Estimating the effects of policies on infertility prevalence worldwide – BMC Public Health – BMC Public Health

National development in selected countries

Ten countries in this study were international representative and covering comprehensive races, different income levels and development status (Additional file 1, Table S4). Generally, infertility prevalence was 12-24% in the past decade. Total fertility rates (TFR) in most surveyed countries were lower than the replacement level of 21 except India (222). TFR of South Korea was as low as 098, which ranked the last among ten countries. The average age at first marriage and childbirth was generally delayed in high-income countries. In terms of assisted reproductive technology (ART) development, the high technological and economic level revealed no complete consistency with the large-scale assisted reproductive market, as the small number of ART institutions or IVF cycles annually in some developed countries (Singapore, the United Kingdom, and Canada).

Forty studies of infertility prevalence around ten countries were included (Additional file 1, Table S5). Three main research methods including cross-sectional, prospective study, and national estimates were applied to estimate infertility prevalence, causing small range variations of results. This can be seen in the example of China, where estimations of infertility prevalence range from 136 to 20% around 2011. Studies with the same method reported matching infertility prevalence in each country. For instance, two independent cross-sectional studies in 2001 in China concluded similar results (1713 and 1800%) despite inconsistent research scales. Those researches spanned 40 years, and the prevalence of infertility exhibited a rapid rise in recent years generally. It was confirmed that infertility prevalence in different age groups varied and increased with age by cohort study. For gender, the prevalence of male infertility was higher than that of female in the United Kingdom in 2010-2012. Although it was considered as severe as female infertility, only a few studies focused on estimates of male infertility prevalence.

Implementation and investment of infertility-related policies varied among included countries. Generally, more infertility-related policy items were in Stage III in high-income countries than lower-middle and upper-middle income countries (Fig. 2). We used CII to evaluate the overall progress of infertility-related policies implementation, and found CIIs increased with the national income level. In another word, high-income countries invested more in policies among ESSTR (Fig. 3).

Landscape of infertility-related policies development in ten countries

Elaboration of CIIs and specific infertility-related policy scores in ten countries. CII: Cumulative Investment Index

The governments had a certain tendency to promote infertility-related policies. Looking around ESSTR, economic support policies would be less prioritized compared with social security policies. From 1990 to 2020, a total of five countries implemented stronger policies in the economic support category while seven countries did that in social security category (Stage III). Three countries (China, India, and Japan) were still under Stage I with no relevant insurance coverage policies (Fig.2). CIIs of social security policies were higher than economic support policies in ten countries. Although reproductive health education and protection policy scores were extremely high in Japan, it was not universal in other countries. For this feature, ten countries were clustered into three policy orientation patterns. South Korea, Singapore, and Australia preferred infertility-related economic support policy, while France, the United Kingdom, and the United States were social security-oriented patterns. Other four countries including China, India, Japan and Canada were basically balanced between economic support and social security (Fig. 3).

Figure 2 also showed that the speed of implementing infertility-related policies varied across countries. On the one hand, China, India, Japan, the United Kingdom, Australia, and Canada followed a gradual-promotion pattern. On the other hand, South Korea, Singapore, France, and the United States had simultaneous-promotion patterns. Notably, countries with the same policy orientation pattern had different implementation paces. Singapore and Australia were both the economic support-oriented pattern while diverse in implementation paces.

The trends of age-standardized infertility prevalence change estimated by Sun H et al. from 1990 to 2017 (Additional file 1, Table S2) were approximately consistent with the results of forty studies. Infertility prevalence in India, France, and the United States increased both in males and females, and decreased changes were observed in Singapore, United Kingdom, and Australia. Besides, age-standardized male infertility prevalence dropped from 1990 to 2017 in China, Japan and Canada, and female infertility prevalence dropped in South Korea.

Our model enabled us to estimate the individual effect of each infertility-related policy, expressed as a value change on infertility prevalence. As Table 2 showed, model 1 displayed the potential positive effects of four policy categories while having no statistical significance. Adjusted with covariates of infertility baseline, first childbearing age, and per capita GDP, parental leave security policy might have a certain positive effect on alleviating infertility although not statistically significant ( = -079, p = 0096).

Figure 4 showed the effectiveness of policy orientation and implementation pace patterns that were presented as means of change values. On average, after adjusting the infertility baseline, the effect of economic support-oriented pattern (-295, [-1105, 516]) was relatively better than other patterns (220, [-277, 717]; -057, [-499, 385]). Nevertheless, the effectiveness of the gradual-promotion pattern (-135, [-285, 014]) was preferable for male infertility relief (Additional file 1, Table S6).

Comparison of effects of different patterns on male and female infertility prevalence, respectively

Under the default model settings, economic support policy had a significant positive role on female infertility improvement ( = -281, p = 0023). In detail, insurance coverage and economic reward policies were crucial ( = -319, p = 0021; = -672, p = 0033). With adjusted with covariates, effectiveness of infertility-related economic security policy, especially insurance coverage and economic reward policies, had been proved ( = -216, p = 0042; = -331, p = 0031; = -410, p = 0025) (Table 2).

Similar to male, the change in female infertility prevalence of the economic support-oriented countries (-542, [-1404, 320]) was larger than that of the other two types of countries (671, [-150, 1492]; 881, [137, 1625]). Gradual-promotion pattern and simultaneous-promotion pattern were similar on female infertility prevalence relief (433, [-432, 1298]; 328, [-747, 1403]) (Additional file 1, Table S6).

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Estimating the effects of policies on infertility prevalence worldwide - BMC Public Health - BMC Public Health

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