OBOA Journal

Europe is ageing [1]. How can we tackle its ageing crisis? One of the causes of this significant demographic transformation is low birth rates, largely influenced by socioeconomic conditions [2-4]. Factors related to housing policy, high cost of living, job insecurity but also the increasing number of women in the labour market and in leadership positions have been accompanied by a rise in the average age at the birth of the first child and a reduction in the number of births per woman [5-8]. For this reason, in European countries, demographics have been central to many public policies [9]. Hence, in recent decades, integrated policies have been implemented with the aim of increasing natality rates. They focus largely on assuring literacy and comprehensive sexuality education, family policy measures (birth allowances, monthly child benefits, access to childcare, and extended parental leave) and efforts to reduce gender inequalities in the workplace [10-12]. In countries where fertility rates have stabilised — such as Sweden and Denmark — policies focus predominantly on reconciling work and family life [13]. Their effectiveness is largely linked to continuity, ensuring economic and social stability and security for families [14,15]. The postponement of parenthood can be a source of stress and has an important impact on the relationship and the couple’s overall well-being [16]. It also has direct implications on reproductive potential: fecundity, which is the ability to reproduce, declines with age, especially for women [17]. In addition, advance pregnancy ages are associated with adverse maternal and perinatal outcomes.

A narrowing time frame to fulfil parental aspirations acts as a driver towards increased demand for assisted reproductive technologies (ART). Unfortunately, fertility treatment success rates also rapidly decline with age [18]. ART is an enabling technology for infertile patients and it can circumvent some reproductive barriers and model social pressures. It is therefore an integrating  part of cultural evolution of modern populations.

The reduced reproductive potential of populations associated with late parenthood addresses governments with a dual challenge: to create socioeconomic conditions that encourage earlier parenthood, and to ensure heathcare systems with equitable and timely access to ART.

Across countries, there are substancial differences in the proportion of babies borns as a result of ART. According to the most recent report from de European Society of Human Reproduction and Embriology, between 1.2% to 6.3% of european children were conceived through ART in 2019. Proportion of ART infants above 5% were reached in Belgium, the Czech Republic, Denmark, Estocina and Iceland.  Cross-country variations are partly due to the existence of different regulatory frameworks anf funding arrangements, which can deeply affect the accessibility and the affordability of services. These are probably the main ways policies can affect the utilization of ART. Governements may place regulatory barriers on ART treatments by limiting access only to women in specific types of relationships, or only to women under a certain age limit. Additionally, governements affect the affordability of treatment for patiensts through their funding arrangements. After subsidization has been taken into account, the cost of an IVF cycle has been estimated to range between 6% of total disposable income (Australia) up to 50% of total disposable income (United States). Age is usually a major requirement for reimbursement, with the age limit to receive public coverage for treatment often considerably lower than the age limit to access services.  Guaranteeing equity in line with the constitutional principle of universal care is an ongoing challenge. The barriers to truly equal access to fertility treatment across Europe are a concern of the European Parliament that calls on Member States to ensure access to ART for all individuals of reproductive age, to treat infertility as a public health issue, and to develop policies aimed at improving accessibility [16].

Despite the marked increased in the use of ART, specially among high-income countries, there is still much to know about its impact on fertility rates [19,20]. Nevertheless, today, 22 countries around the world provide full or partial public funding for ART.

It therefore seems clear that effective natality policies cannot be limited to providing financial support to families: they must also integrate strategic investments in ART centres. Thus, it is essential to consider the financial sustainability of health systems, also in a context of scarce resources, while guaranteeing the principle of universal health care. Public decision-making must always be informed, ensuring three fundamental pillars: efficiency, comprehensiveness, and outcomes. From this perspective, strengthening investment in ART as part of natality policies should include: (1) dedicated funding: the State, as a purchaser of healthcare, should set treatment prices and annual activity levels for each public centre. Capitation funding can promote sustainability and preventive health, but it shoud not substitute a specific funding line for this area; (2) laboratory investment: technological advances enable substantial gains in the number and success of ART cycles; (3) national data registry: unified information systems allow efficient cycle management and resource sharing between units; (4) national waiting list management, to insure equity, efficiency, and transparency in access to treatment; (5) the establishment of a Public Gamete Bank, to meet population needs, creating financial incentives for donation that benefit both donors and centres; (6) research promotion, as scientific development and advancement are essential to the sustainability and improvement of existing care techniques; (7) uniform referral criteria- equal access to fertility treatments across Europe should be imperative.

Given the available evidence and in a results-based evaluation framework, it is essential for governements to understand the reality of patients racing the sunset to achieve their reproductive goals. This implies assuming clear responsibilities and setting concrete priorities for integrating ART into natality strategies. Precise data is crucial: how many patients are awaiting treatment, how many are duplicated on waiting lists, how many lose eligibility due to age limits, and the actual cost per birth achieved through ART.

In summary, the main performance indicator of an ART centre — the birth of a healthy child — must be accompanied by public policies based on transparency, accountability, and efficiency. Consistent investment in public ART centres, combined with centralised resource management and uniform access criteria, is not only desirable: it is a necessary condition to ensure equity and fulfil the constitutional principle of universal health care.

References

1. Eurostat (2025) Population Structure and Ageing. Statistics Explained, European Union.
2. Rolden H J A, van Bodegom D, Westendorp R G J (2014) Variation in the costs of dying and the role of different health services, sociodemographic characteristics, and preceding health care expenses. Social Science & Medicine 120: 110–117.
3. Collins J, Page L (2019) The heritability of fertility makes world population stabilization unlikely in the foreseeable future. Evol Hum Behav, 40: 105–111.
4. Beaujouan E(2020) Latest-late fertility? Decline and resurgence of late parenthood across the low-fertility countries. Popul Dev Rev 46: 219–247.
5. McDonald PF (2007) Time for Action: Public Policies to revert low fertility. Pharmaceuticals, policy and law 9: 237-243.
6. Eurofound (2013). Women, Men and Working Conditions in Europe: A Report Based on the Fifth European Working Conditions Survey.
7. Eurostat (2020) Women are having their first child at an older age. Statistics Explained, European Union.
8. Eurostat (2025) Fertility Statistics. Statistics Explained, European Union.
9. World Health Organization. (2015). World report on ageing and health.
10. Fent T, Aparicio Diaz B, Prskawetz A (2013) Family policies in the context of low fertility and social structure. Demographic Research 29: 963–998.
11. Kaufmann, Franz-Xaver, Kuijsten, Anton Schulze, Hans-Joachim, et al. (2002) Family Life and Family Policies in Europe.
12. Gray E, Reimondos A, Lazzani E, Breuning R, Steinhauser R (2022) Impacts of policies on fertility rates (2022) Australian National University.
13. European Union. (2024) Report on equality between women and men in the EU. Luxembourg: Publications Office of the European Union, 2024.
14. European Coucil (2020) Gender Equality Strategy 2018-2023.
15. Wall K, Escobedo A (2013). Parental Leave policies, gender equity and family well being in Europe: A comparative perspective. In Family Well-Being: European Perspectives. Edited by Almudena Moreno Mínguez. Dordrecht: Springer pp 103–29;
16. Fertility Europe & European Parliamentary Forum for Sexual and Reproductive Rights. (2023). The imperative of equal access to fertility treatments across Europe.
17. García D, Brazal S, Rodríguez A, Prat A, Vassena R (2018). Knowledge of age-related fertility decline in women: A systematic review. Eur J Obstet Gynecol Reprod Biol, 230:109-118.
18. Tan T, Lau S, Loh S, Tan H (2014) Female ageing and reproductive outcome in assisted reproduction cycles. Singapore Medical Journal 55: 305.
19. Hoorens S, Gallo F, Cave J, Grant J C (2007) Can assisted reproductive technologies help to offset population ageing? An assessment of the demographic and economic impact of ART in Denmar k and UK. Human Reproduction, 2: 2471-2475.
20. Sobotka T (2017) Post-transitional fertility: The role of childbearing postponement in fuelling the shift to low and unstable fertility levels. Journal of Biosocial Science S20-S45.
21. Keane M, Long J, O´Nolan G, Faragher L (2017) Assisted reproductive technologies: International approaches to public funding mechanisms and criteria – an evidence review. Health Research Board, Dublin.
22. Bardach E (2011) A practical guide for policy analysis: The eightfold path to more effective problem solving (4th ed.).
23. Bresciani M J (2011) Identifying barriers in implementing outcomesbased assessment program review: A grounded theory analysis. Research & Practice in Assessment 6: 20-35.
24. Chambers G, Sullivan E A, Ishihara O, Chapman M G, Adamson G D (2009). The economic impact of assisted reproductive technology: a review of selected developed countries. Fertility and Sterility, 91: 22812294.
25. Eydal GB, Rostgaard T, Hiilamo H (2018) Family policies in the Nordic countries: aiming at equality.
26. European Parliament P9_TA (2021). Report on Sexual and reproductive health and rights in the EU, in the frame of women’s health.
27. Osman SG, Seher KA (2025) Adverse Perinatal Outcomes at Advanced Pregnancy Ages: A Single Center Study. Clin Exp Obstet Gynecol 52: 31319.
28. Smeenk J, Wyns C, De Geyter C, Kupka M, Bergh C, et al. (2023) ART in Europe, 2019: results generated from European registries by ESHRE. (2023). Hum Reprod 38: 2321-2338.
29. World Health Organization (‎2010) ‎ The world health report: health systems financing: the path to universal coverage. World Health Organization.
30. World Health Organization (2023) Population health management in primary health care: A proactive approach to improve health and wellbeing: Primary health care policy paper series.