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On the outside, Sarah Flaata鈥檚 sticker-covered bin could be a container for craft supplies or family photos. One sticker reads, 鈥淵our now is not your forever鈥� 鈥� Flaata鈥檚 mantra.

But open the lid, and it looks more like an at-home pharmacy, filled with syringes, creams and other prescriptions.

鈥淚 don鈥檛 know anybody in this process who likes needles,鈥� Flaata said. 鈥淏ut you know, what are you going to do?鈥�

Flaata has to take one injection every day. She and her husband have been trying for a baby for eight years. Having exhausted all other options, the Flaatas turned to in vitro fertilization.

Flaata had her first Lupron injection on March 17. Each day after taking the shot, her husband fans out a deck of cards printed with colorful, expletive-laden affirmative phrases for Flaata to draw. It helps lighten the mood, she said, as she flipped through the cards, laughing at some and picking out favorites.

To prepare for the treatment, Flaata took birth control and a cocktail of supplements and thyroid medication for several weeks. Now, it鈥檚 a shot a day and daily use of a testosterone lotion.

Flaata has a calendar mapping out the next few weeks of her life, the font so small it swims like a swarm of ants on the white page. It鈥檚 peppered with appointments and an army of different medications.

In early April, she鈥檒l have a baseline ultrasound. On April 7, she starts stimulation injections 鈥� between four and five per day.

The earliest she can expect an embryo transfer is late July or August 鈥� and that鈥檚 assuming the embryos are genetically normal. If not, she and her husband will have to decide if they pursue another egg retrieval cycle.

The success rate for the first cycle is a little less than 30%. For a second cycle, those odds jump to about 43%. A third cycle has a 51% chance of working.

鈥淚t鈥檚 like a Monopoly game,鈥� Flaata said. 鈥淕o back, start over.鈥�

A February Alabama Supreme Court case turned legislation around IVF into a national debate. But in New Mexico, people experiencing infertility face other barriers 鈥� a lack of resources in a state with few choices for fertility treatment.

Accessibility

The World Health Organization classifies infertility as a disease. And it might be more common than people think.

鈥淥ne in six couples go through infertility, and that鈥檚 not counting people who are single going through it,鈥� said Aleya Hoerlein, who runs an infertility support group in New Mexico. 鈥淓verybody knows somebody. There鈥檚 people in the military going through IVF, there鈥檚 the teacher at your school, it鈥檚 your next-door neighbor.鈥�

IVF can take a physical and emotional toll, Hoerlein said. It鈥檚 also a financial burden. If there aren鈥檛 nearby clinics, couples and individuals can face long travel times and high costs. It can affect where people live and work as they seek insurance coverage and time to go to numerous appointments.

Hoerlein called New Mexico an IVF 鈥渄esert.鈥�

Compared with other U.S. states and territories, the use of IVF and other fertility treatments is low in the state. According to 2021 U.S. Centers for Disease Control and Prevention data, New Mexico had just two fertility clinics and had the second-lowest rate of assisted reproductive treatment procedures performed, after Puerto Rico.

鈥淭here鈥檚 so many obstacles to this whole process,鈥� Hoerlein said. 鈥淚t鈥檚 difficult to travel; it would be better to have more options here.鈥�

The lack of options almost deterred Flaata鈥檚 IVF journey. There are three doctors in the state who will perform IVF, she said. Just one of those doctors is a woman.

Not having a female doctor was a 鈥渄eal-breaker鈥� for Flaata, and when she thought that doctor might be unavailable, she and her husband wrote off treatment in New Mexico.

Instead, the sa国际传媒官网网页入口 couple started looking at other states. The couple traveled to California for two consultations at clinics there. One of the preliminary appointments cost about $250.

Eventually, Flaata was guaranteed a female doctor in New Mexico. But she wasn鈥檛 able to get the specific treatment she wanted in the state.

Flaata was interested in minimal stimulation IVF. Mini IVF uses less medication and produces a smaller number of eggs for retrieval, making it cheaper and easier on the body. But that treatment isn鈥檛 offered in the state, and traveling to an out-of-state clinic seemed less and less feasible.

Although a handful of states mandate coverage for IVF from insurance providers, New Mexico isn鈥檛 one of them. Some employers may choose to cover assisted reproductive technology, but it鈥檚 not required. People may choose jobs that are more flexible with medical leave or provide IVF coverage, Hoerlein said.

Hoerlein said she stayed in California 鈥� despite wanting to move to New Mexico 鈥� in order to continue IVF treatment, which was covered by her husband鈥檚 work benefits. She didn鈥檛 conceive during her IVF journey but eventually became pregnant naturally.

Not knowing how the medication would affect her and wanting to make sure she had time for appointments, Flaata decided not to work during the process. In March, a recruiter reached out to her. But the timing wasn鈥檛 right.

Harold Atencio, an sa国际传媒官网网页入口 lawyer who specializes in assisted reproduction and adoption law, said the low rates of assisted reproduction in New Mexico could be caused by the high cost of IVF and surrogacy, coupled with the socioeconomics of the state. When Hoerlein first went through IVF, her egg retrieval cycles cost about $20,000. Now, she said she鈥檚 hearing costs of upward of $30,000. With each cycle, the chance of success increases, so doctors typically recommend people try four cycles, Hoerlein said.

鈥淚f you鈥檙e a person of moderate means and you have an infertility problem," Atencio said, "you might not be able to afford that."

Flaata鈥檚 first cycle will cost more than $19,000. That doesn鈥檛 include the cost of medications, which is around $4,600 鈥� and that first prescription may not get her through the entire process, Flaata said.

From there, the couple will have to pay for anesthesia out of pocket, which costs around $500. If the embryos can be transferred, the medication will cost around $1,500.

鈥淲e have individual insurance plans (in) the state of New Mexico. I have a gold plan,鈥� Flaata said. 鈥淚t does not cover infertility or IVF. There鈥檚 no amount of money that I can pay as an individual on the marketplace to have insurance coverage here that covers IVF. It鈥檚 really frustrating.鈥�

Flaata said she and her husband were able to afford the treatments with family support. But she said not having mandated coverage creates an equity problem for people who want to grow their family but can鈥檛 afford treatment.

"I feel like there鈥檚 probably a lot of people here that wish they could pursue this and just financially can鈥檛,鈥� Flaata said.

Surrogacy in New Mexico

Couples may choose to use a gestational carrier 鈥� a surrogate that becomes pregnant through IVF and has no biological relationship to the child 鈥� rather than going through IVF themselves.

Laura Gibson decided to become a gestational carrier after having her first daughter. Gibson chose to pursue surrogacy after seeing a photo of an old classmate, another surrogate, posing with the intended parents.

鈥淚 love being a mom,鈥� said Gibson, who now has two daughters. 鈥淭he idea of being able to help someone else have the family that they want, however they choose to do that, something about it really hit deep.鈥�

Gibson worked through an agency to connect with a couple that had the same expectations and goals she did. They were from New Jersey, so Gibson traveled back and forth for IVF treatments on the East Coast. A local clinic helped monitor when she was in sa国际传媒官网网页入口.

Seeing the couple meet their child for the first time was 鈥渉umbling,鈥� Gibson said. She still keeps in touch with the family.

Gibson is part of a small group 鈥� gestational carriers from New Mexico.

鈥淚 think that just from a national level, New Mexico can sometimes get overlooked,鈥� Gibson said. 鈥淚 don鈥檛 think people realize that we鈥檙e as good of an option as we are, especially with being one of the more gestational surrogacy-friendly states.鈥�

Atencio said the cost to use a surrogate is increasing. In the first gestational carrier contract he drafted, Atencio said the woman was paid $10,000 plus medical expenses. Now, the average is closer to $45,000, although Atencio said he's seen a contract as high as $75,000 plus expenses for a repeat carrier.

New Mexico laws

Ellen Trachman, a lawyer specializing in assisted reproductive technology law and the co-director of Southwest Surrogacy, works in New Mexico, Colorado, Montana and California. She said that New Mexico is 鈥渇riendly鈥� toward parents trying to conceive using a surrogate via IVF. Judges in the state, she said, typically legally recognize intended parents as parents.

But she said the state鈥檚 laws around assisted reproductive technology are less developed than in other states. In Colorado, for example, Trachman said a surrogacy law was recently passed that sets specific requirements and mandates best practices for surrogacy contracts, including giving the surrogate the final say on health and welfare decisions.

鈥淣ew Mexico just doesn鈥檛 have applicable law for surrogacy, so we work to follow best practices without, necessarily, the law requiring it,鈥� Trachman said.

Nationwide, Trachman said, there is some incremental progress from government entities and employers to offer more coverage for IVF.

Atencio and Trachman are the state's only practicing lawyers certified by the national Academy of Adoption and Assisted Reproductive Attorneys.

Atencio said adoption codes require that health insurers treat adopted children the same as biological children born into a family. That means that insurers are required to provide coverage for adopted children as soon as their parents assume guardianship.

鈥淏ut assisted reproduction does not have any kind of similar provision that says insurance companies have to treat this child a certain way,鈥� Atencio said. 鈥淗owever, if the child is going to be the child of the intended parents, you鈥檙e going to have a pre-birth order that鈥檚 going to say, for all purposes, this child is the same as the genetic or biological child of the intended parents. So that gets them the ability to use their own health care for their child.鈥�

The main law on the books is the Uniform Parentage Act, Atencio said, which specifies that children conceived using donors are the children of the intended parents, not the donor. Like Trachman, Atencio said that, in general, the state is friendly to surrogacy contracts 鈥� with one exception.

鈥淲e do have provision in our statute that is a little incongruous with how friendly we seem to be and how well our courts handle this,鈥� Atencio said. 鈥�(The provision) says that gestation agreements are not authorized or prohibited in New Mexico. Since it鈥檚 not authorized and it鈥檚 not prohibited, the question is, 'Well, what does that mean?'鈥�

Atencio said he thought the provision may have been a compromise to get the Uniform Parentage Act on the books.

Impact of Alabama decision

In February, the Alabama Supreme Court ruled that embryos created through IVF should be counted as children. Destroying such an embryo could result in a wrongful death charge. The ruling caused several clinics in that state to stop providing IVF services.

Trachman said given the New Mexico Legislature鈥檚 support in the past for reproductive rights, she doesn鈥檛 anticipate challenges to IVF in the state.

鈥淣o one really believed there was a threat to (IVF) before,鈥� Trachman said. 鈥淚 can tell you that after the Dobbs decision came in, there was a lot of panic, at least in my world of assisted reproduction, that IVF was next. 鈥� I鈥檓 not worried about New Mexico, but I hope I don鈥檛 need to worry. You never know.鈥�

The 2022 Dobbs decision by the U.S. Supreme Court upheld a Mississippi law restricting abortion and overturned Roe v. Wade, which had for several decades enshrined the constitutionality of abortion.

Alabama legislators moved to exempt IVF from their own state Supreme Court's ruling, adopting a law in March that protects providers from legal liability under the ruling.

But Trachman said she thinks the Alabama went 鈥渢oo far鈥� to correct the unintended consequences of the Alabama Supreme Court decision.

鈥淭he law provides a liability shield for fertility clinics, which, it鈥檚 very good that they can offer it again,鈥� Trachman said. 鈥淏ut it鈥檚 not good that they have this complete immunity from responsibility, that if they were to act negligently 鈥� many people believe there should be legal options for accountability, which looks like they have none in Alabama now.鈥�

Last year, the New Mexico Legislature passed a bill to protect reproductive health care providers, including fertility treatment providers.

One bill sponsor, Sen. Linda Lopez said New Mexico needs to recruit more OB-GYN providers and interest medical students in pursuing reproductive health care. She saw a 鈥渃hilling effect鈥� on reproductive health care after other states such as Texas, and now Alabama, adopted legislation restricting some reproductive services.

That was the impetus for the bill, the sa国际传媒官网网页入口 Democrat said.

鈥淲e wanted to make sure that those who are in the process of trying to get pregnant, their access to health care, their access to reproductive rights, and everything else is going to be protected,鈥� Lopez said. 鈥淪eeing what happened in Alabama, we were right on point.鈥�

Lopez said some are concerned about the implications of the Alabama decision. But she feels that IVF is safe in New Mexico 鈥� as long as lawmakers stay apprised of nationwide moves.

鈥淲e have to keep our eyes open,鈥� Lopez said.