In ageing societies with low birth rates in Europe and beyond and the continued postponement of childbearing towards older ages, (in)fertility has become both a pressing social and political issue in recent decades. In this context, medically assisted reproduction (MAR), which includes a range of treatments such as ovulation induction, artificial insemination and assisted reproductive technologies (e.g. IVF and ICSI), has become increasingly available and utilized. As a consequence, MAR has enjoyed growing research interest from the medical sciences since the late 1970s[1] and from social science disciplines in the following decades.
However, as the number of children conceived through MAR and the number of adults undergoing these treatments continues to grow, many questions remain about access to MAR and the consequences of its use. In response, the three-day “International Symposium on Medically Assisted Reproduction: Health, Social and Demographic Aspects” at the German-Italian Centre for the European Dialogue in Villa Vigoni, Italy, from 16 to 18 September 2024, aimed to discuss a wide range of issues related to MAR, fertility levels, health, rights, and childlessness in Europe and beyond. Co-organised by Alice Goisis, Maria Palma Carvajal, Alina Pelikh (all three from University College London), and Jenny Chanfreau (University of Sussex), the event brought together eminent researchers in the field from a range of disciplines such as demography, sociology, psychology, anthropology, medicine and law.
The symposium was opened by two demographers, Francesco Billari (Bocconi University, Milan), who reflected on the changing meanings of “becoming a parent”, and Alice Goisis, who gave an overview of her recently completed ERC project on the impact of MAR on children, adults, and families.[2] Three keynote speeches on the role of MAR for men (Lone Schmidt, University of Copenhagen) and for same-sex couples (Diederik Boertien, Centre D’Estudis Demogràfics, Barcelona) and on the interplay between social processes, biology, and low fertility (Mikko Myrskylä, Max Planck Institute for Demographic Research, Rostock), set the scene for the five panels of the event:
1 – Late Fertility, Fecundity & Medically Assisted Reproduction
2 – Cultural, Social and Normative Challenges
3 – Social Disparities
4 – Non-normative Families
5 – Family Dynamics
These panels were further complemented by an interdisciplinary poster session. Some of the key findings of the symposium are presented below.
Interdisciplinary Understanding of MAR as Medical Treatment and Social Practice
Methodology and terminology play a crucial role in how medical treatments for low fertility and infertility are perceived, researched, and discussed.[3] To include a large variety of perspectives from diverse sets of data and surveys, the term medically assisted reproduction was used throughout the conference in its broadest medical sense, reflecting the current understanding of MAR as “various interventions, procedures, surgeries and technologies to treat different forms of fertility impairment and infertility.”[4] This includes, but is not limited to, assisted reproductive technologies (ART) such as in vitro fertilisation (IVF) and oocyte (egg) donation, as well as other medical treatments.
Notably, the symposium also sought to move beyond a purely medical understanding of MAR. As Alice Goisis pointed out, MAR “is also a social process highly embedded into [sic] social structures.” Positioning MAR as a set of social practices opened the door to an interdisciplinary discussion of MAR and its social implications, drawing attention to social inequalities and geographical differences in access to reproductive treatments and to the changing concepts of parenthood, motherhood, and family.
Challenges in Data Availability, Quality, and Comparability
In this context, it is important to note that the symposium’s presenters and participants constantly pointed out the sometimes significant discrepancies and gaps in the availability and comparability of the data and surveys they used to study MAR and fertility. Most of these datasets have been produced in regional and national contexts such as the Nordic registry data, the U.K. Human Fertilisation and Embryology Authority (HFEA) Register, or the German longitudinal Panel Analysis of Intimate Relationships and Family Dynamics (PAIRFAM). Depending on the comparability of these data collections, these geographical boundaries have complicated cross-border understanding of the issue at hand.
In addition, specific time periods, background information, terms and (types of) questions, and the number of participants in the data collections and surveys further influenced the information that they could provide, and whether they could be linked to other data and studies. For example, although the U.K. HFEA Register is one of the longest-running databases of its kind (since 1991), it provides little information about the educational background of patients, nor about their partners. This limits the extent to which researchers can explore the (in)equalities associated with different levels of education and how they might study different family conceptions. Similarly, participants highlighted that questions on gender identity have only recently been included in some surveys and that national registration data often do not classify the sex of the second parent, making it difficult to explore the relationship between non-normative families, fertility and MAR. In addition, some surveys resulted in incomplete or inconsistent responses, such as the German demographic family survey FReDA, where respondents claimed not to have consulted a doctor or not to have a specific illness, but gave a medical diagnosis for their infertility.
Geographical Differences and Social Inequalities in Access to MAR
Many presentations explored the impact of social inequalities on the use of assisted reproductive treatments, mostly focusing on ethnic, educational, socio-economic, and age-related differences in access to MAR. A recurring theme throughout the conference was the paradox that women with higher levels of education are often less well informed about the risks of infertility in later life, but tend to have better access to MAR due to their often higher socio-economic status. For example, Lone Schmidt noted large social inequalities across all cycles in Denmark, despite overall generous access to MAR, pointing to the impact of different travel distances to fertility clinics, which were easier to overcome for people with higher incomes and mobility. Against this backdrop, demographer Kazuyo Machiyama (Human Fertilisation and Embryology Authority & London School of Hygiene and Tropical Medicine) presented a HFEA report on ethnic diversity in fertility treatment in the U.K. to show that regional variations in financial support for MAR exacerbate ethnic inequalities, with a dramatic fall in NHS-funded IVF cycles among Black patients. Demographer and migration scholar Nadja Milewski (Federal Institute for Population Research, Wiesbaden) used the German FReDA survey to show that the rate of perceived infertility was much higher among migrants and less educated respondents, often from lower socio-economic backgrounds; as around 90% of them sought medical advice, she suggested that this discrepancy may be more related to processes of marginalisation in reproductive health care.
Another topic was the importance of legislation for access to MAR. Using the Czechian National Register of Assisted Reproduction (NRAR), (geo)demographer Anna Št'astná (Charles University, Prague) showed that the country’s liberal laws on reproductive care have resulted in one of the highest rates of ART use in Europe and a broad number of public and private clinics offering MAR treatment, attracting large numbers of “reproductive tourists” from Europe and beyond. The possibility for women to undergo up to four IVF cycles at a relatively advanced age, combined with high rates of young egg donors and donor anonymity make the Czech Republic particularly attractive for cross-border reproductive care. Conversely, several presenters argued that the legal possibility of reciprocal IVF treatment in Spain, also known as the reception of oocytes from partner (ROPA) method, attracts a large number of female couples because it allows both partners to be physically involved in the pregnancy process.
Largely missing from these nuanced discussions of MAR practices were reflections on the role of ethics, religious beliefs and market-driven interests and mechanisms. In her poster on attitudes towards MAR in Hungary, for example, sociologist Ivett Szalma highlighted that religious people are less likely to accept reproductive treatments. However, despite the continued influence of Catholicism and other religions on matters related to the family and intimate life in social and political discourse across Europe,[5] this issue was not otherwise discussed. And while participants suggested responding to financial limitations in access to MAR by proposing to expand access through public health care systems, the complex intersection of MAR with neoliberal discourse and its exclusionary logic of commodification,[6] as manifested in the concept of “reproductive tourism”, was barely addressed. In the context of increasingly socio-culturally and economically polarised societies, such perspectives could further contribute to a better understanding of inequalities in access to MAR.
Queering Concepts of Parenthood, Motherhood, and Family
Despite persistent social and legal barriers to MAR for same-sex couples in many countries, their access to reproductive treatments has increased in recent years. In combination with the legalisation of adoption and same-sex marriage in primarily Western countries, this development has been complicating heteronormative notions of parenthood, motherhood, and family, as a number of speakers from various disciplines demonstrated.
For example, social psychologist Susie Bower-Brown (University College London) argued that the use of reciprocal IVF by female couples “disrupts” the heteronormative concept of motherhood as both women strategically seek biological kinship as an integral form of family perception. They showed that this method of reproduction allows for creative, complex and potentially conflicting conceptions of motherhood, as both women see themselves as mothers, but within a legal framework that recognises the birth mother as the “real” mother, the genetic mother who donated her egg is not recognised. Legal scholar Ruth Zafran (Reichman University, Herzliya) further discussed this issue of legal recognition of non-normative parents and its implications for diversifying family models, which are traditionally heterosexual and marital in most countries. Arguing that the lack of legal recognition of the non-biological partner makes it more difficult to care for the child in the event of death or separation and may also risk psychological consequences, she proposed a shift away from biological kinship, heterosexuality, and marital status towards a legal recognition of multiparental models based on consent.
Other issues were psychological and health implications of queer parenthood. While sociologist Robert Pralat (University of Cambridge) reflected on the contingent nature of queer parenthood desires and imaginations in the UK due to legal barriers and the need to undergo fertilisation or adoption procedures to become a parent, he argued that the “cultural literacy of queer parenthood” has nonetheless increased significantly since the 2000s. In a poster discussion, psychologist Catherine Jones (King's College London) showed that donor-conceived young adults in the UK experience poorer positive wellbeing than their non-donor conceived peers due to greater identity confusion, and argued for better support for them.
Given the novelty of these developments, participants suggested that these diverse issues should be followed up in longitudinal studies that further explore shared motherhood after birth, the socio-emotional attachment of children to same-sex parents, and the impact of donor conception on child wellbeing. Transgender perspectives were not discussed in this context.
Policy-Making Implications of MAR to Address (In)Fertility in Europe and Beyond
Given the urgency of (in)fertility as a social and political challenge at a global level, the discussions also reflected on the importance of policy-making in relation to MAR. Although not the focus of this symposium, several participants highlighted the role of policies to support MAR as a way to address pregnancy postponement and low birth rates in Europe and beyond.
For example, demographer Ester Lazzari’s (University of Vienna) case study on later and lower marital fertility in Japan reflected on the extent to which national policies promoted MAR as a tool to augment the country’s fertility rate. Although it was debated whether MAR could be seen as a “unique solution”, as it was not a universal response to pregnancy postponement, Lazzari argued that the legal and financial support for MAR through specific policies offered a complementary way to increase marital fertility. In a discussion of the often unknown risks of infertility at older ages among Italian women, in turn, social demographer Agnese Vitali (University of Trento) suggested that perhaps some of the public funding for MAR should be used to increase fertility awareness through the public health care system.
Similarly, Francesco Billari emphasised the importance of policies to enhance financial support for low-income individuals and couples seeking reproductive treatment to slow down pregnancy postponement and increase fertility across Europe. Central to his argument was the need to find long-term solutions to promote access to MAR that can outlast potential changes in governments and policies and provide stable living conditions. In this context, Billari suggested that the convergence of family policies across European countries might be a valuable way forward, although he acknowledged that there is currently little knowledge about the feasibility of such an approach.
Meanwhile, participants also discussed the role of policies and political narratives on social perceptions and accessibility of MAR for same-sex couples. Sociologist Diederick Boertien, for example, showed that the realization of queer parenthood in Western countries such as the US, Australia, the UK, and Spain was highly dependent on political decisions facilitating legal access and financial support. In her case study on the parenthood intentions of same-sex couples in Italy, in turn, sociologist Rebecca Soldo (University of Trento) showed the extent to which contemporary political discourse has increased legal, economic, and social barriers for queer individuals and couples. In combination with the restrictive regulations of MAR, the country’s strong political emphasis on traditional family values and heterosexuality increased fears of the social unacceptability of queer parenthood. However, despite the limiting effects on parental desires, Soldo argued, same-sex couples with parenthood intentions also effectively created an alternative social support network outside of traditional family structures, suggesting a “much more progressive” Italian society than the country’s restrictive laws and policies.
As population decline affects Europe and other countries in unprecedented ways, these perspectives invite further research and discussion on the political, sociocultural, financial, and legal possibilities for promoting access to MAR at the EU level and beyond. This includes the question of whether access to MAR can and should be defined as a basic human right for all individuals regardless of sexual orientation and relationship status, which could mitigate the exclusionary mechanisms of national and regional policies and top-down pronatalist discourses.
However, the diversity of regional and national legal and socio-political approaches to MAR discussed at the symposium suggests that such a generalised understanding and regulation is currently unrealistic. Rather, the following policy recommendations may be helpful in improving access to reproductive health care in Europe as an important means of increasing fertility in the coming years:
- To address the multidimensionality and complexity of the issue, policy-makers should encourage interdisciplinary exchanges between medical and psychological researchers and practitioners, social scientists, legal scholars, ethicists, and religious scholars.
- As the European Society of Human Reproduction and Embryology (ESHRE) argues, policy-makers should recognise infertility as an important health issue and ensure that both the general public and governments are better informed.[7] In addition to raising awareness of age-related fertility decline through public health systems, policy-makers should ensure that individuals seeking MAR have the best possible access to information, financial and administrative support.
- This approach should also extend to a shift in the understanding of MAR as an individual choice and personal freedom. Irrespective of the libertarian, pronatalist or economic motivations for embracing MAR, governments should see MAR as an opportunity to increase individual fertility and provide coherent support systems, rather than encouraging or forcing people to have children while restricting access to certain groups.
- Rather than interfering with individual fertility choices, policy-makers need to ensure that biological and non-biological parents have the same rights and responsibilities as parents, regardless of the method of conception. This includes contributing to a non-stigmatising social discourse on the issue in order to reduce the risk of mental health problems among children conceived through MAR.
- The EU should support the creation of a European database with comparative information on regional and national legislation, administrative procedures and costs, which could greatly facilitate cross-border access to MAR. Such a database could also enhance European research on the topic and complement ongoing EU-funded projects such as ESHRE’s pan-European registry project “European Monitoring of Medically Assisted Reproduction” (2023-2025)[8], which reflect and respond to the relevance of the topic for contemporary European societies.
Speakers
Anna Barbuscia (University of the Basque Country)
Eva Beaujouan (University of Vienna)
Francesco Billari (Bocconi University, Milan)
Diederik Boertien (Centre D’Estudis Demogràfics, Barcelona)
Susie Bower-Brown (University College London)
Marco Cozzani (University of Florence)
Alessandro Di Nallo (Max Planck Institute for Demographic Research, Rostock)
Alice Goisis (University College London)
Ester Lazzari (University of Vienna)
D. Susie Lee (Max Planck Institute for Demographic Research, Rostock)
Kazuyo Machiyama (Human Fertilisation and Embryology Authority & London School of Hygiene and Tropical Medicine)
Nadja Milewski (Federal Institute for Population Research (BiB), Wiesbaden)
Mikko Myrskylä (Max Planck Institute for Demographic Research, Rostock)
Jasmine Passet-Wittig (Federal Institute for Population Research (BiB), Wiesbaden)
Alina Pelikh (University College London)
Robert Pralat (University of Cambridge)
Lone Schmidt (University of Kopenhagen)
Christine Schnor (Université Catholique de Louvain)
Rebecca Soldo (University of Trento)
Anna Št'astná (Research Institute for Labour and Social Affairs, Prague)
Heini Väisänen (Institut National d’Études Démographiques, Aubervilliers)
Agnese Vitali (University of Trento)
Sophie Zadeh (Sussex University, Brighton)
Ruth Zafran (Reichman University, Herzliya)
Poster Session
Evgeniya Borisova (Centre D’Estudis Demogràfics, Barcelona)
Chiara Fusco (University of Milano-Bicocca)
Rolf Granholm (University of Groningen)
Catherine Jones (King’s College London)
Selin Köksal (London School of Hygiene & Tropical Medicine)
Denise Musni (Université Catholique de Louvain)
Ivett Szalma (Centre for Social Sciences, Budapest)
Heike Trappe (University of Rostock)
Agnese Vitali (University of Trento)
References
[1] Fasouliotis, Sozos J., and Schenker, Joseph G. (1999). A Historical Perspective of the Clinical Evolution of the Assisted Reproductive Technologies, Gynecological Endocrinology, 13(6), 420-440.
[2] Centre for Longitudinal Studies (undated). Medically Assisted Reproduction: The Effects on Children, Adults and Families. https://cls.ucl.ac.uk/cls_research/medically-assisted-reproduction-the-effects-on-children-adults-and-families/ (accessed September 24, 2024).
[3] Passet-Wittig, Jasmin, and Bujard, Martin (2021). Medically Assisted Reproduction in Developed Countries: Overview and Societal Challenges. In Norbert F. Schneider, and Michaela Kreyenfeld (Eds.), Research Handbook on the Sociology of the Family, Cheltenham, UK: Edward Elgar Publishing, 418.
[4] Zegers-Hochschild, Fernando, et al. (2017). The International Glossary on Infertility and Fertility Care, 2017, Human Reproduction, 32(9), 1796.
[5] Pérez Agote, Alfonso, and Dobbelaere, Karel (2015). The Intimate - Polity and the Catholic Church: Laws about Life, Death and the Family in So-Called Catholic Countries. Leuven: Leuven University Press.
[6] Hoppania, Hanna-Kaisa, and Tiina Vaittinen (2015). A Household Full of Bodies: Neoliberalism, Care and 'the Political'. Global Society, 29(1), 70-88.
[7] European Society of Human Reproduction and Embryology (undated). Advocacy and Policy Engagement. https://www.eshre.eu/Europe (accessed September 30, 2024).
[8] European Society of Human Reproduction and Embryology (undated). EU-MAR – European Monitoring of Medically Assisted Reproduction. https://www.eshre.eu/Data-collection-and-research/EuMAR (accessed September 30, 2024).