MONTPELLIER, FRANCE — In vitro fertilization, a procedure first used more than 45 years ago, has suddenly become the topic of political debate on both sides of the Atlantic — but for wildly different reasons. 

In France, President Emmanuel Macron’s government is eyeing policies to promote the use of assisted reproductive technology, including IVF, to increase the nation’s declining birth rate. But French feminist groups say the proposal unduly inserts the government into private lives of women. They also worry that nationalist sentiment is driving the effort to boost birth rates.

The political fault lines look quite different in the U.S. where conservatives are the primary obstacle to IVF access. Despite former President Donald Trump’s endorsement of IVF this month, the fertility treatment has left many ultraconservative and evangelical conservatives conflicted, particularly when it comes to the disposal of unused embryos.

Legislatures in at least 13 states have introduced so-called personhood legislation that would classify an embryo as a human life. And in February, the Alabama Supreme Court ruled that frozen embryos created for the purpose of IVF can be considered children — a decision that caused some IVF clinics to close their doors. 

By comparison, fertility experts in France are drafting a national fertility plan at Macron’s request to combat the country’s declining fertility rate. Those drafting the plan are recommending increased government investment in IVF as well as other fertility treatments.

Birth rates in France have been steadily declining in recent years, and decreased roughly 7 percent between 2022 and 2023. This isn’t as sharp a decline as in some other European countries, but in a January speech, Macron declared that France needs a “demographic rearmament.”

In France, IVF is paid for by the French national health plan, and each woman is entitled to four cycles of IVF per child. About 4 percent of French births are a result of IVF, and in the process the country discards roughly 150,0000 embryos per year.

In 2021, slightly more than 2 percent of U.S. births were a result of IVF. But Democrats and advocates now worry access to the procedure may become more challenging, as some fertility clinics are shutting their doors out of fear that they could be criminalized for discarding embryos.

Despite public comments from many Republicans in support of the procedure, it’s clear some hesitation remains: Last month, when Senate Democrats brought up a vote to protect IVF, Republicans shot it down.

“It’s crazy, it’s absolutely crazy,” Samir Hamamah, a Montpellier, France-based infertility doctor charged with writing Macron’s fertility plan, said of the IVF landscape in the U.S. “It’s strange and stupid to consider an embryo with five, six cells a human.”

Parisian pregnancy push

In a Jan. 16 address, Macron said he wanted to prioritize fertility. Part of that effort is making IVF and other forms of medically assisted reproduction more widely available while limiting factors that cause infertility. 

“You have to consider that infertility is a disease like others,” Hamamah said, when asked why the French health system covers the costs of IVF.

France is a rare Western country to fully cover the costs of IVF. There are 103 IVF centers across France to serve a population of about 68 million.

By contrast, U.S. health plans, including Medicaid and TRICARE, do not cover infertility treatments. The 2010 health care law does not mandate coverage of infertility services on the health exchanges, but at least eight states mandate coverage of IVF on exchange plans.

Beginning this year, the U.S. federal government expanded IVF benefits for federal workers. Government employees have the option to select a health plan covering up to $25,000 per year for in vitro procedures and up to three artificial inseminations per cycle. But federal health benefits are much more generous than typical employer health plans for nonfederal workers.

“The government supports everything here,” Hamamah said, noting that France first began covering the cost of IVF in 1994. More recently, in 2022, the government extended IVF coverage to LGBTQ couples and single women for the first time.

“The limiting factor in your country is the money,” he added, speaking of the U.S. health care system.

A draft copy of France’s national plan, which is set to be finalized this fall, emphasizes the importance of government investment in IVF, medical research for new fertility treatments as well as research into the causes of infertility.

French feminist pushback

But Macron’s plan isn’t being well-received by women’s groups in France. Many see his fertility plan as government overreach into women’s reproductive rights and worry that the push to have more French babies stokes nationalist fires. A big part of Macron’s proposed plan is allowing for free fertility tests for women beginning at age 25.

In a wide-ranging, hour-long conversation, Hamamah, the infertility doctor tasked with writing the fertility plan, said France’s burgeoning immigrant population is directly linked to the country’s fertility crisis, and that’s “creating a problem in French society.”

 As “true French people” are having fewer babies, immigrants are helping to prevent huge population dips, he said

“We have to anticipate all problems of integration generated by these people,” he said.

This sort of attitude toward fertility has repelled leading women’s health groups. 

“We don’t agree with this plan,” said Carine Favier, the co-president of the Occitanie branch of Le Planning Familial, the French group that acts similarly to Planned Parenthood. She added that she believes it should be entirely up to “the couple, not the country, to make babies.”

Judith Migny, a volunteer at a family planning clinic in Montpellier, described Macron’s fertility plan as “a step backward” for the abortion rights movement because it involves the government too much in women’s reproductive decisions. 

She also cautioned about the nationalist, anti-immigrant ideology surrounding the plan.

“It’s to scare people that we are not a country, not united, not French enough anymore,” she said of the fertility plan.

Across the Atlantic

In the U.S., the battle over IVF is dividing Republicans on Capitol Hill. 

Speaker Mike Johnson, R-La., an anti-abortion, evangelical Christian, said he supports IVF, but refuses to take up a bill protecting in vitro fertilization on the House floor.

Particularly divisive is the anti-abortion movement’s focus on “personhood” and giving embryos and fetuses legal rights on par with people outside the womb. The 1973 Roe v. Wade decision said that personhood does not apply to the unborn, but the Alabama decision declared that embryos have personhood.

Some Republicans reacted quickly to the Alabama ruling: In March, Alabama Gov. Kay Ivey signed a law aimed at providing civil and criminal immunity to providers and patients for the destruction or damage to embryos. That law spurred at least two of the IVF clinics to say they would resume operations.

On April 8, presumptive Republican presidential nominee Trump released a video statement declaring his support for IVF.

He also said abortion policies, including personhood bills, should be left to the states.

“The Republican party should always be on the side of the miracle of life…IVF is an important part of that,” the former president said on Truth Social.

But advocates aren’t convinced this could protect access to IVF at the state level, arguing the anti-abortion movement still supports personhood bills that could threaten IVF.

And at the federal level, some 126 Republicans have signed onto a bill from Rep. Alex X. Mooney, R-W.Va., that would declare that the right to life guaranteed in the Constitution is “including the moment of fertilization.”  

When asked about next steps for the bill, Mooney said “I am proud that a majority of the House Republican Conference once again believes life begins at conception. The pro-life spirit is alive and well in the Republican Conference.”

Sen. Rand Paul, R-Ky., who introduced the Senate counterpart of the bill in the last Congress, did not respond to requests for comment.

Prominent anti-abortion lobby Susan B. Anthony Pro-Life America, meanwhile, argues that Louisiana’s IVF law is a model that could be applied nationally. 

A 1986 law in that state grants embryos some personhood rights and prevents the destruction of embryos created during IVF. As a result, clinics often must ship unused embryos to out-of-state storage facilities, and women have to pay storage fees for nonviable embryos. 

Others take a more strict view. Jon Haas, the president emeritus of the National Catholic Bioethics Center in Boston, argues that IVF is immoral because it circumvents the natural process of creating new life and is “dehumanizing.”

But Democrats say it’s important for Congress to protect IVF access nationwide. 

IVF is popular: 86 percent of U.S. adults say IVF should be legal, according to a recent CBS-YouGov poll. Roughly 10 percent of women and men in the United States experience fertility problems, according to the National Institutes of Health. 

“We really see that as the next frontier. We knew that Republicans were not going to stop at abortion…and IVF is definitely the next frontier here,” said Samantha Paisley, national press secretary at the Democratic Legislative Campaign Committee.

In March, Iowa House Republicans passed a personhood bill that caused concern about access to IVF. After an outcry, the GOP Senate blocked the measure.

Iowa House Democratic Leader Jennifer Konfrst said she’s frustrated that Republicans in the Iowa House would not protect IVF access with legislation, but pay lip service to the concept because they know fertility treatments are popular with voters. 

Even though this effort was stymied, she said she’s worried this is just the beginning of GOP efforts to advance so-called personhood bills.

“They have made it clear that IVF is not a barrier to their efforts to ban abortion,” Konfrst said of Republicans in the Iowa legislature.

This story is part of a reporting fellowship sponsored by the Association of Health Care Journalists and supported by The Commonwealth Fund.