Black women face systemic barriers throughout fertility treatment journeys, major qualitative study reveals
Mapping fertility trajectories: An endarkened narrative inquiry of Black women’s fertility experiences and pathways through infertility treatment. (Morgan, 2025)
Morgan, I., Tucker, C., Palmquist, A. E. L., Baker, S., Jennings Mayo-Wilson, L., Martin, C. L., Hernandez, N., & Clarke, L. (2025). Mapping fertility trajectories: An endarkened narrative inquiry of Black women’s fertility experiences and pathways through infertility treatment. Social Science & Medicine, 376, 118082. https://doi.org/10.1016/j.socscimed.2025.118082
Geographic Region: United States
Research Question: How do Black women experience and navigate their fertility care and medically assisted reproduction treatment, and what barriers contribute to their higher rates of treatment discontinuation?
Design: 60 semi-structured interviews conducted between November 2022 and June 2023. Initial interviews lasted approximately 60 minutes and covered topics including experiences as a Black woman, overall fertility experiences, physical and emotional effects of infertility, engagement with medical providers, sources of community support, conversations about fertility, types of support experienced or desired, and advice for other Black women navigating fertility challenges. Follow-up interviews (conducted April-June 2023) lasted approximately 20 minutes and expanded on fertility treatment experiences with specific questions about infertility treatments completed, perceived causes of infertility, and influences of spirituality and religiosity. The study team held two virtual listening sessions in November 2023 to present preliminary findings to participants for validation and feedback.
Sample: 41 Black women who participated in 60 semi-structured interviews (41 initial interviews and 22 follow-up interviews). At the time of initial interviews, most participants were aged 35-45 years (63%), married, identified as heterosexual, held advanced educational degrees (63% had Master’s degrees), worked full-time, and had some or full health insurance coverage with fertility benefits. Nearly two-thirds reported annual household incomes greater than $100,000, though the sample also included women across income levels. Participants had varying reproductive health diagnoses, ranging from one to four conditions each, with the most commonly reported being diminished ovarian reserve (39%), polycystic ovarian syndrome (33%), fibroids (48%), and male factor infertility (23%). Regarding fertility treatment status: 38 participants (93%) had completed fertility testing, 32 (78%) had initiated medically assisted reproduction (MAR), including 11 who attempted medicated timed intercourse, 11 who attempted intrauterine insemination (IUI), and 26 who attempted in vitro fertilization (IVF). Across the 41 participants, 35 naturally conceived pregnancies were reported across the life course (including those preceding MAR), of which 22 ended in miscarriage, 2 in terminations, and 11 in live births. Participants were recruited through fertility advocacy groups, online fertility forums and support groups, and medical providers.
Key Findings
Lack of health insurance, limited fertility benefits, discrimination due to Medicaid coverage, and delayed referrals to fertility specialists prevented or delayed access to fertility testing for some participants. One participant experienced discrimination when providers “see Medicaid on my file and then I’m overlooked,” being referred from doctor to doctor without receiving fertility testing.
Even with health insurance coverage for IVF, out-of-pocket expenses for medications and services not covered by insurance (such as genetic screening) created significant financial barriers. Two participants were only able to afford IVF because of financial gifts from parents or inheritance from deceased parents’ life insurance policies.
Participants described using self-managed Facebook groups to find other women reselling hormonal medications to reduce costs, with one explaining she was “buying medication from people in parking lots and going to people’s houses.”
Life circumstances, including caring for ill family members, and advice from family and friends that participants were “still young” contributed to delayed initiation of fertility testing.
Disconnect between clinical guidance about fertility options (particularly recommendations to use donor eggs or sperm) and participants’ desires for biological children created barriers to treatment initiation.
Financial constraints prevented access to donor sperm from cryobanks, leading some same-sex couples to use informal arrangements with friends for sperm donation.
Limited availability of Black donor eggs and sperm created challenges for participants needing donor specimens, with one noting: “It is seriously a lack of Black sperm, to be able to find Black donors. There’s no Black sperm out there.”
Racial discrimination was evident in treatment quality, with one participant noting: “None of the techs are any race other than White... They range from being really cold and callous and not really talking to me, but then when a White woman walks in after me, she’s very chipper.”
Racial and gender patient-provider concordance was important for many participants, with one explaining: “I’ve always made sure that all my doctors were female and Black. They made me feel comfortable and I felt like they were treating me just like everyone else.”
Spirituality and faith were critical coping mechanisms, with participants describing how their relationship with God helped them navigate the emotional challenges of infertility treatment.
Limitations: The study’s high-income, high-education sample may underestimate the barriers faced by less economically advantaged Black women.
Applications: Mental health professionals should understand that Black women’s fertility treatment journeys are often complicated by experiences of medical gaslighting, dismissive care, and assumptions about their fertility based on racist stereotypes.
Funding Source: Ferring Pharmaceuticals. The funder was not involved in the collection, analysis, or interpretation of data; writing the report; or deciding to submit the article for publication.
Lead Author: Isabel Morgan is affiliated with the Center for Maternal Health Equity at Morehouse School of Medicine in Atlanta, Georgia, where she serves as a researcher focusing on reproductive health equity. No personal connection to donor conception was disclosed.
Regulatory Context
The United States has no comprehensive federal legislation governing donor conception, with regulation primarily occurring at state level, creating a patchwork of laws across the country. The Food and Drug Administration (FDA) provides minimal federal oversight, mainly focused on screening requirements for disease prevention.
There are no federally mandated limits on the number of children conceived from a single donor. The American Society for Reproductive Medicine (ASRM) recommends limiting donors to 25 live births per population area of 850,000, but this is voluntary and not enforced. Colorado became the first state to establish a statutory limit in 2022, capping donor use at 25 families per donor, regardless of location, effective January 2025.
No centralized national registry exists to track donor-conceived births OR donors, making it difficult to enforce any limits in practice.
Commercial donation is permitted throughout most of the United States. Donors can be compensated for their gametes.
Access to donor conception is generally open to a wide range of individuals regardless of marital status, sexual orientation, or gender identity. Most major medical organizations support the position that fertility treatments should be available to any individual who is fit to parent.
The U.S. does not have national laws prohibiting anonymous donations, but this practice is gradually changing. Colorado’s 2022 “Donor-Conceived Persons Protection Act” (effective January 2025) bans anonymous donation and gives donor-conceived individuals the right to access their donor’s identity upon reaching age 18. In January 2024, the Uniform Law Commission amended the Uniform Parentage Act to require disclosure of donor identifying information to adult donor-conceived persons upon request, though states must adopt this amendment for it to become law in their jurisdictions.
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Powerful findings on how structural inequalities compound throughout the fertility care pipeline. The data point about women buying meds in parking lots because insurance gaps force informal markets is stark. I've seen parallel dynamics in other healthcare domains where coverage limitations push people into grey market solutions that increase risk. The donor availabilty gap is undertheorized too, shows how reproductive autonomy gets constrained by demographic skews in gamete banking infrastructure.