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Social determinants of human reproduction

Social determinants of human reproduction Abstract Developed countries have experienced both some population growth and unprecedented declines in fertility rates during the last half of the twentieth century. Couples now have fewer than two children on average in most European countries and they tend to postpone these births until a later age. A decline in male fertility has been suggested by some studies of semen quality, but there is contrasting evidence of shorter times to pregnancy for couples trying to conceive. An important economic factor is the income of young men relative to their parents' incomes, which determines how they rate the ability of their own earnings to support a family. Lower relative income in the 1970s was associated with a lower fertility rate. The decline in fertility in the USA may have been attenuated by the sharp rise in female income during the late 1960s and early 1970s, allowing women to take advantage of purchased child care, thus maintaining the relative family income. The level of demand for children does not appear to be set by known psychological factors, although explanations for the desire to reproduce have been sought in biological, psychoanalytical and socio-cultural research. Recent studies indicate that adults with secure attachment relationships are more interested in being parents. Possible epidemiological factors include age at first marriage, but in Eastern Europe, where age at first marriage is as low as 22 years, fecundity rates do not exceed 1.5. When mothers' age cohorts are analysed, the mean fecundity rate has been falling since the 1920s. Health factors affecting population trends include the change in contraceptive prevalence over the last 40 years. The prevalence of sub-fertility remains close to 10%, and studies from a number of countries indicate that ~50% of infertile couples make use of infertility services including IVF and intracytoplasmic sperm injection which are available in 45 countries covering 78% of the world's population. It is estimated that the level of service is sufficient for less than one-third of the need. Introduction During the twentieth century changes in human reproductive behaviour have had striking effects on the growth of populations. Some changes in reproductive behaviour have reflected contraceptive availability but to a greater extent these social trends have taken place independently of known health care factors. Before beginning coverage of the social determinants of the alterations in reproductive behaviour, a few definitions should prove useful. Fertility: based on the distribution of fecundity observed in a `normal' population, normal fertility was defined by the ESHRE Group as achieving a pregnancy within 2 years by regular coital exposure. Sterility, subfertility, infertility: those couples who do not achieve a pregnancy within 2 years include the sterile members of the population, for whom there is no possibility of natural pregnancy, and the remainder who are subfertile. Together, these comprise the infertile population. The term sterile may refer to either the male or the female, whereas the term subfertile refers to the couple. Fecundability is the probability of achieving a pregnancy within one menstrual cycle. Fecundity is the ability to achieve a live birth from one cycle's exposure to the risk of pregnancy. Total fertility rate (per woman) is the average number of children that would be born per woman if all women lived to the end of their reproductive years and bore children, according to the current age patterns of fertility. Interactions between reproductive capacity and social changes From natural to controlled fertility Current levels of fertility in most parts of the world are well below their possible maximum. However, the exact magnitude of the gap is not known, and bio-demographic models can help measure the shortfall (Leridon, 1977). Under traditional regimes, the level of fertility is mainly determined by three factors: the age at marriage, the intensity of breastfeeding, and the level of mortality. Detailed studies in historical demography have shown that in 18th century Europe, the average number of children per marriage was between 5–6 children. This (relatively) low score was due to late marriage (at 25 years or older in most countries), universal breastfeeding, and a significant proportion of women dying or becoming widows before the age of 50 years. In the developed world mortality is now almost negligible before the age of 50 years, and breastfeeding is so limited (in incidence and duration) that its effect on fertility is minimal. In many countries marriage is not as frequent as it used to be, but if we take the time of entry into first union, consensual or legal, the mean age when starting conjugal life is not so different from what it was in the past. The consequence of these trends is that the potential number of children a couple might expect if not using any form of family planning is no longer 5–6, but now around 10. If this number of children were born, there would be a doubling of the population every 15 years, a four-fold increase from one generation to the next. Changes in the time of childbearing In fact, couples now have fewer than two children on average in most European countries (Recent demographic developments in Europe, 1999; Macura et al., 2000). Not only are couples limiting the number of their children, but they also tend to postpone the births to older ages. In France, the mean age at first birth is now over 27 years (for women), roughly 3 years more than 20 years earlier. This new trend has several causes: the lengthening of the period of education, the more frequent entry of women into the labour market, the uncertainties of this market, and the availability of effective contraceptive methods. It is thus unlikely to be reversed in the near future (Leridon, 1999). Is fecundity declining? Therefore, the main reason for low fertility is obviously that men and women want fewer children. Some couples, however, are not able to have the children they would like to have, and the point has been raised whether fecundity is currently declining or not. The issue is made more crucial by the new behaviour shown above: if women tend to postpone childbearing to older ages, they might also face a decline of fecundity due to age. This decline is not easy to assess, because several causes interfere: the risk of spontaneous abortion undoubtedly increases with maternal age (Leridon, 1977), permanent sterility comes well before menopause (Leridon, 1977; Menken et al., 1986), and fecundability might also be declining after a particular age. This last point is the more controversial: some analyses based on artificial insemination tend to show that the decline in fecundability starts rather early (after the age of 30 years), but these results cannot easily be extrapolated to natural insemination (Schwartz et al., 1982). A possible decline of fecundity over time has been suggested by studies of sperm quality and counts (Carlsen et al., 1992; Auger et al., 1995; Irvine et al., 1996), but not everywhere (Bujan et al., 1996). There is also some evidence of such a trend from demographic surveys, in which individuals are asked about their past fertility and problems in conceiving or childbearing. We must be cautious, however, because couples tend to be more and more impatient when they decide to have a child (Leridon, 1992), and a recent study has shown that the time to pregnancy is currently declining in Britain (Joffe, 2000). Possible explanations for the very low birth rate Although the world population has been estimated to have reached 6 billion in 1999 and is still substantially increasing (Editorial, 1999), in most European countries the total fecundity rate in the mid-late 1990′s was appreciably below 2. In 1995, the average rate for the European Union was 1.4, ranging from 1.17 in Spain and 1.18 in Italy, to 1.81 in Finland and Denmark, and 1.87 in Iceland. Very low fecundity rates were also observed in the Russian Federation (1.34), and in most other eastern European countries (i.e. 1.28 in the Czech Republic, 1.61 in Poland). The only countries with fecundity rates per woman >2 were Iceland (2.08), Cyprus (2.13) and Turkey (2.62). Birth rates per 1000 individuals in 1996 were 10.8 in the European Union as a whole (ranging from 9.1 in Spain to 13.9 in Iceland), only 8.8 in the Russian Federation, but reached 22.0 in Turkey (Sorvillo, 1997a). To understand the fecundity rates of a population in a given time period, the role of calendar period of birth should be disentangled from that of the mother's cohort. In Italy, for instance, the peak fecundity rate after the second world war was reached around 1965 (2.67/1000 women), as compared with 2.3–2.4 in the 1950s, and the fecundity rate has been substantially declining since, especially from the mid-1970s onwards. However, an analysis by mother's cohort showed that the mean fecundity rate has been steadily declining for the generations born since 1922, and especially for those born after 1932, in the absence of any appreciable change in trends. Thus, the cross-sectional rates may be strongly influenced by the composition of the different cohorts, and their reproductive pattern (Sorvillo, 1997b; IARC, 1999). The most likely possible reasons for the declining birth rates in most European countries are clearly social and economic rather than medical, since no clear correlation can be made between availability and practice of contraceptive methods, nor between abortion rates and birth rates (IARC, 1999). Thus, countries like Italy or Spain, with relatively low frequency of use of oral contraceptives and other contraceptive methods in the past, as well as relatively low and declining abortion rates, also have very low birth rates. In the same way, at least within the ranges observed within the European Union, there is no clear correlation between age at first marriage and fecundity rate. For example, age at first marriage was around 26–27 years in Italy or Spain, with very low birth rates, but around 29 years in Denmark, Sweden and Iceland, with appreciably higher birth rates. In all eastern Europe, the mean age at first marriage was as low as 22 years, but fecundity rates were still around or below 1.5 (Annuario Statistico Italiano, 1998, 1999). Thus, neither medical nor demographic factors are correlated with or explain fecundity rates in a satisfactory manner. The interpretations must, therefore, be found essentially in economic but mainly social determinants, since again no clear correlation is observed between GNP and fecundity rates. Some of the differences observed in different countries may be due to different immigration patterns, since immigrant populations tend to have higher birth rates. This may explain the higher fecundity rates in central and northern Europe than in Mediterranean countries, in which immigration has been a more recent and numerically limited phenomenon. The cohort patterns indicate, in any case, that the decline in birth rates for Europe has been long-lasting, and shows no clear sign of levelling off. Economic issues in human reproduction Three different `fertility regimes' In discussing the economics of human fertility behaviour, it is necessary to differentiate between three different stages in any society's economic development, centred on what is known as the `demographic transition', the period when countries move from high to low fertility and mortality rates. It is generally believed that prior to the transition there is little conscious individual control of fertility: it is even suggested that in agrarian societies couples experience an `excess demand' for children. That is, children are seen as assets because of their ability to help in agriculture, but biological restrictions and high mortality rates keep couples from having as many children as they would like. Then as development progresses, mortality rates decline—thus allowing more children to survive to adulthood—but at the same time couples' `demand' also declines because the net benefit of having children falls with urbanization, the introduction of schooling, and the growing availability of other forms of `old-age security'. At this point couples begin to practice deliberate fertility control, and economists' models become relevant. Therefore the focus will be on economic factors that are thought to be relevant in determining the level of fertility after a society has reached the potential `replacement level', of ~2.1 children per woman. Economic factors influencing post-transitional fertility For a time it was thought that economic models might be unnecessary in modern societies: perhaps fertility would reach replacement level and then simply remain at about that level. However, the post World War II baby boom in many Western nations, and then the subsequent baby `bust' that has brought fertility rates to as low as 1.2 in some countries, disabused economists of that notion. Two competing but to some extent complementary theories, developed largely with respect to US experience, are generally referred to in explaining the baby boom and bust in the second half of the twentieth century. One, the `price of time' model, juxtaposes the desire for children, which is assumed to be positively related to family income, with the price of time spent in caring for children, and emphasizes the importance of women's labour force participation and their wages relative to men's in determining that price (Butz and Ward, 1979; Becker, 1981). It is hypothesized that during the postwar 1940s and 1950s men's wages rose more rapidly than women's, as women were displaced by men returning from the military, so that the price of children fell relative to families' ability to support them, encouraging a baby boom. This situation was assumed to have reversed itself in the late 1960s and into the 1970s as labour market opportunities for women increased and pushed up their wages, leading to an increase in the relative price of children and hence the baby bust. The competing theory, usually referred to as the `relative cohort size' hypothesis, also assumes a positive relationship between the desire for children and family income but juxtaposes this with a couple's material aspirations, which are assumed to be strongly influenced by the standard of living experienced by young adults when they were growing up (Easterlin, 1987). A couple feels able to afford children only if family income surpasses some threshold determined by material aspirations. It is hypothesized that young adults in the 1950s, who were born and raised in the depression and war years, set a lower threshold on average than young adults in the 1960s and 1970s, who were raised in the affluent postwar years. Compounding this effect of changing tastes, young adults in the 1950s were members of a very small birth cohort (product of the 1930s baby bust) relative to the size of the rest of the labour force, so that their wages were driven up relative to those of older workers in their parents' generation (Welch, 1979; Macunovich, 1999). The result was higher wages relative to their own (already low) material aspirations, making children appear very affordable. The large baby boom cohorts had the opposite experience when they entered the labour force, leaving them with reduced wages relative to inflated aspirations, and the baby bust resulted. Recent work suggests that a model combining these two theories can be used to explain the path of fertility in the USA both before and after 1980 (Macunovich, 1996). The model suggests that the sharp rise in women's wages that occurred in the late 1960s and early 1970s, unique to the USA, actually `buffered' that country from the extremely low fertility rates observed in other Western nations in recent years. Women's wages became an important source of family income during that period when relative male income was low, so that they had a positive effect on fertility rates (Figure 1). All of this suggests that one of the most important factors contributing both to the current low fertility in developed nations and to the declining fertility in developing nations is the relative income of young men: their potential earnings relative to the (contemporaneous) income of prime aged adults who are, for the most part, their own parents. The latter sets the desired standard of living for the young adults, against which they evaluate the ability of their own earnings to support a family. This relative income is affected by relative cohort size, but also by institutional policies that might affect the wage structure in a country. The current relative economic situation of young adults in Italy and Spain, who often feel unable financially to set up households independent of their parents, despite growth in the economy generally, suggests that this might be a very significant factor in those countries' current low fertility rates. The other important economic factor affecting fertility today is the female wage. Young women's wages exert both a (negative) `price of time' and a (positive) income effect on fertility, and the strengths of these two effects vary depending on young men's relative income and on the availability and acceptability of purchased child care. When relative income is high, female labour force participation tends to be lower and the negative `price of time' effect dominates, but when relative income is low, female labour force participation increases as young couples try to supplement their income and increasing proportions of young women remain single; in this case the idea of purchased child care tends to become more acceptable and the `income' effect of women's wages dominates. This dominant income effect of women's wages appears to have influenced the path of fertility in industrialized countries since about 1985. Many of these countries experienced a `baby boomlet' after 1985, when fertility rates rose appreciably, and recent analyses suggest that during this period fertility rates and women's wages moved in parallel. That is, fertility rates increased most in those countries where female labour force participation rates were highest and female unemployment rates were lowest. This suggests that (i) there is a continuing `demand' for children; (ii) women feel increasingly comfortable with purchased child care; and (iii) they are more able to take advantage of purchased child care as their own earning potential rises. Psychological aspects `Why do people want children?' The answer is not simple. The various theories will be considered together with the empirical evidence in support of each perspective, where there is such evidence (Robinson and Stewart, 1989). The motivations for parenthood among infertile couples and single women will also be examined in order to shed further light on this issue. Explanations for the desire to reproduce have generally been either biological in nature, psychoanalytic, or associated with social pressure. More recently, developments in attachment theory have led to a different approach that focuses on the security of a person's attachment relationships. Biological explanations It is often assumed that women's desire to have children is genetically or hormonally based, i.e. because of their capacity to have children, women are biologically predisposed to wish to reproduce. This issue has been addressed by studying individuals with an atypical genetic pattern, or who were exposed to abnormally high or low prenatal sex hormone concentrations. If, for example, women with Turners syndrome (females with an XO genetic pattern), or women who had been exposed to abnormally high concentrations of androgens prenatally (women with congenital adrenal hyperplasia), are found to be less likely to wish to have children, then sex chromosomes or prenatal androgen levels, would appear to be influential in women's desire to reproduce. There is no evidence for either a genetic or hormonal basis to women's motivation to become mothers. Psychoanalytical explanations From a traditional psychoanalytical perspective, motherhood is viewed as essential for women's development of a female identity. According to Freud, the successful resolution of the Oedipal conflict for girls involved substituting the desire for a penis with the desire for a baby. Entrenched in traditional psychoanalytical theory is the idea of the `maternal instinct', i.e., women's inborn need to procreate (Deutsch, 1945). For Deutsch, motherhood was considered to be essential in order for women to achieve a sense of fulfillment. Although some psychoanalytic theorists disagreed with Freud's views on penis envy (Horney, 1967; Thompson, 1967), motherhood remained closely tied to the development of a female identity. An influential reformulation of the psychoanalyical perspective (Chodorow, 1978) posited that women become mothers as a result of their experiences with their own mother throughout childhood. However, Chodorow also believed that biological differences between the sexes are at the root of women's desire to reproduce. It was not until the advent of the women's movement in the 1960s and 70s that the idea of the `maternal instinct' as a biologically-based drive, and the importance of motherhood for female identity, were rejected as explanations for women's decision to procreate. Interestingly, this was also the beginning of a new era for women; the introduction of the contraceptive pill meant that, for the first time, women were able to control their fertility. Socio-cultural explanations The view that women's desire for children is a function of socio-cultural factors took precedence over psychoanalytical and biological explanations in the latter part of the 20th century. It has been argued not only that women obtain approval for having children (Leiffer, 1980) but also that childlessness is viewed as a form of deviant behaviour, and that those who do not have children, particularly childless married women, are stigmatized by society (Miall, 1989). In recent years, a number of empirical studies of women's reasons for wanting to have children have been carried out. Of particular interest have been studies of women undergoing infertility treatment, and of single women who have become pregnant through donor insemination, as these women have made an active decision to have a child. In one study (Balen and Trimbos-Kemper, 1995) it was found that women's motivations were strongly associated with the expectation that motherhood would bring happiness, a sense of fulfilment and a secure adult identity. Attachment relationships A burgeoning of interest in adult attachment relationships, i.e. the extent to which adults feel secure in their relationship with their own parents, has begun to shed light on why some people are more motivated to have children than others. Attachment relationships are generally categorized as secure, avoidant (when attachment relationships are dismissed as having little importance and intimacy is not expected) or ambivalent (when unresolved conflicts with parents are still ongoing and there is a preoccupation with unfulfilled intimacy needs). In some studies (Rholes et al., 1995, 1997) it was found that avoidant adults were less interested in becoming parents than secure or ambivalent adults suggesting that a person's history of attachment relationships influences the desire to have a child of his or her own. There are no clear answers to the question of why women, and to a lesser extent men, wish to have children. However, a substantial proportion of women who attend infertility clinics are at risk of developing clinical depression if their treatment is unsuccessful. This tells us that whatever the reasons for wanting a child, the desire to be a mother is of central importance in many women's lives. The role of family planning Family planning is a fundamental human right, as repeatedly acknowledged by International Conferences sponsored by the United Nations. Thus, in 1968 The International Conference on Human Rights in Teheran unanimously adopted the Proclamation of Teheran, in which the Conference `solemnly proclaimed' that `Parents have a basic human right to determine freely and responsibly the number and spacing of their children'. Subsequently, the World Population Conference in Bucharest, August 1974, reiterated in the World Population Plan of Action [Paragraph 14(f)] that `All couples and individuals have the basic right to decide freely and responsibly the number and spacing of their children and to have the information, education and means to do so'. As an important practical follow-up, in the context of the Tokyo declaration, the Family Planning Associations of the World (Dennis, 1987) pledged to take a series of measures to reduce `the appalling toll of sickness and death caused by unplanned pregnancies', such as to: spread awareness of optimum conditions for childbearing; launch campaigns in each country to ensure that family planning is recognized as an essential component of primary health care; discourage pregnancy before the age of 18; promote spacing of births at least two years apart as an essential life-saving measure; further reduce infant mortality by giving advice and services to mothers and fathers in order to limit family size; counsel parents to cease childbearing after a woman has reached the high-risk age of 35; work within the national, legal and cultural framework to reduce the incidence of illegal abortion; and act without delay to help combat the spread of AIDS through education and appropriate services. In 1951 the Government of India, for the first time in history, established a national family planning programme. By the 1990s, 155 of 179 governments provided direct, or indirect, support to such programmes and access to contraceptives was limited in two countries (Saudi Arabia and the Vatican State) (United Nations, Population Division, 1998) (Table I). In 1951, when the national family planning programme of India was established, oral contraceptives, or modern intrauterine devices (IUDs) were not yet available and global contraceptive prevalence did not exceed 30 million couples. The first oral contraceptive was approved by the US Food and Drug Administration in 1959 and the first second generation IUDs, the Margulies coil and Lippes loop, became available in 1960 and 1962 respectively. By 1983, the number of contraceptive users worldwide was estimated at 403 million (United Nations, Population Division, 1989) and ten years later, in 1993, it was around 550 million (United Nations, Population Division, 1999). The use of the different methods by the 550 million contraceptive users is indicated in Table II. The data of Table II indicate that, in the nineties, female sterilization was the quantitatively most important contraceptive method, followed by the use of intrauterine devices and oral, injectable and implantable steroidal contraceptives. It also appears from the data that there are major differences in contraceptive use between more developed and less developed countries; in the former, pill and condom use and traditional methods are more popular than female sterilization. (United Nations, Population Division, 1999). The percentage of couples using any method worldwide, is 58% and the percentage of users employing modern methods (including sterilization, the pill, IUDs, injectables, implants, condom and vaginal barrier methods) is 87%. In the more developed regions (Australia, New Zealand, Europe, Japan and Northern America), these percentages are 70 and 74% respectively, and in the less developed regions, 55 and 91%, respectively (United Nations, Population Division, 1999). Estimating the real prevalence of subfertility in an affluent Western society Many textbooks of obstetrics and gynecology, even the oldest ones, quote an incidence of 10% subfertility in their respective chapters dealing with people having problems conceiving. The source of this figure however is hard to retrieve. In order to obtain a reliable estimate of the incidence of subfertility in an affluent Western society, a prospective observational study was carried out in all six regional hospitals and one university medical centre in a clearly defined region of The Netherlands (Beurskens et al., 1995). For this region, with a population of 650 000 at the time of the study, the cumulative incidence of subfertility was estimated to be 10%. During the period of the study 15% of couples sought specialist medical care for their fertility problem. Not all of them fulfilled the criteria for subfertility however. These findings are in accordance with previous findings (Hull et al., 1985), who found that at least one in six couples needed specialist help at some time in their lives, and with Greenhall and Vessey's figure of 24% of all women who attempt to conceive experiencing an episode of subfertility at some stage in their reproductive life (Greenhall and Vessey, 1990). Snick and co-workers (1997), in the Walcheren follow-up study presented data collected for 726 couples in the course of a 9-year review period of primary fertility care in the only hospital of a geographically isolated area of The Netherlands (Snick et al., 1997). The 726 couples represent 10% of the Walcheren population seeking medical care for subfertility problems at least once during their reproductive life span. Strict diagnosis and treatment protocols were adhered to, and only evidence-based treatment was instituted. If no such treatment was available for the couple under consideration, they were counselled extensively on the findings instead. Management was expectant in such cases. This allowed for the calculation of the baseline pregnancy prognosis in untreated subfertility couples from a representative population in a developed country. The couples described in this study had a shorter duration of infertility (mean 21 months) than in most published studies, which may be explained by the fact that most other studies considered patients from referral institutions, whereas Snick's patients visited the Walcheren hospital for their initial fertility work-up. Given the short lines of communication between general physicians and specialist care providers in Walcheren, the regional organization of fertility care, and the demographic characteristics of the population in their investigation, the authors propose that their study reliably reflects baseline fertility prognosis in untreated couples (Table III). The baseline prognosis in their primary care study is much better (two year cumulative live birth rate 41.9%) than the one calculated from secondary and tertiary care populations (e.g. 21.2% in the CITES study) (Collins et al., 1995), reflecting different compositions of the respective study populations, notwithstanding their identical inclusion criteria of subfertility. When applying models, this difference should impact on the decision about when to resort to assisted reproduction. For the incidence of subfertility, the present literature review confirms that the figure of 10% subfertility mentioned in the textbooks, is a correct estimate after all. Availability and uptake of profertility programmes A further means of assessing the social determinants of reproduction is exploration of demographic and economic factors that may influence the uptake of services by couples with infertility. The availability of infertility services ranges from non-existent to virtual oversupply in different countries and regions. Whether the available services are sufficient depends on the prevalence of infertility and the uptake of infertility services by infertile couples. Because the group was unable to find administrative information or medical care literature about the international availability of conventional infertility diagnosis and treatment services, the factors affecting the availability of IVF services have been evaluated, assuming that IVF is an indicator of the presence of high quality infertility services. Uptake of infertility services The current prevalence of infertility in Western and developing countries is ~10% of married and co-habiting couples in which the female partner is aged 15–44 years, as indicated above (Zarger et al., 1997; Sundby et al., 1998). Since females aged 15–44 years comprise ~20% of the population of developed countries, 2% of a given country's population are infertile female partners. Thus the current prevalence of infertility is one infertile couple for every 50 individuals in the population (or 20 000 per million population). Women who seek help for fertility problems are older, have a higher income and are more likely to be married than infertile women who do not (Chandra and Stephen, 1998). Nevertheless, the distribution of occupations among those attending tertiary care infertility centres is typical of the distribution in the population (Collins et al., 1994). In five European countries, the proportion of infertile couples seeking medical attention ranged from 19% in Poland to 61% in Denmark (Olsen et al., 1996). The uptake of clinical services by infertile couples in four other surveys averaged <50% of those with infertility (Templeton et al., 1990; Schmidt and Munster, 1995; Chandra and Stephen, 1998; Sundby et al., 1998). Estimating that 50% of infertile couples seek medical care services, that is equivalent to 5000 couples seeking care for current infertility per million population. Need for IVF services Approximately 5% of infertile couples have tubal obstruction and a similar proportion have severe male infertility (The ESHRE Capri Workshop Group, 1996). Thus, 10% of the 5000 couples seeking care for current infertility have indications for primary IVF/intracytoplasmic sperm injection (ICSI) treatment. IVF/ICSI is also indicated for couples with persistent infertility after conventional management. The long-term prognosis with conventional management of infertility was ~30% in tertiary care centres, (Collins et al., 1993; Eimers et al., 1994) 50% in a national estimate, (US Congress Office of Technology Assessment, 1988) and 70% in a primary referral practice (Snick et al., 1997). Thus ~50% of infertile couples who seek medical care services or 25% of all those with current infertility continue to have persistent infertility after conventional management. Because persistent infertility is a standard indication for IVF treatment, it is estimated that 2500 couples per million population would be eligible for IVF treatment on this basis, in addition to the 500 couples for whom IVF/ICSI services were indicated as a primary treatment for severe male infertility or tubal obstruction. Of course, it is not known what proportion of eligible couples would choose IVF/ICSI treatment, and cost is not the only governing factor. Assuming an uptake of 50%, there would be an annual need for IVF/ICSI services for 1500 couples with current infertility and the number of cycles would be in excess of this figure. Availability of IVF services Based on the premise that IVF/ICSI services indicate the presence of high-quality infertility treatment services, IVF/ICSI 1999 data for Europe were taken from an ESHRE report, (EIM Programme, 1999) 1995 data were from a questionnaire circulated to ART units in Asia, (Schenker and Shushan, 1996) and 1993 data for other countries were taken from an international registry (Schenker and Shushan, 1996; EIM Programme, 1999). National demographic and economic data were drawn from the World Health Organization World Health Report 1999 (Dodson et al., 1987). IVF/ICSI treatment centres were reported in 45 (24%) of the 191 member states of the World Health Organization, accounting for 78% of the world population and 91% of the worlds gross domestic product. IVF/ICSI centre density ranged from 0.01–3.6 centres per million population. The outlying density countries were China, Indonesia, Pakistan, Egypt, India, Poland, Kazachstan and Thailand with fewer than 0.1 reported centres per million and Iceland with one centre and 0.276 million population (3.6 centres per million). The majority of countries in Western Europe, the USA and Australia/New Zealand, however, report one to two IVF/ICSI centres per million population. Israel, Denmark, Finland, Greece and Belgium report more than three IVF/ICSI centres per million population. IVF/ICSI centre density was higher in countries with low infant mortality rates, which are an indicator of high-quality health services. Even so, two centres per million population would be required to provide IVF/ICSI cycles for more than 750 infertile couples each per annum to meet the needs of the 1500 couples with current infertility and standard indications for IVF and ICSI or persistent infertility. The number of IVF/ICSI cycles per annum was reported for 35 of the 45 countries having IVF/ICSI centres. Ten had fewer than 100 IVF/ICSI cycles per annum per million population, seven had 100–200 cycles, nine had 200–500 cycles, eight had 500–1000 cycles and Israel reported more than 1600 IVF/ICSI cycles per annum per million population. The number of cycles per million population correlates with the level of public funding for health services. Only Israel appears to have approached the level of IVF/ICSI services that would be sufficient for the 1500 couples with current infertility per million population. Cost of IVF services The cost of a single IVF/ICSI cycle has been reported from 24 countries (Fluker and Tiffin, 1996; Golombok et al., 1996; Phillips et al., 2000). In 18 of the 24 countries a single IVF/ICSI cycle cost >25% of the gross domestic product per capita. The exceptions were Ireland, the Netherlands, Japan, Norway, Sweden and the UK. IVF/ICSI cost did not contribute significantly to the variability in IVF/ICSI cycles per million among the countries, possibly because IVF/ICSI cost is high relative to income in all countries. IVF/ICSI costs tended to be lower in countries with a higher proportion of public spending on health. Summary IVF/ICSI services, which indicate the presence of a full range of infertility treatment services, are available in only 45 countries with 78% of the world population. Moreover, in nearly all countries with such services there is an insufficient supply of IVF/ICSI services to meet the estimated needs of couples with appropriate indications. One reason for the insufficient level of service is the high cost of IVF/ICSI cycles. Access to IVF/ICSI services is limited to the well-off in many countries and the limited number of cycles in many clinics precludes savings that might be associated with higher service volumes. Higher levels of public funding for health are associated with higher levels of IVF/ICSI service and lower IVF/ICSI cycle costs. In some European countries IVF/ICSI births contributed 1–2% of the total births. In countries in which there is public concern about falling fertility rates, increased levels of IVF/ICSI services through public funding would serve as one way to face these declining rates. The resources available to treat infertility should be directed more toward the appropriate use of IVF/ICSI services and less toward ineffective treatments. Table I. Government policies on providing access to contraceptive methods (number of countries) Policy  World  Regions      More developed  Less developed   Source: United Nations: National Population Policies, Sales No. E99.XIII.3. United Nations, New York, 1998.  Limits  2  1  1  No support  22  9  13   Indirect support  13  4  9  Direct support  142  30  112  Total  179  44  135  Policy  World  Regions      More developed  Less developed   Source: United Nations: National Population Policies, Sales No. E99.XIII.3. United Nations, New York, 1998.  Limits  2  1  1  No support  22  9  13   Indirect support  13  4  9  Direct support  142  30  112  Total  179  44  135  View Large Table II. Estimated number of couples (married or in union) with female partner of reproductive age using specific contraceptive methods, by region, 1993 (×106) (Figures are rounded) Contraceptive method  World  Regions      More developed  Less developed  Source: United Nations Population Division: Levels and Trends of Contraceptive Use as Assessed in 1998. ST/ESA/P/WP.155. United Nations, New York, 1999.   Total  550  125  425  Female sterilization  180  16  164  Male sterilization  41  9  32  Oral contraceptives  78  30  48  Injectables and implantables  16  1  15  Intrauterine devices  120  11  110  Condom  43  24  18  Vaginal barriers  5  4  1  Rhythm  27  10  17  Withdrawal  37  21  16  Others  5  0  5  Contraceptive method  World  Regions      More developed  Less developed  Source: United Nations Population Division: Levels and Trends of Contraceptive Use as Assessed in 1998. ST/ESA/P/WP.155. United Nations, New York, 1999.   Total  550  125  425  Female sterilization  180  16  164  Male sterilization  41  9  32  Oral contraceptives  78  30  48  Injectables and implantables  16  1  15  Intrauterine devices  120  11  110  Condom  43  24  18  Vaginal barriers  5  4  1  Rhythm  27  10  17  Withdrawal  37  21  16  Others  5  0  5  View Large Table III. Cumulative spontaneous live birth rate by diagnosis group among 726 subfertile couples in an affluent Western society (modified after Snick et al., 1997) Diagnostic category  Number of couples  Proportion of couples (%)  Cumulative live birth rate at 36 months (%)   Unexplained  218  30  61   Ovulation defect  188  26  12  Male defect  218  30  28  Oligospermia  185  25  33  Azoospermia  33  5  0  Tubal defect  94  13  6  Endometriosis  23  3  15  Cervical factor  201  28  29  All couples  726  100  52   Diagnostic category  Number of couples  Proportion of couples (%)  Cumulative live birth rate at 36 months (%)   Unexplained  218  30  61   Ovulation defect  188  26  12  Male defect  218  30  28  Oligospermia  185  25  33  Azoospermia  33  5  0  Tubal defect  94  13  6  Endometriosis  23  3  15  Cervical factor  201  28  29  All couples  726  100  52   View Large Figure 1. View largeDownload slide The fertility of US women aged 20–24, actual and simulated holding the female wage at its 1968 level, prior to its sharp rise in the early 1970s. A lower female wage would have raised fertility when male relative income was high, in the early 1970s, but would have reduced fertility when male relative income was low, in the 1980s. High female wages in the 1980s actually buffered US fertility rates, relative to those in European countries in the 1980s (Macunovich, 1996). Figure 1. View largeDownload slide The fertility of US women aged 20–24, actual and simulated holding the female wage at its 1968 level, prior to its sharp rise in the early 1970s. A lower female wage would have raised fertility when male relative income was high, in the early 1970s, but would have reduced fertility when male relative income was low, in the 1980s. High female wages in the 1980s actually buffered US fertility rates, relative to those in European countries in the 1980s (Macunovich, 1996). * A meeting was organized by ESHRE (Capri, August 26–28, 2000) with financial support from Ferring AG to discuss the above subjects. The speakers included J.Collins (Hamilton), H.Evers (Maastricht), S.Golombok (London), P.Hannaford (Aberdeen), H.S.Jacobs (London), C.La Vecchia (Milano), D.J.Macunovich (New York). The discussion group included P.G.Crosignani (Milano), P.Devroey (Brussels), K.Diedrich (Lubeck), T.Farley (WHO), L.Gianaroli (Bologna), I.Liebaers (Brussels), J.Persson (Copenhagen), J.P.Quartarolo (Copenhagen), G.Ragni (Milano), B.Tarlatzis (Thessaloniki) and A.Van Steirteghem (Brussels). 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Social determinants of human reproduction

Group, The ESHRE Capri Workshop
Human Reproduction , Volume 16 (7) – Jul 1, 2001
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Abstract

Abstract Developed countries have experienced both some population growth and unprecedented declines in fertility rates during the last half of the twentieth century. Couples now have fewer than two children on average in most European countries and they tend to postpone these births until a later age. A decline in male fertility has been suggested by some studies of semen quality, but there is contrasting evidence of shorter times to pregnancy for couples trying to conceive. An important economic factor is the income of young men relative to their parents' incomes, which determines how they rate the ability of their own earnings to support a family. Lower relative income in the 1970s was associated with a lower fertility rate. The decline in fertility in the USA may have been attenuated by the sharp rise in female income during the late 1960s and early 1970s, allowing women to take advantage of purchased child care, thus maintaining the relative family income. The level of demand for children does not appear to be set by known psychological factors, although explanations for the desire to reproduce have been sought in biological, psychoanalytical and socio-cultural research. Recent studies indicate that adults with secure attachment relationships are more interested in being parents. Possible epidemiological factors include age at first marriage, but in Eastern Europe, where age at first marriage is as low as 22 years, fecundity rates do not exceed 1.5. When mothers' age cohorts are analysed, the mean fecundity rate has been falling since the 1920s. Health factors affecting population trends include the change in contraceptive prevalence over the last 40 years. The prevalence of sub-fertility remains close to 10%, and studies from a number of countries indicate that ~50% of infertile couples make use of infertility services including IVF and intracytoplasmic sperm injection which are available in 45 countries covering 78% of the world's population. It is estimated that the level of service is sufficient for less than one-third of the need. Introduction During the twentieth century changes in human reproductive behaviour have had striking effects on the growth of populations. Some changes in reproductive behaviour have reflected contraceptive availability but to a greater extent these social trends have taken place independently of known health care factors. Before beginning coverage of the social determinants of the alterations in reproductive behaviour, a few definitions should prove useful. Fertility: based on the distribution of fecundity observed in a `normal' population, normal fertility was defined by the ESHRE Group as achieving a pregnancy within 2 years by regular coital exposure. Sterility, subfertility, infertility: those couples who do not achieve a pregnancy within 2 years include the sterile members of the population, for whom there is no possibility of natural pregnancy, and the remainder who are subfertile. Together, these comprise the infertile population. The term sterile may refer to either the male or the female, whereas the term subfertile refers to the couple. Fecundability is the probability of achieving a pregnancy within one menstrual cycle. Fecundity is the ability to achieve a live birth from one cycle's exposure to the risk of pregnancy. Total fertility rate (per woman) is the average number of children that would be born per woman if all women lived to the end of their reproductive years and bore children, according to the current age patterns of fertility. Interactions between reproductive capacity and social changes From natural to controlled fertility Current levels of fertility in most parts of the world are well below their possible maximum. However, the exact magnitude of the gap is not known, and bio-demographic models can help measure the shortfall (Leridon, 1977). Under traditional regimes, the level of fertility is mainly determined by three factors: the age at marriage, the intensity of breastfeeding, and the level of mortality. Detailed studies in historical demography have shown that in 18th century Europe, the average number of children per marriage was between 5–6 children. This (relatively) low score was due to late marriage (at 25 years or older in most countries), universal breastfeeding, and a significant proportion of women dying or becoming widows before the age of 50 years. In the developed world mortality is now almost negligible before the age of 50 years, and breastfeeding is so limited (in incidence and duration) that its effect on fertility is minimal. In many countries marriage is not as frequent as it used to be, but if we take the time of entry into first union, consensual or legal, the mean age when starting conjugal life is not so different from what it was in the past. The consequence of these trends is that the potential number of children a couple might expect if not using any form of family planning is no longer 5–6, but now around 10. If this number of children were born, there would be a doubling of the population every 15 years, a four-fold increase from one generation to the next. Changes in the time of childbearing In fact, couples now have fewer than two children on average in most European countries (Recent demographic developments in Europe, 1999; Macura et al., 2000). Not only are couples limiting the number of their children, but they also tend to postpone the births to older ages. In France, the mean age at first birth is now over 27 years (for women), roughly 3 years more than 20 years earlier. This new trend has several causes: the lengthening of the period of education, the more frequent entry of women into the labour market, the uncertainties of this market, and the availability of effective contraceptive methods. It is thus unlikely to be reversed in the near future (Leridon, 1999). Is fecundity declining? Therefore, the main reason for low fertility is obviously that men and women want fewer children. Some couples, however, are not able to have the children they would like to have, and the point has been raised whether fecundity is currently declining or not. The issue is made more crucial by the new behaviour shown above: if women tend to postpone childbearing to older ages, they might also face a decline of fecundity due to age. This decline is not easy to assess, because several causes interfere: the risk of spontaneous abortion undoubtedly increases with maternal age (Leridon, 1977), permanent sterility comes well before menopause (Leridon, 1977; Menken et al., 1986), and fecundability might also be declining after a particular age. This last point is the more controversial: some analyses based on artificial insemination tend to show that the decline in fecundability starts rather early (after the age of 30 years), but these results cannot easily be extrapolated to natural insemination (Schwartz et al., 1982). A possible decline of fecundity over time has been suggested by studies of sperm quality and counts (Carlsen et al., 1992; Auger et al., 1995; Irvine et al., 1996), but not everywhere (Bujan et al., 1996). There is also some evidence of such a trend from demographic surveys, in which individuals are asked about their past fertility and problems in conceiving or childbearing. We must be cautious, however, because couples tend to be more and more impatient when they decide to have a child (Leridon, 1992), and a recent study has shown that the time to pregnancy is currently declining in Britain (Joffe, 2000). Possible explanations for the very low birth rate Although the world population has been estimated to have reached 6 billion in 1999 and is still substantially increasing (Editorial, 1999), in most European countries the total fecundity rate in the mid-late 1990′s was appreciably below 2. In 1995, the average rate for the European Union was 1.4, ranging from 1.17 in Spain and 1.18 in Italy, to 1.81 in Finland and Denmark, and 1.87 in Iceland. Very low fecundity rates were also observed in the Russian Federation (1.34), and in most other eastern European countries (i.e. 1.28 in the Czech Republic, 1.61 in Poland). The only countries with fecundity rates per woman >2 were Iceland (2.08), Cyprus (2.13) and Turkey (2.62). Birth rates per 1000 individuals in 1996 were 10.8 in the European Union as a whole (ranging from 9.1 in Spain to 13.9 in Iceland), only 8.8 in the Russian Federation, but reached 22.0 in Turkey (Sorvillo, 1997a). To understand the fecundity rates of a population in a given time period, the role of calendar period of birth should be disentangled from that of the mother's cohort. In Italy, for instance, the peak fecundity rate after the second world war was reached around 1965 (2.67/1000 women), as compared with 2.3–2.4 in the 1950s, and the fecundity rate has been substantially declining since, especially from the mid-1970s onwards. However, an analysis by mother's cohort showed that the mean fecundity rate has been steadily declining for the generations born since 1922, and especially for those born after 1932, in the absence of any appreciable change in trends. Thus, the cross-sectional rates may be strongly influenced by the composition of the different cohorts, and their reproductive pattern (Sorvillo, 1997b; IARC, 1999). The most likely possible reasons for the declining birth rates in most European countries are clearly social and economic rather than medical, since no clear correlation can be made between availability and practice of contraceptive methods, nor between abortion rates and birth rates (IARC, 1999). Thus, countries like Italy or Spain, with relatively low frequency of use of oral contraceptives and other contraceptive methods in the past, as well as relatively low and declining abortion rates, also have very low birth rates. In the same way, at least within the ranges observed within the European Union, there is no clear correlation between age at first marriage and fecundity rate. For example, age at first marriage was around 26–27 years in Italy or Spain, with very low birth rates, but around 29 years in Denmark, Sweden and Iceland, with appreciably higher birth rates. In all eastern Europe, the mean age at first marriage was as low as 22 years, but fecundity rates were still around or below 1.5 (Annuario Statistico Italiano, 1998, 1999). Thus, neither medical nor demographic factors are correlated with or explain fecundity rates in a satisfactory manner. The interpretations must, therefore, be found essentially in economic but mainly social determinants, since again no clear correlation is observed between GNP and fecundity rates. Some of the differences observed in different countries may be due to different immigration patterns, since immigrant populations tend to have higher birth rates. This may explain the higher fecundity rates in central and northern Europe than in Mediterranean countries, in which immigration has been a more recent and numerically limited phenomenon. The cohort patterns indicate, in any case, that the decline in birth rates for Europe has been long-lasting, and shows no clear sign of levelling off. Economic issues in human reproduction Three different `fertility regimes' In discussing the economics of human fertility behaviour, it is necessary to differentiate between three different stages in any society's economic development, centred on what is known as the `demographic transition', the period when countries move from high to low fertility and mortality rates. It is generally believed that prior to the transition there is little conscious individual control of fertility: it is even suggested that in agrarian societies couples experience an `excess demand' for children. That is, children are seen as assets because of their ability to help in agriculture, but biological restrictions and high mortality rates keep couples from having as many children as they would like. Then as development progresses, mortality rates decline—thus allowing more children to survive to adulthood—but at the same time couples' `demand' also declines because the net benefit of having children falls with urbanization, the introduction of schooling, and the growing availability of other forms of `old-age security'. At this point couples begin to practice deliberate fertility control, and economists' models become relevant. Therefore the focus will be on economic factors that are thought to be relevant in determining the level of fertility after a society has reached the potential `replacement level', of ~2.1 children per woman. Economic factors influencing post-transitional fertility For a time it was thought that economic models might be unnecessary in modern societies: perhaps fertility would reach replacement level and then simply remain at about that level. However, the post World War II baby boom in many Western nations, and then the subsequent baby `bust' that has brought fertility rates to as low as 1.2 in some countries, disabused economists of that notion. Two competing but to some extent complementary theories, developed largely with respect to US experience, are generally referred to in explaining the baby boom and bust in the second half of the twentieth century. One, the `price of time' model, juxtaposes the desire for children, which is assumed to be positively related to family income, with the price of time spent in caring for children, and emphasizes the importance of women's labour force participation and their wages relative to men's in determining that price (Butz and Ward, 1979; Becker, 1981). It is hypothesized that during the postwar 1940s and 1950s men's wages rose more rapidly than women's, as women were displaced by men returning from the military, so that the price of children fell relative to families' ability to support them, encouraging a baby boom. This situation was assumed to have reversed itself in the late 1960s and into the 1970s as labour market opportunities for women increased and pushed up their wages, leading to an increase in the relative price of children and hence the baby bust. The competing theory, usually referred to as the `relative cohort size' hypothesis, also assumes a positive relationship between the desire for children and family income but juxtaposes this with a couple's material aspirations, which are assumed to be strongly influenced by the standard of living experienced by young adults when they were growing up (Easterlin, 1987). A couple feels able to afford children only if family income surpasses some threshold determined by material aspirations. It is hypothesized that young adults in the 1950s, who were born and raised in the depression and war years, set a lower threshold on average than young adults in the 1960s and 1970s, who were raised in the affluent postwar years. Compounding this effect of changing tastes, young adults in the 1950s were members of a very small birth cohort (product of the 1930s baby bust) relative to the size of the rest of the labour force, so that their wages were driven up relative to those of older workers in their parents' generation (Welch, 1979; Macunovich, 1999). The result was higher wages relative to their own (already low) material aspirations, making children appear very affordable. The large baby boom cohorts had the opposite experience when they entered the labour force, leaving them with reduced wages relative to inflated aspirations, and the baby bust resulted. Recent work suggests that a model combining these two theories can be used to explain the path of fertility in the USA both before and after 1980 (Macunovich, 1996). The model suggests that the sharp rise in women's wages that occurred in the late 1960s and early 1970s, unique to the USA, actually `buffered' that country from the extremely low fertility rates observed in other Western nations in recent years. Women's wages became an important source of family income during that period when relative male income was low, so that they had a positive effect on fertility rates (Figure 1). All of this suggests that one of the most important factors contributing both to the current low fertility in developed nations and to the declining fertility in developing nations is the relative income of young men: their potential earnings relative to the (contemporaneous) income of prime aged adults who are, for the most part, their own parents. The latter sets the desired standard of living for the young adults, against which they evaluate the ability of their own earnings to support a family. This relative income is affected by relative cohort size, but also by institutional policies that might affect the wage structure in a country. The current relative economic situation of young adults in Italy and Spain, who often feel unable financially to set up households independent of their parents, despite growth in the economy generally, suggests that this might be a very significant factor in those countries' current low fertility rates. The other important economic factor affecting fertility today is the female wage. Young women's wages exert both a (negative) `price of time' and a (positive) income effect on fertility, and the strengths of these two effects vary depending on young men's relative income and on the availability and acceptability of purchased child care. When relative income is high, female labour force participation tends to be lower and the negative `price of time' effect dominates, but when relative income is low, female labour force participation increases as young couples try to supplement their income and increasing proportions of young women remain single; in this case the idea of purchased child care tends to become more acceptable and the `income' effect of women's wages dominates. This dominant income effect of women's wages appears to have influenced the path of fertility in industrialized countries since about 1985. Many of these countries experienced a `baby boomlet' after 1985, when fertility rates rose appreciably, and recent analyses suggest that during this period fertility rates and women's wages moved in parallel. That is, fertility rates increased most in those countries where female labour force participation rates were highest and female unemployment rates were lowest. This suggests that (i) there is a continuing `demand' for children; (ii) women feel increasingly comfortable with purchased child care; and (iii) they are more able to take advantage of purchased child care as their own earning potential rises. Psychological aspects `Why do people want children?' The answer is not simple. The various theories will be considered together with the empirical evidence in support of each perspective, where there is such evidence (Robinson and Stewart, 1989). The motivations for parenthood among infertile couples and single women will also be examined in order to shed further light on this issue. Explanations for the desire to reproduce have generally been either biological in nature, psychoanalytic, or associated with social pressure. More recently, developments in attachment theory have led to a different approach that focuses on the security of a person's attachment relationships. Biological explanations It is often assumed that women's desire to have children is genetically or hormonally based, i.e. because of their capacity to have children, women are biologically predisposed to wish to reproduce. This issue has been addressed by studying individuals with an atypical genetic pattern, or who were exposed to abnormally high or low prenatal sex hormone concentrations. If, for example, women with Turners syndrome (females with an XO genetic pattern), or women who had been exposed to abnormally high concentrations of androgens prenatally (women with congenital adrenal hyperplasia), are found to be less likely to wish to have children, then sex chromosomes or prenatal androgen levels, would appear to be influential in women's desire to reproduce. There is no evidence for either a genetic or hormonal basis to women's motivation to become mothers. Psychoanalytical explanations From a traditional psychoanalytical perspective, motherhood is viewed as essential for women's development of a female identity. According to Freud, the successful resolution of the Oedipal conflict for girls involved substituting the desire for a penis with the desire for a baby. Entrenched in traditional psychoanalytical theory is the idea of the `maternal instinct', i.e., women's inborn need to procreate (Deutsch, 1945). For Deutsch, motherhood was considered to be essential in order for women to achieve a sense of fulfillment. Although some psychoanalytic theorists disagreed with Freud's views on penis envy (Horney, 1967; Thompson, 1967), motherhood remained closely tied to the development of a female identity. An influential reformulation of the psychoanalyical perspective (Chodorow, 1978) posited that women become mothers as a result of their experiences with their own mother throughout childhood. However, Chodorow also believed that biological differences between the sexes are at the root of women's desire to reproduce. It was not until the advent of the women's movement in the 1960s and 70s that the idea of the `maternal instinct' as a biologically-based drive, and the importance of motherhood for female identity, were rejected as explanations for women's decision to procreate. Interestingly, this was also the beginning of a new era for women; the introduction of the contraceptive pill meant that, for the first time, women were able to control their fertility. Socio-cultural explanations The view that women's desire for children is a function of socio-cultural factors took precedence over psychoanalytical and biological explanations in the latter part of the 20th century. It has been argued not only that women obtain approval for having children (Leiffer, 1980) but also that childlessness is viewed as a form of deviant behaviour, and that those who do not have children, particularly childless married women, are stigmatized by society (Miall, 1989). In recent years, a number of empirical studies of women's reasons for wanting to have children have been carried out. Of particular interest have been studies of women undergoing infertility treatment, and of single women who have become pregnant through donor insemination, as these women have made an active decision to have a child. In one study (Balen and Trimbos-Kemper, 1995) it was found that women's motivations were strongly associated with the expectation that motherhood would bring happiness, a sense of fulfilment and a secure adult identity. Attachment relationships A burgeoning of interest in adult attachment relationships, i.e. the extent to which adults feel secure in their relationship with their own parents, has begun to shed light on why some people are more motivated to have children than others. Attachment relationships are generally categorized as secure, avoidant (when attachment relationships are dismissed as having little importance and intimacy is not expected) or ambivalent (when unresolved conflicts with parents are still ongoing and there is a preoccupation with unfulfilled intimacy needs). In some studies (Rholes et al., 1995, 1997) it was found that avoidant adults were less interested in becoming parents than secure or ambivalent adults suggesting that a person's history of attachment relationships influences the desire to have a child of his or her own. There are no clear answers to the question of why women, and to a lesser extent men, wish to have children. However, a substantial proportion of women who attend infertility clinics are at risk of developing clinical depression if their treatment is unsuccessful. This tells us that whatever the reasons for wanting a child, the desire to be a mother is of central importance in many women's lives. The role of family planning Family planning is a fundamental human right, as repeatedly acknowledged by International Conferences sponsored by the United Nations. Thus, in 1968 The International Conference on Human Rights in Teheran unanimously adopted the Proclamation of Teheran, in which the Conference `solemnly proclaimed' that `Parents have a basic human right to determine freely and responsibly the number and spacing of their children'. Subsequently, the World Population Conference in Bucharest, August 1974, reiterated in the World Population Plan of Action [Paragraph 14(f)] that `All couples and individuals have the basic right to decide freely and responsibly the number and spacing of their children and to have the information, education and means to do so'. As an important practical follow-up, in the context of the Tokyo declaration, the Family Planning Associations of the World (Dennis, 1987) pledged to take a series of measures to reduce `the appalling toll of sickness and death caused by unplanned pregnancies', such as to: spread awareness of optimum conditions for childbearing; launch campaigns in each country to ensure that family planning is recognized as an essential component of primary health care; discourage pregnancy before the age of 18; promote spacing of births at least two years apart as an essential life-saving measure; further reduce infant mortality by giving advice and services to mothers and fathers in order to limit family size; counsel parents to cease childbearing after a woman has reached the high-risk age of 35; work within the national, legal and cultural framework to reduce the incidence of illegal abortion; and act without delay to help combat the spread of AIDS through education and appropriate services. In 1951 the Government of India, for the first time in history, established a national family planning programme. By the 1990s, 155 of 179 governments provided direct, or indirect, support to such programmes and access to contraceptives was limited in two countries (Saudi Arabia and the Vatican State) (United Nations, Population Division, 1998) (Table I). In 1951, when the national family planning programme of India was established, oral contraceptives, or modern intrauterine devices (IUDs) were not yet available and global contraceptive prevalence did not exceed 30 million couples. The first oral contraceptive was approved by the US Food and Drug Administration in 1959 and the first second generation IUDs, the Margulies coil and Lippes loop, became available in 1960 and 1962 respectively. By 1983, the number of contraceptive users worldwide was estimated at 403 million (United Nations, Population Division, 1989) and ten years later, in 1993, it was around 550 million (United Nations, Population Division, 1999). The use of the different methods by the 550 million contraceptive users is indicated in Table II. The data of Table II indicate that, in the nineties, female sterilization was the quantitatively most important contraceptive method, followed by the use of intrauterine devices and oral, injectable and implantable steroidal contraceptives. It also appears from the data that there are major differences in contraceptive use between more developed and less developed countries; in the former, pill and condom use and traditional methods are more popular than female sterilization. (United Nations, Population Division, 1999). The percentage of couples using any method worldwide, is 58% and the percentage of users employing modern methods (including sterilization, the pill, IUDs, injectables, implants, condom and vaginal barrier methods) is 87%. In the more developed regions (Australia, New Zealand, Europe, Japan and Northern America), these percentages are 70 and 74% respectively, and in the less developed regions, 55 and 91%, respectively (United Nations, Population Division, 1999). Estimating the real prevalence of subfertility in an affluent Western society Many textbooks of obstetrics and gynecology, even the oldest ones, quote an incidence of 10% subfertility in their respective chapters dealing with people having problems conceiving. The source of this figure however is hard to retrieve. In order to obtain a reliable estimate of the incidence of subfertility in an affluent Western society, a prospective observational study was carried out in all six regional hospitals and one university medical centre in a clearly defined region of The Netherlands (Beurskens et al., 1995). For this region, with a population of 650 000 at the time of the study, the cumulative incidence of subfertility was estimated to be 10%. During the period of the study 15% of couples sought specialist medical care for their fertility problem. Not all of them fulfilled the criteria for subfertility however. These findings are in accordance with previous findings (Hull et al., 1985), who found that at least one in six couples needed specialist help at some time in their lives, and with Greenhall and Vessey's figure of 24% of all women who attempt to conceive experiencing an episode of subfertility at some stage in their reproductive life (Greenhall and Vessey, 1990). Snick and co-workers (1997), in the Walcheren follow-up study presented data collected for 726 couples in the course of a 9-year review period of primary fertility care in the only hospital of a geographically isolated area of The Netherlands (Snick et al., 1997). The 726 couples represent 10% of the Walcheren population seeking medical care for subfertility problems at least once during their reproductive life span. Strict diagnosis and treatment protocols were adhered to, and only evidence-based treatment was instituted. If no such treatment was available for the couple under consideration, they were counselled extensively on the findings instead. Management was expectant in such cases. This allowed for the calculation of the baseline pregnancy prognosis in untreated subfertility couples from a representative population in a developed country. The couples described in this study had a shorter duration of infertility (mean 21 months) than in most published studies, which may be explained by the fact that most other studies considered patients from referral institutions, whereas Snick's patients visited the Walcheren hospital for their initial fertility work-up. Given the short lines of communication between general physicians and specialist care providers in Walcheren, the regional organization of fertility care, and the demographic characteristics of the population in their investigation, the authors propose that their study reliably reflects baseline fertility prognosis in untreated couples (Table III). The baseline prognosis in their primary care study is much better (two year cumulative live birth rate 41.9%) than the one calculated from secondary and tertiary care populations (e.g. 21.2% in the CITES study) (Collins et al., 1995), reflecting different compositions of the respective study populations, notwithstanding their identical inclusion criteria of subfertility. When applying models, this difference should impact on the decision about when to resort to assisted reproduction. For the incidence of subfertility, the present literature review confirms that the figure of 10% subfertility mentioned in the textbooks, is a correct estimate after all. Availability and uptake of profertility programmes A further means of assessing the social determinants of reproduction is exploration of demographic and economic factors that may influence the uptake of services by couples with infertility. The availability of infertility services ranges from non-existent to virtual oversupply in different countries and regions. Whether the available services are sufficient depends on the prevalence of infertility and the uptake of infertility services by infertile couples. Because the group was unable to find administrative information or medical care literature about the international availability of conventional infertility diagnosis and treatment services, the factors affecting the availability of IVF services have been evaluated, assuming that IVF is an indicator of the presence of high quality infertility services. Uptake of infertility services The current prevalence of infertility in Western and developing countries is ~10% of married and co-habiting couples in which the female partner is aged 15–44 years, as indicated above (Zarger et al., 1997; Sundby et al., 1998). Since females aged 15–44 years comprise ~20% of the population of developed countries, 2% of a given country's population are infertile female partners. Thus the current prevalence of infertility is one infertile couple for every 50 individuals in the population (or 20 000 per million population). Women who seek help for fertility problems are older, have a higher income and are more likely to be married than infertile women who do not (Chandra and Stephen, 1998). Nevertheless, the distribution of occupations among those attending tertiary care infertility centres is typical of the distribution in the population (Collins et al., 1994). In five European countries, the proportion of infertile couples seeking medical attention ranged from 19% in Poland to 61% in Denmark (Olsen et al., 1996). The uptake of clinical services by infertile couples in four other surveys averaged <50% of those with infertility (Templeton et al., 1990; Schmidt and Munster, 1995; Chandra and Stephen, 1998; Sundby et al., 1998). Estimating that 50% of infertile couples seek medical care services, that is equivalent to 5000 couples seeking care for current infertility per million population. Need for IVF services Approximately 5% of infertile couples have tubal obstruction and a similar proportion have severe male infertility (The ESHRE Capri Workshop Group, 1996). Thus, 10% of the 5000 couples seeking care for current infertility have indications for primary IVF/intracytoplasmic sperm injection (ICSI) treatment. IVF/ICSI is also indicated for couples with persistent infertility after conventional management. The long-term prognosis with conventional management of infertility was ~30% in tertiary care centres, (Collins et al., 1993; Eimers et al., 1994) 50% in a national estimate, (US Congress Office of Technology Assessment, 1988) and 70% in a primary referral practice (Snick et al., 1997). Thus ~50% of infertile couples who seek medical care services or 25% of all those with current infertility continue to have persistent infertility after conventional management. Because persistent infertility is a standard indication for IVF treatment, it is estimated that 2500 couples per million population would be eligible for IVF treatment on this basis, in addition to the 500 couples for whom IVF/ICSI services were indicated as a primary treatment for severe male infertility or tubal obstruction. Of course, it is not known what proportion of eligible couples would choose IVF/ICSI treatment, and cost is not the only governing factor. Assuming an uptake of 50%, there would be an annual need for IVF/ICSI services for 1500 couples with current infertility and the number of cycles would be in excess of this figure. Availability of IVF services Based on the premise that IVF/ICSI services indicate the presence of high-quality infertility treatment services, IVF/ICSI 1999 data for Europe were taken from an ESHRE report, (EIM Programme, 1999) 1995 data were from a questionnaire circulated to ART units in Asia, (Schenker and Shushan, 1996) and 1993 data for other countries were taken from an international registry (Schenker and Shushan, 1996; EIM Programme, 1999). National demographic and economic data were drawn from the World Health Organization World Health Report 1999 (Dodson et al., 1987). IVF/ICSI treatment centres were reported in 45 (24%) of the 191 member states of the World Health Organization, accounting for 78% of the world population and 91% of the worlds gross domestic product. IVF/ICSI centre density ranged from 0.01–3.6 centres per million population. The outlying density countries were China, Indonesia, Pakistan, Egypt, India, Poland, Kazachstan and Thailand with fewer than 0.1 reported centres per million and Iceland with one centre and 0.276 million population (3.6 centres per million). The majority of countries in Western Europe, the USA and Australia/New Zealand, however, report one to two IVF/ICSI centres per million population. Israel, Denmark, Finland, Greece and Belgium report more than three IVF/ICSI centres per million population. IVF/ICSI centre density was higher in countries with low infant mortality rates, which are an indicator of high-quality health services. Even so, two centres per million population would be required to provide IVF/ICSI cycles for more than 750 infertile couples each per annum to meet the needs of the 1500 couples with current infertility and standard indications for IVF and ICSI or persistent infertility. The number of IVF/ICSI cycles per annum was reported for 35 of the 45 countries having IVF/ICSI centres. Ten had fewer than 100 IVF/ICSI cycles per annum per million population, seven had 100–200 cycles, nine had 200–500 cycles, eight had 500–1000 cycles and Israel reported more than 1600 IVF/ICSI cycles per annum per million population. The number of cycles per million population correlates with the level of public funding for health services. Only Israel appears to have approached the level of IVF/ICSI services that would be sufficient for the 1500 couples with current infertility per million population. Cost of IVF services The cost of a single IVF/ICSI cycle has been reported from 24 countries (Fluker and Tiffin, 1996; Golombok et al., 1996; Phillips et al., 2000). In 18 of the 24 countries a single IVF/ICSI cycle cost >25% of the gross domestic product per capita. The exceptions were Ireland, the Netherlands, Japan, Norway, Sweden and the UK. IVF/ICSI cost did not contribute significantly to the variability in IVF/ICSI cycles per million among the countries, possibly because IVF/ICSI cost is high relative to income in all countries. IVF/ICSI costs tended to be lower in countries with a higher proportion of public spending on health. Summary IVF/ICSI services, which indicate the presence of a full range of infertility treatment services, are available in only 45 countries with 78% of the world population. Moreover, in nearly all countries with such services there is an insufficient supply of IVF/ICSI services to meet the estimated needs of couples with appropriate indications. One reason for the insufficient level of service is the high cost of IVF/ICSI cycles. Access to IVF/ICSI services is limited to the well-off in many countries and the limited number of cycles in many clinics precludes savings that might be associated with higher service volumes. Higher levels of public funding for health are associated with higher levels of IVF/ICSI service and lower IVF/ICSI cycle costs. In some European countries IVF/ICSI births contributed 1–2% of the total births. In countries in which there is public concern about falling fertility rates, increased levels of IVF/ICSI services through public funding would serve as one way to face these declining rates. The resources available to treat infertility should be directed more toward the appropriate use of IVF/ICSI services and less toward ineffective treatments. Table I. Government policies on providing access to contraceptive methods (number of countries) Policy  World  Regions      More developed  Less developed   Source: United Nations: National Population Policies, Sales No. E99.XIII.3. United Nations, New York, 1998.  Limits  2  1  1  No support  22  9  13   Indirect support  13  4  9  Direct support  142  30  112  Total  179  44  135  Policy  World  Regions      More developed  Less developed   Source: United Nations: National Population Policies, Sales No. E99.XIII.3. United Nations, New York, 1998.  Limits  2  1  1  No support  22  9  13   Indirect support  13  4  9  Direct support  142  30  112  Total  179  44  135  View Large Table II. Estimated number of couples (married or in union) with female partner of reproductive age using specific contraceptive methods, by region, 1993 (×106) (Figures are rounded) Contraceptive method  World  Regions      More developed  Less developed  Source: United Nations Population Division: Levels and Trends of Contraceptive Use as Assessed in 1998. ST/ESA/P/WP.155. United Nations, New York, 1999.   Total  550  125  425  Female sterilization  180  16  164  Male sterilization  41  9  32  Oral contraceptives  78  30  48  Injectables and implantables  16  1  15  Intrauterine devices  120  11  110  Condom  43  24  18  Vaginal barriers  5  4  1  Rhythm  27  10  17  Withdrawal  37  21  16  Others  5  0  5  Contraceptive method  World  Regions      More developed  Less developed  Source: United Nations Population Division: Levels and Trends of Contraceptive Use as Assessed in 1998. ST/ESA/P/WP.155. United Nations, New York, 1999.   Total  550  125  425  Female sterilization  180  16  164  Male sterilization  41  9  32  Oral contraceptives  78  30  48  Injectables and implantables  16  1  15  Intrauterine devices  120  11  110  Condom  43  24  18  Vaginal barriers  5  4  1  Rhythm  27  10  17  Withdrawal  37  21  16  Others  5  0  5  View Large Table III. Cumulative spontaneous live birth rate by diagnosis group among 726 subfertile couples in an affluent Western society (modified after Snick et al., 1997) Diagnostic category  Number of couples  Proportion of couples (%)  Cumulative live birth rate at 36 months (%)   Unexplained  218  30  61   Ovulation defect  188  26  12  Male defect  218  30  28  Oligospermia  185  25  33  Azoospermia  33  5  0  Tubal defect  94  13  6  Endometriosis  23  3  15  Cervical factor  201  28  29  All couples  726  100  52   Diagnostic category  Number of couples  Proportion of couples (%)  Cumulative live birth rate at 36 months (%)   Unexplained  218  30  61   Ovulation defect  188  26  12  Male defect  218  30  28  Oligospermia  185  25  33  Azoospermia  33  5  0  Tubal defect  94  13  6  Endometriosis  23  3  15  Cervical factor  201  28  29  All couples  726  100  52   View Large Figure 1. View largeDownload slide The fertility of US women aged 20–24, actual and simulated holding the female wage at its 1968 level, prior to its sharp rise in the early 1970s. A lower female wage would have raised fertility when male relative income was high, in the early 1970s, but would have reduced fertility when male relative income was low, in the 1980s. High female wages in the 1980s actually buffered US fertility rates, relative to those in European countries in the 1980s (Macunovich, 1996). Figure 1. View largeDownload slide The fertility of US women aged 20–24, actual and simulated holding the female wage at its 1968 level, prior to its sharp rise in the early 1970s. A lower female wage would have raised fertility when male relative income was high, in the early 1970s, but would have reduced fertility when male relative income was low, in the 1980s. High female wages in the 1980s actually buffered US fertility rates, relative to those in European countries in the 1980s (Macunovich, 1996). * A meeting was organized by ESHRE (Capri, August 26–28, 2000) with financial support from Ferring AG to discuss the above subjects. The speakers included J.Collins (Hamilton), H.Evers (Maastricht), S.Golombok (London), P.Hannaford (Aberdeen), H.S.Jacobs (London), C.La Vecchia (Milano), D.J.Macunovich (New York). The discussion group included P.G.Crosignani (Milano), P.Devroey (Brussels), K.Diedrich (Lubeck), T.Farley (WHO), L.Gianaroli (Bologna), I.Liebaers (Brussels), J.Persson (Copenhagen), J.P.Quartarolo (Copenhagen), G.Ragni (Milano), B.Tarlatzis (Thessaloniki) and A.Van Steirteghem (Brussels). 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Human Reproduction – Oxford University Press

Published: Jul 1, 2001

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