With Alabama’s IVF court ruling, a scary future for women’s health care
AUBURN, Ala. - She removed the tiny vials from her refrigerator and began filling syringes laid out on her dining room table, determined to continue injections that could make her a mother.
“I am going to keep fighting,” said Gabrielle “Gabby” Goidel, wincing as her husband gave her the first shot of an in vitro fertilization cycle precisely timed so a doctor could extract eggs, fertilize them and implant embryos before month’s end.
Just a few days earlier, Alabama’s Supreme Court had ruled that frozen embryos are children and that people can be held liable for destroying them. The outcome had thrown countless women’s hopes and plans into doubt. Already, the state’s biggest IVF clinic had announced it would suspend creating embryos.
“What’s going to happen if these clinics shut their doors?” asked Goidel, a 26-year-old property manager. “How many women are going to miss out on care?”
The court ruling was only the latest in Alabama’s increasingly draconian restrictions on women’s reproductive health care, which experts say are driving away doctors, delaying treatment and endangering lives.
The state’s abortion ban is one of the strictest in the country, with no exceptions for rape or incest. The attorney general has threatened to prosecute anyone helping women seek abortions out of state. And Alabama law enforcement has a history of surreptitious drug testing and charging pregnant women with endangering their fetuses if results come back positive.
For those having a baby, their options for care often are limited. More than 2 million women of childbearing age - a third of Alabama’s population - live in maternity care deserts, areas without access to birthing facilities or providers, a 2023 March of Dimes report found. The closure of 14 hospitals since 2000 has meant longer delays for prenatal appointments, with providers especially scarce outside of hubs in Birmingham, Huntsville, Mobile and Tuscaloosa.
State lawmakers recently extended Medicaid coverage for women to a year after giving birth, but without overall state Medicaid expansion, many have trouble qualifying and finding providers. The obstacles are particularly acute for women in the Black Belt, an area named for its dark soil and settled by the descendants of enslaved people. They face some of the longest drives to get care.
One tragic consequence: Alabama has one of the highest maternal mortality rates in the country, according to a Milken Institute report last year.
“Any person capable of becoming pregnant - either now or in the future - is extremely vulnerable,” Robin Marty, executive director of West Alabama Women’s Center in Tuscaloosa, said Thursday. “Nobody knows what the rules are anymore.”
Marty’s clinic sees women who have waited hours at local hospitals, bleeding without being examined. “We are taking care of a lot of patients who are unable to get in to see OB/GYNs and … get the care they need until the second trimester,” she said. “Having doctors that are terrified to practice medicine here is not going to change that.”
Physicians across the state echoed those concerns this week. Heather Skanes, a Birmingham OB/GYN who sees about 100 to 200 patients weekly, fears the cascading impact of the legislature’s restrictions on abortion and the court’s ruling on IVF.
“Women’s health care is comprehensive, so taking or chipping away at one point affects the whole,” she said. “You have to have comprehensive legislation and rules in place that allow women to decide whether or not they want to become pregnant, how to prevent pregnancy, how to terminate a pregnancy if they desire to, and how to continue pregnancy if they decide to continue.”
“If you don’t have that,” Skanes added, “the whole thing crumbles.”
A hundred miles north, hard against the Tennessee border, Sanithia Williams is just as worried.
“People talk about IVF as if it is so different than abortion care or pregnancy care. It’s all the same people, just at different points in their lives,” said Williams, an OB/GYN in Huntsville. “Being able to have an abortion is equally as important as a pregnant person being able to decide where and how they birth and people having the access and right to fertility services. All of those things are super connected.”
She expects other OB/GYNs will leave Alabama because of the IVF ruling, just as they left after the abortion ban. “The idea that we could lose more maternal care providers is potentially devastating,” she said. “It just makes it harder for people to access the care that they need. It will worsen the safety of pregnancy care here.”
Such is the stark fallout from the Feb. 16 court ruling, which came in the second week of Alabama’s 2024 legislative session. Some lawmakers have proposed measures to both overturn the abortion ban and protect the in vitro procedure. Despite a national GOP group urging party candidates to support IVF - a position echoed by Donald Trump on Friday - the bills’ prospects are uncertain in Alabama’s Republican-controlled House and Senate.
The court’s decision is supported by conservatives like Natalie Brumfield in Birmingham, a longtime antiabortion speaker and volunteer at a crisis pregnancy center. She empathizes with women undergoing IVF who are suddenly in limbo, with nearly every clinic in the state now suspending its IVF work or halting embryo disposal. Yet Brumfield, who rejoiced in the abortion ban, said the state needed to also impose limits on IVF to protect embryos.
“Being in the middle of something, it’s devastating. But at some point, we have to have reform,” she said. “There needs to be someone standing up for these frozen embryos as children.”
Brumfield always wanted a big family but suffered several miscarriages early on. She and her husband adopted three children from foster care before resorting to IVF. They imposed their own limits on the process given their belief that conception begins at fertilization and committed to using all embryos they created, up to 10. They got three, which resulted in two births.
She thinks there need to be government limits on IVF for doctors as well as patients. “They encourage them to conceive as many as possible to have a live birth,” she said. “When you put language saying, ‘No, this is a human life,’ couples now understand the weight when they are choosing to conceive.”
After days of emotional turmoil in Alabama - and with the state in the crosshairs of an exploding national discussion - the office of Attorney General Steve Marshall (R) said Friday that he has “no intention” of using the Supreme Court decision to prosecute IVF families or providers. Gov. Kay Ivey (R) also said she was “working on a solution” with legislators to safeguard IVF treatments in the state.
Their assurances came too late for Goidel, who has long wanted children but already suffered three miscarriages since she married in 2021. After one, which occurred while she was living in Texas, she remembers a doctor praying over her after balking at performing a procedure frequently done to clear the uterus after a miscarriage.
She hopes genetic testing during IVF may help her conceive. And she doesn’t think she should have to limit how many embryos she creates, since more would give her a better chance of a successful pregnancy. Goidel worked for child protective services in Texas and saw “how hard it is to adopt and foster, and I’m not really up to that right now. To us, this is the only way we are able to start a family.”
The IVF process has taken over much of her life. She had to wait two months for an appointment with an OB/GYN, who then referred her to one of Alabama’s seven IVF clinics. Her health insurance didn’t cover the doctor visits, shots and procedures, so she and her husband, Spencer, an assistant political science professor at Auburn University, paid $20,000 up front.
She began her first 10-day IVF cycle just hours after the court ruled.
Doctors had advised her to inject the medication to stimulate her ovaries at the same time every night. Goidel decided on 8 p.m., and so she would assemble the paraphernalia at that hour, trying not to let the unfolding controversy interfere. She wasn’t usually squeamish about needles but soon realized it was easier if her husband injected her.
Wednesday night was day six. She felt bloated from the hormone drugs and had put on a black and white tunic because it was loose and easy to expose her belly for each shot.
Out of the refrigerator came the zippered pouches of medications, one decorated with rhinestones. On the table Goidel had organized stacks of alcohol pads, needles, Band-Aids - the supplies she keeps in a pink toolbox, as neat as the rest of her farmhouse-style home.
She was intent on controlling as much of the process as she could.
Goidel had seen the news earlier in the day, that the University of Alabama at Birmingham clinic had suspended its IVF work. She had called her doctor’s office, and staff sent back a message: “take it day by day and we will update you if anything changes.”
“I fear for delays and the money I put into this,” she said. Spencer stood nearby, a look of concern on his face.
The next morning, the clinic sent a new message: It, too, was suspending IVF.
But Goidel was unwilling to relinquish control of her fertility to the state. “I’ll try other states,” she insisted. “If I can’t do it in other states, I’ll try other countries. I am, by golly, doing an egg retrieval this cycle.”
She called a clinic at Emory University in Atlanta that she had visited but ruled out because of the distance and higher cost. The staff said the liability issue meant they couldn’t help finish her cycle.
It felt, Spencer said, like Alabama officials were telling them, “Don’t like things? Get out.”
“That’s an awful message,” he added.
But get out is what they did.
Goidel made more calls, searching for an IVF doctor willing to help. Finally, one said yes. She started packing.
By Thursday night, she was on a plane to Texas.
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