Abstract / Summary
Access to assisted reproductive technology (ART) is shaped by intersecting medical, legal, cultural and financial factors. While biological infertility is well studied, social infertility (where societal conditions constrain reproductive possibilities) remains comparatively underexplored. Existing research identifies distinct barriers affecting LGBTQ+ people, migrants, religious communities, people of colour, rural populations, and those with limited financial resources. Although group-specific research reveals important forms of exclusion, a siloed approach can obscure shared institutional barriers. Comparative analysis is therefore needed to examine where barriers converge, where they operate differently, and how these differences shape access to ART. We conducted a qualitative study in Aotearoa New Zealand between 2020 and 2023, comprising 52 in-depth interviews with 73 individuals and four focus groups with 40 participants (total n = 113). Participants included heterosexual, gay, lesbian, older, single, coupled, Muslim, migrant, Māori and Pacific individuals. Recruitment occurred through fertility clinics, community organisations, and social networks. Data were analysed using reflexive thematic analysis, followed by structured comparison of where barriers converged, differed in form, were especially pronounced, or were not clearly evidenced across participant groups. Six recurring barriers were identified: exclusionary clinical design; privileging of the heterosexual nuclear family; cultural and religious tensions around kinship and permissible reproduction; emotional labour and parental deservingness; scarcity and governance of gametes and surrogacy; and economic barriers. These barriers did not occur uniformly. For example, donor scarcity affected single women and lesbian participants through waitlists and donor availability, Muslim participants through restrictions on third-party gametes, and gay men through dependence on both egg donation and surrogacy. Funding rules were especially consequential where age, residency, BMI and pathway-specific costs intersected with migration trajectories, singlehood, sexuality, and later-life family formation. The findings identify cross-group convergence in institutional barriers without suggesting that different social locations are interchangeable. Reproductive inequity is produced through distinct mechanisms, including formal funding rules, clinic and administrative design, donor-market conditions, legal regulation and informal cultural exclusion. Policy responses should therefore be mechanism-specific: equitable eligibility and funding, inclusive administrative and clinical design, culturally and religiously responsive care, clearer information pathways, and reforms that address donor and surrogacy scarcity.