I started my career working with sperm in the laboratory and making babies under the microscope. Working in the field of infertility in 2012 as a junior andrologist in Quebec, Canada, it seemed like a niche industry. where individuals struggling with fertility challenges sought assistance from clinics like ours, hoping for successful outcomes. The landscape changed dramatically in 2010 when the Quebec government was one of the first in the world to introduce free in vitro fertilisation (IVF) for all residents through the provincial health plan.

The impact was profound. Our clinic experienced a surge in demand, reflecting the pent-up need for accessible fertility treatments. Prior to the programme's launch, approximately 1,800 IVF cycles were performed in Quebec in 2009. By 2013, this figure nearly quadrupled, to 7,000. However, the free IVF programme came to an end in 2015, as policymakers deemed it financially unsustainable and overly permissive, with the health minister at the time calling it an “open bar”. This transition showed us the pressing need for a deeper understanding of the funding dynamics surrounding assisted reproductive technology (ART).

Over my five years in andrology and embryology working in fertility clinics, I actively participated in numerous conferences and congresses to learn about new research and connect with other professionals. These conferences bring together clinicians and scientists who are involved in the management of fertility, and their aim is to promote awareness and improve infertility-related services across the world.

More than a decade later, I am still involved in reproductive medicine, but from another perspective—research and policy with Economist Impact. And the world is looking quite different than it did. A 2023 report by the World Health Organisation estimated that around 17.5% of the adult population—roughly one in six worldwide—now experience infertility, showing the urgent need to increase access to affordable, high-quality fertility care.

After a few years away from the conferences, I recently attended ASPIRE, the Asia-Pacific Initiative on Reproduction. There was a new theme which took centre-stage and which had never been a big topic before: global falling fertility rates, a decline in the average number of children being born. I attended the congress to present a recent Economist Impact report, a Fertility Toolkit for the APAC region, supported by Merck. This toolkit serves as a guiding resource for policymakers, addressing social and economic challenges associated with falling birth rates in APAC countries, and proposing effective policy measures to mitigate this decline. It was through conducting research for this toolkit that I learned about the mounting problems caused by falling fertility rates, especially in the Asia-Pacific region, where countries have some of the lowest birth rates in the world (South Korea, Japan and Singapore). Economist Impact were not the only ones addressing this theme.

In a room filled with ART experts, the keynote address that opened the congress had a heaviness in stark contrast to the usual aspirational talks of the value of assisted reproduction. Instead, the keynote sounded the alarm about the fall of fertility rates and the dire consequences that may accompany this. The message was clear: if we do not recognise the situation and take action, a decline in population numbers is likely, accompanied by a major demographic shift with far-reaching implications. At the most extreme, some APAC countries (including many represented at this congress) may see their population levels reduced by about half in the coming decades, due to slowing fertility rates. We were presented with numbers and graphs which showed the undeniable trends. And what does this mean? As population growth slows it will become harder for countries to maintain their economic growth, as they are faced with a declining workforce and rapidly ageing populations, who also depend more on public services. While richer countries currently have around three people between 20 and 64 years old for everyone over 65, by 2050 they will have fewer than two.

The total fertility rate (TFR)—the average number of children a woman is expected to have in her lifetime—has been steadily decreasing, and globally the largest 15 countries by GDP all have a fertility rate below 2.1, which is known as the “replacement rate”. When the TFR is at the replacement rate, a population size will remain stable, and if it falls below then the population will shrink. There are many reasons for this decline, including:

• Industrialisation and urbanisation;
• Later age of marriage and childbearing;
• The rising cost associated with starting and raising a family; and
• Changing personal aspirations, particularly among women of reproductive age delaying or deciding against motherhood to pursue lifestyle or career paths.

Often cited as a solution, the IVF industry is in many ways also a culprit, as it allows infertility-linked genes to pass to the next generation, and up to 40% of cases of infertility are believed to be associated with genetic causes. However, this inconvenient fact is an unpopular one at this conference: “IVF should not be used as a default infertility treatment”—this is not what a room full of ART specialists want to hear!

So what are the solutions?

Since cost and other priorities are often cited as primary reasons why families have fewer children, many policy responses exist to help with these barriers including parental support in the workplace, which may encourage parents to have children earlier without sacrificing career progression. Baby-bonus incentive payments from governments (a cash transfer to the parents at the time of birth) could help reduce financial burdens, as could income-tax reforms to ease cost-of-living pressures on working people of reproductive age and the provision of affordable housing. The private sector is also getting involved; in Korea, one company is currently awarding male and female employees a $75,000 payout each time they have a baby. Child care is often lacking, and increasing availability and affordability of quality child care is one of the most effective solutions. For infertile couples whose only option is ART, this is often unaffordable or unavailable, and subsidies and funding from governments could help alleviate involuntary childlessness. Most of these policies have been shown to have at least some impact on fertility rates, as well as being cost-efficient, as discussed in our Fertility Toolkit.

The problem and the barriers are well understood, and possible solutions are known. Which countries are doing things right? France stands out from many European countries because of its relatively high and stable fertility. Its TFR stabilised in the mid-1970s and has since remained constant at around 1.8-2.0, compared with 1.53 in the rest of the EU. This is partly thanks to France having very high public spending on families with children as a percentage of GDP. This includes parental leave (a working parent is entitled to take parental leave for up to three years after the birth of a child and to return to their same or similar position), family allowance (received by all families with two or more children) and good child-care services (free public nursery schooling is provided for all children aged three to six). Many studies (including Economist Impact’s own policy Toolkit) suggest that policies that provide financial support to families or provide paid leave at the time of childbirth have a positive impact on fertility, with the provision of child-care services being the most effective in encouraging families to have children and women to remain in the workforce. These strong, long-term policies may be one of the reasons why France has maintained its stable fertility rate while other countries have struggled.

Funding of fertility treatment is also being explored in more and more countries as a potential solution to help raise birth rates and alleviate involuntary childlessness. South Korea is one of the most generous; as of 2019, funding is available for up to seven fresh embryo transfers, five frozen embryo transfers and five artificial insemination procedures, and there is no age limit. In Taiwan, a large subsidy (approximately 50% of the cost of a treatment cycle) is available depending on household income, and this can be claimed for between three and six cycles depending on age. In the last two years these subsidies have already assisted in more than 15,000 births, according to Taiwan’s Health Promotion Administration.

Newer technology such as egg freezing is also being explored as a potential “solution” for preserving fertility, allowing women to delay childbearing for non-medical reasons. As it becomes more effective, accepted, normalised and safe, some countries may start to see it as an answer to demographic decline in situations where delaying motherhood is a key factor in TFR decline. However, it is important to remember that medical technology does not present the ideal solution to what is, at heart, a social problem.

To help countries prepare for the unavoidable demographic transition that is occurring (particularly in the APAC region) and to help slow the population decline, we must first understand the driving forces behind the rapidly falling fertility rates in the different countries and markets, to address these at a socioeconomic level. Declining birth rates and falling fertility is becoming a key political and economic issue, and will probably become a recurring theme at reproduction and population conferences in the future.

Quebec has recently reintroduced free IVF treatment, though only for one cycle. Eligibility requires that patients have a medical note stating that they cannot conceive as a couple or on their own. The “open bar” has ended, but this should hopefully be more economically sustainable and enable those in real need to be able access the necessary treatments and to have the family they desire.