By Chuck Donovan and David Prentice

Kick-off has happened for a potentially revolutionary federal policy initiative on in vitro fertilization (IVF), and the clock is running. Thanks to a new executive order issued on February 18, the White House Office of Domestic Policy is charged to produce a set of policy recommendations on this particular infertility practice within 90 days.

The order carries out a promise President Trump made on the campaign trail last summer to, as the order states, “ensure reliable access to IVF treatment, including by easing unnecessary statutory or regulatory burdens to make IVF treatment drastically more affordable.” The order understandably cites empathy for the “emotional and financial struggle” faced by couples experiencing infertility who seek to “navigate their path to parenthood.”

At first appearance, the challenge to ease IVF through federal policies that assist with insurance, whether through private sector mandates or expansion of federal program coverage, seems straightforward. Lacking insurance coverage in most cases now, a cycle of IVF — stimulating egg production in the mother, harvesting and inseminating, screening for various purposes, and implantation in the hope of achieving pregnancy — can cost, the order states, between $12,000 and $25,000.

The Domestic Policy recommendations may only seek to address the coverage and cost issues of IVF, but even here there are many important questions to be answered in the short stretch of 90 days. Beyond those questions lie a raft of deeper ones about a practice that, in the United States at least, is very minimally regulated and severely under-analyzed.

As the White House begins its review, it might be helpful to lay out what some of those additional questions are, to test what we really know about IVF and what pitfalls lie ahead for a practice with the potential to both create and destroy millions of human lives and alter what we now mean by parenthood and family. Here is a starter’s list.

1. Will this policy review survey existing policies and identify the status of human embryo storage in the U.S.?

IVF has existed since the conception of the first “test tube” baby, Louise Brown, in the United Kingdom in 1978. Since then, IVF has spread globally and as many as 12 million babies have been born worldwide via this methodology. In the process, additional tens of millions of embryonic humans are estimated to be in frozen storage around the world. In the United States, a 2020 study indicated at that time over 1.2 million embryos were being housed in storage freezers. The goal for them is future implantation, but case studies reveal a variety of potential statuses, including adoption by other couples, donation to research, and discarding.

2. Will the policy review international practice and the same set of questions overseas?

The United States has a virtually unregulated IVF industry in terms of legal protection for frozen embryos, rules on the number of embryos that can be created at one time, the resolution of disputes among couples, and other conditions. Rules vary significantly internationally, leading to nations that, in contrast with the United States, have very few embryos in frozen storage and fewer knotty issues with their disposition. Under Germany’s 1990 Embryo Protection Law, for example, egg donation for IVF is barred, embryos may be frozen only in exceptional cases, and a maximum of three embryos can be created per cycle and all embryos created, without genetic screening, must be implanted. Germany’s sensitivity to genetic selection has, of course, strong historical roots.

3. Will the policy support the creation of multiple embryos with concomitant freezing of “spares”?

The United States, without (until now) significant national policy, has no consistent public policy on the “quantity and quality” issues in embryo creation. With insurance coverage and federal subsidies, the wide variety of private sector practices become matters for policy review and potential boundaries. Will the Domestic Policy office review established policies on these practices, some of which are controversial even with people who advocate allowing IVF with guardrails like those in Germany and elsewhere?

4. Will the review examine existing studies on the health impact of egg retrieval procedures on women seeking IVF?

IVF relies on hyperstimulation of the ovaries to produce eggs for fertilization. Adequate studies exist on the short-term risks associated with this process, but what about long-term impacts like breast cancer? Schneider, Lahl and Kramer write, “[L]ong-term follow-up studies of egg donors are lacking and their health risks are unknown. The lack of information may be misleadingly interpreted as lack of risk.” Will the Domestic Policy recommendations cover this topic or take steps to ensure the kinds of intensive health studies the administration has vaunted will be its hallmark?

5. Will the review examine existing studies on the health impact on children who were conceived via IVF?

Like the women affected, what steps will be taken to examine whether IVF results in differentials in health outcomes for the children conceived in vitro, whether frozen or transplanted immediately? Studies to date are limited by small sample sizes and relatively short follow-up periods. Jennifer Lahl of the Center for Bioethics and Culture Network detailed the concerns for a Senate briefing last summer. She cites one study that mentions such risks as “heart defects, musculoskeletal and central nervous system malformations, very severe preterm and preterm birth, and low birth weight. The risks seem to be based on maternal and paternal factors, but also on the IVF technique itself.”

6. Will the policy recommendations require the number of created embryos be limited to those to be immediately implanted and will they exclude coverage for selective abortion of “excess” embryos?

Selective reduction is a process of reducing risk to the mother and perhaps the babies when multiple children are conceived via IVF. It is done by aborting one or more of the children. The American College of Obstetricians and Gynecologists guidelines on the practice acknowledge that “fertility treatments” have contributed to an increase in what it calls “multifetal pregnancies” and it recommends reducing the practice by transfer of fewer embryos. But will a new federal funding policy codify this advice or require coverage of reduction-by-abortion procedures?

A comprehensive committee opinion on IVF from the American Association of Pro-Life Obstetricians and Gynecologists adds: “While this might reduce maternal risks to some extent, multifetal pregnancy reduction can endanger all of the developing fetuses, does not completely eliminate risks associated with multiple pregnancies, and can have adverse psychological consequences for the mother. Additionally, multifetal pregnancy reduction is clearly the intentional ending of human lives.”

7. Will the policy bar sex selection and genetic screening of embryos for “best quality”?

Some families resort to IVF to avoid the conception of a child with a particular disease. Mapping of the human genome opens up a far wider vista, in theory available to all couples, to use IVF to select the baby’s sex or a whole range of other qualities deemed healthier or otherwise superior. The destruction of embryos via these routes could occur on an industrial scale. Companies like Orchid and Gattaca Genomics make promises regarding the better babies they can help produce. Apart from the profound ethical questions at issue, questions persist about the accuracy of these better-baby claims.

8. Will the policy require all public and private U.S. insurers to cover IVF and will it have limitations on the number of attempts the insurers must cover?

This question relates to the overall cost of these procedures, which may be reduced for the users but result in higher overall costs for the taxpayer and other members of private insurance plans. If the practice is subsidized, experience teaches it will grow in frequency even if it declines somewhat in per-patient cost. Will these effects be quantified in advance?

9. Will the policy limit who may be covered to married, male-female couples or will it permit coverage for anyone?

This relates to the frequency of use of IVF but involves more sweeping subject matter about who may be eligible for private or public sector insurance coverage — in short, to the fundamental question about whether it is always and everywhere an exercise in family-building. Will subsidized or paid-for IVF be available to married couples only, to male-female couples, to same-sex partners, to individuals, to people regardless of age or income or other capacity? Will any legal limitation on eligibility pass judicial review? Will insurers exercising a conscience exemption be able to draw lines around who is insured, or will it merely be a yea or nay proposition?

10. Will the recommendations include coverage for conception and bearing of children by surrogates and any payments for such services?

One review article notes that surrogates who bear children, where IVF is typically involved, receive an extra $5,000 payment if they agree to carry a multifetal pregnancy to term. Some surrogate arrangements require the surrogate to agree to abort the child under these circumstances or should an anomaly be detected in the baby. Will the Domestic Policy office recommendations address these issues?

The Obama-era Affordable Care Act purported to address concerns about abortion coverage by requiring a separate payment by the insured to cover the abortion rider. Would some finesse of this type be proposed to allow coverage of abortion of IVF babies under a similar provision? In addition, six states currently require all private insurance plans offered in the state to cover abortion. Will those mandates apply in these circumstances as well?

11. What will the policy cost in both private sector and public sector terms and will this cost be tracked, including its impact on other plan members’ and taxpayers’ premiums?

Americans are generous people and the White House executive order echoes this sympathy for the one in seven couples unable to conceive due to infertility. Nonetheless, the potential exists under federal health insurance programs for the cost of implementing IVF affordability to soar. How much information will the Domestic Policy office make available about the budget impacts of its recommendations? The same question applies to private sector coverage.

12. Will information and coverage of other fertility repair approaches be included in the policy recommendations?

This may be the most important question of all, since analysts across the spectrum agree that the rising demand for IVF is related to delayed marriage and childbearing, as well as to a host of behavioral and environmental factors that have fed the increase in infertility. In addition to these factors, recognition is slowly increasing that while IVF provides an ad hoc answer to couples seeking to have their own genetically related child, it is not restorative.

Groups like Facts About Fertility are expanding their presence in communities and at medical schools, with the goal of ensuring “women and couples everywhere have access to fertility awareness education and restorative reproductive medical services.” In addition to cleaner ethical pathways, these services have major cost-saving potential and long-term application. Will they be vigorously pursued?

13. Will any other child-supporting policies be included in the recommendations, including expansion of the child tax credit, the unborn child tax credit, adoption, defunding of Planned Parenthood, or other reforms?

Other policy initiatives promised by the administration, either in its first term or now, have not yet been unveiled. Planned Parenthood’s business model of abortion promotion is in self-destruct mode. Expansion of child tax credits and creation of a new unborn child tax credit have been discussed but no action has occurred to date. The latter policies could have far more impact on family formation than expansion of access to and payments for IVF. Are these items on the Domestic Policy agenda as well?

14. Will untrammeled IVF with federal support tempt at least some actors to exploit embryos that are deemed unfit for implantation or designed for other uses?

Under the Aderholt amendment first adopted by Congress in 2015 and reenacted each year since, federal funds may not be used for any gene editing or genetic alteration of human embryos. Would this same limitation reach embryos created via the new funding made available under the Domestic Policy office recommendations? What about the other temptations attending the tiny lives of embryonic human beings, for example, cloning experiments, single-sex-parent embryos, and three-parent embryos? Current policies tend to punt on these questions, but it is incumbent on White House policymakers to reflect on them and to consult at the level of expertise required outside the government to make wise and legally sound decisions.

The Domestic Policy recommendations are due just a week after Mother’s Day. Completing the tasks and answering the questions outlined above represent a tall order in that time frame. America celebrates new life but owes itself a thorough and searching examination of issues that have the ability to renew, as well as to collapse, a regime of respect for the family and every human life.

Chuck Donovan served in the Reagan White House as a senior writer and as Deputy Director of Presidential Correspondence until early 1989. He was executive vice president of Family Research Council, a senior fellow at The Heritage Foundation, and founder/president of Charlotte Lozier Institute from 2011 to 2024. He has written and spoken extensively on issues in life and family policy.

David Prentice, Ph.D., is an internationally recognized expert on stem cell research, cell biology and bioethics. He has almost 50 years’ experience as a scientific researcher, professor, academic leader, and policy advisor. In addition to his extensive record of research and publication, he has provided scientific lectures, policy briefings and legislative testimonies in 40 states and 21 countries, including before the U.S. House and Senate, numerous state legislatures, the U.S. National Academy of Sciences, the European Parliament, British and Canadian Parliaments, German Bundestag, and many more.