Global socioeconomic and cultural factors affecting the number of embryos transferred Fernando Zegers-Hochschild, MD ICMART Symposium: “Global socioeconomic, cultural and regulatory differences that affect the number of embryos transferred” ASRM, San Francisco 2008

2 Regional contribution of ART cycles to the World Report (2004) * Corresponds to aspiration cycles in IVF, ICSI & GIFT and transfer cycles in FET & OD. N = 764,628 Middle East 6.5% Latin America 3.0% Australia & New Zealand 5.2% ICMART, World Report 2004.

3 1 st Hypothesis Socioeconomic factors influence access to ART

GDP per capita (dollars) ( ) Country (Total Health Exp. as % of GDP) (2004) Public (%) Private (%) ART Cycles / hab. (2004) 29, ,000 France (11.2%) Sweden (9.2%) Denmark (9.1%) UK (8.2%) Japan (8.2%) Australia (8.8%) , ,000USA (15.2%) , ,000Argentina (10.2%) Brazil (7.9%) Chile (5.4%) Mexico (6.4%) Peru (4.3%) , ,000Israel (7.8%) Number of ART Cycles according to Public/Private Health Expenditure (2004) 4, ,600Egypt (8.2%) United Nations Statistics Division

5 Out-of-pocket expenditure as % of Private health expenditure (2004) United Nations Statistics Division

6 Is “ART cycles/million Inhabitants” a good marker of availability? It does not consider the age distribution of the population and the willingness to become pregnant Access

Births Age of the female partner (years) Number of births and age of female Spontaneous Pregnancy - The Netherlands Central Statistics Bureau of the Netherlands N=1000 births / period

8 Number of births and age of Female Spontaneous pregnancy - Chile Age of Female Number of births Instituto Nacional de Estadísticas (INE) N=1000 births / year

9 Estimated Need for ART Cycles Number of ART cycles performed in one year Female population aged 25 through 40 (10% infertility prevalence) x (30% ART) x 100%

10 Access to ART * (women aged 25-40) (*) ICMART, World Report

11 2 nd Hypothesis Demographic factors influence access to ART

Access to ART (2004) according to: age of female population and fertility rate Country/RegionFemale median age (2006) Total fertility (children per woman) ( ) Population Annual Growth Rate (2004) Access (cycles per million) (2004) France Sweden Denmark UK Japan USA Argentina Brazil Chile Mexico Peru Egypt Israel US Census Bureau/International Data Base (IDB) / UN Statistics Division

13 Socioeconomic and demographic factors determine access to ART  HIGH median age of the female population Countries with  LOW median age of the female population  LOW population growth  HIGH population growth SOCIETY SOCIETY needs access to ART INDIVIDUAL INDIVIDUAL needs access to ART

14 Is fertility a national priority? How does it compete with other health issues?

15 Under-5 mortality rate US Census Bureau/International Data Base (IDB) / Nations Statistics Division

16 Fertility rate becomes a priority once other vital health issues have been solved

17 3 rd Hypothesis Cultural and religious factors influence access to ART

18 Cultural and religious factors influence access to ART Religious authority Principles Evidence and consequence Catholic / Islamic Protestant / Jewish Moral decisions

19 Socioeconomic, demographic & religious factors influence access to ART Does access to ART determine HOW it is performed?

20  Number of embryos transferred and multiplicity  Proportion of ICSI vs IVF  Embryo Cryopreservation

21 Number of embryos transferred per region, IVF & ICSI (2004) x= 3.10 x= 2.2 x= 2.9 ICMART, World Report 2004.

22 Factors influencing the number of transferred embryos (2004) - Source of Funding - Regulatory body CountryMean Number Embryos Transf. (2004) High order Multiple births (2004) Twin (%) Triplet +(%) - Public - National Denmark France Sweden UK Private - None Argentina Brazil Chile Mexico Peru Private - None Egypt Private - None USA

23 Conclusion Cultural, Socio-economic and demographic factors influence: who has access to ART, when they have access to ART, and how ART is performed.