In some parts of England, a female same-sex couple may have to spend up to £25,000 of their own money on fertility treatment before the NHS will help them have a baby. A heterosexual couple may also face restrictions, but they can usually meet the NHS requirement to show that they have struggled to conceive without paying for repeated clinical procedures.
The gap even has a nickname: the “gay tax”.
In vitro fertilisation, or IVF, involves fertilising an egg with sperm in a laboratory before transferring an embryo to the womb. Before the NHS will fund IVF for two women, some local NHS bodies require them to pay privately for repeated rounds of artificial insemination. This involves placing sperm into the reproductive system to increase the chance of pregnancy. In intrauterine insemination, or IUI, sperm is placed directly into the womb.
The aim is to show that the couple has not been able to conceive. Heterosexual couples are usually expected to show that they have tried unsuccessfully for a baby for two years, alongside meeting other eligibility criteria. They are rarely asked to pay for repeated clinical procedures to prove it.
The decision is made locally by integrated care boards, or ICBs: the NHS bodies that decide which treatments will be funded in their areas. A 2023 investigation by the BBC found that only four offer fertility treatment to same-sex couples who have not already paid privately for artificial insemination. Government guidance updated in 2025 states that some ICBs may require female same-sex couples to fund up to 12 rounds of artificial insemination privately before entering the NHS pathway.
Earlier figures from the UK’s fertility regulator illustrate the gap. In 2018, the NHS funded 39% of IVF cycles for heterosexual couples, compared with 14% for women in same-sex relationships.
Beyond the bill
The money, though, is only the part you can see.
We conducted 36 interviews with 54 people, including LGBTQ+ people who had used UK fertility clinics and professionals working in fertility care, to understand how LGBTQ+ patients navigate services that place additional barriers in their way. What stood out was the amount of hidden work they take on simply to be treated fairly. It is work that heterosexual couples are rarely asked to do.
Some of it is physical. Because there is, as one woman put it, “no NHS tick box for same-sex couples”, many arrive at a private clinic without the basic tests that a GP, or family doctor, would normally arrange. One couple had their tests done on the NHS, only for the clinic to reject the results and make them pay to repeat everything.
For transgender patients, the bodily toll can be greater still. One transgender woman wanted to store sperm before continuing her transition but was refused funded treatment because of her weight. She paid privately and temporarily stopped taking the hormones used as part of her transition. She described this as going back to “living as a man” for several months before facing the procedure in what she called “the strangest room I’ve been in in my life”.
‘Relentlessly delightful’
Then there is the emotional work. Fertility care can be saturated with forced cheerfulness: positivity planners, gratitude journals and promises that it will all be fine. Patients learn to play along.
One gay father pursuing surrogacy, having a child with the help of a woman who carries the pregnancy, described the pressure to seem “relentlessly delightful”. He felt he had to prove that he was warm and “parently” at all times. It took energy to put on this front and energy to resist it. One woman who went through seven rounds of IVF wanted honesty about her chances, rather than false hope that made each disappointment land harder.
Much of the work is also mental: a steady stream of high-stakes decisions. Whose egg should be used? Who will carry the pregnancy? Which donor should they choose? Which clinic?
One woman and her wife spent weeks choosing a sperm donor, only to be told afterwards that the clinic would not allow them to use him. The decision, and the cost, began again.
Choosing the clinic itself also carries risk. One transgender man and his partner carefully selected two local options, then encountered such ignorance and prejudice that they ended up travelling 230 miles to a clinic that was, in his words, “basically designed for queer people”. All the effort they had already put in was wasted. They had to start again.
A 2024 audit of fertility clinics across the UK found widespread gaps in clinical knowledge and cultural understanding, despite efforts to improve LGBTQ+ inclusion.
Their own experts
When clinics offer little guidance, patients become their own experts. They teach themselves through online groups, peer networks and, in one case, “hundreds of voice notes” from other queer women explaining how treatment actually works. As one woman said of learning about her options this way: “that’s the only way we knew what to do”.
This self-teaching can be powerful. One gay man researched his surrogate’s failed cycle, realised that the clinic’s reasoning was flawed, pushed for a different approach and achieved the pregnancy he had been told was unlikely.
But becoming your own expert depends on having the time and confidence to challenge a doctor. Those without that head start are left further behind. The current system tends to reward people who are already advantaged.
These problems are not confined to Britain. The UK case is revealing because LGBTQ+ people can legally access fertility treatment, yet the system still places additional barriers in their way. The obstacles are embedded in the daily running of clinics built around a heterosexual couple with a fertility problem.
The result is a hidden second shift. One couple’s path through the clinic is smoothed and paved. Another couple, hoping for the same outcome, has to lay every slab themselves and pay for the privilege.
