MINNEAPOLIS -- Annamarie McDonald has long wanted to have three children.

To do so, though, the 36-year-old and her husband needed some medical help. After multiple rounds of in vitro fertilization (IVF), they now are thankful parents of a 2-month-old daughter, with embryos remaining.

But they also have a $60,000 home equity loan that they took out to pay for the two egg retrievals and three embryo transfers. They’ve been making $400 monthly payments since before their daughter was born, McDonald said, and expect that to continue until they eventually sell their home.

“We grappled with, do we have kids at all?” said McDonald, of Apple Valley. “And is our financial security ... going to hold us back from being parents, which we wanted more than anything?”

As the U.S. debates the social causes and solutions for its declining birthrate, one thing is clear: Family-building is a costly affair.

Demand for fertility care, which can cost tens of thousands of dollars that patients often must pay out-of-pocket, is growing. Roughly half the states now require insurance companies to cover the cost, but legislative efforts to do the same in Minnesota have failed five times.

The 2026 legislative session marked the latest unsuccessful attempt to pass the Minnesota Building Families Act, a bipartisan measure that would have required health plans to cover infertility diagnosis and treatment, fertility preservation such as removing and freezing eggs or sperm, and IVF.

Having insurance coverage can be the difference between starting an IVF cycle and holding off, said Dr. April Batcheller, medical director at the fertility clinic CCRM Minneapolis. Patients might time a cycle with switching to a spouse’s insurance plan or changing jobs, she said.

“I think of the number of patients that I’ve had, even in the past couple weeks, like, ‘Oh, do you think that bill you were talking about, is it going to pass?’ And waiting to do IVF in hopes that it was going to pass,” she said. “It’s just so disappointing.”

Twenty-five states and Washington, D.C., have laws requiring insurance coverage for infertility-related health care, including 15 that mandate IVF coverage.

One round of IVF, in which a lab fertilizes a retrieved egg before doctors transfer the resulting embryo to the uterus, costs $15,000 to $20,000 on average, with no guarantee of success.

Patients pursue IVF for myriad reasons. Many have been diagnosed with infertility, a condition that affects 1 in 6 adults worldwide.

Scar tissue from a ruptured appendix when Denise Miller was 15 meant that now at 40, she and her husband were unable to conceive by traditional means. Two rounds of IVF — the first unsuccessful, the second resulting in identical twin daughters — cost more than $30,000, paid for with a 401(k) loan.

Miller, of Elko New Market, had to repay the loan within a few years at a time when the couple were juggling the cost of child care and other essentials.

More than seven years later, she said, they’re still paying off credit card debt they accrued as a result.

“It did put a big financial strain on our household,” Miller said.

‘The support is there’

Lawmakers and advocates said the Minnesota Building Families Act came closer to passage this year than ever before. But concerns about the cost of a new health insurance mandate at a time of already-rising premiums, as well as religious opposition, stood in the way.

A 2023 state Commerce Department analysis estimated the legislation would raise monthly premium costs an average $1.30 per member in the first year of implementation, and rise to $2.20 per member by the tenth.

“Most data suggest that the increase in total monthly premiums for an infertility coverage mandate would be less than 1%,” the department wrote.

Industry groups argue the increase could be more. In an April 8 letter to lawmakers, Jonathan Cotter, health care and commerce policy director at the Minnesota Chamber of Commerce, cited estimates from the Minnesota Council of Health Plans, which also opposed the measure, of an average $12 monthly premium increase per member.

“We encourage continued restraint when considering new health insurance mandates, particularly as employers face ongoing cost pressures in providing coverage,” Cotter wrote.

Legislators narrowed the bill over the course of the session to include just large-group insurers and approved an exemption for religious objections. But after passing the Senate with bipartisan support, the bill died during conference committee negotiations.

“I think the support is there, and I think it was very unfortunate,” said Rep. Robert Bierman, DFL-Apple Valley, who served on the conference committee.

He said negotiations continued “down to the wire” and included eliminating coverage for embryo storage. The final version of the bill carried no cost to the state.

“The good news is we were having a conversation about it, more so than we ever have in the past,” said Lakeville’s Sen. Zach Duckworth, one of two Republican co-authors on the Senate bill. “With a little more time, it may have been doable.”

Growing families

The debate over making IVF and related health care more affordable comes at a time when the U.S., like countries across the globe, is grappling with a declining birthrate.

Like every other state, Minnesota has a fertility rate lower than population replacement level, which is 2.1 babies per woman of childbearing age. With federal policies tamping down international immigration and persistently low levels of domestic migration, Minnesota has few options for growing its population.

“It is an issue, it’s a change, and it’s something that will have impacts on the economy and on many different dimensions of our community,” said Susan Brower, Minnesota state demographer.

Government policies aimed at encouraging people to have children haven’t historically moved the needle. And though the number of babies conceived through IVF and born in the U.S. has grown, it’s makes up only about 3% of all births.

Still, for individual Minnesotans, insurance coverage for infertility treatment could change everything — especially when many families are already cutting back amid rising prices and economic uncertainty.

“There might have been people for whom 18 months ago, saving to have a child, to go through the infertility treatment process, was possible, [and today it is not,” said Sen. Erin Maye Quade, DFL-Apple Valley, the bill’s chief author.

Miraya Gran, 42, has advocated for the Minnesota Building Families Act for years in hopes of helping families like hers to grow. She and her husband conceived their daughter through IVF and have two embryos remaining, but they can’t afford to transfer them without insurance coverage.

“I’d love to give my daughter a sibling,” Gran said. “She asks for one all the time.”

Allison Kite of the Minnesota Star Tribune contributed to this story .

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