Most heterosexual couples spend more of their reproductive years trying not to get pregnant than hoping to conceive, which can make it even harder to handle when efforts to make a baby fail. Today, there are many options that can help couples facing infertility, as well as same-sex couples, have a biological child. A new report card, however, suggests that where the couple lives may have a lot do with how many options are readily available.

The “fertility report card” was created by RESOLVE: The National Infertility Association. The organization graded each state based on the number of fertility specialists working there, how many infertility support groups were available, and whether the state had an insurance mandate requiring coverage for in vitro fertilization (IVF). RESOLVE also noted the number of women “who have experienced physical difficulty in getting pregnant or carrying a pregnancy to live birth” in each state.

Most states got Bs and Cs. Texas, for example, received a B because there are 86 specialists and eight support groups serving the 580,552 women in the state who have experienced physical difficulty getting pregnant or carrying a pregnancy to live birth. The state also has an insurance mandate, though religious employers are exempt. Another large state, California, got the same grade because it also has a mandate, and has 142 specialists and 20 support groups for its 858,579 women facing infertility. What likely prevented a better grade was the fact that the mandate requires insurers to offer coverage but not necessarily to provide it (couples could buy it). Moreover, the coverage does not have to include IVF, and religious organizations were exempt.

Two states in the country received failing grades—Wyoming and Alaska. Wyoming has only 11,621 women facing infertility, but there are no fertility doctors or support groups to help them get services and no mandate for coverage. Alaska is in a similar situation, with 15,612 women facing infertility and no specialists, support groups, or insurance mandate.

Only five states received an A from RESOLVE: Connecticut, Illinois, Massachusetts, Maryland, and New Jersey. Connecticut, for example, has 23 specialists and two support groups for only 75,348 women facing infertility. There is a mandate in place, though it has a number of exemptions. For example, religious organizations are exempt, policies have a lifetime max of two rounds of IVF, and women over 40 are excluded. New Jersey’s law has fewer exemptions; religious organizations are not exempt but employers with fewer than 50 employees are, plus cryopreservation and nonmedical egg or sperm donation are not covered.

These mandates, however, may be at risk as the Affordable Care Act is interpreted and implemented. The federal health-care law itself does not consider infertility treatments to be an essential health benefit (EHB) that has to be covered, but states were required to choose a benchmark insurance plan based on 2012 plans in their states. These benchmark plans were then used to set the specific EHBs for that state. Some states that had mandates chose plans including infertility treatments, while others did not. As of now, infertility treatments are considered EHBs in Connecticut, Hawaii, Illinois, Massachusetts, New Jersey, and Rhode Island. This could change going forward as states face pressure to pay for any EHBs above what the federal government requires.

RESOLVE designated these states, as well as Arkansas and Maryland, as requiring advocacy efforts to make sure that the mandate for coverage stays in place. Other states, including Arizona, North Dakota, and Texas, were also designated as requiring advocacy despite the fact that they each got a B on the report card, because, according to RESOLVE, “lawmakers have a history of trying to pass laws that negatively impact the infertility community.”