Prague time, just like it did every morning. Andrea Murillo accepted the incoming FaceTime call from her husband in her small, short-term rental apartment. Outside her window, the sun had just broken through the cloudy Czech sky. “Hey honey,” she said cheerfully when she could see his face, in a tone that would make it hard to guess that they had been more than 5,000 miles apart for over two months.

Tony was lying in bed alone, his chin on a pillow, the lights off and his face illuminated by the phone’s screen, inside their three-bedroom house in a Dallas suburb. He’d be off to work in a couple of hours, but he had to check in with his wife first. The summer before, neither of them would have pictured their attempt to get pregnant quite like this. When she hung up the phone, Andrea said, “Boy, it’s early for him.” It was 4:30 a.m. in Dallas.

Like many modern couples, the Murillos spent most of their young adulthood focused on their careers. They didn’t start trying to have children until they married in 2016, when Tony was 41 and Andrea was 38 — past her peak fertility, when it’s usually easier to conceive without medical intervention. Within six months, they had progressed from old-fashioned intercourse to medically-assisted conception — expensive procedures that weren’t covered under their insurance plan. The procedures all failed, nearly wiping out their life savings in the process.

As a last resort before turning to other routes like adoption, they cast their eyes overseas. It was Tony who first had the idea. “We were looking for whatever options we could before we had to say we’d give up on trying to have a child,” he said. Through online research — “all his YouTubing, all his whatevers” — as Andrea put it, he started to realize that costs for fertility treatments, also often called infertility treatments, were lower outside the United States. “The more and more I researched,” Tony said, “the more and more it made sense for us.”

As fertility rates fall around the world, including in the U.S., the Murillos and many other hopeful parents are part of a different trend: the fast-growing and lucrative globalization of fertility treatments, also known as “reproductive travel” or “fertility tourism.”

Although a handful of states require insurance companies to cover such treatments, most don’t. That means patients still need to pay out of pocket for common services like in vitro fertilization (IVF) — where a woman’s eggs are fertilized by a man’s sperm outside of her body and then implanted as an embryo — which can run into tens of thousands of dollars. Estimates vary on just how many Americans respond to that high cost by looking abroad. Some experts suggest the number is as few as 1,000, while others have put the number as high as 70,000 — all of it without firm basis, because governments don’t tend to track the trend. What’s clear, however, is that a steady stream of Americans with perfectly good health insurance are traveling to countries they otherwise might never have set foot in to go through one of life’s most fundamental pursuits: starting a family.

“The whole process of birth is a miracle itself,” Andrea said. “It’s the most normal and natural thing in the world to do,” she added, “but it’s the hardest thing for some women, and I’m one of them, and it sucks.”

“We were looking for whatever options we could before we had to say we’d give up on trying to have a child,” said Tony Murillo.

After Tony mentioned the idea of traveling abroad to Andrea, she joined in the search and would spend all day exploring overseas clinics, which have flourished in some parts of the world and often cater to patients who live in other countries. Tony would do his part in the evenings after he came home from work. When they found a clinic that was promising, they would usually watch a YouTube tour with an introduction to the staff and facilities. If they were interested in the clinic, they could choose to have a Skype consultation with the doctor for a fee.

“You just kind of trust your gut,” Andrea said about the selection process.

After about two months of research, the Murillos had winnowed the list down to the Czech Republic and Spain, both countries that have thriving fertility industries, modern medical practices, and English speakers in clinics. But either way, they weren’t sticking around to try more treatments at home. “Either we could do it one time here in the U.S. and that was it,” Tony said, “or go overseas and do a couple of different times if we had to.”


IT’S NEVER BEEN easy to have a baby, at least when it comes to the precise timing. In her lifetime, the average woman releases between 300 and 400 eggs through ovulation over a period of around 35 years. If an egg isn’t fertilized by sperm within about 24 to 36 hours, it dissolves, and since sperm can live inside a woman’s body for almost a week, there are only about six days each month where it’s possible to get pregnant through natural intercourse, without the help of a fertility doctor.

Couples who are unable to conceive after one year of unprotected sex (six months if a woman is over 35) meet the threshold of what the Centers for Disease Control and Prevention (CDC) define as infertility, which is also the point at which most doctors recommend seeing a fertility specialist. There are all sorts of causes of infertility — the CDC lists at least six in its 2016 Assisted Reproductive Technology National Summary Report, in addition to other health issues or combinations of factors. Most relate to female infertility, generally involving issues with the reproductive organs or the inability to produce eggs; around half involve male infertility, generally concerning issues with the quality or delivery of sperm. But 25 percent of women with fertility issues receive the most ambiguous of diagnoses: unexplained infertility.

According to one common metric, having a baby seems to be getting even harder: The number of women who have problems either getting pregnant or carrying a pregnancy to term has risen by more than 21 percent since 1982, according to the CDC’s most recent National Survey of Family Growth.

Women are also having fewer children. In 2019, America’s fertility rate, the average number of children a woman has in her lifetime, reached an all-time low, according to the World Population Data Sheet, which is published annually by the Population Reference Bureau, a nonprofit that collects data about the structure of populations. Despite this contraction in fertility rates and a persistent public perception that infertility is on the rise, the infertility rate — which measures those couples having difficulty getting pregnant but doesn’t account for miscarriages or stillbirths — has been declining since at least 1965. Around one in 15 women in America meet this threshold, according to the CDC’s latest statistics (which only take into account married women). In 2014, the CDC published its first National Public Health Action Plan for the Detection, Prevention, and Management of Infertility. Three years later, the American Medical Association joined the World Health Organization in categorizing infertility as a disease.

But the issues of infertility are especially acute in older couples. “There is an infertility epidemic,” said Sherman Silber, director of the Infertility Center of St. Louis, who helped invent many of the treatments commonly used for infertility today. “But it’s simply related to the fact that people are starting at an older age.”

Age is inversely related to fertility, so the older you are, the harder it is to conceive. It affects both sexes but has an outsized impact on women because the quality of a woman’s eggs decreases with time. Until age 34, the probability of pregnancy goes down gradually; after that, it falls by 10 percent a year. At 40, 95 percent of women are infertile, according to Silber.

American women have children at a much older age than a century ago, and many couples just don’t anticipate problems getting pregnant. “People are like, ‘Oh, we live longer, we don’t have to rush into marriage and childbearing,’” explains Marcia Inhorn, an anthropologist at Yale University who studies infertility and infertility treatments. “So people are pushing it back, pushing it back, but without adequate fertility education.”

When people can’t have children and they start looking for help, it often comes in the form of assisted reproductive technology (ART) ,  a catchall term for treatments that handle eggs and sperm outside of the human body.

The earliest successful example, in vitro fertilization, or IVF, dates back to 1978 and involves mixing eggs and sperm in a Petri dish to encourage fertilization. Since then, many reproductive technologies have appeared, including, but not limited to: egg donation, where a healthy egg is removed from a donor, fertilized in a lab, and implanted into another woman; genetic screening, which helps identify potential illnesses and disorders prior to the embryo being implanted in the uterus; and intracytoplasmic sperm injection, or ICSI (pronounced “ik-sea”), a variant of IVF where a single sperm is inserted directly into an egg.

The article was published at Facing High Costs at Home, Americans Seek Fertility Help Abroad.

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