IVF coverage proposal could squeeze U.S. fertility clinics without improving access

Every family should have reproductive choices, including the opportunity to become parents. For families experiencing infertility, in vitro fertilization (IVF) is a promising avenue. But that hope often comes with a hefty price tag of $20,000 per cycle, and it takes an average of 2.5 cycles nationwide to produce a healthy baby.

Although recent signals appear to be mixed, the Trump administration initially considered in vitro fertilization as an “essential health benefit” under the Affordable Care Act (ACA), seeking to fulfill a campaign promise that it would lead a transformative shift in reproductive health care and address troubling demographic trends. This is similar to Democratic efforts in Congress, where they introduced HR 3480, the Inclusive and Valuable Families Health Insurance Act of 2025, which also seeks to expand access to fertility treatments to more families. What these plans fail to address is that when you stimulate demand without increasing supply, this inevitably leads to further increases in IVF costs without adding significant capacity.

Let's look at Medicaid, which covers approximately 18 million women aged 20-45, accounting for 40% of all births in the United States. If IVF services were made available to this population through expanded insurance coverage, based on recent averages, we might expect that 2% of this population would receive treatment, resulting in an additional approximately 360,000 cycles per year. For context, in 2023, U.S. fertility clinics reported performing more than 430,000 IVF cycles.

Of course, if insurance companies follow suit, the problem becomes more complicated. We need to apply downward price pressure while continuing to focus on quality results.

Historically, this has had the opposite effect of increasing coverage through the U.S. health insurance industry. If its scope is expanded to cover in vitro fertilization, why should we expect anything different? Let's come up with a better model, similar to LASIK, where the cost has dropped 30% since 2008, without sacrificing quality.

infrastructure gap

The most significant challenge to large-scale expansion of IVF coverage is the critical shortage of critical infrastructure and professionals. Unlike routine outpatient care, IVF is a highly complex and hands-on procedure that involves multiple stages, from ovarian stimulation and egg retrieval to fertilization, embryo culture, and transfer. Each step must be performed with extreme precision in a tightly controlled laboratory environment. IVF treatment uniquely relies on a small group of highly skilled professionals, especially embryologists. These specialists work with eggs, sperm and embryos at a cellular level, often making split-second decisions that can determine the outcome of a cycle. According to industry data, there are only about 1,500 board-certified reproductive endocrinologists and about 5,000 embryologists actively working in the country. At the same time, there are a limited number of accredited embryologist training programs in the United States, and certification can take years.

Despite growing demand, these numbers have remained relatively stagnant over the past decade. This bottleneck leads to capacity constraints, which are most evident outside large urban centers. While metropolitan areas such as New York, Los Angeles, and Chicago may have multiple full-service fertility clinics, rural and underserved areas often lack enough qualified personnel and well-equipped facilities. Some states have only one IVF clinic.

This geographic imbalance results in long wait times and travel burdens, especially for those in low-income or medically underserved communities. Given the highly manual nature of many sensitive steps, the entire process has become manualized, with worrying inconsistencies in quality and results between clinics, between experienced and inexperienced embryologists, and between well-rested and overworked staff.

Addressed access

All of this raises serious equity questions about all the proposed “solutions”: expanding insurance coverage for IVF without first addressing underlying infrastructure shortages may actually widen the gap between those who have access to fertility care and those who are only entitled to it on paper.

If insurance coverage leads to a sudden increase in demand for IVF services, many already stretched clinics may struggle to accommodate the influx of new patients. This can result in longer wait times for appointments, diagnostic tests and treatment cycles, potentially delaying a patient’s ability to start or complete fertility treatment. This delay is especially distressing for individuals and couples facing infertility, as fertility rates decline with age.

Moreover, even if coverage is mandated, insurance does nothing to reduce systemic costs—in fact, the history of U.S. health insurance suggests just the opposite.

To truly expand access, we need to focus on alleviating bottlenecks in a way that money cannot. This means strong parallel investments in workforce development, hiring incentives and clinic infrastructure. Nonetheless, in the best case scenario, these are long-term projects that will not be able to keep up with the expected growth in demand for IVF due to changing demographics at home and abroad.

The missing piece is the modernization of IVF technology, specifically automation. If implemented correctly, automation alone can help standardize quality in a number of ways. It will ease the burden on employees by reducing the number of manual steps and allow those with less experience to perform procedures equivalent to those who have performed these tasks throughout their careers. It will speed up certain procedures and eliminate process glitches.

Automation potential

A good example is the fertilization process itself, which requires a delicate manual protocol called ICSI that can destroy the potential embryo as the sperm is forced into the egg. It can take months to learn and years to become proficient. A new technology called piezoelectric ICSI makes the injection process gentler, resulting in higher quality eggs and cyst cells. Automated piezoelectric ICSI robots have recently entered the market, simplifying the process and allowing less experienced embryologists to perform complex procedures like experts.

Improving the overall quality of the process will lead to better outcomes, thereby lowering the average of 2.5 IVF cycles we see today. Producing healthier babies in fewer cycles will soon free up more system capacity.

Taking it one step further: Automation has its greatest impact when it goes beyond simply using a robot to optimize steps. Creative design can change paradigms. Take a look at the highly manual and delicate steps of vitrification, where eggs are carefully frozen for later use. As more young professionals decide to postpone starting a family until later in life, egg freezing is becoming an increasingly important component of reproductive planning. But like other complex steps, it must be performed in a controlled embryology laboratory environment, in a dedicated IVF clinic. For those wondering why we don't open more clinics in more places: These clinics cost about $4 million to open and about $1 million per year to operate.

Newer platforms are entering the market that enable automated vitrification in desktop devices with minimal non-expert training. As these become commonplace, they are expected to further expand access. We see a world coming where these devices are commonplace in obstetrics and gynecology offices, and the devices themselves are more widely distributed and closer to where patients are.

Whether we expand insurance coverage or not, there are many things the government can do to reduce out-of-pocket costs for IVF. For example, promoting biosimilars of the cocktail of hormones needed to stimulate ovulation (already available in Europe) could reduce the cost per cycle by up to a third. But cost is not the central limitation on access; This is a symptom. If we fail to address supply constraints, government-mandated insurance coverage will become another subsidy for insurance companies without undermining the growing demand for IVF.

Photo: luismmolina, Getty Images

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