Global socioeconomic and cultural factors affecting the number of embryos transferredFernando Zegers-Hochschild, MD

ICMART Symposium: Global socioeconomic, cultural and regulatory differences that affect the number of embryos transferred ASRM, San Francisco 2008

*Regional contribution of ART cycles to the World Report (2004)* Corresponds to aspiration cycles in IVF, ICSI & GIFT and transfer cycles in FET & OD. N = 764,628Middle East 6.5% Latin America 3.0% Australia & New Zealand 5.2%ICMART, World Report 2004.

fzegers - cambiar color y orientacion de paises

*1st Hypothesis

Socioeconomic factors influence access to ART

Number of ART Cycles according to Public/Private Health Expenditure (2004)United Nations Statistics Division

GDP per capita (dollars) (2004-2006)Country (Total Health Exp. as % of GDP) (2004)Public (%) Private(%)ART Cycles /1 000 000 hab. (2004)

29,000 - 36,000France (11.2%)79.920.11154Sweden (9.2%)81.718.31433Denmark (9.1%)84.115.92131UK (8.2%)87.112.9660Japan (8.2%) 82.217.8924Australia (8.8%)67.033.01861

39,000 - 44,000USA (15.2%)45.154.9498

5,500 - 13,000Argentina (10.2%)43.956.1118Brazil (7.9%)44.155.954Chile (5.4%)51.448.663Mexico (6.4%)45.554.533Peru (4.3%)49.051.036

23,000 - 25,000Israel (7.8%) 66.533.516243

4,000 - 4,600Egypt (8.2%)42.657.3399

fzegers - Poner australia y japon al final del primer grupo

*Out-of-pocket expenditure as % of Private health expenditure (2004)United Nations Statistics Division

*Is ART cycles/million Inhabitants a good marker of availability?

It does not consider the age distribution of the population and the willingness to become pregnantAccess

*1975-91995-92001-51965-9Births1750015000125001000075005000250020253035404550Age of the female partner (years)Number of births and age of female Spontaneous Pregnancy - The NetherlandsCentral Statistics Bureau of the NetherlandsN=1000 births / period

*Number of births and age of FemaleSpontaneous pregnancy - ChileAge of FemaleNumber of birthsInstituto Nacional de Estadsticas (INE)N=1000 births / year

Grfico2

395513925735143

663265714154032

659046381253401

524855067549906

277732947128810

673774828604

1997

2000

2005

Hoja1

199719972000200020052005

15-193955115.2%3925715.8%3514314.8%

20-246632625.5%5714123.0%5403222.8%

25-296590425.4%6381225.6%5340122.5%

30-345248520.2%5067520.4%4990621.1%

35-392777310.7%2947111.8%2881012.2%

>40 o mas67372.6%74823.0%86043.6%

259959248893236831

Hoja1

000

000

000

000

000

000

1997

2000

2005

Hoja2

Hoja3

*Estimated Need for ART Cyclesx 100%

*Access to ART* (women aged 25-40)10078.950.556.040.923.716.421.38.46.62.42.10.90.8(*) ICMART, World Report

*2nd Hypothesis

Demographic factors influence access to ART

Access to ART (2004) according to:age of female population and fertility rateUS Census Bureau/International Data Base (IDB) / UN Statistics Division

Country/RegionFemale median age (2006)Total fertility (children per woman) (2000-2005)Population Annual Growth Rate (2004)Access (cycles per million) (2004)

France39.71.880.61154Sweden41.51.670.41433Denmark40.21.760.32131UK39.81.700.5660Japan44.31.290.1924

USA37.42.041.0498

Argentina29.92.351.0118Brazil27.72.351.454Chile30.82.001.163Mexico25.52.400.833Peru 24.82.701.236

Egypt23.82.911.8399Israel29.03.171.816243

*Socioeconomic and demographic factors determine access to ART HIGH median age of the female populationCountries with LOW median age of the female population LOW population growth HIGH population growthSOCIETY needs access to ARTINDIVIDUAL needs access to ART

*

Is fertility a national priority?

How does it compete with other health issues?

*Under-5 mortality rateUS Census Bureau/International Data Base (IDB) / Nations Statistics Division

*

Fertility rate becomes a priority once other vital health issues have been solved

*3rd Hypothesis

Cultural and religious factors influence access to ART

*Cultural and religious factors influence access to ART Religious authorityPrinciplesEvidence and consequence Catholic / IslamicProtestant / JewishMoral decisions

*Socioeconomic, demographic & religious factors influence access to ART

Does access to ART determine HOW it is performed?

*

Number of embryos transferred and multiplicity

Proportion of ICSI vs IVF

Embryo Cryopreservation

*Number of embryos transferred per region, IVF & ICSI (2004) x= 3.10x= 2.2 x= 2.9 ICMART, World Report 2004.

*Factors influencing the number of transferred embryos (2004)

Source of Funding Regulatory body CountryMean NumberEmbryos Transf. (2004)High order Multiple births (2004) Twin (%) Triplet +(%) Public NationalDenmark1.821.00.4France2.122.00.5Sweden1.35.6-UK2.023.90.3

Private NoneArgentina2.618.13.5Brazil3.224.56.2Chile2.629.83.8Mexico3.022.24.5Peru2.821.14.2 Private NoneEgypt3.026.79.3

Private NoneUSA2.730.41.1

*ConclusionCultural, Socio-economic and demographic factors influence: who has access to ART, when they have access to ART, and how ART is performed.

*******A que corresponden los ejes?*****Female median age: Age that divides the population in two parts of equal size, that is, there are as many persons with ages above the median as there are with ages below the median.

Total Fertility rate (per women): A basic indicator of the level of fertility, calculated by summing age-specific birth rates over all reproductive ages. It may be interpreted as the expected number of children a women who survives to the end of the reproductive age span will have during her lifetime if she experiences the given age-specific rates.

Population annual growth rate: Annual growth rates are rates expressed over the corresponding period of the previous year. In the tables, the annual growth rates are expressed as Yt/Yt-1.

***Under-5 mortality rate (probability of dying by age 5 per 1000 live births) both sexes:Probability of dying between birth and exact age 5. It is expressed as deaths per 1,000 births

Crude birth rate: Number of births over a given period divided by the person-years lived by the population over that period. It is expressed as number of births per 1,000 population.********