Black women are more likely to experience infertility than their white counterparts, but they’re less likely to seek treatment for it because of steep barriers to entry. And 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 two-pronged issue: Black women use IVF and other assisted reproductive technology less, and later. That means many people aren’t getting the help they need, and even among those who get it eventually, the delay in care contributes to worsened outcomes.

The racial disparities among those who pursue assisted reproductive technology are striking. 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 started with IUI, and then turned 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 didn’t want to tell anybody because I was embarrassed. No one that I knew was talking about it.”

When Denise Hendricks hit her early 40s, she was unmarried and decided to look into IVF. After visiting a fertility specialist, she found that she was able to carry, but her egg reserve was too low. She decided to try IVF with a sperm donor and an egg donor. Like Eastman, it wasn’t easy for her to talk about.

“It never was discussed in my household, or even among my friends,” Hendricks said.

Despite the prevalence of infertility—about 1 in 6 adults worldwide are infertile, according to the World Health Organization—it’s still largely taboo, especially in the Black community, Hendricks and Eastman said.

“I just always thought I would get married and have babies the natural way; it didn’t even cross my mind that I might need to freeze my eggs or think about my fertility,” Hendricks said.

That stigma comes at least in part from the pervasive but inaccurate belief that Black women are naturally fertile. 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 labeled this way and conditioned to believe it ourselves, even though it’s not true. We experience the same issues that everyone else experiences, but we don’t get the same attention, the same research, or the same access to care.”

Other barriers to entry

Even aside from harmful stereotypes and stigmas, assisted reproductive care has significant barriers to entry—the biggest one being 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. Ultimately, she only completed one round before turning to adoption—which, she pointed out, is also an expensive undertaking. For a private domestic adoption, which is how Hendricks adopted her son in May 2016, rates can range from $20,000 to $45,000. International adoptions can cost between $20,000 and $50,000.

“The way the system is set up, if you can’t have kids naturally, it’s hard to have them at all,” Hendricks said. “Both IVF and adoption are incredibly expensive, not to mention the costs of actually raising the child.”

The lack of diversity in patients, thanks to inequitable coverage of fertility treatments, has contributed to the persistence of these racial disparities. Eastman said that at the fertility clinic she went to, she was consistently the only person of color in the waiting room.

The lack of diversity in providers doesn’t help. Only 5.7 percent of doctors in the U.S. are Black, according to the Association of American Medical Colleges, compared to the 13.7 percent of the population who is Black, but time and time again, it’s been proven that Black patients who are treated by Black doctors tend to have better outcomes because of higher levels of trust and care.

Eastman didn’t seek out a Black doctor, but when the white doctor she had been assigned at the fertility clinic left the practice, she happened to end up with a Black doctor, Dr. Desireé McCarthy-Keith. 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. “There was one specific time, when my grandmother had passed away and we traveled back to New York for her funeral, that everyone kept asking. 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 shared a message on Facebook urging people to stop asking about other people’s plans to have children. Later that night, her sister told her to check her account.

“A lot of people were messaging me, Black people specifically, saying, ‘I’m struggling with infertility too and no one in my family knows I’m going through this,’” Eastman said. “There were literally so many messages that I was overwhelmed trying to answer them all. It made me feel like I wasn’t alone.”

The fact that so many people were more willing to open up to a stranger on Facebook than their own families spoke volumes to her, Eastman said. It inspired her to create the web series Black Girls Guide to Fertility about the struggles of suffering in silence while dealing with infertility. She wrote an accompanying play and produced a podcast discussing different aspects of infertility, with episodes like “Life After a Miscarriage: How to Cope,” “Planning, Praying, and Hoping,” and “Pregnancy After 40.” It’s connected her with dozens of women, many of whom haven’t shared their stories with anyone else.

“There was one woman I met who told me she went through the same thing but gave up, and when I asked her why, she said it just became too overwhelming,” Eastman said. “She said after two IVF failures, and not being able to talk to anybody about it, it was just 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. Earlier this year, the organization hosted its first annual Black (in)Fertility Awareness Week, dedicated to raising awareness, fostering dialogue, and advocating for the human rights of Black communities 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 get into Black and brown spaces, I think it’s eventually going to click for folks to know this is something we have to pay attention to, and it’s something that can be talked about.”

The week included four events, including a discussion of the intersection of infertility, sickle cell disease, and fibroids (both sickle cell and fibroids are much more prevalent in Black communities than in others), and a panel with experts in reproductive and Black maternal health.

Jones is passionate about this work because she too has struggled with fertility. In her early 20s, she had an ectopic pregnancy and needed a medication abortion. She didn’t try again until she was in her mid 30s, when she found herself wishing there had been more follow-up at the time so she could have had an opportunity to learn about her own fertility before she reached an older age.

“I had more than 40 eggs retrieved, and I ended up with over 20 embryos frozen,” Jones said. “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. They will also look at outdated parentage laws that may be causing issues for LGBTQ+ families and create a toolkit that other states can adopt.

“So far we’re talking with Kentucky, Tennessee, and North Carolina, but our goal is to make this a national campaign because we know the right to IVF keeps getting voted down,” Jones said.

An interrelated issue

Last month, Senate Republicans blocked the Right to IVF bill for the second time. The bill would have barred state restrictions on the procedure and required insurance coverage.

“We have to ask, who do our systems support?” Ukoha said. “Who is prioritized to be allowed to build families in the way they see fit, and who is not?”

Access to infertility treatments is one piece of the large puzzle that is reproductive freedom. 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 be making sure that we’re giving people access to all of these options, and that people don’t have unnecessary barriers to receive care.”