On estimating the prevalence of use of medically assisted reproduction in developed countries: a critical review of recent literature

Abstract

Background: Existing reviews on the prevalence of use of medically assisted reproduction (MAR) are relatively old and include mainly studies from the 1980s and 1990s. Since then, MAR has developed at a rapid pace, public awareness and acceptance of medical solutions to infertility problems has increased, and, consequently, the use of MAR has risen in developed countries.

Objective and rationale: This study provides a comprehensive overview of the state of research on the prevalence of MAR use in women and men, as well as a critique of methodology used in studies of the use of MAR, and suggestions for moving forward.

Search methods: Articles were located via the databases Academic Search Complete, Biomed Central, FirstSearch, Google Scholar, Medline, Health and Medical Collection, Medline and Social Science Citation Index using the key words 'infertile', 'infertility', 'subfecund', 'subfecundity', 'treatment', 'help-seeking', 'service use', 'service utilization', 'ART use' and 'MAR use' separately and in various combinations. The focus was on studies from developed countries, published between 1990 and 2018, in English, German or French.

Outcomes: In this article, we have reviewed 39 studies covering 13 countries or regions; approximately half of these covered the USA. Ten studies were published in the 1990s, 10 in the 2000s and 19 since 2010. Studies report different types of prevalence rates such as lifetime and current prevalence rates of MAR use. Prevalence rates are based on very different denominators: women who tried to become pregnant for at least 12 months without success, women who experienced at least 12 months of unprotected intercourse without success, women of reproductive age from the general population or women with a life birth. There are few studies that report help-seeking rates for men or make direct comparisons between genders. Knowledge on medical help-seeking across different stages, such as seeing a doctor, undergoing tests, having operations to restore fertility or ART, has started to accumulate in recent years. There are conceptual reasons for being cautious about drawing conclusions about gender, regional, country level and differences over time in help-seeking rates.

Limitations reasons for caution: In a narrative review, the risk of bias in the interpretation of findings cannot be completely eliminated. The literature search was limited to languages the authors speak: English, French and German.

Wider implications: In line with earlier reviews, we found that studies on help-seeking are not comparable across time and space, preventing researchers and healthcare providers from understanding the relation between social change, social policy, social structure and help-seeking for infertility. The discussion in this article should assist future researchers in designing better studies on the prevalence of MAR use. We provide suggestions for producing better estimates of the prevalence of MAR use. More cross-country and cross-gender comparisons are needed. Studies that treat help-seeking as a continuum and report on different stages are preferable compared to choosing arbitrary cutoff points, as is common practice in the studies reviewed.

Study funding/competing interests: None.

Keywords: ART; developed countries; fertility treatment; help-seeking; impaired fecundity; infertility; medical help to get pregnant; medically assisted reproduction (MAR); prevalence; treatment-seeking.