A landmark international study has found that halving patient out-of-pocket costs was associated with a 2.67-fold increase in births achieved through assisted reproductive technology (ART).
Presented today at the 42nd Annual Meeting of the European Society of Human Reproduction and Embryology (ESHRE), the study analysed ART registry, economic and demographic data from 22 countries and regions between 2021 and 2023, representing more than 95% of global ART activity, to assess international variations in affordability.
To compare countries/regions consistently, researchers developed a ‘cost-to-baby’ affordability metric estimating the cost required to achieve one live birth through assisted reproductive technology (ART).
Gross cost-to-baby was calculated using average per-cycle treatment costs, including embryo transfer, preimplantation genetic testing where used, and medications, alongside the age-weighted number of cycles required to achieve a live birth. Net out-of-pocket cost-to-baby then accounted for reimbursement programs, subsidies and tax benefits applicable to each region or country. Both gross and net costs were expressed as a percentage of median after-tax household income.
The results revealed significant international differences in affordability. Gross cost-to-baby varied more than 12-fold across countries and regions, ranging from 66% of median household income in Israel to 833% in Africa (excluding Egypt, Tunisia and South Africa), while net out-of-pocket cost-to-baby ranged from 13% in Israel to 825% in Africa.
Countries with gross cost-to-baby below 100% and net out-of-pocket cost-to-baby below 50% of median household income consistently achieved the highest levels of ART utilization, including South Korea (11.8% of births via ART), Spain (11.7%) and Japan (9.3%).
Conversely, in countries and regions such as Brazil, India and South-east Asia, where costs approach two or three times the annual median household income, the proportion of ART births plummeted to between 0.2% and 0.4%.
While it is already understood that cost influences patient decisions, it was genuinely striking to see how much of the variation in access between countries and regions could be explained by a single affordability metric. Our models explained between 77% and 84% of the variation in ART utilization.”
Dr. Stephanie Kuku, lead author, Conceivable Life Sciences
“We also found that the relationship followed a power-law pattern rather than a simple linear one. In practical terms, this means that reducing costs could produce disproportionately large increases in utilization, with the greatest gains seen in countries and regions where affordability barriers are highest,” she added.
Looking ahead, Dr Kuku said that the findings provide a clear and measurable benchmark for improving access to fertility treatment. “Our analysis is fundamentally patient-centric: it asks what a typical household actually earns and what they would actually have to spend to have a baby through ART. The 50% threshold isn’t a theoretical construct; it’s a grounded observation of what top-performing nations have achieved.”
While policies to improve access to fertility care will depend on regional healthcare systems and economic contexts, Dr Kuku said the findings pointed to several clear areas for action. “Perhaps the most straightforward answer is that insurance mandates and public funding programs need to cover multiple complete treatment cycles, not just one,” she said. “Our entire analysis is built around cost-to-baby, not cost-per-cycle, because that is what matters to patients. The data are unambiguous that countries funding multiple cycles achieve higher utilisation.”
Dr Kuku also highlighted the importance of tax policy, pointing to South Korea’s 30% income tax credit for fertility treatment, alongside workforce licensing reform that could expand clinical capacity and reduce gross treatment costs. She added that industry also has a role to play in improving affordability through workflow optimisation, standardisation and automation.
Discussing the next steps for research, Dr Kuku said, “Chronically underserved communities, whether defined by race, geography or socioeconomic status, are not captured in this analysis. Future work will focus on how to serve those who need ART, not just describe who can currently access it.”
“However, we now have a clear starting point. Affordability is a measurable constraint on access and the data show where some of the greatest opportunities to improve access may exist,” Dr Kuku concluded.
Commenting on the study’s findings, Professor Dr Anis Feki, Chair of ESHRE, said: “This study puts numbers behind what many patients experience: affordability is not a secondary issue, but a major determinant of access to fertility care. While solutions must be adapted to each healthcare system, the data offer a clear and hopeful message: policies that reduce the real cost to patients can meaningfully improve access to ART.”
The study abstract will be published today in Human Reproduction, one of the world’s leading reproductive medicine journals.
