners are infected with

HIV”(Ethics Committee of the American Society for Reproductive Medicine 2015). This means

that less than half of ART service centers in the US provide fertility treatment to carriers of HIV

struggling with infertility. Moreover, in an article discussing recommendations on how to reduce

viral transmission during fertility, it was mentioned that “fertility services cannot be withheld

ethically from individuals with chronic viral infections, including HIV” (The Practice Committee

of the American Society for Reproductive Medicine 2012). Therefore, further emphasizing the

ASRM position on ARTs clinics and insurance providers across the US reducing barriers to ART

service. 
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    In summary, the American Society for Reproductive Medicine’s (ASRM) position on Assisted

reproductive technology centres  and insurance providers  addressing the existing barriers to

infertility care is very valid. This is due to the large amountsignificant of barriers that different

individuals face in the US. To start-off the cost of receiving ART treatment is very expensive,

because it is only accessible to those that can pay for insurance, moreover, insurance is needed

for both private and public healthcare. The factor of race is also barrier to accessing ART

treatment because of the of lack of sufficient research done on ART outcomes towards for

minority women, which . Thus, makesing it hard for minority women to attempt Art treatment

successfully. The stigma involved in using Art can be seen as  a barrier , because some women

may fear the reactions of their family and family on her decision to make use of ART. Women

may feel scared to disclose their fertility status, so as to make sure they are not a victim of

stigmatization. Location could be a factor that restricts individuals from accessing art treatment

due the unequal distribution of ART centres across the US. This unequal distribution results in

additional cost like travelling expenses for those who live in areas where Art services  are

limited. An individual’s sexual orientation also plays a role to accessing ART , because

physicians may feel that bisexual couples are not suitable enough to raise a child. The restrictive

access of ART to  women over the age of 40 is also very concerning . This is because different

research studies as stated above have proven that women over the age of 40 can conceive

children with the aid of ART. Lastly, individuals living with HIV in the US also struggle with

access to ART. This may be due to the lack of fertility service centres that handle HIV fertility

treatments in ART, hence making it difficult to provide service to HIV carriers .

 
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