Estimating the effects of policies on infertility prevalence worldwide

Infertility, defined as the inability to conceive a child after one year of intercourse without contraception, troubled millions of people worldwide [1]. It exerts damaging effects on individual physical and psychological health and national fertility capability, causing burdens of healthcare costs and the aging of the population [2]. In the context of diverse population problems, alleviating infertility has been an urgent issue that all countries face. With babies born through in vitro fertilization (IVF) for the first time in 1978, there is a trend of enlargement for infertility treatments. Technically, it provided solutions for individuals to fertility problems by treatment, while more concerns were called out for prevention and early detection of infertility [3]. In recent years, the World Health Organization (WHO) has paid more attention to “prevention” as a core policy to relieve the global burden of infertility and promoted a tertiary care level approach for infertility [4].

In addition to genetics, other factors such as sexually transmitted infections, smoking, delayed childbearing and unsafe abortion increased the risk of infertility, which were alterable by policies and interventions [1]. Compared with individuals, governments have more choices including achieving primary prevention of infertility by advocating healthy lifestyles and creating a social atmosphere conducive to fertility [5, 6]. Governments can also rely on secondary prevention, by launching early diagnosis and treatment methods to benefit fertility recovery [3]. Moreover, appropriate financial support for fertility treatment was proved to represent sound fiscal policy that benefits equities in access to care [7]. Thus, policies that directly or indirectly benefit the infertile population are conducive to achieving tertiary prevention of infertility. Governments play a significant role in promoting these infertility-related policies for better access to infertility services and comprehensive supports for them.

Recent studies were concerned about the significance and investments of some infertility-related policies, which were incomplete. Iris G. Insogna et al [8] found the unequal gaps in infertility items through the summary of medical insurance coverage in the United States. Meanwhile, other aspects like service package for infertile populations were not considered. In another study, Morshed-Behbahani et al. [9] revealed that less financial protection policy in lower middle-income countries. However, the effectiveness of particular policies on the decline in infertility prevalence still lacked evidence.

As more data was accessible, we can conclude exhaustive infertility-related policies in various countries and gradually understand the effects of individual policies. Due to the different strategies for implementing policies (e.g., the year of release, the degree of intervention) in various countries, we can classify these differences into various policy implementation patterns and compare their benefits. Our study could encourage governments to efficiently improve infertility status by focusing on the most effective infertility-related policies and appropriate implementation patterns while issuing new guidelines on the policies.

We used a data-driven approach to evaluate the effects of infertility-related policies on the relief of infertility in ten countries between 1990 and 2017. We included research objects in view of geographical representation and evidence-based exclusion criteria that covered comprehensive species, three gradations of income levels, and different national development statuses. As a consequence, the results fully considered the differences generated by various races and economic development levels and were representative around the world. Our model first proved that insurance coverage and economic reward policies were related to a clear reduction in female infertility prevalence. In addition, we found that the economic support-orientation pattern outperformed others, and the gradual-promotion pattern was preferable for male infertility prevalence improvement.

Our results revealed the continuously severe infertility problem worldwide and common late marriage and childbirth in high-income countries. Combined with current reports, the infertility prevalence was 12-24% in selected countries. The frequency of involuntary infertility in a nationally representative population was estimated as high as 24% in France in 2007-2008, [11] which was above the global infertility prevalence reported by WHO (about 15%), warning about the critical infertility situation we face [12]. As a disease with complex etiology and various factors, infertility was influenced not only by a number of psychological and pathophysiological factors in both partners of a couple, but also by multiple social, economic, gestational age, and physiological factors changing over time. In developed countries, socioeconomic advantages with high-income level and education are associated with fecund postponement and infertility [13, 14]. A national survey study of 850 US surgeons reported that female surgeons were more likely to delay pregnancy because of work, leading to increased medical risks of infertility [15]. Noticeably, increased environmental health pressure, unwanted pregnancy, and unsafe abortion also exacerbated the infertile crisis in developing countries, although the average fertile age is relatively low [16]. Meanwhile, limited access to reliable infertility diagnosis and treatment aggravates the infertility problem in those countries [17]. What’s worse, infertility is a low-priority issue in countries with high fertility rates and limited health resources, considered as a natural method to overpopulation by those governments [18]. Therefore, encouraging populations to give birth at the optimal age and raising awareness of reproductive health through appropriate policies are urgent issues over the period of infertility alleviation.

The establishment of ESSTR system expanded the theoretical framework in infertility policy-making. Economic reward policy and four policies in the Social Security dimension stimulated public willingness to have children [19]. The effectiveness of the economic reward policy for the decrease of female infertility prevalence was proved in our study, which revealed that the additional effects of fertility policies on infertility relief were underestimated. On the one hand, infertility caused by late marriage and childbirth could be avoided to some extent. On the other hand, comprehensive support policies might encourage infertile people to seek medical treatment. Other fertility supporting policies for children’s enrollment, childcare facilities, compulsory education & housing security, living security, and family welfare provided backup force and solved the back-end problem, despite no statistical significance in our study. Furthermore, fertility supporting policies are related to the increase of national fecundity level, that could coordinate the resolution of population structure issues such as the aging of population, and promote sustainable development [20]. The significance of reproductive health care and public education was shown in other studies. Accessible maternal & child health service and sexual education decrease the risk of reproductive diseases, which have positive consequences for infertility prevention [21].

We found a large effect of insurance coverage policy for female infertility status relief, which was remarkably robust across different model structures. Taking infertility treatments into insurance coverage encourages patients to seek assisted reproductive help at a younger age, which is a significant factor in the live-birth rate of the IVF cycle [22]. Andrew D. A. C. Smith et al [23] reported that female patients younger than 40 years experienced the highest live-birth rate for the first cycle than women aged 40-42 years and older than 42 years. Besides, most infertile patients undergo IVF cycles several times during their successful treatment. It was illustrated that female patients with insurance coverage were more likely to experience IVF again, which means the increasing cumulative live-birth rate compared with single IVF cycle, and had a higher cumulative probability of live-birth than patients who paid for IVF personally [23]. In low- and middle-income countries, limited ART treatments are provided for infertile people because of limited resources and high treatment costs. However, a South African case study estimating the government public economic benefits attributed to investing in ART suggested that funding for IVF may create positive economic benefits and promote the sustainability of health systems [24].

Theories of the Policy Cycle emphasized the core position of policy formulation and implementation, and how to promote policies efficiently is a question worthy of discussion [25]. Policies of relieving infertility status cover associated aspects that containing insurance coverage, government funding, service optimization, clinic and laboratory supervision, and public health guidance [3]. The main difficulty is how to find the most cost-effective policy in the context of limited resources. It is also significant to regulate assisted reproductive technologies and avoid over-regulating [26]. Our study showed that insurance coverage investment was at a low level in most surveyed countries. Gender inequality also exists in that some regions take female infertility items into insurance coverage. In contrast, male items do not, which hinders the goal-achievement of universal health coverage (UHC) [27]. The positive association between national income level and UHC performance causes difficulties in implementing an infertility insurance policy. In comparison, governments could improve both financial protection and service coverage within the capacity to achieve the goal of UHC [28].

Classification and quantification of infertility-related policies in various countries make it possible to identify different patterns of implementation paces and policy orientation. Combined with results for male and female infertility improvement, the overall effect of the economic support-oriented pattern was better than that of the social security-oriented and balanced pattern. It prompted to prioritize the implementation of insurance coverage and/or birth reward policies within the limits of national power. Compared with other public policy models, incrementalism, which was proposed by Charles E. Lindblom, is more easily accepted by policymakers because of the consistency of actual policies, continuity of current plans, and the difficulty of technology [29]. Similar conclusions were also reflected in the policy implementation paces. Our research suggested that policy implementation can be more progressive when alleviating the problem of infertility. For countries with large population bases and limited economic resources, a gradual-promotion pattern could be considered more cost-effective than a simultaneous-promotion pattern. Implementing several policies gradually was low-cost, especially in countries with a large population base and certain restrictions on economic investment. Otherwise, despite similar effects on female, a gradual-promotion pattern was preferable for the relief of male infertility.

There were still several limitations in this study. Due to restrictions on the language or access to the data, some documents lacked specific years and were not included when grading and scoring in order to avoid bias, and thus only ten countries were included in our study. Additional studies with more adequate data will be needed to develop a full picture of infertility-related policies quantitative research. On the other hand, it is recognized that precise numbers of the infertile population are difficult to be estimated, and different global studies concluded inconsistent results [30]. In this study, age-standard infertility prevalence estimated by Sun H et al. [10] was used for statistical analyses.

Governments around the world seek to relieve infertility while minimizing the social and economic costs of their policy implementations. Our data-driven analysis revealed that insurance coverage and economic reward policies played the pivotal role in moderation of female infertility status. Economic support-oriented pattern and gradual-promotion pattern were preferable when promoting infertility-related policies. These results enriched infertility policy research, and provided theoretical basis and practical guidance for government decision-making that gradually promoting economic support policies could be prioritized; however, our estimates should not be taken as the final word on infertility-related policy effectiveness.