The study, led by Sharyn Graham Davies of Monash University together with Nelly Martin-Anatias of Massey University and Carina Truyts of Deakin University, was conducted between 2020 and 2023 and funded by a New Zealand Royal Society Marsden Fund grant. Rather than treating each marginalized group in isolation, as most previous research has done, the team set out to map where barriers overlapped, where they took different forms, and where they were especially punishing. The design reflects a growing critique in reproductive health scholarship: that siloed studies of LGBTQ+ exclusion, migrant exclusion, or religious exclusion can each reveal important injustices while obscuring the shared architecture of the system that produces them all.

The evidence base is substantial. The researchers carried out 52 in-depth interviews with 73 individuals and ran four focus groups involving 40 participants, for a total of 113 people. Participants spanned heterosexual, gay, lesbian, older, single, coupled, Muslim, migrant, Māori and Pacific communities, and were recruited through fertility clinics, community organisations and social networks. All data were analysed using reflexive thematic analysis, a qualitative method in which researchers iteratively code interview material and refine themes while explicitly reflecting on how their own positions shape interpretation. Crucially, the team then subjected those themes to a structured comparison across participant groups, asking systematically where barriers converged, where they differed in form, where they were most pronounced, and where they were not clearly evidenced at all.

What emerged were six recurring barriers to accessing assisted reproductive technology. The first was exclusionary clinical design, meaning that clinics and their administrative processes were built around a narrow model of who a fertility patient is. The second was the privileging of the heterosexual nuclear family, an assumption embedded in eligibility criteria, referral pathways and everyday clinical interactions. The third involved cultural and religious tensions around kinship and permissible reproduction, particularly acute for Muslim participants for whom third-party gametes raise serious religious questions. The fourth was the emotional labour demanded of patients, together with judgments about parental deservingness that participants felt were imposed on them. The fifth concerned the scarcity and governance of gametes and surrogacy. The sixth was economic: the sheer cost of treatment, compounded by funding rules that determine who receives public support and who pays out of pocket.

The analytical heart of the paper lies in showing that these six barriers did not operate uniformly. Donor scarcity, for example, hit different groups through entirely different mechanisms. Single women and lesbian participants faced it as long waitlists and limited donor availability, a straightforward supply problem. Muslim participants encountered it as a religious constraint, because restrictions on third-party gametes meant that donor programs could be theologically off-limits regardless of supply. Gay men faced a compounded version of the problem, since building a family through surrogacy requires both egg donation and a surrogate, multiplying the scarcity they must navigate. The same underlying shortage, in other words, was refracted through religion, sexuality and family structure into three distinct experiences of exclusion.

Funding rules emerged as especially consequential, particularly where they intersected with age, residency status, body mass index and pathway-specific costs. New Zealand’s public fertility funding, like that of many countries, attaches conditions to eligibility, and the study shows how those conditions land differently depending on a person’s social location. Migration trajectories interact with residency requirements, so that a migrant may become ineligible precisely during the years when treatment would be most effective. Singlehood and sexuality determine which clinical pathways are even offered, and later-life family formation collides with age thresholds. A rule that appears neutral on paper, the authors suggest, becomes a mechanism of inequity once it passes through the realities of migration status, relationship recognition and the biological clock.

Central to the study’s framing is the concept of social infertility, a term the researchers use to describe situations where societal conditions, rather than biological dysfunction, constrain a person’s reproductive possibilities. A lesbian couple with no medical fertility problem is infertile only in the sense that the system is not built for them; the same applies to a single woman, a gay couple, or someone whose religion forbids the only treatments on offer. Biological infertility has been studied exhaustively, the authors note, but social infertility remains comparatively underexplored. By placing social infertility at the centre of a comparative design, the study reframes what looks like a series of private misfortunes as a public, structural problem, one that is produced by formal funding rules, clinic and administrative design, donor-market conditions, legal regulation and informal cultural exclusion.

The researchers are careful about what their comparison does and does not show. Finding cross-group convergence, they stress, does not mean that different social locations are interchangeable. A Muslim woman navigating religious prohibitions on donor gametes faces a qualitatively different challenge from a gay man negotiating international surrogacy law, and a migrant on a temporary visa faces constraints neither of them will ever encounter. The value of the comparative approach is precisely that it distinguishes the shared institutional scaffolding from the group-specific mechanisms that operate within it. That distinction matters because it changes what policy can realistically fix: a barrier produced by a funding rule requires a legislative answer, while one produced by clinical culture requires changes in how clinics are designed and how staff are trained.

Those policy implications form the study’s practical core. The authors call for mechanism-specific responses rather than blanket statements of inclusivity. Equitable eligibility and funding rules would address the formal gatekeeping that disadvantages migrants, older prospective parents and those on non-heteronormative pathways. Inclusive administrative and clinical design would tackle the everyday friction of forms, intake systems and assumptions that signal to patients who belongs. Culturally and religiously responsive care would acknowledge that for some communities, permissible reproduction is a live theological question that clinics must engage with rather than ignore. Clearer information pathways would reduce the burden of emotional labour that currently falls on patients to decode the system themselves. And reforms addressing donor and surrogacy scarcity would attack the supply-side bottleneck that constrains single women, lesbian couples and gay men in particular.

The study arrives at a moment when assisted reproduction is expanding globally, with clinics marketing their services to an ever-broader clientele even as access remains rationed by cost, law and culture. Its findings suggest that the inequities embedded in fertility care are not incidental frictions but features of how the system was designed, and that they will persist until the mechanisms producing them are addressed one by one. For the 113 New Zealanders who shared their experiences, the message of the research is that their struggles were not separate stories of bad luck or individual circumstance, but chapters of a single structural account. For policymakers, the message is sharper still: making fertility care genuinely equitable will require looking past the categories that divide patients and fixing the machinery that excludes them all.

Subject of Research: Social infertility and intersecting barriers to assisted reproductive technology access in Aotearoa New Zealand

Article Title: Shared struggles: Muslim, migrant, lesbian, gay, single and older experiences of accessing assisted reproductive technology

Article References: Davies, S. G., Martin-Anatias, N., & Truyts, C. (2026). Shared struggles: Muslim, migrant, lesbian, gay, single and older experiences of accessing assisted reproductive technology. International Journal for Equity in Health. https://doi.org/10.1186/s12939-026-03050-3

Image Credits: AI Generated

DOI: 10.1186/s12939-026-03050-3

Keywords: assisted reproductive technology, social infertility, reproductive equity, LGBTQ+ family building, migrant health, Muslim perspectives, donor scarcity, surrogacy, fertility funding, heteronormativity, Aotearoa New Zealand, qualitative research