Navigating Fertility Care in Ontario
Types and cost of fertility treatments
In recent years reproductive technology has helped many families. Fertility treatments are used for various reasons. Fertility treatment can be used for people experiencing infertility, LGBTQIA+ families looking to expand their families, to reduce the chance of a baby inheriting a genetic disease or abnormality and fertility treatments like embryo freezing or embryo preservation are used to preserve fertility. Fertility treatments can range from a simple intervention like Ovulation medication to more complicated interventions categorized as assisted reproductive technology. Some of the treatments are Ovulation induction (OI), Artificial insemination (IUI), In-vitro fertilization (IVF), surrogacy and donor conception (spam or eggs).
Ovulation induction (OI): involves the use of medication in the form of a tablet or injection to simulate ovulation in a person. OI success rates vary with age, type of medication and other factors.
Artificial insemination, or IUI: involves the insertion of a donor’s or partner’s sperm into the uterus. Artificial insemination (IUI) is more famous for families who are infertile for unknown reasons or experiencing sperm dysfunction. IUI is less expensive than IVF and other treatments and is considered a less invasive procedure; (Wang et al., 2014).
In-vitro fertilization (IVF): is used to help with fertility or prevent genetic problems and assist with the conception of a child. IVF involves hormone injections to stimulate ovaries to produce eggs. Eggs are retrieved, and egg and sperm are placed in the laboratory to fertilize. If the embryo is developed, it is placed into the uterus.
Surrogacy: involves a surrogate carrying a child for another family or person with the intention to give the child to the family or person after birth.
The cost of fertility treatment can be very expensive. In Ontario, some treatments are eligible with a coverage limitation. In-vitro fertilization (IVF) is covered if it is One treatment cycle per patient, and the client must be under 43. Artificial insemination (AI) or IUI is covered with no limitation. Still, any fertility drugs needed, $5,000 per IVF cycle or $1,000 per AI (or IUI) cycle, genetic testing, and storing sperm, eggs and/or embryos are not covered by OHIP (Government of Ontario, 2021).
Black individuals’ experience accessing fertility treatments
There are multiple barriers black families/people face when accessing these treatments,
including lack of access to health care, lack of social support, low socioeconomic status, systemic racism, stigma and stereotypes. According to Deepa (2022), it is found that black and Hispanic individuals were approximately 70% less likely to utilize any form of fertility treatment. Access to fertility care is the major contributing factor to this disparity. It is confounded by several sociodemographic factors such as education, income level, insurance coverage, institutionalized racism, and cultural stigmas associated with infertility (Dongarwar, 2022).
The disparity exists around accessing fertility treatment and the quality of care delivered to black communities. Research shows that black individuals had lower live birth rates associated with fertility treatments than white individuals (18.7% vs 26.3%) (Eichelberger et al., 2016). Black individuals also have a higher miscarriage rate than white individuals (20.4% vs 13.2%) (Eichelberger et al., 2016). These results show the lack of research and the absence of black communities from clinical studies.
Low socioeconomic status is one of the barriers to fertility treatments in black communities. For example, the average woman under the age of 35 is expected to undergo at least three cycles of IVF (Dongarwar, 2022). As we discussed, in Ontario, only one cycle is covered. Fertility treatments are expansive, disproportionately reducing access by the black community with low socioeconomic status. Black individuals and families with lower incomes may not have the financial means to pay for fertility treatments or may not have access to health insurance that covers fertility treatments.
The black sperm shortage is another barrier black families face when assessing fertility treatments. Black sperm donors represent just a fraction of the available supply, fewer than 2 percent at sperm banks, according to an analysis by The Washington Post (Ferguson, 2022). Black families face a challenging decision to choose another race or find an alternative way to find a black donor. The reason for the shortage can be criteria set by the sperm bank for their donors. Donors are required to have a generalized health care history and family history. This can be challenging for black donors who have low socioeconomic status. The mistrust between black communities and medical professionals caused by many years of discrimination and racial profiling is another reason black donors move away from donating.
Black individuals experience neglect and violence where they are subjected to criticism and policing of their bodies. The stereotype that black people are hyper‑fertility that exists in the community and the medical field is one of the barriers to assessing fertility support. These stereotypes result in the assumption and dismissal of black individuals' fertility concerns. Furthermore, they lead to improper or late diagnosis and black individuals losing the chance of early treatment.
Barriers experienced by the LGBTQIA+ community
Besides racial minorities, sexual minorities in the LGBTQIA+ community experience stigmas and discrimination around accessing fertility treatments. In general, fertility treatments are geared toward heterosexual couples. This can be seen in the under-representation of LGBTQIA+ in infertility-related research (Maxwell et al., 2018). The exclusion of LGBTQIA+ individuals from fertility-related research is a significant problem that can lead to a lack of understanding of their unique experiences and needs. When they are represented, critical information seems to be lacking. As such, in studies that have examined the experiences of transgender individuals with regard to fertility preservation services, there is a lack of understanding as to why there is such a low level of service uptake among this population. Without a better understanding of the reasons for this, it is challenging to develop effective strategies to improve access to fertility services for transgender individuals. Factors contributing to this underutilization include financial barriers, discrimination, and a lack of education among healthcare providers.
Besides, the lack of adequate research heteronormative framing of fertility treatment services creates a lack of inclusivity for the LGBTQIA+ community. This creates inequality, such as patient education and health assessment forms that cater only to heterosexual couples. They may also face additional screening to ensure suitability as parents compared to a heterosexual couple and individuals, inappropriate questioning, and refusal of care (Maxwell et al., 2018).
There are also several socioeconomic barriers that affect the ability of the LGBTQIA+ community to access fertility treatments. One of the primary barriers is the cost of treatment, as many insurance plans do not cover fertility treatments or may have exclusionary clauses that limit coverage for LGBTQ+ individuals. This can make fertility treatments expensive for many individuals and couples, particularly those already facing discrimination and marginalization in other areas of their lives, including workplaces, which can impact their income and ability to afford fertility treatments.
Furthermore, socioeconomic factors such as race, ethnicity, and immigration status can also affect the ability of LGBTQ+ individuals to access fertility treatments. These groups may face additional barriers to healthcare access, such as language barriers or fear of losing immigration status. This can limit their ability to seek and receive fertility treatments.
It is essential to address these barriers and ensure that all individuals and families have access to the resources and support they need to make informed decisions about their reproductive health. This can include increasing access to affordable healthcare, improving education and awareness about fertility treatments, providing cultural competence training for medical professionals and addressing systemic inequalities that disproportionately affect black and LGBTQIA+ communities.
The role of a fertility Doula
A fertility doula is a person who supports people from the being of their journey to pregnancy. A doula serves as an advocate and support system in an exciting yet challenging time in people's lives. Fertility doulas also provide education around conception, health education and navigating the health care system. As community members face discrimination and inequitable access to fertility care, fertility doulas are essential as they advocate for their clients to receive the best care possible. Fertility doulas are also beneficial for mental health support; fertility treatments can be stressful. And fertility doulas can connect individuals to their community and the resources catered to them.
Reference
Wang, L., Sun, N., Lu, X., Zhang, Q., Xu, C., Cao, Y & Li, W. (2014).Clinical Outcome. Journal of Reproduction and Contraception, 25, (4), pp. 219–226, https://doi.org/10.7669/j.issn.1001-7844.2014.04.0219.
Government of Ontario (2021). Get fertility treatment. https://www.ontario.ca/page/get-fertility-treatments
Dongarwar, D., Mercado-Evans, V., Adu-Gyamfi,S., Laracuente, M. L., & Salihu, H.M (2022). Racial/ethnic disparities in infertility treatment utilization in the US, 2011–2019, Systems Biology in Reproductive Medicine, 68:3, 180–189, DOI: 10.1080/19396368.2022.2038718
Maxwell, E., Mathews, M. & Mulay, S. (2018). More Than a Biological Condition: The Heteronormative Framing of Infertility. Canadian Journal of Bioethics / Revue canadienne de bioéthique, 1(2), 63–66. https://doi.org/10.7202/1058269ar
Ferguson, A. (2022). America has a Black sperm donor shortage. Black women are paying the price. Retrieved April 4, 2023
Eichelberger, K. Y., Doll, K., Ekpo, G. E., & Zerden, M. L. (2016). Black Lives Matter: Claiming a Space for Evidence-Based Outrage in Obstetrics and Gynecology. American Journal of public health, 106(10), 1771–1772. https://doi.org/10.2105/AJPH.2016.303313
