1. 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. 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. 3 1 st Hypothesis Socioeconomic factors influence access to ART

4. GDP per capita (dollars) (2004-2006) Country (Total Health Exp. as % of GDP) (2004) Public (%) Private (%) ART Cycles / 1 000 000 hab. (2004) 29,000 - 36,000 France (11.2%)79.920.11154 Sweden (9.2%)81.718.31433 Denmark (9.1%)84.115.92131 UK (8.2%)87.112.9660 Japan (8.2%) 82.217.8924 Australia (8.8%)67.033.01861 39,000 - 44,000USA (15.2%)45.154.9498 5,500 - 13,000Argentina (10.2%)43.956.1118 Brazil (7.9%)44.155.954 Chile (5.4%)51.448.663 Mexico (6.4%)45.554.533 Peru (4.3%)49.051.036 23,000 - 25,000Israel (7.8%) 66.533.516243 Number of ART Cycles according to Public/Private Health Expenditure (2004) 4,000 - 4,600Egypt (8.2%)42.657.3399 United Nations Statistics Division

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

6. 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

7. 7 1975-9 1995-9 2001-5 1965-9 Births 17500 15000 12500 10000 7500 5000 2500 20253035404550 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. 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. 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. 10 Access to ART * (women aged 25-40) 100 78.9 50.5 56.0 40.9 23.7 16.4 21.3 8.4 6.6 2.42.1 0.9 0.8 (*) ICMART, World Report

11. 11 2 nd Hypothesis Demographic factors influence access to ART

12. Access to ART (2004) according to: age of female population and fertility rate Country/RegionFemale median age (2006) Total fertility (children per woman) (2000-2005) Population Annual Growth Rate (2004) Access (cycles per million) (2004) France39.71.880.61154 Sweden41.51.670.41433 Denmark40.21.760.32131 UK39.81.700.5660 Japan44.31.290.1924 USA37.42.041.0498 Argentina29.92.351.0118 Brazil27.72.351.454 Chile30.82.001.163 Mexico25.52.400.833 Peru24.82.701.236 Egypt23.82.911.8399 Israel29.03.171.816243 US Census Bureau/International Data Base (IDB) / UN Statistics Division

13. 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. 14 Is fertility a national priority? How does it compete with other health issues?

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

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

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

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

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

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

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

22. 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 Denmark1.821.00.4 France2.122.00.5 Sweden1.35.6- UK2.023.90.3 - Private - None Argentina2.618.13.5 Brazil3.224.56.2 Chile2.629.83.8 Mexico3.022.24.5 Peru2.821.14.2 - Private - None Egypt3.026.79.3 - Private - None USA2.730.41.1

23. 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.