European citizens affected by infertility need your support in developing regulations that ensure easy, publicly funded, and timely access to evidence-based psychosocial care at any stage of their infertility journey.

Background

Infertility, defined as the inability to achieve a pregnancy after 12 months of regular unprotected sexual intercourse, affects 17% of people worldwide¹ and was ranked as fifth in the list of moderate to severe disabilities within the global population under the age of 60 by the World Health Organization². In Europe, infertility affects 1 in 6 couples of reproductive age, and in some countries, it is as high as 20%. This translates to 25 million EU citizens in need of diagnosis and treatment for infertility³. Furthermore, many other people are unable to reproduce either as an individual (e.g., single women) or with his/her partner (e.g., gay people, people with genetic conditions). For instance, in the United Kingdom and other European countries, around 1 in 5 women reach 45 without a child, with only 3% of these being childless by choice⁴.

At a time when the total fertility rate in Europe is the lowest of all continents¹ and has stayed under replacement rate since the 70s, there is strong public support for European citizens to have access to publicly funded medically assisted reproduction (MAR). MAR contributes to increase fertility rates in European countries and helps involuntary childless pople realise parenthood^{5, 6}, thereby supporting Europe’s economy and ageing population. However, the efficacy of MAR in dependent on people’s ability to undergo multiple cycles. For instance, in vitro fertilisation (IVF) has a 33% success rate per cycle but can go up to 60% if patients do three cycles⁷.

Why is psychosocial care crucial to successful infertility management?

The European Commission’s ‘Comprehensive approach to mental health’ communication, published in June 2023⁸, states mental health is a precondition for a productive economy and inclusive society and urges all Member States to adopt an approach that promotes mental health across all policies.

Psychosocial care is defined as care that enables patients, their families, and their healthcare providers to optimize fertility care and manage the psychological and social implications of infertility and its treatment⁹. There are 5 key reasons why easy and timely access to publicly-funded and evidence-based psychosocial care for people affected by infertility is required:

1. Infertility has significant societal and health consequences for most affected people, including social stigma, poor physical and mental wellbeing, and even economic hardship¹⁰. People with infertility have poorer mental health and quality of life than the general population^{11, 12} and report equal levels of distress to people with life-threatening conditions such as cancer and HIV¹³.
2. Medically assisted reproduction assists patients in achieving parenthood. Therefore, most people may have to manage the psychosocial consequences of infertility throughout their full lives, for instance, if they decide to have more children.
3. Most patients find it difficult to manage the typically lengthy, technically demanding, physically intrusive, and disruptive fertility treatment, as well as the high uncertainty of success. Most patients experience some degree of emotional distress during treatment¹⁴, and around 30% of women and 10% of men are diagnosed with a mental-health disorder¹⁵.
4. Two in every 10 patients who start MAR stop it before doing three cycles or achieving pregnancy because they are unable to cope with the emotional challenges of treatment^{16, 17}.
5. Three to four in every 10 patients who start MAR end it without children⁷. This loss triggers a prolonged and intense grief period lasting on average 2-years, during which people experience lower mental health and wellbeing than those who have children with treatment¹⁸. The psychosocial sequels of infertility can also persist into pregnancy, as patients using assisted reproduction report higher anxiety about foetal viability and health¹⁹.

Overall, the impacts of infertility are comparable to that of mental health issues during pregnancy or the post-partum period, for instance post-partum depression, but are much less acknowledged and not yet properly addressed.

The best available evidence show that the provision of routine evidence-based psychosocial care for infertility and assisted reproduction successfully reduces the distress of infertility and its treatment, as well as concerns about medical procedures²⁰. It can improve lifestyle outcomes²¹, knowledge²², and patient optimism and wellbeing during stressful moments of treatment, for instance when waiting to know its outcome^{23, 24}. Empathic care is also associated with better experiences of and satisfaction with care^25-27.

Overall, provision of psychosocial care mean people affected by infertility will be empowered to manage their fertility and treatment journey in a healthier way, avoiding deterioration of mental health and associated spillover effects such as loss of work productivity^28,29 or additional use of medication and mental health services³⁰. It can also foster resilience during childbirth and the postpartum period, during which the risk of mental illness and use of residential parenting services is high in people who conceive with fertility treatment^31,32.

Importantly, multiple systematic reviews show psychosocial care interventions increase pregnancy rates for patients undergoing MAR^33-35. This is most likely because these interventions impart patients with education and skills that help them cope with the challenges of treatment, enabling them to do multiple cycles of treatment. Finally, psychosocial interventions can also ease grief reactions and facilitate adjustment when treatment doesn’t work³⁶.

Why is regulation needed?

Despite the strong evidence in support of the provision of psychosocial care for infertility and assisted reproduction, there are clear indications that this is not the reality observed across Europe.

1. Our recent patient European Survey showed that 8 in 10 patients reported needing psychosocial care during fertility treatment, but only 2 in 10 were offered it, and only 12% reported the costs were included with treatment (Fertility Europe SURVEY findings).
2. Mental health professionals are not routinely employed nor integrated within a multidisciplinary team at fertility clinics³⁷.
3. Evidence-based guidelines³⁸ to implement psychosocial care in infertility and MAR exist and professionals perceive their patients benefit from them implementing these, but only 30% actually feel able to do it³⁹
4. Field research shows that around 10-20% of patients are at risk for experiencing significant distress during MAR, but that these patients are not identified nor prioritised for support⁴⁰.
5. There an imbalance in the provision of psychosocial care in MAR: most existing interventions and initiatives focus on supporting patients through treatment, reflecting a neglect of the duty of care towards those for whom treatment does not work ⁴¹.

Stronger regulation of psychosocial care for infertility and assisted reproduction is needed to ensure it is an integral part of infertility management in Europe and that it meets minimum quality standards:

Empowering Infertility Patients with Psychosocial Care

Integrated psychosocial care promotes healthier adjustment to infertility, ensures better experiences of treatment, and contributes to higher success rates in MAR, which has the potential to offset population aging in Europe⁶ and support the economy and an ageing population. Nonetheless, it is systematically under prioritised across Europe. We urge policy makers, public health authorities, regulator bodies, and scientific societies in EU Member States, to reinforce regulation that ensures the implementation of psychosocial care standards in public and private healthcare practice.

Thank you to Dr. Sofia Gameiro – Cardiff University, for supporting us in creating the recommendations!

References

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2.           World Health Organization, et al., World Report on Disability. 2011, World Health Organization: Geneva.

3.           ESHRE, Facsheet on infertility – prevalence, treatment and fertility decline in Europe. 2021.

4.           Präg, P., et al., Childlessness and Assisted Reproduction in Europe. in Families and Societies Working Paper Series. 2017.

5.           Fauser, B.C., et al., Beliefs, attitudes and funding of assisted reproductive technology: Public perception of over 6,000 respondents from 6 European countries. PLoS One, 2019.

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7.           McLernon, D.J., et al., Predicting the chances of a live birth after one or more complete cycles of in vitro fertilization: population based study of linked data from 113873 women. BMJ, 2016.

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