Mara Pellittieri, the thirty-year-old editor of TalkPoverty, a Web site devoted to class and inequality, lives with her spouse, who identifies as nonbinary, in the liberal suburb of Takoma Park, Maryland. Pellittieri’s spouse was assigned female at birth; the couple married in 2012, just before Maryland voters endorsed same-sex marriage in a ballot initiative, and decided to start a family around a year ago. Like most queer couples, they knew that they’d require medical assistance to get pregnant. They were glad, therefore, to learn that the health plan at Stanley Black & Decker, where Pellittieri’s spouse works as an engineer, offered intrauterine insemination (I.U.I.), in-vitro fertilization (I.V.F.), and other fertility care to employees who have been diagnosed as infertile. They assumed that such a diagnosis would apply to them.

Almost immediately, they hit a snag. According to their insurance policy, heterosexual couples could receive an infertility diagnosis after “one year of unprotected intercourse” without conception. Queer couples, by contrast, could be diagnosed only after six failed rounds of I.U.I., which they would have to pay for out of pocket. Each I.U.I., which has, at best, a twenty-per-cent chance of succeeding, can range in cost from five hundred to four thousand dollars. Pellittieri and her spouse were daunted by the expense. They were also alarmed by the difference between the way heterosexual and queer couples were treated. Sixteen U.S. states, including Maryland, now require insurance companies to cover some level of infertility care; in 2015, Maryland extended those requirements to mandate equal coverage for married same-sex couples—although the law also requires six unsuccessful attempts at intrauterine insemination to meet the definition of infertility. And Stanley Black & Decker, like many large companies, is self-insured—it doesn’t rely upon an outside insurance company—and so its policy fell outside the jurisdiction of Maryland’s regulations.

These divergent requirements for the same diagnosis put Pellittieri and her spouse at the center of a larger, conceptual debate about the meaning of the word “infertility.” Their insurance policy defined infertility physiologically: from its perspective, Pellittieri couldn’t receive an infertility diagnosis until doctors discovered something wrong with her reproductive system. She saw things differently. In her view, it was inarguably true that, as a member of a non-heterosexual couple, she couldn’t have children without medical help. Definitions drive diagnoses, and diagnoses determine access to care. By hewing to a physiological definition of infertility, Pellittieri’s insurance policy would leave her untreated.

In recent years, precisely to take account of people like Pellittieri, scholars, activists, and medical practitioners have begun urging policymakers to adopt a more expansive definition of infertility. They argue that infertility is only sometimes physiological; it’s also possible to suffer from social infertility, a condition that stems from the broader factors that shape our lives. In a 2018 paper, “Expanding the Clinical Definition of Infertility to Include Socially Infertile Individuals and Couples,” the bioethicist Lisa Campo-Engelstein and the physician Weei Lo propose that an infertility diagnosis should be available to anyone who, during a twelve-month period, possesses the “intent” to conceive but cannot “due to social or physiological limitations.” Meanwhile, the sociologists Jasmine Fledderjohann and Liberty Barnes have pointed out that statistics about infertility, which tend to be based on the reports of married heterosexual couples, ignore the “invisible infertile”—the single, poor, or non-heterosexual people who can’t have children for reasons that are only sometimes related to their bodies.

Broadening the definition of infertility, of course, would raise new questions in turn. Many people struggle to have children because of non-physiological factors. Should all of them—would-be parents who are single by choice, overworked women who decide to freeze their eggs, gay men in need of surrogates—be considered infertile? And what, for these different groups, would constitute a fair distribution of infertility treatment? Such debates are complex and morally urgent, affecting the lives of numberless would-be parents. On the phone with Cigna, which administers Stanley Black & Decker’s health plan, Pellittieri’s spouse tried to absorb the fact that the couple would be ineligible for coverage.

“With your plan, unfortunately, it would not be covered,” the representative explained, referring to I.U.I.

“So artificial insemination—period—is not covered,” Pellittieri’s spouse said, after some back and forth.

“Correct, unfortunately.”

Pellittieri’s spouse asked specifically about I.V.F. and was told that the procedure couldn’t be covered without a diagnosis of infertility, which the representative, reading from the coverage policy, defined as “the inability of a woman to achieve conception after six trials of artificial insemination over a one-year period.”

“The person working at the insurance company felt really bad about it,” Pellittieri recalled. “They apologized for it.” But the policy, with its strictly physiological definition, was immovable.

On the surface, the effort to expand access to infertility treatment depends on the idea of equal rights. There are different kinds of rights, however, to which we might have equal access. Political philosophers have long distinguished between negative rights (“freedoms from”), which demand noninterference, and positive rights (“freedoms to”), which demand facilitation. In 1965, when the Supreme Court guaranteed marital couples the right to use contraception, in Griswold v. Connecticut, it relied on the principle of “marital privacy,” ruling, in effect, that married couples had the negative right to make their own decisions about contraceptive matters without government interference. In 1972, in Eisenstadt v. Baird, the Court extended that right to unmarried couples, deciding that they should have equal access to marital privacy. For most of its history, the fight for reproductive rights has conceived of them negatively. In 2012, when the Inter-American Court of Human Rights overturned Costa Rica’s ban on I.V.F., citing the “right to life” possessed by unimplanted embryos, it was careful to note that, in its opinion, the case was not about the “presumed right to have a child or a right to have access to I.V.F.” Instead, the ruling focussed on how the ban unduly interfered with couples’ private lives.

The shift to a positive understanding of reproductive rights has been driven, to a large extent, by technology, demography, and social change. In the years after Louise Brown, the world’s first I.V.F. baby, was born, in July, 1978, reproductive technologies were expensive and unreliable. But success rates for I.V.F., egg freezing, and related technologies improved, and the fertility industry grew into a multibillion-dollar behemoth. During the same period, new kinds of households and families entered the mainstream. In 1992, the protagonist of the television series “Murphy Brown” had a son out of wedlock; in the following years, I.U.I. and I.V.F. helped gay icons such as Elton John and Melissa Etheridge become parents. In general, Americans began staying in school longer, working harder, and marrying later, if at all. In 1960, only nine per cent of Americans over the age of twenty-five had never been married; by 2012, the figure was one in five. (More couples have been living together without tying the knot, of course.) Once exotic, “assisted reproductive technologies,” or A.R.T.s, now seem commonplace. It’s become commonsensical, therefore, to propose that, just as there is a positive right to education, there is a positive right to have children, and to ask whether all Americans are equally free to exercise that right.

Other countries—especially those with government-run health-care systems—have held spirited public debates about which infertility services to extend and to whom. In the early nineteen-eighties, Mary Warnock, a philosopher, chaired the United Kingdom’s Committee of Inquiry Into Human Fertilisation and Embryology; its findings shaped the U.K.’s first law regulating fertility treatment, the Human Fertilisation and Embryology Act, passed in 1990. (Warnock elaborated on the committee’s findings in a 2002 book, “Making Babies: Is There a Right to Have Children?”) In France, where Emmanuel Macron made access to “la procréation médicalement assistée” a campaign promise, citizens are currently debating the extension of state-funded I.V.F. to lesbian couples and single women. Different countries have developed different rules. At the moment, France provides four I.V.F. cycles to heterosexual couples but bans all forms of surrogacy. Belgium offers women under the age of forty-five six cycles of I.V.F. Pro-birth policies in Israel mean that a woman can access as many I.V.F. cycles as she needs to have two “take-home babies,” or live births.

Americans utilize assisted-reproduction technologies less often than citizens of other industrialized countries; except for an inconsistently administered program for service members whose infertility is deemed service-related, the nation’s public health-insurance programs, which cover roughly half the population, do not substantively fund any A.R.T.s. Private insurance policies vary widely. More and more people now find themselves in need of A.R.T.s., but, in a country where abortion and paid family leave are still contentious issues, the hard work of consensus-building has barely begun.