Denmark's Investment in Fertility Treatment to Normalize Demography

Guest newsletter from Professor Claus Yding Andersen

As fertility and live birthrates decline to historic lows they become hot political issues. To sustain a nation’s population, women need to give birth to 2.1 children on average in their lifetime. Births have fallen below this replacement threshold in all major regions of the world except for Africa and the Middle East. The levels are well below in most European countries and have even fallen to 1.0 in the Far East. The total fertility rate now approaching 0.7 in South Korea is an extreme case that has prompted its Prime Minister to declare a national emergency. Although the demographic shift has been evident for some time, socio-economic projections of too few people of working age to support longer-lived elders is now rising high on agendas in world capitals. So the pressing question is what can be done about it.

Several factors contribute to declining births. The major and most difficult to fix is that young adults increasingly choose to remain childless. Another acute challenge in Western Europe is a widening generational interval as women postpone their first child until an average age of about 30. They do so for good reason, but it puts them at greater risk of infertility from ovarian aging and other factors for which they might later need assisted conception. On top of those primary movers, there is mounting evidence of environmental pollution impacting fertility in both sexes. Research is needed to understand these threats and how to combat them.

Governments are exploring ways of raising birth rates for the sake of national wellbeing whereas in the past a more stable balance between reproduction and mortality rates preserved the shape of the population pyramid. They pull on financial levers, including tax relief for people who struggle to have and afford children (e.g. in France) and subsidies for public services that ease the work-life balance of couples raising families. In our small Scandinavian country, we pay the costs of most people needing treatment with assisted reproduction technologies (ARTs).

Denmark’s public sector services provide high-quality healthcare and ARTs funded by taxation on the principle of collective insurance. Taxpayers contribute to national costs according to their means and receive care in return depending on their needs. They are typically net contributors when young who become beneficiaries later when they require more healthcare.

When I give lectures in the USA, the audience often responds to a description of the Danish system as “Obamacare times ten.” Bemused and joking about dollars growing on our trees, they look bewildered when I assure them the public accepts high taxation as a fair exchange for generous benefits that avoid straining the domestic budget of patients receiving care.

Infertility is the most common reason for 20 to 40-year-old Danes to seek any type of medical care. They receive free ART treatment for qualifying under government rules. Women up to age 40 can benefit whether or not they have a male partner or are lesbians. If they become infertile again after having one or more children, they need proof from a medical consultation before receiving benefits. Doctors are not allowed to offer these public services to persons they believe won’t make good parents.

Every woman is entitled to five stimulation cycles with IVF/ICSI for a maximum of three reaching the stage of embryo transfer. They are disqualified from further treatment if they get pregnant and deliver a baby unless they have frozen embryos for another free transfer. Then their only option is private treatment. Private clinics thrive in Denmark despite the availability of robust public services. They offer treatment to women up to age 45 when the chances of success are slim, and five years later than the limit set in the public sector by health economics.

Denmark has one of the highest birth rates in the world for assisted conception at around 8-10% of all babies. The percentage corresponds to about two children for every school classroom across the country. The government recently gave more help to patients who cannot afford private care after their quota of free treatment runs out. It raised the allowance from three to six cycles to boost the chances of pregnancy for the 20% who weren’t successful in their first three attempts. The Prime Minister announced in her New Year message that patients who want a second child, as many do, will be entitled from January 2025 to six more attempts for a total of 12. Some of the extra cycles are intended to cover demand that the private sector is currently unable to satisfy.

Each country seeks its own path to raise birthrates, and no single policy is likely to be a panacea. Denmark’s direct approach guarantees more babies. It offers a generous and equitable allowance of ART and bridges financial barriers for people who qualify but cannot afford private care. Helping people overcome infertility is an obvious strategy for tackling the demographic problem. The condition is equally common in other countries, although the political will to emulate our policy may lack public support.

If direct action with publicly supported ARTs is problematic, perhaps indirect funding is more acceptable. Although they are highly effective, there is room to improve ARTs by making them more patient-friendly and improving treatment for late maternity when they are likely to fail without costly egg donation. Hitherto, technologies have mainly advanced from initiatives in clinics and a few specialized firms. Government research funding could provide more heft for future breakthroughs, so more people can share the joy of family building that carries a social dividend.

Contact the author: cya@yding.com

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