When Aimee MacDonald and her wife Allison MacLennan were going through the years-long process of getting pregnant with assisted reproductive therapy, they decided to keep it quiet. “This was a journey that we took alone, no one really knew we were doing this,” MacDonald says.
There were a number of reasons for keeping the experience under wraps, she says. Pursuing fertility care comes with extreme highs and lows—celebration when procedures went well, followed by periods of major grief when insemination failed.
“We weren’t sure if people grieving alongside us would make it harder or easier,” MacDonald says. “But it was something we weren’t ready to do at that point.”
She and MacLennan, with the support of a couple very close friends who cared for the couple’s daughter Ceileigh (MacDonald’s biological child from a previous relationship), spent three years traveling between their Antigonish home and the province’s lone fertility treatment centre, in Halifax. There were countless medical appointments, procedures and tests, but they kept the reason for the trips under wraps.
“Three years is a lot of time. There were always questions about why we were going to the city again,” she says with a laugh. After years of travel, countless procedures, a line of credit and about $40,000 spent on assisted reproductive therapy and travel costs, their efforts paid off when MacLennan gave birth to their son Charley.
“Numbers are important to me, and they’re telling us that the likelihood that we’ll conceive during your ovulation cycle, if the circumstances are perfect, is only eight percent,” MacDonald says. “There was no rhyme nor reason why, other than that the timing was just perfect. It’s almost mind blowing that it did work. ”
About one in six Canadian couples suffer from infertility. Thirty-five Nova Scotians who’ve pursued fertility treatment (some who have had children with the help of assisted reproductive therapy, some who did not and some who are still in the process of trying to conceive) filled out a detailed Coast survey about their experience seeking fertility care. As in the first part of this series on the state of gynecological health care in Nova Scotia, survey responses and subsequent follow-up interviews provide a rare human dimension to help understand an institutional crisis.
Across the responses, many people shared that they felt shame, depression, “recurring sadness from loss,” major financial pressure, and “astronomical” highs and lows during the fertility treatment process. Nearly 65 percent sought out mental health support as a result of seeking fertility care.
“I have had several losses during my treatments and developed anxiety and feelings of being overwhelmed,” one woman says.
“I physically and emotionally suffered, and it leads to a lot of hopelessness, fear and frustration,” says another.
The families who responded to the survey have spent anywhere from $1,000 to upwards of $80,000 on various forms of assisted reproductive therapy, or ART. The average cost from those surveyed was $24,750. Because fertility treatment is rarely covered by insurance, about 83 percent of respondents said the investment towards trying to become parents significantly impacted their lives or future plans. Many took out loans or sold property in order to try and become pregnant.
Premier Tim Houston won this summer’s election on a health-care-heavy platform, which included a pledge to fund 40 percent of fertility treatment costs up to $20,000 ($8,000 per year) for all Nova Scotians. Asked about progress on this campaign promise, a department of health spokesperson says in an email that “work is underway on this commitment,” though she did not elaborate.
Costs vary significantly depending on a number of factors, like which therapy type is chosen (in vitro fertilization or IVF, intrauterine insemination, intrafallopian transfer and intracytoplasmic sperm injection are all possible ART options), and whether sperm is purchased or it comes from another source. The most significant factor for treatment cost is how many attempts are necessary. Added costs to seeking treatment include travel and accommodations for Nova Scotians living far from Halifax’s IWK Health Centre.
“Myself and my partner are fortunate enough to have jobs that allow us to afford the treatments, although they added to my crippling student debt. But hey—at least we were able to do this,” one respondent says. “It has drained all savings we both had, but will be worth it in the end.”
One family sold their residential home in Halifax and their cottage in the South Shore to cover two rounds of IVF, which were not successful. The family now rents an apartment outside the city.
“It was our life savings,” says the family. “Though, had we not taken that giant leap, sold everything and moved, we would have never known what might have been.”
2SLGBTQ+ patients pay more
A straight cisgender couple going into the Atlantic Assisted Reproductive Therapies fertility clinic in Halifax—it’s known as AART—will start with an initial examination, investigation and follow-up appointments to determine if they require medical assistance to get pregnant. These first few appointments are fully covered by Nova Scotia’s MSI program and won’t cost them a cent. Only once they’ve begun some type of fertility treatment will they be billed for care.
The billing is different for queer couples or single people: Out-of-pocket costs start at the very first appointment, even before they elect to have medical intervention. This means queer couples automatically spend around $300-$500 more than their straight counterparts before reproductive therapy begins, says AART doctor Heather Cockwell.
“If a single person, with ovaries or testes, or a 2SLGBTQIA+ couple sees me, their appointments are not covered. Because it is assumed, sometimes wrongly, that they will need ART to get pregnant,” Cockwell says.
To Cockwell, this additional financial barrier to queer and single people trying to have a baby is discriminatory. She’s been pushing the province to alter its billing policy, but so far has “not been able to gain traction.”
In 2020 she wrote twice to the health minister at the time, Zach Churchill. She never heard back. During the 2021 summer election campaign, she shared the same concerns in a letter with 12 MLA candidates in the HRM. Only the NDP representatives responded. When Tim Houston’s PCs took government, she sent the same letter to two members of the new cabinet—minister of health Michelle Thompson, and minister of equity and anti-racism initiatives Pat Dunn.
When The Coast asked why this extra billing is in place for queer couples, the department of health responded through a spokesperson: “Appointments that are covered by MSI are those that examine whether there is a medical reason a couple or individual may be struggling with infertility. Once a couple or individual has determined they will be pursuing assisted reproductive technology, regardless of their gender identity, those expenses are not covered by MSI.”
Cockwell says the topic of costs comes up “all the time” with 2SLGBTQ+ patients who come to see her. “They have to pay for all their appointments, which can be a serious deterrent to coming to see us and or accessing fertility care,” she says.
Queer people looking to have children are not surprised they have to pay for these initial appointments, says Cockwell, because it’s well known that all ART care isn’t covered. “But they are surprised to find out heterosexual couples don't have to pay,” she says. “Ultimately, I think the community has come to expect discrimination from the medical field, which is both saddening, frustrating and somewhat embarrassing.”
Aimee MacDonald says that while she didn’t realize straight couples had appointments covered, she felt the burden of extra costs that come with being a same-sex couple that isn’t able to conceive without intervention. She and her wife had additional costs like sperm (for about $600 per vial), just as others may have to rely on donor eggs or surrogacy.
“That was what felt unjust to me,” she says. “I honestly didn’t know that what was happening for us [with appointment payments] was any different than for a hetero couple.”
Wait and access
Like accessing gynecological care in Nova Scotia, waiting is part of the ART experience. Unless you are undergoing cancer treatment that will impact fertility, people referred by a primary care provider will likely wait from five to 12 months to be seen at Atlantic Assisted Reproductive Therapies, Nova Scotia’s only fertility treatment centre. Straight cisgender couples are expected to have tried conceiving for at least a year before they’re seen by the specialists at AART.
The clinic is not for profit and is served by three doctors, including Cockwell, who work there part time alongside work in other areas of the health care system. Cockwell, for example, also works at the IWK, the Victoria General hospital and the Halifax Infirmary. This is on top of the medical teaching she does at Dalhousie University as a member of the department of obstetrics and gynecology.
It takes five years of med school to become an OBGYN. After that, fertility doctors must do an additional two years studying gynecological reproductive endocrinology and infertility medicine. Doctors Nova Scotia is aware of three fertility specialists in Nova Scotia, all of whom are working at AART.
Nova Scotia’s medical school, Dalhousie University, had five doctors graduate from obstetrics and gynecology in June 2021, and will have another seven OBGYNs graduate in June 2022. Over the same period of time no one graduated from the infertility and endocrinology speciality. The province has roles for the equivalent of 58.4 full-time OBGYNs across the health authority and IWK. Often these full-time hours are split among multiple doctors who, like Cockwell, work in more than one facility. The lack of doctors in gynecology is a problem, many in the sector believe, and the province needs more OBGYNs and fertility specialists.
AART sees 1,000 new patients a year, some from beyond Nova Scotia. The clinic has treated more than 15,000 people since it opened as an independent centre in 2005. Julie Keizer, the chief operating officer of AART, says the province is well aware of the clinic’s need for another doctor to serve its large patient base.
“We need another physician to meet demand,” Keizer says. The demand for fertility care is expected to only increase in the coming years when the province progresses on its plan to cover a portion of costs, making assisted reproductive therapies accessible to more people.
Doctor Renda Bouzayen, AART’s medical director, says the wait times in fertility are long, but they’re not much different than other areas of Nova Scotia’s health system. What is very different about fertility is how closely viable pregnancy is tied to a patient’s age.
“What’s very particular about our subspecialty is that the success rate for in vitro if you’re under 36 is 60 percent. If you wait two or three years and join the 36-to-40 age range, the success rate is going to be 40 percent,” Bouzayen says.
After age 40, the success rate drops to 20 percent, then bottoms out at one percent once you’re over 43.
“So if a couple is waiting, and they’re around the age of 39 and they’re waiting a year or a year and a half, we go from the chance at a successful treatment to it being too late. You miss the boat,” she says.
“There’s the misconception that infertility is not an emergency and it can wait. It can’t.”
The fertility survey respondents ranged from 26 to 44, with an average age of 35.
Theresa Hudson, a 36-year-old Dartmouth woman, first sought out for fertility care through AART at age 33. She’s endured two unsuccessful IVF rounds since Oct 2020, which resulted in an ectopic pregnancy and miscarriage, which is not uncommon—miscarriages occur in as many as one in four pregnancies. With one remaining embryo, she and her husband transferred care to a Toronto clinic in order to avoid local wait times.
“Toronto has around 15 clinics, so there’s no waitlists. You call and get in within the next month. And that’s huge when you're my age,” she says.
“If we had been able to get help when I was 33 we might have had more follicles and more eggs frozen, and now that I’m 36 the quality of eggs has gone down.”
Hudson says the care and professionals at AART were exceptional (as did many survey respondents). But with a limited number of doctors at the clinic, there are month-long waits throughout the fertility treatment process in the province. Hudson had to wait three months after a miscarriage before she could get an appointment to discuss it on the phone with her medical team.
“We felt that maybe everything we could do in Nova Scotia we had done,” she says. “So now that we can travel, why not try somewhere different?”
Kali Arthurs, a 29-year-old woman from Beaverbank, says waiting has only heightened the emotional toll of the experience. She and her husband tried for three years to conceive without assisted therapies, before getting a referral to AART in February 2021. She was told in March 2021 she’d likely be waiting at least a year to get in the clinic.
“It’s been really hard emotionally,” Arthurs says. Learning about the expected wait time “was like a shot in the heart.”
Aimee MacDonald says she hopes the province sees the importance of fertility care, and better supports assisted reproductive therapies through doctor recruitment and financial coverage. She says in her community of Antigonish she sees neighbours and members of her community struggling with fertility but who are unable to access the costly care.
“Fertility care must be made more accessible to people,” she says. “It’s unfair that not everyone has the means to do this.”
This is the second part of a series about the Nova Scotia crisis in gynecological care. The first part of the series focused on endometriosis and other chronic uterine conditions. Subscribe to The Coast Daily newsletter to make sure you get the next part in your inbox when it’s out.Correction: names of Aimee MacDonald’s children have been updated.