Why IVF and Fertility Technology Are Becoming Major Inequality Issues with Professor Leonard M. Lopoo.

Access to fertility care is changing rapidly, but who gets access to these technologies is a growing concern. On this episode of Ask the Doulas, we speak with Professor Leonard M. Lopoo, author of Wanting Children, about the intersection of fertility, technology, economics, and inequality.

We explore how IVF and other reproductive technologies are increasingly shaping who can become a parent, why access is far from equal, and how income, race, geography, insurance coverage, and social policies can influence fertility outcomes. Professor Lopoo also shares insights from his research on Americans' changing attitudes and experiences around having children.

This thoughtful conversation looks beyond the technology itself to ask a bigger question: What happens when the ability to build a family depends on who can afford the opportunity?

If you are navigating fertility treatment, considering your options, or interested in the larger social and economic forces shaping parenthood today, this episode offers an important perspective on the future of family building.

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Ask the Doulas is a pregnancy, birth, postpartum, and parenting podcast for expecting families, new parents, and birth and baby professionals. Hosted by Kristin Revere and Alyssa Veneklase of Gold Coast Doulas, the podcast features conversations with doulas, childbirth educators, lactation consultants, sleep consultants, newborn care specialists, fertility experts, and perinatal mental health professionals. Ask the Doulas is designed for both parents and professionals looking for trusted guidance, continuing education, and real-world strategies.

Transcript

Episode #353 | August 21, 2026

Access to fertility care is changing rapidly, but who gets access to these technologies is a growing concern.  On this episode of Ask the Doulas, we speak with Professor Leonard M. Lopoo, author of Wanting Children, about the intersection of fertility, technology, economics, and inequality.

We explore how IVF and other reproductive technologies are increasingly shaping who can become a parent, why access is far from equal, and how income, race, geography, insurance coverage, and social policies can influence fertility outcomes.  Professor Lopoo also shares insights from his research on Americans' changing attitudes and experiences around having children.

This thoughtful conversation looks beyond the technology itself to ask a bigger question: What happens when the ability to build a family depends on who can afford the opportunity?

If you are navigating fertility treatment, considering your options, or interested in the larger social and economic forces shaping parenthood today, this episode offers an important perspective on the future of family building.

Hello, hello!  This is Kristin Revere with Ask the Doulas, and I am thrilled to chat with Professor Len M. Lopoo.  He is an economist, a professor at Syracuse University, and author of Wanting Children, which explores fertility inequality, reproductive policy, and the growing divide to access to parenthood in America. 

Welcome, Len! 

Thank you, Kristin!  I’m delighted to be here. 

Yes, I am so excited to chat about policy, especially related to IVF and fertility technology and how that relates to a lot of inequality issues for those that don’t have access.  I would love to hear your take on it as an economist, as a professor, and certainly as an author. 

Yeah, it’s really an important topic.  Thanks for asking.  I think it’s really important to emphasize the inequality that you just mentioned.  When we speak about things like assistance with IVF or artificial insemination, ovulation stimulating drugs – these are not resources that everyone in the country has access to.  It’s really something that mostly people who have a lot of wealth and have a lot of resources can gain access to.  And you mentioned my book, Wanting Children.  That’s really kind of a focal point of the book itself: why is there this big difference between someone without a lot of resources and their ability to get access to them versus those with a lot of – you know, maybe a more affluent family who wants to have children and may be having some infertility difficulties, and the resources that are available to them.  How do we get a more fair system in the United States and why does it look the way that it does? 

Yes.  And there are so many factors that affect fertility, and obviously, delaying parenthood is one of the biggest ones, to focus on career and education.  Or delay in meeting a partner.  But certainly as a birth and postpartum doula, I see a lot of secondary infertility, so there may not have been challenges with the first child, but then wanting to build a larger family, I’ve had so many clients with those challenges with secondary infertility and have sought out IVF and other fertility treatments. 

Yeah, I think from a social standpoint, what we really want to do is try to help anyone who wants to be a parent or to have another child have access again to the sorts of resources that would help them to succeed, to become a parent.  And a lot of our federal programs really aren’t designed that way.  They’re often designed to help people control their fertility: access to contraception and other reproductive health services.  But we really don’t think at all about this question, so absolutely. 

And it certainly has been a big topic in this current administration, about wanting more children and larger families.  And so we certainly need policy to come along with that. 

Yeah, it’s been a huge emphasis within the current administration, as you said.  This pronatalism movement is what it’s frequently called.  And it’s interesting because it’s not really sort of a universal interest in pronatalism; it’s a very specific set of individuals that they’re focusing on.  For example, they recently introduced Trump Rx, which is a policy designed to help people get ovulation stimulating medications, but only those who can pay sort of out of pocket for it are eligible for the services.  So someone who uses public health insurance, for example, would not be allowed to take advantage of that opportunity.  So it really isn’t everyone who is the focus of the pronatalism that we’re seeing.  It’s really sort of the middle class, more affluent individuals.  That seems to be the set of people that’s really the focus of a lot of this pronatalism. 

So how do we make this more equitable and allow the same options for everyone? 

It’s a great question.  I think that what’s interesting to me and what really motivated me to write the book was to think a little more about what our goals for population policy should be in the United States.  I’ll give you a simple example.  If we introduce an economic policy in the US, you might have differences in how we can succeed economically between maybe the right and the left side of the aisle, but everyone would universally agree, economic growth is a good thing.  So economic growth is good; we may have different approaches to it.  When we think about things like our population in the United States, we don’t even have a policy or sort of a guideline that we go by for what would be in the best interests of the country.  There have been times when we have thought shrinking the size of our population would be a good thing.  We’re now at a place, as we just discussed, where we think growing the population would be a good thing.  So we’re just not very consistent.  So part of the thing that I introduce in the book is where the title comes from.  We should really have, as our population policy, an approach to helping anyone who wants to have a child to have that child.  And anyone who doesn’t want to have a child, we should be focused on assisting that as well.  We seem to do a pretty good job with that second goal, meaning there are lots of resources if you want to try to control your fertility.  So the book really is about how do we generate more openness to helping everyone who might be having difficulty having a child to reach that goal, and part of that is changing our resources, making health insurance, for example, more broad, covering more options for individuals, and that’s both public and private health insurance.  Public health insurance is only designed for low income families.  So when you think about family planning and what government does for family planning, targeting low income families and providing them contraception – that is the US policy.  My perspective is, we should be broadening that.  We should have many more people having access to all family planning services in the US, and we should be thinking about that for our private health insurance coverage, as well.  Most states in the United States will not cover any infertility services.  They’re not mandated to, and if they’re not mandated to, they won’t cover them.  So the book is really about, we need to change our emphasis.  We need to be thinking about helping people who want to have children do that, both through the public and the private health insurance markets. 

And I know obviously a lot of this is going to be in the book, but do you feel it should be on a state by state basis, or is it better to be overarching federal policy?  Where do you see this being most effective as an introduction? 

So I love our federal system.  There are many programs where we say, here is a broad set of guidelines.  Take our welfare program, for example.  The federal government has said this is, broadly speaking, what your welfare program should look like.  Now, each state should have the discretion to craft that policy in a way to make sure they meet those goals.  And I think having that kind of federal emphasis does a bunch of things that can be really important.  So the state of New York may never look like the state of Nebraska, may never look like the state of California, but the state of Nebraska and the state of California can craft a system that they think is going to be most effective there.  Again, this has been done repeatedly.  In fact, our family planning program, the Medicaid program, for example, also has a set of universal policies but recognizes that each state can craft the policy that they think is most appropriate, making sure that they meet some minimum set of guidelines.  And I think that there’s a lot of evidence that that can be successful.  That can allow for differences, and that can allow for leadership in any particular area to create the program that they think is going to be most beneficial and representative of the people that they’re working with, that they’re representing. 

Yes, and certainly with self-funded benefits and employer benefits, especially in the technology and banking space, there are options within Carrot Fertility, for example, Progeny, and Maven.  Those come to mind, that not only cover IVF and fertility support but also cover doulas, both birth and postpartum.  But that is not as inclusive as you mentioned, looking into overarching federal programs. 

Right, exactly.  So it’s not surprising that some corporations will introduce these benefits as a way to attract talent.  There’s lots of evidence of that.  And that’s a great thing.  If those are options that are available in the company that you’re working within, terrific.  But there’s so many individuals who don’t have that option, who don’t have that benefit available to them.  And again, we should be trying to help people who want to parent to become parents.  You know, that’s where the universality of it, I think, can be so important.  And by the way, those benefits can be taken away and reintroduced or removed, depending on the bottom line at any particular corporation at any particular time, as opposed to a state mandate which would require certain things happening.  I think the other value, Kristin, of offering or having these state mandates is once things become more universal, you’ll start to see a lot of technological advancements in this space.  You’ll start to see costs going down.  There’s a lot of beneficial things that can happen if a state decides to mandate as opposed to a particular company deciding that this is a good thing. 

That makes a whole lot of sense, Len.  In our field as doulas, we have seen state by state Medicaid coverage for birth doulas, and Michigan and New York are some of those states, but it is slowly growing over time, and there’s so much evidence in doulas not only increasing satisfaction but reducing interventions and surgical births.  So I can see how going state by state and having the overarching access for everyone can be beneficial because doulas used to be seen as only something that those with means could afford, especially postpartum doulas, and now getting health savings and flex spending and some self-funded benefits, and Medicaid in certain states, has certainly allowed more people to have access to support. 

Yeah, it’s a perfect example.  The incredibly important work that doulas are doing is not only beneficial for the parent and the child, the family, but the great work that they’re doing is creating more health.  And therefore in the long term, costs go down.  This is another – there is great evidence that, again, if you were to sort of expand benefits, the costs that people throw around right now are really not the right costs.  They’re the cost when you provide this exclusive service to a small set of people, but as you expand it, average costs are going to drop dramatically, and you’re going to see better health.  You’re going to see healthcare costs in the long term go down.  You’re going to see all sorts of benefits that I don’t think makes its way into the conversation.  So I’m so glad that you brought that up.  I think it’s a perfect example of why making an important resource available can actually save in so many dimensions we don’t even think about. 

Right.  And this conversation is so important because again, that emphasis on growing families and having access and affordable healthcare – it really starts with conception, and you mentioned prevention, but also the ability to grow your family, to start your family, with support if needed, because there are so many issues right now, whether it’s environmental concerns or food or medical care that are preventing conception without intervention. 

Absolutely.  Absolutely.  I think that’s exactly right, and again, getting to a place where people who want to have children have that opportunity is so very important.  I’d love to just say a couple of words about sort of what the research shows on this.  There’s been actually a number of studies that explain that if – you know, what I always say is, all births are not the same.  Clearly, there’s a lot of joy and value and importance to all births, but when a parent plans a birth, when a parent is sort of ready emotionally, financially, psychologically to have a child – they may be at a point in their career when they’re ready – when they do this on their timing, the evidence is overwhelming that the children of that parent who wants to have that child do better on every dimension.  You can look at their education.  You can look at their employment.  You can look at their psychosocial outcomes.  You can look at really just about any dimension, and those children are better off.  So someone who might be having trouble becoming pregnant or having a second or a third child – they want to have that child.  That’s so much better.  That’s the kind of individual – socially, right, from kind of a social welfare standpoint – that we should be encouraging.  So that’s again really kind of the point of emphasis.  We should be really kind of reallocating resources in a way that can help anyone who wants to become a parent to become that parent.  It’s better for them.  It’s better for their children.  It’s better for us as a society. 

Right.  And I know that even as fertility is rapidly changing, and there are ways to – I don’t want to call it designer babies, but help that preselection, and I know with certain genetic conditions, ALS being one, that you can take out markers and be able to focus on prevention with using IVF and fertility treatments.  So there’s so much benefit beyond being able to, say, choose a gender down the road. 

So a good portion of my book – I talk a lot about the past and why we’re in this situation that we’re in and what kind of led to it.  And some of it is very reasonable and people were making good choices, and some of it was a little more nefarious behavior, I think, on behalf of some of the people who were creating this programs back in the ‘50s, ‘60s, and ‘70s.  But the book also talks about the future and some of the questions we’re going to have to grapple with, and you’ve really touched on a number of them.  We are at a point now where people – where the medical community can do testing, either before you become pregnant or once one becomes pregnant and learn a lot about the future for that child, should it be born.  And you mentioned designer babies.  I think that’s a really important question.  If only a certain segment of our society has access to the resources that will allow their child to be healthy, for example, then that’s really not fair.  That’s not equitable.  And I don’t mean this is about the wealthy and very poor Americans.  I mean the vast majority of Americans cannot afford to do the sorts of things that we’re talking about, learning a lot about the health consequences of a particular pregnancy.  And so by not making that available to everyone, we really are kind of creating a system that is not going to be fair, and you’re going to see more and more separation within our society among the people who can afford a child that has certain genetic markers that signal a potential health problem eventually and those who can’t.  And that’s also something I think we need to think a lot about as a society. 

Yeah, the future of healthcare – I mean, it can go in so many directions, and there’s a lot of ethical concerns, certainly. 

Absolutely.  There are lots of concerns.  I mean, in many ways, you know, there are technological changes that are occurring that are exciting and beneficial and a little scary and worrisome, and many places on our globe are taking advantage of those.  So the question is, are we going to pursue that in the United States, and if we’re pursuing that in the United States, are we going to give everyone access to those opportunities, or are we not?  And what are the implications of that?  I think these are really important questions that we don’t really think very much about right now, and I’m hoping to kind of bring some of that into the discussion.  You know, people have brought up the older movie, Gattaca, which is sort of this notion of the designer baby and what does that actually mean, and I always say we’re kind of there now.  We really need to be thinking about those conversations. 

I agree.  Even Elon Musk and his focus on having as many children with many different mothers and having his own idea of controlling the gene pool.

Elon Musk has got some interesting perspectives on children and how this should be operating.  And by the way, it’s not just Elon Musk.  There are lots of – there is some evidence that there are a number of people of extraordinary wealth who are having lots and lots of children, and what are the ethical implications of that?  And that’s certainly far from the goal of my book – again, Wanting Children, we should be thinking about children that are going to grow up in a loving environment where parents are investing in them and spending lots and lots of time with them.  That’s sort of an extreme version of what can happen as we’re moving forward and these technologies are made available to a lot of people. 

Yeah.  So Len, you mentioned other countries and models that you have researched.  Could you give an example of a country that is making fertility more equitable all around and not just for the elite class? 

Yeah, that’s a great question, Kristin.  And there are a lot.  So I can give you a number of examples.  Europe is a great place to start.  There are a number of countries in Europe that have been thinking about this a lot longer than we have, and the reason is fairly straightforward.  We’ve never had huge declines in our fertility in the United States like we’ve seen in a lot of the rest of the world.  In Europe and in Asia, fertility levels below two, which basically means you’re going to have fewer children in the next generation than you do parents in the previous generation.  So most demographers say you want about 2.1 children born per woman to sustain the population.  In Europe, they’ve been well below two for decades now.  So they’ve thought a lot more about it and I think are a little more progressive.  Take a country like France that even as long ago as World War II where they had big differences in the number of men and women as a result of the war and had big concerns about their ability to grow their populations.  So they’re very generous with their IVF and other fertility-related coverage.  A lot of Scandinavian countries are very generous.  Poland has really had a big change.  You can get multiple cycles of IVF in nearly all of these countries through public health insurance, in many places up to six cycles of IVF.  My research suggests that even a country like Estonia, which is very different in terms of economic well-being than the United States, is much more generous in terms of what they do to help people who want to have children gain access to the resources that we’re talking about. 

Fantastic.  Yeah, I would love for you to let our listeners and our doula clients know how to find your book and a bit more about what you cover that we may not have discussed in this conversation. 

Yeah, thanks!  So the book again is called Wanting Children.  It was published the University of Chicago Press, but it’s available broadly and wildly.  You can get the book really wherever you buy your books: Barnes and Noble and Amazon are two prime examples of places where you can find the book.  And as far as what we didn't discuss, I offer some pretty specific policies about what we should be doing.  Again, a lot of that is broadly speaking, becoming a little more universal in the way that we think about providing this coverage.  I think I go back in time and talk a lot about why the policies that currently exist do look this way.  I think there’s a health equity argument that’s always been made.  Health equity is the idea that anything that’s available for an affluent American should be available for someone with less, and that’s a very reasonable, important, and absolutely foundational idea behind our family planning.  But I also discuss a little more of the eugenic history of this country and how we have, for a very long time, not wanted certain people or certain sets of people in our population having children, and that probably played a large role in why contraception is the emphasis of our family planning and low income people are the only individuals that gain access to these publicly provided contraceptive services.  So I really talk a lot about the past.  I talk about the way things look today from a federal standpoint, as well as the future, which we’ve talked a little bit about with designing babies and what that can ultimately mean if we don’t think very seriously about making a lot of these options more broadly available. 

Well, I can’t wait to read your book.  So fascinating!  And thank you for sharing all of your research with our audience.  Any final tips for our listeners or final thoughts, Len? 

No, Kristin, I just really want to thank you.  I’ve certainly really enjoyed our conversation.  You really bringing this important topic to the public and trying to understand how we can make resources more broadly available to everyone is really beneficial to our entire society and so I just really want to recognize what you’re doing and how important it is.  Thank you for the time that we’ve had together. 

Thank you, Len!  I appreciate the work that you’re doing.  It’s so important.  We’ll have to have you back on again as things change.  Hopefully, you’ll some good news for us at the next episode! 

I’d love to come back anytime!  Absolutely.  Thanks so much! 

IMPORTANT LINKS

Buy Dr. Lopoo’s book, Wanting Children 

Birth and postpartum support from Gold Coast Doulas

Becoming A Mother course

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