Willingness to pay for in vitro fertilization: results from a national sample of reproductive-aged adults in the US.

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Learn more: PMC Disclaimer | PMC Copyright Notice J Assist Reprod Genet . 2025 Jun 4;42(7):2293–2303. doi: 10.1007/s10815-025-03539-w Willingness to pay for in vitro fertilization: results from a national sample of reproductive-aged adults in the US Sitara Murali 1, ✉ , David Suh 2 , S Sriram 3 , Anna Kirkland 4 , James M Dupree 5, 6 Author information Article notes Copyright and License information 1 Department of Urology, Institute for Research on Women and Gender, University of Michigan, Ann Arbor, MI United States 2 Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI United States 3 Ross School of Business, University of Michigan, Ann Arbor, MI United States 4 Kim Lane Scheppele Collegiate Professor of Women’s and Gender Studies, Arthur F. Thurnau Professor of Women’s and Gender Studies, Political Science, Sociology, and Health Management & Policy (By Courtesy), University of Michigan, Ann Arbor, MI United States 5 Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI United States 6 Department of Urology, University of Michigan, Ann Arbor, MI United States ✉ Corresponding author. Received 2024 Dec 16; Accepted 2025 May 28; Issue date 2025 Jul. © The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2025. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law. PMC Copyright notice PMCID: PMC12356779  NIHMSID: NIHMS2156141 PMID: 40465151 Abstract Purpose To assess United States (US) reproductive-aged adults’ willingness to pay for in vitro fertilization (IVF) and determine socio-demographic factors associated with their willingness to pay. Methods We conducted a cross-sectional survey of reproductive-aged adults (18–50 years old) to ask respondents demographic and reproductive health questions, including the US dollar amount they would be willing to pay out-of-pocket for IVF over a 12-month period. We used linear regression models to determine associations between socio-demographic factors and respondents’ willingness to pay for IVF. Results There were 2,035 survey respondents from 49 states and the District of Columbia. 43.6% were female assigned at birth, 81.7% were heterosexual, 42.6% were married, and 7.2% of respondents reported having infertility. 66% ( n = 1,353) of respondents were willing to pay a non-zero amount for IVF, with a median willingness to pay of $5,000. Annual household incomes between $121,000 and $199,000 ( p = 0.003) and greater than $200,000 ( p = 0.005) and familiarity with IVF treatment ( p < 0.001) were associated with a higher willingness to pay. Among infertile respondents ( n = 133), the median willingness to pay was also $5,000 and familiarity with IVF ( p = 0.04) was associated with a higher willingness to pay. Conclusion We found a median willingness to pay for IVF of $5,000 among respondents, which is one-third of the average out-of-pocket cost of one IVF cycle in the US (~ $15,000). These findings highlight the need for policymakers and clinicians to advocate for expanded health insurance coverage for IVF to align with reproductive-aged adults’ willingness to pay and address barriers accessing infertility services. Keywords: Infertility, In vitro fertilization, Affordability, Willingness to pay Introduction Approximately one in five people in the Americas has infertility [ 1 ], which is defined as the inability to achieve pregnancy after 12 months or more of regular, unprotected intercourse [ 2 ] and is designated as a disease by the World Health Organization [ 3 ]. While the prevalence of infertility does not vary by education, income, and insurance status, these factors do influence the rate at which individuals access fertility services [ 4 ]. Women with lower than a high school diploma, lower-income women, and uninsured women are less likely to see a medical provider regarding infertility than their counterparts with college degrees, higher income, and insurance, respectively [ 4 ]. Although the majority of reproductive-aged adults in the US have employer-sponsored health insurance [ 5 ], few employers offer insurance coverage for fertility care [ 6 ], especially in vitro fertilization (IVF), which is generally regarded as the most effective treatment for infertility [ 7 ]. Lack of insurance coverage results in high out-of-pocket costs for IVF, and research has shown that affordability of IVF is the greatest barrier to infertility care [ 8 , 9 ]. However, it is unknown how much reproductive-aged adults in the United States (US) are willing to pay for IVF treatments. Currently, one standard cycle of IVF costs approximately $15,000 out-of-pocket [ 10 ], but studies show that a successful pregnancy via IVF can cost over $60,000 [ 7 ], and there is no upper limit to this spending as individuals can repeat cycles as often as they desire and can afford. Prior studies have attempted to characterize willingness to pay for IVF, but these studies focused on small university populations or were conducted in other countries [ 11 – 14 ] and thus have limited generalizability and are unable to capture the broader willingness to pay of reproductive-aged adults in the US. It is further unknown what socio-demographic factors are associated with an individual's willingness to pay for IVF. Without this knowledge, we do not know at what out-of-pocket cost IVF will become affordable for most people nor do clinicians and policymakers have adequate information to advocate for expanded health insurance coverage for IVF. The purpose of our study was to assess willingness to pay for IVF in a widely drawn sample of US reproductive-aged adults and determine what socio-demographic factors are associated with their willingness to pay for IVF. We hypothesized that the amount reproductive-aged adults would report being willing to pay for IVF would be less than the average cost of IVF in the US. We used an online platform to survey adults aged 18–50 in the US about willingness to pay for IVF and relevant medical, demographic, and socioeconomic characteristics. Our findings can inform clinical and policy changes to reduce the costs of IVF and improve access to care. Materials and methods Data source We used Prolific, an online survey recruitment platform designed for academic research, to recruit reproductive-aged adults (ages 18–50 years old) living in the US to respond to a 34-question survey. We included respondents up to 50 years old because the survey included male respondents. Prolific has been used for surveys in health [ 15 – 17 ] and social science research [ 18 – 20 ]. Other researchers have found the Prolific platform to be methodologically superior to other recruitment options such as listservs and social media blasts and comparable in data quality to Amazon’s Mechanical Turk (MTurk) survey platform [ 21 ]. Furthermore, comparisons to other survey platforms have found that Prolific uses recruitment and screening processes that yield a more reliable population for sampling [ 21 – 23 ]. The platform verifies respondents’ photo identifications and Internet Protocol addresses, generates internal “trust scores,” and monitors respondents’ answer quality [ 24 ]. We could not identify a previously published survey that adequately addressed our questions about willingness to pay for IVF. Therefore, we used our clinical, legal, and social science backgrounds to develop the 34 survey questions, making sure to include key topic areas including demographics, fertility status, IVF familiarity, insurance status, and willingness to pay for IVF. A colleague with expertise in organizational psychology and survey design reviewed our draft survey, and we made further revisions based on their feedback to minimize risks of bias. Additionally, we piloted the study with our team members to identify any formatting or presentation errors. The full survey is available in Appendix . Respondents were paid at $20 per hour for the time they took completing the survey. For our study, all responses were collected in September 2022. We excluded respondents older than 50 and younger than 18 from all analyses. Our study was deemed exempt from review by University of Michigan Institutional Review Board HUM00222177. Outcome measures Our primary outcome of interest was willingness to pay for IVF. Survey respondents were given an open text field with no upper limit to input the US dollar amount they would be willing to pay out-of-pocket for IVF over a 12-month period, which we defined as willingness to pay. We also asked respondents about socio-demographic information including sex assigned at birth, age, race, ethnicity, annual household income (defined in the survey as “all sources of income from everyone in the household”), employment status, and health insurance status. Since the definition of infertility at the time the survey was distributed was heteronormative and 6.4% of individuals using fertility treatments are women in same-sex relationships, and 3.2% are single [ 25 ], we also asked respondents for their current gender identity, sexual orientation, and relationship status. We also asked respondents about their infertility status and history of accessing infertility care. Respondents were defined as having infertility if they answered “yes” to the question “Have you or your partner had trouble getting pregnant in the last 12 months?” Respondents were defined as accessing infertility care if they answered “yes” to the question “Have you seen a doctor to talk about trouble getting pregnant in the last 12 months?”. We also surveyed respondents regarding their familiarity with IVF using a 5-point Likert scale of not at all familiar, slightly familiar, moderately familiar, very familiar, and extremely familiar. During our analyses, we collapsed this scale to create three categorical variables for the regression analyses: 1) Not at all familiar, 2) Somewhat familiar (encompassing slightly and moderately familiar), and 3) Very familiar (encompassing very and extremely familiar). Statistical analyses We generated descriptive statistics for the socio-demographic characteristics of the survey respondents and analyzed the distribution of respondents’ willingness to pay for IVF in US dollars. For respondents willing to pay a non-zero amount, we analyzed associations between socio-demographic factors and willingness to pay amounts using a generalized linear model (GLM) with gamma distribution and log link function. GLMs with gamma distribution and log link functions have been used in previous research analyzing cost data to address the positively skewed, non-normal distributions of cost data [ 26 – 29 ]. The regression models were adjusted for the covariates of age, sex assigned at birth, household income, IVF familiarity, health insurance status, and whether or not respondents were trying to get pregnant in the last 12 months. Reference groups for the analyses were selected based on the group with the greatest number of respondents. We also conducted subgroup analyses of individuals with infertility and adjusted for age, sex assigned at birth, household income, IVF familiarity, and health insurance status. For both sets of analyses, we reported the median and interquartile range (IQR) willingness to pay amounts and reported the adjusted mean ratio estimates with their corresponding 95% confidence intervals (CIs). For respondents willing to pay a non-zero amount, we visualized the distribution of willingness to pay for IVF using violin and box plots. For our visual displays only, we truncated the violin and box plot to exclude the 5 respondents (0.4% of respondents with a non-zero willingness to pay) who indicated a willingness to pay at or above $100,000. These 5 respondents were included in all other results described in the text and table below. Analyses were performed using Stata (StataCorp. 2015. Stata Statistical Software: Release 14 . College Station, TX: StataCorp LP) at the 5% significance level. Figures were generated in R version 4.4.0. Results Our final analytic cohort consisted of 2,035 reproductive-aged adults from 49 states (except for South Dakota) and the District of Columbia. Socio-demographic information, reproductive history, prevalence of infertility, and familiarity with IVF of the study population are presented in Table 1 . 43.6% of respondents were female assigned at birth, and 42.7% of respondents reported their current gender as women. The plurality of respondents were heterosexual (81.7%), were married (42.6%), between 26 and 50 years old (95.6%), were White (83.7%), earned between $26,000 and $120,000 (68.7%), were working full time (82%), and were covered by private insurance (74.4%). 7.2% of respondents reported having infertility, and 4.4% reported having accessed infertility care. 13.3% of respondents were trying to get pregnant in the last 12 months, and 73.9% were somewhat familiar with IVF as a way of having a baby. Table 1. Demographic characteristics of survey respondents Characteristic Respondents, % (n/N) Sex assigned at birth Female 43.6 (888/2035) Current gender Woman 42.7 (868/2035) Man 55.6 (1132/2035) Non-binary 1.4 (28/2035) Use a different term 0.2 (4/2035) Prefer not to answers 0.1 (3/2035) Sexual orientation Heterosexual 81.7 (1662/2035) Gay or lesbian 4.4 (90/2035) Bisexual 9.0 (183/2035) Pansexual 2.2 (44/2035) Asexual 1.6 (33/2035) Queer 0.9 (19/2035) Don’t know 0.1 (3/2035) Use a different term 0.05 (1/2035) Relationship status Married 42.6 (866/2035) Single 26.0 (530/2035) In a relationship 10.8 (219/2035) Living with a partner 14.7 (299/2035) Dating or looking to date 1.9 (38/2035) Divorced 3.3 (68/2035) Other 7.4 (15/2035) Age 18–25 4.3 (88/2035) 26–34 47.3 (963/2035) 35–42 30.8 (627/2035) 43–50 17.5 (357/2035) Race* White 83.7 (1703/2035) Black or African American 9.1 (186/2035) American Indian or Alaska Native 2.1 (42/2035) Asian or Asian American 9.3 (189/2035) Native Hawaiian or Other Pacific Islander 0.7 (15/2035) Middle Eastern or North African 0.8 (17/2035) Ethnicity Hispanic or Latino 7.6 (154/2035) Income ($) < 26,000 9.6 (196/2035) 26,000–50,000 22.2 (451/2035) 51,000–85,000 26.4 (537/2035) 86,000–120,000 20.1 (408/2035) 121,000–199,000 15.6 (318/2035) 200,000 and above 5.7 (116/2035) Prefer not to answer 0.4 (8/2035) Employment status Working full time 82.0 (1669/2035) Working part time 15.9 (323/2035) Between jobs and actively looking for work 0.8 (16/2035) Not working 0.4 (9/2035) On disability 0.3 (7/2035) Other 0.5 (11/2035) Have health insurance 90.7 (1846/2035) Have private health insurance** 74.4 (1515/2035) Trying to get pregnant in last 12 months 13.3 (271/2035) Infertile 7.2 (147/2035) Have accessed infertility care in the last 12 months 4.4 (89/2035) Familiarity with IVF Not familiar at all 7.3 (148/2035) Somewhat familiar 73.9 (1504/2035) Very familiar 18.8 (383/2035) Open in a new tab * Respondents were given the option to select more than one race. As a result, percentages do not add up to 100% ** Respondents who indicated they have employer-sponsored coverage themselves or through their spouse, partner, or parent, or are self-employed and insured through the Affordable Care Act marketplace were defined as having private health insurance Two-thirds of survey respondents ( n = 1,353) were willing to pay a non-zero amount for IVF, with a 25 th percentile willingness to pay of $1,000, median willingness to pay of $5,000, and a 75 th percentile willingness to pay of $10,000. The range of respondents’ willingness to pay was from $1 to $500,000. The distribution of respondents’ willingness to pay for IVF as a dollar amount over a 12-month period is visualized as a violin and box plot in Fig. 1 . For Fig. 1 , we truncated the violin and box plot to exclude the 5 respondents (0.4% of respondents with a non-zero willingness to pay) who indicated a willingness to pay at or above $100,000. These 5 respondents were included in all other results. Fig. 1. Open in a new tab Distribution of Willingness to Pay (WTP) for IVF. WTP = Willingness to pay. We found a 25 th percentile WTP for IVF of $1,000, a median WTP of $5,000, and a 75 th percentile WTP of $10,000. The average cost of 1 cycle of IVF is $15,000. For our visual displays only, respondents with a willingness to pay at or above $100,000 [ n = 5, 0.4% of sample with a non-zero willingness to pay ( n = 1,353)] were excluded from the violin and box plot. Three of the excluded respondents reported a willingness to pay of $100,000, 1 reported $200,000, and 1 reported $500,000. The median willingness to pay of $5,000 and all other quantitative results include these 5 respondents For respondents with a non-zero willingness to pay, individuals with an annual household income between $121,000 and $199,000 and greater than $200,000 were willing to pay, on average, 1.58 times (95% CI, 1.17–2.13; p = 0.003) and 1.89 times (95% CI, 1.22–2.93; p = 0.005) more for IVF, respectively, than individuals with an annual household income between $51,000 and $85,000 (Table 2 ). Individuals who were very familiar with IVF as a way of having a baby were willing to pay, on average, 1.54 times (95% CI, 1.21–1.97; p < 0.001) more for IVF, while individuals who were not familiar with IVF were willing to pay, on average, 0.38 times (95% CI, 0.25–0.57; p < 0.001) as much for IVF compared to individuals with some familiarity of IVF (Table 2 ). Sex at birth, age, insurance coverage, and whether or not respondents were trying to get pregnant in the last 12 months were not significantly associated with willingness to pay. While female respondents were willing to pay, on average, 1.21 times (95% CI, 0.99–1.48; p = 0.06) more for IVF than male respondents, the difference was not statistically significant. Table 2. Socio-demographic characteristics, reproductive history, and familiarity with IVF for willingness to pay for IVF among respondents with a non-zero willingness to pay All respondents ( n = 1,353) Respondents with infertility ( n = 133) n (%) Median WTP (IQR) Mean ratio estimate (95% CI) p -value n (%) Median WTP (IQR) Mean ratio estimate (95% CI) p -value Overall 1,353 (100%) $5,000 ($1,000–10,000) 133 (100%) $5,000 ($2,000–10,000) Sex at birth Male 782 (57.8%) $3,000 ($1,000–9,000) Ref Ref 76 (57.1%) $5,000 ($1,750–10,000) Ref Ref Female 571 (42.2%) $5,000 ($1,500–10,000) 1.21 (0.99, 1.48) 0.06 57 (42.9%) $5,000 ($3,000–10,000) 1.23 (0.82, 1.84) 0.31 Age 18–25 63 (4.7%) $2,000 ($500–10,000) 0.68 (0.43, 1.08) 0.10 4 (3.0%) $6,500 ($2,000–11,000) 0.96 (0.33, 2.77) 0.94 26–34 671 (49.6%) $4,500 ($1,000–10,000) Ref Ref 64 (48.1%) $5,000 ($1,500–10,000) Ref Ref 35–42 407 (30.1%) $5,000 ($1,200–10,000) 0.86 (0.77, 1.20) 0.73 50 (37.6%) $5,000 ($2,500–10,000) 1.22 (0.80, 1.86) 0.35 43–50 212 (15.7%) $5,000 ($1,200–10,000) 1.00 (0.75, 1.32) > 0.99 15 (11.3%) $4,000 ($1,000–5,000) 0.66 (0.37, 1.18) 0.16 Household income Less than $26,000 91 (6.7%) $2,000 ($350–5,000) 0.86 (0.56, 1.33) 0.51 2 (1.5%) $12,000 ($4,000–20,000) 0.91 (0.21, 3.86) 0.90 $26,000—$50,000 281 (20.8%) $3,000 ($500–10,000) 1.17 (0.89, 1.55) 0.27 24 (18.0%) $4,000 ($1,000–10,000) 0.64 (0.38, 1.06) 0.08 $51,000—$85,000 375 (27.7%) $4,000 ($1,000–8,000) Ref Ref 37 (27.8%) $5,000 ($2,000–10,000) 0.97 (0.61, 1.53) 0.88 $86,000—$120,000 290 (21.4%) $5,000 ($1,200–8,000) 1.01 (0.77, 1.34) 0.93 45 (33.8%) $5,000 ($5,000–10,000) Ref Ref $121,000—$199,000 235 (17.4%) $5,000 ($1,500–10,000) 1.58 (1.17, 2.13) 0.003 19 (14.3%) $3,000 ($1,000–9,000) 0.72 (0.41, 1.25) 0.24 $200,000 and above 78 (5.8%) $9,000 ($4,000–10,000) 1.89 (1.22, 2.93) 0.005 6 (4.5%) $10,000 ($5,000–15,000) 2.39 (0.99, 5.81) 0.05 Prefer not to answer 3 (0.2%) $100 ($10–3,000) 0.17 (0.02, 1.31) 0.09 0 N/A N/A N/A IVF familiarity Not familiar 80 (5.9%) $500 ($100–3,750) 0.38 (0.25, 0.57) < 0.001 5 (3.8%) $1,000 ($1,000–1,000) 0.30 (0.12, 0.77) 0.01 Some familiarity 973 (71.9%) $5,000 ($1,000–10,000) Ref Ref 83 (62.4%) $5,000 ($2,000–10,000) Ref Ref Very familiar 300 (22.2%) $5,000 ($1,850–10,000) 1.54 (1.21, 1.97) < 0.001 45 (33.8%) $6,000 ($3,000–10,000) 1.51 (1.01, 2.26) 0.04 Insurance No do not have insurance 96 (7.1%) $2,534 ($875–7,750) 1.00 (0.67, 1.48) > 0.99 4 (3.0%) $4,000 ($2,100–7,500) 0.72 (0.26, 2.00) 0.53 Yes have insurance 1,257 (92.9%) $5,000 ($1,000–10,000) Ref Ref 129 (97.0%) $5,000 ($2,000–10,000) Ref Ref Trying to get pregnant in last 12 months No 1,132 (83.7%) $5,000 ($1,000–10,000) Ref Ref N/A N/A N/A N/A Yes 221 (16.3%) $5,000 ($1,000–10,000) 0.93 (0.71, 1.22) 0.61 N/A N/A N/A N/A Open in a new tab Among individuals with infertility ( n = 133), we found a median willingness to pay of $5,000 (IQR, $2,000-$10,000), which was the same median willingness to pay reported by all respondents. Among those with infertility, familiarity with IVF was also significantly associated with willingness to pay: individuals with infertility who were very familiar with IVF were willing to pay, on average, 1.51 times (95% CI, 1.01–2.26; p = 0.04) more for IVF, while individuals who were not familiar with IVF were willing to pay, on average, 0.30 times (95% CI, 0.12–0.77; p = 0.01) as much for IVF compared to individuals with some familiarity of IVF. Discussion This is the first study to use a nationwide survey of US adults to characterize willingness to pay for IVF. We found that two-thirds of survey respondents were willing to pay a non-zero amount for IVF, with a median willingness to pay of $5,000 (IQR, $1,000-$10,000). This amount is approximately one-third of the average $15,000 out-of-pocket cost for IVF in the US [ 10 ]. Individuals with higher income and who were very familiar with IVF had a significantly higher willingness to pay. Individuals who were not familiar with IVF had a significantly lower willingness to pay. Prior studies have attempted to characterize willingness to pay, but these studies had small sample sizes and/or limited generalizability. For instance, a 1994 study of 231 students, administrative staff, physicians, nurses, and parents at a daycare center at Harvard University who were aware of their fertility status found a mean willingness to pay of $17,730 for a 10% chance of having a child through IVF [ 13 ]. While this 1994 study offers some information about willingness to pay for IVF, the findings are restricted to a small population of individuals from one university community. Two studies that offer an international perspective were conducted in Sydney, Australia and Brazil. In 1996, Ryan studied 339 individuals enrolled in a private infertility service in Sydney and found a mean willingness to pay of $2,506 per IVF attempt, which would be roughly $4,800 adjusted for inflation today [ 14 ]. In Australia, the current average cost of an IVF cycle is $5,550 [ 30 ], and the national healthcare system funds roughly 50% of the cost of an IVF cycle [ 31 ]. In 2020, Lima et al. studied 80 infertile couples in an academic medical center in Brazil and found a mean willingness to pay of $4,800 [ 12 ]. While Brazil does not provide public funding for IVF [ 32 ], the average cost of an IVF cycle is $4,000 [ 33 ]. Our results also showed that individuals with income between $121,000 and $199,000 ( p = 0.003) and greater than $200,000 ( p = 0.005) and who were very familiar with IVF ( p < 0.001) were significantly more likely to have a higher willingness to pay for IVF. Individuals who were not familiar with IVF were significantly more likely to have a lower willingness to pay for IVF ( p < 0.001). Similar research has not been conducted in the US; however, these results are consistent with prior studies conducted in other countries. Lima et al. found that willingness to pay for IVF was positively associated with household income and the woman’s education level [ 12 ]. Similarly, a 1995 study of 40 couples in Sweden found that higher income individuals were more likely to access IVF treatment at private clinics in order to avoid long waiting times at public clinics where the national healthcare system would reimburse three cycles of IVF, suggesting that higher income individuals were willing to pay more to access IVF treatment quickly [ 11 , 34 ]. In our study of reproductive-aged adults surveyed in 2022, 7.2% of respondents had infertility. Prior studies have demonstrated that reported rates of infertility are sensitive to the populations of patients who are queried. For example, the National Survey of Family Growth (NSFG) measured infertility as a couple-based phenomenon, limited respondents to married or cohabiting men and women, and did not differentiate based on which partner is experiencing infertility [ 35 ]. Infertility was further defined as having had “as a lack of pregnancy in the 12 months prior to survey, despite having had unprotected sexual intercourse in each of those months with the same husband or partner” [ 35 ]. In 2010, the NSFG found a prevalence of infertility of 6% and 9.4% among married women and men, respectively, and 4.9% among cohabiting women, which is consistent with our findings [ 35 ]. On the other hand, the National Health and Nutrition Examination Survey (NHANES) studied reproductive-aged women independent of marital status and intention to conceive from 2013 to 2016 and found an infertility prevalence of 12.5% [ 4 ]. In our study, we also did not measure infertility dependent upon marital status or intention to conceive; however, we sampled men, women, and non-binary individuals, whereas NHANES sampled only women, which likely accounts for some of the differences in our reported infertility prevalence. Our study does have several limitations. First, there is a risk of selection bias as the survey recruited individuals who are already registered with the Prolific survey platform. However, Prolific uses rigorous recruitment and screening to ensure a reliable study population with over 120,000 vetted participants [ 24 ]. Additionally, studies have found that Prolific provides greater transparency for researchers, comparable data quality, and greater variety in the sample than other recruitment options, such as listservs, social media, and the MTurk survey platform [ 21 – 23 ]. Second, the study population may not be representative of the general US population due to convenience sampling. The demographic characteristics of our sample are roughly similar to that of the general US population when examining reported income but vary when examining self-reported race, as published by the US Census Bureau. The 2020 US Census reports that the US population is 19% Hispanic, 64% White, and 12% Black, while our survey respondent population, which was allowed to select more than one race, reported being 8% Hispanic, 84% White, and 9% Black [ 36 – 38 ]. However, the prevalence of infertility found in our study was similar to rates reported by other large-scale US surveys [ 35 , 39 , 40 ]. Third, we utilized a nationwide sample of US adults rather than a sample limited to individuals with a history of infertility in our primary analyses. Since most individuals are not aware of their infertility status before they attempt to have children, surveying the general US population offers a meaningful estimate for willingness to pay as compared to surveying individuals with a history of infertility. However, we found the same median willingness to pay for IVF of $5,000 among all respondents and among the subset of infertile respondents, demonstrating that fertility status was not significantly associated with median willingness to pay. Additionally, we found that individuals who were attempting pregnancy in the last 12 months did not have a statistically significant difference in median willingness to pay amounts when compared to individuals who were not attempting pregnancy. These findings suggest that willingness to pay for IVF is relatively stable across different samples with different fertility statuses, reinforcing the value of using a broad sample rather than exclusively surveying individuals with a history of infertility. Fourth, we did not assess willingness to pay for shared risk programs for IVF in this study. Some fertility clinics offer shared risk programs for IVF with potentially higher up-front costs for patients but some financial protection if there is not a live birth [ 41 , 42 ]. Now that we have established a baseline willingness to pay for IVF within a year, future studies can build upon this information to create studies that investigate how patients’ willingness to pay for IVF may differ under shared risk arrangements. These limitations notwithstanding, our findings have important public health and policy implications. For policymakers, we demonstrate that the current average cost of one cycle of IVF ($15,000 [ 10 ] but ranging as high as $60,000 for a live birth [ 7 ]) is far greater than the public’s median willingness to pay for treatment. Prior studies have shown socio-demographic differences in accessing infertility care among reproductive-aged women [ 4 ], and similarly, our findings that higher-income individuals have a higher willingness to pay for IVF suggest that IVF is more accessible for higher-income individuals due to the high out-of-pocket cost of IVF for most people. The median willingness to pay found in our study of $5,000 can inform policymakers and clinicians of the out-of-pocket costs for IVF that are affordable for most people and support efforts to advocate for expanded health insurance coverage for IVF. In conclusion, our study of reproductive-aged US adults indicates that, on average, individuals’ willingness to pay is about one third of the typical out-of-pocket cost for IVF. Willingness to pay was not significantly associated with age, whether or not respondents were trying to get pregnant in the last 12 months, or health insurance coverage; however, higher-income individuals and those with greater familiarity with IVF reported being willing to pay more for treatment. The difference in willingness to pay among high income and low income respondents and among respondents with more or less familiarity with IVF is notable and suggests that decreasing costs for IVF treatment through expanded health insurance and/or increased education about IVF may lead to greater access to IVF. Acknowledgements Sabir Meah, MS, generated the figures in R and proofread the methods section. Phyllis Yan, MA, provided statistical guidance for the methods section. Christina Agostino, MPH, assisted with the submission of the manuscript. Appendix. Pilot study on infertility and insurance in prolific sample of US adults Advance Prolific filters that we will use: Age 25–50 Full or part time employment U.S. location Survey questions In this study you will answer questions about your plans to have a baby (or not) and what kind of health insurance coverage you have. Some of these questions are personal. We will not collect any information that could identify you. Your responses are anonymous. This study will help us understand Prolific users’ experiences By proceeding to complete this survey, you are indicating that you are consenting to participate in this survey. Thanks again for your time – your perspective is unique and cannot be replaced Consent I consent to participate in this study. yes or no Demographics What is your unique Prolific ID? enter in box What is your age? pick one 18–25 26–34 35–42 43–50 51 and above What US state do you currently live in? (dropdown list of states, pick one) What is your race? (check all that apply) White Black or African American American Indian or Alaska Native Asian or Asian American Native Hawaiian or Other Pacific Islander Middle Eastern or North African Are you Hispanic or Latino? yes, Hispanic or Latino no, not Hispanic or Latino How would you describe your relationship status? (pick the best one) married divorced single in a relationship living with a partner dating or looking to date other (explain) What is your current employment status (not counting this survey work for Prolific)? (pick the best one) Working full time Working part time Retired Between jobs and actively looking for work Not working On disability other (explain) What is the industry in which you currently work? (pick the best one) Education Retail Healthcare Leisure and hospitality (travel, food services) Agriculture Construction Government or public sector Manufacturing Sales Information technology Other (please explain, open text box) Do you consider yourself to be: Heterosexual or straight Gay or lesbian Bisexual Asexual Pansexual Queer I use a different term (please explain) I don’t know What sex were you assigned at birth, on your original birth certificate? Female Male What is your current gender? Woman Man Non-binary Two-Spirit I use a different term: [free text] Don’t know Prefer not to answer Do you consider yourself to be transgender? (yes or no) What is your current annual household income (counting all sources from everyone in your household)? Less than 26,000 26,000–50,000 51,000–85,000 86,000–120,000 121,000–199,000 200,000 and above Prefer not to answer Fertility status (for everyone with skip) 14. Have you or your partner been trying to get pregnant in the last 12 months? yes or no (if no, skip to 23) 15. Have you or your partner gotten pregnant at any point in the last 12 months? Yes or no If yes, are you or your partner still pregnant now? Yes or no If yes, did the pregnancy result in a live birth? Yes or no 16. Have you or your partner had trouble getting pregnant in the last 12 months? yes or no 17. Have you had a sterilization procedure (like a hysterectomy for a woman or vasectomy for a man)? yes or no 18. Have you seen a doctor to talk about trouble getting pregnant in the last 12 months? yes or no 19. Have you or your partner been diagnosed with infertility by a doctor? yes or no 20. If you or your partner has been diagnosed with infertility, how long ago was that diagnosis made? in the last 12 months 2 years ago 3 years ago 4 years ago 5 years ago more than 5 years ago Neither my partner nor I have been diagnosed with infertility 21. Infertility is defined medically as the inability to achieve a pregnancy after having unprotected intercourse regularly for 12 months (or for 6 months if the female partner is 35 years old or older). Do you think you have infertility under this definition? Yes, this definition of infertility applies to me No, this definition does not apply to me 22. If this definition does not apply to you, why not? (check all that apply) I am using some form of birth control now or in the last 12 months (for myself or my partner) I have not been trying to achieve a pregnancy (for myself or my partner) I am in a relationship that does not fit this heterosexual definition I am not having sexual intercourse regularly I am infertile for other reasons (previously sterilized, due to cancer treatment, age, etc.) and if checked, please explain open text box Other (please explain open text box) 23. Has someone else close to you (not your current partner or yourself) been diagnosed with infertility by a doctor? IVF Familiarity (for everyone) 24. How familiar are you with in vitro fertilization (IVF) as a way of having a baby? Likert scale (how familiar are you… on a 5 point scale) 25. Have you talked to a doctor about IVF for yourself or your partner? yes or no 26. Have you done any research on your own about IVF as an option for you or your partner? yes or no 27. If you have done any research on your own about IVF, where did you go for information? check all that apply online searches, Googling talked to a friend who has experience with IVF or infertility family member or friend Facebook group or other online group (check box here, also if checked, fill out a text box saying what it was) support group or other in person source, like a therapist or pastor (explain) asked a health care professional other (please explain) 28. Have you or your partner undergone IVF? yes or no Insurance Status (for everyone) 29. Do you currently have health insurance? yes or no, if no skip to the end 30. How do you get your health insurance coverage? From my employer (including COBRA) From my spouse, partner, or parent’s employer (including COBRA) Medicaid Medicare Veteran’s benefits, TRICARE Indian Health Service Self-employed and insured with an ACA Marketplace individual plan No health insurance/uninsured 31. Have you ever looked to see if your current health insurance plan offers coverage for in vitro fertilization (IVF)? yes, I have looked into IVF coverage in my health plan no, I have not looked into IVF coverage in my health plan I don’t have health insurance now other < explain > 32. What coverage, if any, does your current health insurance plan offer for in vitro fertilization (IVF)? My health plan doesn’t cover IVF coverage (doesn’t say anything or excludes it) My health plan offers at least some IVF coverage with limitations like a lifetime cap or cycle limits I don’t know what my health plan offers for IVF coverage other < explain > 33. How much would you be willing to pay (in US dollars) out of pocket over 12 months for IVF? Please enter only numeric values without decimals or commas (open text box) 34. Last step: supply Prolific completion code URL Authors contributions JMD, AK, and SS conceived and designed the research. SM, DS, and JMD wrote the manuscript. DS analyzed the data. All authors read and approved the manuscript. Funding Funding to support this work came from the University of Michigan Medical School Office of the Vice President for Research Pandemic Research Recovery Program, the Kim Lane Scheppele Collegiate Professorship of Women’s and Gender Studies, general internal faculty research funds, and R01HD113625 from the National Institutes of Health. Data availability Data will be made available to the editors of the journal for review or query upon request. Declarations Ethical approval Our study was deemed exempt from review by University of Michigan Institutional Review Board HUM00222177. Conflict of interest SM has nothing to disclose. DS has nothing to disclose. SS has nothing to disclose. AK receives grant funding from the National Institutes of Health (R01HD113625). JMD receives grant funding from the National Institutes of Health (R01HD103603 and R01HD113625) and Blue Cross Blue Shield Michigan Value Collaborative, serves on the Medical Advisory Board for Posterity Health and Team Maggie for Cure, serves on the Scientific Advisory Board for the Maven Clinic, serves on the American Society for Reproductive Medicine Scientific Congress Planning Committee and Board of Directors, serves as Vice President for the Society for the Study of Male Reproduction, and has personal common stock in Lipocine. Footnotes Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. References 1. World Health Organization. Infertility prevalence estimates, 1990–2021. https://iris.who.int/bitstream/handle/10665/366700/9789240068315-eng.pdf?sequence=1 . Accessed 2 Jan 2024. 2. Frieden TR, Jaffe HW, Cono J, Richards CL, Iademarco MF. Providing quality family planning services. 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