IFFS Surveillance 2019 - Nova IVI Fertility5. Number of embryos for transfer in assisted reproductive technology (ART) 6. Cryopreservation 7. Posthumous reproduction 8. Donation and

IFFS Surveillance 2019The International Federation of Fertility Societies (IFFS) is a federation of national membership societies that have an interest in theclinical and research aspects of reproduction and fertility. IFFS is a non-governmental organization (NGO) in official relations with theWorld Health Organization (WHO).

Copyright 2019 by International Federation of Fertility Societies(IFFS). All rights reserved. No part of this publication may be repro-duced by any means without the prior written consent of the IFFS.

The designations employed and the presentation of the material in this publication do not imply theexpression of any opinion whatsoever on the part of the IFFS concerning the legal status of anycountry, territory, city or area or of its authorities, or concerning the delimitation of its frontiers orboundaries. The editorial board members and survey respondents are responsible for the views andcomments, respectively, expressed in this publication and they do not necessarily represent thedecisions, policy, or views of the IFFS.

Copyright © 2019 The Authors. Published by Wolters Kluwer on behalf of theInternational Federation of Fertility Societies. This is an open-access articledistributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download andshare the work provided it is properly cited. The work cannot be changed in any wayor used commercially without permission from the journal.

Global Reproductive Health (2019) 4:e29

http://dx.doi.org/10.1097/GRH.0000000000000029

’Supplement Article

1

PREFACE

Table of contents

1. Number of centres2. Legislation and policy guidelines3. Insurance coverage4. Marital status and same sex and single parenting policy5. Number of embryos for transfer in assisted reproductive

technology (ART)6. Cryopreservation7. Posthumous reproduction8. Donation and anonymity of donors9. Oocyte maturation10. Micromanipulation11. Welfare of the child and identity rights12. Fetal reduction and sex selection13. Preimplantation genetic testing14. Surrogacy15. Cross border reproductive care16. Human pre-implantation embryo research17. Status of the embryo18. Conclusions

PREFACE

The triennial Surveillance project, initiated in 1998 by Drs.Howard Jones, Jr and Jean Cohen, continues to evolve, now witha new name, the International Federation of Fertility Societies’Surveillance (IFFS) 2019: Global Trends in Reproductive Policyand Practice, 8th Edition. The new name more accurately reflectsthe scope and focus of the project, and makes the report moreaccessible to a global audience, particularly those seeking thisinformation online. IFFS is a non-state actor (NSA) in officialrelations with the World Health Organization (WHO), and thepublication of Surveillance serves as part of the IFFS’ WHOmandate.

The 2019 version has several major changes. Some chaptershave been expanded, and some topics have been combined toeliminate redundancies. The number of chapters has beenreduced from 24 to 18, but all previous topics and questions havebeen retained.

The 2018 online questionnaire was the sole source of data forIFFS Surveillance 2019: Global Trends in Reproductive Policyand Practice, 8th Edition. The online questionnaire was furtherrefined, and was again administered by Medtech for Solutions®.The refined questionnaire consisted of 94 questions, in English,with translated versions available. On average, it took 90minutes(cumulative on-site time) to complete. The survey was accessibleonline from February 1 through March 31, 2018.

Although a few responses were accepted shortly after thedeadline, they reflect the practices of assisted reproductive tech-nology (ART) (also called assisted reproductive treatment)through that time. Respondents representing 97 countries (22more than in 2015) registered online at the website, and allprovided at least some responses to the 2018 questionnaire,enough to be included in the analysis. There were 27 more usableresponses than in the 2015 survey, in which 26 responseswere new to Surveillance. Responses were not received for all

questions, and this is reflected in the variations in amount of datasubmitted for the individual queries. The percent positiveresponse is given for all answers, for that particular query. Forspecific questions, participants could answer “yes’, “no” or“unknown” if the respondent did not know the answer to aparticular query.

Many individuals contributed to the success of this project. Iam profoundly grateful for the efforts of the 191 respondents,representing 97 countries, who completed the survey. The ques-tionnaire is lengthy, and the answers to some questions are notreadily accessible. The diligence and commitment of a wide arrayof colleagues around the world was essential to the successfulcompletion of the publication.

Although Surveillance 2019 is a global project, relying onmany individuals from many nations, the ultimate success inengaging such a diverse representation hinged on personal rela-tionships. To this end, many IFFS officers and representativesgave generously of their time, contacting and enlisting manyinternational colleagues who were new to Surveillance. I wouldparticularly like to acknowledge the efforts of Drs. Silke Dyer andFernando Zegers, who issued countless personal appeals; theydeserve a large share of the credit for the increased representationthis year. Closer to home, our administrative assistant, LeilaGrass, resorted to extensive social media searches to identify ARTcentres in countries that we had previously been unable to engage;her efforts were ultimately successful. The Surveillance EditorialBoard worked tirelessly; all had roles in developing the 2018questionnaire, reformatting the organization of Surveillance, andconducting data analysis, and were also involved in chapterpreparation and editing.

Special recognition is due Drs. Edgar Mocanu and MarcosHorton. The Assistant Editor, Dr. Horton, worked relentlessly, ashe did in previous editions, andwas particularly invaluable in thiscapacity. OurManaging Editor, Dr. KathleenMiller, deserves thegreatest accolades for her passionate pursuit of a comprehensive,high-quality product. Finally, I would like to recognize the con-tinuing support, encouragement, and participation of the IFFSofficers and Board of Directors, and the administrative staff of theIFFS Secretariat, for their essential roles in the project’s successfulcompletion.

Surveillance 2019 presents a more comprehensive globalassessment of the status of reproductive policy and practice thanprevious editions, drawing input from 97 of the 132 countriesbelieved to offer ART services. Data collection was improved byfurther refinements in the questionnaire, a more robust processfor identifying and engaging prospective participants, and manylocal and regional developments that facilitated cooperation andparticipation. Consequently, Surveillance 2019 depicts a furthermaturation of the field, with wide adoption of technologicadvances, and an emerging consensus regarding some of the morecontroversial aspects of ART.

Significant limitations remain, however. Although the reportrefers to practices and policies of countries, responses for most ofthe participating countries were provided by a single well-informed, responsible individual. The responses have not beenvalidated for the majority, andmay include inherent inaccuracies.Some respondents were not able to provide complete data sets.Some ART practices have undoubtedly changed since the surveywas completed and answers may not reflect current practices. For

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IFFS Surveillance 2019. Global Reproductive Health (2019) 4:e29 Global Reproductive Health

these reasons, caution should be exercised in interpreting thedata. When feasible, responses from previous triennial surveysand multiple respondents have been compared. When dis-crepancies were identified among multiple respondents, or fromother published reports, the editors adjudicated the incon-sistencies. However, this occurred infrequently.

IFFS Surveillance 2019: Global Trends in Reproductive Policyand Practice, 8th Edition is unique in its depiction of world-wideART policy and practice. This report attests to the dynamic,ongoing growth of the practice of ART, the local and regionaldifferences, and the continued international collaboration thathas characterized the field since its inception (Table 1).

Steven J OryEditor-in-Chief

Surveillance 2019December 2018

Preface. Table 1Participants.

Participant Name Participant Country

Nigri Kamal AlgeriaA. Gustavo Martinez ArgentinaAntonio Sarra Pistone ArgentinaFabian Lorenzo ArgentinaEster Polak de Fried ArgentinaIdelma Serpa ArgentinaJorge Blaquier ArgentinaKarina Mercedes ArgentinaMarcos Horton ArgentinaNoelia Cabral ArgentinaPaula Siverino Bavio ArgentinaRoberto Coco ArgentinaSergio D. Papier ArgentinaStella Lancuba ArgentinaYoanky Ibarra Tendero ArgentinaEduard Ambartsoumian ArmeniaRob Norman AustraliaSonia Allan AustraliaMichael Feichtinger AustriaMosammat Rashida Begum BangladeshRashida Begum BangladeshJuliet Skinner BarbadosOleg Tishkevich BelarusKatleen Hostens BelgiumPhillipe Koninckx BelgiumJoaquin Lopez Arana BoliviaPatricia Frias BoliviaVincent Molelekwa BotswanaPedro Augusto Araujo Monteleone BrasilCaio Parente Barbosa BrazilHitomi Miura Nakagawa BrazilMaria do Carmo Borges de Souza BrazilRoberto de Azevedo Antunes BrazilSandro Esteves BrazilIavor K. Vladimirov BulgariaDr. Konyaole Burkina FasoErnestine Gwet Bell CameroonArt Leader CanadaMark Evans CanadaSamer Tannus CanadaScot Hamilton CanadaAbril Salinas Chile

Preface. Table 1

(Continued)


Anibal Scarella ChileOscar Espinosa ChileLiangzhi Xu ChinaEduardo Castro Valderrama ColombiaRicardo Rueda ColombiaDelia Ribas Valdes Costa RicaPavel Ventruba CzechiaVentruba Pavel CzechiaVerona Blumenauer DeutschlandVictor Montes De Oca Dominican RepublicJustin Mboloko Esimo CongoPablo Valencia EcuadorHassan Sallam EgyptMostafa Fouad Gomaa EgyptTaymour Mostafa EgyptWalid Sherbiny EgyptJose Roberto Bonilla Henriquez El SalvadorDeniss Soritsa EstoniaLiisa Kuusipalo FinlandNathalie Massin FranceLia Chkonia GeorgiaCharles Senaya GhanaMichael B. Yakass GhanaAsimakis Pappas GreeceJose Rodrigo Salguero Ruata GuatemalaRaymond Li Hong Kong (China*)Arthur Bernard HungaryAttila Torok HungaryTamas Korosi HungaryHilmar Bjorgvinsson IcelandHarpreet Kaur IndiaManish Banker IndiaMonis Bilal Shamsi IndiaPraveena Pai IndiaRajni Asthana IndiaRamgopal M. Pillai IndiaVijay Mangoli IndiaBudi Wiweko IndonesiaAlireza Shams IranJafar Mahmoud IraqEdgar Mocanu IrelandAdrian Ellenbogen IsraelJoseph Schenker IsraelAntonio Colicchia ItalyDomenico Canale ItalyDomenico Carone ItalyMariangela Palmieri ItalyLuca Gianaroli ItalyStephane Robale Côte d’IvoireOsamu Ishihara JapanMazen Y. Elzibdeh JordanPolumiskov Vadim KazakhstanVyacheslav Lokshin KazakhstanYelena Popova KazakhstanAlfred Murage KenyaAndris Grunskis LatviaEgle Drejeriene LithuaniaDiakite Djadi Kaba MaliJose M. Mojarra-Estrada MexicoSarbu Zinaida MoldovaEnkhtaivan Odkhuu MongoliaJargalsaikhan badarch MongoliaTatjana Motrenko Montenegro

IFFS Surveillance 2019. Global Reproductive Health (2019) 4:e29

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CHAPTER 1: NUMBER OF CENTRES

As noted in previous editions, compiling a reliable estimate of thenumber of ART centres in any country entails considerablemethodologic limitations. The total number of ART programmesin theworld is dynamic; newARTprogrammes are emerging, andsome centres are consolidating or closing. As we noted in 2016,“significant global progress in establishing registries and over-sight has been made over the intervening three years, and the2016 data for these countries may represent a more accurate andcomplete estimate than previous estimates. However, there arestill many countries in which this information is collected spor-adically, if at all, and there are no reliable estimates.”

These conclusions remain valid three years later. The numberscited herein represent the best estimate of the nations’ respon-dents when the questionnaire was completed. In countries withnational registries, accurate estimates are a matter of publicrecord and are easily accessible. Compiling a list of centres incountries with more limited ART resources, but a more finiteroster of known facilities, is often a less arduous task, and thosereports are probably more reliable. For countries such as Chinaand India, known to have many centres, but lacking compre-hensive registries and validation mechanisms, compiling accurateestimates is considerably more challenging.

The 2018 questionnaire used to compile Surveillance 2019:Global Trends in Reproductive Policy and Practice, 8th Editionreveals that progress has been made in developing registries,monitoring ART activities, and, in many countries, tracking thenumber of centres. In 2018, we engaged 97 countries to registeron our website and provide some ART data for their respective

Preface. Table 1

(Continued)


Khin May Thin MyanmarAdriaan P van der Colf NamibiaFJ Broekmans NetherlandsCynthia Farquhar New ZealandJohn Peek New ZealandVernon Halleslevens NicaraguaAbiola Adewusi NigeriaAdaora Ekechi-Agwu NigeriaEnebe Joseph Tochukwu NigeriaJoel-Medewase Victor Idowu NigeriaMaxwell Odiegwu NigeriaOluwafemi Adewusi NigeriaRosemary Opara NigeriaSa'adatu Sule NigeriaTolulope Ademulegun NigeriaVictoria Toyosi Adebowale NigeriaAbubakar Abubakar Panti NigeriaIjeoma Ezeome NigeriaGareth Greggains NorwayTom Tanbo NorwayRoberto Epifanio Malpassi PanamaRoger Molinas ParaguayElard Arriaga PeruErnesto Escudero PeruLuis Noriega Hoces PeruTeresa Villamayor Batario PhilippinesJacek Szamatowicz PolandPawel Janczyk PolandCarlos Calhaz Jorge PortugalEduardo Rosa PortugalIsabel Reis PortugalSusana Silva PortugalTeresa Almeida Santos PortugalMihai Surcel RomaniaMircea Onofriescu RomaniaAnna Smirnova Russian FederationTidiane Siby SenegalSava Micic SerbiaP C Wong SingaporeTomaz Tomazevic SloveniaMichelle Rijsdijk South AfricaMmaselemo Veronica Tsuari South AfricaNicole Lan South AfricaPaul le Roux South AfricaSilke Dyer South AfricaTae Ki Yoon The Republic of KoreaNicolas Mendoza SpainRocio Nunez Calonge SpainSilvia Sanchez-Raman SpainSanjeeva S.Godakandage Sri LankaLars Nilsson SwedenOuti Hovatta SwedenElisabeth Berger-Menz SwitzerlandFu-Tsai Kung Taiwan (China*)Gwo-Jang Wu Taiwan (China*)Kuo-Jang Wu Taiwan (China*)Chanin Asvadhares ThailandKamthorn Pruksananonda ThailandCamiller Aduayi Ata TogoCatherine Minto-Bain Trinidad and TobagoBasly Mohamed TunisiaSellami Afifa TunisiaA. Seval Ozgu- Erdinc Turkey

Preface. Table 1

(Continued)


Mehmet Ertan Kervancioglu TurkeySezgin Gunes TurkeyZehra Sema Ozkan TurkeyMark Muyingo UgandaEugenia (Ievgeniia) Zhylkova UkraineSanne F. Biesemans United Arab EmiratesMarta Jansa Perez United Kingdom of Great

Britain and Northern IrelandBruce Rose The United States of AmericaCarolina Sueldo The United States of AmericaDavid Adamson The United States of AmericaDavid Albertini The United States of AmericaDmitry Kissin The United States of AmericaJoanne Kwak-Kim The United States of AmericaJose Carugno The United States of AmericaMeike Uhler The United States of AmericaSuheil Muasher The United States of AmericaLidia Cantu UruguayRita Vernocchi UruguayFrancisco Risquez VenezuelaVo Thanh Lien Anh VietnamVuong Thi Ngoc Lan VietnamMhlanga Tinovimba ZimbabweRumbidzai Majangara Zimbabwe

*Reporting separately for this report.


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Chapter 1. Table 1Registered countries.

Algeria+ China Greece Latvia+ Paraguay SwitzerlandArgentina Colombia Guatemala Lithuania+ Peru Taiwan (China*)Armenia+ Congo Hong Kong (China*) Malaysia Philippines Thailand+Australia Costa Rica+ Hungary Mali Poland Togo+Austria Côte d’Ivoire+ Iceland+ Mexico Portugal Trinidad and TobagoBangladesh Czechia India Moldova+ Romania TunisiaBarbados Dominican Republic Indonesia Mongolia+ Russian Federation TurkeyBelarus Ecuador Iran Montenegro+ Senegal Uganda+Belgium Egypt+ Iraq Myanmar Serbia+ Ukraine+Bolivia+ El Salvador+ Ireland Namibia+ Singapore United Arab Emirates+ (UAE)Botswana+ Estonia Israel Netherlands Slovenia United Kingdom of Great Britain and Northern Ireland (UK)Brazil Finland Italy New Zealand+ South Africa The United States of America (USA)Bulgaria France Japan Nicaragua+ The Republic of Korea UruguayBurkina Faso+ Georgia+ Jordan Nigeria Spain VenezuelaCameroon Germany Kazakhstan Norway Sri Lanka Viet Nam+Canada Ghana+ Kenya Panama Sweden Zimbabwe+Chile

+ Denotes countries new to Surveillance.*Reporting separately for this report.

Chapter 1. Chart 1. Participating and non-participating countries.

Chapter 1. Table 2Countries without ART.

Andorra Dominica Holy See Mauritania Saint Kitts and Nevis South SudanAngola Equatorial Guinea Kiribati Micronesia Saint Lucia SurinameAntigua & Barbuda Eritrea Kyrgyzstan Monaco Saint Vincent and the Grenadines EswatiniBelize Ethiopia Lesotho Mozambique Samoa TajikistanBenin Fiji Liberia Nauru San Marino Timor-LesteBurundi Gabon Liechtenstein Niger Sao Tome and Principe TongaCabo Verde Gambia Luxembourg Palau Seychelles TurkmenistanCentral African Republic Grenada Malawi State of Palestine Sierra Leone TuvaluChad Guinea Maldives Papua New Guinea Solomon Islands UzbekistanComoros Guinea-Bissau Malta Congo Somalia VanuatuDjibouti Guyana Marshall Islands


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Chapter 1. Table 3Non-responding countries with ART.

Afghanistan Cambodia Kosovo Morocco Saudi ArabiaAlbania Croatia Kuwait Nepal Slovak RepublicAzerbaijan Cuba The Lao People’s Democratic Republic The Democratic People’s Republic of Korea SudanBahamas Cyprus Lebanon Oman SyriaBahrain Denmark Libya Pakistan United Republic of TanzaniaBhutan Haiti The former Yugoslav Republic of Macedonia Qatar YemenBosnia and Herzegovina Honduras Madagascar Rwanda ZambiaBrunei Darussalam Jamaica Mauritius

Chapter 1. Table 4Number of centres.

Reporting Year 2019 Type of Centre

Country 2010 (N) 2013 (N) 2016 (N) 2019 (N)

PrivatePhysicians

ClinicPrivate HospitalBased Clinics

Private orPublic

UniversityBased Clinics

Public HospitalBased Clinics

SolePractitioner

Clinic

Algeria Did not report Did not report Did not report 2Argentina 23-25 30-44 60 65 37 1 2 2Armenia Did not report Did not report Did not report 6 6Australia 63 Did not report 76 100 100Austria 25 25 27 28 17 3 5 2 0Bangladesh Did not report Did not report 12 11 9 2Barbados Did not report Did not report 1 1 1Belarus 4 4 8 8 5 3Belgium 16-29 31 34 10 0 0 6 4 0Bolivia Did not report Did not report Did not report 10 10 0 0 0 0Botswana Did not report Did not report Did not report 1 1Brazil 150 200 180 200 141 10 5 4Bulgaria 16 23 31 37 13 7 1 3 13Burkina Faso Did not report Did not report Did not report 1 6 60 1 12Cameroon 2 2 2 3 2 1Canada Did not report Did not report 32 34 31 0 0 3Chile 8-9 7 9 12 5 3 4China 102-300 > 200 358 400 400Colombia 19-21 27 25 23 15 3 0 0 5Costa Rica Did not report Did not report Did not report 2 2 0 0 0 0Côte d’Ivoire 3 2 Did not report 4 0 3 0 1 0Croatia 7-11 13 12 Did not reportCzechia 30 38 42 42 27 5 5 3 2Denmark 18-22 18-21 21 Did not reportDominicanRepublic

4 5 Did not report 7 7 0 0 0 10

Congo 1 1 Did not report 3 3Ecuador 6-8 11 10 12 12Egypt 52-55 58 Did not report 70 40 10 5 3 12El Salvador Did not report Did not report 0 2 30 0 0 0 30Estonia Did not report Did not report 4 6 3 1 2Finland 19-20 18 24 21 11 9 1France 90-106 100 104 101 50 50Georgia Did not report Did not report Did not report 9 4 5 0 0 0Germany Did not report Did not report 134 125 110 10 5Ghana Did not report Did not report Did not report 18 18 0 0Greece 50-60 ~60 66 50 5 8 4 6 3Guatemala Did not report Did not report 3 4 3 0 0 0 50Honduras Did not report Did not report 2 Did not reportHong Kong(China*)

7 9-12 11 42 18 4 2 7 11


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Chapter 1. Table 4

(Continued)


Country 2010 (N) 2013 (N) 2016 (N) 2019 (N)

PrivatePhysicians


Private orPublic



SolePractitioner

Clinic

Hungary 12 14 13 11 7 3 1 0Iceland 1 1 Did not report 1 1 0 0 0 0India 500 500-600 1000 1500 350 100 5 10 1000Indonesia Did not report Did not report 26 32 0 23 6 3 0Iran Did not report Did not report 62 60Iraq Did not report Did not report 13 5Ireland 7 7-8 28 8 7 1Israel 24-30 29 34 23 19 4Italy 360 350 350 350 200 150 100 100 100Japan 606-618 591 587 574 44 71 10 400Jordan Did not report Did not report 20 22 20 55 7 20 400Kazakhstan Did not report 12 19 23 2 2 3 16Kenya Did not report Did not report 5 9 8 1 0 0 4Latvia 4-5 4 Did not report 7 7Lithuania Did not report Did not report Did not report 6 3 0 0 1 2Malaysia Did not report Did not report 36 12Mali Did not report Did not report 1 1 3 13Mexico "Uncertain" ~30 48 81 70 8 1 2Moldova Did not report Did not report Did not report 1Mongolia Did not report Did not report Did not report 4 3 1Montenegro Did not report Did not report Did not report 5 3 1 1Myanmar Did not report Did not report 1 2 1 1Namibia Did not report Did not report Did not report 2 1 1 0 0 0Netherlands Did not report Did not report 13 15 1 1 8 5 0New Zealand 7 7 9 8 7 0 0 1 0Nicaragua Did not report Did not report Did not report 1 1Nigeria Did not report Did not report 50 36 3 30 2 1 0Norway 11 10 12 10 5 0 0 5 0Oman Did not report Did not report 14 Did not reportPanama 7 9 12 10 3 3 0 1 3Paraguay Did not report Did not report 2 2 2 0 0 0 0Peru 5-7 6 12 18 17 0 0 1 0Philippines 4 5 6 7Poland Did not report Did not report 50 70 50 20Portugal 24 28 24 24Romania Did not report Did not report 21 23 21 3 2RussianFederation

80 110-130 170 200

Saudi Arabia 24-30 30 50 Did not reportSenegal 2 2 2 100 118 5 1 20 450Serbia Did not report Did not report Did not report 15 8 0 4 1 2Singapore 9 11 11 11 2 5 0 3 1SlovakRepublic

Did not report Did not report 9 Did not report

Slovenia 3 3 3 3 0 1 2 0 0South Africa 12-15 15 20 22 19 3 0The Republicof Korea

142 150 148 154 59 53 42 0 0

Spain 177-203 > 100 371 150 110 40Sri Lanka Did not report Did not report 6 110 50 30 4 35 20Sweden 15-16 16 17 10 3 4 3Switzerland 26 26 25 29 16 1 5 6 1

72-78 76 79 78 7 29 19 5 18


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countries (Table 1, Chart 1). This represents 19 more registrantcountries and 23 more total responses than the 2015 ques-tionnaire, and includes 28 countries new to Surveillance.

Unfortunately, six countries in the 2016 report (Croatia,Denmark, Guatemala, Oman, Saudi Arabia, and the SlovakRepublic) did not respond to the current survey. In 2018, wecompiled for the first time a list of countries that we believecurrently have no ART activity. Countries were included in thislist after a diligent effort was made to confirm the absence of ARTservices. This entailed contacting allied health professionals in thecountry, health ministry officials, fertility specialists in neigh-boring countries or within the region, and social media profiles.As many of these sources were used as was feasible.

We compiled a list of 63 countries that did not appear to haveART programmes as of March 31, 2018 (Table 2). This inclusionovercomes some of the limitations of previous surveys. Weidentified another 39 countries that are known to provide ARTservices, but that we were unable to recruit for our survey(Table 3). We included all 195 countries currently recognized bythe United Nations in one of the three categories depicted in thethree tables.

In 2018, all 97 countries that registered on our site providedsome data regarding the number of ART centres in their countries(Table 4). Several countries were able to provide only estimates,but in aggregate these figures are consistent with previous totals.The estimated total number of ART facilities in the 2018 tally was6,201, compared to 5,353 centres calculated in 2016. However,this figure does not include six countries that responded in 2015but not in 2018 (previous total number of those centres was 108),

but does include the 28 new respondents. Their inclusion added334 centres. The new countries with the largest number of ARTprogrammes were Egypt, Thailand, and Ukraine, with 70, 75,and 40 centres, respectively. Twenty-four of the 28 respondentsnew to Surveillance noted the presence of ten or fewer centres,suggesting that ART has only recently become available in someof these countries.

Many countries (34) reported a modest increase or no sig-nificant change in the number of centres over the triennial, but 22countries recorded a decrease. Of particular note, India reportedan increase in centres, from 1,000 to 1,500; Senegal, from 2 to110; and Sri Lanka, from 6 to 110 centres. Conversely, Belgiumsaw a decrease, from 34 to 10 centres, as did Spain, from 371 to150. It is not clear whether these changes are real, or if they reflectdifferent methodologies or inclusion criteria for the tabulation.Nor is it clear what might have accounted for the differences, ifthey are actual changes.

We also queried about the type of ART programme, i.e., privatephysician clinic, private hospital-based clinic, private or public uni-versity-based clinic, public hospital-based clinic, or sole practitionerclinic. While not all respondents provided data regarding thebreakdown for type of clinic, the solo practitioner and private phy-sician clinics appear to be the predominant clinic models (Table 4).The popularity of the sole physician model represents a strikingchange from 2016, when it was the least commonly utilized.

Summary

Overall, the 2018 questionnaire results reflect a more modestincrease in the total number of ART centres than noted in

Chapter 1. Table 4

(Continued)


Country 2010 (N) 2013 (N) 2016 (N) 2019 (N)

PrivatePhysicians


Private orPublic



SolePractitioner

Clinic

Taiwan(China*)

Thailand Did not report Did not report Did not report 75 30 27 11 2 5Togo 1 1 Did not report 2 2Trinidad andTobago

Did not report Did not report 1 1 1 1 0 0 0

Tunisia 8 12 9 13 10 0 0 3Turkey 112-116 131 153 154 30 71 36 13 4Uganda 1 2 Did not report 6 2 4 0 0 0Ukraine Did not report Did not report Did not report 40 20 5 4 3 8United ArabEmirates

Did not report Did not report Did not report 10 100 50 5 5 150

UK 66 71-117 78 82 82USA 450-480 430 410 450 200 90 100 10 50Uruguay 4 4 3 3 3Venezuela 17-18 10 30 22 14 8 0 0 0Viet Nam 11-12 13 Did not report 26 0 12 4 10 0Zimbabwe Did not report Did not report Did not report 2 0 1 0 0 1Totals 3524-3870 3701-3890 5335 6201 2245 1075 529 914 2775



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previous surveys: from 5,353 to 6,201, with 500 centres aloneaccounted for by India’s putative increase. An apparent reductionin the number of clinics in some developed countries is a new andprovocative finding. If validated, this reduction might be due toconsolidation, declining populations, or other economic drivers,and should be a topic for future queries. Priorities for the nextedition of Surveillance will be to engage as many of the non-responding countries as is feasible, and to continue to refine ourlist of countries that are not performing ART procedures.

CHAPTER 2: LEGISLATION, POLICY, ANDGUIDELINES

Introduction

The 2019 Surveillance Survey provides a unique comparison ofgovernance systems among different countries. Data fromrespondents in 89 countries covered modes of regulation, gov-ernance, and oversight. The overall trend appears to be one ofincreasing uniformity, and some form of regulation now exists inmost countries where ART is available. Most often the regulationconsists of legislative requirements that establish the boundariesof practice. The legal framework often is supplemented withguidelines promulgated by the government, or by professionalsocieties; many countries also have provisions for licensing andagency oversight.

The limits of such regulation are determined by the local sta-keholders, including patient advocacy groups, local health careproviders, professional organizations, local and national gov-ernment agencies, legislative bodies, religious organizations, andinsurance companies and other organizations responsible forpayment. The position adopted for various issues is dependent ondifferent social, cultural, and political norms, and is discussed ingreater detail in later chapters of this report. Topics of extensiveattention over the past three years include advances in the geneticassessment of embryos, trends in cross-border reproductive care,ethical controversies regarding the appropriateness of preservinganonymity for gamete donation, access to ART services for sin-gles and for individuals in same-sex relationships, and proscrip-tions on commercial surrogacy.

Analysis of the survey

The 89 respondents reported as follows: 77 (87%): the practice ofART was regulated by legislation, guidelines, or both; 57 (64%):legislation existed in their country to regulate ART; and 29(33%): no legislation existed. Respondents in two countriesreplied “Unknown”. In the 2016 Surveillance report, respondentsfrom 40 countries (57%) reported having legislation; that wasfewer countries than did so in the 2018 survey (Table 1).

Of the 57 respondents that had legislation in 2018, 38 (67%)reported federal laws; 18 (32%) had both federal and state/pro-vincial/regional laws; and one had state/provincial laws only. Inaddition, most respondents, 49 (86%), had some form of agencyoversight, licensing body, or professional standards and guide-lines: of these 49,14 (29%) had all three; 26 (53%) had agencyoversight and licensing body (2); agency oversight and profes-sional standards and guidelines (1); licensing body and profes-sional standards and guidelines (23); and 15 (31%) had one of thefollowing: agency oversight (1); licensing (5); professional stan-dards/guidelines (9).

Of the 32 respondents who reported no legislation in theircountry, 20 (62.5%) acknowledged having some other form ofregulation: 2 (6.0%), all three regulations; 12 (37.5%), two of thefollowing: agency oversight and licensing body (3); agencyoversight and professional standards and guidelines (3); licensingbody and professional standards and guidelines (6); 10 (31%),one regulation: one had licensing, nine had a regulation related toprofessional standards or guidelines.

There were 64 countries that responded to the 2018 survey,and had also participated in the 2015 survey; 21 (33%) of thesecountries reported intervening updates to legislation, and 32(50%) reported no changes since the previous survey. The 11remaining respondents (17%) were unsure whether updates hadoccurred (Chart 1).

Table 2 lists the various aspects of ART addressed by legisla-tion in the past three years, in rank order, illustrating the mostprevalent topics in new legislation.

When the countries were queried about incidents in whichnational ART policies had been violated, 86 responded, as fol-lows: violations had taken place in 13 countries (15%), and nonehad occurred in 50 (58%); the response from the remaining 23countries (27%) was, “Unknown”. Respondents also were askedabout specific licensing criteria and credentialing bodies, andwere questioned about the monitoring of governance pertainingto ART centres, physicians specializing in reproductive medicine,obstetrician/gynecologist specialists practicing ART, the ARTlaboratory, and the laboratory director and staff.

The ART centre

The survey noted that out of 88 countries, 63 (72%) requiredART centres to be licensed. Most of these countries, 44 (70%),had multiple licensing requirements; only 3 (5%) had just one.

Of the 63 countries with multiple requirements, 3 (5%)required an examination or certification procedure; 10 (16%), anon-site inspection; and 21 (31%), continuing education.

ART centres were monitored in 56 of the countries (64%). Ofthe countries with monitoring systems in place, the principalmechanisms used were: a national registry, in 45 (80%); an on-site inspection, in 42 (75%); and a periodic report, in 32 (57%).Twenty-one of the countries (37%) also submitted their data toan international registry.

Government employees were responsible for monitoring ARTcentres in 30 of the 56 countries (53%), independent agenciesmonitored in 8 countries (14%), and medical officers did so in 16countries (28.5%). Again, some countries used more than onemethod ofmonitoring. Thirteen countries (23%) reported that noone was responsible for monitoring.

Reproductive medicine physicians

Of the 89 countries responding, 45 (51%) had mechanisms for licen-sing or credentialing physicians in reproductive medicine, or endocri-nologists who had special training in ART. In 40 of these 45 countries(89%), the mechanisms used were examination and certification.

In 87 of the 89 countries, 36 respondents (41%) said that ongoingmonitoring of physicians in reproductive medicine was performedprimarily by government agencies, medical officials, or both, butsome physicians were monitored by an independent agency.


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Chapter 2. Table 1How is ART regulated in your country?

CountryNo

Regulations

Federal/National Laws/Statutes/Ordinances/

PoliciesState/Provincial/RegionalLaws/Statutes/Ordinances

Municipal Laws/Statutes/Ordinances

AgencyRegulations/Oversight

LicensingBody

ProfessionalOrganization Standards/

Guidelines

Argentina No Yes Yes No No Yes YesArmenia Yes YesAustralia Yes Yes Yes Yes YesAustria No Yes Yes Yes Yes Yes YesBangladesh Yes No No No No No NoBarbados YesBelarus No Yes Yes Yes Yes NoBelgium No Yes No No No Yes YesBolivia Yes Yes YesBotswana Yes YesBrazil Yes No No Yes Yes YesBulgaria No Yes No No Yes No NoBurkina Faso No No No No No No NoCameroon Yes No No No No No YesCanada No Yes Yes No No No YesChile No Yes No No Yes Yes YesChina Yes Yes Yes Unknown Unknown Unknown UnknownColombia Yes No No No Yes Yes YesCosta Rica No Yes No No Yes Yes YesCôte d’Ivoire Unknown Unknown Unknown Unknown Unknown Unknown UnknownCzechia No Yes Yes No Yes Unknown YesCongo NoEcuador Yes No No No No No YesEgypt Yes YesEl Salvador Yes Unknown Unknown Unknown Yes Yes YesEstonia No Yes No No No No NoFinland No Yes No No No Yes YesFrance No Yes No No Yes Yes NoGeorgia YesGermany Yes Yes Yes YesGhana Yes No No No No No YesGreece Yes Yes No No No No YesGuatemala Yes No No No No No NoHong Kong(China*)

No Yes Yes No No Yes Yes

Hungary No Yes No No No Yes YesIceland No Yes No No No Yes YesIndia Yes Unknown YesIndonesia No Yes Yes Unknown Unknown YesIreland No Yes No No Yes Yes YesIsrael YesItaly No Yes Yes Yes Yes Yes NoJapan No No No No No No YesJordan Yes Unknown No No No Yes YesKazakhstan No Yes No No No Yes NoKenya Yes Yes YesLatvia No Yes No No Yes Yes YesLithuania No Yes No No No Yes YesMali No YesMexico Yes No No No No NoMongolia Yes Yes No No No Yes YesMontenegro No Yes YesNamibia Yes Yes YesNetherlands No Yes No No No No YesNew Zealand Yes No No No Yes YesNicaragua Yes YesNigeria No No No No No Yes NoNorway No Yes No No No Yes YesPanama NoParaguay No No No No No No No


10

Chapter 2. Table 1

(Continued)

CountryNo

Regulations


PoliciesState/Provincial/RegionalLaws/Statutes/Ordinances



LicensingBody

ProfessionalOrganization Standards/

Guidelines

Peru Yes No No No No No YesPhilippines No No No No Yes YesPoland No Yes Yes Yes Unknown Unknown YesPortugal No Yes No Yes Yes YesRomania Yes No No No Yes Yes NoRussianFederation

Yes Yes No Yes Yes Yes

Senegal Yes No No No No No YesSerbia No Yes No No Yes Yes YesSingapore Yes YesSlovenia No Yes No No No Yes YesSouth Africa No Yes Yes No No Yes YesThe Republicof Korea

No Yes No No No No Yes

Spain No Yes Yes Yes Yes Yes YesSri Lanka No No No No Yes No YesSweden No Yes Yes No Yes Yes YesSwitzerland No Yes No No Unknown Unknown YesTaiwan(China*)

No Yes No No No No No

Thailand Yes Yes YesTogo Yes No No No No YesTrinidad andTobago

Yes No No No No No No

Tunisia Yes No No No No Yes YesTurkey No Yes No No No No NoUganda No No No No No NoUnited ArabEmirates

No Yes Yes No No Yes Yes

UK No Yes No No No Yes YesUSA No Yes Yes No Yes Yes YesUruguay No Yes No No Yes Yes YesVenezuela Yes No No No No No YesViet Nam No Yes No No No No YesZimbabwe No No No No No No No


5%

5%

5%

5%

5%

10%

10%

10%

19%

19%

24%

24%

29%

Micromanipulation

Cryopreservation

Cloning

Posthumous Reproduction

Marital Status

Same sex/single parenting policy

Number of embryos for transfer

Cross Border Reproduction

Surrogacy

Experimentation on the embryo

Legislation and guidelines

PGT

Donation

Chapter 2. Chart 1. % of countries reporting legislation changes since 2016 (more than one topic may have been modified per country).


11

The obstetrician/gynecologist practicing ART

For physicians in this category, licensing criteria were in place in44 of the 89 countries responding (49%). In 35 of the countries(79.5%), examination or certification was the criterion forlicensing; 28 of the 44 countries (64%) also required continuingeducation. The survey did not query respondents about whetherthey had separate sub-specialization fellowship programmes forreproductive medicine specialists. Overlap likely exists betweenthe categories of obstetrician/gynecologist, with and withoutfurther fellowship qualifications.

The ART laboratory

Of the 89 countries, 52 (58%) reported licensing requirementsspecific to the ART laboratory. In all but 2 cases, this was inaddition to the licensing requirements for the whole centre. Ofthose 52 countries with ART-specific requirements, 41 (79%)relied on a certification system; 42 (81%) required an on-siteinspection; and 23 (44%) called for a periodic report. Mostcountries indicated they had a combination of such licensingrequirements.

Of the 87 respondents with ongoingmonitoring, 51 (58%) hadongoing monitoring criteria for the ART labs, and 39 (76%) usedon-site inspection for this process. Others used a combination ofperiodic reporting, registry, and re-certification. Twenty-fourrespondents (47%) indicated the monitoring was performed bygovernment employees, 22 (43%) said it was by medical officials,and 7 (14%) indicated it was by independent agencies. Again,some respondents used more than one such monitoring method.

Lab director and lab staff

Thirty-three of 88 respondents (37%) reported licensing criteriafor the lab director, and 38 of 85 (45%) did so for the lab staff.Examination, certification, and continuing education were thecriteria specified in more than 80% of these cases. Twenty-nineout of 84 (34%) reported using ongoing monitoring for the labdirector; and 31 out of 87 (35%) used it for lab staff, withmechanisms similar to those of the original licensing criteria.

Penalties for violation of governance, licensure, orcredentialing

Of 86 respondents, 51 (59%) indicated penalties existed forviolations of governance, licensure, or credentialing. Twenty-nine

of 86 respondents (34%) said no penalties were in place; and 6 of86 (7%) answered “unknown”.

The respondent countries described various types of penalties,including those listed below:• admonishment;• administrative penalties;• publication of deficiencies;• reporting to medical board (with possible sanctions);• suspension of ART license;• refusal of registration renewal;• revocation of ART license;• closure of the ART centre;• financial penalties (fines);• criminal charges against the person responsible;• criminal penalties (including incarceration). The sanctions

used most often were financial penalties, loss of license, andthe possibility of criminal prosecution.

Summary

Eighty-nine country respondents to the 2018 IFFS Surveillancequestionnaire provided data about the regulatory system gov-erning the practice of ART, using monitoring, governance,oversight, or penalties. The response from the 89 countries wasgreater than the 2016 response of 70 countries, and greater thanthe 2013 response of 60 countries. The 2019 survey revealed aclear trend favoring some form of regulation, indicated by86.5%. New or expanded areas for ART regulation includedcontinued attention to anonymous donation, cross-borderreproduction, IVF surrogacy, pre-implantation genetic diagnosis,experimentation on embryos, micromanipulation, marital status,and same-sex parenting. Other important topics: more activeregulation of ART centres, professionals, laboratories, andstaff, via extensive licensing and monitoring requirements.Certification, examination, continuing education, and periodicreporting featured prominently in the responses.

CHAPTER 3: INSURANCE COVERAGE

Introduction

Eighty-five responding countries submitted data on the extent ofinsurance coverage, a 21% increase (70 to 85) over the 2016 IFFSSurveillance report. The 2018 questions pertaining to insurancecoverage sought information related to changes since the 2016

Chapter 2. Table 2Main modification to legislation in last 3 years.

Main Modification (In rank order)% of Countries that Reported Legislation Change Out of 89 Countries (More than One Topic May have been

Modified Per Country)

General changes to legislation and guidelines 29%Donation 29%IVF surrogacy 19%Pre-implantation genetic diagnosis 19%Experimentation on the embryo 14%Same sex/single parenting policy 10%Micromanipulation 10%Posthumous reproduction 5%Marital status 5%Cross border reproduction 5%


12

Chapter 3. Table 1Are there regulations that address reimbursement of ART procedures in your country?

CountryFederal National LawsStatutes Ordinances

State Provincial RegionalLaws Statutes Ordinances

Municipal LawsStatutes Ordinances

ReligiousDecree

AgencyRegulationsOversight

CulturalPractice

Professional OrganizationStandards Guidelines

Argentina Yes Yes No No Yes No NoArmenia No No No No No No NoAustralia Yes Yes Yes YesAustria Yes No No No No No YesBangladesh No No No No No No NoBarbados No No No No No No NoBelarus No No No No NoBelgium Yes No No No No No NoBolivia No No No No No No NoBotswana No No No No No No NoBrazil No No No No No No NoBulgaria Yes Yes Yes No Yes No NoBurkina Faso No No No No No No NoCameroon No No No No No No YesCanada No Yes No No No No NoChile Yes No No No No No NoChina No No No No No No NoColombia No No No No No No NoCongo No No No No No No NoCôte d’Ivoire Yes Unknown Unknown Yes Yes Unknown YesCzechia Unknown Yes No No No No NoEcuador No No No No No No NoEgypt No No No No No Yes NoEl Salvador No No No No No No NoFinland Yes No No No No NoFrance Yes No No No No No NoGeorgia No No No No No No NoGermany Yes Yes Yes No No No NoGhana No No No No No No NoGreece No No No No No Yes NoGuatemala No No No No No No NoHong Kong(China*)

No No No No Yes No No

Hungary Yes No No No No No YesIceland Yes No No No No No NoIndia No No No No No No NoIreland Yes No No No No No NoIsrael Yes YesItaly Yes Yes Yes Yes Yes Yes NoJordan No No No No No Yes YesKazakhstan Yes Unknown Unknown Unknown Unknown Unknown YesKenya Yes No No No No No NoLatvia Yes No No No No No NoLithuania Yes No No No No No YesMali No No No No No No NoMexico No No No No No No YesMongolia Yes No No No Yes No NoMontenegro YesNamibia Unknown Unknown Unknown Unknown Unknown Unknown YesNetherlands Yes No No No No No NoNew Zealand No No No No Yes No NoNicaragua No No No No No No NoNigeria No No No No No No NoNorway Yes No No No No NoPanama No No No No No No NoParaguay No No No No No No NoPeru No No No No No No NoPhilippines No No No No No No NoPoland No Yes Yes No Unknown Unknown UnknownPortugal Yes No No No Yes No Yes


13

report, availability of funding for infertility treatments, existenceof regulation governing the reimbursement of ART, extent ofcoverage and services covered by insurance, mode of reimburse-ment, and specifics related to demographics and good clinicalpractice.


In 2018, 85 countries responded to a question about whethereither insurance coverage or government funding was availablefor infertility treatment. Forty countries (47%) reportedly didprovide such funding, compared to 37 in 2015. Moreover, 45 ofthe 85 countries responding (53%) did not offer any type offinancial support. For the 2012 and 2015 questionnaires, thefigures were 40% providing some funding, and 36% not offeringany financial support.

Regarding other changes since previous reporting, Japan andthe United Kingdom of Great Britain and Northern Ireland noteddecreased financial support for ART, 16 countries reportedexpanded financial support, and 42 countries indicated nochanges from three years ago. Notably, in Africa, Cameroon, andSenegal are progressing ART legislation, Burkina Faso is

beginning to fund insurance and, in Asia, India has introducedrestrictions for international patients seeking surrogacy access.

In Europe, Montenegro offered coverage for 3 full, fresh cyclesof IVF; and in Slovenia, ART coverage spans 6 cycles for 1 livebirth, and 4 for the next live birth, provided that single ET is used.The United States of America has seen an increase in access forsmall, selected populations, and increased coverage by some largeemployers.

Where ART reimbursement is in place, some countries regulateassociated finances, as follows: at the national or federal level, 36of 85 countries (42%); regional, 16 of 83 countries (19%);municipal, 5 of 81 countries (6%); and by religious decree, 2 of 79countries (3%). Other countries regulate reimbursement throughdedicated agencies, 11 of 82 countries (13%), or professionalorganizations, 14 of 79 countries (18%) (Table 1).

The extent of coverage for ART services varies with location.For this report, coverage was divided as complete coverage andpartial reimbursement. When reimbursement or coverage was ata national level, 15 of 38 countries (39%) offered completecoverage, and 23 of 38 countries (61%) offered partial reim-bursement. Where a regional plan was in place, 3 of the 15countries responding (20%) offered complete coverage, and 12(80%) offered partial coverage. Of note, private insurance offers

Chapter 3. Table 1

(Continued)

CountryFederal National LawsStatutes Ordinances

State Provincial RegionalLaws Statutes Ordinances

Municipal LawsStatutes Ordinances

ReligiousDecree


CulturalPractice

Professional OrganizationStandards Guidelines

Romania Yes No No No No No NoRussianFederation

Yes Yes No No No No No

Senegal No No No No No No NoSerbia Yes No Yes No No No YesSingapore YesSlovenia Yes Yes No No No No YesSouth Africa Yes No No No No No NoThe Republicof Korea

No No No No No No No

Spain Yes Yes No No Yes NoSri Lanka No No No No No No NoSweden No No No No No No YesSwitzerland No No No No No No NoTaiwan(China*)

No Unknown No No No No No

Thailand No No No No No No NoTogo No No No No No No NoTrinidad andTobago


Tunisia Yes Yes No No No No NoTurkey Yes No No No No No NoUganda No No No No No No NoUnited ArabEmirates

Yes Yes Unknown Unknown Unknown Unknown Unknown

UK No Yes No No No No NoUSA Yes Yes No No Yes No NoUruguay Yes No No No Yes No NoVenezuela No No No No No No NoViet Nam No No No No No No NoZimbabwe No No No No No No No



14

Chapter 3. Table 2What is the coverage or reimbursement of ART services by health plans?

Country National Health PlanState/Provincial/Regional

Health Plan Private Insurance

Combination of GovernmentHealth Plan

and Private Insurance

Argentina Partial Coverage or Reimbursement Partial Coverage or Reimbursement Partial Coverage or Reimbursement No Coverage or ReimbursementAustralia Partial Coverage or Reimbursement Partial Coverage or Reimbursement Partial Coverage or ReimbursementAustria Partial Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementBangladesh No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementBarbados No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementBelarus No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementBelgium Partial Coverage or Reimbursement No Coverage or Reimbursement Unknown UnknownBolivia Partial Coverage or ReimbursementBrazil No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementBulgaria Complete Coverage or Reimbursement Partial Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementBurkina Faso Unknown Unknown Unknown No Coverage or ReimbursementCameroon No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementCanada Partial Coverage or Reimbursement Partial Coverage or Reimbursement Partial Coverage or Reimbursement Partial Coverage or ReimbursementChile Complete Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementChina Unknown Unknown Unknown UnknownColombia No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementCzechia Complete Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementCongo Unknown Unknown Unknown UnknownEcuador No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementFinland Partial Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementFrance Complete Coverage or ReimbursementGeorgia No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementGermany Partial Coverage or Reimbursement Partial Coverage or Reimbursement Complete Coverage or Reimbursement Complete Coverage or ReimbursementGreece No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementGuatemala UnknownHong Kong(China*)

Partial Coverage or Reimbursement Partial Coverage or Reimbursement Unknown Unknown

Hungary Complete Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementIceland Partial Coverage or ReimbursementIndia No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementIreland Partial Coverage or Reimbursement Partial Coverage or ReimbursementIsrael Complete Coverage or Reimbursement Partial Coverage or ReimbursementItaly No Coverage or Reimbursement Partial Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementCôte d’Ivoire Unknown Unknown Unknown UnknownJapan Partial Coverage or Reimbursement Partial Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementJordan No Coverage or Reimbursement Unknown Partial Coverage or Reimbursement Partial Coverage or ReimbursementKazakhstan Partial Coverage or Reimbursement Unknown Unknown UnknownKenya Partial Coverage or Reimbursement Unknown Partial Coverage or Reimbursement UnknownLatvia Complete Coverage or Reimbursement No Coverage or Reimbursement Unknown No Coverage or ReimbursementLithuania Partial Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementMali Unknown Unknown Unknown UnknownMexico No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementMongolia No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementMontenegro Complete Coverage or ReimbursementNamibia No Coverage or Reimbursement No Coverage or Reimbursement Partial Coverage or Reimbursement Partial Coverage or ReimbursementNetherlands Complete Coverage or Reimbursement Complete Coverage or ReimbursementNew Zealand Partial Coverage or Reimbursement No Coverage or ReimbursementNicaragua No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementNigeria No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementNorway Partial Coverage or ReimbursementPanama No Coverage or Reimbursement No Coverage or Reimbursement Partial Coverage or Reimbursement No Coverage or ReimbursementParaguay No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementPeru No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementPhilippines Unknown Unknown No Coverage or Reimbursement UnknownPoland No Coverage or Reimbursement Partial Coverage or Reimbursement Unknown No Coverage or ReimbursementPortugal Partial Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementRomania No Coverage or Reimbursement No Coverage or Reimbursement Partial Coverage or ReimbursementRussianFederation

Complete Coverage or Reimbursement Complete Coverage or Reimbursement Unknown No Coverage or Reimbursement

Senegal No Coverage or Reimbursement No Coverage or Reimbursement Complete Coverage or Reimbursement No Coverage or Reimbursement


15

Chapter 3. Table 2

(Continued)

Country National Health PlanState/Provincial/Regional

Health Plan Private Insurance

Combination of GovernmentHealth Plan

and Private Insurance

Serbia Complete Coverage or Reimbursement Unknown Complete Coverage or Reimbursement UnknownSingapore Partial Coverage or ReimbursementSlovenia Complete Coverage or ReimbursementSouth Africa No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementThe Republicof Korea

Partial Coverage or Reimbursement

Spain Complete Coverage or Reimbursement Complete Coverage or Reimbursement Partial Coverage or Reimbursement Partial Coverage or ReimbursementSri Lanka No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementSweden Complete Coverage or Reimbursement Partial Coverage or Reimbursement Partial Coverage or ReimbursementTaiwan(China*)

No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement

Thailand No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementTogo No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementTunisia Partial Coverage or Reimbursement Partial Coverage or Reimbursement Partial Coverage or Reimbursement Partial Coverage or ReimbursementTurkey Partial Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementUganda Unknown Unknown Unknown UnknownUAE Complete Coverage or Reimbursement Complete Coverage or Reimbursement Complete Coverage or Reimbursement UnknownUK Partial Coverage or Reimbursement Partial Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementUSA No Coverage or Reimbursement Partial Coverage or Reimbursement Partial Coverage or Reimbursement Partial Coverage or ReimbursementUruguay Partial Coverage or Reimbursement no Coverage or Reimbursement Partial Coverage or Reimbursement Partial Coverage or ReimbursementVenezuela No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or ReimbursementViet Nam Unknown Unknown Unknown Partial Coverage or ReimbursementZimbabwe No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement No Coverage or Reimbursement


Chapter 3. Table 3aIf there are programs for coverage or reimbursement of ART services, which of the following do they include?

Country Diagnostic Evaluation Fertility Medications Intrauterine Insemination

Argentina National health planState/Provincial/Regional health planPrivate insurance

National health planState/Provincial/Regional health planPrivate insurance


Australia National health planPrivate insurance

National health planPrivate insurance


Austria No coverage National health plan No coverageBangladesh No coverage No coverage No coverageBarbados No coverage No coverage No coverageBelarus National health plan

State/Provincial/Regional health planPrivate insurance

No coverage No coverage

Belgium National health plan National health plan National health planBolivia No coverage No coverage No coverageBotswana No coverage No coverage No coverageBrazil Private insurance No coverage No coverageBulgaria No coverage National health plan

State/Provincial/Regional health planState/Provincial/Regional health plan

Burkina Faso Private insurance No coverage No coverageCameroon Private insurance No coverage No coverageCanada National health plan Private insurance National health planChile National health plan

Private insuranceNational health planPrivate insurance

National health plan

China No coverage No coverageColombia No coverage No coverage No coverageCongo No coverage No coverage No coverageCôte d’Ivoire Private insurance Unknown UnknownCzechia National health plan National health plan National health planEcuador Private insurance


16

Chapter 3. Table 3a

(Continued)


El Salvador No coverage No coverage No coverageFinland National health plan National health plan National health planFrance National health plan National health plan National health planGeorgia No coverage No coverage No coverageGermany National health plan


National health plan

Ghana No coverage No coverage No coverageGreece No coverage No coverage No coverageGuatemala Private insurance No coverage No coverageHong Kong (China*) National health plan




Hungary National health plan National health plan National health planIceland National health plan No coverageIndia No coverage No coverage No coverageIreland Private insurance National health plan Private insuranceIsrael National health plan National health plan National health planItaly State/Provincial/Regional health plan National health plan

Jordan No coverage No coverage No coverageKazakhstan No coverage National health plan No coverageKenya National health plan


Unknown

Latvia National health plan National health plan National health planLithuania National health plan National health plan No coverageMali National health plan


No coverage

Mexico No coverage No coverage No coverageMongolia No coverage No coverage No coverageMontenegro National health plan National health plan No coverageNamibia State/Provincial/Regional health plan

Private insuranceNo coverage No coverage

Netherlands National health planPrivate insurance



New Zealand National health plan National health plan National health planNicaragua No coverage No coverage No coverageNigeria No coverage No coverage No coverageNorway National health plan National health plan National health planPanama No coverage No coverage National health planParaguay Private insurance No coverage No coveragePeru No coverage No coverage No coveragePhilippines No coverage No coverage No coveragePoland No coverage No coverage No coveragePortugal National health plan

Private insuranceNational health plan National health plan

Romania National health plan National health plan No coverageRussian Federation National health plan

State/Provincial/Regional health planNational health planState/Provincial/Regional health plan

No coverage

Senegal Private insuranceNo coverage

Private insuranceNo coverage


Serbia National health plan National health plan National health planSingapore No coverage No coverage National health planSlovenia National health plan National health plan National health planSouth Africa State/Provincial/Regional health plan


The Republic of Korea National health plan National health plan National health planSpain National health plan

Private insuranceNational health plan National health plan


Sri Lanka No coverage No coverage No coverageSweden National health plan National health plan National health planSwitzerland Private insurance Private insurance Private insuranceTaiwan (China*) National health plan No coverage No coverage


17

Chapter 3. Table 3a

(Continued)


Thailand No coverage No coverage No coverageTogo No coverage No coverage No coverageTrinidad and Tobago No coverage No coverage No coverageTunisia National health plan


No coverage

Turkey National health plan National health plan National health planUganda Unknown Unknown UnknownUAE Private insurance Private insurance Private insuranceUK State/Provincial/Regional health plan State/Provincial/Regional health plan State/Provincial/Regional health planUSA National health plan




Uruguay National health plan National health plan Private insuranceVenezuela No coverage No coverage No coverageViet Nam No coverage No coverage No coverageZimbabwe Private insurance Private insurance Private insurance


Chapter 3. Table 3bIf there are programs for coverage or reimbursement of ART services, which of the following do they include?

Country IVF ICSI Assisted Hatching

Argentina National health planState/Provincial/Regional health planPrivate insurance


National health plan,State/Provincial/Regional health planPrivate insurance

Australia National health planPrivate insurance


No coverage

Austria National health plan National health plan No coverageBangladesh No coverage No coverage No coverageBarbados No coverage No coverage No coverageBelarus No coverage No coverage No coverageBelgium National health plan UnknownBolivia Private insurance Private insurance No coverageBotswana No coverage No coverage No coverageBrazil National health plan No coverage No coverageBulgaria National health plan


No coverage

Burkina Faso No coverage No coverage No coverageCameroon No coverage No coverage No coverageCanada National health plan National health plan National health planChile National health plan National health plan No coverageChina No coverage No coverage No coverageColombia No coverage No coverage No coverageCzechia National health plan No coverage No coverageCongo No coverage No coverage No coverageEl Salvador No coverage No coverage No coverageFinland National health plan National health plan No coverageFrance National health plan National health plan No coverageGeorgia No coverage No coverage No coverageGermany National health plan


No coverage

Ghana No coverage No coverage No coverageGreece No coverage No coverage No coverageGuatemala No coverage No coverage No coverageHong Kong (China*) National health plan


No coverage

Hungary National health plan National health plan National health planIceland National health plan National health plan No coverageIndia No coverage No coverage No coverage


18

Chapter 3. Table 3b

(Continued)

Country IVF ICSI Assisted Hatching

Ireland Private insurance Private insurance Private insuranceIsrael National health plan National health plan National health planItaly State/Provincial/Regional health plan State/Provincial/Regional health plan No coverageCôte d’Ivoire Unknown Unknown UnknownJordan No coverage No coverage No coverageKazakhstan National health plan National health planKenya National health plan


Unknown

Latvia National health plan National health plan No coverageLithuania National health plan National health plan No coverageMali No coverage No coverage No coverageMexico No coverage No coverage No coverageMongolia No coverage No coverage No coverageMontenegro National health plan National health plan No coverageNamibia No coverage No coverage No coverageNetherlands National health plan


No coverage

New Zealand National health plan National health plan No coverageNicaragua No coverage No coverage No coverageNigeria No coverage No coverage No coverageNorway National health plan National health plan No coveragePanama No coverage No coverage No coverageParaguay No coverage No coveragePeru No coverage No coverage No coveragePhilippines No coverage No coverage No coveragePoland No coverage No coverage No coveragePortugal National health plan National health plan National health planRomania National health plan National health plan National health planRussian Federation National health plan


National health planState/Provincial/Regional health plan

Senegal Private insurance, No coverage Private insurance, No coverage UnknownSerbia National health plan No coverage National health planSingapore National health plan National health plan National health planSlovenia National health plan National health planSouth Africa No coverage No coverage No coverageThe Republic of Korea National health plan National health plan National health planSpain National health plan




Sri Lanka No coverage No coverage No coverageSweden National health plan No coverageSwitzerland No coverage No coverage No coverageTaiwan (China*) No coverage No coverage No coverageThailand No coverage No coverage No coverageTogo No coverage No coverage No coverageTrinidad and Tobago No coverage No coverage No coverageTunisia National health plan



Turkey National health plan National health plan National health planUganda Unknown Unknown UnknownUAE Private insurance Private insurance Private insuranceUK State/Provincial/Regional health plan State/Provincial/Regional health plan No coverageUSA State/Provincial/Regional health plan

Private insuranceState/Provincial/Regional health plan Private insurance State/Provincial/Regional health plan

Private insuranceUruguay National health plan National health plan National health planVenezuela No coverage No coverage No coverageViet Nam No coverage No coverage No coverageZimbabwe No coverage No coverage No coverage



19

full coverage in 5 of the 19 countries (26%) and partial coveragein 15 of the 19 (74%) (Table 2). Tables 3a–h lists full details ofservices covered at these multiple levels. Additional informationregarding coverage is presented in Chart 1.

The report also probed to determine which specific fertilityprocedures and therapies are reimbursed, such as diagnosticevaluation; fertility medications; intrauterine insemination (IUI);in vitro fertilization (IVF); intracytoplasmic sperm injection(ICSI); assisted hatching; use of donor sperm, eggs or embryos;use of surrogacy; and use of fertility preservation (sperm, oocytes,embryos, tissue) for medical (“social”) and non-medical indica-tions (Charts 3–5).

Additional data accrued addressed coverage for cryopre-servation of oocytes or embryos for ART cycles, in which

Chapter 3. Table 3cIf there are programs for coverage or reimbursement of ARTservices, which of the following do they include?

Country

Cryopreservation ofSupernumerary

Oocytes from an IVF Cycle

Cryopreservation ofSupernumerary Embryos

from an IVF Cycle

Argentina National health planState/Provincial/Regionalhealth plan

Private insurance

National health planState/Provincial/Regionalhealth plan

Private insuranceAustralia No coverage No coverageAustria No coverage No coverageBangladesh No coverage No coverageBarbados No coverage No coverageBelarus No coverage No coverageBelgium National health plan National health planBolivia No coverageBotswana No coverage No coverageBrazil No coverage No coverageBulgaria No coverage National health plan

State/Provincial/Regionalhealth plan

Burkina Faso No coverage No coverageCameroon No coverage No coverageCanada National health plan National health planChile No coverage No coverageChina No coverage No coverageColombia No coverage No coverageCongo No coverage No coverageCôte d’Ivoire Unknown UnknownCzechia No coverage No coverageEl Salvador No coverage No coverageFinland No coverage National health planFrance National health plan National health planGeorgia No coverage No coverageGermany No coverage No coverageGhana No coverage No coverageGreece No coverage No coverageGuatemala No coverage No coverageHong Kong (China*) No coverage No coverageHungary National health plan National health planIceland No coverage National health planIndia No coverage No coverageIreland Private insurance Private insuranceIsrael National health plan National health planItaly No coverage No coverageJordan No coverage National health planKazakhstan No coverage No coverageKenya Unknown UnknownLatvia No coverage National health planLithuania No coverage No coverageMali No coverage No coverageMexico No coverage No coverageMongolia No coverage No coverageMontenegro No coverage No coverageNamibia No coverage No coverageNetherlands National health plan


New Zealand National health plan National health planNicaragua No coverage No coverageNigeria No coverage No coverageNorway National health plan National health planPanama No coverage No coverageParaguay No coverage No coveragePeru No coverage No coverage

Chapter 3. Table 3c

(Continued)

Country



Cryopreservation ofSupernumerary Embryos

from an IVF Cycle

Philippines No coverage No coveragePoland No coverage No coveragePortugal National health plan National health planRomania No coverage No coverageRussian Federation National health plan



Senegal Private insuranceNo coverage


Serbia Unknown UnknownSingapore National health plan National health planSlovenia National health plan National health planSouth Africa No coverage No coverageThe Republic of Korea National health plan National health planSpain National health plan


Private insurance


Private insuranceSri Lanka No coverage No coverageSweden National health plan National health planSwitzerland No coverage No coverageTaiwan (China*) No coverage No coverageThailand No coverage No coverageTogo No coverage No coverageTrinidad and Tobago No coverage No coverageTunisia No coverage No coverageTurkey No coverage National health planUganda Unknown UnknownUnited Arab Emirates Private insurance Private insuranceUK No coverage State/Provincial/Regional

health planUSA State/Provincial/Regional

health planPrivate insurance



Uruguay No coverage National health planVenezuela No coverage No coverageViet Nam No coverage No coverageZimbabwe No coverage No coverage



20

embryos are screened for chromosome abnormalities and geneticdiseases. These procedures include preimplantation geneticscreening (PGS), preimplantation genetic diagnosis (PGD), com-prehensive chromosome screening (CCS), preimplantationgenetic testing (PGT), and the PGT subtypes, PGT-Mand PGT-A.(PGT-M refers to monogenic/single-gene disorders; the A in PGT-A is for aneuploidy, indicating an abnormal number of chro-mosomes.) The two tests offer at-risk patients an opportunity toselect embryos that carry a reduced risk of birth defects.

Tables 4a–d present details of insurance coverage for fertilitytreatments. Of 83 responses, only 37 countries (45%) providereimbursement for IVF/ICSI. The patient’s demographic back-ground affects the extent of ART support. As for infertility status(primary, secondary, or family-building), many countries setspecific limits for ART funding (Table 5, Chart 2). Of 79 coun-tries responding, 28 (35%) cover patients with primary infertility,while 23 of 77 countries queried (30%) cover secondary inferti-lity. Of 75 countries responding to a query about family-buildingcoverage, 25 (33%) say that they offer it.

Female age is also a determinant factor for reimbursement in40 countries, with 31 respondents (78%) providing data. Thelowest age limit for coverage, 38 years, was cited for Latvia andLithuania; the highest was age 50, in Australia. Only two coun-tries impose an age limit for males: Austria and Germany, both50 years. Coverage also is influenced by duration of infertility.According to 5 responses from 40 countries reporting (12.5%),minimum duration varies widely, from 1 year in The United

Chapter 3. Table 3dIf there are programs for coverage or reimbursement of ARTservices, which of the following do they include?

Country PGT-M PGT-A

Argentina No coverage No coverageAustralia No coverage No coverageAustria No coverage No coverageBangladesh No coverage No coverageBarbados No coverage No coverageBelarus No coverage No coverageBelgium Unknown UnknownBolivia No coverage No coverageBotswana No coverage No coverageBrazil No coverage No coverageBulgaria No coverage No coverageBurkina Faso No coverage No coverageCameroon No coverage No coverageCanada No coverage No coverageChile No coverage No coverageChina No coverage No coverageColombia No coverage No coverageCzechia National health plan National health planCongo No coverage No coverageEl Salvador No coverage No coverageFinland No coverage No coverageFrance No coverage No coverageGeorgia No coverage No coverageGermany No coverage No coverageGhana No coverage No coverageGreece No coverage No coverageGuatemala No coverage No coverageHong Kong (China*) No coverage No coverageHungary No coverage No coverageIceland Unknown UnknownIndia No coverage No coverageIreland Unknown UnknownIsrael National health plan Private insuranceItaly No coverage No coverageCôte d’Ivoire No coverage No coverageJordan No coverage No coverageKazakhstan No coverageKenya Unknown UnknownLatvia No coverage No coverageLithuania National health plan No coverageMali No coverage No coverageMexico No coverage No coverageMongolia No coverage No coverageMontenegro No coverage No coverageNamibia No coverage No coverageNetherlands National health plan

Private insuranceNew Zealand National health plan No coverageNicaragua No coverage No coverageNigeria No coverage No coverageNorway National health plan No coveragePanama No coverage No coverageParaguay No coverage No coveragePeru No coverage No coveragePhilippines No coverage No coveragePoland No coverage No coveragePortugal National health plan National health planRomania No coverage No coverageRussian Federation No coverage No coverageSenegal Unknown UnknownSerbia National health plan No coverage

Chapter 3. Table 3d

(Continued)

Country PGT-M PGT-A

Singapore National health plan National health planSlovenia National health plan No coverageSouth Africa No coverage No coverageThe Republic of Korea No coverage No coverageSpain National health plan


Private insurance

No coverage

Sri Lanka No coverage No coverageSweden National health plan No coverageSwitzerland No coverage No coverageTaiwan (China*) No coverage No coverageThailand No coverage No coverageTogo No coverage No coverageTrinidad and Tobago No coverage No coverageTunisia No coverage No coverageTurkey National health plan No coverageUganda Unknown UnknownUnited Arab Emirates Private insurance Private insuranceUK State/Provincial/Regional

health planNo coverage

USA State/Provincial/Regionalhealth plan

Private insurance


Private insuranceUruguay No coverage No coverageVenezuela No coverage No coverageViet Nam No coverage No coverageZimbabwe No coverage No coverage



21

States of America and United Kingdom of Great Britain andNorthern Ireland, to 2 years in Romania and 3 in Turkey(Chart 6).

In 40 reporting countries, 3 replies (8%) indicate that reim-bursement for ART is contingent upon personal income: Japan,The Republic of Korea and the United Arab Emirates. The 2015survey listed only 3 of 35 responding countries (9%) with thiscontingency: Canada, Italy, and The Republic of Korea.

In 40 reporting countries, 9 replies (22.5%) indicate thatreimbursement for ART is contingent upon the number ofembryos transferred. The 9 countries are Australia, Belgium,Canada, Czechia, Iceland, Israel, Netherlands, Turkey and TheUnited States of America. The 2015 survey listed only 7 of 38responding countries (18%) with this contingency: Belgium,Canada, Czechia, Israel, Netherlands, Turkey and The UnitedStates of America.

Chapter 3. Table 3eIf there are programs for coverage or reimbursement of ARTservices, which of the following do they include?

Country Donor Sperm Donor Egg Donor Embryos

Argentina State/Provincial/Regional healthplan

Private insurance

State/Provincial/Regional healthplan

Private insurance


Private insuranceAustralia National health plan



Austria No coverage No coverage No coverageBangladesh No coverage No coverage No coverageBarbados No coverage No coverage No coverageBelarus No coverage No coverage No coverageBelgium Unknown Unknown UnknownBolivia No coverage No coverage No coverageBotswana No coverage No coverage No coverageBrazil No coverage No coverage No coverageBulgaria No coverage State/Provincial/

Regional healthplan


Burkina Faso No coverage No coverage No coverageCameroon No coverage No coverageCanada No coverage No coverage No coverageChile No coverage No coverage No coverageChina No coverage No coverage No coverageColombia No coverage No coverage No coverageCongo No coverage No coverage No coverageCôte d’Ivoire No coverage No coverage No coverageCzechia No coverage No coverage No coverageEl Salvador No coverage No coverage No coverageFinland No coverage No coverage No coverageFrance National health plan National health plan National health planGeorgia No coverage No coverage No coverageGermany No coverage No coverage No coverageGhana No coverage No coverage No coverageGreece No coverage No coverage No coverageGuatemala No coverage No coverage No coverageHong Kong(China*)

No coverage No coverage No coverage

Hungary National health plan National health plan National health planIceland No coverage No coverage National health planIndia No coverage No coverage No coverageIreland Private insurance

No coverageNo coverage No coverage

Israel No coverage Private insurance No coverageItaly No coverage No coverageJordan No coverage No coverage No coverageKazakhstan No coverage No coverage No coverageKenya No coverage No coverage No coverageLatvia No coverage No coverage No coverageLithuania No coverage No coverage No coverageMali No coverage No coverage No coverageMexico No coverage No coverage No coverageMongolia No coverage No coverage No coverageMontenegro No coverage No coverage No coverageNamibia No coverage No coverage No coverageNetherlands No coverage Private insurance National health plan

Private insuranceNew Zealand National health plan National health plan National health planNicaragua No coverage No coverage No coverageNigeria No coverage No coverage No coverageNorway National health plan No coverage No coveragePanama No coverage No coverage No coverageParaguay No coverage No coverage No coverage

Chapter 3. Table 3e

(Continued)


Peru No coverage No coveragePhilippines No coverage No coveragePoland No coverage No coverage No coveragePortugal National health plan National health plan National health planRomania No coverage No coverage No coverageRussianFederation


Senegal Unknown Unknown UnknownSerbia No coverage No coverage No coverageSingapore No coverage National health plan National health planSlovenia National health plan National health plan No coverageSouth Africa No coverage No coverage No coverageThe Republic ofKorea


Spain National health planState/Provincial/Regional healthplan

Private insurance

National health planState/Provincial/Regional healthplan

Private insurance

No coverage

Sri Lanka No coverage No coverage No coverageSweden National health plan National health plan National health planSwitzerland No coverage No coverage No coverageTaiwan (China*) No coverage No coverage No coverageThailand No coverage No coverage No coverageTogo No coverage No coverage No coverageTrinidad andTobago


Tunisia No coverage No coverage No coverageTurkey No coverage No coverage No coverageUganda Unknown Unknown UnknownUnited ArabEmirates


UK State/Provincial/Regional healthplan



USA No coverage No coverage No coverageUruguay National health plan National health plan National health planVenezuela No coverage No coverage No coverageViet Nam No coverage No coverage No coverageZimbabwe No coverage No coverage No coverage



22

Regarding a limit on the number of cycles covered by insur-ance, out of 39 countries surveyed, 36 (92%) responded.Australia, Israel, and the Russian Federation do not limit thenumber of cycles for reimbursement. Canada, Chile, Kenya, NewZealand, Romania, Senegal, Tunisia, and United Arab Emirates

Chapter 3. Table 3fIf there are programs for coverage or reimbursementof ART services, which of the following do they include?

CountryTraditionalSurrogacy

GestationalSurrogacy UsingDonated Ova andCommissioningMale’s Sperm

GestationalSurrogacy UsingCommissioningCouples’ Ovaand Sperm

GestationalSurrogacyUsing

Donated Ovaand Donated

Sperm

Argentina No coverage No coverage No coverage No coverageAustralia No coverage No coverage No coverage No coverageAustria No coverage No coverage No coverage No coverageBangladesh No coverage No coverage No coverage No coverageBelarus No coverage No coverage No coverage No coverageBelgium Unknown Unknown Unknown UnknownBolivia No coverage No coverage No coverage No coverageBotswana No coverage No coverage No coverage No coverageBrazil No coverage No coverage No coverage No coverageBulgaria No coverage No coverage No coverage No coverageBurkina Faso No coverage No coverage No coverage No coverageCameroon No coverage No coverage No coverage Private

insuranceCanada Unknown Unknown Unknown UnknownChile No coverage No coverage No coverage No coverageChina No coverage No coverage No coverage No coverageColombia No coverage No coverage No coverage No coverageCongo No coverage No coverage No coverage No coverageCôte d’Ivoire No coverage No coverage No coverage No coverageCzechia No coverage No coverage No coverage No coverageEl Salvador No coverage No coverage No coverage No coverageFinland No coverage No coverage No coverage No coverageFrance No coverage No coverage No coverage No coverageGeorgia No coverage No coverage No coverage No coverageGermany No coverage No coverage No coverage No coverageGhana No coverage No coverage No coverage No coverageGreece No coverage No coverage No coverage No coverageGuatemala No coverage No coverage No coverage No coverageHong Kong(China*)

No coverage No coverage No coverage No coverage

Hungary No coverage Nationalhealth plan


Iceland No coverage No coverage No coverage No coverageIndia No coverage No coverage No coverage No coverageIreland No coverage No coverage No coverage No coverageIsrael No coverage No coverage No coverage No coverageItaly No coverage No coverage No coverage No coverageJordan No coverage No coverage No coverage National health

planNo coverage

Kazakhstan No coverage No coverage No coverage No coverageKenya No coverage No coverage No coverage No coverageLatvia No coverage No coverage No coverage No coverageLithuania No coverage No coverage No coverage No coverageMali No coverage No coverage No coverage No coverageMexico No coverage No coverage No coverage No coverageMongolia No coverage No coverage No coverage No coverageMontenegro No coverage No coverage No coverage No coverageNamibia No coverage No coverage No coverage No coverageNetherlands No coverage No coverage No coverage No coverageNew Zealand National

healthplan

Nationalhealthplan

Nationalhealthplan

Nationalhealthplan

Nicaragua No coverage No coverage No coverage No coverageNigeria No coverage No coverage No coverage No coverageNorway No coverage No coverage No coverage

Chapter 3. Table 3f

(Continued)

CountryTraditionalSurrogacy

GestationalSurrogacy UsingDonated Ova andCommissioningMale’s Sperm

GestationalSurrogacy UsingCommissioningCouples’ Ovaand Sperm



Sperm

Panama No coverage No coverage No coverage No coverageParaguay No coverage No coverage No coveragePeru No coverage No coverage No coverage No coveragePhilippines No coverage No coverage No coverage No coveragePoland No coverage No coverage No coverage No coveragePortugal National

healthplan

Nationalhealthplan

Nationalhealthplan

Nationalhealthplan

Romania No coverage No coverage No coverage No coverageRussianFederation


Senegal Privateinsurance

Privateinsurance

Privateinsurance

No coverage

Serbia No coverage No coverage No coverage No coverageSingapore No coverage No coverage No coverage No coverageSlovenia No coverage No coverage No coverageSouth Africa No coverage No coverage No coverage No coverageThe Republicof Korea


Spain No coverage No coverage No coverage No coverageSri Lanka No coverage No coverage No coverageSweden No coverage No coverage No coverage No coverageSwitzerland No coverage No coverage No coverage No coverageTaiwan(China*)


Thailand No coverage No coverage No coverage No coverageTogo No coverage No coverage No coverage No coverageTrinidad andTobago


Tunisia Nationalhealthplan

Privateinsurance

Nationalhealthplan

Privateinsurance

Nationalhealthplan

Privateinsurance

Nationalhealthplan

Privateinsurance

Turkey No coverage No coverage No coverage No coverageUganda Unknown Unknown Unknown UnknownUnited ArabEmirates


UK No coverage No coverage No coverage No coverageUSA No coverage No coverage No coverage No coverageUruguay National

healthplan

Nationalhealthplan

Nationalhealthplan

No coverage

Venezuela No coverage No coverage No coverage No coverageViet Nam No coverage No coverage No coverage No coverageZimbabwe No coverage No coverage No coverage No coverage



23

Chapter 3. Table 3gIf there are programs for coverage or reimbursement of ART services, which of the following do they include?

Cryopreservation for Fertility Preservation for Medical Indications

Country Oocytes Sperm Embryos Testicular Tissue Ovarian Tissue

Argentina National health plan State/Provincial/Regional health plan

Private insurance


Private insurance


Private insurance


Private insurance

No coverage

Australia No coverage No coverage No coverage National health planPrivate insurance


Austria No coverage No coverage No coverage No coverage No coverageBangladesh No coverage No coverage No coverage No coverage No coverageBarbados No coverage No coverage No coverage No coverage No coverageBelarus No coverage No coverage No coverage No coverage No coverageBelgium Unknown Unknown Unknown Unknown UnknownBolivia No coverage No coverage No coverage No coverage No coverageBotswana No coverage No coverage No coverage No coverage No coverageBrazil No coverage No coverage No coverage No coverage No coverageBulgaria National health plan No coverage No coverage No coverage No coverageBurkina Faso No coverage No coverage No coverage No coverage No coverageCameroon No coverage No coverage No coverage No coverage No coverageCanada National health plan National health plan National health plan National health plan UnknownChile No coverage No coverage No coverage No coverage No coverageChina No coverage No coverage No coverage No coverage No coverageColombia No coverage No coverage No coverage No coverage No coverageCongo No coverage No coverage No coverage No coverage No coverageCôte d’Ivoire No coverage No coverage No coverage No coverage No coverageCzechia No coverage National health plan No coverage No coverage No coverageEl Salvador No coverage No coverage No coverage No coverage No coverageFinland National health plan National health plan National health plan National health plan National health planFrance National health plan National health plan National health plan National health plan National health planGeorgia No coverage No coverage No coverage No coverage No coverageGermany No coverage No coverage No coverage No coverage No coverageGhana No coverage No coverage No coverage No coverage No coverageGreece No coverage No coverage No coverage No coverage No coverageGuatemala No coverage No coverage No coverage No coverage No coverageHong Kong (China*) No coverage No coverage No coverage No coverage No coverageHungary No coverage No coverage No coverage No coverage No coverageIceland No coverage No coverage National health plan No coverage No coverageIndia No coverage No coverage No coverage No coverage No coverageIreland Private insurance Private insurance National health plan


Israel National health plan National health plan National health plan National health plan National health planItaly State/Provincial/Regional

health planState/Provincial/Regionalhealth plan

No coverage No coverage State/Provincial/Regionalhealth plan

Jordan No coverage No coverage No coverage No coverageKazakhstan No coverage No coverage No coverage No coverage No coverageKenya No coverage No coverage No coverage No coverage No coverageLatvia No coverage No coverage No coverage No coverage No coverageLithuania No coverage No coverage No coverage No coverage No coverageMali No coverage No coverage No coverage No coverage No coverageMexico No coverage No coverage No coverage No coverage No coverageMongolia No coverage No coverage No coverage No coverage No coverageMontenegro No coverage No coverage No coverage No coverage No coverageNamibia No coverage No coverage No coverage No coverage No coverageNetherlands National health plan




New Zealand National health plan National health plan National health plan National health plan No coverageNicaragua No coverage No coverage No coverage No coverage No coverageNigeria No coverage No coverage No coverage No coverage No coverageNorway National health plan National health plan National health plan Unknown National health planPanama No coverage No coverage No coverage No coverage No coverageParaguay No coverage No coverage No coverage No coverage No coveragePeru No coverage No coverage No coverage No coverage No coveragePhilippines No coverage No coverage No coverage No coverage No coverage


24

Chapter 3. Table 3g

(Continued)

Cryopreservation for Fertility Preservation for Medical Indications


Poland No coverage No coverage No coverage No coverage No coveragePortugal National health plan National health plan National health plan National health plan National health planRomania No coverage No coverage No coverage No coverage No coverageRussian Federation No coverage No coverage No coverage No coverage No coverageSenegal Unknown Private insurance

No coveragePrivate insuranceNo coverage


Unknown

Serbia No coverage No coverage No coverage No coverage No coverageSingapore No coverage No coverage National health plan No coverage No coverageSlovenia National health plan National health plan National health plan National health plan National health planSouth Africa No coverage No coverage No coverage No coverage No coverageThe Republic ofKorea

No coverage No coverage No coverage No coverage No coverage

Spain National health planState/Provincial/Regionalhealth plan

Private insurance


Private insurance


Private insurance


Private insurance


Private insuranceSri Lanka No coverage No coverage No coverage No coverage No coverageSweden National health plan National health plan National health plan National health plan National health planSwitzerland No coverage No coverage No coverage No coverage No coverageTaiwan (China*) No coverage No coverage No coverage No coverage No coverageThailand No coverage No coverage No coverage No coverage No coverageTogo No coverage No coverage No coverage No coverage No coverageTrinidad andTobago

No coverage No coverage No coverage No coverage No coverage

Tunisia No coverage No coverage No coverage No coverage No coverageTurkey National health plan National health plan National health plan National health plan National health planUganda Unknown Unknown Unknown Unknown UnknownUAE Private insurance Private insurance Private insurance Private insurance Private insuranceUK State/Provincial/Regional

health planState/Provincial/Regionalhealth plan



USA Private insurance Private insurance Private insurance Private insurance Private insuranceUruguay No coverage No coverage National health plan National health plan No coverageVenezuela No coverage No coverage No coverage No coverage No coverageViet Nam No coverage No coverage No coverage No coverage No coverageZimbabwe No coverage No coverage No coverage No coverage No coverage


Chapter 3. Table 3hIf there are programs for coverage or reimbursement of ART services, which of the following do they include?

Cryopreservation for Fertility Preservation for Nonmedical Indications


Argentina No coverage No coverage No coverage No coverage No coverageAustralia No coverage No coverage No coverage No coverage No coverageAustria No coverage No coverage No coverage No coverage No coverageBangladesh No coverage No coverage No coverage No coverage No coverageBarbados No coverage No coverage No coverage No coverage No coverageBelarus No coverage No coverage No coverage No coverage No coverageBelgium Unknown Unknown Unknown Unknown UnknownBolivia No coverage No coverage No coverage No coverage No coverageBotswana No coverage No coverage No coverage No coverage No coverageBrazil No coverage No coverage No coverage No coverage No coverageBulgaria No coverage No coverage No coverage No coverage No coverageBurkina Faso No coverage No coverage No coverage No coverage No coverageCameroon No coverage No coverage No coverage No coverage No coverageCanada Private insurance Private insurance Private insurance Private insurance UnknownChile No coverage No coverage No coverage No coverage No coverageChina No coverage No coverage No coverage No coverage No coverageColombia No coverage No coverage No coverage No coverage No coverage


25

Chapter 3. Table 3h

(Continued)



Congo No coverage No coverage No coverage No coverage No coverageCôte d’Ivoire No coverage No coverage No coverage No coverage No coverageCzechia No coverage No coverage No coverage No coverage No coverageEl Salvador No coverage No coverage No coverage No coverage No coverageFinland No coverage No coverage No coverage No coverage No coverageFrance No coverage National health plan No coverage No coverage No coverageGeorgia No coverage No coverage No coverage No coverage No coverageGermany No coverage No coverage No coverage No coverage No coverageGhana No coverage No coverage No coverage No coverage No coverageGreece No coverage No coverage No coverage No coverage No coverageGuatemala No coverage No coverage No coverage No coverage No coverageHong Kong (China*) No coverage No coverage No coverage No coverage No coverageHungary No coverage No coverage No coverage No coverage No coverageIceland No coverage No coverage National health plan No coverage No coverageIndia No coverage No coverage No coverage No coverage No coverageIreland Private insurance Private insurance Private insurance No coverage No coverageIsrael Private insurance Private insurance Private insurance Private insurance Private insuranceItaly No coverage No coverage No coverage State/Provincial/Regional health plan No coverageJordan No coverage No coverage No coverage No coverage No coverageKazakhstan No coverage No coverage No coverage No coverage No coverageKenya No coverage No coverage No coverage No coverageLatvia No coverage No coverage No coverage No coverage No coverageLithuania No coverage No coverage No coverage No coverage No coverageMali No coverage No coverage No coverage No coverage No coverageMexico No coverage No coverage No coverage No coverage No coverageMongolia No coverage No coverage No coverage No coverage No coverageMontenegro No coverage No coverage No coverage No coverage No coverageNamibia No coverage No coverage No coverage No coverage No coverageNetherlands No coverage No coverage No coverage No coverage No coverageNew Zealand No coverage No coverage No coverage No coverage No coverageNicaragua No coverage No coverage No coverage No coverage No coverageNigeria No coverage No coverage No coverage No coverage No coverageNorway No coverage No coverage No coverage Unknown No coveragePanama No coverage No coverage No coverage No coverage No coverageParaguay No coverage No coverage No coverage No coverage No coveragePeru No coverage No coverage No coverage No coverage No coveragePhilippines No coverage No coverage No coverage No coverage No coveragePoland No coverage No coverage No coverage No coverage No coveragePortugal Unknown Unknown Unknown Unknown UnknownRomania No coverage No coverage No coverage No coverage No coverageRussian Federation No coverage No coverage No coverage No coverage No coverageSenegal Unknown Private insurance

No coveragePrivate insuranceNo coverage


Unknown

Serbia No coverage No coverage No coverage No coverage No coverageSingapore No coverage No coverage No coverage No coverage No coverageSlovenia No coverage No coverage No coverage National health plan No coverageSouth Africa No coverage No coverage No coverage No coverage No coverageThe Republic of Korea No coverage No coverage No coverage No coverage No coverageSpain No coverage No coverage No coverage No coverage No coverageSri Lanka No coverage No coverage No coverage No coverage No coverageSweden No coverage No coverage No coverage No coverage No coverageSwitzerland No coverage No coverage No coverage No coverage No coverageTaiwan (China*) No coverage No coverage No coverage No coverage No coverageThailand No coverage No coverage No coverage No coverage No coverageTogo No coverage No coverage No coverage No coverage No coverageTrinidad and Tobago No coverage No coverage No coverage No coverage No coverageTunisia No coverage No coverage No coverage No coverage No coverageTurkey No coverage No coverage No coverage No coverage No coverageUganda Unknown Unknown Unknown Unknown UnknownUnited Arab Emirates Unknown Private insurance Unknown Private insurance UnknownUK No coverage No coverage No coverage No coverage No coverage


26

reimbursed 1 cycle only; and Belgium, Japan, Singapore, and TheUnited States of America provide up to 6 reimbursed treatments.

In 2015, no country reported reimbursement for cryopreserva-tion of either oocyte or ovarian tissue for non-medical reasons. Butin 2018, Canada, Ireland, Israel, and The United States of Americareported private insurance covering oocyte cryopreservation. Israeland some American insurers covered ovarian tissue cryopre-servation for non-medical indications. Of note, elective (“non-medically indicated”) sperm cryopreservation is covered inCanada, France, Ireland, Israel, Senegal, United Arab Emirates;and support for non-medically indicated testicular tissue cryopre-servation is offered in Canada, Israel, Senegal, Slovenia, TheUnited States of America, and United Arab Emirates.

Discussion

In the 2018 questionnaire, 85 countries were surveyed aboutfunding for infertility treatment; 40 (47%) replied that somefunding was available. As the tables attest, considerable inter-national variation exists in the level of support available andrequirements for obtaining it.

Minimal change was noted in the number of countries man-dating single embryo transfer (eSET), or otherwise limiting thenumber of embryos transferred (see Chapter 5). The policy forART reimbursement for the same policy increased 18% in 2015,and 23% in 2018. Multiple subsequent pregnancies resulting

from transfer of an inappropriate number of embryos has longbeen recognized as the most significant complication of ART. Thesmall number of positive responses to the question of multipleembryo transfer may, in part, reflect other mechanisms or sanc-tions already in place, addressing the problem. But it also suggeststhat the problem remains significant, and offers considerableroom for improvement.

In contrast, support for genetic testing of embryos, both PGT-Mand PGT-A, seems to have increased, but there has been littlechange in funding support for either (14 responses out of 83 forPGT-M [17%]; 5 responses out of 81 for PGT-A [6%]). Modestprogress has beenmade for funding non-medical cryopreservation.

While current data may be more reliable, due to the familiarityand greater experience with the survey of many of the respon-dents, caution should be taken when interpreting the data. Thereare limitations in the completeness and accessibility of the dataincluded.

Summary

A minority of countries provide insurance coverage for ART.Only 47% give any support for infertility therapy. To date,genetic screening appears to have greater support, but no sig-nificant changes have occurred in the proportion of countries thattie reimbursement to number of embryos transferred.

18%

20%

19%

10%

64%

53%

58%

39%

18%

27%

23%

51%

Combination of government health plan and privateinsurance

Private insurance

A state provinicial regional health plan

A national health plan

Yes No Unknown

Chapter 3. Chart 1. What type of coverage or reimbursement?

Chapter 3. Table 3h

(Continued)



USA Private insurance Private insurance Private insurance Private insurance Private insuranceUruguay No coverage No coverage National health plan No coverage No coverageVenezuela No coverage No coverage No coverage No coverage No coverageViet Nam No coverage No coverage No coverage No coverage No coverageZimbabwe No coverage No coverage No coverage No coverage No coverage



27

95%

91%

91%

93%

88%

86%

84%

5%

9%

9%

6%

12%

14%

16%

1%

Gestational surrogacy using donated ova & donated sperm

Gestational surrogacy using commissioning couples ova & sperm

Gestational surrogacy using donated ova & commissioning males sperm

Traditional surrogacy

Donor embryos

Donor egg

Donor sperm

No Yes Unknown

Chapter 3. Chart 4. What does insurance coverage or government funding cover?

7%

4%

4%

60%

66%

61%

33%

30%

35%

Family Building

Secondary Infertility

Primary Infertility

Yes No Unknown

Chapter 3. Chart 2. What is coverage or reimbursement based on?

89%

78%

75%

54%

54%

60%

54%

57%

6%

17%

18%

45%

45%

39%

45%

43%

5%

5%

7%

1%

1%

1%

1%

PGT-A

PGT-M

Assisted hatching

ICSI

IVF

IUI

Fertility Medications

Diagnostic Evaluation

No Yes Unknown



28

Chapter 3. Table 4aDoes insurance coverage or government funding typically cover the following ART services?

Country Diagnostic Evaluation Fertility Medications Intrauterine Insemination IVF ICSI Assisted Hatching

Argentina Yes Yes Yes Yes Yes YesArmenia No No No No NoAustralia Yes Yes Yes Yes Yes UnknownAustria No Yes No Yes Yes NoBangladesh No No No No No NoBarbados No No No No No NoBelarus Yes No No No No NoBelgium Yes Yes Yes Yes Yes UnknownBolivia No No No No No NoBotswana Yes No No No No NoBrazil Yes No No No No NoBulgaria No Yes No Yes Yes NoBurkina Faso Yes No No No No NoCameroon Yes No No No No NoCanada Yes No Yes Yes Yes NoChile Yes Yes Yes Yes Yes NoChina No No No No No NoColombia No No No No No NoCzechia Yes Yes Yes Yes No NoCongo No No No No No NoEcuador Yes No No No No NoEl Salvador No No No No No NoFinland Yes Yes Yes Yes Yes NoFrance Yes Yes Yes Yes Yes NoGeorgia No No No No No NoGermany Yes Yes Yes Yes Yes NoGreece No No No No No NoGuatemala No No No No No NoHong Kong (China*) Yes Yes Yes Yes Yes NoHungary Yes Yes Yes Yes Yes YesIceland No Yes No Yes Yes NoIndia No No No No No NoIreland Yes Yes Yes Yes Yes YesIsrael Yes Yes Yes Yes Yes YesItaly Yes Yes No No NoCôte d’Ivoire Yes Unknown Unknown Unknown Unknown UnknownJapan Yes Yes No Yes YesJordan Yes No No No No No

93%

79%

93%

75%

92%

75%

93%

75%

95%

15%

2%

20%

5%

23%

5%

23%

1%

7%

6%

5%

5%

4%

3%

2%

3%

4%

Cryo of ovarian tissue for fertility preservation for nonmedical indications

Cryo of ovarian tissue for fertility preservation for medical indications

Cryo of testicular tissue for fertility preservation for nonmedical indications

Cryo of testicular tissue for fertility preservation for medical indications

Cryo of embryos for fertility preservation for nonmedical indications

Cryo of embryos for fertility preservation for medical indications

Cryo of sperm for fertility preservation for nonmedical indications

Cryo of sperm for fertility preservation for medical indications

Cryo of oocytes for fertility preservation for nonmedical indications

No Yes Unknown



29

Chapter 3. Table 4a

(Continued)

Country Diagnostic Evaluation Fertility Medications Intrauterine Insemination IVF ICSI Assisted Hatching

Kazakhstan No No No No No NoKenya No No No Yes Yes UnknownLatvia Yes Yes Yes Yes Yes NoLithuania Yes Yes No Yes Yes NoMali Yes Yes No No No NoMexico No No No No No NoMongolia No No No No No NoMontenegro Yes Yes No Yes Yes NoNamibia Yes No No No No NoNetherlands Yes Yes Yes Yes Yes NoNew Zealand Yes Yes Yes Yes Yes NoNicaragua No No No No No NoNigeria No No No No No NoNorway Yes Yes Yes Yes Yes UnknownPanama No No Yes No No NoParaguay No No No No No NoPeru No No No No No NoPhilippines No No No No No NoPoland No No No No No NoPortugal Yes Yes Yes Yes Yes YesRomania No No No Yes Yes YesRussian Federation Yes Yes No Yes Yes YesSenegal Yes Yes Yes Yes Yes UnknownSerbia Yes Yes Yes Yes Yes YesSingapore No No Yes Yes Yes YesSlovenia Yes Yes Yes Yes Yes NoSouth Africa Yes No No No No NoThe Republic of Korea Yes Yes Yes Yes Yes YesSpain Yes Yes Yes Yes Yes YesSri Lanka No No No No No NoSweden No No Yes No No NoSwitzerland Yes Yes Yes No No NoTaiwan (China*) Yes No No No No NoThailand No No No No No NoTogo No No No No No NoTrinidad and Tobago No No No No No NoTunisia Yes Yes No Yes Yes YesTurkey Yes Yes Yes Yes Yes YesUganda No No No No No NoUnited Arab Emirates Yes Yes Yes Yes Yes YesUK Yes Yes Yes Yes Yes NoUSA Yes No No No No NoUruguay Yes Yes Yes Yes Yes YesVenezuela No No No No No NoViet Nam No No No No No NoZimbabwe Yes Yes Yes No No No


Chapter 3. Table 4bDoes insurance coverage or government funding typically cover the following ART services?

Country




Embryos from an IVF Cycle PGT-M PGT-A

Argentina Yes Yes No NoArmenia No No No NoAustralia No No No NoAustria No No No NoBangladesh No No No No


30

Chapter 3. Table 4b

(Continued)

Country





Barbados No No No NoBelarus No No No NoBelgium Yes Yes Unknown UnknownBolivia No No No NoBotswana No No No NoBrazil No No No NoBulgaria No Yes No NoBurkina Faso No No No NoCameroon No No No NoCanada No No NoChile No No No NoChina No No No NoColombia No No No NoCongo No No No NoCôte d’Ivoire Unknown Unknown NoCzechia No No Yes YesEcuador No No No NoEl Salvador No No No NoFinland No Yes No NoFrance Yes Yes No NoGeorgia No No No NoGermany No No No NoGreece No No No NoGuatemala No No No NoHong Kong (China*) No No No NoHungary Yes Yes No NoIceland No Yes No NoIndia No No No NoIreland Yes Yes Unknown UnknownIsrael Yes Yes Yes NoItaly No No No NoJordan No No No NoKazakhstan No No No NoKenya Yes Yes Unknown UnknownLatvia No Yes No NoLithuania No No Yes NoMali No No No NoMexico No No No NoMongolia No No No NoMontenegro No No No NoNamibia No No No NoNetherlands Yes Yes Yes NoNew Zealand Yes Yes Yes NoNicaragua No No No NoNigeria No No No NoNorway Yes Yes Yes NoPanama No No No NoParaguay No No No NoPeru No No No NoPhilippines No No No NoPoland No No No NoPortugal Yes Yes Yes YesRomania No No No NoRussian Federation Yes Yes No NoSenegal Unknown Unknown Unknown UnknownSerbia Yes Yes Yes YesSingapore Yes Yes Yes YesSlovenia Yes Yes Yes NoSouth Africa No No No NoThe Republic of Korea No No No No


31

Chapter 3. Table 4b

(Continued)

Country





Spain Yes Yes Yes NoSri Lanka No No No NoSweden No No No NoSwitzerland No No No NoTaiwan (China*) No No No NoThailand No No No NoTogo No No No NoTrinidad and Tobago No No No NoTunisia No No NoTurkey No Yes Yes NoUganda No No No NoUnited Arab Emirates Yes Yes Yes YesUK No Yes Yes NoUSA No No No NoUruguay No Yes No NoVenezuela No No No NoViet Nam No No No NoZimbabwe No No No No


Chapter 3. Table 4cDoes insurance coverage or government funding typically cover the following ART services?

CountryDonorSperm Donor Egg

DonorEmbryos

TraditionalSurrogacy

GestationalSurrogacy UsingDonated Ova andCommissioningMales’ Sperm

GestationalSurrogacy UsingCommissioningCouples’ Ova and

Sperm



Sperm

Argentina Yes Yes Yes No No No NoArmenia No No No No No No NoAustralia Yes Yes Yes No No No NoAustria No No No No No No NoBangladesh No No No No No No NoBarbados No No No No No No NoBelarus No No No No No No NoBelgium Yes No No No No No NoBolivia No No No No No No NoBotswana No No No No No No NoBrazil No No No No No No NoBulgaria No No No No No No NoBurkina Faso No No No No No No NoCameroon No No No No No No NoCanada No No No Yes Yes Yes YesChile No No No No No No NoChina No No No No No No NoColombia No No No No No No NoCongo No No No No No No NoCôte d’Ivoire No No No No No No NoCzechia No No No No No No NoEcuador No No No No No No NoEl Salvador No No No No No No NoFinland No No No No No No NoFrance Yes Yes Yes No No No NoGeorgia No No No No No No NoGermany No No No No No No NoGreece No No No No No No NoGuatemala No No No No No No No


32

Chapter 3. Table 4c

(Continued)

CountryDonorSperm Donor Egg

DonorEmbryos


GestationalSurrogacy UsingDonated Ova andCommissioningMales’ Sperm

GestationalSurrogacy UsingCommissioningCouples’ Ova and

Sperm



Sperm

Hong Kong (China*) No No No No No No NoHungary Yes Yes Yes No Yes No NoIceland No No No No No No NoIndia No No No No No No NoIreland No No No No No No NoIsrael No No No No No NoItaly No No No No No No NoJordan No No No No No NoKazakhstan No No No No No No NoKenya No No No No No No NoLatvia No No No No No No NoLithuania No No No No No No NoMali No No No No No No NoMexico No No No No No No NoMongolia No No No No No No NoMontenegro No No NoNamibia No No No No No No NoNetherlands Yes Yes Yes Unknown No Yes NoNew Zealand Yes Yes Yes Yes Yes Yes YesNicaragua No No No No No No NoNigeria No No No No No No NoNorway Yes No No No No No NoPanama No No No No No No NoParaguay No No No No No No NoPeru No No No No No No NoPhilippines No No No No No No NoPoland No No No No No No NoPortugal Yes Yes Yes Yes Yes Yes YesRomania No No No No No No NoRussian Federation No No No No No No NoSenegal No No No No Yes Yes YesSerbia No No No No No No NoSingapore No Yes Yes No No No NoSlovenia Yes Yes No No No No NoSouth Africa No No No No No No NoThe Republic of Korea No No No No No No NoSpain Yes Yes No No No No NoSri Lanka No No No No No No NoSweden No No No No No No NoSwitzerland No No No No No No NoTaiwan (China*) No No No No No No NoThailand No No No No No No NoTogo No No No No No No NoTrinidad and Tobago No No No No No No NoTunisia No No No Yes Yes Yes NoTurkey No No No No No No NoUganda No No No No No No NoUnited Arab Emirates No No No No No No NoUK Yes Yes Yes No No No NoUSA No No No No No No NoUruguay Yes Yes Yes Yes Yes Yes NoVenezuela No No No No No No NoViet Nam No No No No No No NoZimbabwe No No No No No No No



33

Chapter 3. Table 4dDoes insurance coverage or government funding typically cover the following ART services?

Cryopreservation for Fertility Preservation for Medical Indications Cryopreservation for Fertility Preservation for Nonmedical Indications

Country Oocytes Sperm EmbryosTesticularTissue

OvarianTissue Oocytes Sperm Embryos

TesticularTissue

OvarianTissue

Argentina Yes Yes Yes Yes No No No No No NoArmenia No No No No No No No No No NoAustralia No No No Yes Yes No No No No NoAustria No No No No No No No No No NoBangladesh No No No No No No No No No NoBarbados No No No No No No No No No NoBelarus No No No No No No No No No NoBelgium Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown UnknownBolivia No No No No No No No No No NoBotswana No No No No No No No No No NoBrazil No No No No No No No No No NoBulgaria Yes No No No No No No No No NoBurkina Faso No No No No No No No No No NoCameroon No No No No No No No No No NoCanada Yes Yes No Yes Unknown No No No No UnknownChile No Yes No No No No No No No NoChina No No No No No No No No No NoColombia No No No No No No No No No NoCongo No No No No No No No No No NoCôte d’Ivoire Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown UnknownCzechia No Yes No No No No No No No NoEcuador No No No No No No No No No NoEl Salvador No No No No No No No No No NoFinland Yes Yes Yes Yes Yes No No No No NoFrance Yes Yes Yes Yes Yes No Yes No No NoGeorgia No No No No No No No No No NoGermany No No No No No No No No No NoGreece No No No No No No No No No NoGuatemala No No No No No No No No No NoHong Kong (China*) No No No No No No No No No NoHungary No No No No No No No No No NoIceland No No Yes Yes Yes No No Yes No NoIndia No No No No No No No No No NoIreland Yes Yes Yes Unknown Unknown Yes Yes Yes Unknown UnknownIsrael Yes Yes Yes Yes Yes No No No No NoItaly No No No No No No No No No NoJordan No No No No No No No No No NoKazakhstan No No No No No No No No No NoKenya No No No No No No No No No NoLatvia No No No No No No No No No NoLithuania No No No No No No No No No NoMali No No No No No No No No No NoMexico No No No No No No No No NoMongolia No No No No No No No No No NoMontenegro No No No No No No No No No NoNamibia No No No No No No No No No NoNetherlands Yes Yes Yes No No No No No No NoNew Zealand Yes Yes Yes Yes No No No No No NoNicaragua No No No No No No No No No NoNigeria no No no no no no no no no noNorway Yes Yes Yes Yes Yes No No No No NoPanama No No No No No No No No No NoParaguay No No No No No No No No No NoPeru No No No No No No No No No NoPhilippines No No No No No No No No No NoPoland No No No No No No No No No NoPortugal Yes Yes Yes Yes Yes No No No No NoRomania No No No No No No No No No NoRussian Federation No No No No No No No No No NoSenegal Unknown Yes Yes Yes Unknown Unknown Yes Yes Yes UnknownSerbia No No No Unknown No No No No Unknown NoSingapore No No Yes No No No No No No NoSlovenia Yes Yes Yes Yes Yes No No No No NoSouth Africa No No No No No No No No No NoThe Republic of Korea No No No No No No NoSpain Yes Yes Yes Yes Yes No No No No NoSri Lanka No No No No No No No No No NoSweden Yes Yes Yes Yes Yes No No No No NoSwitzerland No No No No No No No No No NoTaiwan (China*) No No No No No No No No No NoThailand No No No No No No No No No NoTogo No No No No No No No No No NoTrinidad and Tobago No No No No No No No No No NoTunisia No No No No No No No No No No


34

Chapter 3. Table 4d

(Continued)

Cryopreservation for Fertility Preservation for Medical Indications Cryopreservation for Fertility Preservation for Nonmedical Indications

Country Oocytes Sperm EmbryosTesticularTissue

OvarianTissue Oocytes Sperm Embryos

TesticularTissue

OvarianTissue

Turkey Yes Yes Yes Yes Yes No No No No NoUganda No No No No No No No No No NoUnited Arab Emirates Yes Yes Yes Yes Yes Yes Unknown Yes UnknownUK Yes Yes Yes No No No No No No NoUSA No No No No No No No No No NoUruguay No No Yes Yes No No No Yes No NoVenezuela No No No No No No No No No NoViet Nam No No No No No No No No No NoZimbabwe No No No No No No No No No No


Chapter 3. Table 5Is insurance coverage or government funding based on fertility status?

Country Primary Infertility Secondary Infertility Family Building

Argentina No No NoArmenia No No NoAustralia YesAustria No No NoBangladesh No No NoBarbados No No NoBelarus No No NoBelgium No No NoBolivia No No NoBrazil No No NoBulgaria No No NoBurkina Faso Unknown Unknown UnknownCameroon No No NoCanada YesChile Yes Yes UnknownChina No No NoColombia No No NoCongo No No NoCôte d’Ivoire Unknown Unknown UnknownCzechia No No NoEcuador No No NoEl Salvador No No NoFinland Yes Yes YesFrance No No YesGeorgia No No NoGermany Yes Yes YesGreece No No NoHong Kong (China*) No No YesHungary Yes Yes YesIceland No No YesIndia No No NoIreland Yes Yes YesIsrael Yes Yes NoItaly No NoJapan No No NoJordan No No NoKazakhstan Yes Yes YesKenya Yes Yes YesLatvia Yes Yes UnknownLithuania Yes Yes NoMali No No NoMexico No No NoMongolia No No NoMontenegro Yes Yes YesNamibia No No Yes


35

Chapter 3. Table 5

(Continued)

Country Primary Infertility Secondary Infertility Family Building

Netherlands No No NoNew Zealand Yes Yes YesNicaragua No No NoNigeria no no noNorway No No NoPanama No No NoParaguay No No NoPeru No No NoPhilippines Unknown Unknown UnknownPoland No NoPortugal No No NoRomania Yes Yes YesRussian Federation Yes Yes YesSenegal No No NoSerbia Yes No YesSingapore Yes Yes YesSlovenia Yes YesSouth Africa No No NoThe Republic of Korea Yes Yes YesSpain Yes Yes YesSweden YesSwitzerland Yes No NoTaiwan (China*) Yes Yes YesThailand No No NoTogo No No NoTunisia Yes Yes YesTurkey Yes No NoUganda No No NoUnited Arab Emirates Yes Yes YesUK No No NoUSA No No YesUruguay Yes Yes YesVenezuela No No NoViet Nam No No NoZimbabwe Yes Yes Yes


92.0%

12.5%

22.5%

77.5%

8.0%

87.5%

77.5%

22.5%

Income

Duration of Infertility

Age

Single Embryo Transfer

Yes No

Chapter 3. Chart 6. What is coverage or reimbursement based on?


36

CHAPTER 4: MARITAL STATUS AND SAME SEX ANDSINGLE PARENTING POLICY

Introduction

This chapter addresses the availability and governance of ARTservices as they relate to the marital status of a couple or a personseeking ART.

The survey questions were intended to determine if a require-ment existed for a specific type of relationship status (i.e., stable,marital, or heterosexual) to access ART services, and within whatkind of relationship these services would be available, if arestriction did exist. Respondents for the individual countrieswere queried about these issues, and about specific potentiallimitations for access to ART—limitations pertaining to genderand to male and female same-sex relationships. The survey alsoevaluated the access of single men, single women, and same-sexcouples to specific diagnostic or therapeutic interventions, andassessed the status of a same-sex partner as a legal parent of aresulting child.


Respondents from 84 countries answered—partially orcompletely—questions pertaining to this chapter. Regarding arequirement for a recognized or stable relationship in order toaccess ART services, 52 countries (62%) reported having no suchrequirement; 32 (38%) said that their country did have such arequirement (Chart 1). As for European countries, most respon-ded that they did not require a recognized relationship for ARTaccess; exceptions included Czechia, France, Greece, Hungary,Italy, Lithuania, Montenegro, Romania, Serbia, Slovenia,Sweden, Switzerland, and Turkey—countries with federal laws,statutes, or ordinances backing up the requirement. Othercountries not requiring a stable relationship for ART accessinclude Australia, Canada, India, New Zealand, The UnitedStates of America, and most Latin American countries.

Most Asian countries do require a stable relationship, and havelaws, statutes, or oversight by professional organizations orgovernment agencies with jurisdiction. These countries includeChina, Hong Kong [China, reporting separately for this report],Singapore, Taiwan [China, reporting separately for this report],Thailand, and Viet Nam. Countries where a stable relationship ismandated by professional organizations, cultural practice, or

Chapter 4. Table 1aAccess to diagnostic and therapeutic interventions.

Country Diagnostic Evaluation Intrauterine Insemination

Argentina Single Women Single WomenSingle Men Single MenSame Sex FemaleMarried Couple

Same Sex FemaleMarried Couple

Same Sex MaleMarried Couple


Transgender TransgenderIntersex Individuals Intersex Individuals

Armenia Single Women Single WomenSingle Men Single Men

Australia Single Women Single WomenSingle Men Single MenSame Sex FemaleMarried Couple





Austria Single Women Same Sex FemaleMarried Couple

Single MenSame Sex FemaleMarried Couple


TransgenderIntersex Individuals

Barbados Single Women Single Women, Single MenSingle Men Same Sex Female

Married CoupleSame Sex FemaleMarried Couple


Belarus Single Women Single WomenSingle Men

Belgium Single Women Single WomenSingle Men Same Sex Female




Bolivia Single Women Single WomenSingle Men Single MenSame Sex FemaleMarried Couple





Botswana Single Women Single WomenSingle Men

Brazil Single Women Single WomenSingle Men Single MenSame Sex FemaleMarried Couple





Bulgaria Single Women Single Women

38%

62%

Require stable relationship Do not require stable relationship

Chapter 4. Chart 1. Requirement for a stable or recognized relationship toaccess ART.


37

Chapter 4. Table 1a

(Continued)


Single MenCameroon Single Women Single Women

Single MenCanada Single Women Single Women

Single Men Single MenSame Sex FemaleMarried Couple





China Single WomenSingle Men

Colombia Single Women Single WomenSingle Men Single MenSame Sex FemaleMarried Couple





Congo Single Women Intersex IndividualsIntersex Individuals

Côte d’Ivoire Single Women Single WomenSingle Men Single Men

Czechia Single WomenSingle Men

Ecuador Single Women Single WomenEl Salvador Single Women Single Women

Single Men Single MenFinland Single Women Single Women

Single Men Single MenSame Sex FemaleMarried Couple




Transgender Intersex IndividualsIntersex Individuals

Georgia Single Women Single WomenGermany Single Women Single Women




Transgender


Ghana Single WomenSingle Men

Greece Single Women Single WomenSingle Men

Guatemala Single Women Single WomenSingle Men Same Sex Female




Hong Kong (China*) Single WomenSingle MenSame Sex FemaleMarried Couple

Chapter 4. Table 1a

(Continued)




Hungary Single Women Single WomenIceland Single Women Single Women

Single Men Same Sex FemaleMarried Couple


Transgender


India Single Women Single WomenSingle Men Single Men

Ireland Single Women Single WomenSingle Men Same Sex Female



Italy Single Women Single WomenJapan Single Women

Single MenKazakhstan Single Women Single Women

Single MenKenya Single Women Single Women

Single MenLatvia Single Women Single Women

Single MenMali Single Women Single Women

Single MenMexico Single Women Single Women



Montenegro Single Women Single WomenNetherlands Single Women Single Women



New Zealand Single Women Single WomenSingle Men Same Sex Female


Transgender


Intersex Individuals


Nigeria Single Women Single WomenNorway Same Sex Female


Panama Single Women Single WomenSame Sex FemaleMarried Couple


Paraguay Single Women Single WomenSingle Men Single MenSame Sex FemaleMarried Couple





Peru Single Women Single Women


38

religious decree, include Bangladesh, Cameroon, Egypt, Japan,the Philippines, Senegal, The Republic of Korea, and United ArabEmirates.

The 52 countries with no requirement for a stable heterosexualunion for access to ART were surveyed as to whether serviceswere available for all the categories listed: single men, singlewomen, male and female same-sex couples, and transgender andintersex individuals. Thirteen countries reported access for all,including Argentina, Australia, Barbados, Bolivia, Brazil,

Chapter 4. Table 1a

(Continued)




Philippines Intersex Individuals Intersex IndividualsPoland Single Women Single Women

Single MenPortugal Single Women Single Women





Romania Single Women Single WomenSingle Men

Russian Federation Single Women Single WomenSerbia Single Women

Single MenSingapore Single Women




Slovenia Single WomenSingle Men

South Africa Single Women Single WomenSingle Men Single MenSame Sex FemaleMarried Couple





The Republic of Korea Single WomenSingle MenSame Sex MaleMarried Couple


Spain Single Women Single WomenSingle Men Same Sex Female


Transgender


Sweden Single Women Same Sex FemaleMarried Couple

Single Men Same Sex MaleMarried Couple


Transgender



Switzerland Single Women

Chapter 4. Table 1a

(Continued)


Single MenTaiwan (China*) Single Women

Single MenTogo Intersex Individuals Intersex IndividualsTrinidad and Tobago Single Women Single Women




Turkey Single WomenSingle Men

Uganda Single Women Single WomenSingle Men Same Sex Female


United Arab Emirates Single WomenSingle Men

UK Single Women Single WomenSingle Men Single MenSame Sex FemaleMarried Couple





USA Single Women Single WomenSingle Men Single MenSame Sex FemaleMarried Couple





Uruguay Single Women Single WomenSame Sex FemaleMarried Couple


Transgender TransgenderViet Nam Single Women Single Women




Zimbabwe Single Women Single WomenSingle Men Single Men



39

Chapter 4. Table 1bAccess to diagnostic and therapeutic interventions.

Country IVF PGT-M PGT-A

Argentina Single Women Single Women Single WomenSingle Men Single Men Single MenSame Sex Female Married Couple Same Sex Female Married Couple Same Sex Female Married CoupleSame Sex Male Married Couple Same Sex Male Married Couple Same Sex Male Married CoupleTransgender Transgender TransgenderIntersex Individuals Intersex Individuals Intersex Individuals

Armenia Single Women Single Women Single WomenSingle Men Single Men Single Men

Australia Single Women Single Women Single WomenSingle Men Single Men Single MenSame Sex Female Married Couple Same Sex Female Married Couple Same Sex Female Married CoupleSame Sex Male Married Couple Same Sex Male Married Couple Same Sex Male Married CoupleTransgender Transgender TransgenderIntersex Individuals Intersex Individuals Intersex Individuals

Austria Same Sex Female Married Couple Same Sex Female Married Couple Same Sex Female Married CoupleBarbados Single Women Single Women Single Women

Single Men Single Men Single MenSame Sex Female Married Couple Same Sex Female Married Couple Same Sex Female Married CoupleSame Sex Male Married Couple Same Sex Male Married Couple Same Sex Male Married Couple

Belarus Single Women Single Women Single WomenBelgium Single Women, Same Sex Female Married CoupleBolivia Single Women, Single Men, Same Sex Female

Married Couple, Same Sex Male Married Couple,Transgender, Intersex Individuals

Single Women, Single Men, Same Sex FemaleMarried Couple, Same Sex Male Married Couple,Transgender, Intersex Individuals


Botswana Single Women, Single Men Single Women, Single Men Single WomenBrazil Single Women, Single Men, Same Sex Female




Bulgaria Single Women Single Women Single WomenCameroon Single WomenCanada Single Women, Single Men, Same Sex Female




Colombia Single Women, Single Men, Same Sex FemaleMarried Couple, Same Sex Male Married Couple,Transgender, Intersex Individuals



Congo Intersex IndividualsCôte d’Ivoire Single Women, Single MenEcuador Single Women Single Women Single WomenEl Salvador Single Women, Single Men Single Women, Single MenFinland Single Women, Same Sex Female Married Couple,

Same Sex Male Married CoupleSingle Women, Same Sex Female Married Couple,Same Sex Male Married Couple

Single Women, Same Sex Female Married Couple,Same Sex Male Married Couple

Georgia Single Women Single Women Single WomenGermany Single Women, Same Sex Female Married Couple,

Transgender, Intersex IndividualsSingle Women, Same Sex Female Married Couple,Transgender, Intersex Individuals

Single Women, Same Sex Female Married Couple,Transgender, Intersex Individuals

Ghana Single Women, Single Men Single Women, Single Men Single Women, Single MenGreece Single Women, Single Men Single Women, Single Men Single Women, Single MenGuatemala Single Women, Same Sex Female Married Couple Single Women, Same Sex Female Married Couple Single Women, Same Sex Female Married CoupleHungary Single WomenIceland Single Women, Same Sex Female Married Couple,

Transgender, Intersex IndividualsSingle Women, Same Sex Female Married Couple,Transgender, Intersex Individuals


India Single Women, Single Men Single Women, Single Men Single Women, Single MenIreland Single Women, Same Sex Female Married CoupleItaly Intersex Individuals Intersex IndividualsKazakhstan Single Women Single Women Single WomenKenya Single Women Single Women Single WomenLatvia Single Women Single Women Single WomenMali Single Women, Single MenMexico Single Women, Same Sex Female Married Couple Single Women, Same Sex Female Married Couple Single Women, Same Sex Female Married CoupleMontenegro Single Women Single Women Single WomenNetherlands Single Women, Same Sex Female Married Couple Single Women, Same Sex Female Married Couple


40

Chapter 4. Table 1b

(Continued)

Country IVF PGT-M PGT-A

New Zealand Single Women, Same Sex Female Married Couple,Transgender, Intersex Individuals

Single Women, Single Men, Same Sex Female MarriedCouple, Same Sex Male Married Couple,Transgender, Intersex Individuals


Nigeria Single Women Single WomenNorway Same Sex Female Married Couple Same Sex Female Married CouplePanama Single Women, Same Sex Female Married Couple Single Women, Same Sex Female Married Couple Single Women, Same Sex Female Married CoupleParaguay Single Women, Single Men, Same Sex Female Married

Couple, Same Sex Male Married Couple,Transgender, Intersex Individuals



Peru Single Women, Same Sex Female Married Couple Single Women, Same Sex Female Married Couple Single Women, Same Sex Female Married CouplePhilippines Intersex Individuals Intersex Individuals Intersex IndividualsPoland Single Women, Single Men Single Women Single WomenPortugal Single Women, Same Sex Female Married Couple Single Women, Same Sex Female Married Couple Single Women, Same Sex Female Married CoupleRomania Single WomenRussianFederation

Single Women Single Women Single Women

South Africa Single Women Single Women, Single Men, Same Sex Female Single Women, Single Men, Same Sex FemaleSingle Men Married Couple, Same Sex Male Married Married Couple, Same Sex Male Married Couple,

Transgender, Intersex IndividualsSame Sex Female Married Couple Couple, Transgender, Intersex IndividualsSame Sex Male Married CoupleTransgenderIntersex Individuals

Spain Single Women Single Women Single WomenSame Sex Female Married Couple Transgender Same Sex Female Married Couple Transgender Same Sex Female Married CoupleIntersex Individuals Intersex Individuals Transgender

Intersex IndividualsSweden Same Sex Female Married Couple Single Women

Same Sex Male Married Couple Single MenTransgender Same Sex Female Married Couple

Same Sex Male Married CoupleTransgenderIntersex Individuals

Togo Intersex IndividualsTrinidad andTobago

Single Women

Same Sex Female Married CoupleTransgenderIntersex Individuals

Uganda Single Women Single Women Single WomenSame Sex Female Married Couple Same Sex Female Married Couple Same Sex Female Married Couple

UK Single Women Single Women Single WomenSingle Men Single Men Single MenSame Sex Female Married Couple Same Sex Female Married Couple Same Sex Female Married CoupleSame Sex Male Married Couple Same Sex Male Married Couple Same Sex Male Married CoupleTransgender Transgender TransgenderIntersex Individuals Intersex Individuals Intersex Individuals

USA Single Women Single Women Single WomenSingle Men Single Men Single MenSame Sex Female Married Couple Same Sex Female Married Couple Same Sex Female Married CoupleSame Sex Male Married Couple Same Sex Male Married Couple Same Sex Male Married CoupleTransgender Transgender TransgenderIntersex Individuals Intersex Individuals Intersex Individuals

Uruguay Single Women Single Women Single WomenSame Sex Female Married Couple Transgender Same Sex Female Married Couple Same Sex Female Married Couple

Transgender TransgenderViet Nam Single Women Single Women Single WomenZimbabwe Single Women Single Women Single Women

Single Men Single Men Single Men



41

Chapter 4. Table 1cAccess to diagnostic and therapeutic interventions.



Armenia Single Women Single Women Single WomenSingle Men


Austria Same Sex Female Married Couple Same Sex Female Married CoupleBarbados Single Women Single Women Single Women

Same Sex Female Married Couple Same Sex Female Married Couple Same Sex Female Married CoupleSame Sex Male Married Couple

Belarus Single Women Single Women Single WomenBelgium Single Women Single Women Single Women

Same Sex Female Married Couple Same Sex Female Married Couple Same Sex Female Married CoupleBolivia Single Women Single Women Single Women

Single Men Single Men Single MenSame Sex Female Married Couple Same Sex Female Married Couple Same Sex Female Married CoupleSame Sex Male Married Couple Same Sex Male Married Couple Same Sex Male Married CoupleTransgender Transgender TransgenderIntersex Individuals Intersex Individuals Intersex Individuals

Botswana Single Women Single Women Single WomenSingle Men Single Men Single Men

Brazil Single Women Single Women Single WomenSingle Men Single Men Single MenSame Sex Female Married Couple Same Sex Female Married Couple Same Sex Female Married CoupleSame Sex Male Married Couple Same Sex Male Married Couple Same Sex Male Married CoupleTransgender Transgender TransgenderIntersex Individuals Intersex Individuals Intersex Individuals

Bulgaria Single Women Single Women Single WomenCanada Single Women Single Women Single Women


Colombia Single Women Single Women Single WomenSingle Men Single Men Single MenSame Sex Female Married Couple Same Sex Female Married Couple Same Sex Female Married CoupleSame Sex Male Married Couple Same Sex Male Married Couple Same Sex Male Married CoupleTransgender Transgender TransgenderIntersex Individuals Intersex Individuals Intersex Individuals

Congo Intersex Individuals Intersex Individuals Intersex IndividualsCôte d’Ivoire Single Men Single Women Single Women, Single MenEcuador Single Women Single Women Single WomenEl Salvador Single Women Single Women Single Women

Single Men Single Men Single MenFinland Single Women Single Women Single Women

Same Sex Female Married Couple Same Sex Female Married Couple Same Sex Female Married CoupleSame Sex Male Married Couple Same Sex Male Married Couple Same Sex Male Married Couple

Georgia Single Women Single Women Single WomenGhana Single Women Single Women Single Women

Single Men Single Men Single MenGreece Single Women Single Women Single Women

Single Men Single Men Single MenGuatemala Single Women Single Women Single Women


42

Chapter 4. Table 1c

(Continued)


Same Sex Female Married Couple Single Men Single MenSame Sex Female Married Couple Same Sex Female Married CoupleSame Sex Male Married Couple Same Sex Male Married Couple

Hungary Single Women Single WomenIceland Single Women Single Women

Same Sex Female Married Couple Transgender Same Sex Female Married Couple TransgenderIntersex Individuals Intersex Individuals

India Single Women Single Women Single WomenSingle Men Single Men Single Men

Ireland Single Women Single Women Single WomenSame Sex Female Married Couple Same Sex Female Married Couple Same Sex Female Married Couple

Kazakhstan Single Women Single Women Single WomenKenya Single Women Single Women Single WomenLatvia Single Women Single Women Single WomenMali Single Women Single Women Single WomenMexico Single Women Single Women

Same Sex Female Married Couple Same Sex Female Married CoupleMontenegro Single Women Single WomenNetherlands Single Women Single Women

Same Sex Female Married Couple Same Sex Female Married CoupleNew Zealand Single Women Single Women Single Women

Same Sex Female Married Couple Transgender Single Men Same Sex Female Married CoupleIntersex Individuals Same Sex Female Married Couple Transgender

Same Sex Male Married Couple Intersex IndividualsTransgenderIntersex Individuals

Nigeria Single Women Single Women Single WomenNorway Same Sex Female Married CouplePanama Single Women Single Women Single Women

Same Sex Female Married Couple Same Sex Female Married Couple Same Sex Female Married CoupleParaguay Single Women Single Women Single Women


Peru Single Women Single Women Single WomenSame Sex Female Married Couple Same Sex Female Married Couple Same Sex Female Married Couple

Philippines Intersex Individuals Intersex Individuals Intersex IndividualsPoland Single WomenPortugal Single Women Single Women Single Women

Same Sex Female Married Couple Same Sex Female Married Couple Same Sex Female Married CoupleRomania Single WomenRussian Federation Single Women Single Women Single WomenSouth Africa Single Women Single Women Single Women


Spain Single Women Single Women Single WomenSame Sex Female Married Couple Same Sex Female Married Couple Single MenTransgender Transgender Same Sex Female Married CoupleIntersex Individuals Intersex Individuals Transgender

Intersex IndividualsTogo Intersex Individuals Intersex Individuals Intersex IndividualsTrinidad and Tobago Single Women Single Women Single Women

Same Sex Female Married Couple Transgender Same Sex Female Married Couple Same Sex Female Married CoupleIntersex Individuals Transgender Transgender

Intersex Individuals Intersex IndividualsUganda Single Women Single Women Single Women

Same Sex Female Married Couple Same Sex Female Married Couple Same Sex Female Married CoupleUK Single Women Single Women Single Women


43

Chapter 4. Table 1c

(Continued)




Uruguay Single Women Single Women Single WomenSame Sex Female Married Couple Same Sex Female Married Couple Same Sex Female Married CoupleTransgender Transgender Transgender

Viet Nam Single WomenZimbabwe Single Women Single Women Single Women

Single Men Single Men Single Men


Chapter 4. Table 1dAccess to diagnostic and therapeutic interventions.

Country Traditional SurrogacyGestational Surrogacy Using Donated

Ova and Commissioning Persons SpermGestational Surrogacy Using Donated

Ova and Donated Sperm


Armenia Single WomenSingle Men


Belarus Single WomenBolivia Single Women Single Women Single Women


Botswana Single Women Single Women Single WomenSingle Men Single Men Single Men

Brazil Same Sex Male Married CoupleCanada Single Women Single Women Single Women


Colombia Single Women Single Women Single WomenSingle Men Single Men Single MenSame Sex Female Married Couple Same Sex Female Married Couple Same Sex Female Married CoupleSame Sex Male Married Couple Same Sex Male Married Couple Same Sex Male Married CoupleTransgender Transgender Transgender


44

Canada, Guatemala, Mongolia, New Zealand, Paraguay, SouthAfrica, The United States of America, and the United Kingdom ofGreat Britain and Northern Ireland. Several countries reportedaccess to single individuals or same-sex couples, but responded“unknown” regarding transgender and intersex individuals; theywere Colombia, Namibia, and Venezuela. Germany indicated“unknown” for all categories. Bulgaria, Finland, and theNetherlands responded that access to single men and male same-sex couples was “unknown.”

Some countries reported access to ART services for singlewomen or female same-sex couples, but no access for single menand same-sex male couples (Belgium, Ecuador, Iceland, Ireland,

Mexico, Peru, Portugal, Trinidad and Tobago, and Uruguay).However, this dichotomy could apply to as many as 52 countriesout of 76 (68%) for single males and 60 countries (79%) for malesame-sex couples—if the “unknown” responses are included.

The following countries reported access to ART for singlewomen only, andmarked the rest of the categories as “no access”,or “unknown”: Belarus, Cameroon, Guatemala, Congo,Georgia, Hungary, Côte d’Ivoire, Kazakhstan, Kenya, Latvia,Montenegro, Nigeria, Russian Federation, Uganda, and VietNam. Finally, 22 countries reported “no access” for anyone notin stable, heterosexual relationships: Bangladesh, Burkina Faso,China, Czechia, Greece, Japan, Jordan, Lithuania, Nicaragua,

Chapter 4. Table 1d

(Continued)

Country Traditional SurrogacyGestational Surrogacy Using Donated

Ova and Commissioning Persons SpermGestational Surrogacy Using Donated

Ova and Donated Sperm

Intersex Individuals Intersex Individuals Intersex IndividualsEcuador Single Women Single Women Single WomenEl Salvador Single Women Single Women Single Women

Single Men Single Men Single MenGhana Single Men Single Women Single Women

Single Men Single MenGreece Single Women Single Women Single Women

Single Men Single Men Single MenGuatemala Single Women Single Women

Single Men Single MenSame Sex Female Married Couple Same Sex Female Married CoupleSame Sex Male Married Couple Same Sex Male Married Couple

Kenya Single Women Single Women Single WomenNetherlands Same Sex Female Married CoupleNew Zealand Single Men Single Men

Same Sex Female Married Couple Same Sex Male Married CoupleSame Sex Male Married Couple TransgenderTransgender Intersex IndividualsIntersex Individuals

Nigeria Single Women Single Women Single WomenPhilippines Intersex Individuals Intersex Individuals Intersex IndividualsRussian Federation Single Women Single WomenSouth Africa Single Women Single Women Single Women


Uganda Single Women, Same Sex Female Married Couple Single Women Single Women, Same Sex Female Married CoupleUK Single Men Single Men Single Women

Same Sex Male Married Couple Same Sex Male Married Couple Single MenTransgender Transgender Same Sex Female Married CoupleIntersex Individuals Intersex Individuals Same Sex Male Married Couple



Uruguay Single Women Single Women single WomenSame Sex Female Married Couple Same Sex Female Married Couple Same Sex Female Married Couple

Zimbabwe Single Women Single Women Single WomenSingle Men Single Men Single Men



45

Philippines, Romania, Senegal, Serbia, Slovenia, The Republic ofKorea, Switzerland, Tunisia, Turkey, and United Arab Emirates.

Access for individuals and same-sex couples to various diag-nostic and therapeutic interventions is depicted in Table 1.Nineteen out of 70 countries (27%) reported offering diagnosticevaluation in all categories surveyed (single women, single men,female same-sex couples, male same-sex couples, and intersexand transgender individuals), but only 7 of the 19 offering thisservice reported access to treatments in all categories. The other12 of the 19 countries responding provided access to treatmentprimarily for single women or same-sex female couples; usuallythey excluded single men, male same-sex couples, and intersexand transgender individuals.

Forty-two countries reported limiting access to diagnostic ortherapeutic interventions primarily to single women or femalesame-sex couples, excluding single men and intersex or trans-gender individuals. Nine reported access to diagnostic evaluationof single men or women, but no access to any treatment in theother categories described.

The legal parenting status of the partner of a same-sex couplewas also surveyed. More than two-thirds of respondents did notrecognize a same-sex partner as a legal parent. This was the caseboth in female same-sex couples, according to 57 of 85 respon-dents (65%) and in male same-sex couples, according to 58 of 84respondents (69%). Twenty-one of 85 (25%) recognize thepartner as a legal parent in female same-sex couples, but only 13of 84 (15%) did so in male same-sex couples. Countries in thiscategory include Argentina, Australia, Brazil, Germany,Guatemala, Italy, New Zealand, South Africa, Spain, Sweden,The United States of America, United Kingdom of Great Britainand Northern Ireland, and Uruguay. Another 6 countriesresponded “unknown” to the question regarding the legal statusof the partner of a male same-sex couple: Armenia, Austria,Colombia, Iceland, Netherlands, and Norway. Seven additionalcountries reported “unknown” for both male and female same-sex couples (Chart 2).

Summary

Most respondents–62%–do not require couples or individuals tohave a recognized or stable relationship in order to access ARTservices. Treatment of single women is more widely accepted andallowed than treatment of single men, according to 51 out of 75respondents (68%). Treatment for female same-sex couples isbetter accepted than treatment services for men, according to 24of 76 respondents, and better accepted than treatment of malesame-sex couples, according to 16 out of 76 respondents (21%).

The situation is similar to that of the legal parenting status ofthe partner of a same-sex couple: it is not recognized in more thantwo-thirds of the countries surveyed.

CHAPTER 5: NUMBER OF EMBRYOS FOR TRANSFERIN ASSISTED REPRODUCTIVE TECHNOLOGY (ART)

Introduction

As ART professionals celebrated the 40th birthday of LouiseBrown, during the summer of 2018, the question of how manyembryos to transfer remained controversial. Louise Brown wascreated from a single retrieved and fertilized oocyte, followed bythe first single blastocyst embryo transfer. As ART became morewidespread and more accessible, clinicians began to transfermultiple embryos, increasing the chances of a successful preg-nancy and delivery. Generally, the number of embryos that couldbe transferred increased with the woman’s age, counteracting theage-related decline in fertility. And now, multiple births haveplagued ART for three decades, and have resulted in unac-ceptably high rates of fetal and maternal complications[1,2].Multiple pregnancies remain the single greatest risk associatedwith ART, despite great concern and efforts to reduce this risk,ever since the technique’s inception.

The advent of blastocyst culture in the late 1990s allowedmany IVF programmes to transfer fewer embryos, yet increasethe rates of implantation and pregnancy. Using blastocyst cultureand implantation, embryologists were better able to choose good-quality embryos, and to select for transfer a limited number thatcould generate high implantation rates[3]. Over the last twodecades, numerous IVF centres have increased implantation ratesfor both selected and non-selected patient groups, using blas-tocyst-stage embryo transfer rather than day-3 embryo transfer.The centres have also reduced the number of high-order multiplepregnancies[4].

Following the success of reducing the incidence of high-ordermultiple pregnancies, the focus of ART has switched to reducingtwin pregnancies. Single embryo transfer (SET) is still meetingsome resistance, despite the fact that several countries have leg-islation or funding restrictions, and despite standard of careguidelines regarding the number of embryos to transfer[5].

Several countries have firm guidelines or regulations mandat-ing SET for women under 40. With the increased utilization ofpre-implantation genetic testing, aneuploidy screening in womenover 37, and the data suggesting that transferring a single euploidembryo negates age-related infertility, SET has become the stan-dard of care[6].


Four questions were included in the 2018 survey to assess currentpractices regarding the number of embryos to transfer.

In response to the question: “Are the number of embryostransferred regulated in your country; if so, by what means”, 85responded—a result very similar to the 2016 result of 84respondents (59%).

Of the 85, 48 countries (56%) confirmed the existence ofguidelines or laws governing the number of embryos permittedfor transfer. Of 84 responders, 37 (44%) indicated that thenumber of embryos for transfer was not regulated in their country(Table 1, Chart 1). The majority of the 48 countries that did have

15%25%

69% 65%

Male same sex couple Female same sex couple0%

10%

20%

30%

40%

50%

60%

70%

80% Recognized Not recognized

Chapter 4. Chart 2. Parenting legal status of the partner of a same sex couple.


46

regulations or guidelines (70%) reported being regulated byfederal or national laws, statutes, or ordinances (50%), or by thestandards or guidelines of professional organizations (46%).

To the query, “If the number of embryos transferred is undergovernance in your country, is there a penalty for violation?”(Table 1), 49 responded. Seventeen of the 49 (35%) indicatedthere was a penalty; 26 of the 49 (53%) noted that no penaltyexisted; 4 (8%) responded “unknown”, and one country did notanswer.

To the question, “What is the maximum number of embryosallowed to be transferred?” (Table 1), 70 countries had completeanswers from respondents, as follows:• Oocyte age <35: 7 countries=Limited to 1 embryo, 18

countries=2 embryos, 15 countries=3 embryos, 2 countries=4 embryos, 20 countries=not addressed, and 8 countriesresponded “unknown”;

Chapter 5. Table 1Are the number of embryos transferred regulated in your countryand is there a penalty for violation?

Country Governance Penalty

Argentina Professional Organization Standards/Guidelines NoArmenia Not regulatedAustralia Professional Organization Standards/Guidelines NoAustria Professional Organization Standards/Guidelines NoBangladesh Not regulatedBarbados Not regulatedBelarus Federal/National Laws/Statutes/Ordinances NoBelgium Federal/National Laws/Statutes/Ordinances YesBolivia Not regulated NoBotswana Not regulatedBrazil Professional Organization Standards/Guidelines YesBulgaria Federal/National Laws/Statutes/Ordinances YesBurkina Faso Not regulatedCameroon State/Provincial/Regional Laws/Statutes/Ordinances No

Professional Organization Standards/GuidelinesCanada Not regulated NoChile Not regulatedChina Not regulated No

Professional Organization Standards/GuidelinesCultural practice

Colombia Not regulated NoCongo Not regulated NoCôte d’Ivoire Not regulated UnknownCzechia Professional Organization Standards/Guidelines NoEcuador Not regulated NoEgypt Not regulated NoEl Salvador Not regulated NoFinland Professional Organization Standards/Guidelines NoFrance Not regulated NoGeorgia Not regulatedGermany Federal/National Laws/Statutes/Ordinances UnknownGhana Professional Organization Standards/Guidelines NoGreece Cultural practice NoGuatemala Not regulated NoHong Kong (China*) Federal/National Laws/Statutes/Ordinances Yes

State/Provincial/Regional Laws/Statutes/OrdinancesHungary Federal/National Laws/Statutes/Ordinances Yes

Professional Organization Standards/GuidelinesIceland Federal/National Laws/Statutes/Ordinances NoIndia Not regulatedIreland Not regulated UnknownItaly Not regulated NoJapan Professional Organization Standards/Guidelines NoJordan Not regulated NoKazakhstan Cultural practice NoKenya Not regulatedLatvia Federal/National Laws/Statutes/Ordinances UnknownLithuania Federal/National Laws/Statutes/Ordinances NoMali Not regulated, Professional Organization No

Standards/GuidelinesMexico Professional Organization Standards/Guidelines NoMongolia Not regulated UnknownMontenegro Professional Organization Standards/Guidelines NoNamibia Professional Organization Standards/Guidelines NoNetherlands Federal/National Laws/Statutes/Ordinances No

Professional Organization Standards/GuidelinesNew Zealand Agency Regulations/Oversight No

Professional Organization Standards/GuidelinesCultural practice

Nicaragua Federal/National Laws/Statutes/Ordinances UnknownNigeria Professional Organization Standards/Guidelines Unknown

Chapter 5. Table 1

(Continued)

Country Governance Penalty

Norway Not regulated NoPanama Not regulated NoParaguay Not regulated NoPeru not regulated noPhilippines Not regulated NoPoland Professional Organization Standards/Guidelines NoPortugal Agency Regulations/Oversight Yes

Professional Organization Standards/GuidelinesRomania Not regulated NoRussian Federation Federal/National Laws/Statutes/Ordinances Yes

Professional Organization Standards/GuidelinesSenegal Not regulated UnknownSerbia Federal/National Laws/Statutes/Ordinances NoSingapore Federal/National Laws/Statutes/Ordinances YesSlovenia Federal/National Laws/Statutes/Ordinances YesSouth Africa Federal/National Laws/Statutes/Ordinances Yes

Professional Organization Standards/GuidelinesThe Republic of Korea Federal/National Laws/Statutes/Ordinances NoSpain Federal/National Laws/Statutes/Ordinances YesSri Lanka Agency Regulations/Oversight

Professional Organization Standards/GuidelinesSweden Federal/National Laws/Statutes/Ordinances YesSwitzerland Federal/National Laws/Statutes/Ordinances YesTaiwan (China*) Federal/National Laws/Statutes/Ordinances YesThailand Professional Organization Standards/Guidelines NoTogo Not regulated NoTrinidad and Tobago Not regulatedTunisia Not regulated NoTurkey Federal/National Laws/Statutes/Ordinances YesUganda Not regulatedUnited Arab Emirates Not regulatedUK Federal/National Laws/Statutes/Ordinances Yes

State/Provincial/Regional Laws/Statutes/OrdinancesAgency Regulations/OversightProfessional Organization Standards/GuidelinesCultural practice

USA Professional Organization Standards/Guidelines NoUruguay Federal/National Laws/Statutes/Ordinances Yes

Agency Regulations/OversightVenezuela Professional Organization Standards/Guidelines NoViet Nam Not regulatedZimbabwe Not regulated No



47

3.5%

6.0%

6.0%

28.0%

32.0%

46.0%

State/Provincial/Regional Laws/Statutes/Ordinances

Cultural Practice

Agency Regulations/Oversight

Federal/National Laws/Statutes/Ordinance

Professional Organization Standards/Guidelines

No Regulations

Chapter 5. Chart 1. How are the number of embryos transferred in your country regulated? (More than one category may have been chosen per country).

Chapter 5. Table 2What is the maximum number of embryos allowed to betransferred in your country?

CountryOocyte Age

< 35Oocyte Age

35-39Oocyte Age> = 40

Argentina 2 2 3Australia 1 1 1Austria 2 2 3Bangladesh 2 Enter max number

transferred4

Belarus 2 3 3Belgium 1 1 1Bolivia Not addressed Not addressed Not addressedBotswana Not addressed Not addressed Not addressedBrazil 2 3 4Bulgaria 3 3 4Burkina Faso Unknown Unknown UnknownCameroon 3 3Canada 1 1 2China 2 2 3Colombia 1 2 2Congo Unknown Unknown UnknownCôte d’Ivoire 3 3 2Czechia Unknown Unknown UnknownEcuador 2 3 3Finland 2 2 2Georgia Not addressed Not addressed Not addressedGermany Unknown Unknown UnknownGhana Not addressed Not addressed Not addressedGreece 4 4 4Guatemala Not addressed Not addressed Not addressedHong Kong (China*) 3 3 3Hungary 3 3 4Iceland Not addressed Not addressed Not addressedItaly Not addressed Not addressed Not addressedJapan 2 2 2Jordan Not addressed Not addressed Not addressedKenya Not addressed Not addressed Not addressedLatvia 3 3 3Lithuania 3 3 3Mali 3 3 3Mexico 3 3 3

Chapter 5. Table 2

(Continued)

CountryOocyte Age

< 35Oocyte Age

35-39Oocyte Age> = 40

Mongolia Not addressed Not addressed Not addressedMontenegro UnknownNamibia 2 3 3Netherlands 1 1 2New Zealand 2 2 3Nicaragua 3 3 3Nigeria 2 3 3Panama Not addressed Not addressed Not addressedPeru Unknown Unknown UnknownPoland Unknown Unknown Not addressedPortugal 3 3 Not addressedRomania Not addressed Not addressed Not addressedRussian Federation Not addressed Not addressed Not addressedSerbia 3 3 UnknownSingapore 2 2 2Slovenia 2 2 2South Africa 3 3 3The Republic ofKorea

Unknown Not addressed Not addressed

Spain 3 3 3Sweden 1 1 1Switzerland 3 3 3Taiwan (China*) 4 4 4Thailand 2 2 3Togo Not addressed Not addressed Not addressedTrinidad andTobago

Not addressed Not addressed Not addressed

Tunisia Not addressed Not addressed 3Turkey 1 2 2United ArabEmirates


UK 2 2 3USA 2 3 5Uruguay 2 2 2Venezuela Not addressed Not addressed Not addressedViet Nam Not addressed Not addressed Not addressedZimbabwe Not addressed Not addressed Not addressed



48

• Oocyte age 35-39: 5 countries limited to 1 embryo, 13countries=2 embryos, 21 countries=3 embryos, 2 countries=4 embryos, 21 countries=not addressed, and 6 countriesresponded “unknown”; and

• Oocytes age > 40: 3 countries limited to 1 embryo, 10countries=2 embryos, 20 countries=3 embryos, 4 coun-tries=4 embryos, 1 country=5 embryos, 2 countries=notaddressed, and 6 countries responded “unknown”.

To the question regarding existence of criteria for the numberof embryos to be transferred for donor oocyte recipients, 75countries responded, as follows: “yes”, 28 countries (38%);“no”, 19 countries (25%); “unknown”, 4 countries (5%); and“not addressed”, 24 (32%).

When considering the age of the donor, 76 countries providedresponses: 27 countries (35.5%) answered “yes”, 18 answered(24%) “no”, 5 answered (6.5%) “unknown”, and 26 answered(34%) “not addressed”

Regarding the quality of the embryos as a determinant, 78countries provided responses: 44 countries answered (56%)“yes”, 12 answered (15%) “no”, 3 answered (5%) “unknown”,and 19 answered (24%) “not addressed”.

Regarding the stage of the embryo (cleavage or blastocyststage), 78 countries provided responses: 45 countries answered(58%) “yes”, 10 answered (13%) “no”, 4 answered (5%)“unknown”, and 19 answered (24%) “not addressed”.

Table 3 lists the countries’ individual policies regarding thenumber of embryos allowed for transfer.

Chapter 5. Table 3What is the number of embryos to be transferred based on?

CountryAge of the Donor

RecipientAge of

Oocyte DonorQuality of theEmbryos

Stage of theEmbryos

Argentina No No No YesArmenia Yes Yes Yes YesAustralia No No No NoAustria Not addressed Not addressed Yes YesBelarus Yes Not addressed Not addressed Not addressedBelgium No No No NoBolivia Yes Yes Yes YesBotswana Not addressed Not addressed Not addressed Not addressedBrazil No Yes Yes YesBulgaria Yes No No NoBurkina Faso Unknown Yes Yes NoCameroon Yes No Yes YesCanada No Yes No YesChina YesColombia Yes No Yes YesCongo Unknown Unknown Unknown UnknownCôte d’Ivoire Yes Yes Yes YesCzechia No No No NoEcuador Yes Yes Yes YesEl Salvador Not addressed Not addressed Not addressed Not addressedFinland Yes No Yes YesGeorgia Not addressed Not addressed Not addressed Not addressedGermany Unknown Unknown Unknown UnknownGhana Yes Yes Yes YesGreece Yes Yes Yes YesGuatemala Yes Yes Yes YesHong Kong(China*)

Not addressed Not addressed Not addressed Not addressed

Hungary Not addressed Not addressed Not addressed Not addressedIceland Yes Yes Yes YesIndia Not addressed Not addressed Not addressed Not addressedIreland Not addressed Not addressed Yes YesItaly Yes Yes Yes YesJapan Not addressed Not addressedJordan Not addressed Not addressed Yes YesKazakhstan Yes No Yes YesKenya Not addressed Not addressed Not addressed Not addressedLatvia Yes No Yes YesLithuania Yes Not addressed Yes YesMali No No Yes YesMexico No Yes Yes YesMongolia Not addressed Not addressed Not addressed Not addressedMontenegro Yes YesNamibia No Yes Yes YesNetherlands Yes Yes Yes NoNew Zealand No Yes Yes YesNicaragua Yes Yes Yes YesNigeria Yes Yes Yes YesNorway Yes YesPanama Not addressed Not addressed Not addressed Not addressedParaguay No Yes Yes YesPhilippines Yes Yes Yes YesPoland Unknown Unknown Unknown UnknownPortugal Yes Unknown Yes YesRomania Yes Yes Yes YesRussianFederation


Senegal Not addressed Not addressed Yes YesSerbia Yes Unknown Yes YesSingapore Yes No No Yes

Chapter 5. Table 3

(Continued)

CountryAge of the Donor

RecipientAge of

Oocyte DonorQuality of theEmbryos

Stage of theEmbryos

Slovenia No Yes Yes YesSouth Africa Not addressed Not addressed Not addressed Not addressedThe Republicof Korea

Not addressed Not addressed No Yes

Spain Yes No Yes YesSri Lanka No No No NoSweden No No No NoSwitzerland No No No NoTaiwan(China*)


Thailand No No Yes YesTogo Not addressed Not addressed Not addressed Not addressedTrinidad andTobago


Tunisia Not addressed Not addressed Yes YesTurkey No No No NoUganda Yes Yes Yes YesUnited ArabEmirates

Not addressed Not addressed Yes Unknown

UK No Yes Yes YesUSA No Yes Yes YesUruguay Yes Yes Yes YesVenezuela Not addressed Not addressed Not addressed Not addressedViet Nam Not addressed Not addressed Not addressed Not addressedZimbabwe Not addressed Not addressed Not addressed Not addressed



49

Discussion

In 2010, Turkey introduced legislation that mandates, regardlessof embryo quality, SET for the first one or two cycles in womenunder the age of 35[7]. Similarly, Belgium, Canada, and Swedenhave comparable restrictions mandating SET in youngwomen[8,9]. In 2013, in an effort to reduce the twin birth rate to10%[10,11], guidelines were issued in the United Kingdom ofGreat Britain and Northern Ireland instructing clinicians to useSET for first cycles for women under 37 years of age, and also forsecond cycles, if a top-quality embryo is available. In Australia,Denmark, Finland, NewZealand, and Norway, the vast majority(85.2%) of embryo transfer cycles for women under 35 years ofage are currently conducted as SET[12,13].

In The United States of America, the guidelines of the AmericanSociety for Reproductive Medicine (ASRM) state, for womenat any age: transfer only one euploid embryo[14,15]. For goodprognosis, patients under 35 years of age (first cycle of IVF, priorIVF success, or good morphology embryos), transfer should belimited to one embryo; patients between 35 to 37 years of age, SETshould be strongly suggested. Despite the stricter ASRM guidelines,preliminary data from the 2016 Society for Assisted ReproductiveTechnologies Clinic Summary Report show that fewer than 40% oftransfers performed in The United States of America were SET.[16]

Summary

The evidence from the 2018 IFFS Surveillance Survey shows nomeaningful increase in the proportion of countries with legisla-tion or clinical guidelines restricting the number of embryospermissible for transfer to women undergoing IVF/ART cycles:59%, vs. 56% in 2015. More countries (35%, vs 24% in 2015)now report the presence of penalties for non-complianceregarding the number of embryos transferred.

Compared to 2016 data, progress in the actual reduction of thenumber of embryos transferred has beenmore gradual, with 10%of countries reporting mandatory SET for patients <35 years ofage, 7% of the countries reporting mandatory SET for patientsaged 35-39 years, and 6.5% of countries reporting mandatorySET for patients > 40 years old.

Recent advances in embryo culture systems, embryo selectionmethods, preimplantation genetic testing, and cryopreservationtechnology are leading to improved embryo implantation rates,but this putative advantage has not yet led to wider adoptionof SET.

References[1] Office for National Statistics. Statistical bulletin: Childhood,

Infant and Perinatal Mortality in England and Wales: 2013;March 2015.

[2] Kulkarni AD, JamiesonDJ, JonesHW, et al. Fertility treatmentsandmultiple births in theUnited States.NEngl JMed 2013;369(23):2218–2225. doi:10.1056/nejmoa1301467.

[3] Gardner DK, Lane M. Culture and selection of viableblastocysts: a feasible proposition for human IVF? HumReprod Update 1997;3:367–382.

[4] Gardner DK, Lane M, Stevens J, et al. Blastocyst scoreaffects implantation andpregnancy outcome: towards a singleblastocyst transfer. Fertil Steril 2000;73:1155–1158.

[5] Maheshwari A, Griffiths S, Bhattacharya S. Global variationsin the uptake of single embryo transfer. Hum Reprod Update2011;17(1):107–120.

[6] Harton G, Munne S, Surrey M, et al. Diminished effect ofmaternal age on implantation after preimplantation geneticdiagnosis with array comparative genomic hybridization.Fertil Steril 2013;100:1695–1703.

[7] Ercan CM, Kerimoglu OS, Sakinci M, et al. Pregnancyoutcomes in a university hospital after legal requirement forsingle-embryo transfer. Eur J Obstet Gynecol Reprod Biol2014;175:163–166.

[8] Bissonnette F, Phillips SJ, Gunby J, et al. Working to elim-inate multiple pregnancies: a success story in Québec.Reprod BioMed Online 2011;23(4):500–504.

[9] Kupka MS, Ferraretti AP, de Mouzon J, et al. European IVF-Monitoring Consortium, for the European Society of HumanReproduction and Embryology. Assisted reproductive tech-nology in Europe, 2010: results generated from Europeanregisters by ESHRE. Hum Reprod 2014;29(10):2099–2113.

[10] NICE, 2013. Available at: www.nice.org.uk/guidance/CG156/chapter/1-Recommendations#procedures-used-during-ivf-treatment. Accessed January 16, 2019.

[11] Harbottle S, Hughes C, Cutting R, et al. Association of ClinicalEmbryologists (ACE) & The British Fertility Society (BFS).Elective single embryo transfer: an update to UK Best PracticeGuidelines. Hum Fertil 2015;18(3):165–183.

[12] Maheshwari A, Griffiths S, Bhattacharya S. Global varia-tions in the uptake of single embryo transfer. Hum ReprodUpdate 2011;17(1):107–120.

[13] Macaldowie A, Wang Y, Chughtai A, et al. 2014. AssistedReproductive Technology in Australia and New Zealand2012. National Perinatal Epidemiology and Statistics Unit.The University of New South Wales, Sydney. Available at:https://npesu.unsw.edu.au/sites/default/files/npesu/data_collection/Assisted%20reproductive%20technology%20in%20Australia%20and%20New%20Zealand%202012.pdf.Accessed January 16, 2019.

[14] Penzias A, Bendikson K, Butts S, et al. Guidance on thelimits to the number of embryos to transfer: a committeeopinion. Fertil Steril 2017;107(4):901–903. doi:10.1016/j.fertnstert.2017.02.107.

[15] Practice Committee of the Society for Assisted ReproductiveTechnology, Practice Committee of the American Society forReproductive Medicine. Elective single-embryo transfer.Fertil Steril 2017;97:835–842.

[16] Society for Assisted Reproductive Technology. CSR 2016.Available at: https://www.sartcorsonline.com/rptCSR_PublicMultYear.aspx?reportingYear=2016. Accessed January 16,2019.

CHAPTER 6: CRYOPRESERVATION

Introduction

Cryopreservation is one of the most significant recent advance-ments in assisted reproduction technology (ART). Althoughinterest in human tissue cryopreservation has existed for morethan 200 years, significant progress in reproductive applicationshas occurred only in the last two or three decades.

The development of slow-freezing techniques and vitrificationtechnology, and expansion in various combinations of newer cryo-protectants, have considerably advanced the field of ART. Sperm,oocytes, and embryos can now be frozen at various stages of devel-opment, making treatment potentially safer and more effective[1].


50

Chapter 6. Table 1How is cryopreservation for fertility treatment regulated?

CountryNo

Regulations

Federal/National Laws/

Statutes/Ordinances

State/Provincial/Regional Laws/

Statutes/Ordinances

MunicipalLaws/

Statutes/Ordinances


ProfessionalOrganizationStandards/Guidelines

CulturalPractices

ReligiousDecree

Sperm for fertilitytreatment

Argentina Yes YesArmenia Yes YesAustralia Yes Yes YesAustria YesBangladesh YesBarbados YesBelarus YesBelgium YesBolivia YesBotswana YesBrazil Yes YesBulgaria YesBurkina Faso YesCameroon Yes YesCanada YesChile YesChina Yes Yes Yes YesColombia YesCzechia YesCongo YesEcuador YesEgypt Yes YesEl Salvador YesFinland Yes YesGeorgia YesGermany YesGhana Yes YesGreece Yes Yes YesGuatemala YesHong Kong [China,reporting separatelyfor this report](China*)

Yes Yes

Hungary Yes YesIceland YesIndia YesIreland Yes YesCôte d’Ivoire Yes YesJapan YesJordan YesKazakhstan Yes YesKenya YesLatvia Yes Yes YesLithuania YesMali YesMexico Yes YesMongolia YesMontenegro YesNamibia YesNetherlands Yes YesNew Zealand Yes Yes YesNicaragua YesNigeria Yes YesNorway YesPanama YesParaguay YesPeru YesPhilippines Yes YesPoland Yes Yes


51

Chapter 6. Table 1

(Continued)

CountryNo

Regulations


Statutes/Ordinances


Statutes/Ordinances

MunicipalLaws/

Statutes/Ordinances



CulturalPractices

ReligiousDecree

Portugal Yes Yes YesRomania Yes YesRussian Federation YesSenegal Yes Yes Yes Yes YesSerbia YesSingapore YesSlovenia Yes Yes YesSouth Africa YesThe Republic of Korea YesSpain Yes YesSri Lanka YesSweden YesSwitzerland Yes Yes YesTaiwan (China*) YesThailand YesTogo YesTrinidad and Tobago YesTurkey Yes YesUganda YesUnited Arab Emirates YesUK YesUSA YesUruguay Yes YesVenezuela YesViet Nam YesZimbabwe Yes

Oocytes forfertilitytreatment

Argentina Yes YesAustralia Yes Yes YesAustria YesBangladesh YesBarbados YesBelarus YesBelgium YesBolivia YesBotswana YesBrazil Yes YesBulgaria YesBurkina Faso YesCameroon Yes YesCanada YesChile YesChina Yes Yes Yes YesColombia YesCzechia YesCongo YesEcuador YesEgypt Yes YesEl Salvador YesFinland Yes YesGeorgia YesGermany YesGhana Yes YesGreece Yes Yes Yes Yes Yes Yes Yes YesGuatemala YesHong Kong (China*) Yes YesHungary Yes Yes


52

Chapter 6. Table 1

(Continued)

CountryNo

Regulations


Statutes/Ordinances


Statutes/Ordinances

MunicipalLaws/

Statutes/Ordinances



CulturalPractices

ReligiousDecree

Iceland YesIndia YesIreland Yes YesCôte d’Ivoire Yes YesJapan YesJordan YesKazakhstan YesKenya YesLatvia Yes Yes YesLithuania YesMali YesMexico Yes YesMongolia YesMontenegro YesNamibia YesNetherlands Yes YesNew Zealand Yes Yes YesNicaragua YesNigeria Yes SpermNorway YesPanama YesParaguay YesPeru YesPhilippines Yes YesPortugal Yes Yes YesRomania Yes YesRussian Federation YesSenegal Yes Yes YesSerbia YesSingapore YesSlovenia Yes Yes YesSouth Africa YesThe Republic of Korea YesSpain Yes YesSri Lanka YesSweden YesSwitzerland Yes Yes YesTaiwan (China*) YesThailand YesTogo YesTrinidad and Tobago YesTurkey Yes YesUganda YesUnited Arab Emirates YesUK YesUSA YesUruguay Yes YesVenezuela YesViet Nam YesZimbabwe Yes

Fertilized oocytespre-zygotes toblastocysts forfertilitytreatment

Country

Argentina Yes YesAustralia Yes Yes YesAustria Yes


53

Chapter 6. Table 1

(Continued)

CountryNo

Regulations


Statutes/Ordinances


Statutes/Ordinances

MunicipalLaws/

Statutes/Ordinances



CulturalPractices

ReligiousDecree

Bangladesh YesBarbados YesBelarus YesBelgium YesBolivia YesBotswana YesBrazil Yes Yes YesBulgaria YesBurkina Faso YesCameroon Yes YesCanada YesChile YesChina Yes Yes Yes YesColombia YesCzechia YesCongo YesEcuador YesEgypt Yes YesEl Salvador YesFinland Yes YesGeorgia YesGermany YesGhana Yes YesGreece Yes Yes YesGuatemala YesHong Kong (China*) Yes YesHungary YesIceland YesIndia YesIreland Yes YesCôte d’Ivoire Yes YesJapan YesJordan YesKazakhstan YesKenya YesLatvia Yes Yes YesLithuania YesMali YesMexico YesMongolia YesMontenegro YesNamibia YesNetherlands Yes YesNew Zealand Yes Yes YesNigeria YesNorway YesPanama YesParaguay YesPeru YesPhilippines Yes YesPolandPortugal Yes Yes YesRomania Yes YesRussian Federation YesSenegal Yes Yes Yes Yes YesSingapore YesSlovenia Yes Yes YesSouth Africa Yes


54

Chapter 6. Table 1

(Continued)

CountryNo

Regulations


Statutes/Ordinances


Statutes/Ordinances

MunicipalLaws/

Statutes/Ordinances



CulturalPractices

ReligiousDecree

The Republic of Korea YesSpain Yes YesSri Lanka YesSweden YesSwitzerland Yes Yes YesTaiwan (China*) YesThailand YesTogo YesTrinidad and Tobago YesTurkey Yes YesUganda YesUnited Arab Emirates YesUK YesUSA YesUruguay Yes YesVenezuela YesViet Nam YesZimbabwe Yes

Sperm for fertilitypreservation

Argentina Yes YesArmenia Yes YesAustralia YesAustria YesBangladesh YesBarbados YesBelarus YesBelgium YesBolivia YesBotswana YesBrazil Yes Yes YesBulgaria YesBurkina Faso YesCameroon YesCanada YesChile YesColombia Yes YesCzechia YesCongo YesEcuador YesEgypt Yes YesEl Salvador YesGeorgia YesGermany YesGhana YesGuatemala YesHungary Yes YesIceland YesIndia YesIreland Yes YesCôte d’Ivoire Yes YesJapan YesJordan YesKazakhstan Yes YesKenya YesLatvia Yes YesLithuania YesMali Yes Yes


55

Chapter 6. Table 1

(Continued)

CountryNo

Regulations


Statutes/Ordinances


Statutes/Ordinances

MunicipalLaws/

Statutes/Ordinances



CulturalPractices

ReligiousDecree

Mexico Yes YesMongolia YesMontenegro YesNamibia YesNetherlands Yes YesNew Zealand Yes YesNicaragua YesNigeria Yes YesNorway YesPanama YesParaguay YesPeru YesPhilippines Yes YesPoland Yes YesPortugal Yes Yes YesRomania YesRussian Federation YesSenegal YesSerbia YesSingapore YesSlovenia YesSouth Africa YesThe Republic of Korea YesSpain Yes YesSri Lanka YesSweden Yes YesSwitzerland Yes YesTaiwan (China*) YesThailand YesTogo YesTrinidad and Tobago YesUganda YesUnited Arab Emirates YesUK YesUSA YesUruguay Yes YesVenezuela YesViet Nam YesZimbabwe Yes

Oocytes forfertilitypreservation

Argentina Yes YesArmenia Yes YesAustralia YesAustria YesBangladesh YesBarbados YesBelarus YesBelgium YesBolivia YesBotswana YesBrazil Yes Yes YesBulgaria YesBurkina Faso YesCameroon YesCanada YesChile YesColombia Yes Yes


56

Chapter 6. Table 1

(Continued)

CountryNo

Regulations


Statutes/Ordinances


Statutes/Ordinances

MunicipalLaws/

Statutes/Ordinances



CulturalPractices

ReligiousDecree

Czechia YesCongo YesEcuador YesEgypt Yes YesEl Salvador YesGeorgia YesGermany YesGhana YesGuatemala YesHungary Yes YesIceland YesIndia YesIreland Yes YesCôte d’Ivoire Yes YesJapan YesJordan YesKazakhstan Yes YesKenya YesLatvia Yes YesLithuania YesMali Yes YesMexico Yes YesMongolia YesMontenegro YesNamibia YesNetherlands Yes YesNew Zealand Yes YesNicaragua YesNigeria Yes YesNorway YesPanama YesParaguay YesPeru YesPhilippines Yes YesPoland Yes YesPortugal Yes Yes YesRomania YesRussian Federation YesSenegal YesSerbia YesSingapore YesSlovenia YesSouth Africa YesThe Republic of Korea YesSpain Yes YesSri Lanka YesSweden Yes YesSwitzerland Yes YesTaiwan (China*) YesThailand YesTogo YesTrinidad and Tobago YesUganda YesUnited Arab Emirates YesUK YesUSA YesUruguay Yes YesVenezuela Yes


57

Chapter 6. Table 1

(Continued)

CountryNo

Regulations


Statutes/Ordinances


Statutes/Ordinances

MunicipalLaws/

Statutes/Ordinances



CulturalPractices

ReligiousDecree

Viet Nam YesZimbabwe Yes

Pre-implantationembryos forfertilitypreservation

Argentina Yes YesArmeniaAustraliaAustria YesBangladesh YesBarbados YesBelarus YesBelgium YesBolivia YesBotswana YesBrazil Yes Yes YesBulgaria YesBurkina Faso YesCameroon YesCanada YesChile YesColombia Yes YesCzechia YesCongo YesEcuador YesEgypt Yes YesEl Salvador YesFinland Yes YesGeorgia YesGermany YesGhana YesGreece YesHungary Yes YesIceland YesIreland Yes YesJapan YesJordan YesKazakhstan Yes YesKenya YesLatvia Yes YesLithuania YesMali Yes YesMexico Yes YesMongolia YesMontenegro YesNamibia YesNetherlands Yes YesNew Zealand Yes YesNigeria Yes YesNorway YesPanama YesParaguay YesPeru YesPhilippines Yes YesRomania YesRussian Federation YesSenegal YesSerbia Yes


58

Chapter 6. Table 1

(Continued)

CountryNo

Regulations


Statutes/Ordinances


Statutes/Ordinances

MunicipalLaws/

Statutes/Ordinances



CulturalPractices

ReligiousDecree

Singapore YesSlovenia YesSouth Africa YesThe Republic of Korea YesSpain Yes YesSri Lanka YesSweden Yes YesSwitzerland Yes YesTaiwan (China*) YesThailand YesTogo YesTrinidad and Tobago YesUganda YesUnited Arab Emirates YesUK YesUSA YesUruguay Yes YesVenezuela YesViet Nam YesZimbabwe Yes

Testicular tissuefor fertilitypreservation

Austria YesBangladesh YesBarbados YesBelgium YesBolivia YesBotswana YesBrazil Yes YesBulgaria YesBurkina Faso YesCanada YesChile YesColombia Yes YesCzechia YesCongo YesEcuador YesEgypt Yes YesGermany YesGreece Yes YesGuatemala YesIceland YesIndia YesIreland Yes YesCôte d’Ivoire Yes YesJapan YesKazakhstan Yes YesKenya YesLatvia YesLithuania YesMali YesMexico Yes YesMongolia YesMontenegro YesNamibia YesNetherlands Yes YesNew Zealand Yes Yes


59

Chapter 6. Table 1

(Continued)

CountryNo

Regulations


Statutes/Ordinances


Statutes/Ordinances

MunicipalLaws/

Statutes/Ordinances



CulturalPractices

ReligiousDecree

Nicaragua YesNigeria YesNorway YesPanama YesParaguay YesPeru YesPhilippines Yes YesPortugal Yes Yes YesRussian Federation YesSenegal YesSerbia Yes YesSingapore YesSlovenia YesSouth Africa YesThe Republic of Korea YesSpain Yes YesSri LankaSweden Yes YesSwitzerland YesThailand YesTogo YesTrinidad and Tobago YesUganda YesUK YesUSA YesUruguayVenezuela YesViet Nam YesZimbabwe Yes

Ovarian tissue forfertilitypreservation

Austria YesBangladesh YesBarbados YesBelgium YesBolivia YesBotswana YesBrazil Yes YesBurkina Faso YesCanada YesChile YesColombia Yes YesCzechia YesCongo Yes YesEcuador YesEgypt Yes YesGermany YesGuatemala YesIceland YesIndia YesIreland Yes YesCôte d’Ivoire Yes YesJapan YesKazakhstan Yes YesKenya YesLatvia YesLithuania Yes


60

Chapter 6. Table 1

(Continued)

CountryNo

Regulations


Statutes/Ordinances


Statutes/Ordinances

MunicipalLaws/

Statutes/Ordinances



CulturalPractices

ReligiousDecree

Mali YesMexico Yes YesMongolia YesMontenegro YesNamibia YesNetherlands Yes YesNew Zealand Yes YesNicaragua YesNigeria YesNorway YesPanama YesParaguay YesPeruPhilippines Yes YesPortugal Yes Yes YesRomaniaRussian Federation YesSenegal YesSingapore YesSlovenia YesSouth Africa YesThe Republic of Korea YesSpain Yes YesSweden Yes YesSwitzerland Yes YesThailand YesTogo YesTrinidad and Tobago YesUganda YesUK YesUSA YesVenezuela YesViet Nam YesZimbabwe Yes

Sperm for medicalindications

Argentina Yes YesArmenia YesAustralia YesAustria YesBangladesh YesBarbados YesBelarus YesBelgium YesBolivia YesBotswana YesBrazil Yes YesBulgaria YesBurkina Faso YesCameroon YesCanada YesChile YesChinaColombia Yes YesCosta RicaCzechia YesCongo YesEcuador Yes


61

Chapter 6. Table 1

(Continued)

CountryNo

Regulations


Statutes/Ordinances


Statutes/Ordinances

MunicipalLaws/

Statutes/Ordinances



CulturalPractices

ReligiousDecree

Egypt Yes YesEl Salvador YesEstoniaFinland YesFranceGeorgia YesGermany YesGhana YesGreece YesGuatemala YesHong Kong (China*) Yes YesHungary Yes YesIceland YesIndia YesIndonesiaIreland Yes YesIsraelItalyCôte d’IvoireJapan YesJordan YesKazakhstan YesKenya YesLatvia Yes Yes YesLithuania YesMali YesMexico Yes YesMongolia YesMontenegro YesNamibia YesNetherlands Yes YesNew Zealand Yes YesNicaragua YesNigeria YesNorway YesPanama YesParaguay YesPeru YesPhilippinesPoland YesPortugal Yes Yes YesRomania YesRussian Federation YesSenegal YesSerbia YesSingapore YesSlovenia YesSouth Africa YesThe Republic of Korea YesSpain Yes YesSri Lanka YesSweden YesSwitzerland Yes YesTaiwan (China*) YesThailand YesTogo YesTrinidad and Tobago YesTunisia


62

Chapter 6. Table 1

(Continued)

CountryNo

Regulations


Statutes/Ordinances


Statutes/Ordinances

MunicipalLaws/

Statutes/Ordinances



CulturalPractices

ReligiousDecree

Turkey YesUganda YesUnited Arab Emirates Yes YesUK YesUSA YesUruguay Yes YesVenezuela YesViet Nam YesZimbabwe Yes

Oocytes formedicalindications

Argentina YesAustralia YesAustria YesBangladesh YesBarbados YesBelarus YesBelgium YesBolivia YesBotswana YesBrazil Yes YesBulgaria YesBurkina Faso YesCameroon YesCanada YesChile YesColombia Yes YesCzechia YesCongo YesEcuador YesEgypt Yes YesEl Salvador YesFinland YesGeorgia YesGermany YesGhana YesGreece Yes YesGuatemala YesHong Kong (China*) Yes YesHungary Yes YesIceland YesIndia YesIreland Yes YesJapan YesJordan YesKazakhstan YesKenya YesLatvia Yes Yes YesLithuania YesMali YesMexico Yes YesMongolia YesMontenegro YesNamibia YesNetherlands Yes YesNew Zealand Yes YesNicaragua Yes


63

Chapter 6. Table 1

(Continued)

CountryNo

Regulations


Statutes/Ordinances


Statutes/Ordinances

MunicipalLaws/

Statutes/Ordinances



CulturalPractices

ReligiousDecree

Nigeria YesNorway YesPanama YesParaguay YesPeru YesPortugal Yes Yes YesRomania YesRussian Federation YesSenegal YesSerbia YesSingapore YesSlovenia YesSouth Africa YesThe Republic of Korea YesSpain Yes YesSri Lanka YesSweden YesSwitzerland Yes YesTaiwan (China*) YesThailand YesTogo YesTrinidad and Tobago YesTurkey YesUganda YesUnited Arab Emirates Yes YesUK YesUSA YesUruguay Yes Yes YesVenezuela YesViet Nam YesZimbabwe Yes

Pre-implantationembryos formedicalindications

Argentina Yes YesArmeniaAustralia YesAustria YesBangladesh YesBarbados YesBelarus YesBelgium YesBolivia YesBotswana YesBrazil Yes YesBulgaria YesBurkina Faso YesCameroon YesCanada YesChileChinaColombia Yes YesCosta RicaCzechia YesCongo YesEcuador YesEgypt Yes Yes


64

Chapter 6. Table 1

(Continued)

CountryNo

Regulations


Statutes/Ordinances


Statutes/Ordinances

MunicipalLaws/

Statutes/Ordinances



CulturalPractices

ReligiousDecree

El Salvador YesEstoniaFinland YesFranceGeorgia YesGermany YesGhana YesGreeceGuatemala YesHong Kong (China*) Yes YesHungary Yes YesIceland YesIndia YesIndonesiaIreland Yes YesIsraelItalyCôte d’IvoireJapan YesJordan YesKazakhstan YesKenya YesLatvia Yes Yes YesLithuania YesMali YesMexico Yes YesMongolia YesMontenegro YesNamibia YesNetherlands Yes YesNew Zealand Yes YesNicaraguaNigeria YesNorwayPanama YesParaguay YesPeru YesPhilippinesPolandPortugalRomania YesRussian Federation YesSenegal YesSerbia YesSingapore YesSlovenia YesSouth Africa YesThe Republic of Korea YesSpain Yes YesSri Lanka YesSweden YesSwitzerland Yes YesTaiwan (China*) YesThailand YesTogo YesTrinidad and Tobago YesTunisiaTurkey Yes


65

Chapter 6. Table 1

(Continued)

CountryNo

Regulations


Statutes/Ordinances


Statutes/Ordinances

MunicipalLaws/

Statutes/Ordinances



CulturalPractices

ReligiousDecree

Uganda YesUnited Arab Emirates Yes YesUK YesUSA YesUruguay Yes YesVenezuela YesViet Nam YesZimbabwe Yes

Testicular tissuefor medicalindications

Argentina YesAustralia YesAustria YesBangladesh YesBarbados YesBelgium YesBolivia YesBotswana YesBrazil Yes YesBulgaria YesBurkina Faso YesCameroon YesCanada YesChile YesColombia Yes YesCosta RicaCzechia YesCongoEcuador YesEgypt Yes YesGeorgia YesGermany YesGreece Yes Yes Yes YesGuatemala YesHong Kong (China*) Yes YesIceland YesIndia YesIreland Yes YesJapan YesJordan YesKazakhstan YesKenya YesLatvia Yes YesLithuania YesMali YesMexico Yes YesMongolia YesMontenegro YesNamibia YesNetherlands Yes YesNew Zealand Yes YesNicaragua YesNigeria YesPanama YesParaguay YesPortugal Yes Yes YesRussian Federation Yes


66

Chapter 6. Table 1

(Continued)

CountryNo

Regulations


Statutes/Ordinances


Statutes/Ordinances

MunicipalLaws/

Statutes/Ordinances



CulturalPractices

ReligiousDecree

Senegal YesSerbia YesSingapore YesSlovenia YesSouth Africa YesThe Republic of Korea YesSpain Yes YesSweden YesSwitzerland Yes YesThailand YesTogo YesTrinidad and Tobago YesTurkey YesUganda YesUK YesUSA YesUruguay Yes YesVenezuela YesViet Nam YesZimbabwe Yes

Ovarian tissue formedicalindications

Argentina YesAustralia YesAustria YesBangladesh YesBarbados YesBelgium YesBolivia YesBotswana YesBrazil Yes YesBurkina Faso YesCameroon YesCanada YesChile YesColombia Yes YesCzechia YesCongo YesEcuador YesEgypt Yes YesGeorgia YesGermany YesGreece YesGuatemala YesHong Kong (China*) Yes YesIceland YesIndia YesIreland Yes YesJapan YesJordan YesKazakhstan YesKenya YesLatvia Yes YesLithuania YesMali YesMexico Yes YesMongolia Yes


67

The chief objectives of cryopreservation are to make gametesor embryos available for future use by individuals or couplesundergoing infertility treatment, and to preserve future fertilityoptions for individuals at risk of losing their reproductivepotential. Cryopreservation also offers the opportunity toforestall pregnancy to a safer, more optimal time. This isimportant for patients who are at risk of ovarian hyper-stimulation syndrome (OHSS), or who have poor endometrialreceptivity.

Frozen embryo transfer (FET) is a procedure – a cycle – inwhich frozen embryos are thawed, then transferred to a uterus.The improved results of embryo cryopreservation have been anessential component of preimplantation genetic diagnosis andscreening.

The improved results of embryo cryopreservation have been anessential component for preimplantation genetic diagnosis/screening, using trophectoderm biopsy and array comparativegenomic hybridization (CGH microarray) or Next GenSequencing (NGS). Blastocysts can be frozen, and genetic testingperformed before the blastocysts are transferred[2]. Embryocryopreservation offers a way to avoid repeated ovarian stimu-lation, optimizes achieving embryo-endometrial synchrony, andaids in single embryo transfer (SET)[3].


Cryopreservation for fertility treatment

None of the respondent countries cited explicit prohibition ofcryopreservation of sperm, oocytes, or pre-implantation embryosfor fertility treatment. Cryopreservation for fertility treatment(Table 1) is expressly allowed or permitted for sperm in 71 of 83(86%) of countries responding; for oocytes, in 68 of 82 (83%);and in all stages of pre-implantation embryos, in 66 out of 82(80%). There are no regulations for cryopreservation for fertilitytreatment for sperm, according to 35 of 82 responders (43%); foroocytes, in 33 of 82 (40%); and all stages of pre-implantationembryos, in 32 of 82 (39%).

For countries that regulated cryopreservation for fertilitytreatment, the following were used to govern:• Federal/national laws/statutes/ordinances were used for sperm

in 39 of 82 (47.5%); to govern oocytes, only 3 of 82 (4%); andall stages of pre-implantation embryos, 36 of 82 (44%);

• State/provincial/regional laws/statutes/ordinances: sperm,oocytes, and all stages of pre-implantation embryos: 7 of 82(8.5%);

• Municipal laws/statutes/ordinances: sperm and all stages ofpre-implantation embryos: only 2 of 82 respondents (2%) andoocytes: only 3 of 82 (4%);

Chapter 6. Table 1

(Continued)

CountryNo

Regulations


Statutes/Ordinances


Statutes/Ordinances

MunicipalLaws/

Statutes/Ordinances



CulturalPractices

ReligiousDecree

Montenegro YesNamibia YesNetherlands Yes YesNew Zealand Yes YesNicaragua YesNigeria YesNorway YesPanama YesParaguay YesPortugal Yes Yes YesRussian Federation YesSenegal YesSerbia YesSingapore YesSlovenia YesSouth Africa YesThe Republic of Korea YesSpain Yes YesSweden YesSwitzerland Yes YesThailand YesTogo YesTrinidad and Tobago YesTurkey YesUganda YesUK YesUSA YesVenezuela YesViet Nam YesZimbabwe Yes



68

Chapter 6. Table 2aWhat is the maximum duration of storage?

CountrySperm for Cryopreservation for

Fertility TreatmentSperm Nonmedical

IndicationsSperm MedicalIndications

Testicular TissueNonmedical Indications

Testicular Tissue MedicalIndications

Argentina Not addressed Not addressed Not addressed Not addressed Not addressedArmenia Unknown Not addressed Not addressed Not addressed Not addressedAustralia Not addressed Not addressed Not addressed Not addressed Not addressedAustria No Limit No Limit No Limit No Limit No LimitBangladesh No Limit No Limit No LimitBelarus No Limit No Limit No Limit No Limit No LimitBelgium Unknown Unknown Unknown Unknown UnknownBolivia No Limit Not addressed No Limit No Limit No LimitBotswana Not addressed Not addressed Not addressed Not addressed UnknownBrazil No Limit No Limit No Limit No Limit No LimitBulgaria 5 y 5 y 5 y 5 y 5 yBurkina Faso No Limit No Limit No Limit No Limit No LimitCameroon 5 yCanada No Limit No Limit No Limit No Limit No LimitChile No Limit No Limit No Limit No Limit No LimitChina No Limit No Limit No LimitColombia No Limit No Limit No Limit No Limit No LimitCzechia Unknown Unknown Unknown Unknown UnknownCongo Not addressed Not addressed Not addressed Not addressed UnknownEcuador No Limit No Limit No Limit No Limit No LimitEgypt No Limit No Limit No Limit No Limit No LimitEl Salvador No Limit No Limit No LimitFinland No Limit No Limit No Limit No Limit No LimitGeorgia Not addressed Not addressed Not addressed Not addressed Not addressedGermany Unknown Unknown Unknown Unknown UnknownGhana No Limit No Limit No Limit No Limit No LimitGreece 25 y 25 y No Limit No Limit No LimitGuatemala No Limit No Limit No Limit Not addressed Not addressedHong Kong (China*) 10 y Not addressed 10 y Not addressed 10 yHungary Unknown Not addressed Not addressed Not addressed Not addressedIceland 10 y 10 y 10 y 10 y 10 yIndia Not addressed Not addressed Not addressed Not addressed Not addressedIreland 10 y 10 y 10 y Not addressed Not addressedItaly Not addressed Not addressed Not addressed Not addressed Not addressedCôte d’Ivoire No Limit Not addressed Not addressed Not addressed No LimitJapan No Limit Not addressed No Limit Not addressed Not addressedJordan Not addressed Not addressed Not addressed Not addressed Not addressedKazakhstan No Limit No Limit No Limit No Limit No LimitKenya Not addressed Not addressed Not addressed Not addressedLatvia No Limit No Limit No Limit No Limit No LimitLithuania No Limit Not addressed No Limit Not addressed UnknownMali No Limit Unknown Unknown Unknown UnknownMexico No Limit No Limit No Limit Not addressed Not addressedMongolia Not addressed Not addressed Not addressed Not addressed Not addressedMontenegro No Limit No Limit No Limit No Limit No LimitNamibia No Limit No Limit No Limit Not addressed Not addressedNetherlands No Limit No Limit No Limit No Limit No LimitNew Zealand 10 y 10 y 10 y 10 y 10 yNicaragua 5 y 5 y 5 y 5 y 5 yNigeria UnknownNorway Not addressed Not addressedPanama Not addressed Not addressed Not addressed Not addressed Not addressedParaguay No Limit No Limit No Limit No Limit No LimitPeru Unknown Unknown Unknown Unknown UnknownPoland Unknown Unknown UnknownPortugal 5 y 5 y 5 y 5 y 5 yRomania Not addressed Not addressed Not addressed Not addressed Not addressedRussian Federation No Limit No Limit No Limit No Limit No LimitSenegal Not addressed Not addressed Not addressed Not addressed Not addressedSerbia 2 y 2 y Unknown 1 y No LimitSingapore 10 y 0 y 10 y 0 y 10 y


69

Chapter 6. Table 2a

(Continued)

CountrySperm for Cryopreservation for

Fertility TreatmentSperm Nonmedical


Testicular TissueNonmedical Indications


Slovenia No Limit No Limit No LimitSouth Africa No Limit No Limit No Limit No Limit No LimitThe Republic of Korea No Limit No Limit No Limit No Limit No LimitSpain No Limit No Limit No Limit No Limit No LimitSwitzerland 10 y 10 y No Limit 10 y No LimitTaiwan (China*) 10 y 10 y 10 y Not addressed Not addressedThailand No Limit No Limit No Limit No Limit No LimitTogo No Limit Not addressed No Limit Not addressed No LimitTrinidad and Tobago Not addressed Not addressed Not addressed Not addressed Not addressedTurkey 5 y 5 y 5 yUganda 10 y 10 y 10 y Unknown UnknownUnited Arab Emirates 5 y 5 y 5 y Unknown UnknownUK 55 y 10 y 55 y No Limit No LimitUSA No Limit No Limit No Limit No Limit No LimitUruguay No Limit No Limit No Limit No Limit No LimitVenezuela No Limit No Limit No Limit No Limit No LimitViet Nam Not addressed Not addressed Not addressed Not addressed Not addressedZimbabwe No Limit No Limit No Limit No Limit No Limit


Chapter 6. Table 2bWhat is the maximum duration of storage?

CountryOocytes for Cryopreservation for

Fertility TreatmentOocytes Nonmedical

IndicationsOocytes Medical

IndicationsOvarian Tissue

Nonmedical IndicationsOvarian Tissue Medical

Indications

Argentina Not addressed Not addressed Not addressed Not addressed Not addressedArmenia Not addressed Not addressed Not addressed Not addressed Not addressedAustralia Not addressed Not addressed Not addressed Not addressed Not addressedAustria No Limit No Limit No Limit No Limit No LimitBangladesh No Limit No Limit No LimitBelarus No Limit No Limit No Limit No Limit No LimitBelgium Unknown Unknown Unknown Unknown UnknownBolivia No Limit No Limit No Limit No Limit No LimitBotswana Not addressed Not addressed Not addressed Not addressed Not addressedBrazil No Limit No Limit No Limit No Limit No LimitBulgaria 5 y 5 y 5 y Not addressed Not addressedBurkina Faso No Limit No Limit No Limit UnknownCanada No Limit No Limit No Limit No Limit No LimitChile No Limit No Limit No Limit No Limit No LimitChina No Limit No Limit No LimitColombia No Limit No Limit No Limit No Limit No LimitCzechia Unknown Unknown Unknown Unknown UnknownCongo Not addressed Not addressed Not addressedEcuador No Limit No Limit No Limit No Limit No LimitEgypt No Limit No Limit No Limit No Limit No LimitEl Salvador No Limit No Limit No LimitFinland No Limit No Limit No Limit No Limit No LimitGeorgia Not addressed Not addressed Not addressed Not addressed Not addressedGermany Unknown Unknown Unknown Unknown UnknownGhana No Limit No Limit No Limit No Limit No LimitGreece 25 y No Limit No Limit No Limit No LimitGuatemala No Limit No Limit No Limit Not addressed Not addressedHong Kong (China*) 10 y Not addressed 10 y Not addressed 10 yHungary Not addressed Not addressed Not addressed Not addressed Not addressedIceland 10 y 10 y 10 y 10 y 10 yIndia Not addressed Not addressed Not addressed Not addressed Not addressedIreland 10 y 10 y 10 y Not addressed Not addressedItaly Not addressed No Limit No Limit No Limit Not addressedCôte d’Ivoire Unknown Not addressed Not addressed Not addressed Not addressedJapan No Limit Not addressed No Limit Not addressed No Limit


70

• Agency regulations/oversight: sperm: 10 of 82 respondents(12%); all stages of pre-implantation embryos, and oocytes aswell: 11 out of 82 (13%);

• Professional organization standards/guidelines: sperm, 24 of82 respondents (29%); oocytes, 23 of 82 (28%); and all stagesof pre-implantation embryos: 21 of 82 (26%);

• Cultural practices to govern sperm: only 1 of 82 (1%), and allstages of pre-implantation embryos andoocytes: 2 of 82 (2%); and

• Religious decree: oocytes: 1 out of 82 responders (1%).

Duration of storage for fertility treatment

Duration of storage for fertility treatment was not limited forsperm in 38 out of 79 (48%); for oocytes, 36 out of 75 (48%); and

for all stages of pre-implantation embryos: 33 out of 76 (43%).The duration of storage was limited for sperm in 17 of 79 (22%);oocytes, 16 of 75 (21%); and all stages of pre-implantationembryos: 19 of 76 (25%). The duration of storage was notaddressed for sperm in 16 of 79 (20%); for oocytes, in 17 of 75(23%); and for all stages of pre-implantation embryos in 18 of 76(24%). The duration of storage for sperm was unknown in 8 of79 (10%); for oocytes, in 6 of 75 (8%); and in all stages of pre-implantation embryos, 6 of 76 responders (8%).

The following durations were reported:• Sperm: 2 years (Serbia); 5 years (Bulgaria, Cameroon,

Nicaragua, Portugal, Turkey, and United Arab Emirates);10 years (Hong Kong [China, reporting separately forthis report], Iceland, Ireland, New Zealand, Singapore,

Chapter 6. Table 2b

(Continued)

CountryOocytes for Cryopreservation for

Fertility TreatmentOocytes Nonmedical


IndicationsOvarian Tissue

Nonmedical IndicationsOvarian Tissue Medical

Indications

Jordan Not addressed Not addressed Not addressed Not addressed Not addressedKazakhstan No Limit No Limit No Limit No Limit No LimitKenya Not addressed Not addressed Not addressed Not addressedLatvia No Limit No Limit No Limit No Limit No LimitLithuania No Limit Not addressed No Limit No Limit UnknownMali 5 y Unknown Unknown Unknown UnknownMexico No Limit No Limit No Limit Not addressed Not addressedMongolia Not addressed Not addressed Not addressed Not addressed Not addressedMontenegro No Limit No Limit No Limit No Limit No LimitNamibia No Limit Not addressed Not addressed Not addressed Not addressedNetherlands No Limit No Limit No Limit No Limit No LimitNew Zealand 10 y 10 y 10 y 10 y 10 yNicaragua 5 y 5 y 5 y 5 yNigeria UnknownNorway Not addressed Not addressed Not addressed Unknown Not addressedPanama Not addressed Not addressed Not addressed Not addressed Not addressedParaguay No Limit No Limit No Limit Not addressed Not addressedPeru Unknown Unknown Unknown Unknown UnknownPortugal 5 y 5 y 5 y 5 y 5 yRomania Not addressed Not addressed Not addressed Not addressed Not addressedRussian Federation No Limit No Limit No Limit No Limit No LimitSenegal Not addressed Not addressed Not addressed Not addressed Not addressedSerbia 2 y Not addressed Not addressed Not addressedSingapore 10 y 0 y 10 y 0 y 10 ySlovenia No Limit No Limit No LimitSouth Africa No Limit No Limit No Limit No Limit No LimitThe Republic of Korea No Limit No Limit No Limit No Limit No LimitSpain No Limit No Limit No Limit No Limit No LimitSwitzerland 10 y 10 y No Limit 10 yTaiwan (China*) 10 y 10 y 10 y Not addressed Not addressedThailand No Limit No Limit No Limit No Limit No LimitTogo No Limit Not addressed No Limit Not addressed Not addressedTrinidad and Tobago Not addressed Not addressed Not addressed Not addressed Not addressedTurkey 5 y 5 y 5 yUganda 10 y 10 y 10 y Unknown UnknownUnited Arab Emirates 5 y Not addressed 5 y Unknown UnknownUnited Kingdom of Great Britainand Northern Ireland

10 y 10 y 55 y No Limit No Limit

The United States of America No Limit No Limit No Limit No Limit No LimitUruguay No Limit No Limit No Limit Not addressed No LimitVenezuela No Limit No Limit No Limit No Limit No LimitViet Nam Not addressed Not addressed Not addressed Not addressed Not addressedZimbabwe No Limit No Limit No Limit No Limit No Limit



71

Switzerland, Taiwan [China, reporting separately for thisreport], and Uganda); 25 years (Greece); and 55 years(United Kingdom of Great Britain and Northern Ireland)(Table 2a).

• Oocytes: 2 years (Serbia); 5 years (Bulgaria, Mali, Portugal,Turkey, and United Arab Emirates); 10 years (Hong Kong[China, reporting separately for this report], Iceland, Ireland,New Zealand, Singapore, Switzerland, Taiwan [China,reporting separately for this report], Uganda, and UnitedKingdom of Great Britain andNorthern Ireland); and 25 years(Greece) (Table 2b); and

• All stages of preimplantation embryos: 5 years (Bulgaria,Cameroon, Mali, Norway, and The Republic of Korea);10 years (Australia, Austria, Hong Kong [China, reportingseparately for this report], Hungary, Iceland, Ireland, NewZealand, Singapore, Slovenia, Switzerland, Taiwan [China,reporting separately for this report], Uganda, and the UnitedKingdom of Great Britain and Northern Ireland); and25 years (Greece) (Table 2c).

Cryopreservation for fertility preservation, medicalindications

None of the respondent countries cited explicit prohibition ofcryopreservation of sperm, oocytes, or pre-implantation embryosfor fertility preservation. Cryopreservation for fertility preserva-tion for medical indications (Table 1) is expressly allowed/per-mitted for sperm in 68 of 81 (84%) of responding countries; for

Chapter 6. Table 2cWhat is the maximum duration of storage?

Country

Fertilized Oocytes,Prezygotes to

Blastocysts for FertilityTreatment

PreimplantationEmbryos

NonmedicalIndications

PreimplantationEmbryosMedical

Indications

Argentina Not addressed Not addressed Not addressedArmenia Not addressed Not addressed Not addressedAustralia 10 y Not addressed Not addressedAustria 10 y Not addressed 10 yBangladesh No Limit No LimitBelarus No Limit No Limit No LimitBelgium Unknown Unknown UnknownBolivia No Limit No Limit No LimitBotswana Not addressed Not addressedBrazil No Limit No Limit No LimitBulgaria 5 y 5 y 5 yBurkina Faso No Limit No LimitCameroon 5 yCanada No Limit No Limit No LimitChile No Limit No Limit No LimitChina No Limit No LimitColombia No Limit No Limit No LimitCzechia Unknown Unknown UnknownCongo Not addressed Not addressed Not addressedEcuador No Limit No LimitEgypt No Limit No Limit No LimitEl Salvador No LimitFinland No Limit No Limit No LimitGeorgia Not addressed Not addressed Not addressedGermany Unknown Unknown UnknownGhana No Limit No Limit No LimitGreece 25 y No Limit No LimitGuatemala No Limit No Limit No LimitHong Kong(China*)

10 y Not addressed 10 y

Hungary 10 y Not addressed 10 yIceland 10 y 10 y 10 yIndia Not addressed Not addressed Not addressedIreland 10 y 10 y 10 yItaly Not addressed No Limit No LimitCôte d’Ivoire No Limit Not addressed Not addressedJapan No Limit Not addressed No LimitJordan Not addressed Not addressed Not addressedKazakhstan No Limit No Limit No LimitKenya Not addressed Not addressed Not addressedLatvia No Limit No Limit No LimitLithuania No Limit Not addressed No LimitMali 5 y Unknown UnknownMexico Not addressed Not addressed Not addressedMongolia Not addressed Not addressed Not addressedMontenegro No Limit No Limit No LimitNamibia No Limit Not addressed Not addressedNetherlands No Limit No Limit No LimitNew Zealand 10 y 10 y 10 yNicaragua Unknown Unknown UnknownNigeria UnknownNorway 5 y 5 yPanama Not addressed Not addressed Not addressedParaguay No Limit No Limit No LimitPeru Unknown Unknown UnknownPortugal Not addressed Not addressed UnknownRomania Not addressed Not addressed Not addressedRussianFederation

No Limit No Limit No Limit

Chapter 6. Table 2c

(Continued)

Country

Fertilized Oocytes,Prezygotes to

Blastocysts for FertilityTreatment

PreimplantationEmbryos

NonmedicalIndications

PreimplantationEmbryosMedical

Indications

Senegal Not addressed Not addressed Not addressedSerbia Not addressed UnknownSingapore 10 y 0 y 10 ySlovenia 10 y No LimitSouth Africa No Limit No Limit No LimitThe Republic ofKorea

5 y 5 y 5 y

Spain No Limit No Limit No LimitSwitzerland 10 y 10 y 10 yTaiwan (China*) 10 y 10 y 10 yThailand No Limit No Limit No LimitTogo No Limit Not addressed Not addressedTrinidad andTobago


Turkey Not addressed Not addressedUganda 10 y Unknown UnknownUnited ArabEmirates


UK 10 y 10 y 10 yUSA No Limit No Limit No LimitUruguay No Limit No Limit No LimitVenezuela No Limit No Limit No LimitViet Nam Not addressed Not addressed Not addressedZimbabwe No Limit No Limit No Limit



72

oocytes, in 60 of 83 (82%); for pre-implantation embryos (allstages), in 62 of 82 (76%); for ovarian tissue, in 52 of 83 (65%);and for testicular tissue, in 53 of 82 (65%).

Countries reporting that cryopreservation to maintain fertilityfor medical indications is commonly performed for sperm in 28 of439 countries (72%); for oocytes, in 18 out of 40 (45%); for allstages of pre-implantation embryos, in 19 of 42 (45%); forovarian tissue, in 7 of 48 (14.5%); and for testicular tissue, 9 of 47(19%).

Cryopreservation for fertility preservation, non-medicalindications

According to responders, cryopreservation in non-medical indica-tions is specifically allowed/permitted for sperm in 60 of 82 (73%);for oocytes, in 56 out of 81 (69%); for pre-implantation embryos(all stages), 51 of 82 (62%); for ovarian tissue, 44 of 82 (54%); andfor testicular tissue, 45 of 83 (54%). Cryopreservation for fertilitypreservation in non-medical indications is frequently performed asfollows: for sperm, 16 of 42 (38%); oocytes, 18 of 42 (43%); allstages of pre-implantation embryos, 8 of 43 (19%); ovarian tissue,3 of 48 (6%); and testicular tissue, 4 of 49 (8%).

In 80 countries surveyed, 33 (41%) have no regulations forcryopreservation performed to preserve fertility for sperm andoocytes in all stages of pre-implantation embryos; 31 (39%); 30(37.5%) have none for ovarian tissue; and 31 (39%) have nonefor testicular tissue.

Countries that regulated cryopreservation for fertility treat-ment provided responses, summarized below, indicating howuses were governed. (In all cases there were 80 responders):• Federal/national laws/statutes/ordinances governed sperm

and oocyte cryopreservation in 28 (35%); pre-implantationembryos, all stages, in 27 (34%); ovarian tissue, in 18 (23%);and testicular tissue, in 17 (21%);

• State/provincial/regional laws/statutes/ordinances governed spermcryopreservation in 2 (3%); oocytes, in 3 (4%); and all stages ofpre-implantation embryos, ovarian tissue, and testicular tissue, in1 (1%);

• Municipal laws/statutes/ordinances were used to governtesticular tissue in 1 (1%);

• Agency regulations/oversight governed sperm in 6 (8%);oocytes in 3 (4%); and pre-implantation embryos (all stages),ovarian tissue, and testicular tissue in 4 (5%);

• Professional organization standards/guidelines were used to gov-ern sperm in 20 (25%); oocytes, 19 (24%); pre-implantationembryos, all stages, 18 (23%); ovarian tissue, 14 (18%); andtesticular, 15 (19%);

• Cultural practices governed sperm and oocytes in 2 (3%), andin pre-implantation embryos (all stages), ovarian tissue, andtesticular tissue (1%); and

• Religious decree was used to govern ovarian tissue in 1instance (1%).

Duration of storage for fertility treatment for medicalindications

Listed below is the duration of storage for fertility preservationfor medical indications. Storage duration was not limited forsperm in 38 of 77 (49%) countries; for oocytes, in 38 of 74 (51%)countries; for pre-implantation embryos (all stages), in 31 of 74(42%), in ovarian tissue, in 30 of 74 (40%); and in testiculartissue, in 35 of 74 (47%).

The duration of storage was limited for sperm in 13 of 77(17%) countries; for oocytes, in 13 of 74 (18%); all stages of pre-implantation embryos, in 18% of 74; for ovarian tissue, in 9% of74, and for testicular tissue, in 11%. The duration of storage wasnot addressed for sperm in 19 of 77 (25%); for oocytes, in 18 of74 (24%); all stages of pre-implantation embryos, 21 of 74(28%); ovarian tissue, 28 of 74 (38%); and testicular tissue, 21 of74 (28%). The duration of storage was unknown for sperm in 7of 77 countries (9%); for oocytes, in 5 of 74 (7%); for all stages ofpre-implantation embryos, in 9 of 74 (12%); for ovarian tissue, in9 of 74 (12%); and for testicular tissue, in 10 in 74 (14%).

The following durations were reported:• Sperm: 5 years (Bulgaria, Nicaragua, Portugal, Turkey, and

United Arab Emirates); 10 years (Hong Kong [China, reportingseparately for this report], Iceland, Ireland, New Zealand,Singapore, Taiwan [China, reporting separately for this report],and Uganda); and 55 years (United Kingdom of Great Britainand Northern Ireland);

• Oocytes: 5 years (Bulgaria, Nicaragua, Portugal, Turkey, andUnited Arab Emirates); 10 years (Hong Kong [China, report-ing separately for this report], Iceland, Ireland, New Zealand,Singapore, Taiwan [China, reporting separately for thisreport], and Uganda); 55 years (United Kingdom of GreatBritain and Northern Ireland);

• All Stages of preimplantation embryos: 5 years (Bulgaria,Norway, and TheRepublic of Korea); 10 years (Austria, HongKong [China, reporting separately for this report], Iceland,Ireland, New Zealand, Singapore, Switzerland, Taiwan[China, reporting separately for this report], and the UnitedKingdom of Great Britain and Northern Ireland);

• Ovarian Tissue: 5 years (Nicaragua, Portugal, and Turkey);10 years (Hong Kong [China, reporting separately for thisreport], Iceland, New Zealand, and Singapore); and

• Testicular tissue: 5 years (Bulgaria, Nicaragua, Portugal, andTurkey); 10 years (Hong Kong [China, reporting separatelyfor this report], Iceland, New Zealand, and Singapore).

Duration of storage for fertility treatment for non-medicalindications

The duration of storage for fertility preservation for non-medicalindications was not limited, as follows: for sperm, in 29 of 70(41%); for oocytes, in 30 of 70 (43%); in all stages of pre-implantation embryos, in 26 of 68 (38%); in ovarian tissue, 28 of69 (40%); and testicular tissue, in 28 of 69 (41%).

The duration of storage was limited, however, as follows: forsperm, in 13 of 70 (19%); for oocytes, in 10 of 70 (14%); in allstages of pre-implantation embryos, in 8 of 68 (12%); in ovariantissue, in 5 of 69 (7%); and in testicular tissue, in 7 out of 69(10%).

The duration of storage was not addressed, as follows: forsperm, in 22 of 70 (31%); for oocytes, in 25 of 70 (36%); allstages of pre-implantation embryos, in 27 of 68 (40%); ovariantissue, 28 of 69 (40%); and testicular tissue in 27 of 69 (39%).

In some cases, the duration of storage was unknown. Theseinclude: for sperm, 6 of 70 (8%); for oocytes, 5 of 70 (7%); for allstages of pre-implantation embryos, 7 of 68 (10%); for ovariantissue, 8 of 69 (12%); and for testicular tissue, 7 of 69 (10%).

The following durations for storage were reported:• Sperm: 2 years (Serbia); 5 years (Bulgaria, Nicaragua,

Portugal, and United Arab Emirates); 10 years (Iceland,


73

Chapter 6. Table 3aIs cryopreservation for fertility treatment or fertility preservation allowed/permitted or practiced/performed in your country?

CountrySperm Cryopreserved for Fertility

TreatmentSperm Nonmedical


Testicular Tissue NonmedicalIndications


Argentina Allowed/Permitted Allowed/Permitted Allowed/Permitted Infrequently Practiced/ Allowed/PermittedCommonly Practiced/Performed Infrequently Practiced/

PerformedCommonly Practiced/Performed

Performed Commonly Practiced/Performed

Armenia Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedAustralia Allowed/Permitted Allowed/Permitted Allowed/Permitted Never Practiced/Performed Allowed/PermittedAustria Allowed/Permitted Never Practiced/

PerformedAllowed/Permitted Allowed/Permitted Allowed/Permitted

Commonly Practiced/Performed Commonly Practiced/Performed

Never Practiced/Performed Infrequently Practiced/Performed

Bangladesh Allowed/Permitted Never Practiced/Performed

Allowed/Permitted Never Practiced/Performed Allowed/Permitted

Barbados Allowed/Permitted Allowed/Permitted Allowed/Permitted Never Practiced/Performed Never Practiced/PerformedCommonly Practiced/Performed Infrequently Practiced/

PerformedInfrequently Practiced/Performed

Belarus Allowed/Permitted Allowed/Permitted,Commonly

Allowed/Permitted Allowed/Permitted Allowed/Permitted

Commonly Practiced/Performed Practiced/Performed Commonly Practiced/Performed

Infrequently Practiced/Performed Infrequently Practiced/Performed

Belgium Allowed/Permitted Allowed/Permitted Allowed/Permitted Unknown UnknownBolivia Commonly Practiced/Performed Commonly Practiced/



Botswana Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedBrazil Allowed/Permitted Allowed/Permitted,

CommonlyAllowed/Permitted Allowed/Permitted Allowed/Permitted

Commonly Practiced/Performed Practiced/Performed Commonly Practiced/Performed


Bulgaria Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedCommonly Practiced/Performed Infrequently Practiced/



Burkina Faso Commonly Practiced/Performed Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedCameroon Allowed/Permitted Never Practiced/

PerformedAllowed/Permitted Never Practiced/Performed Never Practiced/Performed

Commonly Practiced/Performed Infrequently Practiced/Performed

Canada Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedChile Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted, Commonly Allowed/Permitted


Commonly Practiced/Performed

Practiced/Performed Commonly Practiced/Performed

China Allowed/Permitted Never Practiced/Performed

Allowed/Permitted Never Practiced/Performed Never Practiced/Performed

Infrequently Practiced/Performed Commonly Practiced/Performed

Colombia Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedCzechia Allowed/Permitted Allowed/Permitted Allowed/Permitted Infrequently Practiced/Performed Infrequently Practiced/

PerformedCongo Allowed/Permitted Unknown Unknown Never Practiced/PerformedEcuador Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedEgypt Allowed/Permitted Allowed/Permitted Allowed/Permitted Unknown Allowed/PermittedEl Salvador Allowed/Permitted Allowed/Permitted Allowed/Permitted Never Practiced/Performed Never Practiced/PerformedFinland Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedGeorgia Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted



Never Practiced/Performed Never Practiced/Performed

Germany Unknown Unknown Commonly Practiced/Performed

Unknown Unknown

Ghana Allowed/Permitted Allowed/Permitted Allowed/Permitted,Commonly

Allowed/Permitted Allowed/Permitted


Practiced/Performed

Greece Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedGuatemala Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted


74

Chapter 6. Table 3a

(Continued)









Hong Kong Allowed/Permitted Unknown Allowed/Permitted Unknown Allowed/Permitted(China*) Commonly Practiced/Performed Commonly Practiced/


Hungary Allowed/Permitted Allowed/Permitted Allowed/Permitted Infrequently Practiced/Performed Infrequently Practiced/Performed

Iceland Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedCommonly Practiced/Performed Infrequently Practiced/



India Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedIreland Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted




Italy Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedCôte Allowed/Permitted Allowed/Permitted Unknown Never Practiced/Performed, Infrequently Practiced/d’Ivoire Commonly Practiced/Performed Commonly Practiced/

PerformedUnknown Performed

Japan Allowed/Permitted Infrequently Practiced/Performed

Allowed/Permitted Unknown Unknown

Jordan Allowed/Permitted Allowed/Permitted Allowed/Permitted Unknown UnknownCommonly Practiced/Performed

Kazakhstan Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedKenya Commonly Practiced/Performed Commonly Practiced/



Latvia Allowed/Permitted Allowed/Permitted, Allowed/Permitted Allowed/Permitted, Unknown Allowed/Permitted, UnknownInfrequently Practiced/Performed Infrequently Practiced/


Lithuania Allowed/Permitted Allowed/Permitted Allowed/Permitted Never Practiced/Performed Allowed/PermittedNever Practiced/Performed

Mali Commonly Practiced/Performed Never Practiced/Performed

Never Practiced/Performed


Mexico Allowed/Permitted Allowed/Permitted Allowed/Permitted Infrequently Practiced/Performed Infrequently Practiced/Performed

Mongolia Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedMontenegro Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedNamibia Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedNetherlands Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedNew Allowed/Permitted Allowed/Permitted, Allowed/Permitted Allowed/Permitted Allowed/PermittedZealand Commonly Practiced/Performed Infrequently Practiced/



Nicaragua Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedNigeria Infrequently Practiced/Performed Commonly Practiced/

PerformedAllowed/Permitted Unknown Unknown

Norway Allowed/Permitted Allowed/Permitted Never Practiced/Performed Never Practiced/PerformedCommonly Practiced/Performed

Panama Commonly Practiced/Performed Commonly Practiced/Performed



Paraguay Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedCommonly Practiced/Performed Commonly Practiced/



Peru Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedPhilippines Allowed/Permitted Allowed/Permitted Allowed/Permitted Infrequently Practiced/Performed Infrequently Practiced/

PerformedPoland Allowed/Permitted Allowed/Permitted Allowed/Permitted Never Practiced/Performed Never Practiced/PerformedPortugal Allowed/Permitted Allowed/Permitted,

UnknownAllowed/Permitted Allowed/Permitted, Unknown Allowed/Permitted



Romania Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedCommonly Practiced/Performed Infrequently Practiced/Performed


75

Chapter 6. Table 3a

(Continued)






Infrequently Practiced/Performed



Russian Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedFederation Commonly Practiced/Performed Infrequently Practiced/



Senegal Infrequently Practiced/Performed Commonly Practiced/Performed



Serbia Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Infrequently Practiced/Performed

Singapore Allowed/Permitted Unknown Allowed/Permitted Never Practiced/Performed Allowed/PermittedInfrequently Practiced/Performed Infrequently Practiced/


Slovenia Commonly Practiced/Performed Never Practiced/Performed


Never Practiced/Performed Commonly Practiced/Performed

South Africa Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedThe Republic ofKorea

Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted

Spain Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedSri Lanka Infrequently Practiced/Performed Infrequently Practiced/


Unknown Unknown

Sweden Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedCommonly Practiced/Performed Infrequently Practiced/



Switzerland Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedCommonly Practiced/Performed Commonly Practiced/



Taiwan (China*) Allowed/Permitted Allowed/Permitted Allowed/Permitted Never Practiced/Performed Never Practiced/PerformedThailand Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedTogo Commonly Practiced/Performed Never Practiced/



Trinidad andTobago


Turkey Allowed/Permitted Never Practiced/Performed

Allowed/Permitted Never Practiced/Performed Allowed/Permitted



Uganda Allowed/Permitted Allowed/Permitted Allowed/Permitted Infrequently Practiced/Performed Infrequently Practiced/Performed

UAE Allowed/Permitted Commonly Practiced/Performed

Allowed/Permitted Unknown Allowed/Permitted

UK Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedCommonly Practiced/Performed Never Practiced/



USA Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedCommonly Practiced/Performed Commonly Practiced/



Uruguay Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedCommonly Practiced/Performed Commonly Practiced/



Venezuela Commonly Practiced/Performed Infrequently Practiced/Performed



Viet Nam Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedZimbabwe Allowed/Permitted Infrequently Practiced/





76

Chapter 6. Table 3bIs cryopreservation for fertility treatment or fertility preservation allowed/permitted or practiced/performed in your country?

CountryOocytes Cryopreserved for Fertility

TreatmentOocytes Nonmedical


IndicationsOvarian Tissue Nonmedical

IndicationsOvarian Tissue Medical

Indications

Argentina Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedCommonly Practiced/Performed Commonly Practiced/



Armenia Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedAustralia Allowed/Permitted Allowed/Permitted Allowed/Permitted Never Practiced/Performed Allowed/PermittedAustria Allowed/Permitted Never Practiced/Performed Allowed/Permitted Allowed/Permitted Allowed/Permitted



Bangladesh Allowed/Permitted Never Practiced/Performed Allowed/Permitted Never Practiced/Performed Allowed/PermittedBarbados Allowed/Permitted Allowed/Permitted Allowed/Permitted Never Practiced/Performed Never Practiced/Performed



Belarus Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedInfrequently Practiced/Performed Infrequently Practiced/



Belgium Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedBolivia Commonly Practiced/Performed Commonly Practiced/



Botswana Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedBrazil Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted



Bulgaria Allowed/Permitted Allowed/Permitted Allowed/Permitted Unknown UnknownInfrequently Practiced/Performed Infrequently Practiced/


Burkina Faso Commonly Practiced/Performed Unknown Allowed/Permitted Never Practiced/Performed Never Practiced/PerformedCameroon Allowed/Permitted Allowed/Permitted Allowed/Permitted Never Practiced/Performed Never Practiced/


Performed

Canada Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedChile Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted




China Allowed/Permitted Never Practiced/Performed Allowed/Permitted Never Practiced/Performed Allowed/PermittedInfrequently Practiced/Performed Infrequently Practiced/


Colombia Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedCzechia Allowed/Permitted Allowed/Permitted Allowed/Permitted Commonly Practiced/Performed Commonly Practiced/

PerformedCongo Allowed/Permitted Unknown Never Practiced/

PerformedNever Practiced/Performed Never Practiced/Performed

Ecuador Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedEgypt Allowed/Permitted Allowed/Permitted Allowed/Permitted Unknown Allowed/PermittedEl Salvador Allowed/Permitted Allowed/Permitted Allowed/Permitted Never Practiced/Performed Never Practiced/PerformedFinland Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedGeorgia Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted

Infrequently Practiced/Performed Never Practiced/Performed Infrequently Practiced/Performed


Germany Unknown Unknown Allowed/Permitted Unknown UnknownGhana Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted



Greece Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedGuatemala Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted




Hong Kong Allowed/Permitted Unknown Allowed/Permitted Unknown Allowed/Permitted(China*) Commonly Practiced/Performed Commonly Practiced/


Hungary Allowed/Permitted Infrequently Practiced/Performed



77

Chapter 6. Table 3b

(Continued)






Indications

Iceland Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedInfrequently Practiced/Performed Infrequently Practiced/



India Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedIreland Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted




Italy Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedCôte d’Ivoire Allowed/Permitted Unknown Never Practiced/Performed, Never Practiced/

Infrequently Practiced/Performed Unknown Performed, UnknownJapan Allowed/Permitted Infrequently Practiced/

PerformedAllowed/Permitted Unknown Allowed/Permitted

Jordan Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted UnknownCommonly Practiced/Performed

Kazakhstan Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedKenya Commonly Practiced/Performed Commonly Practiced/



Latvia Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted, Unknown Allowed/Permitted, UnknownInfrequently Practiced/Performed Infrequently Practiced/


Lithuania Allowed/Permitted Allowed/Permitted Allowed/Permitted Never Practiced/Performed Allowed/PermittedNever Practiced/Performed

Mali Infrequently Practiced/Performed Never Practiced/Performed Never Practiced/Performed


Mexico Allowed/Permitted Allowed/Permitted Infrequently Practiced/Performed Infrequently Practiced/Performed

Mongolia Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedMontenegro Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedNamibia Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedNetherlands Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedNew Zealand Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted




Nicaragua Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedNigeria Infrequently Practiced/Performed infrequently Practiced/

PerformedAllowed/Permitted Unknown Unknown

Norway Allowed/Permitted Never Practiced/Performed Allowed/Permitted Never Practiced/Performed Allowed/PermittedCommonly Practiced/Performed Commonly Practiced/

PerformedPanama Commonly Practiced/Performed Commonly Practiced/



Paraguay Allowed/Permitted Allowed/Permitted Allowed/Permitted Never Practiced/Performed Never Practiced/Commonly Practiced/Performed Commonly Practiced/


Performed

Peru Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedPhilippines Allowed/Permitted Allowed/Permitted Allowed/Permitted Infrequently Practiced/Performed Infrequently Practiced/

PerformedPoland Unknown Unknown Unknown Unknown UnknownPortugal Allowed/Permitted Allowed/Permitted,

UnknownAllowed/Permitted Allowed/Permitted, Unknown Allowed/Permitted



Romania Allowed/Permitted Allowed/Permitted Allowed/Permitted Never Practiced/Performed Never Practiced/Infrequently Practiced/Performed Infrequently Practiced/


Performed

RussianFederation





Senegal Never Practiced/Performed Never Practiced/Performed Never Practiced/Performed



78

Ireland, New Zealand, Switzerland, Taiwan [China, report-ing separately for this report], Uganda, and United Kingdomof Great Britain and Northern Ireland); and 25 years(Greece);

• Oocytes: 2 years (Serbia); 5 years (Bulgaria, Nicaragua, andPortugal); 10 years (Iceland, Ireland, New Zealand,Switzerland, Taiwan [China, reporting separately for thisreport], Uganda, and United Kingdom of Great Britain andNorthern Ireland);

• All Stages of preimplantation embryos: 5 years (Bulgaria andThe Republic of Korea); 10 years (Iceland, Ireland, NewZealand, Switzerland, Taiwan [China, reporting separatelyfor this report], Uganda, and the United Kingdom of GreatBritain and Northern Ireland);

• Ovarian Tissue: 5 years (Nicaragua and Portugal); 10 years(Iceland, New Zealand, and Switzerland); and

• Testicular tissue: 1 year (Serbia), 5 years (Bulgaria,Nicaragua, andPortugal); 10 years (Iceland, New Zealand, and Switzerland).

Chapter 6. Table 3b

(Continued)






Indications

Serbia Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Infrequently Practiced/Performed

Singapore Allowed/Permitted Never Practiced/Performed Allowed/Permitted Never Practiced/Performed Allowed/PermittedInfrequently Practiced/Performed Infrequently Practiced/


Slovenia Allowed/Permitted Never Practiced/Performed Commonly Practiced/Performed


South Africa Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedThe Republic ofKorea


Spain Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedSri Lanka Infrequently Practiced/Performed Unknown Infrequently Practiced/

PerformedUnknown Unknown

Sweden Allowed/Permitted Allowed/Permitted Allowed/Permitted,Commonly



Practiced/Performed Commonly Practiced/Performed Commonly Practiced/Performed

Switzerland Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedCommonly Practiced/Performed Commonly Practiced/



Taiwan (China*) Allowed/Permitted Allowed/Permitted Allowed/Permitted Never Practiced/Performed Never Practiced/PerformedThailand Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedTogo Infrequently Practiced/Performed Never Practiced/Performed Never Practiced/

PerformedNever Practiced/Performed Never Practiced/Performed

Trinidad andTobago


Turkey Allowed/Permitted Never Practiced/Performed Allowed/Permitted Never Practiced/Performed Allowed/PermittedInfrequently Practiced/Performed Infrequently Practiced/


Uganda Infrequently Practiced/Performed Infrequently Practiced/Performed



UAE Allowed/Permitted Infrequently Practiced/Performed

Allowed/Permitted Never Practiced/Performed Infrequently Practiced/Performed

UK Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedInfrequently Practiced/Performed Infrequently Practiced/



USA Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedCommonly Practiced/Performed Commonly Practiced/



Uruguay Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedCommonly Practiced/Performed Commonly Practiced/



Venezuela Infrequently Practiced/Performed Commonly Practiced/Performed



Viet Nam Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedZimbabwe Infrequently Practiced/Performed Infrequently Practiced/





79

Chapter 6. Table 3cIs cryopreservation for fertility treatment or fertility preservationallowed/permitted or practiced/performed in your country?

CountryPreimplantation EmbryosNonmedical Indications

Preimplantation EmbryosMedical Indications

Argentina Allowed/Permitted, InfrequentlyPracticed/Performed

Allowed/Permitted, CommonlyPracticed/Performed

Armenia Allowed/Permitted Allowed/PermittedAustralia Never Practiced/Performed Allowed/PermittedAustria Never Practiced/Performed Allowed/Permitted, Infrequently

Practiced/PerformedBangladesh Never Practiced/Performed Allowed/PermittedBarbados Allowed/Permitted, Infrequently

Practiced/PerformedAllowed/Permitted, InfrequentlyPracticed/Performed

Belarus Allowed/Permitted, CommonlyPracticed/Performed

Allowed/Permitted, InfrequentlyPracticed/Performed

Belgium Allowed/Permitted Allowed/PermittedBolivia Commonly Practiced/Performed Commonly Practiced/PerformedBotswana Allowed/Permitted Allowed/PermittedBrazil Allowed/Permitted, Infrequently


Bulgaria Allowed/Permitted, InfrequentlyPracticed/Performed


Burkina Faso Unknown UnknownCameroon Never Practiced/Performed Never Practiced/PerformedCanada Allowed/Permitted Allowed/PermittedChile Allowed/Permitted Allowed/Permitted, Commonly

Practiced/PerformedChina Allowed/Permitted, Infrequently


Colombia Allowed/Permitted Allowed/PermittedCzechia Allowed/Permitted Allowed/PermittedCongo Unknown Never Practiced/PerformedEcuador Allowed/Permitted Allowed/PermittedEgypt Allowed/Permitted Allowed/PermittedEl Salvador Never Practiced/Performed Never Practiced/PerformedFinland Allowed/Permitted Allowed/PermittedGeorgia Allowed/Permitted, Infrequently


Germany Unknown UnknownGhana Allowed/Permitted, Infrequently


Greece Allowed/Permitted Allowed/PermittedGuatemala Allowed/Permitted, Commonly

Practiced/PerformedAllowed/Permitted, CommonlyPracticed/Performed

Hong Kong(China*)

Unknown Allowed/Permitted, CommonlyPracticed/Performed

Iceland Allowed/Permitted, InfrequentlyPracticed/Performed


India Allowed/Permitted Allowed/PermittedIreland Allowed/Permitted, Infrequently


Italy Allowed/Permitted Allowed/PermittedCôte d’Ivoire Never Practiced/Performed, Unknown Never Practiced/Performed,

UnknownJapan Never Practiced/Performed Allowed/PermittedJordan Unknown Allowed/PermittedKazakhstan Allowed/Permitted Allowed/PermittedKenya Infrequently Practiced/Performed Infrequently Practiced/

PerformedLatvia Allowed/Permitted, Infrequently

Practiced/Performed, UnknownAllowed/Permitted, InfrequentlyPracticed/Performed,Unknown

Lithuania Allowed/Permitted, Never Practiced/Performed

Allowed/Permitted

Chapter 6. Table 3c

(Continued)

CountryPreimplantation EmbryosNonmedical Indications

Preimplantation EmbryosMedical Indications

Mali Never Practiced/Performed Never Practiced/PerformedMexico Allowed/Permitted Allowed/PermittedMongolia Allowed/Permitted Allowed/PermittedMontenegro Allowed/Permitted Allowed/PermittedNamibia Allowed/Permitted Allowed/PermittedNetherlands Allowed/Permitted Allowed/PermittedNew Zealand Allowed/Permitted, Infrequently


Nicaragua Unknown UnknownNigeria infrequently Practiced/Performed Allowed/PermittedNorway Never Practiced/Performed Allowed/Permitted, Commonly

Practiced/PerformedPanama Commonly Practiced/Performed Commonly Practiced/PerformedParaguay Allowed/Permitted, Commonly


Peru Allowed/Permitted Allowed/PermittedPhilippines Allowed/Permitted Allowed/PermittedPoland UnknownPortugal Unknown UnknownRomania Allowed/Permitted, Infrequently


RussianFederation



Senegal Never Practiced/Performed Never Practiced/PerformedSerbia Unknown UnknownSingapore Never Practiced/Performed Allowed/Permitted, Infrequently

Practiced/PerformedSlovenia Never Practiced/Performed Commonly Practiced/PerformedSouth Africa Allowed/Permitted Allowed/PermittedThe Republicof Korea


Spain Allowed/Permitted Allowed/PermittedSri Lanka Unknown Infrequently Practiced/PerformedSweden Allowed/Permitted, Commonly


Switzerland Allowed/Permitted, CommonlyPracticed/Performed


Taiwan(China*)


Thailand Allowed/Permitted Allowed/PermittedTogo Never Practiced/Performed Never Practiced/PerformedTrinidad andTobago


Turkey Never Practiced/Performed Allowed/Permitted, InfrequentlyPracticed/Performed

Uganda Allowed/Permitted Allowed/PermittedUnited ArabEmirates


UK Allowed/Permitted, InfrequentlyPracticed/Performed


USA Allowed/Permitted, CommonlyPracticed/Performed


Uruguay Allowed/Permitted, InfrequentlyPracticed/Performed


Venezuela Infrequently Practiced/Performed


Viet Nam Allowed/Permitted Allowed/PermittedZimbabwe Infrequently Practiced/




80

Discussion

Sperm cryopreservation is an established procedure, a standardtechnique for donor insemination and for preservation of malefertility in men who have a malignancy. Attempts are being madeto cryopreserve small numbers of sperm from men who areinfertile, and men with reduced fertility. Cryopreservation mayreduce the need for future surgical procedures or the use ofdonor sperm.

Sperm can now be frozen using the freeze-drying technique,lyophilization. This procedure can preserve sperm for longerperiods and more economically than current methods, withoutaffecting the integrity of sperm DNA[4]. Sperm banking is indi-cated for cancer patients facing gonadotoxic therapy. Testiculartissue has been obtained and preserved from prepubertal boysundergoing gonadotoxic treatment and those with cryptorchid-ism, but the procedure is experimental.

Some reviews have shown two procedures performed onoocytes – slow freezing and vitrification – have comparable rateswhen the oocytes are assessed for fertilization, pregnancy, andimplantation, but vitrification is preferred because of its simpli-city[5]. The limited available studies suggest that the technique ofvitrification of oocytes yields higher pregnancy rates when com-pared to slow-freezing[6].

Preliminary data on the safety of oocyte cryopreservation arereassuring, and the procedure is no longer considered experi-mental. Good evidence indicates that fertilization and pregnancyrates are similar with fresh oocytes or frozen-thawed oocytes. Noincreases in chromosomal abnormalities, birth defects, or devel-opmental deficits have been noted in the children born fromcryopreserved oocytes. Oocyte freezing has developed sub-stantially, finding wider applications and use. There are not yetsufficient data to recommend oocyte cryopreservation as amainstream option to mitigate reproductive aging in healthywomen[7].

Also, oocyte freezing has simplified the oocyte donation process.The advent of donor egg cryobanks with cryopreserved oocytesfacilitates creation of greater numbers of potential donor oocytesand uncouples the donor stimulation process from the recipientendometrial preparation cycle, which eliminates the need for cyclesynchronization[8]. Oocyte cryopreservation also allows for thequarantining of human immunodeficiency virus (HIV)-exposedoocytes[8,9]. Furthermore, it is a model for conserving potentialfertility in women with malignancy or those who seek electivepostponement of childbirth, potentially extending their reproduc-tive lifespan in optimal circumstances[10].

Use of cryopreserved embryos appears to be increasing, andmany centres are now switching to a “freeze all” protocol, inwhichall or almost all of the freshly created embryos are not transferred,but cryopreserved for subsequent transfer in a programmed cycle.A recent meta-analysis suggests that pregnancies after FET areassociated with better clinical outcomes, including lower risks ofplacenta previa, placental abruption, low birth weight, very-low-birth-weight-very-pre-term birth, short-for-gestation age, andperinatal mortality, compared with fresh embryo transfer.Conversely, pregnancies following FET were associated withincreased risks of pregnancy-induced hypertension, postpartumhemorrhage, and large-for-gestational-age fetuses compared tothose produced with fresh embryo transfer[11].

Among the established methods for preserving fertility inwomen diagnosed with cancer, cryopreservation is the preferred

option for the post-pubertal age group oocyte, and ovarian tissuecryopreservation is generally the only available option for pre-pubertal girls. Ovarian tissue cryopreservation before treatmentfor malignancy has been performed, and has led to a smallnumber of live births following transplantation. The procedure ofovarian tissue cryopreservation has been found to be safe, rela-tively simple, and promising[12]. Cited advantages are that it mayeliminate certain ethical, moral, and potentially legal obstacles tooocyte or embryo freezing in minors.

Ovarian tissue cryopreservation is still considered an experi-mental procedure. It is an option for patients requiring immediategonadotoxic treatment who must forego oocyte or embryo freez-ing, and it is the only option available for prepubertal girls.Vitrification of ovarian tissue was found to be similar to slowfreezing, and both preserved the morphologic integrity of theovarian tissue[13]. Orthotopic transplantation of the cortical stripsfrom the tissue has been successful, and live births have beenreported[14]. In vitro-activated ovarian tissue cryopreservation andtransplantation is a new method requiring more clinical research.This procedure involves stimulation of dormant follicles within thecryopreserved tissue graft prior to transplantation, in order togenerate mature oocytes shortly after transplantation[15].

Summary

Advances in cryopreservation, most notably vitrification, haveled to wide adoption and successful application of cryopre-servation of sperm, oocytes, and embryos. The 2018 Surveillancequestionnaire did not uncover any countries that expressly pro-hibit cryopreservation of gametes or pre-implantation embryosfor fertility treatment or for fertility preservation performed formedical or other indications. Approximately 65% to 80% ofrespondent countries noted the existence of laws, regulations,agency oversight, or professional guidelines that provided gov-ernance. However, there is extensive variation among the countryrespondents in terms of which practices are regulated, and howthey are regulated.

References[1] Griveau JF, Lopes M, Jouve G, et al. Vitrification: principles

and results. J Gynecol Obstet Biol Reprod (Paris) 2015;44(6):485–495. French.

[2] Adler HL, Lee E, Ampeloquio M, et al. Blastocyst cultureselects for euploid embryos: comparison of blastomerebiopsy (EB) and trophectoderm biopsy (TE) for aneuploidyrates using array comparative genomic hybridization (a-CGH). Fertil Steril 2011;96:108–109.

[3] Konc J, Kanyo K, Kriston R, et al. Cryopreservation ofembryos and oocytes in human assisted reproduction.Biomed Res Int 2014;2014:307268.

[4] Meirow D, Roness H, Kristensen SG, et al. Optimizing out-comes from ovarian tissue cryopreservation and transplan-tation; activation versus preservation. Hum Reprod 2015;30(11):2453–2456.

[5] The Practice Committees of the American Society forReproductive Medicine; Society for Assisted ReproductiveTechnology. Mature oocyte cryopreservation: a guideline.Fertil Steril 2013;99(1):37–43.

[6] GlujovskyD, Riestra B, SueldoC, et al. Vitrification versus slowfreezing for women undergoing oocyte cryopreservation.Cochrane Database Syst Rev 2014;9:CD010047.


81

[7] Gianaroli L, Racowsky C, Geraedts J, et al. Best practices ofASRM and ESHRE: a journey through reproductive medi-cine. Fertil Steril 2012;98(6):1380–1394.

[8] Cobo A, Remohi J, Chang CC, et al. Oocyte cryopreserva-tion for donor egg banking. Reprod Biomed Online 2011;23(3):341–346.

[9] Vajta G, Rienzi L, Ubaldi FM. Open versus closed systemsfor vitrification of human oocytes and embryos. ReprodBiomed Online 2015;30(4):325–333.

[10] BielanskiA.A reviewof the risk of contamination of semen andembryos during cryopreservation and measures to limit cross-contamination during banking to prevent disease transmissionin ET practices. Theriogenology 2012;77(3):467–482.

[11] Sha T, Yin X, Cheng W, et al. Pregnancy-related complica-tions and perinatal outcomes resulting from transfer ofcryopreserved versus fresh embryos in vitro fertilization: ameta-analysis Fertil Steril 2018;109(2):330–342.

[12] Lee JA, Barritt J, Moschini R, et al. Optimizing humanoocyte cryopreservation for fertility preservation patients:should we mature then freeze or freeze then mature? FertilSteril 2013;99(5):1356–1362.

[13] Diedrich K, Fauser B, Devroey P. Cancer and fertility: stra-tegies to preserve fertility. Reprod Biomed Online 2011;22(3):232–248.

[14] Sanfilippo S, Canis M, Smitz J, et al. Vitrification of humanovarian tissue: a practical and relevant alternative to slowfreezing. Reprod Biol Endocrinol 2015;13:67.

[15] Anderson RA, Wallace WHB, Telfer EE. Ovarian tissuecryopreservation for fertility preservation: clinical andresearch perspectives. Human Reproduction Open, 2017:Issue 1. Available at: https://academic.oup.com/hropen/article/2017/1/hox001/3092402. Accessed January 25, 2019.

CHAPTER 7: POSTHUMOUS REPRODUCTION

Introduction

Posthumous reproduction broaches a diverse scope of emotional,medical, legal, and ethical concerns that represent one of themorechallenging and sensitive areas in reproductive medicine. There isstill substantial debate over the ethics and legality of severalaspects of posthumous reproduction, and the rights of thedeceased person’s parents, surviving partner, and any resultingoffspring.

Posthumous reproduction utilizes cryopreserved gametes, orembryos created when the person was alive, but inseminated ortransferred after the person’s death. Posthumous reproduction canoccur in two distinctly separatemodes, referred to as (1) immediateposthumous reproduction and (2) posthumous reproduction.Immediate posthumous reproduction involves either the immedi-ate harvesting of gametes from a person declared to be in a brain-dead state, on life support; or the extraction of gametes from aperson declared dead within the previous 24 hours. Reports ofsperm retrieval post 24 hours have been described[1]. Posthumousconception by artificial insemination using cryopreserved spermhas been practiced since the 1950s[2].

The acceptance, legality, and utilization of posthumous repro-duction varies from country to country (Table 1). With the adventof more successful cryopreservation techniques, patients are cryo-preserving gametes and embryos for a wider number of reasons,including onco-banking, elective fertility preservation, and delayed

embryo transfer in in vitro fertilization (IVF), with or without pre-implantation genetic testing. The actual use of cryopreservedreproductive tissue after death depends on existing legislation, priorwritten legal agreements, and/or consent documentation. MostART programmes now use consents that cover the deposition ofgametes and embryos after death. When immediate posthumousreproduction is being considered, family input often is the only formof intent available to interpret the wishes of the deceased person. Insome locales, gametes are considered an individual’s property, andthe gamete’s subsequent ownership must be documented in a will.Otherwise, the burden to determine whether the person may havetrulywished to procreate after death devolves to the courts to decide.This often precipitates the need for governments to update relevantlegislation.

The first data regarding posthumous reproduction werereported in 2003, in the cryopreservation chapter. Surveillancereports from 2007 through 2013 included data regarding only thepermissibility and utilization of posthumous insemination. The2015 Surveillance questionnaire for the 2016 Surveillance reportwas expanded to include questions about posthumous repro-duction involving insemination of frozen sperm or frozen ova,and implantation of frozen embryos from deceased persons.Questions were added regarding legislation and the frequency ofuse of posthumous reproduction. In 2018, responses regardingposthumous reproduction were received from 82 countries – a23% increase from the 2015 survey.

Analysis of the Survey

Of the 97 countries participating in the survey, respondents from82 countries (85%) addressed questions regarding posthumousreproduction governance. Fewer countries than in the 2016Surveillance report said they had regulations that governedimmediate posthumous reproduction: 16 of 82 (20%). The reportbroke down the governance data as follows: posthumous sperminsemination: 19 of 82 (23%), posthumous insemination of fro-zen ova: 19 of 82 (23%); and posthumous implantation of frozenembryos: 23 of 28 (28%). An additional 7 of 82 (9%) (Belgium,Côte d’Ivoire, Germany, Jordan, Mongolia, Namibia, andNetherlands) reported it was “unknown” whether any type ofregulations existed to govern posthumous reproduction.

When regulations existed, posthumous reproduction proce-dures were reportedly largely covered by federal law (immediateposthumous reproduction, 13 of 19 (68%); insemination withfrozen sperm, 16 of 19 (84%); insemination of frozen ova, 14 of19 (74%); and implantation of frozen embryos, 17 of 19 (89%).Regulations were addressed by state, regional, or provincial laws,5 of 39 (13%), municipal laws, 1 of 19 (5%); agency oversight, 4of 60 (7%); a professional organization’s standards and guide-lines, 12 of 60 (20%); cultural practice, 1 of 17 (6%); and reli-gious decree 5 of 60 (8%).

In addition, respondents were then asked questions about thepermissibility and utilization of posthumous reproduction.

Immediate posthumous reproduction

Respondents from 41 countries reported data on immediate post-humous reproduction procedures in their country. In 28 (68%) ofthe respondent countries, it was “unknown” whether immediateposthumous reproduction was “allowed/permitted or practiced/performed”. In 11 of 41 (27%), posthumous reproduction proce-dures were allowed/permitted, with 5 of 11 (45%) of these


82

Chapter 7. Table 1What posthumous reproduction treatments are allowed/permitted or practised/performed in your country?

Country

Immediate PosthumousCollection

of Sperm or OocytesPosthumous Sperm

InseminationPosthumous Insemination

of Frozen OvaPosthumous Transferof Frozen Embryos

Argentina Allowed/Permitted Allowed/Permitted Allowed/Permitted UnknownAustralia Allowed/Permitted Allowed/Permitted, Practiced/Performed Allowed/Permitted Allowed/Permitted Practiced/

PerformedPracticed/Performed Practiced/Performed

Bolivia Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedBotswana Unknown Unknown Unknown UnknownBulgaria Unknown Unknown Unknown UnknownBurkina Faso Unknown Unknown Unknown UnknownCanada Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedChile Unknown Unknown Unknown UnknownColombia Unknown Unknown Unknown UnknownCongo Unknown Unknown Unknown UnknownEcuador Unknown Allowed/Permitted Allowed/Permitted Allowed/PermittedEl Salvador Unknown Unknown Unknown UnknownGeorgia Unknown Unknown Unknown Practiced/PerformedGermany Unknown Unknown Unknown UnknownGhana Unknown Unknown Unknown UnknownGreece Practiced/Performed Allowed/Permitted Practiced/Performed Allowed/PermittedGuatemala Unknown Unknown Unknown UnknownHungary Practiced/Performed Practiced/PerformedIndia Practiced/Performed Practiced/Performed Practiced/Performed Practiced/PerformedIreland Unknown Practiced/Performed Practiced/Performed Practiced/PerformedItaly Unknown Unknown Unknown UnknownCôte d’Ivoire Unknown Unknown Unknown UnknownJordan Unknown Unknown Unknown UnknownKenya Unknown Unknown Unknown UnknownLatvia Allowed/Permitted Allowed/Permitted, Practiced/Performed

UnknownAllowed/Permitted Allowed/Permitted

Practiced/Performed Unknown Practiced/PerformedUnknown

Practiced/Performed Unknown

Mongolia Unknown Unknown Unknown UnknownNetherlands Practiced/Performed Practiced/Performed Practiced/PerformedNew Zealand Allowed/Permitted Allowed/Permitted Allowed/Permitted

Practiced/Performed Practiced/PerformedNigeria allowed/Permitted allowed/Permitted allowed/PermittedPanama Unknown Unknown Unknown UnknownParaguay Unknown Unknown Unknown UnknownPortugal Unknown Allowed/PermittedRussian Federation Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedSenegal Unknown Unknown Unknown UnknownSouth Africa Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedSpain Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedTaiwan (China*) Unknown Unknown Unknown UnknownThailand Allowed/PermittedTrinidad and Tobago Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedUganda Unknown Unknown Unknown UnknownUnited ArabEmirates

Unknown Unknown Unknown Unknown

UK Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedPracticed/Performed Practiced/Performed Practiced/Performed Practiced/Performed

USA Allowed/Permitted Allowed/Permitted Allowed/Permitted Allowed/PermittedPracticed/Performed Practiced/Performed Practiced/Performed Practiced/Performed

Uruguay Unknown Allowed/Permitted Allowed/Permitted Allowed/PermittedVenezuela Unknown Unknown Unknown UnknownViet Nam Unknown Unknown Unknown Allowed/Permitted



83

countries practicing/performing immediate posthumous reproduc-tion procedures, and another 1 of 5 (20%) reporting “unknown” ifthis procedure was actually being practiced/performed. Twocountries did not report whether posthumous reproduction wasallowed/permitted, but did note that the procedure was beingpracticed/performed in their country (Table 1).

Insemination with Frozen Sperm

Respondents from 44 countries reported data on insemination withfrozen sperm in their country. In 24 of 44 (54.5%), it was“unknown” whether insemination with frozen sperm was allowed/permitted or practiced/performed. In 16 of 44 (36%), inseminationwith frozen sperm was allowed/permitted, with 4 of 16 (25%) ofthese countries practicing/performing insemination with frozensperm and another 6%, 1 in 16, reporting “unknown” if this pro-cedure was actually being practiced/performed. Four countries didnot report if insemination with frozen spermwas allowed/permittedbut reported that the procedure was being practiced/performed intheir country.

Insemination of Frozen Ova

Respondents from 43 countries provided data on insemination offrozen ova in their country. In 24 of the 43 (56%), it was“unknown” whether insemination of frozen ova was allowed/permitted or practiced/performed. In 15 of the 43 (35%), inse-mination of frozen ova was allowed/permitted, with 3 of 15(20%) practicing/performing insemination of frozen ova, andanother 1 in 15 (7%) reporting “unknown” as to whether thisprocedure was actually being practiced/performed. Four coun-tries did not report if insemination of frozen ova was allowed/permitted, but did report that the procedure was being practiced/performed in their country.

Implantation of Frozen Embryos

Respondents from 46 countries reported data on implantation offrozen embryos in their country. In 23 of the 46 (50%), it was“unknown” whether implantation of frozen embryos wasallowed/permitted or practiced/performed. In 28 of the 46 (39%),implantation of frozen embryos was allowed/permitted, with 4out of 18 (22%) of these countries practicing/performingimplantation of frozen embryos, and another 1 out of 18 (6%)reporting “unknown” as to whether this procedure was actuallybeing practiced/performed. Five countries did not report if frozenembryo implantation was allowed/permitted, but did report thatthe procedure was being practiced/performed in their country.

Summary

Compared to past Surveillance surveys, the use of any type ofposthumous reproduction procedures has increased over the last3 years. While scientific and medical advances allow the practi-tioner to retrieve and use gametes and embryos from deceasedpersons, complex issues remain unresolved, when it comes toclarifying who can decide when the retrieval and disposition ofthese reproductive tissues is appropriate, and under whatcircumstances.

In the 2016 Surveillance survey, more than a third of countriesreported legislation in place to govern posthumous reproduction.In 2019, only about a quarter of the countries had governance. The2019 Surveillance data illustrate the continued global need to

address the controversial and complex issues of ethics and legalitiesassociated with posthumous reproduction – especially now, whenthe procedure is being used more frequently, under what continuesto be a limited extent of regulations and legislation.

References[1] Gilbert S. Fatherhood from the grave: An analysis of

postmortem insemination. Hofstra Law Rev 1993;22:521–565.

[2] Shefi S, Raviv G, Eisenberg ML, et al. Posthumous spermretrieval: Analysis of time interval to harvest sperm. HumReprod 2006;21(11):2890–2893.

CHAPTER 8: DONATION AND ANONYMITY OFDONORS

Introduction

Assisted reproductive technology (ART) programmes around theworld increasingly rely on male and female gamete donation inART cycles. From a cultural perspective, social trends leading toprogressive legislation have improved global access to ART andwidened the spectrum of potential users. In previous Surveillancereports, changes in legislation pertaining to gamete donation,marital status, and same-sex parenting policies, were observed inabout 23% of countries over a three-year interval[1]. Prospectiveparents seeking medical care now comprise not only infertilitypatients, carriers of genetic conditions, and HIV sero-discordantcouples, but also single women, single men, same-sex couples,and transgender subjects. Enacting anti-discrimination policiesfavors access for these groups, and a current trend leans towardequal, inclusive, fair, safe, and efficient access to ART, mostnotably in Europe[2].

An additional driver, from a biological standpoint, has beenthe social phenomenon favoring delayed childhood in modernsocieties. This has shifted the “reproductive window” to an age inwhich ovarian follicular depletion impairs female fertilitypotential. As a result, use of donated oocytes has increasedsteadily over the last decades, a trend reflected in recently pub-lished global registry data (ICMART, 2017)[3]. Oocyte donationcan also be performed with vitrified oocytes. Currently, moreprogrammes are using egg banking for donation, as IVF resultshave been shown to be similar with the use of fresh and frozenoocytes[4].


The vast majority of countries surveyed allowed gamete donation(Table 1, Charts 1 and 2). Sperm donation is allowed in 48 of 71(68%), and is practiced in 41 of the 71 (58%). Oocyte donation ispermitted in 43 of 69 (62%), but is performed in only 39 of 69(56.5%). Donation of an embryo created by another couple in aprevious IVF cycle is allowed in 31 of 53 (58%), but, surprisingly,is performed in 25 of 53 (47%).

Less commonly allowed is creating embryos purely for dona-tion, “de novo” generation of embryos from donor gametes.Allowed in 21 of 50 countries (42%), it reportedly is practiced in19 of 50 (38%). Overall, 49 of 71 (69%) reported “commonlyusing” sperm; oocyte, 44 of 71 (62%); embryo, 17 of 66 (26%).Less frequently allowed is cytoplasmic donation, 7 of 48 (14.5%),and gamete tissue donation—usage with either ovarian tissue 12of 51 (23.5%) or testicular tissue, 11 of 50 (22%) permitted but


84

only performed cytoplasmic donation 3 of 48 (6%), ovarian tis-sue donation, 3 of 51 (6%); or testicular tissue donation, 3 of 50(6%); six countries reported “never having used” sperm, oocyte,or embryo donation. The same six countries indicated they hadnever used cytoplasmic and gamete tissue donation (Botswana,Egypt, Jordan, Lithuania, Mali, and Senegal).

More than half the countries surveyed have regulationsaddressing oocyte donation, 40 of 73 (55%), and sperm dona-tion, 43 of 74 (58%) (Table 2). Many countries have regulationspertaining to embryo donation, 29 of 69 (42%), including pre-vious IVF; or de novo embryos, 26 of 68 (38%). 17% of coun-tries, 11 of 65, have regulations for cytoplasmic donation(Australia, Canada, Finland, Greece, Kazakhstan, New Zealand,Nicaragua, Singapore, Thailand, United Kingdom of GreatBritain and Northern Ireland, and The United States of America),and 20% have regulations regarding ovarian (13 of 65) andtesticular tissue donation, 13 of 66. Fourteen countries out of 65(22%) reported allowing agencies to recruit and match thirdparty donors; including donors, recipients, surrogates and/orgestational carriers. These countries are Australia, Canada,Finland, Greece, India, Kazakhstan, Mexico, Nicaragua,Portugal, Singapore, Thailand, United Arab Emirates, UnitedKingdom of Great Britain and Northern Ireland, and Uruguay.

Themajority of countries allowed compensation for sperm andoocyte donors; 67 responders (67%) vs 64 responders (72%) andembryo donors 26% (n= 54) of the countries surveyed permit-ting the practice (Chart 3). This includes reimbursement fordonors’ time and expenses only, as follows: for sperm, 54%;oocyte, 55%; and for embryo, 2%. Compensation beyond

reimbursement occurred in 12% of sperm donors, 17% of oocytedonors, and 7% of embryo donors. The eleven countries thatallowed compensation of oocyte donors beyond simple reim-bursement include Argentina, Brazil, Bolivia, Colombia,Ecuador, Georgia, Greece, India, Russian Federation, The UnitedStates of America, and Venezuela. Embryo donation with reim-bursement/compensation practices is permitted in Armenia,Australia, Bolivia, Brazil, Georgia, Greece, Hong Kong [China,reporting separately for this report], India, New Zealand,Nigeria, Sri Lanka, The United States of America, Uruguay, andZimbabwe. Reimbursement for gamete tissue, and for cyto-plasmic and testicular tissues, was reported in 3 of 43 (7%); andfor ovarian tissues, 4 out of 44 (9%). Such reimbursement is rare,and reportedly occurred only in Australia, Colombia, Finland,and Greece.

When addressing a specific value paid in terms of compensationto donors, only a few countries reported minimum and maximumamounts for gamete donors. For oocyte donors, amounts rangedfrom US $ 700 to $ 2,000 in some countries (e.g., Ecuador,Guatemala, Latvia, Hong Kong [China, reporting separately forthis report], and Spain) to $ 5,000 to $ 99,000 in others (Brazil,Namibia, South Africa, Taiwan [China, reporting separately forthis report], and The United States of America). Some countriesreported no minimum or maximum values established, includingArgentina, Bulgaria, Chile, Hungary, India, Côte d’Ivoire,Mexico,Panama, and Uganda. Twenty-one out of 41 countries (51%)responded to the item as “not addressed” or “unknown”).

When asked if subjects were required to meet medical, mentalhealth, or lifestyle criteria to qualify as donors, 46 of 64 (72%)

10%

13%

23%

38%

80%

74%

76%

58%

56%

47%

38%

6%

6%

6%

68%

62%

58%

42%

14%

23%

22%

Sperm donation

Oocyte donation

Embryo donation from previous IVF cycle

De novo generation of embryos

Cytoplasmic donation

Ovarian tissue donation

Testicular tissue donation

Allowed/Permitted Practiced/Performed Unknown

Chapter 8. Chart 1. Is donation allowed/permitted or practiced/performed?

Chapter 8. Table 1Percentage of countries surveyed allowing gamete and embryo donation practices.

Sperm Donation Oocyte Donation Embryo Donation from IVF “de Novo” Embryo Donation

Allowed Performed Allowed Performed Allowed Performed Allowed Performed

64% 85% 57% 80% 41% 54% 24% 34%


85

Chapter 8. Table 2Gamete donor anonymity regulation.

Country

No Practicesor

Regulations


Policies

State/Provincial/Regional Laws/Statutes/

Ordinances



ProfessionalOrganization

Standards/GuidelinesCulturalPractice

ReligiousDecree

Argentina No No No No No Yes No NoArmenia YesAustralia Yes YesAustria No Yes No No No No No NoBangladesh YesBarbados YesBelarus YesBelgium NoBolivia YesBotswana No No No No No No No NoBrazil Yes YesBulgaria Unknown Yes Unknown Unknown Unknown Unknown Unknown UnknownBurkina Faso No No No No No No No NoCameroon Yes No No No No Yes Yes NoCanada YesChile NoChina Yes YesColombia Yes No No No No No Yes NoCzechia Yes Yes No No Unknown No NoEcuador YesEgypt Unknown Unknown Unknown YesEl Salvador No No No No No No No No

15%

10%

8.5%

32%

17%

14%

26%

62%

69%

27%

11%

9%

Embryo donation from previous IVF cycle

Oocyte donation

Sperm donation

Never Performed Commonly Used Infrequently Used Unknown

20%

39%

34%

31%

25%

6%

6%

6%

11%

1.5%

44%

55%

60%

61%

De novo generation of embryos

Cytoplasmic donation

Ovarian tissue donation

Testicular tissue donation


A

B

Chapter 8. Chart 2a. How often is third party reproduction? Chart 2b. How often is third party reproduction performed in your country?


86

Chapter 8. Table 2

(Continued)

Country

No Practicesor

Regulations


Policies


Ordinances





ReligiousDecree

Finland No Yes No No No No No NoGeorgia Yes No No No No No No NoGermany No Yes No No Yes Yes Yes YesGhana YesGreece No Yes Yes No Yes Yes Yes YesGuatemala Yes YesHong Kong(China*)

Yes Yes

Hungary YesIceland YesIndia Unknown YesIreland Yes YesItaly No No No No No No No NoCôte d’Ivoire Yes Unknown Unknown Unknown Yes Yes Unknown UnknownJapan Yes YesJordan Yes YesKazakhstan Yes Yes No No No Yes No NoKenya YesLatvia YesLithuania No Yes No No No No No NoMali Yes Unknown Unknown Unknown Unknown Yes Unknown UnknownMexico No Unknown Unknown Unknown Unknown Unknown Unknown UnknownMongolia Yes Unknown Unknown Unknown Unknown Unknown Unknown UnknownMontenegro Yes YesNamibia YesNew Zealand No Yes YesNicaragua Unknown YesNigeria Unknown yes Unknown Unknown Unknown Unknown Unknown UnknownNorway Yes Yes Yes No NoPanama NoParaguay YesPeru noPhilippines Unknown Unknown Unknown Unknown Unknown Unknown Unknown UnknownPoland Yes Yes YesPortugal No Yes No No Yes Yes Unknown NoRomania Yes No No No No No NoRussianFederation

Yes

Senegal Yes Yes Yes Yes Yes Yes Unknown UnknownSerbia No Yes No Yes Yes No NoSingapore YesSlovenia YesSouth Africa yes YesThe Republicof Korea

No

Spain No Yes No No No Yes No NoSri Lanka No No No No Yes No No NoSwitzerland No Yes No No No Yes Yes NoTaiwan(China*)

Yes

Thailand YesTogo UnknownTrinidad andTobago

No No No No No No No No

Uganda Yes No No No Yes Yes Unknown UnknownUnited ArabEmirates

Yes

UK YesUSA No No No No No No No No


87

responded affirmatively for sperm donation, 47 of 63 (75%)for oocyte donation, and 28 out of 50 (56%) for embryodonation.

Anonymity

Ten of 78 countries (13%) reported having no regulations per-taining to the treatment of anonymity of donors; 37 of 65 (57%)of countries reported the existence of national or federal laws; 6of 65 countries (9%) have municipal or regional laws; 10 of 65(15%) countries reported the presence of governmental agencyoversight, and 23 of 65 (35%) reported having professionalorganization oversight (Table 2). Seven countries, Cameroon,Colombia, Egypt, Germany, Greece, Jordan, and Switzerland,reported regulation of anonymity via “cultural practice or reli-gious decree.”

Disclosure of information about gamete donors to the off-spring varied widely. Some countries, 22 of 46 (48%), allowednon-identifying data to be provided by the donor to the offspring.Another 14 of 43 (30%) allow identifying data to be disclosed,including Australia, Austria, Cameroon, Canada, Finland,Greece, Iceland, Kazakhstan, NewZealand, Nicaragua, Norway,Russian Federation, Switzerland, and The United States ofAmerica. Nonetheless, when queried if these practices were“customary” only 8 of the former 22 countries (36%) and 6 of thelatter group of 14 (43%) responded affirmatively.

Disclosure of information from the offspring to the donor isless frequently allowed. In 17 of 43 (40%) of countries surveyed,non-identifying data from the offspring could be obtained by thedonors. Those countries include Australia, Barbados, Bolivia,Colombia, Finland, Greece, Hungary, Iceland, Kazakhstan, New

Zealand, Russian Federation, Sri Lanka, Switzerland, Thailand,The United States of America, United Kingdom of Great Britainand Northern Ireland, and Uruguay. Identifying informationfrom the offspring, in contrast, was allowed to be obtained bydonors in only 6 out of 41 (15%) of other countries: Australia,Cameroon, Kazakhstan, New Zealand, Russian Federation, andThe United States of America. Regarding how often these dis-closure practices were observed, only 9 of 17 (53%) in the firstgroup—offspring to donor—and 2 out of 6 (33%) in the secondgroup—donor to offspring—responded positively.

Summary

Gamete and embryo donation are well established ART practices,employed, if not sanctioned, by a large majority of the respondingcountries. These donation trends are likely to continue due toevolving social and cultural norms in developed and developingcountries. Most of the European countries, as well as Australia,New Zealand, and some Asian countries, are extensively regu-lated by national or regional laws and statutes. Overall, about50% to 60% of countries surveyed report using gamete orembryo donation, although “de novo” embryo donation issomewhat less commonly accepted (about 25% to 35% ofcountries). Cytoplasmic donation is infrequent, as is ovarian tis-sue and testicular tissue donation, and used for the most part inexperimental environments.

References[1] Ory S, Miller K, Horton M, et al. IFFS Surveillance 2016.

Global Reprod Health 2016;1–144.[2] “Access and diversity of medically assisted reproduction in

Europe”, organized by the European Society of HumanReproduction and Embryology, together with the Council ofEurope Bioethics Committee, Strasbourg, France. Feb 22-23, 2018.

[3] Zegers-Hochschild F, Adamson GD, Dyer S, et al. TheInternational Glossary on Infertility and Fertility Care, 2017.Hum Reprod 2017;32:(9):1786–1801.

[4] Laura Rienzi L, Romano S, Albricci L, et al. Embryo devel-opment of fresh “versus” vitrified metaphase II oocytes afterICSI: a prospective randomized sibling-oocyte study. HumReprod 2010;25:66–73.

CHAPTER 9. OOCYTE MATURATION

Introduction

Utilization of in-vitromaturation (IVM) following the recovery ofimmature oocytes was first suggested as a potential usefulapplication for women undergoing ART in the 1990s. This

Chapter 8. Table 2

(Continued)

Country

No Practicesor

Regulations


Policies


Ordinances





ReligiousDecree

Uruguay Yes YesVenezuela YesViet Nam YesZimbabwe No No No No No No No No


Sperm Oocyte Embryo

67%

72%

26%

Chapter 8. Chart 3. Percentage of countries allowing compensation to gametedonors.


88

technology differs markedly from conventional in vitro fertiliza-tion (IVF) in that oocytes are retrieved without prior controlledovarian hyperstimulation (COH), and the collected immatureoocytes are then cultured in vitro in enhanced culture environ-ments until maturation is completed, which occurs when meta-phase II (MII) stage is achieved.

Several advantages of IVM over conventional IVF have beensuggested. They include greater safety via elimination of COH,with less risk of ovarian hyperstimulation syndrome (OHSS),particularly with patients with polycystic ovarian syndrome(PCOS); and lower cost, by reducing the need for additionalmedications and monitoring. This advantage has an additionalbenefit for the patient: potentially less stress. But broad accep-tance of IVM techniques has been slow in coming, due to per-ceived lower clinical success rates, and a relative dearth of dataregarding safety issues. The safety issues of concern include theoverall health of the resulting offspring, and the possibility ofinducing permanent changes in the expression of imprintedgenes[1].


The 2018 survey included responses from 75 countries. IVMwaspermitted in 64 of the 75 (86%), and was disallowed in only 4countries (Bangladesh, Germany, Mali, and Nigeria). Seven

countries (9%) stated that the status of IVM application in theircountry was “unknown” (Chart 1). The procedure was infre-quently used in 41 of 72 countries (57%), and was commonlyemployed in only 15 of the 72 (21%). Reportedly, it was neverperformed in 10 of the 72 countries (14%) (Chart 2).

IVM is regulated in 16 of 77 countries responding (21%), and isunknown in 7 (9%) of the countries that responded. IVM isregulated in 15 countries of the 75 (20%) by federal statute(Belgium, Bulgaria, Egypt, Germany, Montenegro, New Zealand,Norway, Portugal, Serbia, Spain, Taiwan [China, reporting sepa-rately for this report], Togo, Turkey, United Kingdom of GreatBritain andNorthern Ireland, andVietNam); 2 of 75 (3%) by stateor provincial statute (Australia and Uruguay); and 9 of 75 (12%)by professional guidelines or agency oversight (Ecuador, Ghana,Guatemala, India, and Côte d’Ivoire). Agency regulations werefollowed in Côte d’Ivoire and Portugal. Oocyte maturation wasbeing held as a “cultural practice” in Switzerland. The status of theregulatory body was reported as “unknown” for Cameroon,Jordan, Panama, and United Arab Emirates (Table 1).

Discussion

Although there have been no significant discernible technicaladvances in IVM technology since the 2015 survey, there appearsto be a continued trend favoring somewhat increased utilization

9%

9%

5%

70%

86%

21%

Allowed/Permitted

Governed/Regulated

Yes No Unknown

Chapter 9. Chart 1. Is oocyte maturation allowed/permitted or governed/regulated?

8%

57%

21%

14%


Chapter 9. Chart 2. How often is oocyte maturation performed?


89

Chapter 9. Table 1Parameters for oocyte maturation.

Country

Is Oocyte MaturationRegulated in Your

Country?

If Oocyte Maturation Regulatedin Your Country,How is it Done?

Is Oocyte MaturationAllowed/Permitted in Your

Country?

Is Oocyte MaturationPracticed/Performed in

Your Country?

Argentina Yes Yes Infrequently UsedAustralia Yes State/Provincial/Regional Laws/Statutes/Ordinances Unknown Commonly UsedAustria No Yes Infrequently UsedBangladesh NoBarbados No Infrequently UsedBelarus No Yes Never PerformedBelgium Unknown Federal/National Laws/Statutes/Ordinances/Policies Yes Commonly UsedBolivia No Yes Commonly UsedBotswana No YesBrazil No Yes Infrequently UsedBulgaria Yes Federal/National Laws/Statutes/Ordinances/Policies Yes Infrequently UsedBurkina Faso No Yes Commonly UsedCameroon No Unknown Yes Infrequently UsedCanada No Yes Infrequently UsedChile No Yes Infrequently UsedChina Unknown Yes Infrequently UsedColombia No Yes Infrequently UsedCzechia No Yes Infrequently UsedEcuador No Professional Organization Standards/Guidelines YesEgypt Yes Federal/National Laws/Statutes/Ordinances/Policies,

Professional Organization Standards/GuidelinesYes Infrequently Used

El Salvador No Yes Never PerformedFinland No Yes Infrequently UsedGeorgia No Yes Never PerformedGermany Unknown Federal/National Laws/Statutes/Ordinances/Policies No UnknownGhana No Professional Organization Standards/Guidelines Yes Infrequently UsedGreece Yes Yes Commonly UsedGuatemala No Professional Organization Standards/Guidelines Yes Infrequently UsedHong Kong (China*) No Yes Infrequently UsedHungary No Unknown Infrequently UsedIceland No Yes Never PerformedIndia Yes Professional Organization Standards/Guidelines Unknown Infrequently UsedIreland No Yes Never PerformedItaly No Yes Commonly UsedCôte d’Ivoire Unknown Agency Regulations/Oversight, Professional Organization

Standards/GuidelinesYes Commonly Used

Japan No Yes Infrequently UsedJordan No Unknown Yes Infrequently UsedKazakhstan No YesKenya No Yes Infrequently UsedLatvia No Yes Infrequently UsedLithuania No Unknown Never PerformedMali No No Never PerformedMexico No Yes Infrequently UsedMongolia No Yes Commonly UsedMontenegro Yes Federal/National Laws/Statutes/Ordinances/Policies Yes Infrequently UsedNew Zealand Yes Federal/National Laws/Statutes/Ordinances/Policies Yes Infrequently UsedNigeria No No commonly Used

Norway Yes Federal/National Laws/Statutes/Ordinances/Policies Yes Infrequently UsedPanama Unknown Unknown Yes Infrequently UsedParaguay No Yes Never PerformedPeru No Yes infrequently UsedPhilippines No Yes Infrequently UsedPoland Unknown Unknown UnknownPortugal Yes Federal/National Laws/Statutes/Ordinances/Policies, Agency

Regulations/Oversight, Professional OrganizationStandards/Guidelines

Yes Unknown

Romania No Yes Never PerformedRussian Federation No Yes Infrequently UsedSenegal No Unknown Never Performed


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of IVM since 2010. Despite having more countries participatingin the 2018 survey, overall responses are similar to those receivedin 2015. Respondents appear to be more reticent to adopt IVM tothe extent that other micromanipulation techniques have beenapplied in the absence of evidence suggesting comparable orsuperior results when compared to conventional IVF.

Summary

Oocyte maturation is a critical step for successful IVF, and it isessential that recovered oocytes be mature, competent,and viable, to achieve fertilization and ultimately produce ahealthy offspring. It is a fundamental molecular and cellularprocess integral to IVF that largely occurs in vivo. Realizing thetrue clinical potential of IVM and opening new opportunities inART awaits additional translational advances, likely to beaccomplished with animal models for IVM [2,3]. Widespreadclinical adoption will require considerable additional evidenceregarding live birth rates, cumulative outcomes from frozenoocytes and embryos, and long-term follow up, to assess risk.

References[1] Paulson RJ, Fauser BCJM, Vuong LTN, et al. Can

we modify assisted reproductive technology practice tobroaden reproductive care access? Fertil Steril 2016;105(5):1138–1143.

[2] Abbara A, Clarke SA, Dhillo WS. Novel concepts for indu-cing final oocyte maturation in In vitro fertilization treat-ment. Endocr Rev 2018;39(5):593–628.

[3] Richani D, Gilchrist RB. The epidermal growthfactor network: role in oocyte growth, maturation and

developmental competence. Hum Reprod Update 2018;24(1):1–14.

CHAPTER 10: MICROMANIPULATION

Introduction

Micromanipulation embraces several unrelated technologiesroutinely used in the successful application of assisted repro-duction technology (ART). Some technologies are essential to theselective practice of ART; they include intracytoplasmic sperminjection (ICSI), embryo biopsy (polar body, cleavage stage, ortrophectoderm), and, possibly, assisted hatching[1]. The intro-duction of ICSI, with the first successful pregnancy achieved in1991, was a transformative event for ART, enabling many menwho previously had no way to achieve biologic fatherhood, toproduce offspring[2].

Embryo biopsy has also been employed for an array of pre-implantation testing (PGT) applications, including selection ofembryos without specific genetic diseases – a process known aspreimplantation genetic testing for monogenic (single-gene) dis-orders (PGT-M). The first successful use of PGT-M was forselecting embryos unaffected by X-linked disease, reported in1991[3]. PGT has also been used to identify and exclude embryoswith structural rearrangements (PGT-SR). Its most challenging,but potentially most impactful application, has been for detectingand excluding aneuploid embryos (PGT-A) for embryo transfer.The latter use has been hampered by the protracted developmentof a robust, reliable platform for performing a complete kar-yotype on a limited number of cells extracted from a developing

Chapter 9. Table 1

(Continued)

Country

Is Oocyte MaturationRegulated in Your

Country?

If Oocyte Maturation Regulatedin Your Country,How is it Done?

Is Oocyte MaturationAllowed/Permitted in Your

Country?

Is Oocyte MaturationPracticed/Performed in

Your Country?

Serbia Yes Federal/National Laws/Statutes/Ordinances/Policies Yes Infrequently UsedSingapore No Yes Infrequently UsedSlovenia No Yes Infrequently UsedSouth Africa No Yes Infrequently UsedThe Republic of Korea No Yes Commonly UsedSpain Yes Federal/National Laws/Statutes/Ordinances/Policies Yes Infrequently UsedSri Lanka Yes Yes Infrequently UsedSweden No YesSwitzerland No Yes Commonly UsedTaiwan (China*) No Federal/National Laws/Statutes/Ordinances/Policies Yes Infrequently UsedThailand Yes Yes Commonly UsedTogo No Federal/National Laws/Statutes/Ordinances/Policies,

Professional Organization Standards/GuidelinesTrinidad and Tobago No Yes Infrequently UsedTurkey Yes Federal/National Laws/Statutes/Ordinances/Policies Yes Infrequently UsedUganda No Yes Commonly UsedUnited Arab Emirates Unknown Unknown Unknown UnknownUK Yes Federal/National Laws/Statutes/Ordinances/Policies Yes Infrequently UsedUSA No Yes Infrequently UsedUruguay No State/Provincial/Regional Laws/Statutes/Ordinances UnknownVenezuela No Yes Commonly UsedViet Nam No Federal/National Laws/Statutes/Ordinances/Policies Yes Commonly UsedZimbabwe No Yes Unknown



91

Chapter 10. Table 1aAre these laboratory techniques allowed/permitted and practiced/performed in your country?

ICSI

With Ejaculated SpermWith SurgicallyRetrieved Sperm Assisted Hatching

Country Allowed/Permitted Practiced/PerformedPracticed/Performed Allowed/Permitted Practiced/Performed

Argentina Yes Commonly Used Commonly Used Yes Commonly UsedArmenia Yes Commonly Used Infrequently Used Yes Infrequently UsedAustralia Yes Commonly Used Commonly Used Yes Commonly UsedAustria Yes Commonly Used Infrequently Used Yes Commonly UsedBangladesh Yes Commonly Used Commonly Used NoBarbados Yes Commonly Used Commonly Used Yes Commonly UsedBelarus Yes Commonly Used Commonly Used Yes Commonly UsedBelgium Yes Commonly Used Commonly Used Yes Commonly UsedBolivia Yes Commonly Used Commonly Used Yes Commonly UsedBotswana Yes YesBrazil Yes Commonly Used Commonly Used Yes Commonly UsedBulgaria Yes Commonly Used Infrequently Used Yes Infrequently UsedBurkina Faso Yes Commonly Used Commonly Used YesCameroon Yes Commonly Used Infrequently Used Yes Never PerformedCanada Yes Commonly Used Commonly Used Yes Commonly UsedChile Yes Commonly Used Commonly Used Yes Commonly UsedChina Yes Commonly Used Commonly Used Yes Commonly UsedColombia Yes Commonly Used Commonly Used Yes Commonly UsedCzechia Yes Commonly Used Commonly Used Yes Commonly UsedEcuador Yes Commonly Used Commonly Used Yes Commonly UsedEgypt Yes Commonly Used Commonly Used Yes Commonly UsedEl Salvador Yes Commonly Used Infrequently Used Yes Infrequently UsedFinland Yes Commonly Used Commonly Used Yes Infrequently UsedGeorgia Yes Commonly Used Commonly Used Yes Infrequently UsedGermany Yes Commonly Used Infrequently Used Unknown UnknownGhana Yes Commonly Used Commonly Used Yes Commonly UsedGreece No Commonly Used Infrequently Used Yes Infrequently UsedGuatemala Yes Commonly Used Commonly Used Yes Infrequently UsedHong Kong (China*) Yes Commonly Used Commonly Used Yes Infrequently UsedHungary Yes Commonly Used Commonly Used Yes Commonly UsedIceland Yes Commonly Used Infrequently Used Yes Never PerformedIndia Yes Commonly Used Commonly Used Yes Infrequently UsedIreland Yes Commonly Used Commonly Used Yes Infrequently UsedItaly Yes Commonly Used Commonly Used Yes Commonly UsedCôte d’Ivoire Yes Commonly Used Infrequently Used Unknown UnknownJapan Yes Commonly Used Commonly Used Yes Commonly UsedJordan Yes Commonly Used Infrequently Used Yes Infrequently UsedKazakhstan Yes Commonly Used Commonly Used Yes Commonly UsedKenya Yes Commonly Used Infrequently Used Yes Infrequently UsedLatvia Yes Commonly Used Commonly Used Yes Commonly UsedLithuania Yes Commonly Used Commonly Used Yes Commonly UsedMali Yes Commonly Used Commonly Used No Never PerformedMexico Yes Commonly Used Commonly Used Yes Infrequently UsedMongolia Yes Commonly Used Infrequently Used Yes Commonly UsedMontenegro Yes Commonly Used Commonly Used Yes Infrequently UsedNew Zealand Yes Commonly Used Commonly Used Yes Commonly UsedNicaragua Yes Commonly Used Commonly UsedNigeria Yes Commonly Used Infrequently Used No UnknownNorway Yes Commonly Used Commonly Used No Never PerformedPanama Yes Commonly Used Commonly Used Yes Commonly UsedParaguay Yes Commonly Used Commonly Used Yes Commonly UsedPeru Yes commonly Used infrequently Used Yes infrequently UsedPhilippines Yes Commonly Used Commonly Used Yes Commonly UsedPoland Yes Commonly Used Commonly Used Unknown UnknownPortugal Yes Commonly Used Commonly Used Yes Commonly UsedRomania Yes Commonly Used Infrequently Used Yes Commonly UsedRussian Federation Yes Commonly Used Commonly Used Yes Commonly Used


92

embryo. Recent progress in this area may lead to much greaterimplantation rates, with potentially much higher live birth rates.It could also provide a chance to greatly reduce the primary risk ofART, multiple pregnancy, if a single euploid embryo could betransferred for all age groups.

Micromanipulation may also be used for several investigative,more controversial applications. These include cytoplasmictransfer, mitochondrial transfer, and the recently described “geneediting” technology, CRISPR-Cas9. No reports of humanapplication of the latter existed when the survey was completed(March 2018).


Of the respondents representing the 97 countries that partici-pated in the 2018 Surveillance questionnaire, more than 70%provided specific responses regarding micromanipulation.Techniques of micromanipulation queried in the survey includedthe performance and legal status of ICSI with ejaculated or sur-gically obtained sperm; PGT with polar body, blastomere, ortrophectoderm biopsy; assisted hatching; and cytoplasmictransfer, mitochondrial transfer, and CRISPR-Cas9 technology.

ICSI was permitted in almost all countries that responded tothe survey – 79 of 80 (99%) – but it was performed in all. ICSIwith sperm recovered following ejaculation is a common

procedure in 77 countries, but it is infrequent in Sri Lanka, and isnever performed in that country on surgically recovered sperm.

Most countries commonly perform ICSI with surgicallyretrieved sperm, but the procedure is infrequent in 21 of 78 (27%)(Table 1a). There were no regulations for ICSI in most countries;it was regulated in 27 out of 79 (34%). In 30 countries out of 79(38%), ICSI was regulated by federal or national laws. Regional/state laws were followed in 7 countries out of 79 (9%). In 16 outof 79 (20%), countries, professional organization standards/guidelines were followed, and in two countries (Italy and Senegal)municipal laws were the regulation authority. ICSI was held as acultural practice in Switzerland, and also in Italy, where theapplication of ICSI was interdicted by religious decree. In 6countries of 79 (7.5%), agencies were used for regulation. Theregulating authority was reported as “unknown” in 4 countriesof 79 (5%).

Polar body biopsy was permitted in 54 of 75 countries (72%),but was commonly used in only 5 out of 70 (41%); infrequentlyused in 29 out of 70 (41%), and never performed in 26 out of 70(15%). Polar body biopsy was not permitted in 10 out of 75countries (13%). Blastomere 61 out of 77 (79%) and tro-phectoderm biopsy 61 out of 76 (80%) were allowed in mostcountries, but were not permitted in 14%: 11 of 77, and 10 of 76,respectively. Blastomere biopsy was used commonly in 30 of 72

Chapter 10. Table 1a

(Continued)

ICSI

With Ejaculated SpermWith SurgicallyRetrieved Sperm Assisted Hatching

Country Allowed/Permitted Practiced/PerformedPracticed/Performed Allowed/Permitted Practiced/Performed

Senegal Yes Commonly Used Infrequently Used Unknown Never PerformedSerbia Yes Commonly Used Infrequently Used Yes Commonly UsedSingapore Yes Commonly Used Infrequently Used Yes Infrequently UsedSlovenia Yes Commonly Used Commonly Used Yes Infrequently UsedSouth Africa Yes Commonly Used Commonly Used Yes Infrequently UsedThe Republic ofKorea

Yes Commonly Used Commonly Used Yes Commonly Used

Spain Yes Commonly Used Commonly Used Yes Commonly UsedSri Lanka Yes Infrequently Used Never Performed Yes Infrequently UsedSweden Yes YesSwitzerland Yes Commonly Used Commonly Used Yes Infrequently UsedTaiwan (China*) Yes Commonly Used Commonly Used Yes Commonly UsedThailand Yes Commonly Used Commonly Used Yes Commonly UsedTogo Yes Commonly Used Commonly Used Yes Commonly UsedTrinidad andTobago

Yes Commonly Used Commonly Used Yes Never Performed

Turkey Yes Commonly Used Commonly Used Yes Commonly UsedUganda Yes Commonly Used Commonly Used Yes Infrequently UsedUnited ArabEmirates

Yes Commonly Used Infrequently Used Yes Infrequently Used

UK Yes Commonly Used Infrequently Used Yes Infrequently UsedUSA Yes Commonly Used Infrequently Used Yes Commonly UsedUruguay Yes commonly Used commonly Used Yes infrequently UsedVenezuela Yes Commonly Used Commonly Used Yes Commonly UsedViet Nam Yes Commonly Used Commonly Used Yes Commonly UsedZimbabwe Yes Commonly Used Commonly Used Yes Unknown



93

Chapter 10. Table 1bAre these laboratory techniques allowed/permitted and practiced/performed in your country?

Polar Body Biopsy Blastomere Biopsy Trophectoderm Biopsy

Country Allowed/Permitted Practiced/Performed Allowed/Permitted Practiced/PerformedAllowed/Permitted

Practiced/Performed

Argentina Yes Unknown Yes Commonly Used Yes Commonly UsedArmenia Yes Yes Infrequently UsedAustralia Unknown Unknown UnknownAustria Yes Commonly Used Yes Never Performed Yes Commonly UsedBangladesh No No NoBarbados Never Performed Never Performed Yes Commonly UsedBelarus No Infrequently Used Yes Infrequently Used Yes Commonly UsedBelgium Yes Commonly Used Yes Commonly Used Yes UnknownBolivia Yes Yes Commonly Used Yes Commonly UsedBotswana Yes Yes YesBrazil Yes Unknown Yes Commonly Used Yes Commonly UsedBulgaria Yes Infrequently Used Yes Infrequently Used Yes Infrequently UsedBurkina Faso Yes YesCameroon Unknown Never Performed No Never Performed No Never PerformedCanada Yes Infrequently Used Yes Infrequently Used Yes Commonly UsedChile Yes Infrequently Used Yes Commonly Used Yes Commonly UsedChina Yes Never Performed Yes Commonly Used Yes Never PerformedColombia Unknown Never Performed Yes Infrequently Used Yes Commonly UsedCzechia Yes Infrequently Used Yes Commonly Used Yes Commonly UsedEgypt Yes Never Performed Yes Commonly Used Yes Commonly UsedEl Salvador No Never Performed No Never Performed No Never PerformedFinland Yes Unknown Yes Commonly Used Yes Commonly UsedGeorgia Yes Unknown Yes Commonly Used Yes Commonly UsedGermany Yes Infrequently Used No Unknown No Never PerformedGhana Yes Never Performed Yes Unknown Yes UnknownGreece Yes Infrequently Used No Commonly Used Yes Commonly UsedGuatemala Yes Never Performed Yes Commonly Used Yes Commonly UsedHong Kong (China*) Yes Infrequently Used Yes Commonly Used Yes Commonly UsedHungary Yes Infrequently Used Yes Infrequently Used Yes Infrequently UsedIceland Yes Never Performed Yes Never Performed Yes Never PerformedIndia Yes Infrequently Used Yes Commonly Used Yes Commonly UsedIreland Yes Infrequently Used Yes Never Performed Yes Infrequently UsedItaly Yes Commonly Used Yes Commonly Used Commonly UsedCôte d’Ivoire No Unknown No Unknown No UnknownJapan Yes Infrequently Used Yes Commonly Used Yes Commonly UsedJordan Yes Infrequently Used Yes Infrequently Used Yes Infrequently UsedKazakhstan Yes Commonly Used Yes YesKenya Unknown Infrequently Used Yes Infrequently Used Yes Infrequently UsedLatvia Yes Unknown Yes Commonly Used Yes Commonly UsedLithuania Yes Infrequently Used Yes Infrequently Used Yes Infrequently UsedMali No Never Performed No Never Performed No Never PerformedMexico Unknown Unknown Yes Commonly Used Yes Commonly UsedMongolia Yes Never Performed Yes Never Performed Yes Never PerformedMontenegro Yes Infrequently Used Yes Infrequently Used Yes Infrequently UsedNew Zealand Yes Never Performed Yes Infrequently Used Yes Commonly UsedNigeria No never Performed No never Performed No never Performed

Norway No Never Performed No Never Performed No Never PerformedPanama Unknown Infrequently Used Yes Commonly Used Yes Commonly UsedParaguay Yes Never Performed Yes Commonly Used Yes Commonly UsedPeru Yes never Performed Yes commonly Used Yes commonly UsedPhilippines Unknown Yes Unknown Yes Infrequently UsedPoland Unknown Unknown Unknown Unknown Unknown UnknownPortugal Unknown Unknown Unknown Unknown Unknown UnknownRomania No Never Performed No Never Performed No Never PerformedRussian Federation Yes Infrequently Used Yes Commonly Used Yes Commonly UsedSenegal Unknown Never Performed Unknown Never Performed Unknown Never PerformedSerbia No Never Performed No Never Performed No Never PerformedSingapore No Never Performed Yes Infrequently Used Yes Infrequently UsedSlovenia Yes Never Performed Yes Commonly Used Yes Infrequently UsedSouth Africa Yes Infrequently Used Yes Infrequently Used Yes Infrequently Used


94

Chapter 10. Table 1b

(Continued)

Polar Body Biopsy Blastomere Biopsy Trophectoderm Biopsy

Country Allowed/Permitted Practiced/Performed Allowed/Permitted Practiced/PerformedAllowed/Permitted

Practiced/Performed

The Republic ofKorea

Yes Commonly Used Yes Commonly Used Yes Commonly Used

Spain Yes Infrequently Used Yes Commonly Used Yes Commonly UsedSri Lanka Unknown Infrequently Used Unknown Infrequently Used Unknown UnknownSweden Yes Yes YesSwitzerland Yes Infrequently Used Yes Infrequently Used Yes Commonly UsedTaiwan (China*) Yes Infrequently Used Yes Infrequently Used Yes Commonly UsedThailand Yes Infrequently Used Yes Commonly Used Yes Commonly UsedTogo Never Performed Never Performed Never PerformedTrinidad and Tobago Yes Never Performed Yes Never Performed Yes Never PerformedTurkey Yes Infrequently Used Yes Commonly Used Yes Commonly UsedUganda Yes Never Performed Yes Infrequently Used Yes Infrequently UsedUnited ArabEmirates

Yes Never Performed Yes Infrequently Used Yes Commonly Used

UK Yes Infrequently Used Yes Infrequently Used Yes Commonly UsedUSA Yes Infrequently Used Yes Infrequently Used Yes Commonly UsedUruguay Yes infrequently Used Yes commonly Used Yes UnknownVenezuela Yes Never Performed Yes Commonly Used Yes Commonly UsedViet Nam Yes Infrequently Used Yes Commonly Used Yes Commonly UsedZimbabwe Yes Unknown Yes Unknown Yes Unknown


Chapter 10. Table 1cAre these laboratory techniques allowed/permitted and practiced/performed in your country?

Cytoplasmic Transfer Mitochondrial Transfer CRISPR

Country Allowed/Permitted Practiced/Performed Allowed/Permitted Practiced/Performed Allowed/Permitted Practiced/Performed

Argentina Yes Unknown Yes Unknown Yes UnknownAustralia No No Never Performed No Never PerformedAustria Unknown Never Performed Unknown Never Performed No Never PerformedBangladesh No No NoBarbados Never Performed Never Performed Never PerformedBelarus No Never Performed No Never Performed No Never PerformedBelgium Unknown Unknown Unknown Unknown Unknown UnknownBolivia Yes Infrequently Used Yes Never Performed Yes UnknownBotswana Yes Yes YesBrazil No Unknown No Unknown Unknown UnknownBulgaria Unknown Unknown Unknown Unknown Unknown UnknownCameroon Unknown Never Performed No Never Performed No Never PerformedCanada Yes Infrequently Used Yes Infrequently Used Yes UnknownChile Unknown Unknown Unknown Unknown UnknownChina Yes Infrequently Used Yes Never Performed Unknown Never PerformedColombia Yes Infrequently Used Yes Infrequently Used Yes Infrequently UsedCzechia No Unknown No Never Performed No Never PerformedEgypt Unknown Unknown Unknown Unknown Unknown UnknownEl Salvador No Never Performed No Never Performed Unknown Never PerformedFinland Unknown Unknown Unknown Unknown Yes Infrequently UsedGeorgia Yes Never Performed Unknown Never Performed Unknown Never PerformedGermany Unknown Unknown No Unknown No UnknownGhana Unknown Never Performed Unknown Unknown Unknown Never PerformedGreece Yes Infrequently Used Yes Commonly Used Yes Commonly UsedGuatemala Yes Never Performed Yes Never Performed Yes Never PerformedHong Kong (China*) Unknown Unknown UnknownHungary No Unknown Unknown Unknown Unknown UnknownIceland Unknown Never Performed Unknown Never Performed Unknown Never PerformedIndia Unknown Infrequently Used Unknown Never Performed Unknown Never Performed


95

(42%) countries, infrequently used in 20 of 72 (28%), and neverperformed in 15 of 72 (21%). Trophectoderm biopsy was used in38 of 73 (52%) countries. It was infrequently used in 13 of 73(18%) of countries, and never performed in 14 of 73 (19%)(Table 1b).

Seventy-six countries responded to questions regarding theregulation of these techniques; 15 countries (20%) regulatedpolar body biopsy, 6 countries (21%) regulated blastomere

biopsy, and 19 countries (25%) regulated trophectoderm biopsy.Biopsy procedures were regulated by federal or national laws in19 of 35 (54%) countries, and state or regional laws in 3 of 8(37.5%) of the reporting countries. Polar body biopsy is regu-lated by municipal rules, agencies, and religious decree in Greece.Brazil also had regulation of polar body biopsy, by agency reg-ulations or oversight. Professional organization recommenda-tions were used in 10 of 17 (59%) of reporting countries. Biopsy

Chapter 10. Table 1c

(Continued)

Cytoplasmic Transfer Mitochondrial Transfer CRISPR

Country Allowed/Permitted Practiced/Performed Allowed/Permitted Practiced/Performed Allowed/Permitted Practiced/Performed

Ireland No Never Performed No Never Performed No Never PerformedItaly No Commonly Used No Commonly Used No Commonly UsedCôte d’Ivoire Unknown Unknown No Unknown Unknown UnknownJapan Unknown Infrequently Used Unknown Infrequently Used Unknown Never PerformedJordan No Infrequently Used Unknown Unknown Unknown UnknownKazakhstan Yes Commonly Used Yes YesKenya Unknown Unknown Unknown Unknown Unknown UnknownLatvia Unknown Never Performed Unknown Never Performed Unknown Never PerformedLithuania Unknown Never Performed Unknown Never Performed Unknown Never PerformedMali No Never Performed No Never Performed No Never PerformedMexico Unknown Unknown Unknown Infrequently Used Unknown UnknownMongolia Yes Never Performed Yes Never Performed Yes Never PerformedMontenegro Never Performed Never Performed Never PerformedNew Zealand No Never Performed No Never Performed No Never PerformedNigeria No Unknown No Unknown No Unknown

Norway No Never Performed No Never Performed No Never PerformedPanama Unknown Infrequently Used Unknown Unknown Unknown UnknownParaguay Unknown Never Performed Unknown Never Performed Unknown Never PerformedPeru Unknown Unknown Unknown Yes UnknownPhilippines Unknown Unknown Unknown Unknown Unknown UnknownPoland Unknown Unknown Unknown Unknown Unknown UnknownPortugal Yes Unknown Unknown Unknown Unknown UnknownRomania No Never Performed No Never Performed No Never PerformedRussian Federation Yes Unknown Yes Unknown Yes UnknownSenegal Unknown Never Performed Unknown Never Performed Unknown Never PerformedSerbia No Never Performed No Never Performed No Never PerformedSingapore No Never Performed No Never Performed No Never PerformedSlovenia Unknown Never Performed Unknown Never Performed Unknown UnknownSouth Africa No Never Performed No Never Performed No Never PerformedThe Republic of Korea No Commonly Used No Never Performed No Never PerformedSpain Unknown Unknown No Never Performed No Never PerformedSri Lanka Unknown Unknown No Unknown Unknown UnknownSweden No No YesSwitzerland No Never Performed No Unknown No UnknownTaiwan (China*) No Never Performed No Never Performed No Never PerformedThailand Yes Infrequently Used Yes Infrequently Used Yes Never PerformedTogo Never Performed Never Performed Never PerformedTrinidad and Tobago Unknown Never Performed Unknown Never Performed Unknown Never PerformedTurkey No Never Performed Unknown Never Performed Unknown Never PerformedUganda Yes Never Performed Unknown Never Performed Unknown UnknownUnited Arab Emirates Unknown Unknown Unknown Unknown Unknown UnknownUK No Never Performed Yes Infrequently Used No Never PerformedUSA No Never Performed No Never Performed Yes Infrequently UsedUruguay Unknown Infrequently Used Unknown Unknown No UnknownVenezuela Yes Never Performed Yes Never Performed Unknown Never PerformedViet Nam Unknown Unknown Unknown Unknown Unknown UnknownZimbabwe Yes Unknown Yes Unknown Yes Unknown



96

procedures were addressed as a cultural practice in Switzerland.Respondents for 6 countries answered “unknown”.

In 71 of 79 (90%) of countries reporting, assisted hatching wassaid to be allowed. Assisted hatching was commonly used in 40 of75 (53%) of countries, and was infrequently done in another 24(32%). Five countries (7%) reported “unknown”, and said it wasnever performed in 6 countries (8%). Twenty-one countries - 78 -did report the existence of regulations for assisted hatching. Themajority of countries – 21 (95%) – that cited regulation ofassisted hatching noted the presence of federal or national law,and three (14%) were regulated by state/regional law. Only onecountry, Portugal, had agency regulation for assisted hatching.Professional organization standards or guidelines were used by 8countries (38%). Assisted hatching was addressed as a culturalpractice in Switzerland and Greece. The regulating body wasreported as “unknown” by 4 countries.

Twenty five of 73 (34%) countries, but was allowed in 17countries (23%). Cytoplasmic transfer was never performed in 33of 71 (46%), and infrequently in 11 of 73 (15%). It was reportedto be commonly used in three countries – Italy, Kazakhstan, andThe Republic of Korea. Specific regulations for cytoplasmictransfer existed in 12 of 75 countries (16%). Cytoplasmic transferwas regulated by federal or national laws in 9 countries of 12(75%). Portugal relied on agencies for regulation, and 6 countriesfollowed professional organization standards or guidelines. Theresponsible regulatory body was reported as “unknown” for 6countries (Table 1c).

Mitochondrial transfer was permitted in only 15 of 72 coun-tries (21%).Mitochondrial transfer was never performed in 37 of70 (53%), and infrequently in 6 countries (9%): Canada,Colombia, Japan, Mexico, Thailand, and United Kingdom ofGreat Britain and Northern Ireland. Mitochondrial transferapplications were regulated by federal or national legislation inAustralia, Norway, Turkey, and United Kingdom of GreatBritain and Northern Ireland. Professional organization stan-dards or guidelines were observed in 4 countries. The regulationauthority was “unknown” in seven countries (Table 1c).

CRISPR-Cas9 technology was permitted in 16 of 73 (22%).CRISPR-Cas9 technology was reported to be commonly used inGreece and Italy, according to 71 responders (3%), and infre-quently used (4%) in Colombia, Finland, and The United Statesof America. Regulations existed in 8 of 74 countries (11%) formitochondrial transfer, and in 6 of 75 (8%) countries forCRISPR-Cas9 technology. Federal or national laws regulatedCRISPR-Cas9 technology in Australia, Norway, Singapore,Turkey, and United Kingdom of Great Britain and NorthernIreland. Professional organization standards or guidelines asexisting recommendations were followed in Guatemala,Thailand, and The United States of America. Six countries replied“unknown” (Table 1c).

Discussion

While all these technologies are micromanipulation techniques,they have a much different status in the successful deployment ofART. ICSI is an indispensable tool, widely embraced after vali-dation and successful global application. It is almost universallyaccepted, performed successfully, and used with minimal reg-ulatory oversight. This has been the case for many years, and thecurrent survey has not revealed any significant changes.

PGT is a promising technology with successful, validatedapplications for PGT-M and PGT-SR. After an earlier proble-matic launch with a less successful technology, PGT-A may nowbe poised to be the next great breakthrough. However, afterprevious false starts, it is particularly critical that it be validatedwith successful widespread application before it can be uni-versally recommended. Assisted hatching has been practiced forover 25 years, and has been shown to improve embryo implan-tation rates in certain circumstances by certain labs. The lack ofclearly defined indications and the variable experience amongART labs has precluded its universal application, thus far. PGT isaddressed in more detail in Chapter 13.

Cytoplasmic and mitochondrial transfer, and CRISPR-Cas9are investigative technologies that hold great promise foraddressing some of the most challenging clinical problems. But allare fraught with potential greater risks, and pose unique ethicaldilemmas. None appears to be ready for broad clinical applica-tion at this time, as reflected by their limited use and acceptance.The 2018 questionnaire did not identify any emerging trendsregarding these three technologies.

Summary

The ability to performmicromanipulation procedures on gametesand embryos has vastly expanded the scope of ART, but thevarious procedures are at different stages of development. ICSI isa universally available procedure, performed in all respondingcountries, but not officially sanctioned in one (Greece).Micromanipulation procedures, including ICSI and PGT-M, arenow essential technologies; they are widely available in compre-hensive ART centres. PGT-A and assisted hatching, shown to beuseful adjuncts in certain circumstances, are still being defined interms of their specific indications and overall value. The pre-liminary experiences with cytoplasmic transfer, mitochondrialtransfer, and CRISPR-Cas9 technology have been promising, butthese applications remain investigative; an accurate assessment oftheir true potential, limitations, and risks is awaited.

References[1] Malter HE. Micromanipulation in assisted reproductive

technology. Reprod Biomed Online 2016;32:339–347.[2] Rosenwaks Z, Pereira N. The pioneering of intracytoplasmic

sperm injection: historical perspectives. Reproduction 2017;154(6):71–77.

[3] Handyside AH, Kontogianni EH, Hardy K, et al. Pregnanciesfrom biopsied human preimplantation embryos sexedby Y-specific DNA amplification. Nature 1990;344(6268):768–770.

CHAPTER 11: WELFARE OF THE CHILD ANDIDENTITY RIGHTS

Introduction

Safety, particularly for the offspring, has been of the utmostconcern since the advent of ART. As early as 1985[1], publicationshave suggested that the risk of obstetrical and neonatal morbiditymight be increased after ART. Reports were many; they includedmatched and non-matched studies of singletons and twins, and,more recently, reviews and meta-analyses[2] comparing outcomesof spontaneous pregnancies after various procedures. The pro-cedures include intracytoplasmic sperm injection (ICSI), elective


97

Chapter 11. Table 1Regulations that address welfare of the child.

CountryNo

Regulations


Policies


Ordinances





ReligiousDecree

Argentina No No No No No Yes No NoAustralia Yes YesAustria No Yes No No No No Yes YesBangladesh YesBarbados YesBelarus UnknownBelgium UnknownBolivia NoBotswana No Yes Unknown Unknown Yes Yes Yes NoBrazil Yes YesBulgaria YesBurkina Faso YesCameroon Yes Yes Yes YesCanada No YesChile YesChina YesColombia Yes Yes Yes Yes Yes Yes No NoCzechia YesEcuador YesEgypt Yes NoEl Salvador No No No No No No No NoFinland No Yes No No No Yes No NoGeorgia YesGermany No Yes YesGhana Yes YesGreece No Yes Yes No Yes No Yes YesGuatemala Yes Unknown Unknown Unknown Unknown Unknown Unknown UnknownHong Kong(China*)

Yes Yes

Hungary YesIceland YesIndia YesIreland NoItaly No No No No No No No NoCôte d’Ivoire Unknown Yes Yes Yes Yes Yes Yes YesJapan YesJordan YesKazakhstan YesKenya YesLatvia Yes No No Yes NoLithuania No Yes No No No Yes No NoMali NoMexico No No No No No No No NoMongolia Yes No No No No No No NoMontenegro No YesNew Zealand Yes YesNicaragua YesNigeria Yes Yes YesNorway Yes Yes No No No No No No

Panama Yes Unknown Unknown Unknown Unknown Unknown UnknownParaguay No Yes No No Yes Yes Yes YesPeru No Yes Yes Yes Yes Yes Yes YesPhilippines Yes Yes Yes Yes YesPoland Yes Yes Yes Yes Unknown Yes Yes YesPortugal No Yes No No Yes Yes Unknown UnknownRomania Yes No No No No No No NoRussianFederation

Yes Yes Yes

Senegal YesSerbia Yes


98

single embryo transfer (eSET), frozen embryo transfer (FET), andblastocyst transfers. A marked increase in cases of antepartumhemorrhage, hypertensive disorders, prematurity, low birthweight, and perinatal mortality has occurred in the latter groups.Many current ART practices and techniques have the potential toharm the embryo; these include extended culture beyond thecleavage stage; invasive genetic testing; vitrification and warmingprocedures; and expanded applications for ICSI. These unre-solved concerns make careful follow-up of newborns and chil-dren born from ART cycles, of paramount importance.

Much more recently, concern for the child’s welfare has beenexpanded to include an assessment of social factors pertaining tothe prospective parents’ ability to provide a suitable homeenvironment, before embarking on treatment. A model for bestpractice was enshrined in the Human Fertilisation andEmbryology Authority’s (HFEA’s) code of practice of the UnitedKingdom of Great Britain and Northern Ireland. The modelprovides guidance parameters for assessing, obtaining furtherinformation, and refusing treatment[5]. These measures have beenadopted by many other countries, as well.

Chapter 11. Table 1

(Continued)

CountryNo

Regulations


Policies


Ordinances





ReligiousDecree

Singapore YesSlovenia YesSouth Africa YesThe Republicof Korea

Yes

Spain Yes Yes No No Yes No NoSri Lanka YesSwitzerland No Yes No No No Yes Yes NoTaiwan(China*)

No Yes

Thailand YesTogo UnknownTrinidad andTobago


Turkey Yes YesUganda Yes Yes Unknown Unknown Unknown Unknown Unknown UnknownUnited ArabEmirates

Yes Yes Yes

UK No Yes No No No No No NoUSA No No No No No Yes No NoUruguay No Yes No No No No No NoVenezuela No No No No No Yes No NoViet Nam Unknown NoZimbabwe Yes Yes Yes Yes Yes Yes Yes


10%

12%

8%

13%

13%

11%

5%

62%

48%

33%

53%

68%

53%

20%

28%

40%

59%

34%

19%

36%

75%

Religious Decree

Cultural Practice

Professional Organization Standards/Guidelines

Agency Regulations/Oversight

Muncipal Laws/Statutes/Ordinances

State/Provinicial/Regional Laws/Statutes/Ordinances

Federal/National Laws/Statutes/Ordinances

Yes No Unknown

Chapter 11. Chart 1. Are there practices or regulations that address the welfare of the child in your country?


99

33%

13%

15%

61%

52%

26%

Can fertility care be declined if there are concernsregarding the welfare of any potential future children?

Is a formal assessment of the welfare of the child anobligatory part of the fertility clinic evaluation of the

prospective parents?

Yes No Unknown

Chapter 11. Chart 2. Formal assessment of the welfare of a child.

Chapter 11. Table 2Welfare of the child, are prospective parents asked about the following?

Country

PreviousConvictionsRelated toHarming a

Child

ContactWith SocialServicesRegardingCare ofOther

Children

A History ofViolence orSerious

Discord withinThe Family

Drug orAlcoholAbuse

The existenceof SeriousMental orPhysicalConditions

Risk to TheChild of aSeriousMedicalCondition

Argentina No No No Yes Yes YesAustralia Yes Yes Yes Yes Yes YesAustria No No No Yes Yes NoBelarus Unknown Unknown Unknown Unknown Unknown UnknownBolivia Yes Yes Yes Yes YesBotswana No Yes No No Yes NoBrazil No No No Yes Yes YesBulgaria Unknown Unknown Unknown Yes Yes YesBurkinaFaso

No No No No No No

Cameroon No No Yes Yes No YesCanada Unknown Unknown Unknown Unknown Unknown UnknownChile No No No No No NoChina No No No No NoColombia No No No Yes Yes YesCzechia Unknown Unknown Unknown Unknown Unknown UnknownEcuador No No No Yes YesEgypt No No No No No NoEl Salvador Unknown Unknown Unknown Yes Yes YesFinland Unknown Unknown Yes Yes Yes YesGeorgia No No No Yes Unknown YesGermany Unknown Unknown Unknown Unknown Unknown UnknownGhana No No No Yes Yes YesGreece No Yes Yes Yes Yes YesGuatemala No No No No No YesHong Kong(China*)

Yes Yes Yes Yes Yes Yes

Hungary No No No Yes Yes YesIceland No Yes No Yes Yes YesIndia No No No No NoIreland No No No Yes Yes YesItaly Yes Yes Yes Yes Yes YesCôte d’Ivoire Unknown Unknown Unknown Unknown Unknown UnknownJapan No No No Yes Yes YesJordan Unknown No Unknown Yes Unknown UnknownKazakhstan Yes No No No No NoKenya No No No Yes Yes Yes


100


Respondents representing 78 countries provided data for the2018 questionnaire about measures in place to address the wel-fare of the child. Of this number, 41 of 55 (74.5%) noted theexistence of federal laws or statutes dealingwith the welfare of thechild. This situation was prevalent in most of the European

countries and in the United Kingdom of Great Britain andNorthern Ireland; Australia, Botswana, Canada, Côte d’Ivoire,Ghana, Hong Kong [China, reporting separately for this report],New Zealand, Nigeria, Philippines, Russian Federation,Singapore, South Africa, Taiwan [China, reporting separately forthis report], Thailand, Uganda, United Arab Emirates, and

Chapter 11. Table 2

(Continued)

Country

PreviousConvictionsRelated toHarming a

Child

ContactWith SocialServicesRegardingCare ofOther

Children

A History ofViolence orSerious

Discord withinThe Family

Drug orAlcoholAbuse

The existenceof SeriousMental orPhysicalConditions

Risk to TheChild of aSeriousMedicalCondition

Latvia No No No Yes No YesLithuania No No No Yes Yes YesMali Unknown Unknown Unknown Unknown Unknown UnknownMexico No No No No No NoMongolia Unknown Unknown Unknown Unknown Unknown UnknownMontenegro Yes YesNewZealand

Yes Yes Yes No Yes Yes

Nigeria No No No No No NoNorway Yes Yes Yes Yes Yes

Panama No No No No No NoParaguay No No No No No NoPeru Unknown Unknown Unknown Yes Yes YesPhilippines Unknown Unknown Unknown Unknown Unknown UnknownPoland Unknown Unknown Unknown Unknown Unknown UnknownPortugal Unknown Yes Unknown Yes Yes YesRomania No No No No No NoRussian Federation No No No Yes Yes

YesSenegal No No No No No NoSerbia Yes Yes Yes Yes Yes YesSingapore No No No Yes Yes YesSlovenia Yes Yes Yes Yes Yes YesSouth Africa No No No Yes Yes YesTheRepublicof Korea

Unknown Unknown Unknown Yes Yes

Spain No No No No Yes YesSri Lanka Unknown Unknown Unknown Unknown Unknown UnknownSwitzerland No No Yes Yes Yes YesTaiwan(China*)


Thailand Yes No No Yes Yes YesTogo Unknown Unknown Unknown Unknown Unknown UnknownTrinidad andTobago


Turkey No No No No No NoUganda No No No No No NoUnited ArabEmirates

No No No Yes Yes Yes

UK Yes Yes Yes Yes Yes YesUSA No No No Yes Yes YesUruguay Yes Unknown Unknown Yes Yes UnknownVenezuela No No Unknown Yes Yes YesViet Nam Yes Yes Yes Yes Yes YesZimbabwe No No No No No No



101

Zimbabwe; also, several countries in South America: Colombia,Nicaragua, Paraguay, Peru, and Uruguay. Some countries, 13 of36 (36%), also had state or provincial laws in place. Twenty-seven of 56 (48%) did not have any regulation regarding thisissue, and 17% (6/36) reported having only professional orga-nization. These included Argentina, Ecuador, India, Japan, TheUnited States of America, and Venezuela. Two countries, Belarusand Belgium, responded “unknown” (Table 1, Chart 1).

Formal assessment of the potential welfare of the child waseither not an obligatory part of the fertility clinic evaluation ofprospective parents, or the issue was “unknown” for the major-ity, 74%, of responding countries (53 of 72). Nineteen countries(26%) responded that a formal assessment of the welfare of thechild was a requirement, including Austria, Bolivia, Botswana,Ecuador, El Salvador, Finland, Ghana, Greece, Hong Kong[China, reporting separately for this report], Hungary, Norway,Portugal, Serbia, Slovenia, Spain, Switzerland, Trinidad andTobago , Turkey, and the United Kingdom of Great Britain andNorthern Ireland (Chart 2).

Fertility care could be denied in 38 of 73 countries (52%) ifconcerns about thewelfare of a potential future child existed. Elevenresponders (15%) reported that they could not deny treatment forthis reason, and the status was “unknown” for 24 (33%).

Additional questions surveyed prior background evaluationsof prospective parents’ clinical, psychiatric, and derelictive his-tories (Table 2). Nine of 73 (12%) report asking about any pre-vious convictions related to any of the following: harming a child,history of family violence, social services contacts regarding careof other children, alcohol or drug abuse, serious mental or phy-sical illness that could impair child care, or counseling about thechild’s risk of a serious medical condition. These countriesinclude Australia, Hong Kong [China, reporting separately forthis report], Italy, Serbia, Slovenia, Taiwan [China, reportingseparately for this report], Trinidad and Tobago, UnitedKingdom of Great Britain and Northern Ireland, and Viet Nam.Another 12 of 73 (16%) declared prospective parents were not

asked about any of these issues. Spain and Ecuador reportedassessing the child’s risk of a serious medical condition, and theexistence of a serious mental or physical condition in prospectiveparents that could impair child care. Botswana reported assessingthe existence of a seriousmental or physical condition, and askingsocial services for contacts regarding care of other children(Chart 3).

Discussion

Although a sizeable majority of countries have no requirementsfor formally assessing the potential welfare of the child, somecountries that do the assessment have considerably expandedtheir concerns. Increasingly, their assessment includes a rigorouspre-conception evaluation of social risk factors, along with apostnatal surveillance of neonatal and ongoing childhooddevelopment, something that has long been in place in manycountries. While these pre-treatment measures now encompassmore, and include sanctions to deny care in some countries, theirimpact has not been determined. In contrast, many of thesecountries have comprehensive registries evaluating the sub-sequent progress of ART children. And a clearer picture of therisks of ART is beginning to emerge.

Congenital anomalies have reportedly increased in newborns,after ART cycles[3]. After adjusting for parental factors, a relativerisk of 1.07 exists (95% CI, 0.90 to 1.26) for IVF and 1.57 (95%CI, 1.30 to 1.90) for ICSI. In newborns conceived with ICSI, butnot with conventional IVF, an increase in de-novo sex chromo-some anomalies and structural autonomic anomalies has beenreported, probably inherited through the paternal pathway[4].

A variety of possible factors may have contributed to thisputative increase in morbidity. These factors include parentalbackground unrelated to the ART process, clinical interventionssuch as ovarian stimulation and endometrial preparation, andtechnical issues involving manipulation of the early developingembryo. While more recent reports have provided some reas-surance regarding safety with a much higher proportion of

25%

23%

26%

15%

18%

18%

55%

55%

52%

26%

24%

23%

20%

22%

22%

58%

58%

59%

Previous convictions related to harming a child

Contact with social service regarding care of other children

A history of violance or serious discord within the family

Drug or alcohol abuse

The existence of serious mental or physical conditions that might impair their ability totake care of a child

Risk to the child of a serious medical condition

Yes No Unknown

Chapter 11. Chart 3. Are prospective parents asked about the following information?


102

singleton pregnancies than earlier reports, potential advantagesof programmed over fresh cycle transfers and more reliablestrategies to prevent ovarian hyperstimulation, a contemporaryestimate of neonatal and maternal risk is still forthcoming.

Summary

The results of the survey reflect a very heterogeneous scenario inthe importance given to the welfare of the child and the attentiongiven to the welfare, although it shows a trend towards moreattention paid to the correct assessment at time of prospectiveparent assessment and consultation. Welfare of the child isaddressed mostly by federal or local laws/statutes, and, in coun-tries without a law in place, professional organizations offerguidelines and standards to properly assess prospective parents.Sometimes these organizations also provide reporting mechan-isms for monitoring newborn and child welfare.

References[1] Lancaster PAL.High incidence of pretermbirths and early losses

in pregnancy after in vitro fertilisation. Australian in vitro fer-tilisation collaborative group. Br Med J 1985;291(6503):1160–1163.

[2] Pandey S, Shetty S, Hamilton M, et al. Obstetric and perinataloutcomes in singleton pregnancies resulting from IVF/ICSI: asystematic review and meta-analysis. Hum Reprod Update2012;18(5):485–503.

[3] Davies MJ, Moore VM, Willson KJ, et al. Reproductivetechnologies and the risk of birth defects. N Engl J Med2012;366(19):1806–1813.

[4] Bonduelle M, Liebaers I, Deketelaere V, et al. Neonatal dataon a cohort of 2889 infants born after ICSI (1991–1999) andof 2995 infants born after IVF (1983–1999). Hum Reprod2002;17(3):671–694.

[5] HFEA Code of Practice 9. Welfare of the Child. Available at:https://www.hfea.gov.uk/media/2609/june-2018-code-of-practice-9th-edition-draft.pdf. Accessed January 25, 2019.

CHAPTER 12: FETAL REDUCTION AND SEXSELECTION

Introduction

Historically, ART has been associated with an unacceptably highmultiple-pregnancy rate. This is a direct consequence of thepractice of transferring more than one embryo. Many countriesmandated the practice of single-embryo transfer more than fifteenyears ago, and recent advances in embryo culture and embryoselection have further reduced the need for multiple transfer.

There has been a dramatic reduction in multiple-pregnancyrates in many countries, but the reduction has not been universal.Multiple pregnancies, especially those of high order, confer aconsiderable risk of inherent complications and sequelae. Fetalreduction is an established method to reduce the number offetuses, improve the live-birth rate, and reduce risks to the sur-viving fetuses – risks of prematurity and other complicationsassociated with multiple pregnancy.

In many ART centres, with preimplantation genetic screeningfor aneuploidy (PGT-A), has greatly improved the embryoselection process, routinely offering a greater than 50% chance ofimplanting a single euploid embryo. While these screening toolshave great benefits in distinguishing normal from abnormal

Chapter 12. Table 1Is selective fetal reduction allowed permitted and practiced/performed in your country?

Country Allowed/PermittedPracticed/Performed Frequency?

Argentina Not allowed Yes Infrequently usedAustralia Allowed Yes Infrequently usedAustria Allowed Yes Infrequently usedBangladesh Not Addressed Yes Infrequently usedBarbados Not Addressed NoBelarus Allowed Yes Infrequently usedBelgium Allowed Yes Frequently usedBolivia Not allowed UnknownBotswana Allowed Yes Infrequently usedBrazil Allowed with

conditionsYes Infrequently used

Bulgaria Allowed Yes Frequently usedBurkina Faso Unknown Yes Infrequently usedCameroon Allowed Yes Infrequently usedCanada Allowed Yes Infrequently usedChile Not allowed NoChina Allowed with


Colombia Allowed Yes Infrequently usedCzechia Allowed with

conditionsYes Frequently used

Ecuador Allowed withconditions

Yes Infrequently used

Egypt Allowed withconditions


El Salvador Not allowed NoFinland Allowed Yes Infrequently usedGeorgia Allowed with


Germany Not allowed NoGhana Allowed Yes Infrequently usedGreece Allowed with

conditionsYes Frequently used

Guatemala Not Addressed UnknownHong Kong (China*) Allowed Yes Infrequently usedHungary Allowed with


Iceland Allowed NoIndia Allowed Yes Infrequently usedIreland Not allowed NoItaly Allowed Yes Infrequently usedCôte d’Ivoire Unknown UnknownJapan Not Addressed Yes Infrequently usedJordan Allowed Yes Infrequently usedKazakhstan Allowed Yes Infrequently usedKenya Not Addressed UnknownLatvia Allowed Yes Infrequently usedLithuania Not allowed NoMali Not Addressed NoMexico Not allowed NoMongolia Not Addressed UnknownMontenegro Allowed Yes Infrequently usedNew Zealand Allowed with


Nicaragua NoNigeria Unknown NoNorway Allowed Yes Infrequently usedPanama Not allowed UnknownParaguay Not allowed NoPeru Not allowed No


103

embryos, a potentially unanticipated or undesired result is thedisclosure of the gender of the embryo. This application hasbecome themost reliable method of selecting fetal gender, and hasbeen extensively used for this purpose in some countries, with itsattendant moral and ethical controversies.


Regarding whether selective fetal reduction (SFR) was permitted, 47of 77 countries (61%) responded positively, compared to 21 coun-tries in the 2015 survey (Table 1, Chart 1). Of note, China andCzechia acknowledged that their status had changed from“allowed,”in the previous survey, to “allowed with conditions” in 2018.

The majority allowing SFR are in Europe. Another 17 (22%)of the countries do not allow SFR at all, and, as noted in 2016,most are in South America. Venezuela and the United ArabEmirates are new additions. The issue has not been addressed in 7(9%) of the countries. The status of SFR in the remaining 6 out of77 (8%) of countries is “unknown”. Seventeen of the 47 per-mitting countries (36%) allow SFR, with conditions applied.

SFR is performed in 52 of 78 countries (67%), but it is usedinfrequently in most – 48 of 68 (62%), Exceptions includeBelgium, Bulgaria, Czechia, and Greece, where SFR is employed“frequently”. This trend toward SFR use has carried forwardsince the last survey. Italy responded in the last survey that SFRwas not used, but in 2018 noted that it is used, but infrequently.Venezuela was the only country that responded in 2018 that SFRis not allowed – but is performed.

Fifty-five percent n=Twenty-six of 47 countries responding(55%) have federal or national regulations governing the practiceof SFR. Of these 26, 2 also have state laws and ordinances;Bolivia has municipal laws, as well. One country (2%) has agencyregulations, and 16 countries (34%) have professional organi-zational guidelines for SFR. Of these 16 with guidelines, 7 (44%)have no federal or state requirements, only professional organi-zational guidelines. Four countries have cultural and religiouspolicies addressing SFR, in addition to other governances.

Only 19 of 66 surveyed (29%) consistently monitor or docu-ment SFR outcomes. That group includes several European

Chapter 12. Table 1

(Continued)

Country Allowed/PermittedPracticed/Performed Frequency?

Philippines Not allowed NoPoland Allowed with


Portugal Allowed withconditions


Romania Allowed withconditions


Russian Federation Allowed Yes Infrequently usedSenegal Allowed with


Serbia Allowed withconditions


Singapore Allowed withconditions


Slovenia Allowed Yes Infrequently usedSouth Africa Allowed Yes Infrequently usedThe Republic ofKorea

Allowed Yes Infrequently used

Spain Allowed Yes Infrequently usedSri Lanka Not allowed NoSwitzerland Allowed Yes Infrequently usedTaiwan (China*) Allowed Yes Infrequently usedThailand Not allowed UnknownTogo Unknown UnknownTrinidad and Tobago Not allowed NoTurkey Allowed with


Uganda Unknown Yes Infrequently usedUnited Arab Emirates Not allowed NoUK Allowed Yes Infrequently usedUSA Allowed Yes Infrequently usedUruguay Allowed with


Venezuela Not allowed Yes Infrequently usedViet Nam Allowed Yes Infrequently usedZimbabwe Unknown No


8%

9%

36%

25%

22%

Unknown

Not addressed

Allowed with conditions

Allowed

Not allowed

Chapter 12. Chart 1. Is selective reduction allowed/permitted?


104

countries, New Zealand, and Singapore. Nine countries of 66(14%) conduct partial or inconsistent monitoring, while 25countries (38%) do not monitor at all. Remarkably, severalcountries – including China, India, Russian Federation, and TheUnited States of America – conducted regular monitoring anddocumentation in 2015, but reported “inconsistent” document-ing and monitoring in 2018.

Twenty one of 48 (44%) permit sex selection with PGT-A.Another 6 countries (12.5%), Chile, Ecuador, Guatemala,Mexico, Panama, and Peru, perform PGT-A, although the surveydid not address whether using it for sex selection is legally per-missible. Twenty-one of 50 countries (42%) also allow sexselection via sperm sorting; 4 countries (8%) actually use it.

Thirteen countries out of 52 (25%) have regulations coveringPGT-A use, 10 countries out of 55 (18%), for sperm sorting, and15 countries out of 55 (59%) for SFR. Only 5 countries, Bulgaria,Hong Kong [China, reporting separately for this report], NewZealand, Singapore, and South Africa have regulations for all 3categories (Table 2, Chart 2).

For PGT-A, 8 countries of 13 (61.5%) reported having gov-ernance regulated by federal or national statutes, ordinances orpolicies: 2 (15%) by state or provincial policies or legislation, 1(8%) by municipal laws, statutes or ordinances, 2 (15%) by pro-fessional organizations standards or guidelines, one (8%) byexisting cultural practices, and one (8%) by religious decrees. Forsperm sorting, 8 countries (n=13) reported having governanceregulated by federal or national statutes, ordinances or policies,and 1 (8%) by state or provincial policies or legislation. For SFR,15 responders in 15 countries (100%) reported having governanceregulated by federal or national statutes, ordinances or policies, 2(21%), by state or provincial policies or legislation, 1 (7%) bymunicipal laws, statutes or ordinances, 2 (21%) by agency reg-ulation or oversight, 2 (21%) by professional organizations stan-dards or guidelines, and one (8%) by existing cultural practices.

Regarding centres where sex selection techniques wereallowed, there was no significant difference in the type of clinicreporting. This applied to sole practitioners, small and largeprivate clinics, public hospitals, and university hospitals. Chinawas the only country that did not allow sex selection or fetalreduction procedures to be conducted in private clinics; a hospitalor university setting was required.

Only two countries in the survey, Australia and Kazakhstan,reported that all three procedures are considered establishedmedical practice. In Greece and The Republic of Korea, (2 of 58or 3%) considered PGT-A an experimental method of sex selec-tion; four countries of 52 (8%) considered sperm sorting to beexperimental, and only Greece (1 of 56 or 2%) considered SFR tobe experimental. Twenty-five of 58 countries (43%) thought ofPGT-A as established medical practice, and 25 of 56 (44%) heldthat opinion of SFR. Only 9 of 52 (17%) considered spermsorting to be established medical practice.

Regarding sex selection: 24 out of 64 (38%) conducted sexselection only during IVF/ICSI procedures; 8 out of 60 (13%)conducted it with IUI, and only 5 of 58 (9%) did it with SFR.

Discussion

Sex selection has historically been used in many countries fornon-medical reasons, such as “family balancing” and patientpreference. Sex selection is a contentious issue, but it is culturallyendorsed and offered in several countries. The practice of sex

selection with ART has steadily increased with the reliability andavailability of PGT-A.

A recent survey[1] noted that 92% of 493 clinics in The UnitedStates of America offered PGT-A. Of these clinics, 94% offered sexselection for family balancing; 82% for elective reasons, such aspatient preference; and 84% for patients without pre-existing infer-tility. Recent literature attests to greater acceptance and performanceof sex selection for a variety of cultural and economic reasons. This istrue in countries as diverse as The Republic of Korea, Ukraine, andViet Nam. Essentially, a two-fold increase has occurred over the pastdecade, primarily favoring selection of males[2–4].

These trends may have profound demographic and culturalimplications, yet to be addressed. Since 1990, the number ofcalculated “missing females” has risen by 43 percent (38 million)to 126 million in 2010[4]. According to Bongaarts andGuilmoto[4], this trend is expected to peak in 2035, with a furtherincrease of 24 million to 150 million, before declining slightly in2050 to 142 million.

This study also outlines the 3 factors that are essential forprenatal sex selection to reach significant levels in any country:• Strong preference for a son• Easy access to prenatal diagnosis• Low fertility

SFR has evolved over the past few years from a rarely used pro-cedure, to avoid higher-order multiple births, to a more commonlyperformed practice in some countries for patients undergoing ART.In other countries, such as The United States of America, its avail-ability has become more restricted as multiple pregnancy rates havefallen. In still others it is not permitted at all, although occasionallyperformed nevertheless by some practitioners.

PGT-A is performed primarily to identify euploid embryos, butgender is determined during the procedure, and this informationinjects gender selection into the decision options for many couplespursuing ART. Evans et al[5] found that although in the late 80’sand early 90’s there was a definite son preference among indivi-duals in The United States of America, the trend has now beendeclining steadily, with as many patients now preferring femalesto males.

Over the past 25 years, fetal reduction has been granted greateracceptance as a safe and preferred procedure in some societies.While reduction of pregnancies of triplets and higher order, toreduce fetal morbidity, has been widely accepted as an essentialgoal over the past two decades, now, even reduction of twins tosingletons is gaining medical and social acceptance.

Summary

SFR remained a very contentious issue in 2018, with 39% of 77responding countries permitting it outright. An additional 22%allowed SFR conditionally, and 22%banned it. The status of SFRwas reported by 17%of responding countries as not addressed or“unknown”. While there has been some change in access in a fewcountries, no significant new trend over the past three years wasdiscernible.

Recent literature suggests that sex selection, particularly withPGT-A, has become much more widely performed, and is almostuniversally available. Despite this trend, the minority of reportingcountries (44%) expressly permit PGT-A for sex selection; evenfewer (25%) have regulations restricting it. Sperm sortingand SFR, while available in a few countries, are infrequentlypracticed.


105

Chapter 12. Table 2Is sex selection allowed permitted and practiced/performed in your country?

PGT-A Sex Selection Sperm Sorting Selective Fetal Reduction

Country Allowed/Permitted Practiced Performed Allowed/Permitted Practiced Performed Allowed/Permitted Practiced Performed

Argentina Allowed/Permitted Allowed/Permitted UnknownAustria Allowed/PermittedBangladesh Practiced/PerformedBarbados Allowed/PermittedBelarus Practiced/PerformedBelgium Unknown Unknown UnknownBolivia Allowed/Permitted Allowed/Permitted UnknownBotswana Allowed/Permitted Allowed/Permitted Allowed/PermittedBrazil Allowed/Permitted Practiced/PerformedBulgaria Unknown Unknown UnknownBurkina Faso Unknown Unknown UnknownChile Practiced/Performed UnknownChina Unknown Unknown UnknownColombia Allowed/Permitted Practiced/Performed Practiced/PerformedEcuador Practiced/Performed Practiced/PerformedEgypt Allowed/Permitted Practiced/Performed Allowed/Permitted Allowed/Permitted Practiced/PerformedEl Salvador Unknown Unknown UnknownFinland Allowed/Permitted Unknown Allowed/Permitted Practiced/PerformedGermany Unknown Unknown UnknownGhana Allowed/Permitted Allowed/Permitted Allowed/PermittedGreece Allowed/Permitted Allowed/Permitted Allowed/PermittedGuatemala Practiced/Performed Practiced/Performed UnknownHong Kong (China*) Allowed/Permitted Practiced/Performed Allowed/Permitted Allowed/PermittedHungary Allowed/PermittedIceland Allowed/Permitted Allowed/Permitted Allowed/PermittedItaly Unknown Unknown UnknownCôte d’Ivoire Unknown Allowed/Permitted UnknownJapan Unknown Unknown Practiced/PerformedJordan Allowed/Permitted Practiced/Performed Unknown UnknownKazakhstan Unknown Allowed/Permitted Allowed/PermittedKenya Unknown Unknown UnknownLatvia UnknownMexico Practiced/Performed Unknown UnknownMongolia Allowed/Permitted Allowed/Permitted Allowed/PermittedNew Zealand Allowed/Permitted Practiced/PerformedNigeria Allowed/Permitted allowed/Permitted UnknownNorway Unknown Unknown UnknownPanama Practiced/Performed Practiced/Performed UnknownParaguay Allowed/Permitted Unknown UnknownPeru Practiced/Performed Unknown UnknownPhilippines Unknown Unknown UnknownPoland Unknown Unknown UnknownPortugal Unknown Unknown Allowed/PermittedRomania Unknown Allowed/Permitted Practiced/PerformedRussian Federation Allowed/PermittedSenegal Unknown Unknown Allowed/PermittedSingapore Allowed/Permitted Practiced/PerformedSlovenia Unknown Unknown UnknownSouth Africa Allowed/Permitted Allowed/Permitted Allowed/PermittedSpain Allowed/Permitted Practiced/Performed Allowed/Permitted Practiced/PerformedSwitzerland Unknown Allowed/Permitted Practiced/PerformedTaiwan (China*) Allowed/PermittedTrinidad and Tobago Allowed/Permitted Allowed/PermittedUganda Unknown Unknown UnknownUnited Arab Emirates Allowed/Permitted Allowed/PermittedUK Allowed/Permitted Practiced/PerformedUSA Allowed/Permitted Practiced/Performed Allowed/Permitted Allowed/Permitted Practiced/PerformedVenezuela Allowed/Permitted Allowed/Permitted UnknownViet Nam Unknown Unknown Allowed/Permitted Practiced/PerformedZimbabwe Unknown Unknown Unknown



106

References[1] Capelouto SM, Archer SR, Morris JR, et al. Sex selection for

non-medical indications: a survey of current pre-implantationgenetic screening practices among U.S. ART clinics. J AssistReprod Genet 2018;35(3):409–416.

[2] King L, Michael M. No country for young girls: marketreforms, gender roles and prenatal sex selection in post-Soviet Ukraine. J Polit Econ Res Inst. Working paper seriesno. 425. 2016:1–29.

[3] Den Boer A, Hudson V. Patrilineality, son preference, and sexselection in South Korea and Vietnam. Popul Dev Rev2017;43(1):119–147.

[4] Bongaarts J, Guilmoto CZ. Howmanymore missing women?Excess female mortality and prenatal sex selection, 1970–2050. Popul Dev Rev 2015;41(2):241–269.

[5] Evans MI, Andriole S, Britt DW. Fetal Reduction: 25 Years’Experience. Fetal Diagn Ther 2014;35(2):69–82.

CHAPTER 13: PREIMPLANTATION GENETICTESTING

Introduction

Preimplantation genetic testing (PGT) was introduced as amethod for embryonic diagnosis of molecular genetic defectslinked to specific inherited diseases. Non-affected embryos wereselected and transferred to the patient, with the expectation ofproducing a child free of that disease[1]. Early in the history ofPGT, other applications emerged. For example, PGT was used toproduce a child selected by HLA haplotyping as a “savior sib-ling” for a family member afflicted with an incurable disease.Other non-traditional social and medical paradigms have beenreported[1]. Currently, PGT is used most commonly to identify avast number of autosomal single-gene disorders (preimplantationgenetic testing for monogenic/single gene disorders, PGT-M), foraneuploidy (preimplantation genetic testing for aneuploidy, PGT-A), and for structural rearrangements (PGT-SR).

PGT-A has been promoted as an adjunct to improve IVFimplantation and birth rates, and to reduce risk of miscarriage[2–6].It is used to identify structural or numerical chromosomal

abnormalities[2–6], because euploid blastocysts are presumed to beoptimal for transfer, by increasing implantation and live-birth ratesper embryo transferred. As such, PGT-A could play an essential rolein selecting embryos for single-embryo transfers (SET), and foravoiding multiple pregnancy[2].

Initially, PGT involved removal of one or two blastomeres fromthe embryo at the cleavage stage, typically on day three of in vitrodevelopment[2–6]. ART centres performing PGT today have for themost part abandoned day three biopsies, and now perform tro-phectodermbiopsy at the blastocyst stage. Removal of five to ten ofthe more than 150 cells normally available at this stage is far morethan was possible with cleavage-stage embryos[2–6].

Other advantages of blastocyst biopsy include improved sur-vival after biopsy; the need for fewer procedures, because day-fiveembryos have survived some of the natural selection process; andless mosaicism, because earlier mosaic embryos seem to have thepotential to self-correct with advancing embryonic maturity.Biopsied blastocysts are usually cryopreserved with vitrification,with the intent of later replacement after the result of the mole-cular analysis is received. Molecular methods have evolved sub-stantially over the past three years.

Molecular diagnosis is now performed on 24 chromosomes,using an array of advanced technologies. These include fluor-escent in situ hybridization (FISH), polymerase chain reaction(PCR), array comparative genome hybridization (aCGH), singlenucleotide polymorphism arrays (SNP arrays), next-generationsequencing technology (NGS), and preimplantation genetichaplotyping (PGH)[2–10]. Unaffected (normal) blastocysts aretransferred after thaw. Because embryos with genetic abnormal-ities are disposed of, PGT allows couples to discard affected orabnormal embryos, rather than having to consider terminating anestablished pregnancy[2–10].

Earlier versions of PGT-A that relied solely on FISH limitedanalysis to smaller subsets of chromosomes – typically five to ten,rather than the 24 chromosomes analyzed with newer moleculartechnology. But clinical outcomes were disappointing. When24-chromosome technology emerged, and three early rando-mized clinical trials using either qPCR-based CCS or rapid aCGHdescribed higher birth rates, and single-pregnancy rates withsingle embryo transfer, the outcomes have not been reproducible

10%

62%

5%

23%

Unknown

Yes-Infrequently

Yes-Frequently

Not Performed

Chapter 12. Chart 2. Is selective reduction performed/practised?


107

in a larger clinical patient population. Although the 2018Surveillance questionnaire reflects increasing global interest andapplication of PGT-A, evidence of improved outcomes is lacking,except in small series and selected cohorts, even with increasinglysophisticated molecular technology. Nevertheless, world-widePGT-A utilization is again expanding, although it has not yetbeen confirmed to be an effective adjunct for IVF[2].

PGT is now typically performed for nine indications:1. Autosomal single gene disorders[8,14] (PGT-M)2. Some chromosomal rearrangements[2,4] (PGT-SR)3. X-linked diseases4. Human leukocyte antigen (HLA) typing5. Cancer predisposition genes[15]

6. Mitochondrial DNA disorders7. Preimplantation genetic testing for aneuploidy (PGT-A)8. Adult onset disorders[8,15]

9. Non-medical sex selection


Fifty-three of 70 responders (76%) indicated that PGT-M(Table 1) is expressly allowed, by statutes, laws, and guidelines.The status of PGT-Mwas not addressed in 17 of the 70 (24%); itsstatus is indicated “unknown” in 16% – but PGT-M is notknown to be specifically prohibited in any of the countries thatresponded.

When PGT-M is allowed, 24 of 53 countries responding (45%)have guidelines governing its use; use is not regulated in 26countries responding (49%); and the procedure has a “not-known” status in three countries (6%). PGT-M for single genedisorders is commonly performed as a clinical service in 47 of 67countries (70%), performed only experimentally in three coun-tries (4%), and not addressed, or unknown, in 17 (25%) of thecountries (Table 2, Charts 1 and 2).

PGT-M for single gene disorders is considered acceptable forpreventing disease in offspring produced with ART – that is theopinion of 46 of 68 responders (68%). Twenty-one of 65 con-sider it acceptable to allow the disease in the offspring producedwith ART. That was the response chosen in 18 of 64 (28%).Twenty-one of 65 (32%) say that it is permitted for helping togenerate an embryo for any immunologically donor-matcheddiseased child, but it is prohibited in 17 (26%) of the countries.Twenty-three of 65 (35%) say it is considered acceptable inhelping to generate a child for any immunologically donor-mat-ched diseased child. It is also allowed for assisting in generatingan embryo on behalf of a diseased sibling in 24 of 66 (36%) of thecountries and for generating a child on behalf of a deceased sib-ling in 26 of 66 responders (39%). It is permitted to generate anembryo with a specific disease for research or experimentation,according to 5 in 65 responders (8%), but that is prohibited in 37of 65 responding countries (57%).

PGT-A is expressly allowed by statutes, laws, and guidelines in48 of 67 (72%) responding to that question; the status was notaddressed or was marked “unknown” in 19 of the 67 (28%).When allowed, it is regulated by guidelines that govern its use in20 of 48 countries responding (42%), not regulated in 24 of the48 (50%); its status is not known in 1 of the 48 (2%).

PGT-A for single gene disorders is commonly performed as aclinical service in 42 of 65 countries (65%), performed onlyexperimentally in 4 countries (6%), and is not addressed, or

unknown, in 19 of the countries (29%). PGT-A is commonlyperformed in tandem with PGT-M in 38 of 62 countries (61%).

Regulatory bodies with oversight for PGT-M and PGT-Arange from none to combinations of federal, provincial andmunicipal statutes; various government agencies; and guidelinesfrom professional organizations (Chart 3).

For PGT-M, 100% of 24 responders reported having gov-ernance by federal or national statutes, ordinances or policies; in4 (17%), this was accomplished by state or provincial policies orlegislation; in 2 (8%), by municipal laws, statutes or ordinances;in another 2 (8%), by agency regulations or oversight; in 12,(50%) by professional organizations standards or guidelines; in 2(8%), by existing cultural practices; and in another 2 (8%) byreligious decrees.

For PGT-A, all of 20 responders (100%) reported havinggovernance by federal or national statutes, ordinances or policies;3 (15%) accomplished this by state, regional or provincial poli-cies or legislation; 1 (5%) by municipal laws, statutes or ordi-nances; 1 (5%) by agency regulations or oversight, 11 (55%) bystandards or guidelines professional organization; 1 (5%), byexisting cultural practices; and 1 (5%) by religious decrees.

Centres providing PGT-M and PGT-A services, respectively,include sole practitioners in private clinics, 19 responders (95%and 100%); 26 responders, (92% and 88%), small private phy-sician clinics; large multiple practitioner clinics, 27 responders(96% and 93%); hospital based clinics, 22 responders (86% and100%); university clinics, 28 (93% and 82%); and public hos-pitals, 19, (95% for both responding countries.

Discussion

Compared to the 2015 Surveillance questionnaire, PGT-M nowcomprises an increasing percentage of ART services throughoutthe world. Its application is often regulated or restricted by statuteor local clinical tradition. It is allowed in all countries surveyed.PGT-M was commonly performed in 43% of the 90 respondingcountries in 2018, compared to 34% of 67 countries in 2015. It isnow a well-established and reliable procedure with a low errorrate. Drawbacks remain the high cost and inefficiency of IVF as arequisite platform, requirements for extended culture to theblastocyst stage, and relatively reduced birth rates even amongfertile women because of the more limited number of embryosavailable for transfer.

In the United States of America, PGT is frequently deemedexperimental by insurance carriers and is usually not coveredexcept for single gene disorders and selected chromosomaldefects. Demand for PGT-M in The United States of America,European Union, and Middle East, however, is expanding toinclude couples that are not infertile but are carriers at risk fortransmission of genetic disorders to their progeny. Many of thesecouples have previously had affected offspring andwere reluctantto consider additional pregnancies without PGT-M and otherswere unwilling to attempt pregnancy at all without some assur-ance of reduced risk. PGT-M also offers the opportunity toidentify embryos carrying relatively common genetic conditionsincluding oncogenes with high penetrance, such as BRCA, thatpose risk for devastating diseases later in life. The availability ofnew molecular genetic tests, public initiatives surrounding spe-cific genetic diseases, and increasing internet marketing of testsand identification of carriers are expected to increased demandfor PGT-M worldwide[4,6].


108

Chapter 13. Table 1Is preimplantation genetic testing allowed/permitted and practiced/performed?

PGT-M PGT-A

Country Allowed/Permitted Practiced/Performed Allowed/Permitted Practiced/Performed

Argentina Allowed/Permitted Practiced/Performed Allowed/Permitted Practiced/PerformedAustralia Allowed/Permitted Allowed/PermittedAustria Allowed/Permitted Allowed/PermittedBangladesh UnknownBarbados Allowed/Permitted Allowed/PermittedBelarus Allowed/Permitted Practiced/Performed Allowed/Permitted Practiced/PerformedBelgium Allowed/Permitted Allowed/PermittedBolivia Allowed/Permitted Allowed/PermittedBotswana Allowed/Permitted Allowed/PermittedBrazil Allowed/Permitted Practiced/PerformedBulgaria Allowed/Permitted Practiced/Performed Allowed/Permitted Practiced/PerformedBurkina Faso Unknown UnknownCanada Allowed/Permitted Allowed/PermittedChile Practiced/Performed Practiced/PerformedChina Allowed/Permitted Allowed/PermittedColombia Allowed/Permitted Allowed/PermittedCzechia Allowed/Permitted Allowed/Permitted Practiced/PerformedEcuador Practiced/Performed Practiced/PerformedEgypt Allowed/Permitted Practiced/Performed Allowed/Permitted Practiced/PerformedEl Salvador Unknown UnknownFinland Allowed/Permitted Allowed/PermittedGeorgia Allowed/Permitted Allowed/PermittedGermany Allowed/Permitted Allowed/PermittedGhana Allowed/Permitted Allowed/PermittedGreece Practiced/Performed Allowed/PermittedGuatemala Practiced/Performed Practiced/PerformedHong Kong (China*) Allowed/Permitted Practiced/Performed Allowed/Permitted Practiced/PerformedHungary Allowed/PermittedIceland Allowed/Permitted Allowed/PermittedIndia Allowed/Permitted Allowed/PermittedIreland Allowed/Permitted Practiced/PerformedItaly Allowed/Permitted Allowed/Permitted UnknownCôte d’Ivoire Unknown UnknownJapan Allowed/Permitted Practiced/Performed Practiced/PerformedJordan Allowed/Permitted Practiced/Performed Allowed/Permitted Practiced/PerformedKazakhstan Allowed/Permitted Allowed/PermittedKenya Unknown UnknownLatvia Allowed/Permitted Practiced/Performed Allowed/Permitted Practiced/PerformedLithuania Allowed/Permitted Practiced/PerformedMexico Allowed/Permitted Allowed/PermittedMongolia Allowed/Permitted Allowed/PermittedMontenegro Allowed/Permitted Allowed/PermittedNew Zealand Allowed/Permitted Practiced/Performed Allowed/Permitted Practiced/PerformedNigeria Allowed/Permitted Allowed/PermittedNorway Allowed/Permitted UnknownPanama Practiced/Performed Practiced/PerformedParaguay Allowed/Permitted Practiced/Performed Allowed/Permitted Practiced/PerformedPeru Practiced/Performed Practiced/PerformedPhilippines Unknown UnknownPoland Unknown UnknownPortugal Allowed/Permitted Practiced/Performed Allowed/Permitted Practiced/PerformedRomania Unknown UnknownRussian Federation Allowed/PermittedSenegal Unknown UnknownSerbia Allowed/Permitted UnknownSingapore Allowed/Permitted Practiced/Performed Allowed/Permitted Practiced/PerformedSlovenia Allowed/Permitted UnknownSouth Africa Allowed/Permitted Practiced/Performed Allowed/Permitted Practiced/PerformedThe Republic of KoreaSpain Allowed/Permitted Practiced/Performed Allowed/Permitted Practiced/PerformedSwitzerland Allowed/Permitted Practiced/Performed Allowed/Permitted Practiced/Performed


109

Chapter 13. Table 1

(Continued)

PGT-M PGT-A

Country Allowed/Permitted Practiced/Performed Allowed/Permitted Practiced/Performed

Taiwan (China*) Allowed/Permitted Allowed/PermittedThailand Allowed/PermittedTrinidad and Tobago Allowed/Permitted Allowed/PermittedTurkey Allowed/Permitted Practiced/Performed Allowed/Permitted Practiced/PerformedUganda Unknown UnknownUnited Arab Emirates Allowed/Permitted Allowed/PermittedUK Allowed/Permitted Practiced/Performed Allowed/Permitted Practiced/PerformedUSA Allowed/Permitted Practiced/Performed Allowed/Permitted Practiced/PerformedUruguay Allowed/Permitted Allowed/PermittedVenezuela Allowed/Permitted Allowed/PermittedViet Nam Allowed/Permitted Practiced/Performed Allowed/Permitted Practiced/PerformedZimbabwe Unknown Unknown


Chapter 13. Table 2Are these techniques considered experimental or part of established medical practice?

Country PGT-M PGT-A PGT-M with PGT-A

Argentina Established medical practice Established medical practice Established medical practiceAustralia Established medical practice Established medical practice Established medical practiceAustria Established medical practice Established medical practice Established medical practiceBelarus Established medical practice Established medical practice Established medical practiceBolivia Established medical practice Established medical practice Established medical practiceBotswana Not addressed Not addressed Not addressedBrazil Established medical practice Established medical practice Established medical practiceBulgaria Established medical practice Established medical practice Established medical practiceBurkina Faso Unknown Unknown UnknownCameroon Not addressed Not addressed Not addressedCanada Established medical practice Established medical practice Established medical practiceChile Established medical practice Established medical practice Established medical practiceChina Established medical practice Established medical practice Established medical practiceColombia Established medical practice Established medical practice Established medical practiceEcuador Established medical practice Established medical practice Established medical practiceEgypt Established medical practice Established medical practice Established medical practiceFinland Established medical practice Established medical practice Established medical practiceGeorgia Not addressed Not addressed Not addressedGermany Established medical practice Established medical practice Established medical practiceGhana Established medical practice Established medical practice Established medical practiceGreece Experimental Experimental ExperimentalGuatemala Not addressed Not addressed Not addressedHong Kong (China*) Established medical practice Established medical practice Established medical practiceHungary Established medical practice Experimental ExperimentalIceland Not addressed Not addressed Not addressedIndia Established medical practice Established medical practice Established medical practiceIreland Established medical practiceCôte d’Ivoire Not addressed Not addressed Not addressedJapan ExperimentalJordan Established medical practice Established medical practice Established medical practiceKazakhstan Established medical practice Established medical practice Established medical practiceLatvia Established medical practice Established medical practice Established medical practiceLithuania Experimental Not addressed Not addressedMexico Unknown Established medical practice Established medical practiceMongolia Not addressed Not addressed Not addressedMontenegro Established medical practice Established medical practice Established medical practiceNew Zealand Established medical practice Established medical practice Established medical practiceNigeria Unknown Unknown UnknownNorway Established medical practice Unknown UnknownPanama Established medical practice Established medical practice Established medical practice


110

PGT-A appears to be universally available in all 90 countriesparticipating in the questionnaire but is commonly performed inonly 50% (Table 1). In 2015, it was commonly performed in 38%of countries. If the newer technologies are proven to trulyimprove implantation rates, application is likely to be vastlyexpanded, as was the case with ICSI. However, available currentdata, while offering preliminary encouragement, are too inade-quate and inconclusive to justify broader use.

Summary

Surveillance 2019 confirms an ongoing trend of increasedaccessibility and use of PGT-M and PGT-A worldwide. PGT,and especially PGT-M, provide proven benefits. Both are gen-erally considered safe, and are associated with a low frequencyof errors. PGT-M largely prevents women from delivering off-spring with serious genetic disorders, avoids the potential needfor pregnancy termination, and provides critical reassurance

Chapter 13. Table 2

(Continued)

Country PGT-M PGT-A PGT-M with PGT-A

Paraguay Established medical practice Established medical practice Established medical practicePeru established medical practice established medical practice established medical practicePhilippines Unknown Unknown UnknownPoland Unknown Unknown UnknownPortugal Established medical practice Established medical practiceRussian Federation Established medical practice Established medical practice Established medical practiceSenegal Not addressed Not addressed Not addressedSingapore Established medical practice ExperimentalSlovenia Established medical practice Not addressed Not addressedSouth Africa Established medical practice Established medical practice Established medical practiceThe Republic of Korea Established medical practice Established medical practice ExperimentalSpain Established medical practice Established medical practice Established medical practiceSri Lanka Established medical practice Established medical practice Established medical practiceSwitzerland Established medical practice Established medical practice Established medical practiceTaiwan (China*) Established medical practice Established medical practice Not addressedThailand Established medical practice Established medical practice Established medical practiceTogo Not addressed Not addressedTrinidad and Tobago Established medical practice Established medical practice Established medical practiceTurkey Established medical practice Established medical practice UnknownUganda Unknown Unknown UnknownUnited Arab Emirates Established medical practice Established medical practice Established medical practiceUK Established medical practice Experimental ExperimentalUSA Established medical practice Established medical practice Established medical practiceUruguay Established medical practice Established medical practice Established medical practiceVenezuela Established medical practice Established medical practice Established medical practiceViet Nam Unknown Unknown UnknownZimbabwe Not addressed Not addressed Not addressed


19%

16%

39%

38%

70%

76%

PGT-Aneuploidy

PGT-Monogenic Disease

Allowed/Permitted Practised/Performed Uknown

Chapter 13. Chart 1. Is PGT allowed/permitted or practised/performed?


111

to fearful couples who otherwise would not choose tohave children.

Since Surveillance 2016was published, advances have occurred inthe discovery of genetic linkages to common diseases. Examplesinclude many cancers, diabetes, cardiovascular disease, degenerativedisorders of old age, somemental illnesses, and even autism spectrumdisorders. It seems likely that there will be expanded indications andgreater use of PGT-M for some of these common disorders.

PGT-A, more widely used in embryo selection now than in2016, remains controversial. Although it is claimed to be avaluable tool for embryo selection, and many ART centres haveattributed improved clinical success to its use, results have notbeen widely replicated in appropriately designed clinical trials.

The potential value and role of PGT-A will likely becomeclearer during the next triennial.

References[1] Simpson JL. Preimplantation genetic diagnosis at 20 years.

Prenat Diagn 2010;30(7):682–695.[2] Penzias A, Bendikson K, Butts S, et al. The use of pre-

implantation genetic testing for aneuploidy (PGT-A): acommittee opinion Fertil Steril 2018;109(3):429–436.

[3] Sermon KD, Spits C, Mertzanidou A, et al. Detectingmosaicism in trophectoderm biopsies Hum Reprod 2017;32(3):712–713.

[4] Sermon K. Novel technologies emerging for preimplantationgenetic diagnosis and preimplantation genetic testing foraneuploidy. Expert Rev Mol Diagn 2017;17(1):71–82.

[5] Sermon K, Capalbo A, Cohen J, et al. The why, the how andthe when of PGS 2.0: current practices and expert opinions offertility specialists, molecular biologists, and embryologists.Mol Hum Reprod 2016;22(8):845–857.

[6] Geraedts J, Sermon K. Preimplantation genetic screening 2.0:the theory. Mol Hum Reprod 2016;22(8):839–844.

[7] Zamani EstekiM, Dimitriadou E,Mateiu L, et al. Concurrentwhole-genome haplotyping and copy-number profiling ofsingle cells. Am J Hum Genet 2015;96(6):894–912.

[8] Roos RA. Huntington’s disease: a clinical review. Orphanet JRare Dis 2010;5:40.

[9] Forman EJ, Hong KH, Ferry KM, et al. In vitro fertilizationwith single euploid blastocyst transfer: a randomized con-trolled trial. Fertil Steril 2013;100(1):100–107.

[10] Scott RT, Upham KM, Forman EJ, et al. Blastocyst biopsywith comprehensive chromosome screening and fresh

10%

13%

11%

16%

19%

18%

4%

6%

6%

70%

62%

65%


PGT-Monogenic Disease with Aneuploidy Screeing

PGT-Aneuploidy Screening

Established medical practice Experimental Not addressed Unknown

Chapter 13. Chart 2. Are PGT techniques considered experimental or established medical practice?

11%

9%

56%

54%

33%

37%

PGT-Aneuploidy


Yes No Uknown

Chapter 13. Chart 3. Are there regulations that govern PGT?


112

embryo transfer significantly increases in vitro fertilizationimplantation and delivery rates: a randomized controlledtrial. Fertil Steril 2013(3);100:697–703.

[11] Yang Z, Liu J, Collins GS, et al. Selection of single blas-tocysts for fresh transfer via standard morphology assess-ment alone and with array CGH for good prognosis IVFpatients: results from a randomized pilot study. MolCytogenet 2012;5(1):24–31.

[12] Calpalbo A, Treff N, Cimadomo D, et al. Comparison ofarray comparative genomic hybridization and quantitativereal-time PCR-based aneuploidy screening of blastocystbiopsies. Eur J Hum Genet 2015;23(7):901–906.

[13] Simpson JL, Rechitsky S, Kuliev A. Next generationsequencing for preimplantation genetic diagnosis. FertilSteril 2013;99(5):1203–1204.

[14] Treff NR, Fedick A, Tao X, et al. Evaluation of targetednext-generation sequencing-based preimplantation geneticdiagnosis of monogenic disease Fertil Steril 2013;99(5):1377–1384.

[15] SenGupta SB, Vadaparampil ST, Menon. Preimplantationgenetic diagnosis for hereditary cancers. Adv Exp Med Biol2012;732:103–113.

CHAPTER 14: SURROGACY

Introduction

Surrogacy is an arrangement in which a woman (the surrogate)becomes pregnant, then carries and gives birth to a child orchildren, with the intention of giving the child to another personor couple (the intended parent or parents), whowill rear the child.The 2018 IFFS Surveillance questionnaire considered “gesta-tional” and “traditional” surrogacy.

Gestational surrogacy, sometimes referred to as full surrogacy,or “IVF surrogacy”, the gametes of both intended parents, or ofone intended parent and a donor egg and/or sperm, are used tocreate the embryo. Alternatively, a donated embryo created fromunrelated gametes is used. The surrogate is genetically unrelatedto the offspring intended to be produced by this arrangement.

Traditional surrogacy, sometimes termed natural surrogacy,or partial surrogacy, the surrogate is inseminated with the semenof an intended parent, and the surrogate’s own oocyte is fertilized

Chapter 14. Table 1Are there regulations that govern gestational carriers in yourcountry?

Country Gestational Surrogacy Traditional Surrogacy

Argentina No NoArmenia Yes YesAustralia Yes YesBarbados No NoBelarus Yes NoBolivia No NoBotswana No NoBrazil Yes YesBulgaria Yes YesBurkina Faso No NoCameroon No NoCanada Yes Yes

Chapter 14. Table 1

(Continued)


Chile Yes YesChina No NoColombia No NoCzechia No YesEcuador No NoEl Salvador No NoFinland Yes YesGeorgia Yes NoGermany Unknown UnknownGhana No NoGreece Yes NoGuatemala No NoHong Kong (China*) Yes YesHungary No NoIceland Yes YesIndia Yes YesIreland No NoItaly No NoCôte d’Ivoire Unknown UnknownJapan YesJordan No NoKazakhstan Yes NoKenya No NoLatvia No NoLithuania No NoMali No NoMexico Yes YesMongolia Unknown UnknownNamibia Unknown UnknownNew Zealand Yes YesNicaragua Yes YesNigeria Unknown noPanama No NoParaguay No NoPeru no noPhilippines Yes YesPoland No NoPortugal Yes YesRomania No NoRussian Federation YesSenegal No NoSingapore Yes YesSlovenia No NoSouth Africa YesSouth Korea YesSpain Yes NoSri Lanka No NoSwitzerland No NoTaiwan (China*) No NoThailand Yes YesTogo No NoTrinidad and Tobago No NoUganda No NoUnited Arab Emirates Yes YesUK Yes YesUSA Yes YesUruguay Yes YesVenezuela Unknown UnknownViet Nam Yes UnknownZimbabwe No No



113

Chapter 14. Table 2If surrogacy is regulated, how is it done?

Country

Federal/NationalLaws/Statutes/

Ordinances/policies


Statutes/Ordinances

MunicipalLaws/Statutes/Ordinances



CulturalPractice

ReligiousDecree Unknown

GestationalSurrogacy

Argentina YesArmenia YesAustralia YesBelarus YesBrazil YesCanada YesChile YesColombia YesCzechia YesEcuador YesFinland YesGeorgia YesGhana YesGreece Yes Yes Yes YesGuatemala YesHong Kong(China*)

Yes Yes

Iceland YesIndia YesCôte d’Ivoire YesJapan YesKazakhstan YesMexico Yes Yes YesMongolia YesNew Zealand Yes YesPanama YesParaguay YesPhilippines YesPortugal Yes Yes YesRomania YesRussianFederation

Yes

Senegal Yes Yes Yes Yes YesSingapore YesSouth Africa YesSouth Korea YesSri Lanka YesSwitzerland YesThailand Yes YesUganda YesUK YesUSA YesUruguay Yes Yes YesVenezuela YesViet Nam Yes

Traditionalsurrogacy

Australia YesBrazil YesCanada YesChile YesColombia YesFinland YesGhana YesGreece Yes Yes Yes YesGuatemala YesHong Kong(China*)

Yes Yes

Iceland Yes


114

in vivo. This may involve reproductive assistance, most often inthe form of artificial or intrauterine insemination performed at afertility clinic. Usually, however, the procedure is performed athome. The resulting child or children are genetically related to thesurrogate, as her oocytes are used.

The laws that govern IVF surrogacy are complex, and varyamong jurisdictions. Determining the local legal status is theusual first step. Full and informed legal advice from someonefamiliar with the laws of the country where the treatment willoccur, or, if different, the country of domicile of the couple, ismandatory. Also essential is careful medical assessment andthorough counseling of all parties involved in an IVF surrogacyarrangement.

The principal reasons people enter into surrogacy arrange-ments are:[1] Medical reasons in which the female intended parent:

(a) Is without a uterus but has one or both ovaries functioning.This may include women with congenital absence of theuterus, and women who have had a hysterectomy forcarcinoma or other reasons;

(b) has had repeated miscarriages, and the potential forcarrying a baby to term is remote. This may includewomen who have repeatedly failed to become pregnantafter IVF treatment;

(c) has a medical condition that may make pregnancy lifethreatening, but whose long-term health prospects are good.

[2] Non-medical or social reasons, such as same-sex coupling,or ongoing single status. This is permitted in only somejurisdictions.


In the 2018 IFFS surveillance of the 89 participating countries, 73countries (82%) sent responses to at least one question pertaining

to surrogacy. This is in comparison to 65 countries in 2016, and62 countries in 2013.

Differential responding to questions may have reflected therespondents’ knowledge of surrogacy regulation and/or practicesin their countries. For example, some respondents knew whetheror not there were laws, but did not know whether surrogacy waspracticed in their country.

Of the countries that responded to the question “are thereregulations that govern IVF surrogacy in your country”, inrelation to gestational surrogacy, answers were: yes, 31 out of 72(43%); no, 35 (49%) and “Unknown”, 6 (8%). In relation totraditional surrogacy: yes, 22 of 68 (32%) no, 40 (59%), and“Unknown,” 6 (9%) (Table 1).1

Twenty-seven countries specified the type or types of regula-tion used for gestational surrogacy, as follows: 13 respondents(48%), only federal laws; 2 (7%), only state laws; and 5 (19%),only professional standards/guidelines. Seven (26%) of thesecountries reported a combination of these regulatory instruments(Table 2).

Seventeen countries specified the type or types of regulationused for traditional surrogacy: six (35%) reported having onlyfederal laws; 3 (18%) reported having only state laws, andanother 3 (18%) said they had only professional standards/guidelines. Five (29%) of these countries reported a combinationof these regulatory instruments.

Regarding the question “is surrogacy permitted or practiced inyour country”, 53 countries responded regarding gestationalsurrogacy, and 45 countries responded regarding traditionalsurrogacy (Table 3).

To the topic of gestational surrogacy, 24 countries (45%)reported that it was allowed/permitted; 22 (41.5%) reported itwas practiced/performed, and 16 (30%) reported “unknown”.For traditional surrogacy, sixteen countries (36%) reported that

Chapter 14. Table 2

(Continued)

Country

Federal/NationalLaws/Statutes/

Ordinances/policies


Statutes/Ordinances

MunicipalLaws/Statutes/Ordinances



CulturalPractice


India YesCôte d’Ivoire YesMexico Yes Yes YesMongolia YesNew Zealand Yes YesPanama YesParaguay YesPhilippines YesPortugal Yes Yes YesRomania YesSingapore YesSri Lanka YesSwitzerland YesThailand Yes YesUganda YesUK YesUSA YesVenezuela Yes



115

Chapter 14. Table 3Is surrogacy allowed/permitted and practiced/performed in yourcountry?


Argentina Allowed/Permitted Allowed/PermittedArmenia Allowed/PermittedAustralia Allowed/Permitted, Practiced/

PerformedAllowed/Permitted, Practiced/Performed

Belarus Allowed/Permitted, Practiced/Performed

Bolivia Allowed/Permitted Allowed/PermittedBotswana Allowed/Permitted Allowed/PermittedBrazil Allowed/Permitted, Practiced/


Bulgaria Unknown UnknownBurkina Faso Unknown UnknownCameroon Unknown UnknownCanada Allowed/Permitted Allowed/PermittedChina Unknown UnknownColombia Practiced/Performed Practiced/PerformedCzechia Practiced/PerformedEcuador Practiced/Performed UnknownEl Salvador Practiced/Performed Practiced/PerformedGeorgia Allowed/Permitted UnknownGermany Unknown UnknownGhana Allowed/Permitted Allowed/PermittedGreece Practiced/Performed Allowed/PermittedGuatemala Practiced/Performed Practiced/PerformedHong Kong (China*) Allowed/Permitted Allowed/PermittedIndia Allowed/PermittedIreland Unknown UnknownItaly Unknown UnknownCôte d’Ivoire Unknown UnknownJordan Unknown UnknownKazakhstan Allowed/Permitted UnknownKenya Practiced/Performed Practiced/PerformedLithuania Allowed/PermittedMexico Allowed/Permitted Allowed/PermittedMongolia Allowed/Permitted Allowed/PermittedNamibia Unknown UnknownNew Zealand Allowed/Permitted, Practiced/


Nigeria Practiced/Performed Practiced/PerformedPanama Unknown UnknownParaguay Unknown UnknownPeru Unknown UnknownPhilippines UnknownPoland Unknown UnknownPortugal Allowed/Permitted Allowed/PermittedRomania Practiced/PerformedRussian Federation Allowed/Permitted, Practiced/

PerformedSenegal Unknown UnknownSouth Africa Allowed/Permitted, Practiced/

PerformedSouth Korea Practiced/PerformedSri Lanka Practiced/Performed Practiced/PerformedUganda Practiced/Performed Practiced/PerformedUK Allowed/Permitted, Practiced/


USA Allowed/Permitted, Practiced/Performed

Allowed/Permitted, Practiced/Performed

Uruguay Allowed/Permitted, Practiced/Performed

Allowed/Permitted

Venezuela Unknown Unknown

Chapter 14. Table 3

(Continued)


Viet Nam Allowed/Permitted UnknownZimbabwe Practiced/Performed Unknown


Chapter 14. Table 4How often is surrogacy performed in programmes within yourcountry?


Argentina Infrequently Used Infrequently UsedArmenia Infrequently Used Never PerformedAustralia Commonly Used Infrequently UsedAustria Never Performed Never PerformedBarbados Never Performed Never PerformedBelarus Infrequently Used Never PerformedBolivia Infrequently Used Infrequently UsedBotswana Never Performed Never PerformedBrazil Infrequently Used Infrequently UsedBulgaria Never Performed Never PerformedCameroon Never Performed Never PerformedCanada Commonly Used Infrequently UsedChile Never Performed Never PerformedChina Never Performed Never PerformedColombia Infrequently UsedCzechia Infrequently Used Never PerformedEcuador Commonly Used Infrequently UsedEgypt Never Performed Never PerformedEl Salvador Unknown UnknownFinland Never Performed Never PerformedGeorgia Commonly Used Never PerformedGermany Unknown UnknownGhana Commonly Used Infrequently UsedGreece Commonly Used Commonly UsedGuatemala Commonly Used Commonly UsedHong Kong (China*) Never Performed Never PerformedHungary Never Performed Never PerformedIceland Never Performed Never PerformedIndia Commonly Used Never PerformedIreland Never Performed Never PerformedItaly Unknown UnknownCôte d’Ivoire Unknown UnknownJapan Never Performed Never PerformedJordan Never Performed Never PerformedKazakhstan Commonly Used UnknownKenya Unknown UnknownLithuania Never Performed Never PerformedMali Never Performed Never PerformedMexico Infrequently Used Infrequently UsedMongolia Unknown UnknownNamibia Unknown UnknownNew Zealand Commonly Used Infrequently UsedNicaragua Never Performed Never PerformedNigeria commonly Used commonly UsedPanama Unknown UnknownParaguay Never Performed Never PerformedPhilippines Infrequently Used Infrequently UsedPortugal Infrequently Used Infrequently UsedRomania Unknown Unknown


116

it was allowed/permitted; 12 (27%) said, practiced/performed;and 22 (49%) reported “unknown”.

Sixty-eight countries participated in the survey regarding thefrequency of usage of gestational and traditional surrogacy, 14(20%) reported that gestational surrogacy was commonly used,17 (25%) said it was infrequently used; 27 (40%) indicated it wasnever performed, and 10 (15%) reported “unknown”. As fortraditional surrogacy, 3 (4%) said that it was commonly used, 18(26%) it was infrequently used, 35 (51%) that it was never per-formed, and 12 (19%) reported “unknown” (Table 4, Chart 1).

In response to the question, “if surrogacy is allowed in yourcountry, are surrogates compensated”, was asked in two ways: forgestational surrogacy and for traditional surrogacy (Table 5).

For gestational surrogacy compensation, 48 responses werereceived (as opposed to 61 in 2016). Of these responses, 9countries (19%) reported that compensation beyond reimburse-ment was permitted; 14 countries (29%) reported that no com-pensation was allowed; 14 countries (29%) reportedreimbursement was allowed for time and expenses only; and 11countries (23%) responded “unknown”.

As for “traditional surrogacy”, 44 responses were received; 4countries (9%) reported that compensation beyond reimburse-ment was permitted; 15 countries (34%) indicated no compen-sation was allowed; 12 countries (27%) said reimbursement fortime and expense was permitted; and 13 countries (30%)responded “unknown”.

In relation to limits on compensation existed, and if so, therange; respondents replied with only limited data. Regardinggestational surrogacy, 33 countries responded. Three countries(9%) replied yes, 4 countries (12%) responded that there was nominimum or maximum amount for compensation, 17 countries(52%) responded that compensation was not addressed, and 9countries (27%) responded “unknown”.

With regards to traditional surrogacy, 30 countries responded.One country (3%) replied yes, 2 countries (7%) indicated therewas no minimum or maximum amount for compensation, 19countries (63%) responded that compensation was not addres-sed, and 8 countries (27%) responded “unknown”.

Regarding the topic, “if third party reproduction is permittedin your country, are the qualifications to be a surrogate, basedupon medical and/or any lifestyle criteria”, 26 countries (51%)replied yes for gestational surrogacy, and 17 of 45 countries(38%) for traditional surrogacy.

Discussion

Surrogacy remains a contentious issue worldwide. Respondentsfrom the countries that replied to the current survey reported thatneither gestational nor traditional surrogacy were commonly used.When surrogacy was used, gestational surrogacy was used slightlymore frequently than traditional surrogacy. Approximately one-third of respondents noted that gestational surrogacy was com-monly or infrequently performed in their countries. In many

Chapter 14. Table 4

(Continued)


Russian Federation Commonly Used Never PerformedSenegal Never Performed Never PerformedSingapore Never Performed Never PerformedSlovenia Never Performed Never PerformedSouth Africa Infrequently Used Never PerformedSouth Korea Infrequently UsedSpain Never Performed Never PerformedSri Lanka Infrequently Used Infrequently UsedSwitzerland Never Performed Never PerformedTaiwan (China*) Never Performed Never PerformedThailand Infrequently Used Never PerformedTogo Never Performed Never PerformedTrinidad and Tobago Never Performed Never PerformedUganda Commonly Used Infrequently UsedUK Infrequently Used Infrequently UsedUSA Commonly Used Infrequently UsedUruguay Infrequently Used Infrequently UsedVenezuela Unknown UnknownViet Nam Infrequently Used UnknownZimbabwe Infrequently Used Infrequently Used


0

10

20

30

40

50

60

Commonly Infrequently Never Unknown

%

Gestational Traditional

Chapter 14. Chart 1. Are there regulations that govern PGT?


117

countries, neither gestational nor traditional surrogacy are used atall. As discussed inChapter 15 (Cross Border Reproduction), somecountries will treat intended parent(s) from other countries thatprohibit or do not offer surrogacy, or that provide surrogacy, butat high costs.

Both gestational and traditional surrogacy are fraught withmultiple potential conflicts when the interests of the various sta-keholders clash. These issues are further exacerbated when con-ducted in an international arena, as several highly publicizedcases have demonstrated.

Payment of surrogates continues to be an issue that provokesmuch debate.Many countries prohibit any form of compensationas a way to prevent the commodification or exploitation ofchildren or reproductive capabilities. In countries where paymentis not allowed, surrogates are usually relatives or personal friendsof the intended parent(s), and may be permitted to receive reim-bursement for “reasonable expenses”. Where there are no laws,practices may occur that are of particular concern, particularly inless developed countries with greater potential for exploitation.

Some limited studies have offered reassurance regarding thepsychological and physical well-being of children produced withgestational surrogacy, the surrogate mothers, and the intendedparents[1,2]. In most countries, the “birth mother” has alwaysbeen the legal mother of a child. This issue has been resolved inmany countries or states by legislation enabling the genetic par-ents to become legal parents at the birth of the child. Most sur-rogacy cases reportedly proceeded without problems, andprovided a positive and successful treatment option for a smallgroup of women who otherwise would be unable to have theirown genetic children.

Both the European Society of Human Reproduction andEmbryology (ESHRE)[3] and the American Society of ReproductiveMedicine (ASRM) have published ethical and clinical guidelinespertaining to surrogacy[4,5], advocating thorough evaluation andprovisions for managing the small group of women who need thisspecialized treatment.

Summary

IVF or gestational surrogacy is a useful and effective treatmentoption for women who have no uterus or are otherwise unable tobear children. It allows the commissioning (genetic) couple tohave their own children. Gestational surrogacy is practiced in42% of responding countries; fewer perform traditional surro-gacy, a procedure that remains controversial and is permitted inrelatively few countries, usually with significant limitations,particularly regarding compensation. The topic engenders con-siderable international debate about indications for its applica-tion, and the potential for exploiting its participants.

References[1] Golombok S, MacCallum F, Murray C, et al. Surrogacy

families: parental functioning, parent-child relationships andchildren’s psychological development at age 2. J ChildPsychol Psychiatry 2006;47(2):213–222.

[2] MacCallum F, Lycett E, Murray C, et al. Surrogacy: theexperience of commissioning couples. Hum Reprod 2003;18(6):1334–1342.

[3] Shenfield F, Pennings G, Cohen J, et al. ESHRE Task Force onEthics and Law 10: Surrogacy. Hum Reprod 2005;20(10):2705–2707.

[4] Pfeifer S, Butts S, Fossum G, et al. Recommendations forpractices utilizing gestational carriers: a committee opinion.Practice Committee of the American Society forReproductive Medicine and Practice Committee of theSociety for Assisted Reproductive Technology. Fertil Steril2017;107(2):e3–e10.

[5] Amato P, Brzyski R, Braverman A, et al. The EthicsCommittee of the American Society of ReproductiveMedicine. Using family members as gamete donors or sur-rogates. Fertil Steril 2012;98(4):797–803.

CHAPTER 15: CROSS BORDER REPRODUCTIVECARE

Introduction

The term cross-border reproduction (CBR) pertains to ART orrelated services sought by citizens of one country from withinanother country. When this situation arises, it usually means thatART procedures are unavailable or encumbered by legal oreconomic barriers in one country, but not in the other.

CBR is a contentious, largely unregulated area, making datacollection particularly challenging. Some topics pertaining to CBRwere covered in the 2018 Surveillance questionnaire; the purposewas to find out if people traveled to or from the respondent’scountry to engage in ART, and, if they did so, the motive was toseek lower cost services, higher quality services, or services notavailable in their home country. Some queries sought informationabout egg, embryo, and sperm donation, and gestational andtraditional surrogacy. Some of the information gathered exploredwhether any regulations applied to inbound and outbound tra-velers wishing to engage in CBR; other information regarded theimportation and exportation of gametes and embryos.


Seventy-five respondents replied to some or all the questionsabout CBR. The following analysis includes data from thecountry respondents who provided at least one relevant answer tothe issues mentioned.

Do people visit your country to seek cross-borderreproduction? (Table 1, Charts 1–3)

Incoming for lower cost ART services

Fifty-six of the 75 countries (75%) responding to this questionreported that people traveled to their country to seek lower cost ARTservices. Austria, Botswana, Ireland, Japan, New Zealand, Norway,Serbia, Singapore, the United Arab Emirates, and The United Statesof America (13%) reported that people do not travel to their countryfor lower cost services. In Australia, Chile, Mali, Nigeria, Poland,Switzerland, and Venezuela, the respondents answered “unknown”(9%). Two countries, Finland and Portugal (3%), providedresponses to other questions on cross-border reproduction, but saidthis issue was “not addressed” in their country.

Incoming for higher quality ART services

Fifty-six of the 71 respondent countries (79%) reported thatpeople travel to their country for higher quality services. Nigeria,Botswana, Ireland, Norway, Serbia, El Salvador, Greece,Mexico,Trinidad and Tobago (13%) responded that people do not travel


118

to their country for higher quality services. In Australia, Poland,Lithuania, Venezuela, and the Philippines, the response was“unknown” (7%). One country, Portugal, reported that this was“not addressed” (1%).

Incoming for ART services unavailable in their home country

Forty-eight of the 72 respondents (66%) that answered questionsabout CBR reported that people travel to their country to accessservices that are not available in their home country. Fifteencountries (21%) reported that people do not engage in CBR andcome to their country for these purposes. One country,Mongolia, answered that this was “not addressed” (1%); andeight countries (11%) replied “unknown”.

Incoming for egg donation

Thirty-four respondents out of 72 (47%) reported that people travel totheir country to access egg donation.Twenty-three respondents (32%)reported that potential recipients from other countries do not travel totheir country for egg donation. Eleven countries (15%) reported“unknown”. Four countries (5.5%) selected “not addressed”.

Incoming for embryo donation

Twenty-six of 70 respondents (37%) that answered questionsconcerning CBR reported that people travel to their country toaccess embryo donation; 27 (39%) reported that people fromother countries do not travel to their country to seek embryodonation; 6 (9%) selected that this was “not addressed” in theircountry; and 11 (16%) reported that the status of this practicewas “unknown”.

Incoming for sperm donation

Thirty-six of 71 who responded to this question (51%) reportedthat people travel to their country to access sperm donation; 21(29%) said that people from other countries do not travel to theircountry to receive sperm donation; 12 (17%) reported this as“unknown”, and 2 (3%) selected the answer “not addressed”.

Incoming for gestational surrogacy

Respondents were asked if people travelled to their country toengage in gestational surrogacy. Twenty of the 71 respondentsanswering questions on cross-border surrogacy (28%) answered

Chapter 14. Table 5Are gestational carriers compensated?


Argentina Unknown UnknownArmenia Reimbursement for time and

expensesAustralia Reimbursement for time and

expensesReimbursement for time andexpenses

Belarus Compensated BeyondReimbursement

Bolivia Compensated BeyondReimbursement

Compensated BeyondReimbursement

Brazil Reimbursement for time andexpenses

Reimbursement for time andexpenses

Bulgaria No NoCameroon No NoCanada No NoColombia Compensated Beyond

ReimbursementCompensated BeyondReimbursement

Czechia Reimbursement for time andexpenses

No

Ecuador Compensated BeyondReimbursement

Unknown

El Salvador Unknown UnknownFinland No NoGeorgia Compensated Beyond

ReimbursementNo

Germany Unknown UnknownGhana Reimbursement for time and


Greece Reimbursement for time andexpenses


Guatemala Reimbursement for time andexpenses


Hong Kong(China*)

No No

India Compensated BeyondReimbursement

Unknown

Italy UnknownCôte d’Ivoire No NoJordan No NoKazakhstan No NoKenya Unknown UnknownMali NoMexico Reimbursement for time and


Mongolia Unknown UnknownNamibia Unknown UnknownNew Zealand Reimbursement for time and


Panama Unknown UnknownParaguay No NoPhilippines Unknown UnknownPortugal Reimbursement for time and


RussianFederation


No

Senegal Unknown UnknownSouth Africa Reimbursement for time and

expensesSouth Korea Reimbursement for time and

expensesSpain No NoSri Lanka Reimbursement for time and


Chapter 14. Table 5

(Continued)


Thailand No NoUganda Compensated Beyond

ReimbursementCompensated BeyondReimbursement

UK Reimbursement for time andexpenses


USA Compensated BeyondReimbursement


Uruguay No NoVenezuela Unknown UnknownViet Nam No UnknownZimbabwe Reimbursement for time and




119

Chapter 15. Table 1Do people visit your country to seek assisted reproduction?

Country

LowerCostART

Services

HigherQualityART

Services

ART ServicesUnavailable in Their Home

CountryEgg

DonationEmbryoDonation

SpermDonation



Argentina Yes Yes No Yes Yes Yes Unknown UnknownAustralia Unknown Unknown Unknown Unknown Unknown Unknown No NoAustria No Yes Yes Yes No Yes No NoBangladesh YesBarbados Yes Yes Yes Yes Yes Yes No NoBelarus Yes Yes Yes No Yes Yes NoBelgium Yes Yes No Unknown UnknownBolivia Yes Yes Yes Yes Yes Yes Yes YesBotswana No No No No No No No NoBrazil Yes Yes Yes No Yes No Yes YesBulgaria Yes Yes Yes Yes Not addressed Yes No NoBurkina Faso Yes Yes Yes Yes No Yes No NoCameroon Yes Yes Yes Yes No Yes No UnknownCanada Yes Yes Yes No No No Unknown UnknownChile Unknown Yes Yes Yes Yes Yes No NoChina YesColombia Yes Yes Yes Yes Not addressed No Yes YesCzechia Yes Yes Yes Yes Yes Yes Yes NoEcuador Yes Yes Yes Yes Yes Yes YesEgypt Yes Yes Yes No No No No NoEl Salvador Yes No Yes No No No Yes YesFinland Not

addressedYes Yes Yes Yes Yes No No

Georgia Yes Yes Yes Yes Yes Yes Yes NoGermany Yes Yes Yes Not

addressedNot addressed Unknown Unknown Unknown

Greece Yes No Yes Yes Yes Yes No NoGuatemala Yes Yes Yes Yes Yes Yes Yes YesHong Kong (China*) Yes Yes Yes Yes Yes No NoHungary Yes Yes No Not

addressedNot addressed Unknown Not addressed Not addressed

India Yes Yes Yes Yes Yes YesIreland No No No No No No No NoItaly Yes Yes Yes Yes Yes Yes Yes YesCôte d’Ivoire Yes Yes Unknown Yes Yes Yes No NoJapan No Yes No No No No No NoJordan Yes Yes Yes No No No No NoKazakhstan Yes Yes No Yes Yes Yes Yes YesKenya Yes Yes Yes Yes Yes Yes Yes YesLatvia Yes Yes Yes Yes Yes Yes No NoLithuania Yes Unknown Unknown No No No No NoMali Unknown Yes Yes Unknown No No Not addressed Not addressedMexico Yes No No Yes Unknown Yes Yes YesMongolia Yes Yes Not addressed Yes Yes Yes Yes YesMontenegro YesNew Zealand No Yes Yes No No Yes No NoNicaragua Yes Yes YesNigeria Unknown No Unknown Unknown Unknown Unknown Unknown Unknown

Norway No No No No No No No NoPanama Yes Yes Yes Yes Yes Yes Unknown UnknownParaguay Yes Yes No Not

addressedNot addressed Not addressed Not addressed Not addressed

Peru Yes Yes Yes Unknown Unknown UnknownPhilippines Yes Unknown Unknown Unknown Unknown Unknown Unknown UnknownPoland Unknown Unknown Unknown Unknown Unknown Unknown No NoPortugal Not

addressedNot

addressedYes Not

addressedNot addressed Not addressed Not addressed Not addressed

Romania Yes Yes Unknown No No No No NoRussian Federation Yes Yes Yes Yes Yes Yes Yes No


120

in the affirmative; thirty-six countries (51%) answered “no”;eleven respondents (15%) said that the status was “unknown”;and four (6%) selected the answer “not addressed”.

Incoming for traditional surrogacy

Respondents were asked if people travelled to their countries toengage in traditional surrogacy. Of the 68 who answered, 13(19%) replied in the affirmative; 39 countries (57%) answered

“no”; 12 respondents (18%) answered “unknown”; and 4 (6%)selected the answer “not addressed”.

Dopeople travel from your country to another country to seekcross-border reproduction? (Table 2, Charts 4–6)

Outgoing for lower cost ART services

Of the 29 countries that responded, (43%) reported that peopletraveled from their country to seek lower cost ART services;twenty-one (31%) indicated that people do not travel from their

Chapter 15. Table 1

(Continued)

Country

LowerCostART

Services

HigherQualityART

Services

ART ServicesUnavailable in Their Home

CountryEgg

DonationEmbryoDonation

SpermDonation



Senegal Yes Yes Yes No No No No NoSerbia No No No No No No No NoSingapore No Yes No No No No No NoSlovenia Yes Yes Yes No No No No NoSouth Africa Yes Yes Yes Yes No Yes No NoSouth Korea Yes Yes Unknown Unknown Yes UnknownSpain Yes Yes Yes Yes Yes Yes No NoSri Lanka Yes Yes Yes Unknown Unknown Unknown Unknown UnknownSwitzerland Unknown Yes No No No Yes No NoTaiwan (China*) Yes Yes Yes Yes No Yes No NoThailand Yes Yes Yes Unknown Unknown Unknown Unknown UnknownTogo Yes Yes Yes Yes Yes Yes No NoTrinidad and Tobago Yes No Yes Yes No Yes No NoTurkey Yes Yes Yes No No No No NoUganda Yes Yes Yes Yes Yes Yes Yes YesUnited Arab Emirates No Yes Yes No No No No NoUK Yes Yes Yes No No No Yes YesUSA No Yes No Yes Yes Yes Yes YesUruguay Yes Yes No Yes Yes Yes No NoVenezuela Unknown Unknown Unknown Unknown Unknown Unknown Unknown UnknownViet Nam Yes Yes Yes Unknown Unknown Unknown Unknown UnknownZimbabwe Yes Yes No No No No No No


0

10

20

30

40

50

60

70

80

90

Lower Cost Services Higher Quality Services Seeking ART not available athome

%

Yes No Unknown Not addressed

Chapter 15. Chart 1. Incoming for services.


121

country for lower cost services; and 14 (21%) chose the answer“unknown”. Three countries (5%) responded “not addressed”.

Outgoing for higher quality ART services

of 72 respondents (60%) affirmed that people travel from theircountry for higher quality services; 12 (17%) responded thatpeople do not travel from their country for higher quality ser-vices;14 respondents (19%) chose “unknown”, and three (4%),“not addressed”.

Outgoing for ART services unavailable in their home country

Forty-two of the 69 respondents (61%) that answered questionspertaining to CBR reported that people travel from their countryto access services that are not available in their home country; 16country respondents (23%) said that people do not travel fromtheir country to engage in CBR elsewhere; 4 (6%) answered thatthis was “not addressed”; and 7 respondents (10%) replied“unknown”.

Outgoing for egg donation

Forty-six of 71 responding countries, 46 (65%) reported thatpeople travel from their country to another country to access eggdonation; 12 (16%) indicated that people from their countries donot travel to other countries to seek egg donation; 11 (16%) saidthat this was “unknown”; and 2 countries (3%) responding toquestions on CBR selected “not addressed”.

Outgoing for embryo donation

Thirty-six of 69 responding (52%) reported that people travel fromtheir country to another country to access embryo donation; 12respondents (17%) said that people from their country do not travelto other countries for embryo donation; 19 (27%) said that the statuswas “unknown”; and 2 respondents (3%) selected “not addressed”.

Outgoing for sperm donation

Thirty-six of 70 country respondents (51%) reported that peopletravel from their country to another country to access sperm

0

10

20

30

40

50

60

Incoming Egg Donation Incoming Embryo Donation Incoming Sperm Donation

%

Yes No Unkown Not Addressed

Chapter 15. Chart 2. Incoming for donor gametes/embryos.

0

10

20

30

40

50

60

Gestational Surrogacy Traditional Surrogacy

%


Chapter 15. Chart 3. Incoming for surrogacy.


122

Chapter 15. Table 2Do people travel from your country to seek assisted reproduction?

CountryLower CostART Services

Higher QualityART Services

ART ServicesUnavailable intheir HomeCountry Egg Donation Embryo Donation Sperm Donation



Argentina No Yes Yes Yes Yes Yes Yes YesAustralia Yes No Yes Yes Yes Yes Yes YesAustria Yes No Yes Yes Yes No Yes YesBangladesh Yes Yes Yes Yes YesBarbados Unknown Unknown Yes YesBelarus Yes Yes Yes Yes No UnknownBelgium Unknown Unknown Yes Yes Unknown Unknown Yes UnknownBolivia Yes Yes Yes Yes Yes Yes Yes YesBotswana Yes Yes Yes Yes Yes Yes Yes YesBrazil No Yes Yes Yes No No Yes NoBulgaria No No No Unknown No Yes YesBurkina Faso Yes Yes No Yes No Yes YesCameroon Not addressed Yes Yes Yes Yes Yes Unknown UnknownCanada Yes Unknown No Yes Yes Unknown Yes UnknownChile Unknown No Yes No No No Yes YesChina Unknown Yes Yes Yes Yes Unknown Yes YesColombia No Yes Yes No No No Yes YesCzechia No Unknown Unknown No Unknown Unknown No YesEcuador Yes Yes Yes Yes Yes YesEgypt No Yes No Unknown Unknown Unknown Unknown UnknownEl Salvador No Yes No Yes Yes Yes Yes YesFinland Yes No Yes Yes Yes Yes Yes YesGeorgia No Unknown No Unknown Unknown Unknown No UnknownGermany No Unknown Unknown Unknown Unknown Unknown Unknown UnknownGreece Yes Yes Yes No Yes Yes Yes YesGuatemala No Yes Yes Yes Yes Yes Yes YesHong Kong (China*) Yes Yes Yes Yes Unknown Yes Yes UnknownHungary No Unknown No Yes Yes Unknown Yes YesIndia Yes YesIreland Yes Yes Yes Yes Yes Yes Yes YesItaly Yes Yes Yes Yes Yes Yes Not addressed Not addressedCôte d’Ivoire Yes Yes Unknown Yes Yes Yes No NoJapan No Yes Yes No No Yes NoJordan No Yes No No No No NoKazakhstan No Yes Yes No No Yes YesKenya Unknown Yes Unknown Yes Yes Yes Unknown UnknownLatvia Unknown Unknown Yes Unknown Unknown Unknown Unknown UnknownLithuania Yes Yes Yes Yes Unknown Yes Unknown UnknownMali Unknown Unknown Unknown Unknown Unknown Unknown Unknown UnknownMexico Yes Yes Unknown Yes Unknown UnknownMongolia Not addressed Not addressed Not addressed Not addressed Not addressed Not addressed Not addressed Not addressedMontenegro No No No Yes Yes Yes Yes YesNew Zealand No No Yes Yes No Yes Yes NoNigeria Yes Yes Yes Yes Yes Yes Yes Yes

Norway Unknown Unknown Yes Yes Yes Yes Yes YesPanama No Yes No No No No Unknown UnknownParaguay Yes Not addressed Not addressed Not addressed Not addressed Not addressed Not addressed Not addressedPhilippines Yes Yes Not addressed Unknown Unknown Unknown Unknown UnknownPoland Unknown Unknown Unknown Unknown Unknown Unknown Unknown UnknownPortugal Not addressed Not addressed Yes Yes Not addressed Yes Not addressed Not addressedRomania Yes No Yes Yes No No NoRussian Federation Yes Yes No No No No No NoSenegal Yes Yes No No No No No NoSerbia Yes Yes Yes Yes Yes Yes No NoSingapore Yes No Yes Yes Yes Unknown Yes UnknownSlovenia Unknown No Yes Yes Unknown No No NoSouth Africa Yes Yes Yes Yes No Yes No NoSouth Korea No Yes Yes Unknown Unknown Unknown Unknown UnknownSpain Yes Yes Yes Yes Yes Yes No NoSri Lanka Yes Yes No Yes Yes Yes Yes YesSwitzerland Yes No Yes Yes Yes Yes Yes YesTaiwan (China*) Unknown Unknown Yes Yes Yes Yes Yes YesTogo Unknown Yes Yes Yes Yes Yes Yes YesTrinidad and Tobago No Yes No Yes Unknown Unknown Yes YesTurkey No Yes Yes Yes Yes Yes Yes YesUganda No Yes Not addressed Unknown Unknown Unknown Unknown UnknownUnited Arab Emirates Yes No Yes Yes Yes Yes Yes YesUK Yes Unknown Yes Yes Yes Yes Yes YesUSA Yes No No No No No No NoUruguay Yes Yes Yes Yes Yes Yes YesVenezuela Unknown Unknown Unknown Unknown Unknown Unknown Unknown UnknownViet Nam Unknown Yes Yes Unknown Unknown Unknown Yes YesZimbabwe No Yes No Yes Yes Yes Yes Yes



123

0

10

20

30

40

50

60

Gestational Surrogacy Traditional Surrogacy

%


Chapter 15. Chart 6. Outgoing for surrogacy.

0

10

20

30

40

50

60

70

Outgoing Egg Donation Outgoing Embryo Donation Outgoing Sperm Donation

%

Yes No Unknown Not Addressed

Chapter 15. Chart 5. Travel from country for donor gametes/embryos.

0

10

20

30

40

50

60

70

Lower Cost Services Higher Quality Services Seeking services not available inhome country

%


Chapter 15. Chart 4. Outgoing for services.


124

Chapter 15. Table 3Are there regulations that govern cross border reproduction in your country?

CountryNo

Regulations

Federal/NationalLaws/Statutes/Ordinances/Policies


Statutes/Ordinances

MunicipalLaws/

Statutes/Ordinances



CulturalPractice


Patients that visityour countryseekingtreatment

Argentina Yes

Australia YesAustria YesBangladesh YesBarbados YesBelarus YesBolivia YesBotswana YesBrazil YesBulgaria YesBurkina Faso YesCameroon YesCanada YesChile YesChina YesColombia Yes YesCzechia YesEcuador Yes YesEgypt YesEl Salvador YesGeorgia YesGermany YesGreece Yes Yes Yes Yes YesGuatemala Yes YesHong Kong(China*)

Yes

Hungary YesIndia YesIreland YesCôte d’Ivoire Yes YesJapan YesJordan YesKazakhstan Yes YesKenya YesLatvia YesLithuania YesMali YesMexico Yes YesMongolia YesMontenegro YesNew Zealand YesNigeria Yes YesNorway YesPanama YesParaguay YesPhilippines Yes YesPortugal YesRomania YesRussianFederation

Yes

Senegal Yes YesSingapore YesSlovenia YesSouth Africa YesSouth Korea YesSpain Yes YesSri Lanka YesSwitzerland Yes


125

Chapter 15. Table 3

(Continued)

CountryNo

Regulations



Statutes/Ordinances

MunicipalLaws/

Statutes/Ordinances



CulturalPractice


Taiwan(China*)

Yes

Thailand Yes YesTogo YesTrinidad andTobago

Yes

Turkey YesUganda YesUnited ArabEmirates

Yes

UK YesUSA YesUruguay YesVenezuela YesViet Nam YesZimbabwe Yes

Citizens that visitother countriesseekingtreatment

Argentina YesAustralia YesAustria YesBangladesh YesBarbados YesBelarus YesBolivia YesBotswana YesBrazil YesBurkina Faso YesCameroon YesCanada YesChile YesChina YesColombia Yes YesCzechia YesEcuador YesEgypt YesEl Salvador YesGeorgia YesGermany YesGreece Yes Yes Yes YesGuatemala YesHong Kong(China*)

Yes

Hungary YesIreland YesItaly Yes Yes Yes Yes Yes Yes Yes Yes YesCôte d’Ivoire YesJapan YesJordan YesKazakhstan Yes YesKenya YesLatvia YesLithuania YesMali YesMongolia YesMontenegro YesNew Zealand YesNigeria Yes


126

donation; 14 respondents (20%) said that people from othercountries do not travel to their country to engage with spermdonation; 18 respondents (26%) reported status “unknown”;and 2 (3%) selected “not addressed”.

Outgoing for gestational surrogacy

Of 70 countries, forty respondent countries (57%) answered“yes”; 12 (17%), “no”; 14 (20%), “unknown”; 4 (6%), “notaddressed”.

Outgoing for traditional surrogacy

Of 69 countries, 32 (46%) responded in the affirmative (“yes”);13 (19%), “no”; 20 (29%) said status was “unknown”; and 4respondents (6%) selected “not addressed”.

Regulation of cross-border reproduction (Table 3)

Respondents were asked if their country had regulations thatgoverned cross-border surrogacy. Specifically, they were askedabout regulations governing citizens that visit other countriesseeking treatment, and people visiting their home country seekingtreatment (Table 3).

Four respondents (6%) (Austria, Italy, Spain, and the UnitedKingdom of Great Britain and Northern Ireland) answered thatthey did not have regulations governing people who travel toother countries to access assisted reproduction. Four respondents

(6%) (Bulgaria, Romania, Slovenia, and Zimbabwe) said thatthey do not have regulations governing people coming to theircountries for ART. Forty-two respondents (60%) reported thatthey had neither.

Five respondents (6%) reported having laws that govern onlyinbound people, not outbound people seeking ART; 1 country,Italy, said it had laws governing only outbound people; 9respondents (13%) reported having laws that governed bothinbound and outbound people seeking treatment. Of thesecountries there was a mixture between federal laws, state/muni-cipal laws, or both. In general, people travelling to a country toaccess ART are governed by the laws and regulations of thatcountry.

Columbia and Senegal reported that cultural practices wererelevant, and Greece and Italy reported that cultural practicesand/or religious decrees were relevant for CBR.

Regulation of the import and export of tissue (Table 4 and 5)

Import

Ova: Thirty-four out of 73 respondents (47%) said that regula-tions covered the importing of oocytes into their countries, while20 (27%) reported no regulations; 12 (16%) claimed an“unknown” status, and 7 (10%) selected “not addressed”.

Thirty five out of 73 (48%) said that regulations applied to theimporting of spermatozoa into their countries; 19 respondent

Chapter 15. Table 3

(Continued)

CountryNo

Regulations



Statutes/Ordinances

MunicipalLaws/

Statutes/Ordinances



CulturalPractice


Norway YesPanama YesParaguay YesPhilippines Yes YesPortugal YesRussianFederation

Yes

Senegal Yes YesSouth Korea YesSpain YesSri Lanka YesSwitzerland YesTaiwan(China*)

Yes

Togo YesTrinidad andTobago

Yes

Turkey YesUganda YesUnited ArabEmirates

Yes

UK YesUSA YesUruguay YesVenezuela YesViet Nam Yes



127

Chapter 15. Table 4Are there regulations regarding the import of reproductive tissueinto your country?

Country Ova Spermatozoa Zygotes

Argentina Yes Yes YesAustralia Yes Yes YesAustria Unknown Unknown UnknownBangladesh Not addressed Not addressed Not addressedBarbados No No NoBelarus No No NoBelgium Unknown Unknown UnknownBolivia Yes Yes YesBotswana No No NoBrazil Yes Yes YesBulgaria Yes Yes YesBurkina Faso No No NoCameroon No No NoCanada No Yes UnknownChile No No NoChina Unknown Unknown UnknownColombia Yes YesCzechia Yes Yes YesEcuador Yes Yes YesEgypt Not addressed Not addressed Not addressedEl Salvador No No NoFinland Yes Yes YesGeorgia No No NoGermany Unknown Unknown UnknownGreece Yes No YesGuatemala Yes Yes YesHong Kong (China*) Yes Yes YesHungary Unknown Unknown Not addressedIndia Yes Yes YesIreland Yes Yes YesItaly Yes Yes YesCôte d’Ivoire Unknown Unknown UnknownJapan No No NoJordan Not addressed Not addressed Not addressedKenya No No NoLatvia Yes Yes YesLithuania Yes Yes YesMali No No NoMexico Yes Yes YesMongolia Not addressed Not addressed Not addressedMontenegro No No NoNew Zealand Yes Yes YesNigeria Yes Yes Yes

Norway Yes Yes YesPanama Yes Yes YesParaguay Not addressed Not addressed Not addressedPeru No No NoPhilippines Unknown UnknownPoland Unknown Unknown UnknownPortugal Yes Yes YesRomania No Yes NoRussian Federation Yes Yes YesSenegal No No NoSerbia No No NoSingapore Yes Yes YesSlovenia Not addressed Not addressed Not addressedSouth Africa Yes Yes YesSouth Korea Not addressed Not addressed Not addressedSpain Yes Yes YesSri Lanka No No NoSwitzerland Yes Yes Yes

Chapter 15. Table 4

(Continued)


Taiwan (China*) Yes Yes YesTogo Unknown Unknown UnknownTrinidad and Tobago Yes Yes UnknownTurkey Unknown Unknown UnknownUganda No No NoUnited Arab Emirates Yes Yes YesUK Yes Yes YesUSA Yes Yes YesUruguay No No NoVenezuela Unknown Unknown UnknownViet Nam Unknown Unknown UnknownZimbabwe Yes Yes Yes


Chapter 15. Table 5Are there regulations regarding the export of reproductive tissuefrom your country?


Argentina Yes Yes YesAustralia Yes Yes YesAustria Unknown Unknown UnknownBangladesh Not addressed Not addressed Not addressedBarbados No No NoBelarus No No NoBelgium Unknown Unknown UnknownBolivia Yes Yes YesBotswana No No NoBrazil Yes Yes YesBulgaria Yes Yes YesBurkina Faso No No NoCameroon No No NoCanada No No NoChile No No NoChina Unknown Unknown UnknownColombia Yes Yes YesCzechia Yes Yes YesEcuador Yes Yes YesEgypt Not addressed Not addressed Not addressedEl Salvador No No NoFinland Yes Yes YesGeorgia No No NoGermany Unknown Unknown UnknownGreece Yes Yes YesGuatemala Yes Yes YesHong Kong (China*) Yes Yes YesHungary Unknown Unknown UnknownIndia Yes Yes YesIreland Yes Yes YesItaly Yes Yes YesCôte d’Ivoire Unknown Unknown UnknownJapan No No NoJordan Not addressed Not addressed Not addressedKenya No No NoLatvia Yes Yes YesLithuania Yes Yes YesMali No No NoMexico Yes Yes YesMongolia Not addressed Not addressed Not addressed


128

countries (26%) reported no regulations; 12 (16%) claimed“unknown” status, and 7 respondents (10%) selected “notaddressed”.

Zygotes: 32 respondents of 71 (45%) said there were regulationsfor importing zygotes into their countries; 19 countries (27%)reported no regulations; 12 (17%) reported the status as“unknown”; and eight respondents (11%) selected “not addressed”.

Export

Ova: Of 74 respondents, 33 (44%) said there were regulationsaddressing the exportation of ova from their countries; and 22(30%) countries reported the absence of regulations. Elevenrespondents (15%) answered “unknown”; and eight (11%)selected the response “not addressed”.

Spermatozoa: 33 of 74 respondents (44%) said there wereregulations for the exportation of spermatozoa from their coun-tries; 22 (30%) reported no regulations; 11 respondents (15%)answered “unknown”; and 8 (11%) selected the response “notaddressed”.

Zygotes: 31 of 74 respondents (42%) affirmed the existence ofregulations pertaining to export of ova from their countries; 22

(30%) reported no regulations; 13 respondents (17%) answered“unknown”; 8 (11%) selected the response “not addressed”.

Discussion

Overall, a rather large proportion of respondents reported thatindividuals and couples were travelling to the respondents’ homecountry to seek treatments that were lower cost (75%), or ofhigher quality (79%) than those in their own home country, ornot available there (66%). Fewer respondents reported peopletravelling to their country to donate tissue (egg, 47%; embryo,37%, or sperm, 51%); and even fewer for gestational surrogacy(28%) or traditional surrogacy (19%). These data confirm theexistence of these practices, but provide no data about the extentor volume of such services.

A smaller proportion of respondents reported people travellingfrom their home country to seek treatment that was lower cost(65%), of higher quality (51%), or services not available at home(51%). Figures for seeking egg, embryo and sperm donation werehigher for outbound for egg and embryos than inbound, (47%vs,65%, 37% vs, 52% respectively) and equal for spermatozoa(51%). Rates for outbound people seeking surrogacy were higherthan inbound figures, with 57% vs. 28%of respondents reportingpeople travelling out of the country for gestational surrogacy, and46% vs. 19% reporting people travelling out of the country fortraditional surrogacy. This reflects the desire of individuals toseek services that are otherwise unavailable to them in their owncountries.

In regard to regulation, despite a perception of significantlyhigher levels of movement across borders, the responses indicatedthat there was little regulation of people travelling to or fromother countries to seek ART treatment. Regulation of the importand export of tissue appeared more prevalent; however, severalrespondents reported no regulation or did not know if regulationexisted.

The lack of regulation and lack of knowledge about regulation,may be relevant to egg, embryo and sperm donation, and sur-rogacy stakeholders. This would likely come about when childrenborn as a result may seek information about their donors orsurrogate mothers in the future. This is occurring more frequentlyall over the world. Tracking and reporting of treatments andtreatment outcomes may also become difficult. Patient follow upacross borders is considerably more challenging.

Summary

CBR appears to be increasingly prevalent; most country respon-dents noted that individuals traveled to their country seekingART services that were less expensive, perceived to be of higherquality, or unavailable in their home country. A much smallergroup noted patients seeking CBR for sperm, egg, or embryodonation, and even fewer for any type of surrogacy. A relativelysmaller proportion reported patients traveling from their countryfor any of these services. Almost two-thirds (64%) of respondingcountries reported the absence of regulations for patients eithercoming to or leaving a country to seek CBR services. These datasuggest that a substantial amount of CBR care is being provided,but no data are available regarding the actual volume, andoversight is limited.

Chapter 15. Table 5

(Continued)


Montenegro No No NoNew Zealand No No NoNigeria Yes Yes Unknown

Norway Yes Yes YesPanama Yes Yes YesParaguay Not addressed Not addressed Not addressedPeru Not addressed Not addressed Not addressedPhilippines Unknown Unknown UnknownPoland Unknown Unknown UnknownPortugal Yes Yes YesRomania No No NoRussian Federation Yes Yes YesSenegal No No NoSerbia No No NoSingapore Yes Yes YesSlovenia Not addressed Not addressed Not addressedSouth Africa Yes Yes YesSouth Korea Not addressed Not addressed Not addressedSpain Yes Yes YesSri Lanka No No NoSwitzerland No No NoTaiwan (China*) Yes Yes YesThailand Yes Yes YesTogo No No NoTrinidad and Tobago Yes Yes UnknownTurkey Unknown Unknown UnknownUganda No No NoUnited Arab Emirates Yes Yes YesUK Yes Yes YesUSA Yes Yes YesUruguay No No NoVenezuela Unknown Unknown UnknownViet Nam Unknown Unknown UnknownZimbabwe Yes Yes Yes



129

CHAPTER 16: HUMAN PRE-IMPLANTATION EMBRYORESEARCH

Introduction

In the United States of America, pre-implantation embryos thatare not intended for pregnancy are protected by federal mandatesof the “Common Rule” at a level surpassing that of surgicallyremoved organs and tissues. Adaptations and interpretationsfrom “Common Rule” governance appear to have been adaptedby local and national regulatory bodies as templates for regula-tion of embryo research internationally, and are reflected in theresponses included in the 2018 Surveillance survey.

“CommonRule” regulations emerged after the introduction ofIVF. The two major US bodies charged with oversight are theOffice of HumanResearch Protections (OHRP) and the Food andDrug Administration (FDA). Additionally, theNational Institutesof Health (NIH), a primary source of funding for research, hasregulations and policies that are followed to the extent that aresearch project (or institution) is funded by the NIH. Subpart Aof the regulations, known as the “Common Rule,” has beenadopted and separately codified by fourteen agencies other thanHealth andHuman Services (HHS). Its tenants are well known toresearchers working in western Europe and in The United Statesof America, and are likely followed by most of the surveyrespondents, some of whom trained in these regions.

The questions posed by the Surveillance 2018 questionnaire tothe respondents of the 90 countries are based on Common Rulestandards. The questions were expected to highlight embryoresearch as practiced internationally and influenced by federaland regional customs, and interpreted by governments, munici-palities, and scholarly committees.


Is experimentation/research on the pre-implantation embryoallowed/permitted in your country?

Research involving donated, unused pre-implantation embryos isallowed in 29 countries out of 74 (39%), and not allowed in 30countries (41%); its status was marked “unknown” in 15 countries(20%). Research on donated, unused pre-implantation embryos forstem cell research is allowed in 25 of 72 countries (35%), and notallowed in 32 countries (44%); its status was “unknown” in 15countries (21%). Reproductive cloning generating a human clone isallowed in 2 of 72 countries (3%), and not allowed in 59 (82%); itsstatus was “unknown” in 11 countries (15%). Therapeutic cloning isallowed in in8of 72 countries (11%), andnot allowed in51 countries(71%); its status was “unknown” in 13 countries (18%). Embryonicstem cell research is allowed in 13 of 72 countries (18%), and notallowed in 45 (63%); its status was “unknown” in 14 countries(19%) (Table 1, Chart 1).

Is there a requirement for specific approval ofexperimentation/research proposals? If the answer is yes,is the following allowed or not allowed?

Research involving donated, unused pre-implantation embryos isallowed with specific approval in 26 of 36 countries (72%) notallowed in 5 countries (14%); the status wasmarked “unknown” in5 countries (14%). Research on donated, unused pre-implantationembryos for stem cell research is allowed, with specific approval, in28 countries out of 37 (76%); not allowed in 5 countries (13%); and

the status was “unknown” in 4 countries (11%). Reproductivecloning generating a human clone is allowed, with specific approval,in 6 of 18 countries (33%), not allowed in 7, (39%); the status wasmarked “unknown” in 5 countries (28%) (Chart 2).

In 2015, a single country, Uruguay, responded that humancloning was permitted. Therapeutic cloning is allowed with spe-cific approval in 8 of 21 countries (38%), not allowed in 7 (33%),and the status was “unknown” in 6 countries (29%). Embryonicstem cell research is allowed, with specific approval, in 11 of 24countries (46%), not allowed in 4 (17%); and the status was“unknown” in 9 countries (37%), compared to five countriesresponding affirmatively in the 2015 survey.

What body or agency approves experimentation/research?

Research involving donated, unused pre-implantation embryos wasreviewed for specific approval by a local or national institutionalreview board in 14 of 48 countries (29%), by a national ethics oroversight panel in 24 countries (50%), and by an ethics panel in 12countries (25%); the status wasmarked “unknown” in 11 countries(23%). Research on donated, unused pre-implantation embryos forstem cell research is reviewed for specific approval by a local ornational institutional review board in 14 countries out of 46 (30%),by national ethics or oversight panels in 25 countries (54%); byethics panels in 12 countries (26%); and the status was marked“unknown” in 10 countries (22%). Reproductive cloning intendedto generate a human clone was reviewed for specific approval by alocal or national institutional review board in 1 country of 25 (4%);by national ethics or oversight panels in 12 countries (48%); and byethics panels in 2 countries (8%). The status was “unknown” in 12countries (48%), and 1 country reported “other” without addi-tional description. Therapeutic cloning is reviewed for specificapproval by a local or national institutional review board in 3countries out of 27 (11%), by national ethics or oversight panels in10 countries (37%), and by ethics panels in 5 countries (18.5%).The status was marked “unknown” in 12 countries (44%), and 1country reported “other” as federal regulations. Embryonic stemcell research is reviewed for specific approval by local or nationaloversight panels in 6 of 33 countries (18%), by national ethics oroversight panels in 14 countries (42%), and by ethics panel in 6countries (18%). The status was marked “unknown” in 11 coun-tries (33%), and 2 countries responded “other”.

In your country up to what age development in days canexperimentation be performed on a developing non-implanted embryo?

There were 20 responses to this question. The full range ofresponses was 0 to 45 days, with a median of 23 days.

Is experimentation/research on the pre-implantation embryoperformed in your country?

Research involving donated unused pre-implantation embryos isunderway in 24 countries out of 65 responders (37%). In compar-ison, 6 countries cited ongoing stem cell research from donated pre-embryos in 2015. Research on donated, unused pre-implantationembryos for stem cell research was performed in 21 of 63 countries(33%). Reproductive cloning generating a human clone wasreportedly performed in 2 countries out of 60 (3%). Therapeuticcloning was performed in 7 of 61 countries (11%). Embryonic stemcell research was performed in 12 of 60 countries (20%).


130

Chapter 16. Table 1Is Research or experimentation on the embryo allowed/permitted and practiced/performed?

Research On

Donated Unused EmbryosDonated Unused Embryosfor Stem Cell Research

Reproductive CloningGenerating a Human Clone Therapeutic Cloning

Embryonic Stem CellResearch

CountryAllowed/Permitted

Practiced/Performed

Allowed/Permitted

Practiced/Performed

Allowed/Permitted

Practiced/Performed

Allowed/Permitted

Practiced/Performed

Allowed/Permitted

Practiced/Performed

Argentina Yes Unknown Yes Unknown Unknown Unknown Unknown Unknown Yes UnknownAustralia Yes Yes, with

restrictionsYes Yes, with

restrictionsNo No Yes, with

restrictionsYes, withrestrictions

Yes, withrestrictions


Austria No No No No No No No No Yes, withrestrictions


Barbados Unknown UnknownBelarus Yes, with


No No No No

Belgium Unknown Yes Unknown Unknown UnknownBolivia No No No No No No No No No NoBotswana Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown UnknownBrazil No No Yes, with

restrictionsYes No No Yes No No No

Bulgaria Yes, withrestrictions



Burkina Faso No Unknown No Unknown No Unknown No Unknown No UnknownCameroon No No No No NoCanada Yes Yes Yes Yes No No No No No YesChile No No No No No No No No NoChina Yes, with


Unknown Yes, withrestrictions

No Unknown Unknown

Colombia Unknown No Unknown No No No No No Unknown NoCzechia No No Yes Yes No No No No No NoEcuador No No No No NoEgypt Yes Yes, with


restrictionsNo No Yes Yes, with

restrictionsUnknown Yes, with

restrictionsEl Salvador No No No No No No No No No NoFinland Yes Yes Yes Yes No No No No No NoGeorgia Unknown No Unknown No No No No No No NoGermany No No No No No No No No NoGhana Yes Yes Yes Unknown Unknown Unknown Unknown Unknown UnknownGreece Yes, with

restrictionsUnknown Yes Yes, with

restrictionsYes Yes Yes Yes Yes, with

restrictionsYes

Guatemala No No No No No No No No No NoHong Kong(China*)

Yes Yes, withrestrictions

Yes Yes, withrestrictions

No No Unknown No No No

Hungary Yes, withrestrictions




No No No No Yes, withrestrictions


India Yes, withrestrictions

No Yes, withrestrictions


Ireland No No No No No No No No No NoItaly Unknown No Unknown No Unknown No Unknown No Unknown UnknownCôte d’Ivoire Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown UnknownJapan Yes Yes, with


restrictionsNo No No No Yes Yes, with

restrictionsJordan No No No No No No No No No NoKazakhstan No No No No No No No No NoKenyaLatvia Yes Yes Unknown Unknown No No No No No NoLithuania No No No No No No No No No NoMali No No No No No No No No No NoMexico No No No No No No No No No NoMongolia Yes, with










Montenegro Yes, withrestrictions

No Yes, withrestrictions


New Zealand No No No No No


131

Are there regulations that address experimentation on thepre-implantation embryo in your country?

Research involving donated, unused pre-implantation embryoswas regulated in 34 of 66 countries (52%). Reproductive cloninggenerating a human clone was regulated in 41 of 68 countries

(60%). Therapeutic cloning was regulated 40 of 61 countries(61%). Embryonic stem cell research was regulated in 33 of 63countries (52%).

Countries that regulated research involving donated, unusedpreimplantation embryos reported having federal or national laws,

Chapter 16. Table 1

(Continued)

Research On

Donated Unused EmbryosDonated Unused Embryosfor Stem Cell Research

Reproductive CloningGenerating a Human Clone Therapeutic Cloning

Embryonic Stem CellResearch

CountryAllowed/Permitted

Practiced/Performed

Allowed/Permitted

Practiced/Performed

Allowed/Permitted

Practiced/Performed

Allowed/Permitted

Practiced/Performed

Allowed/Permitted

Practiced/Performed

Nigeria Yes, withrestrictions

Unknown No Unknown No No No Unknown

Norway Yes Yes, withrestrictions

No No No No No No Yes No

Panama No No No No No No No No Yes, withrestrictions

Paraguay Unknown No Unknown No Unknown No Unknown No Unknown NoPeru No No No No No No No No No NoPhilippines No No No No No No No No No NoPoland No No No No No No No No No NoPortugal Yes Yes, with


restrictionsNo No No No No No

Romania No No No No No No No No NoRussianFederation

Unknown Unknown Unknown Unknown No Unknown No Unknown Unknown Unknown

Senegal No No No No NoSerbia No No No No NoSingapore Yes, with


restrictionsYes No No No No Yes, with

restrictionsYes

Slovenia Yes, withrestrictions



No No No No No No

South Africa Yes, withrestrictions




No No Yes, withrestrictions


No No

South Korea Yes, withrestrictions








Spain Yes, withrestrictions

Unknown Yes, withrestrictions

Unknown No No No No No No

Sri Lanka No No No No NoSwitzerland No No No No No No No No No NoTaiwan(China*)





No No No No Yes, withrestrictions


Thailand Yes Yes Yes Yes, withrestrictions

No No No No No No

Togo Unknown UnknownTrinidad andTobago

Unknown No Unknown No Unknown No Unknown No Unknown No

Turkey No No No No No No No No No NoUganda Unknown No Unknown No Unknown No Unknown No Unknown NoUAE No No No No No No No No NoUK Yes Yes, with


restrictionsNo No No No No No

USA Yes, withrestrictions








Uruguay No No No No No No No No NoVenezuela Unknown No Unknown No No No No No No NoViet Nam Unknown Yes Unknown Unknown Unknown Unknown Unknown Unknown Unknown UnknownZimbabwe Unknown No Unknown No Unknown No Unknown No Unknown No



132

20%

21%

19%

15%

18%

41%

44%

63%

82%

71%

39%

35%

18%

3%

11%

Research on donated unused pre-implantation embryos

Research on donated unused pre-implantation embryos forstem cell research

Embryonic Stem Cell Research

Reproductive Cloning

Therapeutic Cloning

Yes No Uknown

Chapter 16. Chart 1. Is experimentation on the pre-implantation embryo allowed/permitted?

14%

11%

37%

28%

29%

14%

13%

17%

39%

33%

72%

76%

46%

33%

38%


Research on donated unused pre-implantation embryos forstem cell research



Therapeutic Cloning

Allowed Not Allowed Unknown

Chapter 16. Chart 2. Is there a requirement for specific approval of experimentation/research proposals?

24%

22%

15%

16%

55%

54%

81%

75%

18%

13%

3%

6%

3%

11%

2%

3%




Therapeutic Cloning

Commonly Performed Infrequently Performed Never Performed Unknown

Chapter 16. Chart 3. How frequently is experimentation performed?


133

statutes, ordinances, or policies in 19 out of 34 (56%); state, pro-vincial, or regional laws, statutes, or ordinances in 2 (6%); agencyregulations or oversight in 2 (6%); professional organization stan-dards and guidelines in 5 (15%); cultural practices in 1 (3%); andreligious decrees in 1 (3%).Countries that regulated embryonic stemcell research reported having federal or national laws, statutes,ordinances, or policies in 18 of 33 (55%); state, provincial, orregional laws, statutes or ordinances in 2 (6%); municipal laws,statutes, or ordinances in 1 (3%); agency regulations or oversight in1 (3%); and professional organization standards and guidelines in 4(12%). Countries that regulated therapeutic cloning reported hav-ing federal or national laws, statutes, ordinances, or policies in 16out of 40 (40%); state, provincial, or regional laws, statutes, orordinances in 2 (5%); and professional organization standards andguidelines in 2 (5%). Countries that regulated reproductive cloningreported having federal or national laws, statutes, ordinances, orpolicies in 15 out of 41 (37%); state, provincial or regional laws,statutes, or ordinances in 2 (5%); professional organization stan-dards and guidelines in 2 (5%); cultural practice in 1 (2%); andreligious decrees in 1 (2%).

Are clinical research programmes in your country performingexperimentation on the pre-implantation embryo?

Research on donated, unused pre-implantation embryos for stemcell research is commonly performed in only 2 countries out of 66reporting (3%), infrequently performed in 12 countries (18%),and never performed in 36 countries (55%); the status wasmarked “unknown” in 16 countries (24%) (Table 1).

Reproductive cloning generating a human clone is commonlyperformed in only 1 country out of 67 (2%), infrequently per-formed in 2 countries (3%), and never performed in 54 countries(81%); the status was marked “unknown” in 10 countries (15%).Therapeutic cloning is commonly performed in only 2 countries of65 (3%), infrequently performed in 4 (6%), and never performedin 49 countries (75%); the status was marked “unknown” in 10countries (16%). Embryonic stem cell research is commonly per-formed in only 7 of 67 countries (11%), infrequently performed in9 countries (13%), and never performed in 36 countries (54%); thestatus was “unknown” in 15 countries (22%) (Chart 3).

Discussion

The United Nations Declaration on Human Cloning, whichprohibits all forms of human cloning, was passed in 2005with 84-member nations voting in support, 34 in opposition, and37 abstaining. No global consensus emerged because there wereconcerns expressed regarding its interpretation and potentialapplication to various types of cloning. The 2018 Surveillancesurvey was intended to assess, in part, the extent of observance ofthe United Nations resolution 13 years later, and not to seekresponses regarding specific research initiatives. As expected,nations that had prior experience with Common Rule tended tohave the most strenuous infrastructures for managing researchfunds, legislation, publication, and enforcement standards. Themajority of responding countries now have some form of over-sight for research in place.

The 2018 survey reflects an increased amount of investigativeactivity with donated, unused embryos, usually with restrictionsin place and a still small but growing number of countries activelyinvolved in embryonic stem cell research. Most of the countriesinvolved in this research have existing oversight that has evolved,

in part, from the Common Rule. Surprisingly, one country,Greece, reported ongoing research pertaining to human repro-ductive cloning.

In November 2018, the U.S. National Academy of Sciences,including the U.S. National Academy of Medicine, the RoyalSociety of the United Kingdom of Great Britain and NorthernIreland, and the Academy of Sciences of HongKong, convened aninternational summit to address human genome editing and otheraspects of embryo research. More than 500 researchers, ethicists,policymakers, patient group representatives, and others fromaround the world took part. The potential benefits and risks ofhuman genome editing, ethical and cultural perspectives, reg-ulatory and policy considerations, and public outreach andengagement efforts were considered, and their recommendationswere recently published[1].

Summary

Human pre-implantation embryo research remains a contentioustopic, with a small minority of countries actively involved in itsinvestigation.With recent advances in clinical application of stemcell research, a small but growing number of countries are con-ducting studies using embryonic stem cells provided by donated,unused embryos, with restrictions. Human reproductive cloningremains almost universally prohibited[1].

Reference[1] Available at: https://www.nap.edu/catalog/25343/second-inter

national-summit-on-human-genome-editing-continuing-the-global-discussion. Accessed January 26, 2019.

CHAPTER 17: STATUS OF THE EMBRYO

Introduction

One of the first issues to be addressed with the inception of lifecreated outside of the mother’s body was the status to be accor-ded the embryo. Determining when life begins is a topic that haspreoccupied theologians, biologists, and legal scholars for mil-lennia, but no one had anticipated the advent of in vitro fertili-zation. Universal moral and ethical principles govern thetreatment of individuals, and are embraced by governments andsocieties, but ART poses unique potential conflicts of interest forprospective mother and child when their mutual welfare does notoverlap. Thesemoral dilemmas are not easily resolved by classicalethical tenets. These issues revolve around the question of whe-ther there is a point in embryonic or fetal development whenpersonhood is conveyed, with its inherent legal rights, beforewhich time a person is not considered to exist. The striking dif-ferences in how various countries reconcile these dilemmashighlight some of the most significant issues in the internationalgovernance of ART.

In the 2018 questionnaire, the following questions were posed:1. “Is there a recognized point in time during human develop-

ment in which a human exists and thus provided humanrights?”

2. “Through which governing bodies or agencies is this time ofhuman existence determined?”

3. “Is there a recognized point in time during human develop-ment before which a human person is considered not to existand thus not provided human rights?”


134

4. “Through which governing bodies or agencies is this time ofhuman non-existence determined?”


Representatives of 74 countries responded to the first question.Thirty-one (42%) noted that such a point existed (Table 1). It wasday “0” (pre-fertilization), stated five nations (7%): Australia,Greece, Ireland, Spain, and Uruguay. Day “1” (post-fertilization)was the choice of 13 countries (18%): Bolivia, Brazil, Ecuador, ElSalvador, Guatemala, Mexico, Nigeria, Peru, Philippines,Poland, Portugal, Senegal, and Zimbabwe. A time between day 2and 126, said 9 countries (12%). The Russian Federation,Thailand, and The United States of America (4%) chose280 days, and United Kingdom of Great Britain and NorthernIreland (1%) specified 281 days as the point at which humanrights are conveyed (Chart 1).

Of the 31 countries that have chosen a point at which a humanis recognized to exist, the majority of countries – 28 of them –

(90%) back up their decision with federal or national statutes,ordinances, or policies, and 7 (23%) do so by state or provincialpolicies or legislation. Only 3 (10%) rely on municipal laws,statutes, or ordinances. Eight (26%) use professional organiza-tions’ standards or guidelines, 9 (29%), existing cultural prac-tices; and thirteen (42%), religious decrees.

Regarding question 3, responses were received from 66countries; responders from 14 countries (21%) acknowledged aspecific point before which a person was not considered to exist.Thirty-five respondents (53%) did not recognize such a point ortime, and 17 (26%) reported “unknown” (Table 2). Amongcountries that did recognize such a point, it was day 0 forEcuador, Ireland, and Senegal; day 1 for Argentina; and 280 daysfor Canada, Finland, The United States of America, and theUnited Kingdom of Great Britain and Northern Ireland. ForEgypt, Kazakhstan, Georgia, Norway, Austria, and Germany,the time ranged from 41 to 97 days (Chart 1). The point wasdetermined in most countries (13 out of 14; 93%) by federal ornational statutes, laws, or ordinances.

Chapter 17. Table 1Is there a recognized point in time during human development atwhich a human exists and thus provided human rights?

Country Response

If Yes, What is theRecognized Timeof Existence? (d)

Argentina No 0Australia Yes 0Austria Yes 91Bangladesh NoBelarus NoBelgium UnknownBolivia Yes 1Botswana NoBrazil Yes 1Bulgaria NoBurkina Faso UnknownCameroon NoCanada UnknownChile NoChina NoColombia UnknownCzechia UnknownEcuador Yes 1Egypt Yes 42El Salvador Yes 1Finland NoGeorgia Yes 84Germany Yes 98Greece Yes 0Guatemala Yes 1Hong Kong (China*) UnknownHungary Yes 2India UnknownIreland Yes 0Italy NoCôte d’Ivoire UnknownJapan NoJordan Yes 126Kazakhstan Yes 42Kenya UnknownLatvia UnknownLithuania NoMali UnknownMexico Yes 1Mongolia NoMontenegro NoNew Zealand NoNigeria Yes 1Norway Yes 84Panama NoParaguay NoPeru Yes 1Philippines Yes 1Poland Yes 1Portugal Yes 1Romania UnknownRussian Federation Yes 280Senegal Yes 1Serbia Yes 40Singapore UnknownSlovenia NoSouth Africa NoSouth Korea UnknownSpain Yes 0

Chapter 17. Table 1

(Continued)

Country Response

If Yes, What is theRecognized Timeof Existence? (d)

Sri Lanka NoSwitzerland NoTaiwan (China*) NoThailand Yes 280Togo UnknownTrinidad and Tobago UnknownTurkey UnknownUganda UnknownUnited Arab Emirates NoUK Yes 281USA Yes 280Uruguay Yes 0Venezuela UnknownViet Nam UnknownZimbabwe Yes 1



135

26%

27%

53%

31%

21%

42%

Not Exist

Exist

Yes No Unknown

Chapter 17. Chart 1. Is there a recognized point in time during human development at which a human person is considered to exist or not exist?

Chapter 17. Table 2Is there a recognized point in time during human developmentbefore which a human person is considered not to exist and thusnot provided human rights?

Country Response

If Yes, What is theRecognized Time ofNon-Existence? (d)

Argentina Yes 1Austria Yes 90Bangladesh NoBelarus NoBelgium UnknownBolivia NoBulgaria NoBurkina Faso UnknownCameroon NoCanada Yes 280Chile NoChina NoColombia NoCzechia NoEcuador Yes 0Egypt Yes 41El Salvador NoFinland Yes 280Georgia Yes 83Germany Yes 97Greece NoGuatemala NoHong Kong (China*) UnknownHungary NoIndia UnknownIreland Yes 0Italy NoJordan UnknownKazakhstan Yes 41Kenya UnknownLatvia UnknownLithuania NoMali Unknown

Chapter 17. Table 2

(Continued)

Country Response

If Yes, What is theRecognized Time ofNon-Existence? (d)

Mexico NoMongolia NoMontenegro NoNew Zealand NoNigeria Unknown

Norway Yes 83Panama UnknownParaguay NoPeru NoPhilippines UnknownPoland NoPortugal NoRomania UnknownRussian Federation NoSenegal Yes 0Serbia NoSingapore UnknownSlovenia NoSouth Africa NoSpain NoSri Lanka NoSwitzerland NoTaiwan (China*) NoThailand NoTrinidad and Tobago UnknownTurkey UnknownUganda UnknownUnited Arab Emirates NoUK Yes 280USA Yes 280Uruguay NoVenezuela UnknownZimbabwe No



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Discussion

In the 2018 survey, 10 more countries responded to the firstquestion than had done so 3 years earlier (74 versus 64 responses).Considerably more countries now recognize a point at whichpersonhood is acknowledged (42% vs 28%). There was less dif-ference in the response rate to question 2 (66 vs 64 responses) andthis time only 21% acknowledged that there was a point beforewhich a personwas not considered to exist. In 2015, the figure was33%. The response “unknown” was given for question 1 by 20responders (27%) and for question 3 by 17 responders (26%); in2015, the responses for the same questions were 30% and 17%,respectively. The results suggest a greater emphasis currently ondetermining a time personhood is reached, but they still show greatvariability in when that time is recognized.

Since the original ruling of the Inter-American Court ofHuman Rights (IACHR) in Costa Rica, granting the rights of 18plaintiffs to access ART, was upheld in February 2016. Since thattime, Costa Rica has established two ART centres and partici-pated in this most recent survey. No countries are currentlyknown to continue to pose statutory obstacles to access of ART.

Summary

IVF now appears to be universally available, but marked differ-ences exist among countries regarding the status and protectiongiven to the embryo. An increasing proportion of countries nowrecognize a point at which an embryo or fetus reaches personhood,with attendant legal rights; and fewer countries are defining a pointbefore which a person is said to not exist. Considerable variationcontinues among nations as to when these points are defined, andthere does not seem to be a trend towards consensus.

CHAPTER 18: CONCLUSIONS

The 2018 questionnaire used to produce the InternationalFederation of Fertility Societies’ Surveillance (IFFS) 2019: GlobalTrends in Reproductive Policy and Practice, 8th Edition, suc-ceeded in engaging respondents from 97 countries to complete allor a portion of the 94 questions in the survey. With 22 morecountries responding than was the case with the 2015 project, the8th edition offers a more complete depiction of the internationalstatus of the practice of ART. But the opportunity to makemeaningful comparisons over the three years is limited, becausethe two editions include some different participating countries.

The data collected suggest that several countries, primarily inAfrica, have recently started their inaugural ART programmes; thatoverall the number of new ART centres around the world hasleveled off, with most countries recording modest increases in thenumber of centres; and that several nations now have fewer centresthan in 2015. If the latter finding is validated, uncovering thecontributing factors will be a query for the next triennial review.

The proportion of countries that have some regulatory over-sight continues to increase. More than 86% of respondents nowcite a regulatory oversight system, including national or federallegislation, provincial or municipal statutes, agency inspections,and professional guidelines. New regulatory efforts haveaddressed anonymous donation, cross-border reproduction,IVF surrogacy, pre-implantation genetic diagnosis, and experi-mentation on embryos, and cover issues such as maritalstatus, micromanipulation, and same-sex parenting. Additional

licensing and monitoring requirements have been imposed, andcertification and examination processes expanded. What has nottaken place is a marked increase in the proportion of countrieswith legislation or clinical guidelines that restrict the number ofembryos permissible for transfer to women undergoing IVF/ARTcycles (currently 59%, vs. 56% in 2015). More countries (35%vs. 24% in 2015) now report penalties for non-complianceregarding the number of embryos transferred.

Insurance coverage for ART is offered by a minority of coun-tries, with only 47%providing support for any infertility therapy.There are significant regional variations for eligibility and theextent of coverage offered. Greater support does seem to beprovided for genetic screening. No significant changes wereidentified in the proportion of countries that tie reimbursement tothe number of embryos transferred.

The majority of countries (62%) do not require couples orindividuals to be in a recognized or stable relationship to accessART services. Countries accepting single women (68%) andfemale same-sex couples (45%) for provision of ART services ismore prevalent than those extending the same access to men(32%) or male same-sex couples (21%).

Technologic advances in ART have been broadly adopted.ICSI is widely accepted and universally available. PGT-M isexpressly permitted in about 75% of respondent countries, notprohibited by any, and performed in about half. PGT-A andassisted hatching have been shown to be valuable adjuncts forsome types of patients, but their indications and overall value arestill being defined. PGT-A for aneuploidy was available in allresponding countries, but is actively performed in 50% (45 of90), compared to 42% in 2015.

Considerable ongoing interest remains for IVM, but there hasbeen no recent significant clinical progress, and clinical adoptionawaits translational investigations and clinical validation. Thesame is true for cytoplasmic transfer, mitochondrial transfer, andCRISPR-Cas9 technology – for which there is ongoing research;but all are considered investigative. Human preimplantationembryo research remains controversial; relatively few countriesare participants. This number is likely to increase, however, withrecent advances in stem cell research. A growing number ofcountries use embryonic stem cells provided by donated, unusedembryos, with restrictions. Human reproductive cloning remainsalmost universally prohibited.

Gamete and embryo donation are well established ARTpractices, and are employed, if not sanctioned, by a large majorityof the responding countries. Overall, about 50% to 60% ofcountries surveyed report using gamete or embryo donation,although “de novo” embryo donation is used less often, acceptedin around 25% to 35%of countries. The vast majority of countryrespondents (71%) noted acceptance and successful applicationof cryopreservation of sperm, oocytes, and embryos. However,extensive variation continues among the country respondents interms of which practices are regulated and how they are regu-lated. Gamete and embryo donation have been well establishedART practices, and are used by a large majority of countries.Overall, 50% to 60% of countries offer gamete or embryodonation. In contrast, “de novo” embryo donation is less com-monly accepted, and available only in 25% to 35% of countries.

The 2018 Surveillance questionnaire reaffirmed the con-troversial aspects of several ART practices, including gestationalsurrogacy, posthumous reproduction, cross-border reproduction(CBR), and selective fetal reduction (SFR). About one-third of


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countries practice gestational surrogacy; fewer, traditional sur-rogacy. Most have measures in place prohibiting or sharplycurtailing the practice.

Surveillance 2019 notes an increased application of all types ofposthumous reproduction, including insemination of cryopreservedsperm and oocytes, and transfer of cryopreserved embryos – despitethe apparent decline in the number of countries that have legislationor other measures in place pertaining to posthumous reproduction.

CBR has become increasingly prevalent. Most countryrespondents noted that individuals have traveled to their countryfor ART services that were less costly, perceived to be of betterquality, or unavailable at home. About two thirds (64%) ofrespondents cited the absence of regulations for patients seekingCBR services entering or leaving a country. Only a third of the 89responding countries permit SFR outright; another 19% allow itconditionally, and 19% ban it completely. Sex selection, usuallyperformed with PGT-A, is being applied more frequently, and isalmost universally available. Despite this, relatively few countries(24%) expressly permit PGT-A for sex selection; even fewer haveregulations restricting it. Sperm sorting and SFR, while availablein a few countries, is infrequently practiced.

There has been ongoing interest and legislative activity haveaddressed several social, legal, and non-technical aspects of ART.While possibly less contentious, they have widely different appli-cations. Some countries have enacted extensive measures to ensurethe welfare of the child; a discernible trend has been directedtowards more intensive assessment of the prospective parentsbefore treatment begins. Yet 74% of countries require no formalassessment. At a later stage in the ART process, an increasingproportion of countries are recognizing a point in embryo devel-opment at which personhood is achieved and specific legal rightsare assigned. These points vary widely among countries, and theredoes not appear to be an identifiable trend towards consensus.

The International Federation of Fertility Societies’ Surveillance(IFFS) 2019: Global Trends inReproductive Policy and Practice, 8thEdition, provides a more complete rendering of the global status ofART. It captures more data from a greater number of respondents,and makes the first effort to define the extent of the ART frontier bylisting countries not thought to be engaged in the practice of ART.The publication provides a vast amount of data for a variety ofstakeholders – including clinicians, researchers, patients, policymakers, and health ministers. It depicts considerable progress in

technical application, access to ART services, and consensus aroundissues pertaining to safety and social justice, but also highlights someinconsistencies between intent and actual application of some ARTpolicy. It attests to the dynamic aspects of a still rapidly evolvingtransformative field.

APPENDIX

Dr. Sonia Allan OAM CFAssociate Professor of Health Law, Deakin University, Australia

Dr. Basak BalabanIVF Laboratory Director, American Hospital of Istanbul, Istanbul, Turkey

Dr. Manish Banker MDMedical Director, Nova IVI Fertility, IndiaConsultant, Nova IVI Fertility Ahmedabad

Dr. John BusterEmeritus Professor, Brown University, Providence, RI

Dr. Marcos HortonART Lab Director, Pregna Medicina Reproductiva, Buenos Aires, ArgentinaTreasurer, IFFS

Dr. Kathleen MillerScientific Director, IVF Florida Reproductive Associates, Margate, FLLaboratory Director, RMA Connecticut, Norwalk, CTLaboratory Director, RMA Michigan, Troy, MILaboratory Director, Billings Clinic, Billings, MTVice President, MedTech For SolutionsManaging Editor, Surveillance

Dr. Edgar MocanuRotunda Hospital and the Royal College of Surgeons in Ireland, Parnell Square,Dublin 1, Ireland

Dr. Steven J OryIVF Florida Reproductive Associates, Margate, FLProfessor of Obstetrics and Gynecology, Florida International University,Miami, FLVoluntary Associate Professor of Obstetrics and Gynecology, University ofMiami, Miami, FloridaEditor-in-Chief, Surveillance

Dr. Hirshikesh PaiMedical Director, Bloom IVF Centre, Mumbai, India

Dr. Sheryl van der PoelScientist/Medical Officer, Population Council, New York, New York

Dr Fernando Zegers-HochschildProfessor, University Diego Portales, Santiago, Chile


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Documents

IFFS Surveillance 2019 - Nova IVI Fertility5. Number of embryos for transfer in assisted reproductive technology (ART) 6. Cryopreservation 7. Posthumous reproduction 8. Donation and