What I learned from looking at one Ontario woman's $100,000+ expenditure on fertility treatment

In Canada, almost all medicine is paid for through a public insurer. In my province, Ontario, that insurer is the Ontario Health Insurance Plan (OHIP). It works by pooling risk, so that people who are lucky enough to be healthy help pay costs for people who are unlucky enough to need medical care. Coronary bypass, hip replacement, brain surgery — all covered. You walk away without a bill.

No so fertility treatment. It's a long story, not one I have space to get into here, but if you live in Ontario and you find that your reproductive system is not working, you are on your own in the strange world of private medicine.

When you have a public insurer like OHIP, that insurer does the heavy lifting in terms of keeping prices down and keeping them fair. We don't even know what individual treatments cost (unless we go looking). We aren't used to talking with our health care providers about prices and deals and financing and refunds. Long story short, Canadian fertility patients make easy targets. The business-minded know that.

I have heard snippets over the years, but recently have been asking around more deliberately about people's experiences with fertility care costs. One woman, Renee Higgins, came forward offering to share with me a full breakdown, with receipts, of what her fertility journey has cost so far. (Spoiler: $117,684.43).

Here are some of the things I learned.

9 minute read

Renee Higgins is a 35-year-old woman living in Sudbury, Ontario, about five hours north of Toronto. In her early thirties, she and her male partner started trying to have children, but she did not get pregnant. In 2021, at age 32, she was diagnosed with diminished ovarian reserve.

In the two years that followed, she attempted nine IVFs and three IUIs. Three IVF cycles had to be abandoned before retrieval because of poor response. Twice she got pregnant, only to miscarry around the ninth week. She currently has one healthy frozen embryo and plans to transfer it in the new year.

Higgins agreed to share with me a full breakdown, with receipts, of what her fertility journey has cost so far ($117,684.43 — they remortgaged their home.) We spent a few evenings talking about what these records ultimately tell us.

1. There are huge cost variations

When Higgins first signed on to do IVF, she says she was told it would cost between $20,000 and $30,000. "I even asked if there were cheaper options," she told me, "and they said no."

Her first two rounds of IVF did in fact cost about that much. But then she switched clinics and discovered that in fact there were cheaper options.

Let's compare two of her cycles. One, which we'll call IVF#1, was done with her first Ontario clinic. The other, which we'll call IVF#3, was done with her second Ontario clinic. (Both clinics were in the Toronto area.) The protocols were very different, but the outcomes were not: in both cases, she developed four mature eggs, grew one good embryo, got pregnant, and subsequently miscarried.

IVF#1 cost $25,219.48.

IVF#3 cost $11,282.97.

Those costs are in Canadian dollars, and include clinic fees plus medications.

Let's look at why they differ. The first IVF clinic charged a $14,050.00 fee, broken down, according to their invoice, as follows:

$1,650.00 "program fee" (presumably admin, monitoring, advising)

$8,900.00 retrieval procedure and lab fees

$1,650.00 intracytoplasmic sperm injection (ICSI)

$850.00 embryo co-culture

$1,000.00 embryo freezing and one year of storage

$3,350.00 frozen embryo transfer

This clinic had an arrangement with a satellite clinic closer to where Higgins lived, and it was the satellite clinic that she first spoke to. The satellite also did some, but not all, of the monitoring in the run-up to retrieval. It charged a $339.00 annual fee. (More on such fees later.)

Higgins' first IVF clinic put her on high doses of fertility medications. These stimulation medications came to $6,562.89.

Now let's look at the other IVF clinic, which did things a little differently.

For one thing, they used lower-dose stimulation medications. That reduced the drug cost to $3,156.49 — less than half that in IVF#1.

They also opted not to do certain procedures: they did not do ICSI and instead used conventional IVF (ICSI involves injecting sperm, whereas IVF puts the sperm together with the egg in a dish and just lets them do their thing); they did a fresh transfer instead of a frozen embryo transfer; they did not do embryo co-culture (a non-standard technique where you develop the embryos on culture that contains cells grown from the patient's own uterine lining).

Why did the first clinic do these extras? Higgins' partner's sperm was top-notch, so there was no apparent need for ICSI ($1,650.00), but it was non-negotiable. Was freezing really necessary with only one embryo available for transfer? Not freezing would have cut out both the cost of freezing and storing ($1,000) and the additional cost of frozen embryo transfer ($3,350.00), but freezing was non-negotiable too.

Not doing those things, in addition to cutting out embryo co-culture, would have shaved $6,850.00 off the cost of IVF#1, bringing it down to $7,200.00 (maybe with an additional fee for fresh transfer). That makes it closer to the IVF#3 treatment fee (not itemized, sadly), which, according to the invoice, was $7,565.00.

The extras make a huge difference to the price.

Higgins didn't realize there could be such a price difference. "We did two cycles at this exorbitant cost before I discovered they were one of the most expensive clinics in Ontario," Higgins told me. They also happened to be the only IVF clinic that her nearby satellite clinic was partnered with.

Interesting to note: the first IVF clinic repeated their protocol in IVF#2. The cycle produced no embryos. (To be fair, the clinic did refund the $1,000.00 the couple had stumped up for freezing, which could not take place, and the $5,000.00 for genetic testing, which also could not take place.) But the meds in IVF#2 cost a whopping $10,977.28. And in the end, the total clinic-plus-meds cost of IVF#2, which yielded no embryos, was $22,622.28.

Higgins wishes there was more consistency in prices, or at least more transparency on where there's not. But many clinics don't provide all the cost information up front. "Many don't publish costs on their website," she says, "and they can charge whatever they want. People don't often speak of fertility treatment, and so it's hard to figure this out until after you've been through it." And by that time, the house has been mortgaged and the money has been spent.

2. There are a lot of strange charges and fees

Remember the $339.00 charge Higgins had to pay just to be seen at the satellite clinic? It's hard to know exactly what that was for, since she was already paying for monitoring through the IVF clinic's $1,650.00 "program fee," some of which, she knows, was paid directly to the satellite clinic for the monitoring it did. (I called the clinic to ask about its so-called "monitoring block fee" and the receptionist said it was an "admin fee" but she wouldn't elaborate.)

Higgins chooses to call it an "annual membership fee" — a fee you pay just to get in the door. And it turns out inscrutable fees like this are not unusual. When Higgins, who has an Instagram following, did a callout about unreasonable charges by fertility clinics, a lot of women mentioned weird fees:

"Yep! Had a large yearly fee to even have appointments made."

"A 2,000 'administration fee' "

"Random admin cost £950 I don't even know what it's for ??!??"

"Oh lord where do I start!!! I'd like to start with 'clinic coordination' fees"

"$500 just to become a patient..."

One Ontario woman told me she was charged, every year for four years, an "annual block administration fee" of $300.88 that covers, according to the clinic, "some non-medical services."

Another clinic she worked with charged a $300.00 "IVF cycle coordination" fee, which is, she told me via email, "basically just a phone call telling you about the process of IVF and asking you when you plan to begin."

The clinic the woman is now working with has no such fees (and apparently didn't know others had them).

Another woman told me about a $2,000.00 "clinic coordination" fee if you are a patient using donor gametes. The clinic said it was to cover the cost of "the necessary screening and compliance" for Health Canada. (Wow, ballsy.) But because this woman had already chosen her sperm and had it in storage, the clinic was willing to cut the fee in half, to just $1,000.00.

But just as one hand giveth, the other taketh away. The woman had her sperm stored at another Ontario fertility clinic, on the other side of Toronto. The clinic that gave her the $1,000.00 "discount" charged a $350.00 fee to receive the sperm into the clinic, and another $420.00 to keep it frozen for a year.

There was more. Because of Health Canada regulations, before the woman's sperm could travel to her new clinic, it had to be returned to the sperm bank she had purchased it through. That meant she had to rent a shipping tank ($169.50, including tax), pay to ship the tank to her first clinic where it could pick up her sperm vials ($84.75), pay to ship the sperm back to the bank ($84.75), pay to ship the sperm to her second clinic ($84.75), then pay to ship the tank back to the sperm bank that was renting her the tank ($84.75). That's more than $500.00 for what was really just a chilled trip across town.

3. Dealing drugs is profitable

Canada is the only country in the world that has publicly-funded medical care without publicly-funded drug coverage. (We are working on it.) A large proportion of the population (like me) have no pharma coverage whatsoever, and have to pay out of pocket every time.

In fertility care, the cost of the drugs make up a significant part of the total. Of Higgins' $117,684.43 bill to date, medications account for $43,783.65.

To a large degree, clinics decide how much you will spend on drugs. Some clinics will prescribe high doses, where others will prescribe low doses — sometimes for the same patient, and with the same outcome, as in Higgins' case. Go figure.

It also matters where you buy your fertility drugs. Higgins discovered that a 900 IU pen of Gonal-F (a synthetic follicle-stimulating hormone, or FSH) cost $991.03 at Rexall pharmacy. But it cost $1,020.00 at her second IVF clinic and $1,046.00 at her first.

Some clinics insist that medications be bought through them, not through a pharmacy. Higgins recalls having to sign a document to that effect for her first IVF clinic. The same clinic that recommended and prescribed very high doses of medications was also, it appears, benefitting from markups.

Another interesting feature of medication sales is that they are typically sold up front, but are not refundable.

One Ontario woman told me she was sold medications that she was ultimately unable to use — she had to throw them out. "It was a bulk purchase of all the medications up front," she said. She bought a $105.00 Ovidrel pen (to trigger ovulation), for instance, and $224.00 of the drug Endometrin (to help with implantation), but because of poor response, she never got to use them. They expired. That's $329.00 in the garbage.

Ironically, some clinics that won't give refunds for meds request that you bring back spent pens... "as they can be recycled."

4. There are extra challenges when you live in the North

Higgins doesn't have exact numbers for her travel costs, but estimates it has cost her around $10,000. There are zero fertility clinics offering IVF anywhere in the north — not even in the near-north where Higgins lives. So the cost is not only in money, but in time and energy.

Between March 2022 and March 2023, Higgins drove south to the Toronto area approximately 20 times. Typically, she woke at 3 a.m., drove to her clinic, attended a 20-minute appointment, then turned around and drove the four hours back. Other times, she couldn't get the day off work, so after driving down and attending her appointment, she set herself up in a coffee shop, worked for seven hours, then drove back home. Many drives were in dangerous winter conditions, alone, after almost no sleep.

It's hard for people in smaller, more populated countries to imagine, but a person could easily travel in-province by car for 15 hours straight and still not get to the nearest Ontario IVF clinic. People in the true north would have to fly for a few hours.

This is true for many medical procedures, of course, and the province recognizes that it can cause economic hardship for rural and remote Ontario patients to have to travel for health care. So it has what it calls the Northern Health Travel Grant: patients who need to travel more than 100 kilometres from their home for a prescribed medical treatment, are eligible to be reimbursed $0.41 per kilometre travelled and up to $100.00 per night in a hotel.

But — wait for it — fertility patients are not eligible.

That's right: because fertility care in Ontario is not covered by the provincial insurer, it is also not eligible for the medical travel grant. Higgins applied anyway, and, adding insult to injury, she was denied.

"Treatment add-ons with limited evidence." Human Fertilisation and Embryology Authority.

HeyReprotech is a weekly newsletter exploring the ripples caused by assisted reproduction. It's written by freelance journalist Alison Motluk. Get stories about donor conception, genetic testing, surrogacy, egg and sperm donation, chicanery in the fertility sector, and more.