SART Fertility Experts - Global Access to IVF and the Status of Women

Hello and welcome to today's episode of SART Fertility Experts. My name is Dr. Kelly Lynch and my guest today is Dr. G. David Adamson. He is a reproductive endocrinologist.

He is the CEO at ARC Fertility. He is a clinical professor at Stanford University. He is also the past president of ASRM, the American Society for Reproductive Medicine, as well as the Society for Assisted Reproductive Technologies.

He is also past chair of the Committee on Reproductive Medicine for FIGO and the chair of the International Committee Monitoring A.R.T. ICMART, and he is also president of the World Endometriosis Foundation. Dr. Adamson, thank you so much for joining me today. Thank you so much, Kelly.

It's really a pleasure to be here with you. Dr. Adamson, I asked you to join me today because I was interested in hearing you talk to me a little bit about access to IVF care around the world and how it helps the status of women. Well, thanks very much for having me.

ICMART actually has been collecting, analyzing, and publishing global A.R.T. data for over 30 years now, and it's really instructive in being involved with that process to see how data from different countries can inform us about not only the scientific aspects of assisted reproductive technologies, but also when those data are combined with other data can give us some insight into different societies and different cultures and how those interact with medicine and with the delivery of health care, in particular to women. And so with a large body of data from ICMART that we've been collecting since 1991 globally, we decided to look at those data and relate them to other data that are out there from the World Bank and United Nations, looking at economic factors, but also looking at some of the indices which are put out regarding social development, economic development, and also gender inequality. And we have just finished with a paper that's just about to be published that has looked at access to A.R.T. and gender inequality in women.

We've had some earlier publications with this, but we continue to be interested in this area and look at it. And what's really, really interesting is that when you look at the many factors that go into social development, if you will, and also in economic development, like gross domestic product of countries, you find there are multiple things. But some of the most important ones have to do with women, of course, and it has to do with the education of women.

It has to do with women in the workplace and what their role is. It has to do with women in positions of power, for example, percentage representation in parliament, et cetera. But if you look at all of these and you look at gender inequality, actually the strongest predictor is reproductive health for women.

And that might come as a surprise to many people because it's often felt if you talk with people about how do you help a society progress that the first answer would be, well, we need to educate people more. And certainly education is critically important. However, the data would tend to support the fact that improving the health of a nation is slightly more important than improving education because if people, of course, aren't healthy, they're probably not able to get educated or work or function well in society.

So the health of the nation is really important. And of course, we also know that reproductive health for women is a very, obviously in a major way related to general health. And so when you put all these together, we shouldn't be too, too surprised that reproductive health is so important.

And when you look at reproductive health, as we know in our country, and certainly in many other countries in the world, some of the major aspects of getting reproductive health for women is access to that reproductive health. But it's also about autonomy to having access because reproduction is a very, very personal thing. And of course, most women don't want to be pregnant all the time, but most women, not everyone, but most women do want to have a child at some point or other.

So reproductive autonomy is really, really important. And reproductive autonomy is a critical aspect of reproductive health because if you can't choose when you're going to have what kind of care with respect to reproducing and what you're going to do to not get pregnant or what you're going to do to get pregnant or what you're going to do if you're pregnant are really critical decisions affecting reproductive health. And so when you back off and look at it, it's actually not that surprising that reproductive health matters.

So with this sort of background thinking, looking at all the data that were out there, we said, well, what about reproductive health in general? And is that related to infertility and IVF treatment? And so because we've been collecting these data since 1991, which is over three decades now, we could look at utilization. And utilization, the way we measured it was the number of cycles performed per million population. We didn't choose just women, and it wouldn't change the overall numbers much, but number of cycles of IVF performed per million population.

And of course, this is very in many different countries. The highest number in the world on that generally is around 6,000 in Israel. And immediately when you hear that, you say, well, yes, that sort of makes sense because there are a lot of reasons Israel has compelling social and political and economic reasons to want to have more babies.

And so they really support IVF. And so it's a very, very high number. Other countries that have very, very high numbers in the 3,000, 4,000 range are some Northern European countries in particular, which are very pro-family, Denmark in particular is.

And then there are many European countries and of course, Australia, New Zealand, which are supportive, which are in the 2,000, 3,000 kind of range. What's really notable is that the U.S. is well under 1,000. We're at something like 840 or 50 cycles per million compared with other countries.

So you can see by any standard, we're only at about 25% of many other developed countries in Europe. And we're literally one seventh or one eighth of the utilization that occurs in a country like Israel that really provides a lot. So it sort of gives a sense of magnitude.

We think we have big IVF in the States and we have lots of clinics and this and this, but it's really not as many cycles as you might think. And the global average number of cycles is still under 500. Some interesting aspects around those numbers are that in fact, in 2019, the last year for which we have complete data, we'll be starting to collect 2020 just in the next few months here.

It was a total of about three and a half million cycles in the world. And China did about 1.15 million. And Japan did almost half a million.

And so when you add those up, two countries in Asia, China and Japan did almost half the cycles in the world. And also compellingly, the top 10 countries in the world, which were mostly European, U.S. was the third in number of cycles after China, then Japan, then U.S. And then a lot of European countries and Australia, New Zealand have made the top 10. But those top 10 countries do almost three quarters of all the cycles.

So there's almost a couple of hundred countries in the world and 10 countries do three quarters of the cycle. So you can see when you look at utilization as number of cycles per million population, there's a huge range from 6,000 in Israel down to under a hundred in some countries in the world and some African countries, of course. And in addition to that, there's clearly some issues around accessibility through cross-border care, et cetera.

So just to point out that there are big differences for a lot of reasons and the U.S. certainly does a lot of IVF, but if you look at it, there's still a huge, huge need. So when you take those numbers and we have all these numbers from a hundred different countries that have reported over the years, and we looked at data from the World Bank and United Nations on how did those utilization numbers relate to gender equality? And we use utilization numbers, if you will, as quote, realized access, end of quote, right? So if somebody uses it, it means they could actually get it. So it was available, they could afford it, they could actually use it.

So we use utilization as realized access and that's the relationship between the two. When we looked at all those numbers, we found that there was a really strong correlation between this utilization or realized access and gender equality or inequality, depending on how you looked at it, very, very strong correlation. And this does not say cause effect.

It doesn't say if you do IVF in a country, all of a sudden women are going to be much better off. And it doesn't say only that if women are better off, you'll do more IVF because we have a very high GDP in this country, but we don't have as much IVF as many other countries, right? So it's not that there's a direct cause and effect, but there is a very high correlation. What was even more interesting than that, I thought, and I had a slide to show this that was a sort of a dynamic slide, is that we took countries and we looked at the gender inequality and looked at utilization.

We put a dot on the graph, you know, a simple XY graph of utilization and gender inequality. And for each of those countries, we looked at what happened over a period of years, about 2005 up through about 2012 or 13, and the dots moved. And so there's very strong correlation, but it showed that as more IVF was done in a country, the gender equality improved.

And so it really sort of helped confirm this relationship between the two. And the reason that gender equality matters so much is that when women have equality, that tends to mean, of course, that they have more autonomy. And with that autonomy, they're empowered.

And they're empowered to make decisions that are right for them, in particular, right for them about their reproductive health. And when they can manage their reproductive health, I mean, it's pretty obvious, but it means that they can manage the number of children they have, which means that they are in a better position to, you know, be a good mom and raise a child. They're probably in a better position to have a partner who can help them with this.

And it also means they can manage their education better, because they're having babies when they want, they're not having them when they don't want, and they can get themselves more educated. And as they're more educated, they clearly also have more control in the workplace and what they're going to do in the workplace. And all of this creates greater wealth and benefit for society.

And so I think one of the really important messages that I know we're trying to get out there is that this is not just about reproductive health. It's not just about women's health. And it's not just about equality or inequality, although that's clearly critical.

But the hard fact is that as women have, as there's more art, which is reflected sort of by the social perception of art and where it stands and how important it is and how much they fund it to make it affordable, that affects reproductive health, that affects the health and empowerment of women and their education and their role in the workplace. And society gets better. The gross domestic product goes up, the health of babies goes up, the health of men goes up, and society gets better.

So without trying to connect too many dots all at once, I think it's really fair to state that access to art care is a very, very important indicator in a society and that all of us in this sector of healthcare who care about women and care about health and care about what we're doing, it's important for us to advocate for better coverage because this will help and be part of empowering women and improving society for everyone. Such a powerful message, Dr. Adamson. Thank you.

Thank you. I feel very fortunate to be able to work in this area and work with wonderful, wonderful people from around the world. I have a question for you.

So you bring up two issues. One is access to care. And what do you think are the barriers to access to care, especially in the U.S. where you mentioned that the number of cycles per population is low compared to some other countries? Right.

Great question. And the answer's not quite as obvious. Most people, when you ask that question, will say, well, IVF's expensive, right? There's no question that the cost matters, right? And all the studies show that the ability to pay for IVF is the number one reason people don't get care.

However, I would really like to make a strong comment that it's not about the fact that IVF is expensive or that it costs too much, because I don't believe that. When we started doing IVF over 30 years ago now, the cost of an IVF cycle was about $13,500 or $14,000, and we were lower than average in our clinic. And across the U.S. now, of course, the cost is more than that.

One of the big issues is add-ons, which I won't get into, but there are a lot of places where you'd get an IVF cycle for almost that kind of price if you don't put all the other things on it. And so the, quote, cost hasn't gone up that much, certainly compared to other healthcare costs or anything else. If you compare the cost of an IVF cycle to, you know, say you broke your arm and had to go to an emergency room and then somebody had to put a pin in your arm or something, it would cost way more than an IVF cycle.

But the capital required to do that in the hospital, compared to what's required to set up an IVF clinic, the amount of resources expended for an IVF cycle would be much more than for fixing that arm. And the expertise, the number of people required, clinicians, embryologists, anesthesiologists, et cetera, for an IVF cycle would be much greater than that for the arm. So it's not that IVF per se is expensive compared to other things.

The reason that people have barriers to it is it's not affordable. And it's not affordable because affordability refers to the out-of-pocket cost relative to net disposable income. So it's the out-of-pocket cost relative to net disposable income.

So in US, the people have more disposable income than a lot of countries, but the out-of-pocket cost is way too high because of high deductibles and lack of IVF coverage. So the real issue is not cost. The real issue is affordability.

And so the affordability comes down to how much other coverage is there from either the government or healthcare companies or whatever. So affordability is number one, but I'd emphasize it's affordability, not the cost, because affordability means are we covering it up? And the obvious answer is no, we're not. The second challenge, which is often not thought about, but is really critical and in many ways is almost, not quite, but almost as important as the financial barrier, is the sort of sociological view of it.

Many people are not aware of IVF, especially in marginalized populations. They're not aware how effective it can be or that could help them. Many of them see these stories on TV about it costs $100,000.

They don't even look into it because there's no way I can do that. And they don't think about coverage. There are different culture perceptions.

Often women in African-American black community will think that they're being punished because they can't get pregnant. Women in Hispanic communities often very focused around families and their perception of infertility is really around family. And white women more often see it as a problem to try to be overcome.

And so there are a lot of cultural differences and these differences are not just here in the US, they're all over the world because we've looked at this in different countries. And so what's really important about that, it's this important increase awareness and education of people about what is it, what can it really do, how can it apply to you. And it goes without saying that we need a lot of emotional support and psychological support in this journey.

So the second big barriers are lack of knowledge, awareness, and lack of emotional support. So providing education, awareness, emotional support are also critical as second barriers after the affordability barrier. So increase awareness of it as a medical problem and not something to be stigmatized or that they're being punished.

That's an excellent comment, Kelly, and especially the word stigmatized. I belong to a number of committees and I was on a call about eight months ago with a group of about 20 female physicians and this call was about infertility. So these are female physicians and some were residents, a couple of medical students, some were residents, but most were younger women who were faculty.

These were trained physicians who presumably, of course, know a lot about medicine and healthcare and their bodies and everything else. The number one word that they used to express in this conversation about their infertility was shame. So you take educated people, knowledgeable, who clearly very successful in managing their lives, and the number one word is shame.

And this shows how much infertility has been stigmatized. Now, fortunately, I think we're really starting to come out of that, but it's still a very, very difficult problem. Absolutely.

And it's something these women, they feel helpless, especially if they had to put off having a family because of medical training. That's right. And, you know, there's some studies, there's a study out there that shows that female physicians have infertility at, you know, several times the rate of the general population.

And probably not surprising because, you know, they're really often, generally speaking, in an older population, right, which just compounds the issues they're facing. I would like to put a shout out to my home state of Connecticut, which has a fertility preservation mandate. And we're seeing many female physicians take advantage of that and freeze their eggs while they're in training, so that they can pursue family building after they complete their residency training.

It's great that, A, this technology has become available, B, that people are more aware of it. And, of course, I think it goes without saying, it's really important for society to support this. And I know there's been the sense, well, we have elective egg freezing and egg freezing, you know, for cancer.

We, you know, at ICHMART, where we've done the glossary, we do not call anything elective egg freezing because we don't think a decision that a woman makes about her reproductive life is elective. And so it's just, obviously, cancer is critical, very time dependent, but we think that freezing of eggs for reproductive autonomy is very, very important for all women to have access to. Land, fertility, preservation.

That's right. Thank you so much, Dr. Adamson, for taking the time to talk with me today. This has been a really wonderful conversation.

Thank you very much, Kelly. It's been a pleasure being with you.