Declining global fertility rates and the implications for family planning and family building: an IFFS consensus document based on a narrative review of the literature.

BACKGROUND: Family-planning policies have focused on contraceptive approaches to avoid unintended pregnancies, postpone, or terminate pregnancies and mitigate population growth. These policies have contributed to significantly slowing world population growth. Presently, half the countries worldwide exhibit a fertility rate below replacement level. Not including the effects of migration, many countries are predicted to have a population decline of >50% from 2017 to 2100, causing demographic changes with profound societal implications. Policies that optimize chances to have a child when desired increase fertility rates and are gaining interest as a family-building method. Increasingly, countries have implemented child-friendly policies (mainly financial incentives in addition to public funding of fertility treatment in a limited number of countries) to mitigate decreasing national populations. However, the extent of public spending on child benefits varies greatly from country to country. To our knowledge, this International Federation of Fertility Societies (IFFS) consensus document represents the first attempt to describe major disparities in access to fertility care in the context of the global trend of decreasing growth in the world population, based on a narrative review of the existing literature. OBJECTIVE AND RATIONALE: The concept of family building, the process by which individuals or couples create or expand their families, has been largely ignored in family-planning paradigms. Family building encompasses various methods and options for individuals or couples who wish to have children. It can involve biological means, such as natural conception, as well as ART, surrogacy, adoption, and foster care. Family-building acknowledges the diverse ways in which individuals or couples can create their desired family and reflects the understanding that there is no one-size-fits-all approach to building a family. Developing education programs for young adults to increase family-building awareness and prevent infertility is urgently needed. Recommendations are provided and important knowledge gaps identified to provide professionals, the public, and policymakers with a comprehensive understanding of the role of child-friendly policies. SEARCH METHODS: A narrative review of the existing literature was performed by invited global leaders who themselves significantly contributed to this research field. Each section of the review was prepared by two to three experts, each of whom searched the published literature (PubMed) for peer reviewed full papers and reviews. Sections were discussed monthly by all authors and quarterly by the review board. The final document was prepared following discussions among all team members during a hybrid invitational meeting where full consensus was reached. OUTCOMES: Major advances in fertility care have dramatically improved family-building opportunities since the 1990s. Although up to 10% of all children are born as a result of fertility care in some wealthy countries, there is great variation in access to care. The high cost to patients of infertility treatment renders it unaffordable for most. Preliminary studies point to the increasing contribution of fertility care to the global population and the associated economic benefits for society. WIDER IMPLICATIONS: Fertility care has rarely been discussed in the context of a rapid decrease in world population growth. Soon, most countries will have an average number of children per woman far below the replacement level. While this may have a beneficial impact on the environment, underpopulation is of great concern in many countries. Although governments have implemented child-friendly policies, distinct discrepancies in access to fertility care remain.

Elective egg freezing and male support: a qualitative study of men's roles in women's fertility preservation.

How do men participate in women's fertility preservation decisions and procedures? This binational, qualitative study assessed whether men play supportive roles either before, during or after women's elective egg freezing (EEF) cycles. From June 2014 to August 2016, 150 women (114 in the USA and 36 in Israel) who had completed at least one cycle of EEF were interviewed by two medical anthropologists, one in each country. The majority (85%) of women in the study identified the lack of a male partner as their main reason for pursuing EEF. However, nearly two-thirds (63%) of women relied on some form of male support during their EEF decision making processes and procedures. Five categories of men, in order of support, included: (i) fathers (or other male father figures), (ii) male partners (past or present), (iii) male friends, (iv) brothers and (v) male judges (some of whom supported EEF in divorce settlements). More than a dozen different forms of assistance were offered by men in four major categories: (i) instrumental, (ii) financial, (iii) physical and (iv) psychological. Although one-third (37%) of women went through EEF alone or with only female support, this study reveals the 'hidden' roles men play in supporting the reproductive aspirations of women.

Cryopreserving Jewish Motherhood: Egg Freezing in Israel and the United States.

Oocyte cryopreservation (i.e., egg freezing) is one of the newest forms of assisted reproduction and is increasingly being used primarily by two groups of women: (1) young cancer patients at risk of losing their fertility through cytotoxic chemotherapy (i.e., medical egg freezing); and (2) single professionals in their late 30s who are facing age-related fertility decline in the absence of reproductive partners (i.e., elective egg freezing). Based on a binational ethnographic study, this article examines the significance of egg freezing among Jewish women in Israel and the United States. As they face the Jewish maternal imperative, these women are turning to egg freezing to relieve both medical and marital uncertainties. In both secular and religious Jewish contexts, egg freezing is now becoming naturalized as acceptable and desirable precisely because it cryopreserves Jewish motherhood, keeping reproductive options open for Jewish women, and serving as a protective self-preservation technology within their pronatalist social environments.

Upholding Success: Asian Americans, Egg Freezing, and the Fertility Paradox.

Asian American women are turning to oocyte cryopreservation (egg freezing) at rates higher than would be expected, given that Asian Americans make up less than six percent of the total United States population. Based on ethnographic interviews with 23 women of East, Southeast, and South Asian ancestry, we examine the "fertility paradox" faced by highly educated Asian American professional women. Despite achieving multiple "pillars of success," these women have difficulty finding educated partners with whom to pursue childbearing. Egg freezing offers feelings of empowerment and relief from pressure for Asian American women, holding open the possibility of future biogenetic motherhood.

Transgender men's fertility preservation: experiences, social support, and the quest for genetic parenthood.

Transgender people assigned female at birth may undergo fertility preservation by egg or embryo freezing, usually prior to gender affirming treatment. In this binational ethnographic study, four transgender men were included as part of a larger comparative project on fertility preservation. In-depth ethnographic interviews allowed informants to talk freely about their fertility preservation experiences, and the circumstances that had enabled them to pursue this option. Prominent in men's accounts were the importance of genetic parenthood and the role of social support from others in the fertility preservation process. Indeed, in all cases, social support-from parents, siblings, partners, peers, physicians and employers-was critical, effectively enabling young transgender men to embark on their fertility preservation journeys and undergo the physically taxing process. This study illustrates the power of thriving through relationships that were critical in young transgender men's experiences of fertility preservation.

Where has the quest for conception taken us? Lessons from anthropology and sociology.

Louise Brown, the world's first test-tube baby, was born more than 40 years ago in England. For Louise Brown's infertile mother, Lesley, in-vitro fertilization (IVF) was the 'hope technology' which allowed her to overcome her tubal infertility after 9 years of heart-breaking involuntary childlessness. Since then, IVF has travelled to diverse global locations, where millions of individuals and couples have embarked on technologically assisted 'quests for conception'. After 40 years of IVF, where has the quest for conception taken us? This article outlines seven major global trajectories - namely, that the quest for conception has become more: (i) technological, because of a profusion of IVF-based innovations; (ii) masculine, because of men's eager uptake of intracytoplasmic sperm injection, their own 'masculine hope technology'; (iii) stratified, due to persistent race- and class-based barriers in IVF access; (iv) transnational, as infertile and other involuntarily childless people search across borders to overcome restrictions in their home countries; (v) selective, as IVF-based reprogenetic technologies eliminate genetic disease while exacerbating sex selection; (vi) moral, as religious sensibilities both accommodate and curtail the possibilities and outcomes of assisted reproductive technology (ART); and (vii) extended, as new cryopreservation technologies prolong the reproductive lifespan and extend reproduction to the transgender community. The article concludes with thoughts on where future quests for conception might take us, and why IVF and other reproductive technologies are 'good to think with' in both the anthropology and sociology of reproduction.

Abrahamic traditions and egg freezing: Religious Women's experiences in local moral worlds.

In this article, we elucidate how elective egg freezing (EEF) has been received within the three Abrahamic traditions-Judaism, Christianity, and Islam-and how these religion-specific standpoints have affected the EEF experiences of women who self-identify as religiously observant. Through an analysis of religious women's narratives, the study explores the "local moral worlds" of religious women who chose to freeze their eggs for non-medical reasons. It draws on ethnographic interviews with 14 women in the United States and Israel who had completed at least one EEF cycle, and who were part of a large, binational study that interviewed, between 2014 and 2016, 150 women who pursued EEF. These religious women, who were all highly educated, faced a particular challenge in finding appropriate marriage partners. Feeling pressured but still hopeful to marry and create large families, the women used EEF to extend their reproductive timelines and reduce their anxieties. As the study showed, the women reinterpreted or reconciled religious restrictions on the use of EEF in various ways, believing that their ultimate pursuit of religiously sanctioned reproduction justified the means. This study, which is the first to compare Jewish, Christian, and Muslim women's experiences of EEF, illustrates how this novel technology is now shaping the local moral worlds of religious women.

Reprint: Where has the quest for conception taken us? Lessons from anthropology and sociology.

Louise Brown, the world's first test-tube baby, was born more than 40 years ago in England. For Louise Brown's infertile mother, Lesley, in-vitro fertilization (IVF) was the 'hope technology' which allowed her to overcome her tubal infertility after 9 years of heart-breaking involuntary childlessness. Since then, IVF has travelled to diverse global locations, where millions of individuals and couples have embarked on technologically assisted 'quests for conception'. After 40 years of IVF, where has the quest for conception taken us? This article outlines seven major global trajectories - namely, that the quest for conception has become more: (i) technological, because of a profusion of IVF-based innovations; (ii) masculine, because of men's eager uptake of intracytoplasmic sperm injection, their own 'masculine hope technology'; (iii) stratified, due to persistent race- and class-based barriers in IVF access; (iv) transnational, as infertile and other involuntarily childless people search across borders to overcome restrictions in their home countries; (v) selective, as IVF-based reprogenetic technologies eliminate genetic disease while exacerbating sex selection; (vi) moral, as religious sensibilities both accommodate and curtail the possibilities and outcomes of assisted reproductive technology (ART); and (vii) extended, as new cryopreservation technologies prolong the reproductive lifespan and extend reproduction to the transgender community. The article concludes with thoughts on where future quests for conception might take us, and why IVF and other reproductive technologies are 'good to think with' in both the anthropology and sociology of reproduction.

Globalised quests for assisted conception: Reproductive travel for infertility and involuntary childlessness.

The global movement of people across international borders to undergo assisted reproductive treatment is common, although there is little accurate data. In this article, we synthesise findings from our own empirical research on reproductive travel in addition to a review of clinical, ethical, legal, and regulatory complexities from studies on reproductive travel since 2010. Motivations for travel include legal and religious prohibitions; resource considerations; lack of access to gametes and reproductive assistors; quality and safety concerns; and personal preferences. Higher risks to mothers and children are associated with multiple embryo transfer and subsequent multiple and higher order pregnancies and the average older age of women undertaking reproductive travel. The potential exploitation of other women as providers of oocytes or surrogacy services, the lack of equity in access to assisted reproduction and the ambiguous legal status of children conceived from international reproductive travel are important ethical considerations. A range of significant legal issues remain given variable and limited international regulation. Scholarship on this trade necessarily engages with issues of power and gender, social inequities, global capitalism and the private decision-making of individuals seeking to form families. Research gaps remain given recent changes in the organisation, demands and destinations of the trade.

Patient-centered elective egg freezing: a binational qualitative study of best practices for women's quality of care.

PURPOSE: How can elective egg freezing (EEF) be made patient centered? This study asked women to reflect on their experiences of EEF, which included their insights and recommendations on the optimal delivery of patient-centered care. METHODS: In this binational, qualitative study, 150 women (114 in the USA, 36 in Israel) who had completed at least one cycle of EEF were recruited from four American IVF clinics (two academic, two private) and three in Israel (one academic, two private) over a two-year period (June 2014-August 2016). Women who volunteered for the study were interviewed by two medical anthropologists. Interviews were audio recorded, transcribed, and entered into a qualitative data management program (Dedoose) for analysis. RESULTS: The majority (85%) of women were without partners at the time of EEF, and thus were undertaking EEF alone in mostly couples-oriented IVF clinics. Following the conceptual framework known as "patient-centered infertility care," we identified two broad categories and eleven specific dimensions of patient-centered EEF care, including (1) system factors: information, competence of clinic and staff, coordination and integration, accessibility, physical comfort, continuity and transition, and cost and (2) human factors: attitude and relationship with staff, communication, patient involvement and privacy, and emotional support. Cost was a unique factor of importance in both countries, despite their different healthcare delivery systems. CONCLUSIONS: Single women who are pursuing EEF alone in the mostly couples-oriented world of IVF have distinct and multifaceted needs. IVF clinics should strive to make best practices for patient-centered EEF care a high priority.

Ten pathways to elective egg freezing: a binational analysis.

PURPOSE: What are the specific pathways that lead women to freeze their eggs? In this binational study, women were asked directly about the life circumstances that led them on the path to elective egg freezing (EEF). METHODS: From June 2014 to August 2016, 150 women (114 in the USA, 36 in Israel) who had completed at least 1 cycle of EEF were interviewed by two medical anthropologists. Study participants were recruited through four American IVF clinics (two academic, two private) and three in Israel (one academic, two private). Interviews were audio-recorded, transcribed verbatim, and entered into a qualitative data management program (Dedoose) for analysis. RESULTS: The majority (85%) of women in the study were without partners, while 15% had partners at the time of EEF. Six pathways to EEF were found among women without partners (being single, divorced, broken up, deployed overseas, single mother, career planner), with career planning being the least common pathway to EEF. Among women with partners, four pathways to EEF were found (relationship too new or uncertain, partner not ready to have children, partner refusing to have children, or partner having multiple partners). With only one exception, the pathways and their frequencies were similar in both countries. CONCLUSIONS: Partnership problems, not career planning, lead most women on pathways to EEF. These pathways should be studied in a variety of national settings, and fertility clinics should offer patient-centered care for single women pursuing EEF in the couples-oriented world of IVF.

Medical egg freezing: How cost and lack of insurance cover impact women and their families.

Medical egg freezing (MEF) is being recommended increasingly for women at risk of losing their reproductive ability due to cancer chemotherapy or other fertility-threatening medical conditions. This first, binational, ethnographic study of women who had undergone MEF sought to explore women's experiences under two different funding systems: (i) the USA, where the cost of MEF is rarely covered by private or state health insurance; and (ii) Israel, where the cost of MEF is covered by national health insurance. Women were recruited from four American and two Israeli in-vitro fertilization clinics where MEF is offered. In-depth, semi-structured interviews were conducted with 45 women (33 Americans, 12 Israelis) who had completed at least one cycle of MEF. All of the Israeli women had cancer diagnoses, but were not faced with the additional burden of funding an MEF cycle. In marked contrast, the American women - 23 with cancer diagnoses and 10 with other fertility-threatening medical conditions - struggled, along with their families, to 'piece together' MEF funding, which added significant financial pressure to an already stressful situation. Given the high priority that both American and Israeli women in this study placed on survival and future motherhood, it is suggested that insurance funding for MEF should be mandated in the USA, as it is in Israel. This article concludes by describing new state legislative efforts in this regard.

Cross border reproductive care (CBRC): a growing global phenomenon with multidimensional implications (a systematic and critical review).

PURPOSE: Many people travel abroad to access fertility treatments. This growing phenomenon is known as cross border reproductive care (CBRC) or fertility tourism. Due to its complex nature and implications worldwide, CBRC has become an emerging dilemma deserving more attention on the global healthcare agenda. METHODS: According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review of the literature was performed for all relevant full-text articles published in PubMed in English during the past 18 years to explore CBRC phenomenon in the new millennium. RESULTS: Little is known about the accurate magnitude and scope of CBRC around the globe. In this systematic and critical review, we identify three major dimensions of CBRC: legal, economic, and ethical. We analyze each of these dimensions from clinical and practical perspectives. CONCLUSION: CBRC is a growing reality worldwide with potential benefits and risks. Therefore, it is very crucial to regulate the global market of CBRC on legal, economic, and ethical bases in order to increase harmonization and reduce any forms of exploitation. Establishment of accurate international statistics and a global registry will help diminish the current information gap surrounding the CBRC phenomenon.

Is Lower Quality Clinical Care Ethically Justifiable for Patients Residing in Areas with Infrastructure Deficits?

Reproductive health services, including infertility care, are important in countries with infrastructure deficits, such as Lebanon, which now hosts more than one million Syrian refugees. Islamic prohibitions on child adoption and third-party reproductive assistance (donor eggs, sperm, embryos, and surrogacy) mean that most Muslim couples must turn to in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) to overcome their childlessness. Attempts to bring low-cost IVF-ICSI to underserved populations might help infertile couples where no other services are available. However, a low-cost IVF-ICSI protocol for male infertility remains technically challenging and thus may result in two standards of clinical care. Nonetheless, low-cost IVF-ICSI represents a form of reproductive justice in settings with infrastructure deficits and is clearly better than no treatment at all.

Medical egg freezing: the importance of a patient-centered approach to fertility preservation.

PURPOSE: This binational qualitative study of medical egg freezing (MEF) examined women's motivations and experiences, including their perceived needs for patient-centered care in the midst of fertility- and life-threatening diagnoses. METHODS: Forty-five women who had undertaken MEF were interviewed in the USA (33 women) and in Israel (12 women) between June 2014 and August 2016. Interviews lasted approximately 1 h and were conducted by two senior medical anthropologists, one in each country. Women were recruited from four American IVF clinics (two academic, two private) and two Israeli clinics (both academic) where MEF is being offered to cancer patients and women with other fertility-threatening medical conditions. RESULTS: Women who undertake MEF view their fertility and future motherhood as important components of their identities and recovery and, thus, are grateful for the opportunity to pursue fertility preservation. However, women who undergo MEF have special needs, given that they tend to be a "vulnerable" population of young (age < 30), unmarried, resource-constrained women, who are facing not only fertility loss but also the "double jeopardy" of cancer. Through in-depth, qualitative interviews, these women's MEF stories reveal 10 dimensions of care important to fertility preservation, including five "system factors" (information, coordination and integration, accessibility, physical comfort, cost) and five "human factors" (adolescent issues, male partner involvement, family involvement, egg disposition decisions, emotional support). Together, these dimensions of care constitute an important framework that can be best described as "patient-centered MEF." CONCLUSIONS: Women pursuing MEF have special medical needs and concerns, which require particular forms of patient-centered care. This study outlines 10 dimensions of patient-centered fertility preservation that are appropriate for MEF patients. This approach may help IVF clinics to be better prepared for delivering top-quality care to mostly young, single women facing the daunting prospect of fertility loss and life-threatening medical diagnoses.

Searching for Love and Test-Tube Babies: Iraqi Refugee Men in Reproductive Exile on the Margins of Detroit.

In this article, I explore the reproductive health problems faced by Iraqi refugees, one of America's most rapidly growing immigrant populations. Based on anthropological research in "Arab Detroit," the "capital" of Arab America, I explore the experiences of Iraqi refugee men seeking medical help for their infertility. Most required intracytoplasmic sperm injection (ICSI), a variant of in vitro fertilization (IVF). However, in America's privatized medical system-where a single cycle can cost more than $12,000-few could possibly afford this assisted reproductive technology (ART). Although Iraqi refugees had diasporic dreams of making a test-tube baby, they were stuck in a situation of "reproductive exile"-forced out of their home country by war, but unable to access costly ARTs in the country that led to their displacement. I elaborate on the concept of reproductive exile, attempting to translate Iraqi refugee men's reproductive agency and desires, but also their profound disappointments.