Infertility affects millions of people worldwide, and many patients today are looking to in vitro fertilization to start a family. At least 65 countries report their annual outcomes of IVF to the International Committee for Monitoring Assisted Reproductive Technology, offering insights into IVF treatment and access around the globe. Although the desire to build a family is felt by patients worldwide, national laws and healthcare systems largely shape the current IVF landscape.
Uneven Access
Each year, clinicians around the world perform more than 2.5 million IVF cycles, resulting in more than a half-million deliveries annually, according to research published in Reproductive Biomedicine Online. According to reports from the International Committee for Monitoring Assisted Reproductive Technology published in Fertility and Sterility, the tiny country of Israel offers the greatest per-capita access to IVF, with 5,206 cycles performed per million inhabitants in 2011 (the most recent year that data was available). The Ivory Coast is a different story, where just five cycles were performed per 1 million residents, though researchers acknowledge that number could be driven down by under-reporting.
Japan initiated 169,169 total assisted-reproduction cycles in 2011, outpacing every other reporting country that year. By way of comparison, Japan initiated twice as many cycles as the United States and roughly three times as many as Germany, Italy or France.
Patient cost may explain these disparities. Denmark, a country with generous national fertility benefits, is home to the greatest proportion of babies born through assisted reproduction. According to the BBC, estimates suggest up to 10 percent of newborns in Denmark are conceived via IVF or related techniques, far surpassing the approximately 1.7 percent of U.S. infants born through assisted reproduction (as reported by the Centers for Disease Control and Prevention).
Legal Hurdles
Laws in just 18 of the European Union's 27 member countries grant legal access to assisted reproduction to same-sex female couples and single women, creating a daunting patchwork of restrictions for those individuals. Laws in Austria and Norway, for example, bar single women from undergoing IVF, but place no such restrictions on same-sex female couples, TIME Magazine reports.
Age limits are another barrier. Swedish women cannot access IVF treatment after age 42. Denmark, in comparison, permits all women, including those coming from abroad, to seek fertility treatment until age 46.
For this reason and others, Denmark has become a destination for international patients, such as single women and LGBTQIA+ couples, who face barriers to IVF in their home countries. TIME Magazine notes that at one Danish clinic, patients from France, Germany, Norway, Sweden, Switzerland and the United Kingdom accounted for the vast majority of the 3,930 IVF and intrauterine insemination treatments performed in 2017.
Public IVF Funding
Striking differences appear in the cost of IVF from one country to another, largely due to factors such as nationalized healthcare systems and public financing for fertility benefits. Understandably, the expense of IVF not only influences who can access treatment but also how clinicians practice fertility medicine in countries with and without public subsidies.
Public insurance coverage or some form of subsidy for IVF is the norm in 64 percent of countries, according to estimates from the International Federation of Fertility Societies published in Fertility and Sterility. Most European countries provide complete funding for a set number of IVF cycles.
In Denmark, for example, the public health service covers the cost of three IVF cycles for a first child for patients up to the age of 40. In contrast, Australia applies no such limits on the number of IVF cycles, but does require copayments from patients.
Lacking a national health system, U.S. patients pay an average of $13,000 per fresh IVF cycle, the study reports — double the price of every other developed country except Canada. According to the American Society for Reproductive Medicine, only one in four infertile couples in the United States can access all the fertility assistance they would need to become pregnant.
Even though just 17 states require insurance coverage of fertility assistance, a growing share of U.S. companies are prioritizing fertility benefits for their employees. In the past three years, more than 1 million employees have gained generous employee-based IVF coverage, and the number is rising. One U.S. start-up that provides corporate fertility benefits estimates it will deliver $3 billion in new employer-sponsored fertility coverage in 2020 alone.
Meanwhile, in countries such as Mexico and Brazil, where assisted reproductive services are far less costly than in the United States, the price of a single fresh IVF cycle still remains prohibitive — representing 40 to 50 percent of a single person's annual disposable income, according to the Fertility and Sterility study.
Innovations to Increase Access
Given the expense of IVF in the United States, a novel research program at the University of California, San Francisco, investigated whether a mild-stimulation protocol might provide an avenue to increase IVF access to infertile patients of limited means.
Researchers recruited low-income patients at a university-affiliated county hospital in California. The patients, mostly immigrants, received a basic infertility evaluation and counseling. The most common causes of infertility were anovulation or tubal factors.
Researchers then assigned the patients to one of four non-randomized treatment groups, where they received a regimen of clomiphene or letrozole alone; clomiphene or letrozole with low-dose gonadotropins; or low-dose gonadotropins alone.
The protocols yielded pregnancy rates from 27 percent to 31 percent in the first three treatment groups, suggesting that economical approaches to IVF do not need to come at the expense of achieving successful pregnancies.
Genetic Screening in Family Planning
By one estimate from a study published in Seminars in Fetal and Neonatal Medicine, 5.3 percent of babies globally are born with a genetic disorder. Given this statistic, the increasing commercialization of preconception genetic screening (PGS) promises to expand access to testing for disease-carrying genetic mutations, a potential boon to parents-to-be who want to avoid passing hereditary conditions on to their offspring.
Although estimates of the global use of PGS are elusive, a survey conducted among 376 clinics on five continents published in Reproductive Biomedicine Online found that 77 percent of respondents routinely carry out the technique for a variety of reasons. The chief usages were for repeated implantation failure (32 percent), recurrent pregnancy loss (31 percent) and advanced maternal age (27 percent). The vast majority of patients paid for the screening out of pocket.
The current pattern of use may represent an untapped opportunity for clinicians around the world. As more patients learn about genetic screening and related options such as preimplantation genetic testing, clinicians may wish to step in to counsel potential parents about the availability of PGS and IVF to avoid passing heredity diseases on to the next generation.
