Illustration by Matt Daley.

Amanda Thompson remembers meeting the other participant in her months-long game of tap-tap. She would tap on her partner’s belly, and someone would tap back from inside. After an eventful day, the result of careful deliberations and a planned C-section, Thompson met her daughter, feeling instantly familiar. As soon as she was born, “it was this lovely recognition of, ‘Oh, you’re this person we already know,’” she says.

Her birth followed purposeful conversations about identity. Thompson’s family is registered to the Flying Post First Nation. No one lives there, what was once a traditional hunting and trapping community. It’s a swamp in the north, she says. Members of her Ojibwe band live dotted around northern districts in Ontario, between Timmins, Nipigon, and Chapleau, her extended family in southwestern Ontario. Thompson grew up urban. “We don’t have the same sense of community in the same way that people who are registered to other First Nations would have a strong sense of place do,” she says. When she moved to Toronto at 21, those ties were built. “I made my community here,” Thompson says. “That means the community that I came from was already a mishmash of people from different nations and different cultures and different understandings of their culture, and they’ve all sort of migrated here in different ways.”

She’s one of three generations of women in her family denied status—starting with her grandmother, who lost recognition to her band under the Indian Act when she married a British man. Over the decades, Thompson and her mother regained their status under bills C-31 and C-3, contested attempts at restraining the paternalism of the Indian Act. When Thompson and her partner decided to start a family, questions of identity quickly entered their considerations.

But they were one of many. Before they had their daughter, meditation on Indigeneity, place, and identity needed to be weighed against morasses of potential legal twists. When couples visit fertility clinics in Toronto—30 percent of which are estimated to be from queer communities—about 20 of the 200 anonymous donors available to them are Canadian. None of those 20 is Indigenous.

Thompson knew she and her partner wanted to choose an Indigenous donor, and that he would be anonymous. The laws governing guardianship made it so they couldn’t be certain a known donor wouldn’t have the ability to retain custody down the line. And when they consulted legal experts, no one could tell them that he couldn’t definitively, not enough that they felt comfortable with the risks. Never mind how or if their child could gain status in such an arrangement.

The circuitous culture of service provision and legislation can descend on prospective families—especially those with members from queer Indigenous communities—in many ways, each on their own bringing a range of potential obstacles. The law in Ontario has only recently changed to better accommodate family planning routes for queer couples who may not always conceive children or come to be families the same way that many with two biological parents do. These choices amount to a process that can help honour and define familial identity for many couples. In ways large and small these systems aren’t set up to give many couples equal access to the choices and clinical experiences white, heterosexual, and cisgender couples can have.

***

Twice a week for about two years in the early 1990s, Harlan Pruden donated sperm to a fertility clinic, so conveniently situated on the University of Alberta campus where he was studying philosophy and political science that his visits could be scheduled in between classes. He earned $50 each time: half every week, and the balance at the end of a six-month cycle when, if he received a clean bill of sexual health, “the lot” would be closed out. The multi-page questionnaire he filled out the first day at the clinic asked about family history, disease, his IQ.

He doesn’t remember much about the donor agreement he signed at the time, in his early 20s. “It’s kind of like the Apple agreement,” he says. But he does recall clinic staff telling him that he was the only Native (they called him at the time) donor on their books. That was incentive enough for him. Pruden, registered to the Whitefish Lake First Nation in Alberta, calculated that while the cash was a nice perk, it was important for his semen to find its way to prospective families who wanted children, in the heart of Cree territory, as they were. Pruden figures he’s an anomaly: a gay-identified Two-Spirit sperm donor. He may be right. If not then, he would be now.

The history of assisted human reproduction (AHR) such as in vitro fertilization (IVF) is that of heteronormative familial and clinical constructions that haven’t prepared the system to consistently and readily welcome families with specifications past blood type and eye colour. The earliest couples to start their families this way did so under a veil of secrecy— conception through a third party clashed with religious mores that neither patients nor doctors would defy. Frequently, sperm donors were medical students, plucked on the basis of little more than loose physical resemblance and proximity. At the time, fertility services largely dealt with offering solutions for male infertility in traditional monied families.

By the 1990s there were more than 100 fertility clinics in Canada operating in the sperm business. The rules governing donorship and tissue sales didn’t constrict until 2000, after a woman was inseminated with sperm carrying a strain of chlamydia. The updated Semen Regulations, active today, outline the criteria with which donors must comply and how clinics operate. These regulations are followed by the few remaining sperm banks in Canada—the largest of which is in Etobicoke, Ont.—to accept local donations.

With IVF costing anywhere from $5,000 to $15,000, the added cost of travel to an urban hub can make an already prohibitive means of starting a family insurmountable

In some ways a bid to create bulwarks against commercializing the trade of genetic material, Parliament passed the Assisted Human Reproduction Act (AHRA) in 2004. This bill featured several provisions to regulate the proliferation of reproductive technologies. One of the provisions that survived the 2010 Supreme Court challenge was the regulation that prohibits compensation for material donation. Subsequently, the number of donors located in Canada plummeted. With little incentive for Canadian men to donate altruistically, the vast majority of sperm donors available to prospective families in Canadian sperm banks are from the U.S., with some from Europe.

Some stakeholders are not convinced by the ban on compensation. It’s one of the areas of the AHRA being taken up by the AHRA/LGBT Working Group, a team of academic, legal, and medical experts consulting with the Ministry of Health to bring a queer lens to policy issues. “The fertility world is so heterocentric,” says Andy Inkster, the health promoter at the LGBTQ Parenting Network leading the charge on the project. “And it’s not just the industry, it’s not just the practitioners. It’s deeply embedded into the structure of what they’re doing. Fertility is where eggs and sperm come together, and it’s embedded with heterosexist and heterocentric assumptions, but the reality is that a huge number of the people using assisted human reproduction are LGBTQ people.”

Where health care is concerned, let alone reproductive technology, the intended focus and professional training tend to be centred on the needs of straight patients. Through policy and practice, health outcomes for queer communities are disproportionately worse than the general population. Fertility services are also riddled with active and coded messaging—the model, centred on heteronormative paradigms as it is, assumes infertility when a couple first arrives. Queer patients don’t inherently need a battery of tests to determine their ability to have children, like a straight couple having tried and failed to conceive for a time, but often the clinic is their first step. Understanding the overall landscape of queer health, the Working Group petitioned the Ministry to amend the law to both correct some of its previously stated incongruities and make room for the queer families that represent a high percentage of fertility clinic patients.

***

For parents like Thompson, there is still little information on laws affecting Indigenous and queer families seeking AHR. Some researchers have attempted to unpack these filigreed legal implications and their unique effects on queer families in Canada. Lori Ross, associate professor at the Dalla Lana School of Public Health in Toronto, spearheaded the Creating our Families study, which surveyed 66 LGBTQ couples in Ontario and their experiences accessing AHR services. According to Ross’s research, non-biological parents could face a variety of pressures, including cost barriers, discrimination, and the stress of pending but uncertain guardianship.

One of the simplest ways to circumvent a lack of donor sperm from one’s community is known donorship, an arrangement between a prospective parent and a friend, family member, or acquaintance. In the expert witness affidavit she wrote for the AHRA, Ross notes the catch-22 inherent to the decision-making for some prospective parents. An Indigenous participant in the study, for example, demonstrates the complexity of navigating known versus unknown donorship for families who want to maintain Indigenous lineage, but don’t want to bring a third parent into the arrangement: “If we had found a sperm donor whom we knew, who was status [according to the Indian Act], we’re then opening ourselves right back up to… the legal implications that would be involved. Because we’d have to list that person as their father, essentially.” Few people are equipped to neutralize the concern. While there are experts in fertility law and how it may pertain to queer families, the question of Indigenous parentage is not understood as ubiquitously. They’re “two different specialties that haven’t come together, really,” says Ross.

A spate of Canadian laws that purportedly exist to protect children have had ways of creeping into the family planning options for queer couples in Canada. In November 2016, Ontario’s All Families Are Equal Act passed, finally contravening one of them. Until then, the Children’s Law Reform Act, which designated how adoptive parents were named and recognized, conferred parenthood to mothers and fathers, and to sperm donors before partners in the province. To assure guardianship of their child, couples would need to apply for a second parent adoption, a process in which the donor would need to actively resign their rights and a member of the family would need to appeal the courts for guardianship. This law arose from Cy and Ruby’s Act, a bill named for a family that, after a harrowing childbirth, feared they would lose guardianship of their child because the laws didn’t automatically recognize a same-sex co-parent. Ontario is the fifth Canadian province to implement parental recognition legislation, following Alberta, Manitoba, Quebec, and B.C.

This legal victory for queer families in Canada came when Thompson’s daughter was already more than than a year old. When she was still navigating the waters of known versus anonymous donorship, there was hardly a dilemma. She and her partner were lucky: Situated in a major urban area in Toronto, as they were, they had access to queer parenting resources and a cluster of fertility clinics and counsel. But none of the lawyers she asked could tell her declaratively how a known donorship would affect her family. At that point, a known donor had de facto guardianship. How could they avoid peril to her partner’s parentship application to the courts? And what of the duty to consult? If her band chose to intervene, what recourse did they have? “It was really important to us from the outset that we were able to reflect our family’s cultural identity. So for us, we had to weigh out the desire to have Indigenous sperm from our area or someone who identified as Ojibwe as our sperm donor with the risks with a known donor,” Thompson says. “In the end we decided to not go with a known donor because the system didn’t seem equipped to support our family.”

Handling issues like donor diversity hasn’t proven feasible under existing regulations. Without the offer of compensation, recruiting volunteers to submit to regular health screenings, waves of ejaculatory abstinence, and the time to commute to the receiving clinic in Etobicoke hasn’t panned out. Furthermore, willing donors are turned away. As with blood donation, men who have sex with men are barred from donating sperm anonymously. And the requirement of a three-generation medical history may hinder Indigenous men, who are overrepresented in child welfare systems and might not know their history that far back, from becoming donors.

Organizations from queer community centre The 519 to the Canadian Bar Association (CBA) have decried the AHRA’s disproportionate impact on queer families. The CBA’s Family and Health Law Section and the Sexual Orientation and Gender Identity Community Forum also acknowledge that the exponential rise of reproductive technology would almost surely outpace the bill’s reason. Stiff penalties apply; paying a sperm donor or surrogate can earn one $500,000 in fines and a 10-year prison sentence.

The lack of proportionality in these measures is being pursued by some in the legal community who are addressing its deficits, from the confounding to the discriminatory. “If you are looking for a white healthy person, that’s an option. But if you are looking for anything beyond that, it becomes incredibly difficult in Canada to access gametes from any other racial or other background,” says Sara Cohen, a Toronto-based fertility lawyer involved with the AHRA/LGBTQ Working Group. “If you or your partner are non-caucasian and would like a specific racial background or heritage reflected in the genetic makeup of your child, you are down to a couple of donors at best—the same couple of donors as are available to everyone else in your community,” she wrote on the Fertility Law Canada blog. “Across the board for any racialized family who is active in LGBTQ communities, they kind of go through their mental Rolodex of who they know and guess that they’ve probably used the same donor,” adds Inkster.

But even if the working group’s consultations yield results for prospective queer parents—training their clinicians and counsellors in culturally competent care for those patients— that’s still only a piece of the question. Of all the clinics they deal with, “There are none that are aligned with Indigenous health principles—with clinicians who are aligned with that modality and trained in culturally safe care for Indigenous folks,” Inkster says. “I’ve never heard a clinician say to me, ‘We’re considering culturally safe care for Indigenous communities.’” He figures it’s likely a matter of place—fertility clinics in Canada are concentrated by density. Kingston, Ont. has none. There is one per Manitoba and Saskatchewan.

It’s a rather uncharted area of reproductive justice. Birth control, abortion, and other areas of health care are scantily accessible in Canada’s more remote regions. With IVF costing anywhere from $5,000 to $15,000, the added cost of travel to an urban hub can make an already prohibitive means of starting a family insurmountable.

“The way that Indigenous people look at families is very different than sort of this Western format of what family looks like,” says Denise Booth McLeod, an Indigenous full-spectrum doula, noting how common adoption and extended kinship ties are in her community. “I have other friends who are talking about when they’re planning on having babies who are already in talks with people within our community: ‘Okay, you’re Indigenous; we’re Indigenous. How do we sort of source your product? How do we do this in a way where it feels right for us as a family?’”

***

For Thompson and families like hers, how can an area like this be problematized? Reproductive justice and health inequity aside, now there’s a child. A living and loved manifestation of laborious decision-making, unexpected relics of the Indian Act, the spillover of second parent adoption laws. Recognition of the complexities of second parent adoptions and its obsolescence after the passage of the All Families Are Equal Act could change course for future families. “That new development I think could be a bit of a game changer,” she says.

In the end, she used an American donor with Indigenous ancestry. Once she and her partner decided that was important to them, it narrowed the selection down to a small pool.

At the time of publication, ReproMed, Canada’s largest sperm bank, had zero Indigenous-identified donors. Not much has changed since Pruden first donated his sperm in the 1990s. He has wondered intermittently over the years about what became of his sperm. A culture of immense racism, internalized, may have meant that some Indigenous families wouldn’t have had the pride in their identities and culture to motivate them to so deliberately expand their lineages in this way, passing down all that came with it, he says.

But today, identity remains a terrain to navigate. “One of the things that happens in the community is there’s a huge focus on who you are and where you’ve come from. And so I think about that for her,” Thompson says. Her Anishnabe family is her daughter’s family. “We’ll talk about that and that’s who she’ll grow up with.”

“We’re happy with the little person we got.”

UPDATE, MAY 25: This story has been updated, removing language surrounding the ancestry of the Thompson family’s sperm donor to protect their privacy.

Illustration by Dave Donald.

It’s just another September day in Nova Scotia—sun shining, birds chirping, a late summer breeze playing in the treetops. Only one thing is different today for Shawna Young: she is pregnant. This one fact makes the sunshine seem a little brighter, the birds’ songs just for her. It’s like carrying around a secret, a secret that makes her smile at strangers and hold her head a little higher. Just yesterday, Shawna and

her husband, Benjie, put their one-bedroom house on the market, already full throttle into planning their lives for their little one. They’d dreamed of moving into a bigger, more family-friendly home when the time came; now, it was finally here. Today, Shawna is on her way to the doctor for her 13-week ultrasound. She knows exactly what to expect: the doctor will say she’s 12 weeks and six days pregnant, and she and Benjie will get to see the little hands and feet of their miracle baby.

But something feels wrong when she lies back in the chair, looking at the ultrasound image up on the screen. There is no movement. She tries to convince herself that everything is fine, even though a nagging feeling in the pit of her stomach suggests otherwise. The nurse’s words come like a blow to the head.

“Well, you’re not 12 weeks and six days.”

“Oh, is the baby measuring a bit small?” Shawna asks, looking helplessly at the blob on the screen.

“I’m sorry,” replies the nurse. “I have no good news for you today.”

When Shawna repeats the nurse’s words to me on the phone from her home in Halifax, I hear her voice crack, and I know it’s not the quality of the connection. For any woman who has miscarried, the emotional devastation is something that lingers long after the event has passed. But for a woman who has had fertility problems and struggled through years of tests, medications, alternative treatments, and thousands of dollars in debt, the devastation is that much harder to bear.

A few days after finding out she had miscarried, Shawna went in for her scheduled “D & C”—dilatation and curettage—which refers to the widening of the cervix so a doctor can scrape tissue from inside the uterus; in this case, excess tissue resulting from the miscarriage.

“I had the distinct feeling we were going to a funeral,” she says of the drive to the hospital. “After a morning of meeting with doctors, nurses, intake people, seemingly half the people who worked in the hospital, I was taken into the operating room. I walked in and climbed up on the table. I extended one arm out straight so they could put the IV in, but they couldn’t get it in, so they had to try the other arm. So I was lying there with my legs in stirrups and both arms extended out and very bright lights shining on me. The operating room itself and the procedure to that point reminded me very much of my egg retrieval for the in vitro fertilization, and as I lay there, the tears just started streaming down my face. I couldn’t wipe them away because both of my arms were extended and being worked on. I felt so alone and such complete and total sorrow. I didn’t fight the feeling, though; I just let myself feel what I felt and grieved for the baby I was about to lose. I was not only mourning the loss of our baby, but I was really grieving for my fertility.”

At 37, Shawna was on her second in vitro fertilization treatment after a year and a half of trying to conceive naturally. The decision put her and Benjie in debt more than $20,000. A single round of IVF can cost up to $10,000, which includes costs other than the procedure fee—women also pay for the drugs they need to inject themselves with in preparation for the procedure, and these can cost as much as $5,000. IVF is currently not covered by the provincial health-care system in Nova Scotia or most provinces in Canada. In Ontario, it is funded only for women with blocked fallopian tubes—no more than 20 percent of infertility cases. Last summer, Quebec became the first Canadian province to bring IVF under its provincial health plan when it passed Bill 26, which allows funding for up to three IVF treatments for women having difficulty conceiving. Outside Quebec, IVF remains a private medical cost in most cases.

IVF involves fertilizing an egg with sperm outside the uterus. It falls under the umbrella of Assisted Reproductive Technologies (ARTs), which emerged in the late 1970s, with the first Canadian fertility clinic opening in 1983. IVF is the most effective ART: with each cycle of treatment, it’s successful 38 percent of the time for women under 35; for women aged 35 to 39, it’s successful 28 percent of the time; starting at age 40, success rates drop to 11 percent. According to the Canadian Fertility and Andrology Society (CFAS), these rates have increased by 10 percent over the last decade.

The causes of infertility are numerous, and doctors usually look at lifestyle factors first—smoking, alcohol, and drug use all inhibit fertility. But the biggest cause of infertility in both men and women is unknown, and the most common type of infertility is unexplained—doctors simply find no reason why a woman cannot conceive naturally; everything seems to be medically normal, but it’s just not happening. In Ontario, infertility is known to occur in one in six couples, and in 2008, the CFAS reported a combined total of almost 10,000 IVF procedures performed in the 28 clinics across the country. However, although it is the most effective treatment, IVF is usually not the first procedure that couples attempt.

According to Dr. Keith Jarvi, director of the Murray Koffler Urologic Wellness Centre and head of urology at Mount Sinai Hospital in Toronto, doctors often try to increase ovulation in women and the number of eggs they produce during ovulation. This is done through stimulation medications that women take for a period of time prior to the procedure, so the sperm have more targets to aim for. If the process, known as Intrauterine Insemination, fails more than once or twice, the next step may be the use of IVF.

“We take the eggs out, take the sperm out, and incubate them together in a dish,” says Jarvi. Once the eggs are fertilized, the doctors take as many embryos as they feel are necessary for optimal chances of conceiving and return them back to the woman’s uterus. If IVF doesn’t work this way, doctors perform Intracytoplasmic Sperm Injection as part of the procedure. “[With ICSI], you can take the sperm and bring it closer to its targets,” Jarvi explains. To do this, doctors take a single sperm and inject it into a single egg, (after they have been extracted from the couple), and then place the fertilized embryo back into the woman’s uterus.

The costs of these procedures ranges anywhere from $5,000 to $8,000 each, not including the cost of the drugs women may need to take at the same time. “And you’re probably going to end up doing it two or three times,” says Jarvi. “You could easily spend a compact car’s worth of money on it. It’s not Lamborghini kind of money, but still, it’s a lot of money.” The huge expense adds a financial burden to the already high emotional cost of infertility, says Shawna. “It is really unfortunate that [the decision to do IVF] has to be a financial decision.”

Beyond the financial or emotional considerations, IVF also has implications for the health-care system. Such procedures result in a high number of multiple births, for one; because IVF costs so much, doctors transfer more than one embryo at a time to increase the chances of one coming to term. Multiple births suffer more complications, and it costs the health-care system a lot to care for them. Many doctors say these multiple births end up costing the government more than publicly funding IVF treatments mandating a single embryo transfer would.

As birth rates continue to drop, many advocates, patients, and doctors alike say that provincial governments need to recognize that these procedures inflict high costs on individuals—emotionally and financially—and additional economic costs on the public healthcare system. The solution, they say, is to make IVF a publicly funded treatment.

Most women spend a great deal of their lives trying to avoid pregnancy. We are taught to practise safer sex and use condoms and go on birth control. We do these things until we want to start a family, and it’s easy to assume that as soon as birth control stops, a pregnancy will occur. We’re conditioned to expect the process to happen naturally, like turning on a light switch. And when it doesn’t, we feel frustrated, angry, and confused.

“You feel at fault because you can’t do something that comes so naturally to everybody else,” says 39-year-old Charmaine Graham, of London, Ont., who has been through 11 IVF treatments. “You’re faced with people who are parenting children and they’re going through [general] parenting angst—they’re frustrated, they’re tired, they yell, they snap—and you just would do anything for that opportunity. I just wanted to go to the grocery store with a baby like everybody else.”

Graham says infertility can be an intensely isolating experience. Not only do women feel like outsiders for not being able to do something natural—and, arguably, what many women may feel is their unique duty—but they are further isolated by constant reminders of their failure.

“No matter where you go, every single person that you meet came from somebody’s womb. That is what we do as a human species—we procreate. And so there’s no way ever to escape that,” she says. “You have a lot of feelings that are paradoxical. You’re really happy for your sister when she gets pregnant, but you also want to smash her head up against the bathtub because you can’t. It’s very hard to live with those feelings all the time.” Of Graham’s IVF treatments four were fresh, and seven were frozen (frozen fertilized eggs are stored in case a fresh treatment fails, which is less expensive than starting again with another fresh treatment). While her husband, Jim, believes the experience ultimately brought them closer, Graham remembers how taxing the treatments were on their marriage at the time.

“You have to deal with the anger and frustration you might have with your partner as a result of them being infertile, or the guilt that you feel for being infertile. And then I have to make this man who loves me live with me when I’m fucking insane going through hormone treatments,” she says. “Women become so focused on just getting pregnant, it doesn’t even become about parenting anymore. Men don’t feel that they’re married to the woman they got married to. Something has hijacked their marriage entirely.”

This is one of the most compelling things about the struggle of infertility: it affects men and women very differently. Even if a man is the one with the issue, the procedure is still done on the woman because she is the child-bearer. “They’re the ones who have to do most of the drugs, they have to do most of the invasive technologies. They’re the ones being poked and prodded,” says Graham. “A man has to masturbate to get his sperm out. A woman has to have a probe put in her vagina, with a 22-gauge needle that goes through the side of her vagina into her ovaries to withdraw the eggs. I think it’s a very separating experience for most men and women.”

Other women agree with Graham that the reminders of what they can’t do never seem to cease. Some describe difficulty attending baby showers, seeing mothers with their children in the grocery store, and even walking by the Santa Claus display in malls around Christmas. And with all of these difficult feelings comes the worst part: paying out of pocket for a procedure that is not even guaranteed to work. No one knows that better than Kerri-Lyn Jessop, 37, of Caledon, Ont., whose three IVF treatments over two years have put her more than $30,000 in debt. “Unless you’re rich, that’s a lot of money to spend to find out an answer to one question,” she says. But it’s not enough to make her want to stop trying.

“Emotionally and physically, I’m not ready to give up, but there’s only so much money in the pot.”

Cheryl Dancey, 41, of London, Ont. agrees. She had 18 IUIs and four IVF treatments, none of which were successful. “As hard as everything else is, it’s not enough to stop you from doing it again. Money is the only thing that can make you not go on.” (Since our original interview, Dancey was able to give birth to a baby girl with the help of a donor embryo.)

Dancey says if IVF was publicly funded, half the burden of the experience would be gone. “It would take all that pressure completely away,” she says. “You wouldn’t have to worry, ‘Well, if I do it, we’re not going to have the house to put the kid in.’”

Many couples struggling with infertility turn to family and friends for financial help to pay for IVF treatments, which brings up the arduous task of explaining their situation to loved ones—something that can be very difficult to do.

“People don’t believe that it’s real,” Dancey says. “They say, ‘You’re not doing it right. All you have to do is relax. So-and-so’s brother’s cousin’s wife did this and she was fine.’ People just don’t get it. Everybody’s got some stupid story that somebody that they’ve known through the grapevine relaxed, or drank a certain tea, and that’s what will fix the problem.”

“The other thing that people also do all the time is that they stop talking to you,” says Graham. “I worked at the university and I was always very open about my situation. So, I’d go missing for a few weeks and I’d come back to work and people would say, ‘Where have you been?’ and I’d be like, ‘Making babies in a petri dish.’ And so everybody knew what I was going through. And then one of them would get pregnant and she wouldn’t come to my office for nine months.”

If IVF were publicly funded, couples could go ahead with treatments privately. They would also be spared having to deal with the naysayers who think seeking such treatment is selfish.

“By the time the government decides—if they ever decide—to fund this, it will be too late for us. My time will come and go by the time that it’s covered,” says Jessop. “We are speaking up for the next group of people that are coming into this. I don’t think I will ever benefit from [it], but I might be able to help somebody else benefit.”

The Ontario government established an expert panel in 2008 to take a closer look at ARTs, especially IVF, and whether it should be funded under the province’s health-care plan. It also examined adoption: its cost and its lengthy, complicated process. The panel released its recommendations this past August, which urged the government to institute a fertility education system, provide a funding strategy for IVF procedures, and make changes to the adoption process.

Dr. Jarvi provided expert advice to the panel, which also included Dr. Arthur Leader, a professor at the University of Ottawa and a partner at the Ottawa Fertility Centre. Both doctors agree that the most important public health reason to fund IVF is to limit the number of multiple births that result from multiple embryo transfers. Leader says that transferring multiple embryos is dangerous and more of a financial burden on the health-care system than IVF procedures would be.

“What the expert panel showed was that, by limiting the multiple birth rate in Ontario, you could save the taxpayer, over a 10-year period, half a billion dollars,” he said. “Twins are more likely to have medical or surgical needs in the first four months of life. The tremendous cost associated with having high rates of twins, never mind triplets, means that caring for them is actually costing the government more than it would have cost to fund IVF for single-embryo transfers.”

One of Leader’s patients became pregnant with twins through IVF. About halfway through the pregnancy, one of the twins died in utero as a result of a congenital heart defect. “It became a highrisk pregnancy,” says Leader’s patient, Kerri Stanford, who was 34 at the time. “We knew that one of the babies wasn’t doing well and was likely not going to make it. It just meant that the whole pregnancy was very complicated and it was watched in a high-risk unit.” Those high risks, of course, entailed high costs, exponentially more than a single healthy pregnancy would have. “Economically, there is a strong argument to be made to fund fertility services,” Leader says.

Leader has another reason he believes IVF should be added to provincial health-care plans: continuity of care for patients. “One of the paradoxes of infertility is that, in almost every province of the country, it’s medically necessary to do fertility testing in order to find out why people can’t get pregnant. In other words, the health plan pays for treatments to diagnose infertility. But once the diagnosis is made, the health plan abandons people, saying it’s not necessary to treat your problem. Then, once people get pregnant, the health plan says now it’s medically necessary to care for pregnant women. There’s a disconnect.”

Months after my first conversation with Shawna, I receive an email from her. “I should be 35 weeks pregnant now,” she writes, still lamenting her miscarriage. She goes on to tell me about one of the hardest parts of dealing with infertility: the public’s misconceptions about it.

“If I had a medical condition that prevented me from being able to walk,” she said, “and there was an effective medical treatment available, society wouldn’t question whether or not I should be able to access it. When someone is paralyzed, people think, ‘Oh my gosh, I could never imagine what that would be like.’ Nobody ever thinks, ‘What would my life be like if I didn’t have my fertility?’”

Advocates for IVF funding see it as positive that the Ontario government commissioned an expert panel to look at the issue, and Quebec’s new law is definitely a step forward. But it’s taking the rest of the country a while to catch up. Medical organizations have questioned Canada’s attitude toward funding, especially in comparison to other countries around the world, many of which do provide funding. Manitoba offers couples who have undergone treatment a tax credit for 40 percent of treatment costs. British Columbia now has the Hope Fertility Fund, which provides financial assistance to residents of the province who can’t afford treatment—commissioned by the UBC Centre for Reproductive Health, the Vancouver General Hospital, and the UBC Hospital Foundation, not by the government. The Nova Scotia government has previously deemed it not medically necessary to provide funding, and the rest of the country seems to agree.

Still, supporters remain hopeful. Beverly Hanck, executive director of the Infertility Awareness Association of Canada, believes all provinces will eventually cover treatment. “I suspect what’s going to happen, and this is my guess, is that they will put it on their platform for the next election,” says Hanck. “It’s a matter of time. But time is important for some of these couples.”

Time is indeed the enemy in the infertility battle. Women feel pressured by time because fertility decreases with age, and after an IVF treatment is performed, waiting to find out if they are pregnant can be excruciating. The burden of infertility is essentially a race against time. And so far, time is winning by a long shot.