Fertility matters draft

Fertility Europe

Fertility Matters
For one in six fertility is an issue

Fertility Matters

What is at stake across Europe regarding Fertility for the years to come

1 Who we are .................................................................................. 3
2 Key facts on Fertility ................................................................. 5
3 Consequences of Infertility........................................................... 7
4Medically Assisted Reproduction (MAR) ....................................... 9
5 Ethics .......................................................................................... 11
6Equality of Access to Treatments ..................................................12
7 Criteria to ensure Equality of Access to Treatment ....................... 14
8 Prevention and Education.......................................................... 16
9 Fertility Europe's recommendations.............................................. 18

Glossary .......................................................................................21
References .................................................................................. 22

Fertility Matters - March 2013
2

Correspondence address: office@fertilityeurope.eu

1 Who we are

Fertility Europe history and values
- To build a strong cross border network
amongst European patients and health
In 2008, a small group of European associations professionals in order to achieve the sharing
involved with fertility issues felt the need to of best practise;
establish a uniting European umbrella
organisation, based on democracy, transparency - To promote societal changes regarding the
and being a truly representative body and voice of perception of infertility;
those concerned with fertility problems, in
discussions with the policymakers and the media. - To promote education in the area of the
protection of reproductive health and a pro-
active approach to family planning.
A European representative
association
Special Families Campaign

TodayFertility Europe is the largest and most
All over Europe, people are struggling to conceive
representative association of European
and Fertility Europe has the deepest respect for
organisations involved with fertility issues with
those in this position. However, although difficult
members from over 20 European countries. In
for some, they can and do move on, and often
our national organisationswe are all, involved on a
create a special family on their own.
daily basis with assisting those affected by
difficulties in conceiving.
In 2011, Fertility Europe started the Special
Families campaign. We have asked those people
who have had to go the extra mile to become a
Our goals family, to share their story through
www.fertilityeurope.eu
The fact that so many people across Europe need
reliable information on fertility, its protection and The idea is to send a Postcard of Hope, whether
improvement, and on infertility, its treatment and you are a family with children after treatment,
options has led us to work together and we share adopted, naturally conceived after years of trying,
four main goals: still waiting for your dream to come true, a family
of two or other “special” family.
- To improve the rights of those affected by
difficulties in conceiving;
3

Within a few months we received hundreds of messages.
stories with photographs and strong personal

Fertility Europe represents 25 million people who have difficulties in conceiving acrossEurope
through 23 patient associations and interest groups in 22 countries

Fertility Europe members

Belgium Sdruzhenie Zachatie Denmark
De Verdwaalde Ooievaar Netwerk www.zachatie.org/ Landsforeningen for ufrivilligt
Fertiliteit Croatia barnlose
http://www.deverdwaaldeooievaar.b www.lfub.dk
e/ Association RODA
www.roda.hr Finland
Bulgaria Lapsettomien yhdistys Simpukka ry
Czech Republic
Iskambebe http://www.simpukka.info/
www.iskambebe.bg ADAM
http://www.adamcr.cz/ France

4

Maia The Netherlands www.infertilitate.com
http://www.maia-asso.org/ Freya - Vereniging voor
Greece Slovak Republic
vruchtbaarheidsproblemen
Kiveli http://www.freya.nl/ Občianske združenie BOCIAN
www.kiveli.gr/ http://www.bocianoviny.sk/

Hungary Norway Sweden

Országos Lombikbébi Támogató ØNSKEBARN Barnlängtan
Alapitvány http://www.onskebarn.no/ www.barnlangtan.com/
http://www.lombikbebialapitvany.hu/ Switzerland
Iceland Verein Kinderwunsch
Poland http://www.kinderwunsch.ch/
Tilvera
www.tilvera.is Nasz Bocian
United Kingdom
http://www.nasz-bocian.pl/
Israel Infertility Network UK
CHEN - Patient Fertility Association Portugal http://www.infertilitynetworkuk.com/
http://www.amotatchen.org/ Associação Portuguesa de (in) Turkey
Fertilidade
Italy www.apfertilidade.org Çider
www.cocukistiyorum.com
Amica Cicogna
www.amicacicogna.it/ Romania
SOS Infertilitatea

2 Key facts on Fertility
i

The first successful birth of a "test tube baby", Louise Brown, occurred in 1978. Since that time over five million
individuals have so far been born worldwide following in vitro fertilisation. Professor Robert G. Edwards, the
physiologist who developed the treatment, was awarded the Nobel Prize in Physiology or Medicine in 2010.

For 1 on 6 Fertility is an issue In 2005 the number of MAR treatment cycles in
the EU exceeded 400,000 compared to
ii
approximately 200,000 cycles ten years earlier so
One in six people worldwide experience some an increase of 100% (see figure 1)
form of fertility problem at least once during their
iii
reproductive lifespanmeaning that a potential 25
million EU citizens are estimated to be having
difficulties in conceiving.
v Number of Medically Assisted Reproduction Cycles
Europe performs the most cycles of 450000
MAR worldwide... 400000
350000
iv
300000
Europe leads the world in the number of cycles 250000
taking place, initiating approximately 54%of all
200000
reported Medically Assisted Reproduction (MAR)
150000
treatment cycles.
100000
50000
... and faces a constant increase
0
1996 1997 1998 1999 2000 2001

5

This includes those diagnosed with secondary
infertility which is defined as infertility in a couple
who already had at least one pregnancy, whether
Infertility is a medical condition that be a pregnancy resulting in the birth of a baby
or a pregnancy that has miscarried, resulted in an
ectopic pregnancy or led to a decision to terminate
Infertility is recognized by the World Health
the pregnancy for medical reasons.
Organization as a disease and, without
investigations and treatment, this medical
condition prevents people of reproductive age
from fulfillingthe life goal of becoming a parent.

People should be referred for investigations after 6
months and up to 2 years of trying to conceive
with regular intercourse. However if there is
something in their medical history which indicates
a fertility problem e.g. amenorrhoea, or where the
female is aged 36 or over (given the impact of the
age of the female on the success of treatment),
investigations and possible treatment should be
considered sooner.

Causes of infertility

vi
20-30% of infertility cases are linked to physiological causes in men, 20-35% to physiological causes in women,
and 25-40% of cases are due to a joint problem. In 10-20% no cause is found.

Causes of infertility
vi Relative frequency of the different causes of infertility
The total is greater than 100% because some couples have more than one cause.

28%

24 %
defect/dysfunction
Endometriosis

21 %
Coital failure
defects/dysfunction
Ovulatory Failure

Other male

14 %
infertility

Unexplained

6
Mucus

11%
Damage

Others
Sperm
Tubal

6% 6%
3% 2%

3 Its consequences

Most people affected by problems in conceiving find it difficult to deal with, both physically and
emotionally.
impacting on relationships with partners, family
members and friends.

Infertility can lead to depression Emotional troubles

Infertility is a medical condition which can cause
If infertility is prolonged, studies have found that
severe side effects such as depression. There is a
people go through an extremely stressful and
widespread mistaken belief that life continues as
emotional experience. Their sense of self, their
before. The childlessness, the prolonged
identity and the meaning and purpose of life are
uncertainty, and the monthly attempts to become
challenged.
pregnant, sometimes over several years, can affect
every aspect of a person’s life, as well as

7

The experiences of couples who have had
infertility treatment in the United Kingdom: results
of a survey performed in 1997:

vii

Tearfulness 97%

Depression/isolation 94%

Anger 84%

Inadequacy 72%
“Having been through infertility myself and benefi
Guilt/shame 62% by the patient association, I recognized how
involved.”
Suicidal feelings 20%

Clare Lewis-Jones MBE, Chief Executive, Infertility Networ
& Chair of Fertility Europe

Societal troubles and isolation The role of patient associations

As the years go by, this is a burden that many Patient associations contribute to the reduction of
people bear. People experience an impaired ability anxiety levels by informing those affected of the
to function normally in society for long periods of reproductive biology, the pathology and the
time. For some, events such as the announcement treatment options.
of pregnancies within close circles, children's
birthdays, and religious celebrations related to They emphasize the role of counseling and its
nativity, Mothers Day and other similar occasions benefitsas well as the importance of offering it at
are extremely distressing, difficult to deal with and an early stage.
are a painful reminder of their fertility problems.
What society do we want?
Medical treatments that can help to resolve this
problem have been developed. However infertility
can still be a socially taboo subject. Society is changing, and with it, the average age of conc
treatments being undergone by women aged between the
People often have to face stereotypes, prejudices, important and increasing issue for Europe. We can't ignore
misunderstandings and guilty feelings. Thus some linked to infertility in our society.
people do not dare to address this issue with
friends and family. Little by little they become
They also offer support groups which provide an
socially isolated, even more so if children are
additional forum for the explanation of many areas
present in their network and neighbourhood.
of reproductive medicine and the impact of related
technology.

Professional troubles They can reduce the sense of isolation by allowing
people to meet others with similar problems.
The impact of fertility problems on men and
women may also affect their professional life.
They need to take time out from their career for
investigations and treatment.

8

4 Medically Assisted Reproduction
Some specifics about IVF

viii
IVF is a process by which an egg is fertilised by
sperm in vitro(“in glass”) i.e. outside the body. IVF
is a treatment for infertility when other methods
What are the different treatments? of assisted reproductive technology have failed.
IVFis performed by monitoring a woman’s
Medically Assisted Reproduction (MAR) ovulatory process and collecting ovum or ova (egg
treatments include fertilisation in vivo such as or eggs) from the woman’s ovaries and placing
simple hormonal treatments and insemination them with sperm in a fluid medium in a petri dish
(Intra-uterine Inseminaton - IUI), as well as in vitro within a laboratory for hopeful fertilisation
fertilisation (IVF) and intracytoplasmic sperm resulting in an embryo/s. The embryos obtained
injection (ICSI). following this procedure are transferred back into
the uterus.

9

Additional techniques that are routinely used in
MAR include ovarian stimulation to retrieve
multiple eggs, ultrasound-guided transvaginal
oocyte retrieval directly from the ovaries, egg and
sperm preparation, as well as culture and selection
of resultant embryos before embryo transfer back
into the uterus.

MAR may also assist in the treatment of male
infertilitye.g. abnormal sperm.In such cases,
intracytoplasmic sperm injection (ICSI) may be
used, where a sperm cell is injected directly into
the egg cell. This is used when sperm have
difficulty penetrating the egg. ICSI is also used
when sperm numbers are very low.

Gamete donation

MAR may also be offeredfor those who are not
able to use their own gametes (egg and/or sperm)
byusing donated gametes. .

10

5 Ethics

Access to Medically Assisted Reproduction creates
a philosophical dilemma regarding the future of
the children born.

In order to raise the issue with public authorities, “I see the need for regulations,
the media and the general public, Fertility Europe best practice exchange and ethics
is actively contributing to the bioethical and on European level and identified
societal reflection. huge need for prevention and
education.”
Our objective is to bring different views and
perspectives to these debates bearing in mind our Denisa Priadková, Chair of Občianske združenie
tireless promotion of progressive policies, effective BOCIAN &Fertility Europe Vice-Chair
practices and universal human rights i.e.

1. The right to found a family and to
procreate;

2. The wellbeing and welfare of
children to come;

3. Responsibilities of the future
parents towards the community;

4. The right of deciding to become
parents through treatments or not.

11

6 Equality of Access to Treatment

Why should there be equity of access
to treatments?

Ensure sustainable population growth
rates

Addressing reproductive care is a challenge that
European governments are tackling whilst
addressing the maintenance of balanced
populations with sustainable population growth
rates. However, infertility may be erroneously side
lined and is considered to be a low priority on the
public health care stage in many European
countries.
The right to found a family and to
European Parliament’sresolution procreate
ix
The European Parliament notes that infertility is x
A recent jurisprudence from the European Court
a medical condition which can cause severe side
of Justice has stated that Article 8 of the
effects such as depression. It points out that
European Convention on Human Rights provides
infertility is on the increase occurring in
a right to respect for one’s “private and family
approximately 15 % of people, and therefore calls
life, home and his correspondence” and that it
on the Member States to ensure the rights of
could be applied in case of Medically Assisted
those affected to universal access to infertility
Reproduction (MAR) because of the special
treatment.
importance of the right to found a family and to
procreate.

Examples of disparities across Europe
Reimbursement of In Vitro Fertilisation / ICSI across Europe in Public Centers and Number of cycles reimbursedEurope
Diverse legislations across across Europe, data
provided from the FE members associations, April 2012
xi
19 Member States of the European Union have
Number of cycles Number of cycles
Countries Laboratory Drugs Consultations Blood
specificUltra Sounds
legislations
in place for MAR. IVF/ICSI
In the
IUI
Czech Rep. 100% 100% 100% remaining 100%
100% 8 countries, MAR is covered by the
6 4 or 3*
France 100% 100% 100% general health legislation. Israel, Switzerland,
100% 100% 6 4 to 5
Poland** Croatia and Norway have different legislation in
3
Portugal 100% 69% 100% place.
100% 100% 3 3
Romania***
Slovakia 75% 75% 100% 100% 100% 0 0 to 2 or 3
Sweden 100% 100% 100% 100% 100% 6 0 to 3
UK 0 or 100%**** 0 or 100% 0 or 100% 0 or 100% 0 or 100% 0 to 6 0 to 3
12
: No reimbursement
* Czech Rep.: 4 if the first 2 with SET or 3 without SET
** Poland: will provide from July 2013 on financing for 15,000 couples; both married and unmarried, for up to three in-vitro procedures for three years after
other fertility treatments fail.
*** Romania: Since 2011 a pilot fund from the Health Ministry funded partially for 800 couples the consultations and IVF procedures (no laboratory, no drugs,
no blood reimbursed) and a partial reimbursement for one IVF cycle for a limited number of couple
****UK: Depend on the postcode

Quality in MAR

As with every medical treatment, MAR has to be a
treatment of quality requiring four dimensions,
relevant from the patient's perspective.

1 Safety

A safe treatment avoids the most common risks
encountered with MAR such as Ovarian
Hyperstimulation Syndrome (OHSS) or multiples
pregnancies. These consequences can highly
impact both on the mother and/or children's
health.

2 Effectiveness
Inequality of access to treatment
The success rates (pregnancy rate, delivery rate...)
of the different MAR treatments are important to
There is inequality of access to fertility treatment thepatientswho need transparent information on
right across Europe. Some countries provide well the important procedures they will undergo in
– some do not. Inequalities consist of disparity in order to make informed decisions.
the treatments which are permitted in some
countries, the eligibility criteria to treatment and
in reimbursement policies.In some countries, the 3 Patient centred
right of access to fertility treatment does not
necessarily mean that there is also a right to Treatments should be patient centred and not
public funding of that treatment. technology centred: communication between
patients and clinics, counselling, emotional
Treatment reimbursement support,patient involvement and privacy,
competence of clinics and staff are elements
facilitating the well being of the patient.
Fertility treatment is fully reimbursed in some
countries but the number of cycles being funded
varies. In others, it is only partially reimbursed 4 Access
with only treatments up to, but not including,
MAR such as In Vitro Fertilisation (IVF), being Inequalities consist of the variation of the
reimbursed forcing those whose only chance of eligibility criteria being employed to access
conceiving using such treatment into the private treatment, the type of treatments allowed and
sector or outside their own country. the disparity in reimbursement.

Disparities in MAR process

13

7 Criteria to ensure Equity of Access to Treatment

Access to Medically Assisted Reproduction
treatments should be governed by the same Clinical effectiveness is the ability of a procedure
principles as other health services, namely needs or treatment to achieve the desired result.
assessment, clinical effectiveness and cost Specifically, how well a particular test or treatment
effectiveness. works when used in the 'real world', rather than in
carefully controlled clinical trial. Clinical
It is inequitable for fertility patients to be subject to effectiveness is not the same as efficacy.
widen access criteria - arising perhaps from social
value judgement - which cannot be fully justified. In
general, the main eligibility criteria for access to
MAR treatments are the age of the female, the
couples’ marital status (married or legally living
together), and the existence of previous children
from the current or a previous relationship.

Health need assessment

Health needs assessmentis a systematic and equal Cost effectiveness
method for reviewing the health issues faced by a
population, leading to agreed priorities and
resource allocation that will improve health and Cost effectiveness is a type of economic evaluation
reduce inequalities. used to determine the best use of money
available for medical care. Value for money. A test
or treatment is said to be 'cost-effective' if it leads
Clinical effectiveness
14

to better result than would otherwise be achieved
by using the resources in other ways.

15

8 Prevention and Education

This subject is about two issues gathered as one, Governments which promote and support birth
promoting prevention to Europe’s politicians and control should equally inform the public of the risk
political institutions, and educating the public to their fertility from delaying having a child.
about the causes of infertility.
Governments should also work towards family
Indeed the importance of the prevention of friendly environments, to make sure delaying
infertility has not been of great enough parenthood is not the only answer for men and
significance to governments, health agencies and women who have not found a balanced
social organisations dealing with fertility. professional, social or economical situation.

European governments need to be more active in
promoting public prevention of infertility.
Infertility needs to be considered a medical Infertility is equally shared by both
condition as much in need of support as other
chronic conditions which attract funding and for
genders
which there are prevention campaigns.
The general public need to know that infertility is
In fact preventive measures can start before not solely a woman’s problem and that 45-70 % of
conception, maybe even before the time people cases are caused by either male factors or joint
xii
realize they wish to have children. But preventive factors . As such infertility is a problem shared by
thinking might also be important for couples who both partners and therefore both genders.
intend to have children much later in life.
Education on the causes of infertility must include
Lifestyle choices can impact on future fertility. If information for men on reproductive health and
people are aware of this they may consider what can impact on their fertility. To do this
lifestyle changes which could help their fertility in effectively, fertility must be separated out from
the future. virility to show it has nothing to do with
masculinity.

How to protect infertility The best place to start educating people on what
impacts on their fertility and the causes of
infertility is with teenagers and young adults, as
One method of prevention should include they are the potential parents of the future, and
information on the types of fertility disorders, the infertility will be a major concern for a large
possibilities of detection, chances and risks of proportion of them without that education. Any
treatments, their psychosocial and ethical context. education curriculum about reproduction must
This knowledge is essential for informed decision- include a component on infertility to ensure
making and to overcome the dilemma such informed decision-making.
decisions may cause.

Fertility Matters - January 2013
16

Infertility NetworkUK's educational leaflet on
Lifestyles impacting on future fertility

Sexually transmitted
infections
Anabolic steroids
The prevention of sexually transmitted
infection is vital for health in general; it is Anabolic steroids, which men
important that the public is aware this is a sometimes take to improve their
minority cause of infertility and can be performance in sports and boost
linked to less than 10 % of causes. muscle, may lead to serious fertility
However in countries which do not provide problems. They can cause the testicles
sexual education the amount of infertility to shut down completely, and the
cases caused by sexually transmitted effects are not always reversible.
diseases seems to be higher than in
countries which apply such programs.

Recreational drugs
Recreational drugs, even those which
you may think are not particularly
Delaying parenthood harmful such as cannabis, may have an
impact on both male and female fertility.
Little is done to advise young adults about
the effects of delaying parenthood which is
a major cause of fertility problems. Fertility
in women drops dramatically from their mid
30’s as well in men. Weight
In addition, the intervening years exposes
Weight problems can affect your
them and their partners to longer periods of
fertility if you are very overweight or
risk such as (i) Changes in egg quality and
underweight. Obesity is linked to
number; (ii) Changes in quality of sperm; (iii)
ovulation problems for women and
Potential to make a normal embryo may be
with lower sperm counts for men.
less good; (iv) Fibroids and early pregnancy
Being very underweight is not good for
losses which also could have a
your fertility either; women need some
detrimentaleffect on their fertility.
body fat in order to produce eggs
normally.

Eating disorders Excess or binge drinking
Eating disorders can lead to fertility Excess or binge drinking can make it
problems. Women who are anorexic often harder to conceive for both men and
find that their periods stop, and this can have women, affecting sperm and egg
a lasting impact even if a woman is able to production.
maintain a normal weight in the future.
Bulimia is linked with polycystic ovary
syndrome, a condition which affects the way Smoking
women’s ovaries work.
Smoking is known to be detrimental to
17 fertility. Women who smoke are twice
as likely to have fertility problems as
those who don’t and also often have a
shorter reproductive life as they tend to
have an earlier menopause

9 Towards a European Pact to address Reproductive
Health: Recommendations by Fertility Europe
One in six people across Europe experience some form of fertility problem at least once during their
reproductive life span, meaning that a potential 25 million EU citizens are estimated to be having difficulties in
conceiving. Infertility is recognized as a disease by both world and regional agencies such as the World Health
Organization. Over the last 35 years medically assisted reproduction techniques have been developed from
simple hormone treatments and artificial insemination up to and including in vitro fertilisation (IVF). Over 5
million people have been born worldwide thanks to IVF.

Ethics men i.e. women and men past the natural age
of conceiving to become parents.

1 People have the basic right to decide
on the number of children they have,
and when they have them. The
responsibility of couples and individuals in the
exercise of this right should take into account
the needs of their living and future children,
as well as their responsibilities towards the
community.

4 In relation to welfare of the child, both
society and the medical profession

2 There are different ways of resolving should take into account not only the
involuntary childlessness, a full range of life expectancy and current state of health of
Medically Assisted Reproduction the person, but also their expected future
treatments, as well as adoption. Those state of health and the known physical and
affected should also have the option of psychological demands of being a parent.
deciding against these treatments and
alternatives and decide to live a life without
children. Both options can bring a happy and
fulfilled life. 5 Donation of gametes on commercial
basis is ethically unacceptable.

3 There are known risks in pregnancy in
relation to age and therefore more
information and national community
debate is required before decisions about
Access to Care

assisting not only older women but also older

18

6 Infertility is a medical condition and a
health need and it should be covered as
such by national social insurance
systems.
document ensuring that the risks and benefits
of treatment are described in a balanced,
evidence-based framework, and
appropriate warnings are given when
that

evidence is inadequate to assess the efficacy

7 The inclusion of a full range of Medically
Assisted Reproduction (MAR)
treatments in the provision of basic
health care at least partially depends on the
general level of welfare in society.
or safety of specific drugs, devices or
procedures.

12 Access to psychological
counselling should be offered in
the framework of fertility

8 Fertility investigations and treatment
should be reimbursed across Europe,
and treatments of proven benefit to
patients should be made available,
investigations and treatments. People should
be offered implications counseling,
particularly if their treatment includes the use
of donated gametes and embryos. They
irrespective of the patient's income and place should be informed about any potential long
of residence. term risks and psychological, social and
medical ramifications.

9 To avoid unjustified discrimination the
principles of needs assessment, cost
effectiveness and clinical effectiveness
should be used to determine the level of
Prevention and Education

reimbursement for all assisted reproduction
possibilities.

Safe and Quality
13 Public prevention of infertility has
been inadequate to date and
governments have a responsibility
to promote unbiased rational information
about all causes, implications and treatments
options to help remove the myths and
Treatments misunderstandings.

10 People with difficulties in
conceiving should be given
accurate information in a range of
formats and languages on all assisted
14 Male infertility needs to be
highlighted as contributing to half
of the causes. Infertility can no
longer be considered a “woman’s” problem.
reproduction possibilities, as well as adoption
and a life without child, as well as being
allowed to accept or to reject the diagnosis or
treatment without discrimination. 15 Education of the next generation
about infertility and
implications needs to start now.
its

11 19
Those undergoing MAR as well as
those donating gametes should
sign an informed consent

16 Patients associations across
Europe should be recognized as a
driving force behind multi-
stakeholders prevention campaigns to make
education programmes happen.

20

xiii
Glossary

Assisted Reproduction Technology (ART): all treatments that include in vitro handling of human
gametes (eggs and sperm) and embryos to establish a pregnancy – often called MAR (Medically
Assisted Reproduction)

Delivery rate: number of deliveries per 100 cycles (aspiration or embryo transfer cycles)

Embryo: the product up to eight weeks after fertilisation, later it is called a foetus

Embryo donation: transfer of an embryo that did not originate from the recipient and her partner

Endometriosis: condition where endometrial tissue grows in areas other than the uterine cavity

Fertilisation: a sperm penetrates the egg leading to a combination of genetic material resulting in a
fertilised egg

Gamete: a reproductive cell, egg in females and sperm in males

Infertility: a disease of the reproductive system defined by the failure to conceive after 12 months of
regular unprotected sexual intercourse

Intracytoplasmic sperm injection (ICSI): process by which an egg is fertilised by injecting a single
sperm into the egg

Intrauterine Insemination (IUI): the insemination of washed semen directly into the uterus

In vitro fertilisation (IVF): fertilisation of an egg by sperm in a laboratory dish

21

References
i
Press Release on the Official site of the Nobel Prize (2010)
http://www.nobelprize.org/nobel_prizes/medicine/laureates/2010/press.html

iiART
fact sheet June 2010 from the European Society for Human Reproduction and
Embryology (ESHRE).
http://www.eshre.eu/ESHRE/English/Guidelines-Legal/ART-fact-sheet/page.aspx/1061

iii
According to Eurostats 2008:48,7 % of the 497,4 millions EU citizens are between 14 and 49 years old :
14-25 y. old (12,5 % ); 25-49 y. old (36,2%) = 242 millions
1/6 of 242 millions = 40,3 millions.
A potential of 25 millions EU citizens are estimated to be have difficulties in conceiving.

Comparative Analysis of Medically Assisted Reproduction in the EU: Regulation and
iv

Technologies European Society for Human Reproduction and Embryology (ESHRE).
http://www.eshre.eu/binarydata.aspx?type=doc&sessionId=q1m1djzhvbgxisyxggghuo55/MAR_for_web[2].pdf
v
ART in Europe, Publications from 1997 to 2006, ESHRE
http://www.eshre.eu/page.aspx/1758

ART fact sheet June 2010 from the European Society for Human Reproduction and
vi

Embryology (ESHRE).
http://www.eshre.eu/ESHRE/English/Guidelines-Legal/ART-fact-sheet/page.aspx/1061

Kerr J. et al. (1999) The experiences of couples who have had infertility treatment in the
vii

United Kingdom : results of a survey performed in 1997. Human Reprod. Vol 14 : 934-938.
viii
Wikipediahttp://en.wikipedia.org/wiki/In_vitro_fertilisation
ix
Resolution on the demographic future of Europe from the European Parliament (2008).
http://www.europarl.europa.eu/sides/getDoc.do?pubRef=-//EP//NONSGML+COMPARL+PE-
392.248+01+DOC+PDF+V0//EN&language=EN

x
European Court of Justice: Case of S.H. and others v. Austria judgment 1 April 2010.
http://cmiskp.echr.coe.int/tkp197/viewhbkm.asp?sessionId=81266049&skin=hudoc-
en&action=html&table=F69A27FD8FB86142BF01C1166DEA398649&key=93863&highlight=

Comparative Analysis of Medically Assisted Reproduction in the EU: Regulation and
xi

Technologies European Society for Human Reproduction and Embryology (ESHRE).
http://www.eshre.eu/binarydata.aspx?type=doc&sessionId=q1m1djzhvbgxisyxggghuo55/MAR_for_web[2].pdf

xi 20-30% of infertility cases are linked to physiological causes in men, 20-35% to
physiological causes in women, and 25-40% of cases are due to a joint problem. In 10-20%
no cause is found.Report from the University of Bristol, Department of Obstetrics &
Gynaecology by Professor Michael Hull: brief summary taken from an extensive review
published in Human Reproduction in 1992.

Law evasion and unequal access to treatment leads to cross-border reproductive care:
xii

Shenfield et al. (in press, 2009) Shenfield, F., de Mouzon, J., Pennings, G., Ferraretti, A.P.F.,
22

Andersen, A.N., de Wert, G., Goossens, V. And Van den Eede, B., on behalf of the ESHRE
Taskforce on cross border reproductive care 2009.

ESHRE Assisted Reproduction Technology (ART) Glossary
xiii

http://www.eshre.eu/ESHRE/English/Guidelines-Legal/ART-glossary/page.aspx/1062

23

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