Not long ago, fertility and pregnancy care was not only a personal journey between someone trying to conceive or manage their pregnancy and their partner, if they had one — it was an often stigmatized secret, at least when it came to the workplace.

"There's been so much of a taboo in the past about telling your employer that you're pregnant and planning those conversations," Molly Howard, chief operating officer at family-building benefits platform Ovia Health, told HR Dive. People felt compelled to hide early months of morning sickness and conceal appointments with their obstetrician. "That [culture] really just takes away from the experience," Howard said. "It gives a message to an employee that you can't be both [parent and employee]."

The stigma hasn't completely disappeared; 20% of infertile women report having experienced discrimination or prejudice based solely on their infertility status, according to a survey from Modern Fertility, and plenty of women still feel compelled to hide their pregnancies. But the rise of employer-provided family-building benefits has helped to address the tension many employees feel between their family life and work life. 

How fertility benefits work

Employers can partner with fertility benefit providers in a variety of ways, meeting a wide range of employee family-building needs. 

Boston-based Ovia Health works with "well over 100" organizations in the U.S., including News Corp and Medtronic, to offer its enterprise model, Howard said. Through the model, employees use a free app to support them through their pre-pregnancy, pregnancy and postpartum experiences, or through the stages of adoption or other nontraditional family-building methods. 

Through the app, users can connect with a care team that helps guide them through the fertility process. Providers answer questions users deem "too silly" to bother their primary care provider with — "We hear that all the time," Dani Bradley, Ovia Health's director of clinical services and evidence, told HR Dive. Other times, providers offer specialized guidance based on the user's personalized health history and risk factors. "It's a lot of filling in those gaps and making people feel comfortable advocating for themselves and having those conversations [with their providers]," Bradley said. 

In addition to an on-call team that can respond to questions 365 days a year, Ovia Health has a "care navigator program," through which users connect with one supportive person who helps them through their entire journey with the app. "If somebody does transition from their fertility experience into pregnancy, their care navigator knows their background," Bradley said. "They don't have to re-explain themselves, they don't have to share again that they had, [for example], a history of miscarriage and conceived with IVF. Just having that personal connection with one person, we find, really enhances the experience and makes people feel a lot more comfortable getting support from us." 

Through another provider, Carrot, employers can offer their employees a financial allowance to use toward fertility and family-building care. "We'll help them find that right amount based on what their goals are, if they're benchmarking against other peers, what the trends are in their industry and what they're trying to achieve," Juli Insinger, Carrot's co-founder and vice president of business development, told HR Dive. On the low end, she said, companies offer a $5,000 lifetime maximum; on the high end, companies offer up to a $75,000 lifetime max. Foursquare, Stitch Fix and Masterclass are some of the current companies that offer the benefit.

Carrot users either get reimbursed or use a "Carrot card," a specialized debit card they can swipe at valid facilities. 

Health insurance gaps

Fertility care benefits providers have sprung up and grown in response to the failure of the standard health insurance system to address particular family-forming needs and costs.

"More than 80% of people who go through fertility treatments have little or no insurance coverage" for that care, Insinger said. Those costs can quickly add up and become untenable for most. Ballpark numbers from Carrot's research are $500 for an initial consultation at a fertility clinic; $8,000 for egg freezing (plus an additional $4,000 to $6,000 for associated medications); $22,000 for in vitro fertilization; $50,000 for adoption; and $160,000 for surrogacy. 

Insurance will sometimes cover egg freezing, but typically only in cases of a cancer diagnosis, Insinger said. IVF and other infertility treatments often require a medical diagnosis of infertility for health insurance providers to chip in, which can require six to 12 months of a heterosexual couple trying to conceive and failing. 

"You can see with this limitation on it, it really makes it much harder for LGBTQ couples and intending single parents to access family-forming care," Insinger said. "They're not going to get that traditional diagnosis of infertility." 

Ovia works with existing health insurance companies and large, self-insured employers to identify at-risk members and "help support them through a healthy family-building experience," Bradley said. Through the guidance of clinicians and other experts, Ovia focuses on avoiding adverse outcomes. In comparing its clients' users with women that didn't have access to preterm Ovia programming, the company found a reduction in preterm births in the range of 10% to 30%.

Helping employees to avoid complications like preterm birth doesn't just reduce the emotional and financial stress for the employee giving birth; it can substantially reduce costs for the employer. In the same report above, Ovia estimated that each preterm birth cost its partners $77,876. 

How employers benefit

But employers can get more than a financial boost by offering fertility benefits; such benefits can be a powerful retention tool. "We know so many people are making the decision to stay or not to stay at their place of employment during this pivotal time" of family formation, Howard told HR Dive. 

An Ovia study from 2019 found that one-third of women did not return to the office once they had a baby, and that most who did return did it for financial reasons. Further, a Care.com survey found that 83% of millennials, the current primary generation of birthing and new-parent age, would change jobs for better benefits. "Working women — and their partners — are a flight risk: they're open to change and actively pursue it," Ovia concluded. 

"Many employees make the decision to stay or leave their employer well before they're pregnant, based on how they perceive their company will be through the process," Howard said in reference to the study. "I think that's such an interesting thing ... If you're having good conversations when [an employee is] six months pregnant, she's already made up her mind about what she's gonna do. And so it really needs to be this culture of, ‘This is important to us.' From day one when you join the employer, maybe you're years away from thinking about building a family, but you've got [to get] the sense of, ‘Oh, if and when this time comes for me, I will be supported.'"

Carrot recently collaborated with RESOLVE: The National Infertility Association to survey mainly women of childbearing age. Together, they found that 88% would consider changing jobs for fertility benefits, and 77% would stay at their company longer if it offered fertility benefits. "If [companies] are able to address fertility, they're going to have a competitive advantage," said Insinger. 

The survey also found that fertility-related issues affected respondents' productivity and emotional state during work time; 89% said fertility and family-forming has negatively affected their mental health, 59% said such issues have affected their job performance and 74% said they'd spent time researching fertility treatments and family-forming at work. More than one-third of workers worried discussing fertility at work would be seen as unprofessional, and 30% said they were concerned talking to their bosses about fertility treatments would put their job at risk. 

"When you offer an inclusive family-forming benefit, it impacts not only the people who are using the benefits, but the entire company culture," Insinger said.

Serving a variety of families

Carrot and Ovia are among the many family-forming benefits providers who are taking an inclusive approach to the concept of fertility. In addition to pathways to a traditional pregnancy — like fertility consultations and IVF — both providers help with the adoption process and surrogacy. 

"We're creating pathways to parenting for whoever wants to build a family, whatever that looks like," Bradley said of Ovia. "On our coaching team in-house, we actually have people who built their families as single parents by choice, who've done third-party reproduction (whether that's sperm or egg donors or using a surrogate), people who've pursued adoption, people who've been surrogates themselves. So we really pride ourselves in understanding the full spectrum of what it means to each individual to build their family, and we have the support there to help people figure out what that is."

"My wife and I are expecting our first child in a few weeks. I've been following along with Ovia and have found it very useful and informative," one of the testimonials on Ovia's site reads, reflecting the changing participation of those in the fertility process. "It's helped me feel more connected and empathized with what's going on. Following along has helped me feel like I'm a part of the process and understand what she and the baby are going through." Forty percent of Carrot members are male, Insinger told HR Dive.

"Time and again, when we launch a Carrot benefit, one of my favorite things ... is people will come up to us and say, ‘Hey, I wasn't planning on using this benefit, I've already completed my family. But I love working at a company that offers this to employees,'" Insinger said, noting that the benefits help to create a "culture of inclusivity."  

Fertility is the next frontier of healthcare, Insinger told HR Dive. More and more, she said, people are starting to think of fertility health proactively; 70% of chats employees have with medical experts at Carrot are on pre-pregnancy topics. "Members [are] interested in learning about how to optimize their fertility health for the future, even though they might not be actively starting a family now. So all of these trends show that fertility and family-forming is really an area where employers can step in and have a big impact."