IVF restrictions in low birth rate countries

Alabama’s controversy is not that unusual, globally

Source: CDC.gov. The CDC defines “infertile women” as those “who are not surgically sterile, and have had at least 12 consecutive months of unprotected sexual intercourse without becoming pregnant.”

I’m often asked what role in-vitro fertilization (IVF) and other medically assisted reproduction (MAR) plays in overall birth trends and with the controversy over IVF in the US state of Alabama in the news lately, now seems like a good time to discuss this.

MAR is a small proportion of all births, so as far as aggregate stats go, it doesn’t drive the trend one way or another. However, when we disaggregate by age, it has a much larger impact, and when it comes to individuals and couples, of course, the impact is life-changing (see the discussion of Elizabeth Katkin’s journey in my book). That’s something I think we forget when we focus just on reproduction rates, but par for the course when it comes to population—it’s too easy to forget that all of these stats aggregate individual experiences.

The age at which women are having their first child continues to increase around the world, and use of medically assisted reproduction is increasing in tandem. MAR includes a range of treatments, including fertility-enhancing drugs, artificial insemination, and other assisted reproductive technologies, like IVF.

About 12% of women in the US report using fertility services at some point. That varies by age, as we would expect, with under 3% of the youngest women surveyed making use of services and over 20% of those women aged 40-49 years, according to the CDC. The group benefiting the most from MAR in the US is first-time mothers over age 40, as research by Tierney and Guzzo indicates:

Data source: “Medically Assisted Reproduction in the United States: A Focus on Parents 40 and Older,” Katherine Tierney and Karen Benjamin Guzzo, 2023.

Should we expect government support for IVF because of low birth rates?

A lot of people I’ve spoken with expressed surprise that Alabama would restrict IVF given how concerned some on the US political right are with low births in the country. From what I’ve seen internationally, however, I’m not surprised. I’m wrapping research on a book and here’s what I’ve learned: it’s not that governments want more births under any circumstances, but that they want more births under specific circumstances, generally within what they define as the “ideal family.” Japan, despite its shrinking population and low births, limits IVF to legally married heterosexual couples. The country does not allow single women or same-sex couples to undergo IVF using a third person’s sperm. They do allow single women to freeze their eggs, however.

South Korea, with a total fertility rate of 0.7 children per woman on average, basically limits IVF to heterosexual married couples as well. In Switzerland, only married couples can use donated sperm cells, including married lesbian couples since 2022—no single women.

The US, however, does allow IVF to single women. So, globally, just because some in power may be alarmed at low birth rates has thus far not led them to encourage births to anyone and everyone in their societies.

But do governments wanting more births subsidize IVF?

Medically assisted reproduction is incredibly expensive and often not covered by any medical insurance. That it might play a larger role in future birth rates if costs were lower has prompted some to see subsidies as a potential pronatalist measure. Japan, with 1.3 children per woman on average, is among countries with the highest uptake of assisted reproductive technology. They began paying 70% of the costs of advanced fertility treatments through public health insurance in 2022. In addition, some cities offer fertility subsidies for the husband’s artificial insemination, egg freezing, or for IVF. According to the Asahi Shimbun, “Under the subsidy program, a woman can receive up to 200,000 yen ($1,370) for the year she freezes her eggs and 20,000 yen annually for a maximum of five years after the procedure.” When Tokyo recently opened its subsidized program to applications, the government was overwhelmed with interest. Likewise, Beijing has begun to include some assisted reproductive treatments under the city’s health care system, although limited to married couples.

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Family trip to New Orleans for spring break. The key to patient shoppers is apparently books and cozy dressing rooms.