A colleague is giving a talk called “The Future of Baby Making.”
I would like to hear the one called “The Present.”
Here is the present.
In 2022, fertility clinics in the United States ran 435,426 treatment cycles and delivered 98,289 babies. That is about 2.6% of all babies born in this country. In 2023 there were 3,596,017 births. So roughly 3.5 million babies were made the ordinary way, at home, with no clinic, no laboratory, and no invoice.
That 2.6% gets the conferences. It gets the investment money. It gets the word “future.”
The other 97.4% got this. The share of pregnant women starting prenatal care in the first three months fell to 76.1% in 2023. The share getting no prenatal care at all rose by 5%. The preterm birth rate sat at 10.41% and has barely moved in twenty years. Those are not small problems. They are the main event.
So why does the small group get called the future?
Look at how the money moves.
Embryo selection, the long menu of laboratory add-ons, and surrogacy arrangements are paid for directly, priced per cycle and per journey, and marketed to people who are frightened and hopeful at the same time. Ordinary prenatal care is bundled into one flat fee, and close to half of all births in this country are paid for by Medicaid. One of those is a product. The other is a line item.
SURROGACY IS THE CLEAREST EXAMPLE
Every surrogacy arrangement runs through a fertility clinic. There is no other way to do it. Eggs have to be retrieved. An embryo has to be made in a laboratory. That embryo has to be transferred into another woman’s uterus. Often donor eggs are used, which means a second retrieval and a second set of fees.
Stop and notice what that means. Each arrangement generates laboratory work whether or not the intended parents have any fertility problem at all. A healthy couple who cannot carry a pregnancy, or chooses not to, still produces a full cycle of clinic revenue. Gay couples, single men, and women born without a uterus or who have lost one are entering this market in growing numbers. At this scale, that market did not exist twenty years ago. It is one of the fastest growing parts of reproductive medicine, and it grows for reasons that have nothing to do with infertility.
Then look at the price. Agencies advertise a full surrogacy journey in the United States at roughly $150,000 to $220,000. These are marketing figures, not registry data, and no one publishes an authoritative national average. But the structure is consistent across every agency that posts its prices. The agency takes something like $35,000 to $55,000 for matching and case management. Lawyers take $10,000 to $25,000. The clinic takes its cycle fees. Escrow companies, insurance brokers, and specialty lenders each take a slice. The carrier is usually paid somewhere between $60,000 and $95,000.
She is also the only person in the arrangement who can end up in an intensive care unit.
That is the part I keep coming back to. The gestational carrier is the patient in the way that matters. She is the pregnant one. She carries the risk of preeclampsia, of hemorrhage, of an unplanned cesarean, of a placenta that will not separate, of a hysterectomy she did not plan for. Everyone else in the arrangement carries financial risk. She carries the medical risk in her body.
Now look at who pays for her protection.
Her lawyer is frequently paid for by the people on the other side of the contract.
Her psychological screening is arranged by an agency that gets paid only when she is matched.
Her medical care is directed by a clinic retained by the intended parents.
Many ordinary health plans exclude carrier pregnancies, so a separate policy has to be bought, and the gap is discovered after she has already signed.
When money moves around a pregnant woman from every direction except toward her own independent counsel, the profession should say so out loud instead of calling it a journey.
I want to be careful here. Many carriers do this knowingly, want to do it, and describe it afterward as one of the best things they have done.
Many agencies screen carefully and behave decently. I am not calling surrogacy wrong, and I am not calling the people who work in it bad. I am saying that informed consent means the person taking the physical risk gets her own advisors, her own doctor, and her own honest numbers about what pregnancy can do to a body. That standard is not met by a contract drafted for someone else’s benefit.
And when the American price is too high, the business travels. There are all-inclusive programs advertised overseas at a fraction of the US figure, in countries with far less oversight of how carriers are recruited, where they live during the pregnancy, what care they receive, and what happens to them if something goes wrong. That is not the future of baby making. That is outsourcing the risk to women with fewer options.
I am not saying anyone is acting in bad faith. I am saying that incentives decide which questions get asked, which talks get booked, and which parts of human reproduction get to call themselves the future.
THE EVIDENCE UNDERNEATH THE FUTURE IS THINNER THAN THE MARKETING
A great deal of what is sold as tomorrow has already been tested and did not deliver. Testing embryos for chromosome number, and testing the lining of the uterus to pick a transfer day, were both studied in randomized trials. Neither raised the chance of taking a baby home for the average patient who started treatment. That is the number a woman thinks she is buying. She is often quoted a different one, usually a success rate calculated on a smaller and healthier group than the one she belongs to.
Now the part nobody books a keynote on.
Most fertility treatment is a workaround for problems we failed to prevent earlier. Women are starting families later, and eggs age on a schedule no clinic can renegotiate. Untreated pelvic infections damage tubes. Weight and metabolic disease affect ovulation. And in a large share of couples, sperm is part of the problem, yet the man is often tested last, or not at all.
None of that is glamorous. None of it can be billed as a journey. All of it is where the real gains are.
WHAT THIS MEANS IF YOU ARE TRYING TO GET PREGNANT
Most couples do not need a laboratory.
They need better timing, an honest look at both partners, and a few unglamorous things done early.
Know your cycle. The fertile window is short, and most people place it wrong. The Fertility and Conception Calendar walks you through it: https://tools.obmd.com/fertility-calculator
Start folic acid before you conceive, not after the test is positive. The neural tube closes in the first month, often before a woman knows she is pregnant.
Test the man early, not after a year of testing only the woman. A semen analysis is cheap, fast, and changes the plan when it is abnormal. The male fertility tools are here: https://tools.obmd.com/male-fertility-tools
Deal with what can be dealt with. Smoking, alcohol, weight, thyroid disease, diabetes, and medications that should be changed before pregnancy.
Know when to ask for help. Twelve months of trying without success is the usual threshold. Six months if you are 35 or older. Sooner if your periods are irregular or absent, or if there are known problems such as tubal or testicular disease.
The full preconception set is here: https://tools.obmd.com/preconception
CONCLUSION
I have no quarrel with in vitro fertilization. It is one of the genuine achievements of my professional lifetime, and for some couples it is the only road. I have no quarrel with a woman who chooses to carry a pregnancy for someone else, either. My quarrel is with the framing, and with what the framing hides.
When we call the laboratory “the future of baby making,” we tell 97 out of every 100 families that their pregnancy is the past. It is NOT. Their pregnancy is the NOW and the THEN.
We let ourselves off the hook for the things that would help far more people: earlier evaluation, honest counseling, prenatal care that actually reaches women, and prevention that starts before anyone is trying.
And we dress a fast growing commercial arrangement in the language of miracles, while the woman doing the physical work of it is the one person in the room without her own paid advocate.
A field that only gets excited about the expensive 2.6% is not looking at reproduction. It is looking at its own invoice.
Ask what the future holds for the 97.4%. If the room goes quiet, that is the talk worth giving.
If this was useful, subscribe. It is free, and so are the tools.
REFERENCES
1. Centers for Disease Control and Prevention. ART surveillance: 2022 national summary. Atlanta (GA): CDC; 2024. Available from: https://www.cdc.gov/art/php/surveillance/index.html
2. National Center for Health Statistics. Births in the United States, 2023. NCHS Data Brief No. 507. Hyattsville (MD): NCHS; 2024. Available from: https://www.cdc.gov/nchs/products/databriefs/db507.htm
3. Munné S, Kaplan B, Frattarelli JL, et al. Preimplantation genetic testing for aneuploidy versus morphology as selection criteria for single frozen-thawed embryo transfer in good-prognosis patients: a multicenter randomized clinical trial. Fertil Steril. 2019;112(6):1071-1079.e7. [PENDING RefVerify]
4. Doyle N, Jahandideh S, Hill MJ, et al. Effect of timing by endometrial receptivity testing vs standard timing of frozen embryo transfer on live birth in patients undergoing in vitro fertilization: a randomized clinical trial. JAMA. 2022;328(21):2117-2125. [PENDING RefVerify]
Note on the surrogacy figures: all dollar ranges in this piece are taken from surrogacy agency and fertility clinic marketing pages, not from peer-reviewed or registry sources. No authoritative national average exists, and published estimates differ because they include different services. Sources consulted include Hatch (hatch.us), Circle Surrogacy (circlesurrogacy.com), SurrogateFirst (surrogatefirst.com), and Egg Donor and Surrogacy Institute (eggdonorandsurrogacy.com), accessed September 2026.