Worldwide differences in access to assisted reproduction technology (ART) influence providers/consumers decisions on the number of embryos transferred, affecting the proportion of multiple births

Abstract

OBJECTIVE: Economic factors influence how risks and benefits are weighed among providers and consumers of ART treatments. This report demonstrates that free access to ART as opposed to out of pocket funding, influence the number of embryos transferred, delivery rates and high order multiple births as well as the type of treatment. DESIGN: Retrospective analysis of 2004 world data. MATERIALS AND METHODS: Availability is expressed as the number of initiated cycles per million inhabitants or by calculating the number of infertile women theoretically requiring ART. This data is correlated with the proportion of 1, 2, 3 and ≥4 embryos transferred; delivery rates by transfer; and the proportion of singletons, twins and ≥ triplets. Numerical data was obtained from procedures reported to the International Committee Monitoring ART (ICMART). RESULTS: In countries with free access to ART, the proportion of initiated cycles varied between 2008/million inhabitants in Denmark to 1062 in France. In countries with no reimbursement, the proportion of ART treatments drops to 26 to 200/million in Latin America and some European countries without reimbursement. The US performs only 357 cycles/million. Conversely, the proportion of 3 and 4 embryos transferred increases from 5 to 9% in Nordic countries to 20 to 40% in southern Europe, 52% in the US and a mean of 60% in Latin America. Consequently, the proportion of multiples/high order births is 33%/6% in Latin America, 32%/1.1% in the US and approximately 15%/0.3% in Denmark, Belgium, and Sweden. Similarly, there is a higher proportion of ICSI (76-80%) performed in countries with limited access to ART. CONCLUSIONS: Social and economic factors influence reproductive decisions. The risks involved in multiple gestations can be minimized if the costs of childbearing are covered by society as a whole. When individuals fund infertility treatment, the desire to conceive has greater influence than the risks of multiple births.