Published 09 January 2023
A recent opinion piece in Fertility & Sterility makes a persuasive case for state-supported fertility treatment based on economic and fiscal arguments; infertility, say the authors, is a personal matter with ‘public importance’
The New Year brought its usual crop of world population forecasts, with most based on the UN’s latest ‘milestone’ statistic – from November 2022 – that the global total has now reached 8 billion, with projections of 9.7 billion in 2050 and a peak of 10.4 billion by the mid-2080s.(1) However, adds the UN, this growth, largely driven by increasing longevity, urbanisation and immigration, is taking place alongside a population decline in most developed countries (especially in Europe), where birth rates continue to lag way behind replacement level (now put at 2.1 children per woman).
The commentaries have drawn the distinction between demographic effects at the global level and those at the local level, and it’s clear, even at the national level, that policies to enhance fertility rate and restore demographic balance have not been entirely successful. Indeed, in a new ‘inkling’ in Fertility & Sterility the health economist Mark Connolly and colleagues cite data showing that pronatalist policies such as child tax credits and baby bonuses have only a moderate effect on birth rates, ranging from 0.5%–4.1%.(2) Indeed, a recent report from China showed that adoption of a newly introduced three-child policy was making only a modest difference to couples’ family intentions; the mean desired family size for women was 1.58 children (and 1.76 for men).(3)
Of far greater demographic value, the authors now argue, would be policies to support medically assisted reproduction, which, ‘when funded adequately, can produce as many children every year as most accepted and funded pronatalist policies’.
The key to their argument is the perception of children as ‘public goods’ and a source of taxation for future generations. Having and raising children is thus a public service from which all members of society might benefit in the future. This, explain Connolly et al, would suggest that society and governments ‘should enable as well as encourage those willing to make the sacrifices of parenthood to optimize economic and fiscal gains’. Such gains, they add, emphasise ‘why infertility as a private matter has public importance’.
Some evidence in support of this view lies in recent annual data from ESHRE’s European IVF Monitoring Consortium, where countries with generous public funding of ART (such as Denmark, Belgium and France) are consistently able to record policy-related levels of ART childbirth far greater than those achieved as a result of other pronatalist policies. Thus, although infertility is deemed a medical condition by the WHO and accepted as such by all patients, successful medical intervention in the form of ART appears to act in a more effective way than any pronatalist policy. Extending their argument, Connolly et al thus propose that governments might better increase their birth rates by shifting their support from ‘the able but unwilling’ (ie, those couples not wanting children and irresponsive to pronatalist encouragement) to ‘the willing but unable’ couples with infertility who might benefit from treatments.
Despite the seemingly economic validity of such a policy, the authors acknowledge that most governments appear reluctant to fund ART programmes mainly as part of their population policies. Technology taking over conception? Too expensive? A lifestyle choice? But the ideal policy mix for governments, they insist, should still ‘embrace family building over the life cycle’, thus a policy which encourages fertile couples to conceive at a time that suits them, and to have public programmes to support those who are medically infertile.
1. See https://www.un.org/en/global-issues/population
2. Connolly MP, Kolsopoulos N, Eisenberg ML. The intergenerational economics of infertility, childrearing, and assisted reproduction. Fertil Steril 2022;
3. See https://www.focusonreproduction.eu/article/News-in-Reproduction-China-fertility-rate
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