’ Supplement Article
International Federation of Fertility
Societies’ Surveillance (IFFS) 2022: Global Trends
in Reproductive Policy and Practice, 9th Edition
Editor-in-Chief: Steven J. Ory
Managing Editor: Kathleen Miller
Assistant Editor: Marcos Horton
Editorial Board: Sonia Allan, Paula Amato, Basak Balaban, Manish Banker, John Buster, Antonio Capalbo, Michael Chapman,
Marcos Horton, Kathleen Miller, and Steven J. Ory2022 IFFS Surveillance Executive Advisory Committee: Peter Brinsden, John Buster, Ian Cooke, Alan DeCherrney, Paul Devroey, Silke
Dyer, Roger Kempers, Hrishikesh Pai, Joe Leigh Simpson, Basil Tarlatzis, Fernando Zegers-Hochschild, and Steven Ory

Frontispiece“The 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
the World Health Organization (WHO).”The 2022 Surveillance report was made possible, in part, through an unrestricted educational grant by Cryos International Sperm &Egg Bank.

Copyright © 2022 The Authors. Published by Wolters Kluwer on behalf of theInternational Federation of Fertility Societies. This is an open access article distributed
under the Creative Commons Attribution-ShareAlike License 4.0, which allows
others to remix, tweak, and build upon the work, even for commercial purposes, aslong as the author is credited and the new creations are licensed under the identicalterms.
Global Reproductive Health (2022) 7:e58
http://dx.doi.org/10.1097/GRH.0000000000000058

1

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Healthas a result of the pandemic[5]. Currently available data suggest a
sharp decline in birth rates in both Europe and the US during theﬁnal two months of 2020. The US Centers for Disease Control
and Prevention and the National Center for Health Statistics
reported a 4% decline in birth rates from 2019 to 2020; theseﬁndings suggest a net reduction in the number of children conceived in 2020, leading to an approximate net loss of 40,000
births in the ﬁnal two months of this year[6]. Italy and Spain bothnoted a 20% decline in the number of births reported in
December 2020 compared to December 2019. By the end of2021, over 5.4 million deaths worldwide have been directly
attributed to COVID-19. However, the actual death toll fromCOVID-19 is expected to be much higher based on measures ofexcess death rates, notably the 2021 versus 2020 comparisons tohistorical all-cause mortality baselines[7]. Although many countries lack mechanisms for analyzing and reporting excess deaths,
others have reported mortality rates over the past two years thatare signiﬁcantly greater than those ofﬁcially attributed to
COVID-19[8]. Historically, pandemics and world wars have been
associated with sudden drops in birth rates. These events are
typically followed by a birth rate “boom” beginning a few years
thereafter. While it is not clear whether the current abrupt
reduction in population growth will follow this trend, its
immediate effects on governmental resources, especially healthcare, present a nearly overwhelming challenge for many nations
around the globe. The reallocation of critical reproductive
healthcare resources to address the pandemic will most likely
result in the challenge of increased demand for these services oncethe pendulum begins to swing in the opposite direction.
Fittingly, the addition of a chapter that focuses on the impact
of COVID-19 was among the most important changes made to
the 9th edition of IFFS’ Surveillance 2019: Global Trends in
Reproductive Policy and Practice. A few additional changes havealso been made. Two previously separate chapters that pertained
to micromanipulation and oocyte maturation are now combined
into a single chapter entitled “Laboratory Techniques”. Also,
each chapter now includes the relevant questions from the 2021
questionnaire in the “Analysis of the Survey” section.
The online questionnaire was developed by the Editorial Board(EB) with help from MedTech for Solutions who conducted thesurvey and performed some of the preliminary data analysis. Thissurvey was the sole source of data presented in our report.
Overall, we received information from 149 respondents representing 93 countries (four less than we received in 2019). Theseﬁndings were used in the development of Surveillance 2022. The
questionnaire was accessible online from February 1, 2021,
through April 30, 2021. The data presented reﬂect each respondent’s impressions of the status of ART in their respective countries during this time interval. Most of the respondents were able
to complete the 122-question survey within an average of
60 minutes. Not all respondents completed all questions; this is
reﬂected in the variation in the amount of data reviewed in eachchapter. The percent positive responses cited refer to answers
received for each question. Participants were asked to respond“yes”, “no”, or “unknown” if they did not know the answer to a
speciﬁc question. Throughout the report, references are made to
the questionnaire or survey which was completed in 2021 and thereport or publication which was released in 2022. The same
distinctions were used for the earlier questionnaires in 2015 and2018 and their subsequent publications in 2016 and 2019,respectively (Table 1).

TABLE OF CONTENTS
Preface
1. Number of centres
2. Legislation and Policy Guidelines
3. Financial Support for ART
4. Covid-19 Issues
5. Marital Status, Same Sex, and Single-Parenting Policies
6. Regulations Governing The Number of Embryo Transferred
7. Cryopreservation
8. Posthumous Reproduction
9. Gamete and Embryo Donation and Anonymity of Donors
10. Laboratory Techniques
11. Welfare of The Child12. Fetal Reduction and Sex Selection
13. Preimplantation Genetic Testing
14. Surrogacy
15. Cross-border Reproductive Care
16. Human Pre-implantation Embryo Research
17. Status of the Embryo
Conclusions
Acknowledgements
Special Thanks

PREFACEOn March 11, 2020, the World Health Organization (WHO)declared that the Coronavirus-disease-2019 (COVID-19) epidemic
had achieved the status of a global pandemic. At this time, almost two
years had elapsed since the completion of the online survey used to
produce the eighth edition of IFFS Surveillance 2019: Global Trends
in Reproductive Policy and Practice. The WHO proclamation had aprofound and immediate impact on governmental and public healthagencies that were tasked with responding to this crisis. Within justone week, several reproductive medicine professional societies called
for the complete suspension of services to avoid potential COVID19-related complications of infertility therapy, pregnancy, and risks to
the fetus as well as to facilitate optimal allocation of limited and critical health care resources[1–3]. In many ways, our world came to acomplete standstill. Within seven weeks, respondents from 97 countries reported in the ﬁrst interim IFFS Surveillance survey that 82.5%of the ART centres in their countries had closed or were able to offer
only limited services in special circumstances[4]. As the COVID-19
pandemic evolved, it clearly had an uneven impact on countries
worldwide, with speciﬁc stresses noted at different times and to different extents that were met with varied responses. The 2021
Surveillance questionnaire reﬂects a wide array of responses fromcountries that remain at various stages of recovery. The execution andcompletion of the current Surveillance project faced formidable
challenges, with reports of ART centres that were closed indeﬁnitely,previous participants who remained inaccessible, and an overall
greater effort required to collect adequate and reliable data. Sadly, we
are aware of several reproductive medicine providers who succumbed
to COVID-19.
The COVID-19 pandemic has had profound demographic
effects, although this has been discerned to only a limited degree
thus far. A recently reported survey conducted in early May 2020
revealed that 40% of women of reproductive age in the US havechanged their plans regarding the number of children planned
and the anticipated timing of their pregnancies; 34% of these
women reported that they were planning to have fewer children2Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive HealthPreface. Table 1

Preface. Table 1
Participants(Continued)

Participant First NameCountry

Participant First NameCountry

Orion Gliozheni
Nigri Kamal
Ester Polak de Fried
Cristian Alvarez Sedo
Eduard HambartsoumianMichael Chapman
Thomas Ebner
Mosammat Begum
Oleg Tishkevich
Simon Azonbakin
Athanase Sodjiedo
Patricia Frias
Roberto Antunes
Paulo Matheus
Iavor Vladimirov
Eric Konyaole
Ammar Chiter
Ernestine Gwet Bell
Jason Hikari
Javier Crosby
Abril Salinas
Jeliang Wu
Lingling Ding
Zhenzhen Hou
Shuai Zhang
Keliang Wu
Jingye Zhang
Miaomiao Wang
Li Lianjie
Cheng Li
Zhen Yang
Yu Ling
Chuanxin Zhang
Xu Kai
Liu Chang
Zhang Meng
Hui Liu
Xiaonan ma
Mei li
Haibin Zhao
Hui Zhao
Nan Peng
Shuiying Ma
Lily Dong
Dong Rab
Wenrong Tao
Qingqing Yu
Ruirui Peng
Qing LiWei Zhou
Chen Mai
Xu HanYuanmei Li
Cui Juan
Lingling Ding
Qin GaiTing Guo
Guo Qingqing
Fuxia Li
Jing LiJose Ignacio Madero
Laura Mendieta
Maria Natalia Posada

Albania
Algeria
Argentina
Argentina
Armenia
Australia
Austria
Bangladesh
Belarus
Benin
Benin
Bolivia
BrazilBrazilBulgaria
Burkina Faso
Cambodia
Cameroon
Canada
Chile
Chile
China
China
China
China
China
China
China
China
China
China
China
China
China
China
China
China
China
China
China
China
China
China
China
China
China
China
China
China
China
China
China
China
China
China
China
China
China
China
China
Colombia
Colombia
Colombia

Fiorella Bagnarello
Stephane Robale
Dejan Ljiljak
Tonko Mardesic
Justin Mboloko Esimo
Ulla Istrup
Pablo Valencia
Gamal Serour
Deniss Soritsa
Ibrahim Hassan
Liisa Kuusipalo
Nathalie Massin
Yves Menezo
Lia Chkonia
Jan Krüssel
Barbara Sonntag
Dunja Baston-Büst
Edem Hiadzi
Basil Tarlatzis
Fredy Mejia
Mario Melendez
Jose Salguero
Raymond Li
Attila Torok
Hilmar Bjorgvinsson
Hrishikesh Pai
Manish Banker
Devan Patel
Tri Septyani
Maryam Shahidi
Marzieh Zamaniyan
Mudhafar Abdulhussein
Eithne Lowe
Edgar Mocanu
Liat Lerner
Yoel Shufaro
Domenico Carone
Simone Palini
Luca Gianroli
Noritaka Fukunaga
Seung Chik Jwa
Osamu Ishihara
Hashimoto Shu
Khaldoun Sharif
Niveen Zahdeh
Vyacheslav Lokshin
Alfred Murage
Ibrahim Abdelazim
Areej Abu Farha
Mamura Azimova
AlaaEldin Elshafey
Maasoumah Makhseed
Andris Grunskis
Habib Azar
Mustapha Chaaban
Abdulaziz Belhaj
Yousef Gadmour
Egle Drejeriene
KK Iswaran
Diakite Djedi Kaba
Udayakiran Doradla
Carlos Salazar
Tatjana Motrenko Simic

Costa Rica
Cote d’Ivoire
Croatia
Czech Republic
Democratic Republic of the Congo
Denmark
Ecuador
Egypt
Estonia
Ethiopia
FinlandFranceFranceGeorgia
Germany
Germany
Germany
Ghana
GreeceGuatemala
Guatemala
GuatemalaHong Kong (China*)
Hungary
Iceland
India
India
India
Indonesia
Iran
Iran
Iraq
Ireland
IrelandIsraelIsrael
Italy
Italy
Italy
Japan
Japan
Japan
Japan
JordanJordanKazakhstan
Kenya
KuwaitKuwaitKuwaitKuwaitKuwaitLatviaLebanonLebanon
Libya
Libya
Lithuania
Malaysia
Mali
Mauritius
MexicoMontenegro

3

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive HealthPreface. Table 1

for independent validation. Seven countries, including Morocco,
Italy, Japan, the United Kingdom, Israel, Italy, Portugal, and
Hungary, elected to do so. The countries that provided this additional validation measure are recognized in Table 1 in Chapter 1
within the list of participating countries.
After completion of the validation process, the ﬁndings were
submitted to the individual EB member responsible for the initialdevelopment of his or her chapter(s). All EB members shared in thedevelopment of both chapter and questionnaire content as well as
data analysis and preparation of the initial draft of their assigned
chapter(s). Following revision by the editors, the entire manuscript
was submitted to the EB and the IFFS Surveillance Executive
Advisory Committee (ISEAC) for ﬁnal review.
Surveillance continues to have several limitations. Responses
from most of the countries included in our survey were provided
by a single well-informed individual and were interpreted as
reﬂecting practices and policies of their entire nation. Most ofthese responses have not been validated and may inevitably
include inherent inaccuracies. Some respondents were not able tocomplete all the questions presented in the survey. Some ART
practices may have changed since the completion of the survey;
thus, the answers provided may not reﬂect the present situation.
For these reasons, caution should be used in interpreting the data.
When possible, responses from earlier triennial surveys and other
respondents have been reviewed and inconsistencies were adjudicated by the editors as necessary.
The EB and the ISEAC played essential roles in the successful
completion of Surveillance 2022. I am most appreciative of all the
respondents that registered online and submitted data on behalf of
their country. Identiﬁcation, engagement, and encouragement forthese individuals were accomplished by a small army of Surveillance
supporters including numerous IFFS ofﬁcers, board members, andstaff. Their persistence in recruiting national representatives andtheir commitment to producing as inclusive, comprehensive, andaccurate a report as possible during an extraordinarily challenging
two years was exemplary. The individuals deserving of special
mention include Silke Dyer, Marcos Horton, and Fernando Zegers
who served as champions for the entire continents of Africa andSouth America. The industry and imagination of our Managing
Editor, Kathleen Miller, were the glue that held the entire enterprise
together, as she played a major role at each stage of the developmentof Surveillance 2022. The IFFS ofﬁcers, Board of Directors, andsupport staff provided unﬂagging encouragement and resources to
see this project to its completion.
Although the level of participation in Surveillance 2022 wascomparable to 2019, the international status of ART is, in many
ways, less clear at this time. The responses do not consistently
reﬂect the trends of growth, greater access, and increased
inclusiveness that were depicted in earlier editions of this survey. The disruption in the healthcare infrastructure and thepolitical, cultural, and public health upheaval that has occurred
during the previous three years has had a profound impact on
reproductive care and suggests an evolution in progress. The
effects of the pandemic will likely be more apparent during thenext three years.

(Continued)
Participant First Name
Omar Sefrioui
Adriaan P van der Colf
Jesper Smeenk
Cynthia FarquharJohn Peek
Abiola Adewusi
Fayeofori Iketubosin
Liv Bente Romundstad
Roberto Enrique Epifanion Malpassi
Roger Molinas
Elard Arriaga
Angela Aguilar
Jacek Szamatowicz
Carlos Calhaz-Jorge
Maryam Al Abdulla
Mircea Onofriescu
Anna Smirnova
Oksana Shurygina
Sava Micic
Veljko Vlaisavljevic
Silke Dyer
Bevan FryPaul Le Roux
Sung Woo Kim
Jeong Ho Rhee
Yosu Franco Iriarte
Enrique Criado
Yassir Elsiddig
Yagoub Magid
Ann Thurin-Kjellberg
Nicole Mazuguni
Nicholaus Mazuguni
Pantaleo Roman
Catherine Minto-Bain
Mohamed Khrouf
Basly Mohamed
Hakan Kozinoglu
Murat Basar
M. Ertan Kervancioglu
Mark Muyingo
Moses Tiri
Raj Mazur
Alison Campbell
Kristen Ivani
David Adamson
Rita Vernocchi
Francisco Risquez
Jose Carlos Rosales Escuredo
Lan Vuong
Tinovimba BagnarelloCountry
MoroccoNamibia
Netherlands
New Zealand
New ZealandNigeria
Nigeria
NorwayPanamá
Paraguay
Perú
Philippines
PolandPortugal
Qatar
Romania
Russian Federation (Russia)
Russian Federation (Russia)
SerbiaSlovenia
South Africa
South Africa
South Africa
The Republic of Korea (South Korea)
The Republic of Korea (South Korea)
Spain
Spain
Sudan
Sudan
SwedenSwitzerland
Tanzania
Tanzania
Trinidad & Tobago
Tunisia
Tunisia
TurkeyTurkeyTurkeyUgandaUgandaThe United Kingdom of Great Britain
and Northern Ireland (UK)The United Kingdom of Great Britain
and Northern Ireland (UK)The United States of America (USA)The United States of America (USA)Uruguay
Venezuela
Venezuela
VietnamZimbabwe

Several new measures were introduced this year to enhance thereliability of the data received for Surveillance 2022. For the 14
countries with greater than 90 ART centres, separate clinical andlaboratory respondents were recruited who were asked to respondto their respective relevant sections of the questionnaire. We also
provided the opportunity to submit data received from the national
respondents to their respective IFFS member professional societies

Steven J Ory
Editor-in-Chief
Surveillance 2022: Global Trends in Reproductive Policy and Practice
December 2021
4

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Healthcountries with ≥ 90 ART centres to enhance the full completionand validation of the surveillance study.
Of the 193 countries currently recognised by the United
Nations (UN), 132 were conﬁrmed as offering ART services in
2021 at the time the online survey was conducted. The Holy See
and the State of Palestine are UN non-member observer states;
neither provide ART services. As has been done in the past, datafrom Hong Kong (also a UN non-member state) have been listed
separately from information provided by China.

References[1] British Fertility Society. Guidance for the care of fertility
patients during the Coronavirus COVID-19 Pandemic 12/31/
2021. Available at: https://www.britishfertilitysociety.org.
uk/2020/03/18/guidance-for-the-care-of-fertility-patients-dur
ing-the-coronavirus-covid-19-pandemic/.
[2] ESHRE News. Available at: https://www.eshre.eu/PressRoom/ESHRE-News#COVID19P2.
[3] American Society for Reproductive Medicine (ASRM).
American Society for Reproductive Medicine (ASRM)
Patient Management and Clinical Recommendations During
the Coronavirus (COVID-19) pandemic. Available at:https://www.asrm.org/globalassets/asrm/asrm-content/
news-and-publications/covid-19/covidtaskforceupdate1.pdf.
[4] Ory SJ, Miller KA, Horton M. The global impact of COVID19 on infertility services. Glob Reprod Health 2020;5(2):e43.
[5] Lindberg LD, vandeVusse A, Mueller J, et al. Early impacts of
the COVID-19 pandemic: ﬁndings from the 2020
Guttmacher survey of reproductive health experiences.
Available at: https://www.guttmacher.org/report/early-impa
cts-covid-19-pandemic-ﬁndings-2020-guttmacher-survey-rep
roductive-health.
[6] Hamiton BE, Martin JA, Osterman, MJK. Births: provisional
data for 2020. Division of Vital Statistics, National Centerfor Health Statistics. Available at: https://www.cdc.gov/nchs/
data/vsrr/vsrr012-508.pdf.
[7] Ritchie H, Mathieu E, Rodés-Guirao L, et al. Coronavirus
pandemic (COVID-19). 2020. Available at: https://ourworl
dindata.org/covid-deaths.
[8] Tracking covid-19 excess deaths across countries. Available
at: https://www.economist.com/graphic-detail/coronavirusexcess-deaths-tracker.

Analysis of the Survey
Ninety-three countries provided data that are included in the 2022
report (Table 1, Chart 1). This represents a slight decline from the
97 countries that participated in 2019. In 2021, 42 countries thatare believed to provide ART services did not participate in the
study, three more than in 2018 (Table 2). Only 61 countries participated in all three of the previous surveys (i.e., those published in2016 and 2019 as well as in 2022). However, 15 countries thatparticipated in the 2022 survey are either new or are contributors
that have returned this year but did not participate in the 2019
survey. Of note, Benin and Ethiopia previously reported that they
did not provide ART services; this year they report the establishment of one and three centres, respectively. Conversely, 17 countries that participated in 2019 did not participate this year.
Honduras, Oman, Saudi Arabia, and the Slovak Republic allparticipated in the past but did not contribute to either the 2019 or
2022 reports. In 2021, 63 countries were identiﬁed that did notoffer ART Services (Table 3).

Chapter 1. Table 1
Participating Countries

CHAPTER 1: NUMBER OF CENTRESIntroduction
Estimating the number of Assisted Reproductive Technology(ART) centres in each country continues to be a formidable
challenge. The number of centres that offer services at any given
time is dynamic by its nature. The numbers reported herein
represent primarily calculations generated by single respondents that were submitted between February and April of 2021.
At that time, many countries were still profoundly affected by
the Coronavirus disease-2019 (COVID-19) pandemic.
Nevertheless, signiﬁcant organizational progress has beenachieved in many countries over the past three years as theirprofessional societies and health ministries have begun torecognise and incorporate the efforts of ART centres within
their jurisdictions. Thus, the ﬁndings that document changes in
the numbers of national ART centres have become more reliable over time. As part of this effort, the results were submitted
to each of the professional societies represented by an IFFS
member for independent validation. The seven countries withvalidated responses are highlighted in Table 1. Tracking andtabulating these data may be less challenging for countries withfewer than 90 ART centres. Countries with large populations
and many ART centres (for example, China and India) were
only able to provide estimates. A separate set of questions
focused on clinical and laboratory facilities was distributed to

Albania+

EcuadorKazakhstan

Portugal#

Argentina
Armenia
Australia
Austria
Bangladesh
Belarus
Benin+
Bolivia
BrazilBulgaria
Burkina
Faso
Cambodia+
Cameroon
CanadaChile
China
Colombia

Egypt
Estonia
Ethiopia+
FinlandFranceGeorgia
Germany
Ghana+
GreeceGuatemalaHong Kong(China*)Hungary#
Iceland
India
Indonesia
Iran
Iraq

Kenya
Kuwait +LatviaLebanon +Libya +
Lithuania
Malaysia
Mali
Mauritius +MexicoMontenegro

Qatar +
Romania
Russian Federation (Russia)
SerbiaSlovenia
South Africa
South Korea
Spain
Sudan+
SwedenSwitzerland

Morocco+ #Namibia
Netherlands
New ZealandNigeria
NorwayCosta Rica
Coted’Ivoire
Croatia+
Czech
Republic
DR Congo
Denmark +IrelandIsrael#PanamaParaguay

United Republic of Tanzania + (Tanzania)
Trinidad & Tobago
Tunisia
TurkeyUgandaThe United Kingdom of Great Britain andNorthern Ireland (UK)The United States of America (USA)Uruguay

Italy#
Japan#

Peru
Philippines

Venezuela
Viet Nam

JordanPolandZimbabwe+ Denotes non-responding countries to 2019 Surveillance.
# Denotes professional society validated data.

5

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

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

Chapter 1. Table 2
Non-responding Countries With ART
Afghanistan
Algeria
Azerbaijan
BahrainBarbados
Belgium
BhutanBosnia & Herzegovina
Botswana
Brunei
Cuba

CyprusDominican Republic
El Salvador
Haiti
Honduras
Jamaica
The Lao People’s Democratic Republic
The Former Yugoslav Republic of Macedonia
Madagascar
Moldova
Mongolia

Mynamar
Nepal
Nicaragua
The Democratic People’s Republic of Korea
Oman
Pakistan
RwandaSaudi Arabia
SenegalSingapore
Slovak RepublicOverall, the number of ART centres documented worldwide
has increased from 6201 to 6977 over the past three years(Table 4). Most of the reported increases can be attributed togains in four speciﬁc countries, including China (400 centres
reported in 2018 and 523 centres reported in 2021), India(1500 centres in 2018 and 2000 centres in 2021), the RussianFederation (200 centres in 2018 and 300 centres in 2021), andSpain (150 centres in 2018 and 300 centres in 2021).
Interestingly, Spain had reported a decline from 200 centres in2015 to 150 centres in 2018. The 21 countries that previously
participated but did not respond in 2021 had collectively
reported a total of 530 centres as part of the previous surveys inwhich they had participated; these countries included Sri Lanka(110 centres, in 2018), Senegal (100 centres, in 2018), Taiwan(China*; 78 centres, in 2018), and Thailand (75 centres, in2018). In 2021, 21 countries recorded increases of more thanﬁve centres, while ten countries reported decreases of ﬁve or
more. Australia (100 centres in 2018 versus 80 in 2021) andBrazil (200 centres in 2018 versus 150 in 2021) reported thegreatest declines over the previous three years. Most of the

Sri Lanka
Syria
Taiwan (China*)
ThailandTogo
UkraineUnited Arab Emirates
Yemen
ZambiaChapter 1. Table 3
Countries Without ART

6

AndorraAngolaAntigua & Barbuda
Bahamas
BelizeBurundiBurundiCabo VerdeCentral African
Republic
Chad
Comoros
Djibouti
Dominica
Equatorial Guinea

Gabon
GambiaGrenadaGuineaGuinea-Bissau
GuyanaHoly See
Kiribati
Kyrgyzstan

Marshall Islands
Mauritania
Micronesia
MonacoMozambique
Nauru
Niger
Palau
Palestine

Sao Tome Principe
Seychelles
Sierra Leone
Solomon Islands
SomaliaSouth Sudan
Suriname
Eswatini
Tajikistan

LesothoLiberia
Liechtenstein
Luxembourg
Malawi

Timor-Leste
Tonga
Turkmenistan
TuvaluUzbekistan

EritreaFiji

Maldives
Malta

Papua New Guinea
Republic of the CongoSaint Kitts and Nevis
Saint Lucia
Saint Vincent &Grenadines
Samoa
San Marino

VanuatuReporting Year (Number of Centres)

Type of Centre

7

2010

2013

2016

2019

2022

Albania
Algeria
Argentina
Armenia
Australia
Austria
Bangladesh
Barbados
BelarusBelgium
Benin
Bolivia
Botswana
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Croatia
Czech Republic
Denmark
Dominican Republic
Democratic Republicof Congo
EcuadorEgypt
El Salvador
Estonia
Ethiopia
FinlandFranceGeorgia
Germany
Ghana
GreeceGuatemalaHonduras

NR
NR
23-25
NR
63
25
NR
NR
4
16-29
NR
NR
NR
150
16
NR
NR
2
NR
8-9
102-300
19-21
NR
7-11
30
18-22
4
1

NR
NR
30-44
NR
NR
25
NR
NR
4
31
NR
NR
NR
200
23
NR
NR
2
NR
7
> 200
27
NR
13
38
18-21
5
1

NR
NR
60
NR
76
27
12
1
8
34
NR
NR
NR
180
31
NR
NR
2
32
9
358
25
NR
12
42
21
NR
NR

NR
2
65
6
100
28
11
1
8
10
NR
10
1
200
37
1
NR
3
34
12
400
23
2
NR
42
NR
7
3

3
3
52
6
80
31
11
NR
8
NR
1
4
NR
150
35
2
7
3
36
12
523
32
4
15
42
27
NR
2

6-8
52-55
NR
NR
NR
19-20
90-106
NR
NR
NR
50-60
NR
NR

11
58
NR
NR
NR
18
100
NR
NR
NR
∼60
NR
NR

10
NR
0
4
NR
24
104
NR
134
NR
66
3
2

12
70
2
6
NR
21
101
9
125
18
50
4
NR

10
110
NR
6
3
22
103
16
130
18
45
5
NR

PrivateHospital BasedClinics

Private or Public
University BasedClinics

3

2

50
2
74
21
10

5
3

1

1

3

5

1
2

3

2
4

1

90
15

50
7
2

32
3
7
36

3
2

3
2

7
1

1
2
2
13

6
710
1

1

1

7
5
3

3

1
13

1

5

5

2

2
2
12

1

1

2
1
4

12
110

4

21
5

10
2

2
4
3
30

13

10
98

5
1
5
1

5

5
3
24
7

Sole
Public Hospital Practitioner
Based Clinics
Clinic

6

21
18
8

9

2

5

Global Reproductive HealthCountry

PrivatePhysicians
Clinic

Abstracts. Global Reproductive Health (2022) 7:e58

Chapter 1. Table 4
Number of Centres 2021

(Continued)
Reporting Year (Number of Centres)

Country

8

2010

2013

2016

2019

2022

7
12
1
500
NR
NR
NR
7
24-30
360
3
606-618
NR
NR
NR
NR
4-5
NR
NR
NR
NR
NR
NR
“Uncertain”
NR
NR
NR
N
NR
NR
NR
7
NR
NR
11
NR
7
NR
5-7
4
NR
24

9-12
14
1
500-600
NR
NR
NR
7-8
29
350
2
591
NR
12
NR
NR
4
NR
NR
NR
NR
NR
NR
∼30
NR
NR
NR
NR
NR
NR
NR
7
NR
NR
10
NR
9
NR
6
5
NR
28

11
13
NR
1000
26
62
13
28
34
350
NR
587
20
19
5
NR
NR
NR
NR
NR
36
1
NR
48
NR
NR
NR
NR
1
NR
13
9
NR
50
12
14
12
2
12
6
50
24

42
11
1
1500
32
60
5
8
23
350
4
574
22
23
9
NR
7
NR
NR
6
12
1
NR
81
1
4
5
NR
2
2
15
8
1
36
10
NR
10
2
18
7
70
24

40
14
1
2000
42
41
15
9
25
329
2
600
35
27
11
15
6
20
40
8
52
3
4
100
NR
NR
6
17
NR
2
16
7
NR
96
11
NR
12
2
32
8
39
26

PrivatePhysicians
ClinicPrivateHospital BasedClinics

Private or Public
University BasedClinics

Sole
Public Hospital Practitioner
Based Clinics
Clinic

18
3
1
400

4

2
11

7

9

100
34

50

25
8

1500

1
4
33

18
20

21
77

58
30
25

71
2
2

52
6

41
8
181
1
421
27
6
3
6
16
80
8
20
2

25
5

11

1

4
50

20

10
50

2
4

5

8

10

4

3
15

1
2

1
15

80

15
3
1
7

1
30

3
15

2
2
6

14
1
59
5

11
2
31
7
35
16

18

7
4

30
2
1
1

1
4
1

9

Global Reproductive HealthHong Kong (China*)
Hungary
Iceland
India
Indonesia
Iran
Iraq
IrelandIsrael
Italy
Ivory CoastJapan
JordanKazakhstan
Kenya
KuwaitLatviaLebanon
Libya
Lithuania
Malaysia
Mali
Mauritius
MexicoMoldova
Mongolia
Montenegro
MoroccoMyanmarNamibia
Netherlands
New Zealand
Nicaragua
Nigeria
NorwayOman
PanamaParaguay
Peru
Philippines
PolandPortugalType of Centre

Abstracts. Global Reproductive Health (2022) 7:e58

Chapter 1. Table 4

NR
NR
80
24-30
2
NR
9
NR
3
12-15
142
177-203
NR
NR
15-16
26
72-78
NR
NR
1
NR
8
112-1161
NRNR
66
450-480
4
17-18
11-12
NR
3524-3870

NR
NR
110- 130
30
2
NR
11
NR
3
15
150
> 100
NR
NR
16
26
76
NR
NR
1
NR
12
131
2
NR
NR
71 -117
430
4
10
13
NR
3701-3890

NR
21
170
50
2
NR
11
9
3
20
148
371
6
NR
17
25
79
NR
NR
NR
1
9
153
NR
NR
NR
78
410
3
30
NR
NR
5335

NR
23
200
NR
100
15
11
NR
3
22
154
150
110
NR
10
29
78
NR
75
2
1
13
154
6
40
10
82
450
3
22
26
2
6201

66
40
300
NR
NR
15
NR
NR
3
40
157
300
NR
8
16
30
NR
1
NR
NR
1
12
135
5
NR
NR
75
450
3
9
34
2
6977

6
34
140

3
4
100

3
2
20

5

20
71
82
12
9
14

3
40

6

1
5
53
58
11
4

30
69
12
7
5

6

2
3
3
40
1

4

12

11

7

1

1
9
50
2

30
275
3
6
1

50
3

3
30

Abstracts. Global Reproductive Health (2022) 7:e58

9

Qatar
Romania
Russian Federation
Saudi Arabia
SenegalSerbiaSingapore
Slovak Republic
Slovenia
South Africa
South Korea
Spain
Sri Lanka
Sudan
SwedenSwitzerland
Taiwan (China*)
Tanzania
ThailandTogo
Trinidad & Tobago
Tunisia
TurkeyUgandaUkraineUnited Arab Emirates
United Kingdom
United States
Uruguay
Venezuela
Viet Nam
Zimbabwe
Totals

5

5
50

20
50

20
25

3
18
1

3

13

50

1

NR indicates no response.

Global Reproductive HealthAbstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Healthguidelines provided by the government or professional societies. Many countries have additional provisions for licensing
and agency oversight.
The limits of these regulations are determined by the local
stakeholders, including patient advocacy groups, local healthcare providers, professional organizations, local and national
governmental agencies, legislative bodies, religious organizations, and insurance companies, as well as other entities that are
responsible for payment. The speciﬁc policies endorsed by theseagencies reﬂect the various positions adopted. These positions arelargely dependent on speciﬁc social, cultural, religious, andpolitical norms in the community. These norms are addressed ingreater detail in subsequent chapters.

countries that reported a decline in the number of ART centres
were in Europe and South America. The COVID-19 pandemic
may have had an especially profound impact on reproductive
services in these regions.
Discussion
While it may not be fully apparent from an assessment of total
numbers, many of the smaller low-to-middle income countries
have made signiﬁcant advances suggesting that they are providing improved access to ART services. Among these countries,
Colombia, Egypt, Georgia, Indonesia, Iran, Iraq, Jordan,
Malaysia, Mexico, Nigeria, Peru, Romania, South Africa, andVietnam have all reported modest but proportionately signiﬁcant increases in the number of ART centres providing services during the previous three years.
ART services are available from various providers and sources.
The private clinic model remains overwhelmingly the mostcommon category; fewer than 10% (633) of these clinics arereported to be university-based. Public clinics that provide ART
services are not common in most countries. Exceptions to this rule
are countries with a large number and/or a high proportion of
public versus private clinics. Findings from 2019 Surveillance
revealed that more than half of the private clinics included in the
study operated under the sole practitioner model. However, thisresult may be an anomaly, as only ﬁve countries (Bulgaria, Costa
Rica, India, Kazakhstan, and Libya) identiﬁed sole practitioners
as the dominant practice model in 2021.
Countries that recorded an increase may be those that haveestablished an ART infrastructure and are now capable ofproviding increased access to care. Many of the countries thatreported a decrease in the number of centres may be those thatwere directly affected by the COVID-19 pandemic and/or
responded to governmental or professional society health carerecommendations by curtailing ART services. Some of the differences reported here may reﬂect the unique perspective ofeach respondent as well as a variety of different samplingtechniques.

Analysis of the Survey
Questions posed by the survey include:
1. Is ART regulated in your country?
2. How is ART regulated in your country?
3. If possible, please specify where government/regulatory
documents or relevant information can be accessed
4. Have there been any updates to the regulation of ART in
your country since 2018?
5. If you answered yes to question 6, what were the main
modiﬁcations?
6. Have there been any instances where violations of national
ART policies have been reported?
7. Are their licensing criteria in your country for ART centres?
REI physicians? OB/GYN physicians? ART Laboratory?
ART Laboratory Director? ART Technical Staff? Mental
Health Professionals? Fertility Nurses?
8. What are the licensing criteria for an IVF/ART centre? REI
physicians? OB/GYN physicians? ART Laboratory? ART
Laboratory Director? ART Technical Staff? Mental HealthProfessionals? Fertility Nurses?
9. Are there monitoring mechanisms for governance, licensure,or credentialing in your country for ART centres? REI
physicians? OB/GYN physicians? ART Laboratory? ART
Laboratory Director? ART Laboratory Technical Staff?
Mental Health Professionals? Fertility Nurses?
10. How is monitoring of governance, licensure or credentialing
carried out? For each of above
11. Who monitors the adherence governance, licensure, orcredentialing in your country? For each of above
12. Are penalties designated for violation of governance, licensure, or credentialing?
Of the 90 countries that provided information pertaining to theregulation of ART, 69% (62) reported the existence of some typesof regulations that govern the practice of ART. Of these 62
countries, 90% (56) reported that ART was governed by federal(national) laws, statutes, ordinances, or policies, while 32% (15of 47) noted the existence of state, provincial, or regional laws,
statutes, or ordinances. By contrast, two of the 43 respondents
reported the existence of municipal laws, statutes, or ordinancesthat regulated ART, while 48% (23) of 48 respondents describedagency-based regulations or oversight. Furthermore, 69% (35 of51) described licensing bodies, and 72% (38 of 53) noted thatoversight was provided by standards or guidelines provided byprofessional organizations (Table 1).
In 2018, 87% (77) of 89 respondents reported the existence oflegislation and/or guidelines that regulated the practice of ART in

Summary
These data do not suggest any clear global trends. Except for thefour countries that recorded increases of more than 100 ART
centres in the previous three years, the others have experienced
relatively modest ﬂuctuations overall. Virtually all the reported
increases can be attributed to growth reported in China, India,
the Russian Federation, and Spain.

Chapter 2: LEGISLATION AND POLICY GUIDELINES
Introduction
The 2021 Surveillance Survey provides a unique opportunity
to compare systems that govern the use of Assisted
Reproductive Technology (ART) in various countries worldwide. Data collected from respondents in 90 countries provided meaningful information regarding regulations,
governance, and oversight of ART. Some form of regulation
currently exists in most countries where ART services areavailable. Most often the regulation focuses on legislativerequirements that establish the speciﬁc boundaries of ART
practice. This legal framework is frequently supplemented with10

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 2. Table 1
Is ART regulated in your country?

Country
Albania
Argentina
Armenia
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Croatia
Czech Republic
Democratic
Republic of theCongo
Denmark
Ecuador
Egypt
Estonia
Ethiopia
FinlandFranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong(China*)Hungary
Iceland
India
Iran
IrelandIsraelItaly
Japan
JordanKazakhstan
Kenya
KuwaitLatviaLebanon
Libya
Lithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia

Regulations?
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No

Federal/National Laws/
Statutes/ Ordinances/
Policies

State/Provincial/Regional
Laws/Statutes/
Ordinances

Municipal Laws/
Statutes/
Ordinances

AgencyRegulations/
Oversight

Yes
Yes
Yes
Yes
Yes

No
No
Yes
No

No
No

No
No
Yes
Yes

Yes
Yes

Yes

Yes
No

No
Yes

No

No
No

Yes
Yes

Yes
Yes
Yes
Yes
Yes
Yes

Professional
Licensing Organization Standards/
Body
Guidelines
No
Yes
Yes

Yes
Yes
Yes
No

Yes

No

Unknown
Yes

Yes
Yes

Yes
Yes
No
Yes

No
No
No

No
Yes
Yes

Yes
Unknown
Yes

Yes
Yes
Yes

Yes

Yes
Yes

No

No

Yes
No

Yes
Yes

Yes
Yes

Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes

Yes

No

No

Unknown

Yes

Yes

No
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No

No
No
No
No
No

No
No
Yes
Yes
No

Yes
Yes
Yes
Yes
No

Yes
No
Yes
No
No

Yes

No

Yes

Yes

Yes
Yes

Yes

Yes

Yes

Yes

No

No

Yes

Yes

Yes
Yes
No
Yes
No
Yes
Yes
Yes
No
Yes
No
Yes
Yes
No
No
Yes
No
No
No
Yes
Yes
No

Yes
Yes

No
No

No
No

No
No

No
Yes

No
No

Yes

Yes

Yes

Yes
Yes
No

Yes
No

No
No

Yes
No

Yes
No

Yes
Yes
Yes

Yes

No

No

No

Yes

Yes

Yes
Yes

Yes
No

Yes
No

No
Yes

Yes
Yes

Yes
Yes

Yes

Yes

No

No

Yes

Yes
Yes

No

No

11

No

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 2. Table 1(Continued)

Country
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
PolandPortugal
Qatar
Romania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain
Sudan
SwedenSwitzerland
Tanzania
Trinidad &TobagoTunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

Regulations?
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
No
Yes
Yes
No
Yes
Yes
Yes
No
Yes
No

Federal/National Laws/
Statutes/ Ordinances/
Policies

State/Provincial/Regional
Laws/Statutes/
Ordinances

Municipal Laws/
Statutes/
Ordinances

AgencyRegulations/
Oversight

Yes
Yes

No

No

No
Yes

Yes
Yes

Yes
No

No

No

No

Yes
Yes
Yes
No

Yes
Yes
Unknown
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
Unknown
No
Yes
No

No
No
Unknown
No
No
No

Yes
No
No

Yes
No
No

Yes
Yes
Yes
Yes
No
Yes
Yes
No
No
No

Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
No
No

No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No

Yes
Yes

No
Yes

No
No

No
Yes

No
Yes

Yes
Yes

Yes
Yes

No

No

No

Yes
No

No

Yes
Yes
Yes

No
Yes
No

No
No
No

Yes
Yes
No

No
Yes
No

No
Yes
No

Yes

No

No

No

No

Yes

Yes

their countries. Of these, 64% (57) reported the existence oflegislation that was designed to regulate ART, while 33% (29)replied that no such legislation existed. Two countries respondedwith “unknown”. In 2015, 57% (40) of the 70 countries thatparticipated in the survey reported that legislation directed at theregulation of ART existed. These varying percentages most likely
reﬂect changes in sampling methods. Overall, the results of thestudy revealed no evidence to suggest that any government has
rescinded regulations pertaining to ART.
As a new feature for this edition of Surveillance, 54 countries
provided information on how and where one can access governmental and regulatory documents and relevant information(Table 2).
Changes made to regulations since the 2018 Surveillance
study: Seventy-two percent (63) of 88 respondents reported thatno changes to regulations governing the practice of ART had been
made in their countries since the 2018 Surveillance study. By
contrast, 27% (24) of the 88 respondents reported speciﬁcchanges in legislation that were made during this interval(Table 3). Speciﬁcally, 75% percent (15) of 20 respondents
described legislative changes that increased access to donations,while three of 20 respondents reported legislative changes that
limited access to donations. Similarly, 33% (ﬁve) of 15 respondents reported changes in regulations that either increased orProfessional
Licensing Organization Standards/
Body
Guidelines

decreased access to pre-implantation genetic testing (PGT). Fourof 16 respondents reported changes in regulations that may resultin an expansion of the number of embryos available for transfer.
By contrast, 63% (ten of 16) reported changes that limited thenumber of embryos available for transfer.
Two of 15 respondents reported that new regulatory changes
may expand access to surrogacy, while 60% (nine of 15) noted
new regulatory changes that decreased access to this practice.
Four of 17 respondents reported changes in regulations that
may increase access to cross-border reproductive care, while 53%(nine of 17) reported changes that limited access to these services.
Twenty-eight percent (ﬁve) of 18 respondents reported legislative changes that resulted in increased access for same-sex
couples, while 33% (six of 18) reported changes that decreased
access for same-sex couples. Similarly, 44% (seven) of 16
respondents reported regulatory changes increased access basedon marital status, while 38% (six of 16) reported changes that
decreased access to treatment based on marital status.
Forty-seven percent (nine) of 19 respondents reported on new
regulatory changes that restricted the utilization of cloning
methodologies. However, 70% (14) of 20 respondents reported
regulatory changes that increased access to cryopreservation,
while two respondents described regulatory changes that
decreased access to this modality. Finally, while 40% (six) of 15
12

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health
Chapter 2. Table 2

Chapter 2. Table 2
Location of government/regulatory documents or relevant
information
Country

Documents

Albania
Argentina
Armenia
Australia

https://www.ishp.gov.al Law nr. 8876, dt. 04.04.2002
Www.samer.org.ar
https://www.arlis.am/
FSANZ RTAC, all state governments have own ledislation forreproductive technology, Embryo Research Act (commonwealthgovernment of Australia)
https://www.ris.bka.gv.at/GeltendeFassung.wxe?Abfrage=
Bundesnormen&Gesetzesnummer=10003046
https://kodeksy-by.com/zakon_rb_o_vspomogatel_nyh_
reproduktivnyh_tehnologiyah.htm; https://pravo.by/upload/docs/op/
W22035340_1589317200.pdf
Child code 2015at ANVISA website or at CFM website
https://www.mh.government.bg; https://iamn.bg
moh.gov.kh
government procedure in progress
Health Canada is the best source. Each province, however, has its own
College that regulates private facilities.
http://www.repositoriodigital.minsal.cl/bitstream/handle/2015/827/
GUIA-PARA-EL-ESTUDIO-Y-TRATAMIENTO-DE-LA-INFERTILIDAD_
2015-FF1.pdf?sequence=1&isAllowed=y
http://www.nhc.gov.cn/
there are 2 regulations of the ministry of health both incomplete and not
updated
Decreto Fertilización In Vitro
https://zdravlje.gov.hr/programi-i-projekti/nacionalni-programiprojekti-i-strategije/nacionalni-transplantacijski-program/godisnjaizvjesca/medicinski-pomognuta-oplodnja-3337/3337
www.uzis.cz

Austria
Belarus

Benin
BrazilBulgaria
Cambodia
Cameroon
CanadaChile

China
Colombia
Costa Rica
Croatia

Czech
Republic
Denmark
Egypt
Estonia
Ethiopia
FinlandFranceGhana
GreeceHong Kong(China*)Hungary
Iceland
Italy
Kazakhstan
LatviaLithuania
MexicoMontenegro
MoroccoNetherlands
New ZealandNigeria
NorwayPortugal
Romania
RussiaSerbiaSlovenia(Continued)
Country

Documents

South Africa
South Korea
Spain
Switzerland
Tunisia

https://www.gov.za/documents/national-health-act
https://www.law.go.kr
BOE
www.admin.ch
http://www.santetunisie.rns.tn/fr/presentations/textes-juridiques-etreglementaires?start=45
ministry of health ivf centers department
www.hfea.gov.uk

TurkeyUnitedKingdom
United States
Uruguay

https://www.cdc.gov/art/nass/policy.html
www.fnr.gub.uy

respondents reported changes that served to increase access to
micromanipulation methodologies, four respondents reported
the opposite situation.
Credentialing: Findings that summarise credentialing of ART
centres and professionals are included in Table 4.
The ART centre: Ninety respondents submitted information
pertaining to speciﬁc licensing criteria in their countries, including
the nature of credentialing bodies and methods used to monitor
ART centres as well as the requirements for physicians specializing in reproductive medicine, obstetricians and gynaecology
specialists practising ART, the ART laboratory, and the laboratory directors and staff. Seventy-seven percent (69) of the 90
respondents reported that ART centres in their countries were
subject to licensing requirements. Country-speciﬁc licensing
requirements for ART centres were reported as follows:• 70% (48) of the respondents reported that ART centres weregoverned by multiple licensing requirements, including combinations of certiﬁcations and/or examinations, continuing
education, periodic reporting, and on-site inspections.
• 20% (14) of the respondents reported that centres were
subject to on-site inspections only.
• Three respondents reported the need for certiﬁcation and/or
examination only.
• Three respondents noted the requirement for periodic reporting and on-site inspections.

Danish Health Authorities, Assisted Reproduction - https://stps.dk/da/
ansvar-og-retningslinjer/vejledning/assisteret-reproduktion/#
Egyptian Medical Council (Medical Syndicate}https://www.riigiteataja.ee/akt/1048155
Ministry of health of Ethiopia
THL and Fimea
https://www.agence-biomedecine.fr
Ministry Of Healthwww.eaiya.gr
https://www.chrt.org.hk/
https://net.jogtar.hu/jogszabaly?docid=99700049.NM
https://www.althingi.is/lagas/nuna/1996055.html
https://www.iss.it/rpma-normativa
The code of health care in Kazakhstan
https://www.zva.gov.lv/lv/
https://e-seimas.lrs.lt/portal/legalAct/lt/TAD/
f31c44c27bd711e6a0f68fd135e6f40c/asr
REDLARAwww.mzd.gov.me
Sgg.gov.ma
https://wetten.overheid.nl
https://www.legislation.govt.nz/act/public/2004/0092/latest/whole.
html
www.afrhnigeria.org
www.helsedirektoratetet.nohttps://www.cnpma.org.pt/
https://sogr.ro/ghiduri-clinice-2019-ﬁnale/
http://rahr.ru/d_index/0001202010190041.pdf
www.gov.rs
http://www.pisrs.si/Pis.web/pregledPredpisa?id=ZAKO2518

Chapter 2. Table 3
Main Modiﬁcation to legislation in the last 3 years

13

Main Modiﬁcation (in rank order)% (More than one topic may havebeen modiﬁed per country)

Legislation and guidelines
Donation
Cryopreservation
Number of embryos for transfer
Cross border reproduction
Marital status
Same sex/single parenting policies
Surrogacy
Pre-implantation genetic testing
Micromanipulation
Posthumous reproduction
Cloning

88%
75%
67%
58%
54%
54%
46%
46%
42%
42%
38%
38%

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health• 16% (ten) required certiﬁcation or examination and on-site
inspections.
• 10% (six) required certiﬁcation or examination, periodic
reporting, and on-site inspections.
• 8% (ﬁve) of the respondents reported that certiﬁcation and/or
examination were the sole criterion for licensing.
• Three of the 62 respondents noted requirements for either• continuing education; or• continuing education and on-site inspections.
• Two respondents noted the need for periodic reporting andon-site inspections.
• One respondent noted requirements for either• certiﬁcation or examination, continuing education, andon-site inspections;• certiﬁcation or examination, continuing education, andperiodic reports;• continuing education, periodic reporting, and on-site
inspections;• continuing education and periodic reporting;• continuing education only; or• periodic reporting only.
In 2018, 58% (52) of the respondents reported on the existenceof licensing requirements that were speciﬁc for ART laboratories.
All but two centres had additional licensing requirements thatapplied to the entire facility. Of the 52 countries that reported
speciﬁc requirements for an ART laboratory, 79% (41) relied ona certiﬁcation system. By contrast, 81% (42) described an on-site
inspection system, while 44% (23) relied on periodic reporting.
These ﬁndings indicate that most countries regulate ART
laboratories using a combination of licensing requirements.
The ART laboratory director and ART laboratory technicalstaff: In 2021, 38% (34) of the 89 respondents reported that there
were speciﬁc licensing requirements for the ART Laboratory
Directors in their countries. This represents an increase from the
37% (33) of 88 respondents who reported the same in 2018.
Several mechanisms were discussed in the 2021 survey including:• 48% (16) of the 33 respondents noted the requirement forcertiﬁcation or examination.
• 24% (eight) reported that certiﬁcation or examination andcontinuing education were required.
• Three noted requirements for either• continuing education and on-site inspections; or• certiﬁcation or examination, continuing education, periodic reporting, and on-site inspections.
• One noted that the requirements included either• certiﬁcation or examination, periodic reporting, and onsite inspections,• certiﬁcation or examination, continuing education, andperiodic reporting; or• on-site inspections only.
In 2021, 30% (27) of the 89 respondents reported that there
were speciﬁc licensing requirements for ART Laboratory
Technical Staff. This represents a decrease from 45% (38 of 85
respondents) that was reported in 2018. The mechanisms cited in
the 2021 survey were as follows:• 37% (ten) of the 27 respondents noted the requirement forcertiﬁcation or examination.
• 26% (seven) reported that certiﬁcation or examination andcontinuing education were required.
• Four noted the need for certiﬁcation or examination, continuing education, periodic reporting, and on-site inspections.

Physicians with advanced training in reproductive endocrinology and infertility (REI): Fifty-seven percent (51) of the
respondents reported that REI physicians with specialised ART
training must be licensed or credentialed. These processes
include:• 21% (19) of the respondents reported that certiﬁcation or an
examination was required.
• 21% (19) reported the need for continuing education for
examination and certiﬁcation.
• Three respondents noted the need for• certiﬁcation and/or examination, continuing education,
on-site inspections, and periodic reporting; or• certiﬁcation and/or examination and on-site inspections
only.
• Two respondents reported that continuing education was
required.
• One respondent reported the need for:• certiﬁcation and/or examination, continuing education,and on-site inspections;• certiﬁcation and/or examination, continuing education,and periodic reporting;• continuing education and on-site inspections only;• on-site inspection only; or• periodic reporting only.
The obstetrician/gynaecologist practising ART: Respondents
from 53% (47 of 89) of the countries in which obstetricians andgynaecologists were practising ART reported the need to comply
with speciﬁc licensing criteria. Multiple combinations ofmechanisms were employed to accomplish this requirement,
including:• 34% (16) of 47 relied on certiﬁcation or examination as thesole criteria for licensing.
• 34% (16) also required continuing education in addition tocertiﬁcation or examination.
• Four respondents noted the need for continuing education forcertiﬁcation.
• Three respondents note that either of the following would besatisfactory:• certiﬁcation or examination, continuing education, andperiodic reporting; or• certiﬁcation or examination and on-site inspections.
• Two respondents reported the need for certiﬁcation or
examination, periodic reporting, and on-site inspection.
• One respondent noted the need for:• continuing education and on-site inspections;• on-site inspections only; or• certiﬁcation or examination, continuing education, andon-site inspections.
The survey did not address the availability of high-quality subspecialty fellowship programmes for reproductive medicine specialists. Overlap likely exists with the qualiﬁcations necessary fortrained obstetricians/gynaecologists. These physicians may havethe capacity to provide appropriate care either with or without
further fellowship training.
The ART laboratory: In 2021, 70% (62) of 89 respondents
noted that ART Laboratories were required to comply withlicensing criteria.
• 26% (16) required on-site inspections only.
• 18% (11) required certiﬁcation or examination, continuing
education, and periodic reporting in addition to on-site
inspections.
14

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 2. Table 4
Are there licensing criteria in your country?
Country
Albania
Argentina
Armenia
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Croatia
Czech Republic
Democratic Republic of theCongo
Denmark
Ecuador
Egypt
Estonia
Ethiopia
FinlandFranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
Iceland
India
Iran
IrelandIsraelItaly
Japan
JordanKazakhstan
Kenya
KuwaitLatviaLebanon
Libya
Lithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandNigeria

ART/IVFcentres

REI
Physicians

OB/GYNphysiciansARTlaboratory

ART Laboratory
Director

ART laboratory
technical staff

Mental healthprofessionals

Fertility
nurses

No
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
No
No
Yes
Yes
Yes
Yes
No
Yes
Yes
No

No
Yes
Yes
Yes
No
No
Yes
Yes
No
Yes
No
No
Yes
No
Yes
Yes
Yes
No
Yes
No
Yes
Yes
No

No
Yes
Yes
No
Unknown
No
Yes
Yes
No
Yes
No
No
Yes
No
Unknown
Yes
No
No
Yes
Yes
Yes
No
No

No
Yes
No
Yes
No
No
No
Yes
No
Yes
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No

No
Yes
No
Yes
No
No
No
Yes
No
Yes
Yes
No
No
No
No
Unknown
No
No
No
Yes
Yes
Yes
No

No
Yes
No
Yes
No
No
No
Yes
No
Yes
No
No
No
No
No
Unknown
No
No
No
Yes
No
No
No

No
Yes
Unknown
No
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Unknown
No
Yes
Yes
Yes
Yes
Yes
No
Unknown
No
No

No
No
No
Yes
No
No
No
No
No
Yes
No
No
Unknown
No
No
No
Yes
No
No
No
No
No
No

Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
No
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
No

No
Yes
Yes
No
Yes
No
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
Yes
No
No
No
No
Yes
No
Yes
Yes
No
No
No
No
Yes

No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
No
Yes
No
Yes
No
No
No
Yes
No
Yes
No
No
No
Yes
Yes

Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
Yes
No
No
Yes
Yes

No
Yes
Yes
No
Yes
No
Yes
No
Yes
Yes
Yes
No
No
No
No
No
Yes
No
Yes
yes
Yes
No
No
No
Yes
No
No
No
No
No

No
Yes
Yes
Yes
No
Yes
No
No
Yes
Yes
No
No
No
No
No
No
No
No
Yes
No
Yes
No
No
No
Yes
No
No
No
Yes
No

Yes
Yes
No
Yes
Yes
Yes
No
Yes
Unknown
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
No
No
Yes
Yes
Yes
No
Yes
No
No

No
No
No
No
No
Yes
No
No
No
Yes
No
No
Yes
Yes
No
No
No
No
Yes
No
Yes
No
No
No
Unknown
No
No
No
No
No

Yes
No
No
No
Yes
Yes
Yes

Yes
Yes
No
Unknown
Yes
Yes
No

Yes
No
No
Unknown
No
Yes
No

Yes
No
No
Unknown
No
Yes
No

Yes
Yes
No
Yes

Yes
No
No
No
No
Yes
No

15

Yes

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 2. Table 4(Continued)
Country

ART/IVFcentres

REI
Physicians

OB/GYNphysiciansARTlaboratory

ART Laboratory
Director

ART laboratory
technical staff

Mental healthprofessionals

Fertility
nursesNorwayPanamá
Paraguay
Peru
Philippines
PolandPortugal
Qatar
Romania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain
Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

Yes
Yes
No
Unknown
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes

No
Yes
No
No
Yes
No
Yes
Yes
Yes
No
Yes
No
Yes
Yes
Yes
No
No
Yes
Yes
No
No
Yes
No
Yes
Yes
No
No
Yes
Yes

Yes
Yes
No
No
Yes
No
No
Yes
Yes
No
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
Yes
Yes
No
No
Yes
Yes

Yes
No
No
No
No
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes

Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
No
No
No
No
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
No
No

Yes
No
No
No
No
No
No
Yes
Yes
No
No
No
Yes
Yes
No
Yes
No
No
No
No
Yes
Yes
No
Yes
Yes
No
No
No
No

No
Yes
No
No
No
No
Yes
No
Yes
No
Yes
No
Yes
Yes
Yes
No
Yes
Yes
No
No
No
Yes
Yes
Unknown
Yes
Yes
Yes
Yes
No

No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
Yes
Yes
No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
No

• 41% (seven) of 17 respondents noted the need for certiﬁcation
or examination plus continuing education.
• Four of the respondents reported that certiﬁcation or examination was required.
• Three respondents noted the need for continuing education
only.
• One respondent noted the need for either• certiﬁcation or examination, continuing education, andon-site inspections;• certiﬁcation or examination, continuing education, periodic reporting, and on-site inspections; or• on-site inspections only.
This question was also not included in previous Surveillance
studies.
Monitoring: Findings that summarise the monitoring of ART
centres and professionals are included in Table 5, Chart 1.
ART centres: Sixty-two percent (55) of the 89 respondents
reported that ART Centres were monitored in their countries. A
wide variety of single and combinations of mechanisms was utilised to monitor ART centres.
• Nine (15%) of the 55 respondents reported that ART Centres
were monitored by a national registry, periodic reporting, onsite inspections, and re-certiﬁcation.
• Five respondents reported that ART Centres were monitored
either by• a national registry only or on-site inspections only; or• a national registry, on-site inspections, and re-certiﬁcation.

• Two reported that the requirements included either• certiﬁcation or examination, continuing education, andon-site inspections; or• on-site inspections only.
• One respondent noted the need for certiﬁcation or examination and on-site inspections only.
Mental health professionals: In the 2021 survey, 56% (49) of
87 respondents reported licensing requirements that were speciﬁcally relevant to Mental Health Professionals. Among these:• 59% (29) of the 49 respondents noted that certiﬁcation or
examination was required.
• 24% (12) reported that certiﬁcation or examination andcontinuing education were required.
• Two respondents noted that only continuing education was
required.
• One responded that the requirements included either• certiﬁcation or examination, continuing education, andon-site inspections;• certiﬁcation or examination, continuing education, periodic reporting, and on-site inspections;• on-site inspections only; or• periodic reporting only.
This question was not included in previous Surveillance studies.
Fertility nurses: Nineteen percent (17 of 89 respondents)
reported speciﬁc licensing requirements for Fertility Nurses. The
following requirements were cited:16

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 2. Table 5
Are there monitoring mechanisms for governance, licensure, or credentialing in your country?
Country
Albania
Argentina
Armenia
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Croatia
Czech Republic
Democratic Republicof the Congo
Denmark
Ecuador
Egypt
Estonia
Ethiopia
FinlandFranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
Iceland
India
Iran
IrelandIsraelItaly
Japan
JordanKazakhstan
Kenya
KuwaitLatviaLebanon
Libya
Lithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandART
centres?

REI
physicians

OB/GYNphysiciansARTlaboratory

ART laboratory
director

ART laboratory
technical staff

Mental healthprofessionals

Fertility
nurses

No
Yes
Yes
Yes
Yes
No
Yes
No
No
Yes
Yes
No
Yes
No
No
Yes
Yes
Yes
Yes
No
Yes
Yes
No

No
Yes
Unknown
Yes
No
No
No
No
No
No
Yes
No
Yes
No
Yes
Yes
Yes
No
No
No
Unknown
Yes
No

No
Yes
Yes
No
No
No
No
No
No
No
Yes
No
Yes
No
Unknown
Yes
No
No
No
No
Yes
No
No

No
Yes
No
Yes
No
No
Yes
No
No
No
Yes
No
Yes
No
Yes
Unknown
Unknown
Yes
Yes
No
Yes
Yes
No

No
Yes
No
Yes
No
No
No
No
No
Yes
No
No
No
No
No
Unknown
Unknown
Yes
No
No
Yes
Yes
No

No
Yes
No
Yes
No
No
No
No
No
Yes
No
No
No
No
No
Unknown
Unknown
Yes
No
No
No
Yes
No

No
Unknown
Unknown
Unknown
No
No
No
No
Yes
No
Yes
Yes
Unknown
No
Unknown
Yes
No
Yes
No
No
Unknown
No
No

No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

Yes
No
No
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
Yes
No
No
Yes
No

No
No
No
No
Yes
No
No
No
No
Yes
No
No
Yes
Yes
No
No
Yes
No
Yes
Yes
No
No
Yes
No
Yes
No
No
No
No
No

No
No
No
No
Yes
No
No
No
No
Yes
No
No
Yes
Yes
No
No
No
Yes
No
Yes
No
No
Yes
Yes
Yes
No
No
No
No
No

No
No
No
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Yes
No
Yes
Unknown
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
Yes
No
No
No
No

No
No
No
No
Yes
No
No
No
Yes
Yes
Yes
No
No
No
No
No
Unknown
No
Yes
No
Yes
No
Yes
No
Yes
No
No
No
No
No

Yes
No
No
Unknown
Unknown
Yes
No
Unknown
Yes
No
No
No
Unknown
No
No
No
No
No
Yes
No
No
No
Yes
Yes
Yes
No
Unknown
No
No
Unknown

No
No
No
No
Yes
No
No
No
No

Yes
No
No
Unknown
No
Yes

Yes
No
No
Unknown
No
No

Yes
No
No
Unknown
Yes
No

Yes
No
No
Unknown
Yes
Yes

Yes
No
No
Yes
No
No

No
No
No
Yes
Yes
No
No
No
Yes
Yes
No
No
No
No
No
No
Yes
No
Yes
No
Yes
No
No
No
Yes
No
No
No
No
No
No
Yes
No
No
Unknown
No
Yes

17

No
Yes
No
Yes
No
Yes

No
No
No
Yes
No
No
Yes
No
No
Yes
No
No
Yes
No
Unknown
No
No
No
No
No
No
No
No
No
No
No
No

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 2. Table 5(Continued)
Country
Nigeria
NorwayPanamá
Paraguay
Peru
Philippines
PolandPortugal
Qatar
Romania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain
Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

ART
centres?

REI
physicians

OB/GYNphysiciansARTlaboratory

ART laboratory
director

ART laboratory
technical staff

Mental healthprofessionals

Fertility
nurses

No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
No
No
Yes
No
Yes
Yes
Yes
No
Yes
Yes

No
No
No
No
No
No
No
No
Yes
Yes
No
Yes
No
No
Yes
Yes
No
No
Yes
No
No
No
No
No
Yes
Yes
No
No
Yes
No

No
No
No
No
No
Yes
No
No
Yes
Yes
No
Yes
No
No
Yes
Yes
No
No
Yes
No
No
Yes
No
No
Yes
Yes
No
No
Yes
Yes

No
Yes
No
No
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
Yes
Yes
No
No
No
Yes
No
Yes
Yes
No
No
Yes
Yes

No
Yes
No
No
No
No
No
No
Yes
Yes
No

No
Yes
No
No
No
No
No
No
Yes
Yes
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No

Unknown
No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
Yes
Yes
No
No
No
No
No
No
No
Unknown
Yes
No
Yes
Yes
Yes
No

No
No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
Yes
Yes
No
No
No
No
No
No
No
Unknown
Yes
No
No
No
No
No

No
No
No
Yes
No
No
Yes
No
No
No
Yes
No
No
Yes
No
No
No
No

• a national registry, an international registry, and recertiﬁcation or a national registry, an international
registry, and re-certiﬁcation;• a national registry, an international registry, and recertiﬁcation;• a national registry, periodic reporting, and re-certiﬁcation;• periodic reporting, on-site inspections, and re-certiﬁcation;or• re-certiﬁcation only.
Forty-nine percent (27) of 55 respondents reported thatgovernment employees were responsible for monitoring ART
centres. By contrast, independent agencies were identiﬁed as
responsible for monitoring ART centres in 16% (nine) of thesecountries; medical ofﬁcials were identiﬁed as responsible inanother four countries. Some respondents reported that theircountry used more than one method for monitoring ART centres. Eleven respondents reported that monitoring was carriedout by a combination of government employees and medicalofﬁcials. Three respondents noted that monitoring was the
responsibility of government employees and independentagencies, while one respondent noted that this was to be carriedout by government employees, medical ofﬁcials, and unofﬁcial
agencies.

• Four respondents reported that monitoring was carried out via
a national registry, periodic reporting, and on-site inspections.
• Three respondents noted that monitoring involved either• a national registry, an international registry, and periodic
reporting;• on-site inspections and re-certiﬁcation; or• periodic reporting only.
• Two respondents reported that monitoring involved either• a national registry and periodic reports;• periodic reporting and re-certiﬁcation;• a national registry and on-site inspection; or• periodic reporting and on-site inspection.
• One respondent reported that monitoring was carried out
by either• national and international registries, periodic reporting,and on-site inspection;• national and international registries, on-site inspection,and re-certiﬁcation;• an international registry, on-site inspection, and recertiﬁcation or an international registry, periodic reporting, on-site inspection, and re-certiﬁcation;• an international registry, on-site inspection, and recertiﬁcation or an international registry, periodic reporting, on-site inspection, and re-certiﬁcation;• national and international registries, periodic reporting,on-site inspection, and re-certiﬁcation;

Physicians with advanced training in reproductive endocrinology and infertility (REI): Thirty percent (27) of 89 respondents
reported that physicians with advanced training in reproductive
18

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health• government employees and independent agencies.
In 2018, 41% (36) of 87 respondents reported that ongoing
monitoring of REI physicians was primarily the responsibility of
government agencies, medical ofﬁcials, or both, but that somephysicians were monitored by an independent agency.
OB/GYN physicians who practise ART: Thirty-two percent(29) of the 89 respondents reported that their countries monitored OB/GYN physicians who practise ART. A variety ofmechanisms and combinations of mechanisms were used toachieve this goal.
• 24% (seven) reported the need for re-certiﬁcation.
• Four reported monitoring by a national registry only.
• Three noted that this was achieved via periodic reporting.
• Two reported that monitoring was carried out by either• periodic reporting, re-certiﬁcation, and on-site inspections; or• both national and international registries.
• One reported that monitoring was achieved by either• an international registry, periodic reporting, on-site
inspections, and re-certiﬁcation;• a national registry, periodic reporting, on-site inspections, and re-certiﬁcation;• a national registry, re-certiﬁcation, and on-site inspections;• an international registry and re-certiﬁcation;• a national registry and periodic reporting;• a national registry and re-certiﬁcation;• on-site inspections and re-certiﬁcation;• an international registry only; or• on-site inspections only.
Fifty-two percent (15) of the 29 respondents reported thatgovernment employees were responsible for monitoring OB/
GYN physicians who practise ART. Two respondents noted thatmonitoring was carried out by independent agencies and ﬁve
respondents reported that this was the responsibility of medicalofﬁcials. Several respondents noted that more than one method ofmonitoring was in use. Seventeen percent (ﬁve) respondents
reported that monitoring was carried out by a combination of
government employees and medical ofﬁcials. One respondent
reported that monitoring was the responsibility of both

endocrinology and infertility (REI) monitored in their countries.
A wide variety of mechanisms and combinations of mechanisms
were utilised by the countries that had strategies in place tomonitor REI physicians including:• 37% (ten) of the 89 respondents reported that these physicians
were monitored by re-certiﬁcation only.
• Three respondents noted that monitoring was carried out by
periodic reporting, on-site inspections, and re-certiﬁcation.
• Two respondents reported that monitoring was carried out by
a national registry, periodic reports, re-certiﬁcation, and onsite inspections.
• One respondent described the following mechanisms:• a national registry, an international registry, periodic
reporting, on-site inspections, and re-certiﬁcation;• an international registry, periodic reporting, on-site
inspections, and re-certiﬁcation;• a national registry, an international registry, and periodic
reporting;• on-site inspections and re-certiﬁcation;• both an international and a national registry;• a national registry and on-site inspections;• a national registry and periodic reporting;• periodic reporting and re-certiﬁcation;• periodic reporting only;• a national registry only;• an international registry only; or• unknown.
Government employees were responsible for monitoring REI
physicians in 33% (nine) of 27 countries. The following
mechanisms were utilised:• Four respondents noted that they relied on independent agencies.
• 19% (ﬁve) reported that medical ofﬁcials were primarily
responsible.
• 26% (seven) reported that monitoring was carried out by amix of government employees and medical ofﬁcials.
• One respondent reported that this was carried out by either• government employees, medical ofﬁcials, and unofﬁcial
agencies; orChapter 2. Chart 1. % Countries reporting legislative changes since 2019.

19

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health• Two provided monitoring via both national and international
registries, periodic reporting, and on-site inspections.
• Two reported that monitoring involved either• periodic reporting and on-site inspections;• national registries and re-certiﬁcation; or• periodic reporting only.
• One reported that monitoring was performed via• both national and international registries, periodic
reporting, on-site inspections, and re-certiﬁcation;• a national registry, periodic reporting, re-certiﬁcation,and on-site inspections;• periodic reporting, on-site inspections, and re-certiﬁcation;• a national registry and on-site inspections;• both national and international registries;• an international registry only; or• a national registry only.
Thirty-ﬁve percent (eight) of 23 respondents reported thatgovernment employees were responsible for monitoring the ART
laboratory director. Three respondents identiﬁed independentagencies, while two respondents noted that medical ofﬁcials
provided this oversight. One respondent identiﬁed unofﬁcial
agencies as the responsible party. Several respondents reported
the use of more than one method of monitoring. Six respondents
reported that monitoring was carried out by both government
employees and medical ofﬁcials. One respondent noted thatgovernment employees and independent agencies were responsible for monitoring the ART laboratory director, while anotherreported that this task was undertaken by medical ofﬁcials,
government employees, and independent agencies.
ART laboratory technical staff: Forty-four percent (20) of the
90 respondents reported monitoring of the ART laboratory
technical staff. A variety of mechanisms and combinations wereused to monitor the technical staff.
• Two respondents reported that monitoring was carried out
either by a national registry only, an international registry
only, on-site inspections only, periodic reporting only, or recertiﬁcation only.
• Two respondents noted that the staff was evaluated byperiodic reporting and on-site inspections.
• One respondent reported that monitoring was performedby either• on-site inspections and re-certiﬁcation or periodic reporting, on-site inspections, and re-certiﬁcation;• a national registry, an international registry, periodic
reporting, on-site inspections, and re-certiﬁcation;• a national registry or an international registry, periodic
reporting, and on-site inspections;• a national registry, periodic reporting, on-site inspections, and re-certiﬁcation;• a national registry and re-certiﬁcation;• a national registry only; or• an international registry only.
Thirty-ﬁve percent (seven) of the 20 respondents reported thatgovernment employees were responsible for monitoring the ART
laboratory technical staff. Another three respondents noted that
this was carried out by independent agencies and medical ofﬁcials, and one respondent reported that this was the responsibilityof unofﬁcial agencies. Some respondents described more than one
method of monitoring. Five respondents reported that bothgovernment employees and medical ofﬁcials were responsible formonitoring the laboratory technical staff, while one respondent

government employees and independent agencies, while anotherreported that monitoring was performed by medical ofﬁcials andunofﬁcial agencies.
The ART laboratory: Forty-nine percent (44) of the 89
respondents reported monitoring of ART laboratories in theirrespective countries. A combination of mechanisms was
employed including:• 14% (six) reported monitoring via on-site inspections and recertiﬁcation.
• 14% (six) reported monitoring via a national registry, periodic
reporting, re-certiﬁcation, and on-site inspections.
• 11% (ﬁve) reported the use of on-site inspections.
• Four reported monitoring via national registry only.
• Three reported the use of either• a national registry and on-site inspections; or• periodic reporting and on-site inspections.
• Two reported monitoring by either• a national registry, an international registry, periodic
reporting, on-site inspections, and re-certiﬁcation;• a national registry, on-site inspections, and re-certiﬁcation; or• periodic reporting only.
• One reported monitoring by either• a national registry, an international registry, and on-site
inspections;• an international registry, on-site inspections, and recertiﬁcation;• a national registry, periodic reporting, and re-certiﬁcation;• both a national registry and an international registry; or• re-certiﬁcation only.
Government employees were identiﬁed as responsible formonitoring ART laboratories in 50% (22) of the 44 countries.
Eighteen percent (eight) of the respondents noted that this was
carried out by independent agencies. Medical ofﬁcials performed
the monitoring function in one respondent country. Several
respondents reported that more than one method of monitoring
was used. Nine respondents reported that monitoring was carriedout by both government employees and medical ofﬁcials, while
three responded that this was performed by both government
employees and independent agencies. One respondent noted that
medical ofﬁcials, government employees, and unofﬁcial agencies
were all responsible for monitoring the ART laboratories.
In 2018, 58% (51) respondents reported that their countries
had established ongoing monitoring criteria for ART laboratories. Of these, 76% (39) relied on on-site inspections alone,while others utilised a combination of periodic reporting, registry, and re-certiﬁcation. Forty-seven percent (24) of the
respondents reported that monitoring was performed by government employees, while another 43% (22) noted that thisfunction was carried out by medical ofﬁcials. Fourteen percent(seven) reported that monitoring was performed by independentagencies. More than one monitoring method was reported bysome of the respondents.
The ART laboratory director: Twenty-six percent (23) of the
88 respondents reported monitoring of the ART laboratory
director. A combination of mechanisms was utilised, including:• 22% (ﬁve) required on-site inspection only.
• Three reported monitoring with on-site inspections andre-certiﬁcation.
• Three required re-certiﬁcation only.
20

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health• Revocation of a licenses• Loss of accreditation• Imprisonment• Suspension of license• Suspension of privileges• Facility closure• Other disciplinary actions
In 2018, 59% (51) of 86 respondents afﬁrmed that penalties
existed for violations of governance, licensure, or credentialing.
By contrast, 34% (29) reported that no penalties existed, while
7% (six) answered “unknown”. The penalties cited in the 2018
survey included:• Admonishment• Administrative penalties• Publication of deﬁciencies• Reporting to the medical board (with the possibility ofsanctions)• Suspension of ART license• Refusal of registration renewal• Revocation of ART license• Closure of the ART centre• Financial penalties (ﬁnes)• Criminal charges and penalties against the responsible parties
The sanctions employed most frequently were ﬁnancial penalties,
loss of license, and the possibility of criminal prosecution.

reported that this was a task carried out by government
employees and independent agencies.
Mental health professionals: Twenty-six percent (23) of the 89
respondents reported that the performance of mental healthprofessionals was monitored. Several methods were used tomonitor the compliance of mental health professionals, including:• 30% (seven) reported monitoring via a national registry only.
• Four reported that compliance was monitored by re-certiﬁcation
only.
• Two reported the use of either• periodic reporting alone or a national registry and on-site
inspections; or• a national registry and re-certiﬁcation or periodic report,
on-site inspection, and re-certiﬁcation.
• One reported that monitoring involved either• a national registry, periodic reporting, on-site inspections, and re-certiﬁcation;• periodic reporting and on-site inspections; or• on-site inspections only.
Fifty-seven percent (13) of the 23 respondents reported thatgovernment employees were responsible for monitoring theactivities of mental health professionals. Four respondents
reported that monitoring was to be carried out by medical ofﬁcials only. More than one method of monitoring was noted byseveral respondents. Four respondents reported that monitoring
was performed by a combination of government employees andmedical ofﬁcials.
Fertility nurses: Twelve percent (11) of 89 respondents reported monitoring of fertility nurses. Several methods for monitoring
compliance of fertility nurses were reported.
• Four respondents reported that monitoring involved re-certiﬁcation only.
• Two respondents reported that compliance was monitored byperiodic reporting only.
• One respondent noted that monitoring involved• a national registry, periodic reporting, on-site inspections, and re-certiﬁcation;• periodic reporting, re-certiﬁcation, and on-site inspections;• both national and international registries;• on-site inspections and re-certiﬁcation; or• a national registry only.
Seventy-six percent (seven) of the respondents reported that themonitoring of fertility nurses was the responsibility of government
employees. Two respondents noted that this was carried out by
independent agencies and only in response to speciﬁc reporting.
Some respondents reported that more than one method of monitoring was used. One respondent reported that fertility nurses weremonitored by both government employees and medical ofﬁcials.
Violations of policies: Twenty percent (18) of 89 respondents
reported that they were aware of ART policy violations taking
place in their countries. By contrast, 55% (49 respondents)
asserted that no violations had occurred in their country, while
25% (22) replied “unknown”.
Penalties for violation of governance, licensure, or credentialing: In 2021, 43% (38) of 88 respondents reported that disciplinary penalties existed for violations of governance, licensure,or credentialing of ART centres and providers. The various typesof penalties reported included:• Financial penalties• Closing of activity• Criminal complaints

Discussion
The 2021 Surveillance Survey conﬁrmed that some form of regulation
exists in most countries where ART is available. Twenty-seven percent (24 of 89 respondents) reported that changes were made to theseregulations since 2018 that generally resulted in increased access todonated gametes or embryos and decreased access to surrogacy andcross-border reproductive care. Countries were evenly divided
regarding legislation that provides access to reproductive services bysame-sex couples with an equal number of countries reporting
improved access and reduced access to these services. Findings weresimilar among the responding countries with respect to marital status.
Respondents also noted some additional regulatory changes that
restricted access to cloning but increased access to cryopreservationand micromanipulation modalities.
Speciﬁc licensing and credentialing criteria for ART centres
were reported by the majority of respondents, with mostreporting multiple licensing requirements. Additional speciﬁclicensing or credentialing requirements were noted for REI physicians, obstetricians and gynaecologists, laboratory staff, mental
health professionals, and nursing staff. Most did not report speciﬁc credentialing criteria for the ART laboratory personnel anddirector, although 70% of the respondents reported on the speciﬁc credentialing requirements for the ART laboratory.
ART centres were and continue to be monitored in most
respondent countries (61%) by a variety of mechanisms.
Monitoring is carried out most frequently by government
employees and independent agencies and, to a lesser extent,
medical ofﬁcers. The data collected for the 2022 survey weremore limited in scope than those collected in 2018 speciﬁcallywith respect to mechanisms used to monitor physicians, laboratory directors, and laboratory technical staff. The vast majorityof the ART centres experienced signiﬁcant adversity as a result of
the COVID-19 pandemic beginning in early 2020. The impactof the pandemic on regulatory activity, enforcement, and21

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

3. Have there been any modiﬁcations to insurance coverage orgovernment funding since 2018?
4. Is insurance coverage of government funding based on
fertility status?
5. Does insurance coverage or government funding typicallycover the following ART services?
6. How are ART services reimbursed?
7. Does your country have insurance coverage or government
funding for infertility treatments?
8. Does insurance coverage or government funding limit the
number of IVF cycles performed per patient? If yes, numberof cycles covered.
9. Is insurance or government funding inﬂuenced by personal
income levels. If yes, income level.
10. Is insurance coverage or government funding contingent on
age limits? If yes, age limit.
11. Is insurance coverage or government funding based on the
duration of infertility? If yes, years of infertility.
12. Is insurance coverage or government funding contingent on
implementation of single embryo transfer (SET, DET)?
In 2021, respondents from 88 countries submitted data pertaining to insurance coverage and government support for
infertility services. This represents a slight increase in response
rate since the 2018 survey when responses were received from 85
countries. In 2021, 53% (47) of the respondents reported that
there were some provisions for ﬁnancial support for ART in theirrespective countries. Forty-seven percent (41) reported that theircountries offered no ﬁnancial support. These ﬁndings can becompared to 53% and 47% of the respondents who reported theexistence of some form of ﬁnancial support for ART in 2015 and2018, respectively. Since 2018, seven additional countries
reported that some form of ﬁnancial support for ART wasavailable.
In countries in which ART reimbursement exists, ﬁnancial
support is administered at the national or federal level (48%; 41
of 86 countries), at state, provincial or regional levels (18%; 14
of 76 countries), or at the municipal level, (9%; seven of 75
countries). Financial support also involves agency regulations
or oversight (9%; seven of 74 countries), utilization of professional organization standards or guidelines (20%; 15 of 76
countries), attention to speciﬁc cultural practices (four of 74
countries), and/or religious decree (two of 73 countries)(Table 1).
Seventy-ﬁve countries reported changes in levels of ﬁnancial
support available to those in need of ART during the previous
three years. Sixteen percent (12 of 75 countries) reported
decreased ﬁnancial support for ART. Thirty-seven percent of the
respondents (28 countries) reported expanded or increased
ﬁnancial support. Forty-seven percent (respondents from 35
countries) reported that there had been no changes or that thiswas “unknown”. The COVID-19 pandemic was cited as a contributor to the reductions. Of note, respondents from Japan
reported the introduction of ﬁnancial support for fertility
preservation.
Seventy-ﬁve percent (64) of the respondents from 85 countries
reported that fertility status was not a determinant or a consideration for ﬁnancial support. Sixty-nine percent (respondents
from 60 of 87 countries) reported that insurance coverage was
not based on a diagnosis of primary infertility. Seventy-fourpercent (64 respondents from 87 countries) reported this to be thecase for secondary infertility. Likewise, 81% (67 of 83 responses)

potentially the surveillance response rates may account at least inpart for the changes in data accrual observed.
Most of the respondents reported that no violations of regulations had been reported in their countries. However, 20%
reported that some violations had occurred, and another 25%
said they did not have sufﬁcient knowledge. Both the 2018 and2021 surveillance surveys describe multiple potential penalties
that may be invoked for non-compliance. These penalties range
from comparatively low-level sanctions to signiﬁcant criminal
concerns. However, the level of enforcement remains unknown.
Summary
In 2021, some form of regulation pertaining to ART was reported
in 69% of countries worldwide, most commonly in the form offederal or national laws or statutes. This can be compared to the2015 and 2018 data in which ART regulations were reported in
57% and 87% of countries, respectively. Fifteen fewer countries
cited the existence of legislation or guidelines governing thepractice of ART than three years ago. Some of the differences
reported here may reﬂect the unique perspective of each respondent as well as a variety of different sampling techniques. As there
is no speciﬁc evidence suggesting that laws have been rescinded or
substantially altered over the past six years, these ﬂuctuations
may represent variations in sampling rather than new trends.
While 72% of the respondents reported no changes in ART
regulations, 27% (24 respondents) reported changes made to theregulatory process since 2018. As noted, these changes were thoseprimarily directed as increasing access to donated gametes orembryos and decreasing access to surrogacy and cross-borderreproductive services. Of signiﬁcant concern, 20% of the
respondents representing 18 countries were aware of ART policy
violations taking place in their countries.

CHAPTER 3: FINANCIAL SUPPORT FOR ART
Introduction
Access to ART services is ultimately limited by the availabilityof ﬁnancial resources. Public funding is provided in somecountries, most notably, albeit to varying extents, in 39
European countries[1]. Most regions offer only limited publicfunding; thus, patients rely primarily on private funding or
insurance to cover the costs of ART services. The International
Committee Monitoring Assisted Reproductive Technologies(ICMART) has reported nearly linear growth in the number ofART cycles performed between 1991 and 2017 (most recent
preliminary data) in the 79 participating countries with nearly
two million cycles now being performed each year. However,striking differences in volume and access were noted among thecontributing regions which largely highlighted barriers associated with cost[2].
Analysis of the Survey
The following questions addressing changes in expense allocation
for ART since the 2018 questionnaire were posed:
1. Are there regulations that address reimbursement of ART
procedures in your country?
2. If there are programs for coverage or reimbursement of ART
services, which of the following do they include?
22

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

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

Country
Albania
Argentina
Armenia
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republicof the Congo
Denmark
Ecuador
Egypt
Estonia
Ethiopia
FinlandFranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
Iceland
India
IrelandIsraelItaly
Japan
JordanKazakhstan
Kenya
LatviaLebanon
Libya
Lithuania
Malaysia
MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay

Municipal Laws/
Statutes/
Ordinances

AgencyRegulations/
Oversight

No
Yes
No

No
Yes
No

No
Unknown
No

No
Yes
No

No

No

Yes

No

No
No
No

No
No
No

No
No
No

No
No
No

No
No
No

No
No
No

No
No

No
No

No
No

No
No

No
No

No
No

No
No
No
Yes
No
Unknown
No
No
No
No
No

No
No
No
No
No
Unknown
No
No
No
No
No

No
No
No
No
No
Unknown
No
No
No
No
No

No
No
No
No
No
Unknown
No
No
No
No
No

No
No
No
No
No
Unknown
No
No
No
No
No

No
No
No
No
No
Unknown
No
No
No
No
No

No
No
No
No
Unknown
No
No
No
Yes
No

No
No
No
No
Unknown
No
No
No
No
No

No
No
No
No
Unknown
No
No
No
Yes
No

No
No
No
No
Unknown
No
No
Yes
Yes
Yes

No
No
No
No
Unknown
No
No
No
No
Yes

No
No
No
No
Unknown
No
No
No
No
Yes

No
No
No
No
No
No
No
Yes
Yes
No
Yes
No
No
No
Unknown

No
No
No
No
No
No
No
No
Yes
No

No
Yes
No
No
No
No
No
No
No
No

No
No
No
No
No
No
No
No
No
No

No
No
No
No
No
No
No
No
No
No

No
No
No
No

No
Yes
No
Unknown

No
No
No
No
No
No
Yes
No
No
No
Yes
No
No
No
No

No
No
No
No

No
No
No
Unknown

No

No

Yes

Yes

Yes

Unknown

No
No
No

No
No
No

No
No
No

No
Yes
Yes

No
Unknown
No

No
Unknown
No

No
Yes
No
No

No
No
No
No

No
No
No
No

No
No
No
No

No
No
No
No

No
No
No
No

Federal/National Laws/ State/Provincial/Regional
Statute/s Ordinances Laws/Statutes/Ordinances
No
Yes
Yes
Yes
Yes
No
Yes
No
No
No
Yes
No
No
No
No
Yes
Unknown
No
No
No
Yes
No
Yes
No
No
Yes
Unknown
Yes
Yes
No
Yes
No
Yes
No
No
Yes
Yes
No
Yes
Yes
Yes
No
No
Yes
No
Yes
No
Unknown
Yes
Yes
No
Yes
No
No
Yes
Yes
No
Yes
No
No

23

Professional
Organization Standards/ Cultural Religious
Guidelines
practice decreeAbstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 3. Table 1(Continued)

Country

Municipal Laws/
Statutes/
Ordinances

AgencyRegulations/
Oversight

No
No
No
No
Yes
Yes
Yes
No
Yes
No

No
No
No
No
Yes
Yes
No
Yes
Yes
No

No
No
No
No
Yes
No
No
No
Yes
No

No
No
No
No
Yes
No
No
Yes
Yes
Yes
Yes

No
No
No
No
Yes
No
No
No
No
No

No
No
No
No
Yes
No
No
No
No
No

Yes
No
Yes

Yes
No
No

No
No

No
No

No
No

No
No

Unknown
No
No
No
No
No
Yes
No
No
No
No

Unknown
No
No
No
No
No
No
No
No
No
No

Unknown
No
Yes
No
No
No
No
No
No
No
No

Unknown
No
No
No
No
Yes
No
No
No
No
No

Unknown
No
No
No
No
No
No
No
No
No
No

Unknown
No
No
No
No
No
No
No
No
No
No

Federal/National Laws/ State/Provincial/Regional
Statute/s Ordinances Laws/Statutes/Ordinances

Peru
Philippines
PolandPortugal
Qatar
Romania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain
Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
No
No
Yes
No
No
No
Yes
No
No
No

Professional
Organization Standards/ Cultural Religious
Guidelines
practice decree

Chapter 3. Table 2
Is insurance coverage or government funding based on fertility status?
Country
Albania
Argentina
Armenia
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
Ecuador
Egypt

Primary infertility

Secondary infertility

Family building

No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
Yes
No
No
Yes
No
Yes
No
Yes
No
No

No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
Yes
No
No
Yes
No
Yes
No
Yes
No
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
Yes
No
No

24

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 3. Table 2(Continued)
Country
Estonia
Ethiopia
FinlandFranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
Iceland
India
Iran
IrelandIsraelItaly
Japan
JordanKazakhstan
LatviaLebanon
Libya
Lithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
PolandPortugal
Qatar
Romania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain
Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

Primary infertility

Secondary infertility

Family building

No
Yes
No
No
No
No
No
No
No
No
Yes
No
No
Yes
No
No
No
Yes
No
Yes
Yes
No
No
Yes
Yes
No
No
Yes
No
No
No
Yes
Unknown
No
No
No
No
No
Yes
No
Unknown
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
No
No
No
No
Yes
No
Yes
No
No
No
No
Yes

No
Yes
No
No
No
No
Yes
No
No
No
Yes
No
No
Yes
No
No
No
Yes
No
Yes
Yes
No
No
Yes
Yes
No
No
Yes
No
No
No
Yes
Unknown
No
No
No
No
No
Yes
No
Unknown
No
No
No
Yes
No
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes

No
Yes
Yes
Yes
No
No
No
Yes
No
No
Yes
No
No

25

No
Yes
No
No
No
Yes
No
No
No

No
No
Yes
No
No
No
No
No
No
No
No
No
Unknown
Yes
Unknown
No
No
No
Yes
No
No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
No
No
No

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive HealthPrimary Infertility

31%

Secondary Infertility

26%

Family Building

19%

Chapter 3. Chart 1. Is Insurance Coverage or Government Funding Based on Fertility Status?

reported that funds were available to support “family building”
strategies (Table 2, Chart 1).
Seventeen percent (eight) of the 47 countries with federal
reimbursement programs reported no limits for the number of
IVF cycles covered. By contrast, 13% (six of 47 countries) provided coverage for only a single IVF cycle; another 13% (six)covered two cycles. Thirty-two percent (15 of 47) provided coverage for three cycles. Three countries provided coverage for as
many as four cycles of IVF. Hungary provided coverage for ﬁve
cycles. Denmark, Finland, Japan, Italy, and Slovenia provided
reimbursement for up six cycles. South Korea provided reimbursement for as many as seven cycles of IVF.
When asked about the number of cycles of IVF covered byinsurance, Australia, Israel, and the Russian Federation responded that there were no limits on the number of cycles that could be
reimbursed. Canada, Chile, Kenya, New Zealand, Romania,
Senegal, Tunisia, and United Arab Emirates each provided coverage for a single cycle. Belgium, Japan, Singapore, and theUnited States provided reimbursement for up to six treatment
cycles.
In Armenia and Uruguay, the amount of government funding
for ART was inﬂuenced by individual income levels. In 2018,
three of 40 respondents (Japan, South Korea, and the United
Arab Emirates) reported that ART reimbursement was contingent on personal income. In the 2015 survey, only Canada,
Italy, and South Korea reported this requirement.
In 2021, 12 countries reported no age limit for ﬁnancial coverage of ART. The 33 countries with age restrictions limited
ﬁnancial coverage to those between the ages of 37 to 46.
Respondents from seven countries reported limits based on the
duration of infertility. Five countries required documentation ofat least one year of infertility. Two countries required two years ofinfertility before offering coverage for ART.

Twenty-eight percent (13 of 46 countries) reported that reimbursement was contingent on the performance of a single embryotransfer (SET) procedure. In 2018, 22% of the respondents
indicated that reimbursement for ART was dependent on thenumber of embryos transferred. In the 2015 survey, only 18% of
the respondents noted this requirement.
The extent of coverage for ART services was also assessed.
For this report, respondents were asked whether full or only
partial reimbursement was provided. In countries with anational insurance plan, 26% (22 of 84 countries) offeredcomplete coverage. Twenty-seven percent (23) offered only
partial reimbursement. In countries with regional healthinsurance plans, 11% (8 respondents of 75) offered complete
coverage. Sixteen percent (12 countries) provided only partial
coverage (Table 3).
The survey also attempted to determine which speciﬁc fertility procedures and therapies were reimbursed. Among these,
the respondents were queried on the ﬁnancial resources available to support diagnostic evaluation, fertility medications,intrauterine insemination (IUI), in vitro fertilization (IVF),
intracytoplasmic sperm injection (ICSI), assisted hatching, useof surrogacy, and/or donor sperm, eggs, or embryos, and/or theuse of fertility preservation methods (sperm, oocytes, embryos,
tissue) for both medical and non-medical indications(Tables 4a–4h, Chart 2a–2c).
The diagnostic evaluation was covered as part of a national
health plan in 53% (46) of the 87 countries responding. By
contrast, 32% (28) had no reimbursement program. The
remaining countries provided coverage through private, state,provincial, or regional health plans.
Forty-one percent (36) of 87 countries that responded to thesurvey provided no reimbursement for fertility medications and
56% (48 of 85) offered no coverage for IUI. Similarly, 54% (47 of
26

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

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

National health plan

State/provincial/regional
health plan

Private insurance

Combination of government
health plan and private insurance

Argentina
Complete Coverage or Reimbursement Complete Coverage or Reimbursement Complete Coverage or Reimbursement Unknown
Armenia
Partial Coverage or Reimbursement
Partial Coverage or Reimbursement
Partial Coverage or Reimbursement
Partial Coverage or Reimbursement
Australia
Partial Coverage or Reimbursement
Partial Coverage or Reimbursement
Partial Coverage or Reimbursement
Austria
Partial Coverage or Reimbursement
No Coverage or Reimbursement
Partial Coverage or Reimbursement
Unknown
Bangladesh
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
BelarusPartial Coverage or Reimbursement
Benin
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Bolivia
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
BrazilNo Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Bulgaria
Complete Coverage or Reimbursement
Burkina Faso
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Cambodia
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Cameroon
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
CanadaNo Coverage or Reimbursement
Complete Coverage or Reimbursement Unknown
Unknown
Chile
Partial Coverage or Reimbursement
No Coverage or Reimbursement
Partial Coverage or Reimbursement
Partial Coverage or Reimbursement
China
Unknown
Unknown
Unknown
Unknown
Colombia
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Costa Rica
Complete Coverage or Reimbursement Complete Coverage or Reimbursement No Coverage or Reimbursement
No Coverage or Reimbursement
Cote d’Ivoire
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Czech Republic
Complete Coverage or Reimbursement Partial Coverage or Reimbursement
Partial Coverage or Reimbursement
Partial Coverage or Reimbursement
Democratic Republic No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursementof the Congo
Denmark
Partial Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Unknown
EcuadorNo Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Egypt
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Estonia
Complete Coverage or Reimbursement No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Ethiopia
Unknown
Unknown
Unknown
Unknown
Finland
Partial Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Partial Coverage or Reimbursement
FranceComplete Coverage or Reimbursement No Coverage or Reimbursement
Partial Coverage or Reimbursement
No Coverage or Reimbursement
Georgia
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Germany
Partial Coverage or Reimbursement
Partial Coverage or Reimbursement
Partial Coverage or Reimbursement
Partial Coverage or Reimbursement
Ghana
No Coverage or Reimbursement
No Coverage or Reimbursement
Partial Coverage or Reimbursement
Partial Coverage or Reimbursement
GreecePartial Coverage or Reimbursement
GuatemalaNo Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Hong Kong (China*) Partial Coverage or Reimbursement
Partial Coverage or Reimbursement
Partial Coverage or Reimbursement
Partial Coverage or Reimbursement
Hungary
Complete Coverage or Reimbursement Partial Coverage or Reimbursement
Partial Coverage or Reimbursement
Partial Coverage or Reimbursement
Iceland
Partial Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
India
No Coverage or Reimbursement
No Coverage or Reimbursement
Partial Coverage or Reimbursement
No Coverage or Reimbursement
Iran
Complete Coverage or Reimbursement
Ireland
Partial Coverage or Reimbursement
No Coverage or Reimbursement
Partial Coverage or Reimbursement
No Coverage or Reimbursement
IsraelComplete Coverage or Reimbursement Unknown
Complete Coverage or Reimbursement Complete Coverage or Reimbursement
Italy
Partial Coverage or Reimbursement
Partial Coverage or Reimbursement
Partial Coverage or Reimbursement
UnknownJapan
No Coverage or Reimbursement
Partial Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
JordanNo Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Kazakhstan
Complete Coverage or Reimbursement Complete Coverage or Reimbursement No Coverage or Reimbursement
No Coverage or Reimbursement
LatviaComplete Coverage or Reimbursement No Coverage or Reimbursement
Partial Coverage or Reimbursement
No Coverage or Reimbursement
LebanonNo Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Lithuania
Complete Coverage or Reimbursement
Malaysia
Partial Coverage or Reimbursement
Mali
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
MexicoNo Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Montenegro
Complete Coverage or Reimbursement
Partial Coverage or Reimbursement
MoroccoPartial Coverage or Reimbursement
Unknown
Partial Coverage or Reimbursement
Partial Coverage or Reimbursement
Namibia
No Coverage or Reimbursement
No Coverage or Reimbursement
Partial Coverage or Reimbursement
No Coverage or Reimbursement
Netherlands
Complete Coverage or Reimbursement Unknown
Unknown
Unknown
New ZealandPartial Coverage or Reimbursement
Nigeria
No Coverage or Reimbursement
No Coverage or Reimbursement
Partial Coverage or Reimbursement
No Coverage or Reimbursement
NorwayPartial Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Panamá
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Paraguay
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Peru
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement27

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 3. Table 3(Continued)
Country
Philippines
PolandPortugal
Qatar
Romania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain
Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

National health plan

State/provincial/regional
health plan

Private insurance

Combination of government
health plan and private insurance

No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Partial Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Complete Coverage or Reimbursement No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Complete Coverage or Reimbursement Complete Coverage or Reimbursement No Coverage or Reimbursement
UnknownComplete Coverage or Reimbursement Complete Coverage or Reimbursement No Coverage or Reimbursement
No Coverage or Reimbursement
Complete Coverage or Reimbursement Complete Coverage or Reimbursement Unknown
UnknownComplete Coverage or Reimbursement Partial Coverage or Reimbursement
Complete Coverage or Reimbursement No Coverage or Reimbursement
Complete Coverage or Reimbursement No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Partial Coverage or Reimbursement
Partial Coverage or Reimbursement
Partial Coverage or Reimbursement
Partial Coverage or Reimbursement
Unknown
Unknown
Partial Coverage or Reimbursement
Partial Coverage or Reimbursement
Partial Coverage or Reimbursement
Partial Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Complete Coverage or Reimbursement Complete Coverage or Reimbursement No Coverage or Reimbursement
No Coverage or Reimbursement
Complete Coverage or Reimbursement
Partial Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Partial Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Partial Coverage or Reimbursement
Unknown
No Coverage or Reimbursement
Partial Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Partial Coverage or Reimbursement
No Coverage or Reimbursement
Complete Coverage or Reimbursement No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Partial Coverage or Reimbursement
Partial Coverage or Reimbursement
No Coverage or Reimbursement
Partial Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
Unknown
Unknown
Partial Coverage or Reimbursement
Partial Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement
No Coverage or Reimbursement

Chapter 3. Table 4a
How are ART services reimbursed?
Country

Diagnostic Evaluation

Fertility Medications

Intrauterine insemination

Argentina

National health plan
State/Provincial/Regional health plan
Private insurance
National health plan
National health plan
State/Provincial/Regional health plan
National health plan
No coverage
National health plan
State/Provincial/Regional health plan
Private insurance
No coverage
No coverage
Private insurance
No coverage
No coverage
No coverage
Private insuranceState/Provincial/Regional health plan
National health plan
Private insurance
No coverage
No coverage
National health plan
Private insurance
National health plan
No coverage

National health plan
State/Provincial/Regional health plan
Private insurance
National health plan
National health plan
Private insurance
National health plan
No coverage
National health plan

National health plan
State/Provincial/Regional health plan
Private insurance
National health plan
National health plan
Private insurance
No coverage
No coverage
No coverage

No coverage
No coverage
No coverage
National health plan
No coverage
No coverage
No coverage
Private insurance
National health plan
Private insurance
No coverage
No coverage
National health plan
No coverage
National health plan
No coverage

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
Private insurance
No coverage
No coverage
National health plan
No coverage
National health plan
No coverage

Armenia
Australia
Austria
Bangladesh
Belarus

Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republicof the Congo28

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 3. Table 4a(Continued)
Country

Diagnostic Evaluation

Denmark
Ecuador
Egypt
Estonia
Ethiopia
FinlandFranceGeorgia
Germany

National health plan
No coverage
No coverage
National health plan
National health plan
National health plan
National health plan
No coverage
National health plan
Private insurance

Ghana
GreeceGuatemalaHong Kong (China*)

No coverage
National health plan
No coverage
National health plan
State/Provincial/Regional health plan
Private insurance
National health plan
National health plan
No coverage
National health plan
Private insurance
National health plan
National health plan
State/Provincial/Regional health plan
Private insurance
National health plan
No coverage
National health plan
No coverage
National health plan
No coverage
No coverage
National health plan
National health plan
National health plan
State/Provincial/Regional health plan
Private insurance
National health plan
National health plan
National health plan
Private insurance
Private insurance
National health plan
National health plan
Private insurance
National health plan
No coverage
Private insurance
No coverage
No coverage
National health plan
National health plan
National health plan
National health plan
State/Provincial/Regional health plan
National health plan
State/Provincial/Regional health plan
National health plan
National health plan
Private insurance
National health plan

Hungary
Iceland
India
Iran
IrelandIsraelItaly

Japan
JordanKazakhstan
Kenya
LatviaLebanon
Libya
Lithuania
Malaysia
Mali

MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
PolandPortugal
Qatar
Romania
RussiaSerbiaSlovenia
South Africa
South Korea

Fertility Medications

Intrauterine insemination

National health plan
No coverage
No coverage
National health plan
National health plan
National health plan
National health plan
No coverage
National health plan
State/Provincial/Regional health plan
Private insurance
Private insurance
National health plan
No coverage
National health plan
State/Provincial/Regional health plan
Private insurance
National health plan
National health plan
No coverageState/Provincial/Regional health plan
National health plan
National health plan
National health plan
State/Provincial/Regional health plan

National health plan
No coverage
No coverage
National health plan
National health plan
National health plan
National health plan
No coverage
National health plan
State/Provincial/Regional health plan
Private insurance
No coverage
No coverage
No coverage
National health plan
State/Provincial/Regional health plan

No coverage
No coverage
National health plan
No coverage
National health plan
No coverage
No coverage
National health plan
National health plan
National health plan
State/Provincial/Regional health plan
Private insurance
No coverage
National health plan
National health plan
Private insurance
No coverage
National health plan
National health plan
No coverage
National health plan
No coverage
No coverage
No coverage
No coverage
National health plan
National health plan
State/Provincial/Regional health plan
No coverage
National health plan
State/Provincial/Regional health plan
National health plan
National health plan
Private insurance
National health plan
State/Provincial/Regional health plan
29

National health plan
No coverage
No coverageState/Provincial/Regional health plan
Private insurance
National health plan
National health plan
State/Provincial/Regional health plan
Private insurance
No coverage
No coverage
No coverage
National health plan
No coverage
No coverage
No coverage
National health plan
No coverage

No coverage
Private insurance
No coverage
No coverage
National health plan
National health plan
No coverage
National health plan
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
State/Provincial/Regional health plan
No coverage

National health plan
National health plan
Private insurance
National health plan
State/Provincial/Regional health planAbstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 3. Table 4a(Continued)
Country

Diagnostic Evaluation

Spain

Switzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States

National health plan
State/Provincial/Regional health plan
Private insurance
No coverage
National health plan
State/Provincial/Regional health plan
Private insurance
National health plan
No coverage
No coverage
No coverage
No coverage
National health plan
Private insurance

Uruguay
Venezuela
VietnamZimbabwe

National health plan
No coverage
Private insurance
Private insurance

Sudan
SwedenFertility Medications
No coverage

No coverage
National health plan
State/Provincial/Regional health plan
Private insurance
No coverage
No coverage
National health plan
National health plan
No coverage
National health plan
State/Provincial/Regional health plan
Private insurance
National health plan
No coverage
No coverage
Private insurance

Intrauterine insemination
National health plan
State/Provincial/Regional health plan
Private insurance
No coverage
National health plan
State/Provincial/Regional health plan
Private insurance
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
State/Provincial/Regional health plan
Private insurance
National health plan
No coverage
No coverage
Private insurance

Chapter 3. Table 4b
How are ART services reimbursed?
Country

IVF

ICSI

Argentina

National health plan
State/Provincial/Regional health plan
Private insurance
National health plan
National health plan
Private insurance
National health plan
No coverage
National health plan
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
No coverage
No coverage
No coverage
National health plan
Private insurance
No coverage
No coverage
National health plan
No coverage
National health plan
No coverage
National health plan
No coverage
No coverage
National health plan
National health plan
National health plan
National health plan
No coverage

National health plan
State/Provincial/Regional health plan
Private insurance
National health plan
National health plan
Private insurance
National health plan
No coverage
National health plan
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
No coverage
No coverage
No coverage
National health plan
Private insurance
No coverage
No coverage
National health plan
No coverage

Armenia
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
Ecuador
Egypt
Estonia
Ethiopia
FinlandFranceGeorgia

No coverage
National health plan
No coverage
No coverage
National health plan
National health plan
National health plan
National health plan
No coverage
30

Assisted hatching
No coverage

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
No coverage
No coverage
Unknown
No coverage
No coverage
No coverage
National health plan
National health plan
National health plan
No coverage

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 3. Table 4b(Continued)
Country

IVF

ICSI

Germany

National health plan
State/Provincial/Regional health plan
Private insurance
No coverage
No coverage
No coverage
Unknown
National health plan
National health plan
Private insuranceState/Provincial/Regional health plan
Private insurance
National health plan
National health plan
State/Provincial/Regional health plan
Private insuranceState/Provincial/Regional health plan
No coverage
National health plan
No coverage
National health plan
No coverage
No coverage
National health plan
National health plan
No coverage
No coverage
National health plan
No coverage
No coverage
National health plan
National health plan
No coverage
National health plan
No coverage
No coverage
No coverage
No coverageState/Provincial/Regional health plan
National health plan
State/Provincial/Regional health plan
National health plan
State/Provincial/Regional health plan
National health plan
State/Provincial/Regional health plan
National health plan
National health plan
Private insurance
National health plan
State/Provincial/Regional health plan
National health plan
State/Provincial/Regional health plan
Private insurance
No coverage
National health plan
State/Provincial/Regional health plan
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
National health plan

National health plan
State/Provincial/Regional health plan
Private insurance
No coverage
No coverage
No coverage
Unknown
National health plan
National health plan
Private insurance
National health plan
Private insurance
National health plan
National health plan
State/Provincial/Regional health plan
Private insuranceState/Provincial/Regional health plan
No coverage
National health plan
No coverage
National health plan
No coverage
No coverage
National health plan
National health plan
No coverage
No coverage
National health plan
No coverage
No coverage

Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
Iceland
India
Iran
IrelandIsraelItaly

Japan
JordanKazakhstan
Kenya
LatviaLebanon
Libya
Lithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
PolandPortugal
Qatar
Romania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain

Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom

National health plan
No coverage
National health plan
No coverage
No coverage
No coverage
No coverageState/Provincial/Regional health plan
National health plan
State/Provincial/Regional health plan
National health plan
State/Provincial/Regional health plan
National health plan
State/Provincial/Regional health plan
National health plan
National health plan
Private insurance
National health plan
State/Provincial/Regional health plan
National health plan
State/Provincial/Regional health plan
Private insurance
No coverage
National health plan
State/Provincial/Regional health plan
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
National health plan
31

Assisted hatching
No coverage

No coverage
No coverage
No coverage
Unknown
National health plan
No coverage
Unknown
National health plan
National health plan

State/Provincial/Regional health plan
No coverage
National health plan
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
Unknown
State/Provincial/Regional health plan
National health plan
State/Provincial/Regional health plan
National health plan
State/Provincial/Regional health plan
No coverage
National health plan
No coverage
National health plan
State/Provincial/Regional health plan
No coverage

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
No coverage

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 3. Table 4b(Continued)
Country
United States
Uruguay
Venezuela
VietnamZimbabwe

IVF

ICSI

Assisted hatching

State/Provincial/Regional health plan
Private insurance
National health plan
No coverage
No coverage
Private insuranceState/Provincial/Regional health plan
Private insurance
National health plan
No coverage
No coverage
Private insuranceState/Provincial/Regional health plan
Private insuranceState/Provincial/Regional health plan
No coverage
No coverage
No coverage

Chapter 3. Table 4c

Chapter 3. Table 4c
How are ART services reimbursed?

(Continued)

Country

Cryopreservation of
Cryopreservation ofsupernumerary oocytes supernumerary embryosfrom an IVF cyclefrom an IVF cycle

Argentina
Armenia
Australia

No coverage
No coverage
No coverage

Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile

National health plan
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage

China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republicof the Congo
Denmark
Ecuador
Egypt
Estonia
Ethiopia
FinlandFranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
IcelandIndia
IranIsraelItaly

No coverage
No coverage
National health plan
No coverage
No coverage
No coverage
National health plan
No coverage
No coverage
No coverage
National health plan
National health plan
National health plan
No coverage
No coverage
No coverage
No coverage
No coverage
Unknown
National health plan
No coverage
Private insurance
National health plan
National health plan
National health plan
State/Provincial/Regional
health plan

Country

No coverage
National health plan
National health plan
Private insurance
National health plan
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
No coverage
No coverage
No coverage
National health plan
Private insurance
No coverage
No coverage
National health plan
No coverage
No coverage
No coverage

Japan
JordanKazakhstan
Kenya
LatviaLebanon
Libya
Lithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
PolandNational health plan
No coverage
No coverage
National health plan
National health plan
National health plan
National health plan
No coverage
No coverage
No coverage
No coverage
No coverage
Unknown
National health plan
No coverage
Private insurance

Portugal
Qatar
Romania
RussiaNational health plan
National health plan
State/Provincial/Regional
health plan
32

Cryopreservation of
Cryopreservation ofsupernumerary oocytes supernumerary embryosfrom an IVF cyclefrom an IVF cycle
Private insuranceState/Provincial/Regional
health plan
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
National health plan
No coverage
National health plan
No coverage
No coverage
No coverage
No coverage
No coverage

SerbiaSlovenia
South Africa
South Korea

National health plan
Unknown
No coverage
National health plan
State/Provincial/Regional
health plan
No coverage
National health plan
No coverage
No coverage

Spain

No coverage

Sudan
SwedenNo coverage
National health plan
State/Provincial/Regional
health plan

Private insuranceState/Provincial/Regional
health plan
No coverage
No coverage
No coverage
National health plan
No coverage
No coverage
No coverage
National health plan
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
National health plan
No coverage
National health plan
No coverage
No coverage
No coverage
No coverageState/Provincial/Regional
health plan
National health plan
Unknown
No coverage
National health plan
State/Provincial/Regional
health plan
No coverage
National health plan
Private insuranceState/Provincial/Regional
health plan
National health plan
State/Provincial/Regional
health plan
Private insurance
No coverage
National health plan
State/Provincial/Regional
health planAbstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 3. Table 4c

Chapter 3. Table 4d(Continued)

Country
Switzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States

Uruguay
Venezuela
VietnamZimbabwe(Continued)
Cryopreservation of
Cryopreservation ofsupernumerary oocytes supernumerary embryosfrom an IVF cyclefrom an IVF cycle
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
State/Provincial/Regional
health plan
Private insurance
National health plan
No coverage
No coverage
No coverageCountry
Hungary
Iceland
India
IsraelItaly

No coverage
No coverage
Unknown
National health plan
National health plan
State/Provincial/
Regional health plan
Private insuranceJapan
No coverage
JordanNo coverage
Kazakhstan
No coverage
Kenya
No coverage
LatviaNo coverage
LebanonNo coverage
Libya
No coverage
Lithuania
No coverage
Malaysia
No coverage
Mali
No coverage
MexicoNo coverageMontenegro
No coverage
Morocco
No coverage
Namibia
No coverage
Netherlands
No coverage
New Zealand
National health plan
Nigeria
No coverage
NorwayNational health plan
Panamá
No coverage
Paraguay
No coverage
Peru
No coverage
Philippines
No coverage
PolandState/Provincial/
Regional health plan
Portugal
National health plan
Qatar
State/Provincial/
Regional health plan
Romania
No coverage
SerbiaNo coverage
Slovenia
National health plan
South Africa
No coverage
South Korea
No coverage
Spain
National health plan
State/Provincial/
Regional health plan
Sudan
No coverage
SwedenNational health plan
State/Provincial/
Regional health plan
Switzerland
No coverage
Tanzania
No coverage
Trinidad & Tobago No coverage
Tunisia
No coverage
TurkeyNo coverage
UgandaNo coverage
United Kingdom National health plan
United States
State/Provincial/
Regional health plan
Private insurance
Uruguay
State/Provincial/
Regional health plan
Venezuela
No coverage
Vietnam
No coverage
Zimbabwe
No coverage

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
State/Provincial/Regional
health plan
Private insurance
National health plan
No coverage
No coverage
No coverage

Chapter 3. Table 4d
How are ART services reimbursed?
Country

PGT- Monogenic disorders

Argentina
No coverage
Armenia
No coverage
Australia
No coverage
Austria
No coverage
Bangladesh
No coverage
Belarus
No coverage
Benin
No coverage
Bolivia
No coverage
BrazilNo coverage
Bulgaria
No coverage
Burkina Faso
No coverage
Cambodia
No coverage
Cameroon
No coverage
CanadaNo coverage
Chile
No coverage
China
No coverage
Colombia
No coverage
Costa Rica
No coverage
Cote d’Ivoire
No coverage
Czech Republic
National health plan
Democratic Republic No coverageof the Congo
Denmark
National health plan
EcuadorNo coverage
Egypt
No coverage
Estonia
National health plan
Ethiopia
Unknown
FinlandNational health plan
FranceNational health plan
Georgia
No coverage
Germany
No coverage
Ghana
No coverage
GreeceNo coverage
GuatemalaNo coverageHong Kong
Unknown(China*)PGT- Monogenic disorders

PGT- Aneuploidy
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
National health plan
No coverage
No coverage
No coverage
Unknown
National health plan
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
Unknown

33

PGT- Aneuploidy
No coverage
No coverage
Unknown
No coverage
No coverage

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverageState/Provincial/Regional healthplan
No coverageState/Provincial/Regional healthplan
No coverage
No coverage
National health plan
No coverage
No coverage
Unknown

No coverage
No coverage

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverageState/Provincial/Regional healthplan
Private insuranceState/Provincial/Regional healthplan
No coverage
No coverage
No coverage

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 3. Table 4e
How are ART services reimbursed?
Country
Argentina
Armenia
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
Ecuador
Egypt
Estonia
Ethiopia
FinlandFranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
Iceland
India
IsraelItaly

Japan
JordanKazakhstan
Kenya
LatviaLebanon
Libya
Lithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines

Donor sperm

Donor egg

Donor embryos

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
No coverage
No coverage
National health plan
No coverage
No coverage
No coverage
No coverage
National health plan
National health plan
No coverage
No coverage
No coverage
No coverage
No coverage
Unknown
National health plan
No coverage
Private insurance
No coverage
National health plan
State/Provincial/Regional health plan
Private insurance
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
National health plan
No coverage
No coverage
No coverage
No coverage

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverageState/Provincial/Regional health plan
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
No coverage
No coverage
National health plan
No coverage
No coverage
No coverage
No coverage
National health plan
National health plan
No coverage
No coverage
No coverage
No coverage
No coverage
Unknown
National health plan
No coverage
Private insurance
No coverage
National health plan
State/Provincial/Regional health plan
Private insurance
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
National health plan
No coverage
No coverage
No coverage
No coverage

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
National health plan
No coverage
No coverage
No coverage
No coverage
No coverage
Unknown
National health plan
No coverage
Private insurance
No coverage
National health plan
State/Provincial/Regional health plan
Private insurance
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage

34Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 3. Table 4e(Continued)
Country

Donor sperm

Donor egg

Donor embryos

PolandPortugal
Qatar
Romania
SerbiaSlovenia
South Africa
South Korea
Spain

State/Provincial/Regional health plan
National health plan
Unknown
No coverage
No coverage
National health plan
No coverage
No coverage
National health plan
State/Provincial/Regional health plan
No coverage
National health plan
State/Provincial/Regional health plan
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
State/Provincial/Regional health plan
Private insurance
National health plan
No coverage
No coverage
No coverageState/Provincial/Regional health plan
National health plan
Unknown
No coverage
No coverage
National health plan
Private insurance
No coverage
National health plan
State/Provincial/Regional health plan
No coverage
National health plan
State/Provincial/Regional health plan
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
State/Provincial/Regional health plan
Private insurance
National health plan
No coverage
No coverage
No coverageState/Provincial/Regional health plan
National health plan
Unknown
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage

Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

No coverage
National health plan
State/Provincial/Regional health plan
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
State/Provincial/Regional health plan
Private insurance
National health plan
No coverage
No coverage
No coverage

Chapter 3. Table 4f
How are ART services reimbursed?

Country
Argentina
Armenia
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republicof the Congo
Denmark
Ecuador
Egypt

Traditionalsurrogacy

Gestational surrogacy
using donated ova andcommissioning male’s sperm

Gestational surrogacy usingcommissioning couple’s
ova and sperm

Gestational surrogacy
using donated ova anddonated sperm

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage

No coverage
No coverage
No coverage

No coverage
No coverage
No coverage

No coverage
No coverage
No coverage

No coverage
No coverage
Unknown

35

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 3. Table 4f(Continued)

Country
Estonia
Ethiopia
FinlandFranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
Iceland
India
IsraelItaly
Japan
JordanKazakhstan
Kenya
LatviaLebanon
Libya
Lithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
PolandPortugal
Qatar
Romania
SerbiaSlovenia
South Africa
South Korea
Spain
Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States

Uruguay

Traditionalsurrogacy
No coverage
No coverage
No coverage
No coverage
No coverage
No coverageState/Provincial/Regional health plan
No coverage
No coverage
Unknown
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverageState/Provincial/
Regional health plan
No coverage
Unknown
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverageState/Provincial/
Regional health plan
Private insurance
National health plan

Gestational surrogacy
using donated ova andcommissioning male’s sperm

Gestational surrogacy usingcommissioning couple’s
ova and sperm

Gestational surrogacy
using donated ova anddonated sperm

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
Unknown
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
No coverage
No coverage
No coverage
No coverage
No coverageState/Provincial/
Regional health plan
No coverage
Unknown
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverageState/Provincial/
Regional health plan
Private insurance
National health plan

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
Unknown
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
No coverage
No coverage
No coverage
No coverage
No coverageState/Provincial/
Regional health plan
No coverage
Unknown
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverageState/Provincial/
Regional health plan
Private insuranceState/Provincial/
Regional health plan

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
Unknown
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
No coverage
No coverage
No coverage
No coverage
No coverageState/Provincial/
Regional health plan
No coverage
Unknown
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverageState/Provincial/
Regional health plan
Private insuranceState/Provincial/
Regional health plan36

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 3. Table 4f(Continued)

Country

Traditionalsurrogacy

Gestational surrogacy
using donated ova andcommissioning male’s sperm

Gestational surrogacy usingcommissioning couple’s
ova and sperm

Gestational surrogacy
using donated ova anddonated sperm

Venezuela
VietnamZimbabwe

No coverage
No coverage
No coverage

No coverage
No coverage
No coverage

No coverage
No coverage
No coverage

No coverage
No coverage
No coverage

Chapter 3. Table 4g
How are ART services reimbursed?
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
No coverage
National health plan
Private insurance
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
No coverage
No coverage

National health plan
State/Provincial/Regional
health plan
Private insurance
No coverage
National health plan
Private insurance
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
No coverage
No coverage

No coverage

Unknown

No coverage
National health plan
Private insurance
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
No coverage
No coverage

No coverage
National health plan
Private insurance
National health plan
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
No coverage
No coverage

National health plan
State/Provincial/Regional
health plan
Private insurance
No coverage
National health plan
Private insurance
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
No coverage
No coverage

National health plan
No coverage
No coverage
National health plan
National health plan
National health plan
National health plan
No coverage
National health plan
No coverage
No coverage
No coverage
Unknown
No coverage
National health plan
Unknown
National health plan
National health plan
National health plan
National health plan
State/Provincial/Regional
health plan
Private insurance

National health plan
No coverage
No coverage
National health plan
National health plan
National health plan
National health plan
No coverage
National health plan
No coverage
No coverage
No coverage
Unknown
No coverage
National health plan
Unknown
National health plan
National health plan
National health plan
National health plan
State/Provincial/Regional
health plan
Private insurance

National health plan
No coverage
No coverage
National health plan
National health plan
National health plan
National health plan
No coverage
No coverage
No coverage
No coverage
No coverage
Unknown
No coverage
National health plan
Unknown
National health plan
National health plan
National health plan
National health plan
State/Provincial/Regional
health plan
Private insurance

National health plan
No coverage
No coverage
National health plan
National health plan
National health plan
National health plan
No coverage
National health plan
No coverage
No coverage
No coverage
Unknown
No coverage
Unknown
Unknown
National health plan

National health plan
No coverage
No coverage
National health plan
National health plan
National health plan
National health plan
No coverage
National health plan
No coverage
No coverage
No coverage
Unknown
No coverage
Unknown
Unknown
National health plan

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

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

Armenia
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republicof the Congo
Denmark
Ecuador
Egypt
Estonia
Ethiopia
FinlandFranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
Iceland
India
Iran
IrelandIsraelItaly

37

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 3. Table 4g(Continued)
Cryopreservation for fertility preservation for medical indications
CountryJapan
JordanKazakhstan
Kenya
LatviaLebanon
Libya
Lithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
PolandPortugal
Qatar
Romania
SerbiaSlovenia
South Africa
South Korea
Spain

Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States

Uruguay
Venezuela
VietnamZimbabwe

Oocytes

Sperm

Embryos

Testicular tissue

Ovarian tissue

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
National health plan
No coverage
No coverage
No coverage
National health plan
National health plan
No coverage
National health plan
No coverage
No coverage
No coverage
No coverageState/Provincial/Regional
health plan
National health plan
Unknown
No coverage
No coverage
National health plan
Private insurance
No coverage

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
National health plan
No coverage
No coverage
No coverage
National health plan
National health plan
No coverage
National health plan
No coverage
No coverage
No coverage
No coverageState/Provincial/Regional
health plan
National health plan
No coverage
No coverage
No coverage
National health plan
Private insurance
No coverage

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
National health plan
No coverage
No coverage
No coverage
National health plan
National health plan
No coverage
National health plan
No coverage
No coverage
No coverage
No coverageState/Provincial/Regional
health plan
National health plan
No coverage
No coverage
No coverage
National health plan
No coverage
No coverage

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
National health plan
No coverage
No coverage
No coverage
National health plan
National health plan
No coverage
National health plan
No coverage
No coverage
No coverage
No coverageState/Provincial/Regional
health plan
National health plan
No coverage
No coverage
No coverage
National health plan
No coverage
No coverage

National health plan
State/Provincial/Regional
health plan
Private insurance
No coverage
National health plan
State/Provincial/Regional
health plan
Private insurance
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
State/Provincial/Regional
health plan
Private insuranceState/Provincial/Regional
health plan
No coverage
No coverage
No coverage

National health plan
State/Provincial/Regional
health plan
Private insurance
No coverage
National health plan
State/Provincial/Regional
health plan
Private insurance
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
State/Provincial/Regional
health plan
Private insuranceState/Provincial/Regional
health plan
No coverage
No coverage
No coverage

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
National health plan
No coverage
No coverage
No coverage
National health plan
National health plan
No coverage
National health plan
No coverage
No coverage
No coverage
No coverageState/Provincial/Regional
health plan
No coverage
No coverage
No coverage
No coverage
National health plan
Private insuranceState/Provincial/Regional
health plan
National health plan
State/Provincial/Regional
health plan
Private insurance
No coverage
National health plan
State/Provincial/Regional
health plan
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
State/Provincial/Regional
health plan
Private insuranceState/Provincial/Regional
health plan
No coverage
No coverage
No coverage

No coverage

No coverage

No coverage
National health plan
State/Provincial/Regional
health plan
Private insurance
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
State/Provincial/Regional
health plan
Private insuranceState/Provincial/Regional
health plan
No coverage
No coverage
No coverage

No coverage
National health plan
State/Provincial/Regional
health plan
Private insurance
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
State/Provincial/Regional
health plan
Private insuranceState/Provincial/Regional
health plan
No coverage
No coverage
No coverage

38Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 3. Table 4h
How are ART services reimbursed?
Cryopreservation for fertility preservation for non-medical indications
Country

Oocytes

Sperm

Embryos

Testicular tissue

Ovarian tissue

Argentina
Armenia
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republicof the Congo
Denmark
Ecuador
Egypt
Estonia
Ethiopia
FinlandFranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
IcelandIndia
IranIsraelItaly
Japan
JordanKazakhstan
Kenya
LatviaLebanon
Libya
Lithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
Netherlands
Nigeria
NorwayPanamá
Paraguay
Peru

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
Unknown
No coverage
No coverage
Unknown
National health plan
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
National health plan
No coverage
No coverage
No coverage
No coverage
No coverage
Unknown
No coverage
No coverage
Unknown
National health plan
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
Unknown
No coverage
No coverage
Unknown
National health plan
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
Unknown
No coverage
No coverage
Unknown
National health plan
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
Unknown
No coverage
No coverage
Unknown
National health plan
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage

39Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 3. Table 4h(Continued)
Cryopreservation for fertility preservation for non-medical indications
Country

Oocytes

Sperm

Embryos

Testicular tissue

Ovarian tissue

Philippines
PolandNo coverageState/Provincial/
Regional health plan
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage

No coverageState/Provincial/
Regional health plan
No coverage
No coverage
No coverage
No coverage
No coverage
Private insurance
No coverage

No coverageState/Provincial/
Regional health plan
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage

No coverageState/Provincial/
Regional health plan
No coverage
Unknown
No coverage
No coverage
No coverage
No coverage
No coverage

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverageState/Provincial/
Regional health plan
Private insuranceState/Provincial/
Regional health plan
No coverage
No coverage
No coverage

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverageState/Provincial/
Regional health plan
Private insuranceState/Provincial/
Regional health plan
No coverage
No coverage
No coverage

No coverageState/Provincial/
Regional health plan
No coverage
No coverage
No coverage
No coverage
No coverage
Private insuranceState/Provincial/
Regional health plan
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverageState/Provincial/
Regional health plan
Private insuranceState/Provincial/
Regional health plan
No coverage
No coverage
No coverage

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverageState/Provincial/
Regional health plan
Private insuranceState/Provincial/
Regional health plan
No coverage
No coverage
No coverage

No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverage
No coverageState/Provincial/
Regional health plan
Private insuranceState/Provincial/
Regional health plan
No coverage
No coverage
No coverage

Portugal
Qatar
Romania
SerbiaSlovenia
South Africa
South Korea
Spain
Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States

Uruguay
Venezuela
VietnamZimbabwe87) reported that reimbursement was available for IVF. Fiftythree percent (45 of 85) covered ICSI. In 2018, only 45% (37 of
83 countries that responded to the survey) provided reimbursement for IVF or ICSI. Twenty percent (17 of 84 countries) provided coverage for assisted hatching.
Other survey questions addressed coverage for cryopreservation of oocytes or embryos for use in future ART cycles to facilitate screening for chromosomal abnormalities and genetic
diseases. These procedures include preimplantation genetic testing (PGT) for aneuploidy (PGT-A) and for monogenic (singlegene) disorders (PGT-M). Twenty-one percent (18 of 84
respondents) reported the availability of coverage for PGTM;10% (eight of 83 countries) covered PGT-A.
Interestingly, only 20% (17 of 84 countries) provided reimbursement for donor sperm utilization; 23% (19) covered donor
egg cycles and 17% (14) offered coverage for donor embryo
cycles. Thirty-ﬁve percent (30 of 86 countries) provided reimbursement for medically-indicated oocyte cryopreservation.
Only four of the 84 countries responding offered coverage for
oocyte cryopreservation for non-medical (“social”) needs. By
contrast, none of the countries that contributed to the 2015
survey reported reimbursement for cryopreservation of either
oocyte or ovarian tissue for non-medical reasons. By 2018,
Canada, Ireland, Israel, and the United States reported thatsome private insurance carriers provided coverage for oocyte

cryopreservation. Israel and some insurers in the United States
also covered ovarian tissue cryopreservation for non-medical
indications (Tables 5a–5d).
Discussion
Fifty-three percent (47) of the 88 countries that responded to the2021 questionnaire noted that some funding for infertility services was available. This represents a notable increase from the
47% reported in 2018 and is comparable to the 53% reported in2015. Considerable variation exists among the responding
countries in terms of the extent of support provided, as well as therequirements for obtaining it and mechanisms underlying its
distribution and administration [Tables 5a–5d, Chart 2a–2c].
A clear trend was noted for the number of countries mandating single embryo transfer (SET) or otherwise limiting thenumber of embryos transferred in a single cycle as a provision
for support (see Chapter 5). The proportion of countries thathave such policies in place increased from 18% in 2015 to 23%
in 2018, and now to 28% in 2021. Multiple pregnancies
resulting from the transfer of numerous embryos have long beenrecognised as among the most signiﬁcant complications of ART.
Support for genetic testing of embryos (e.g., PGT-M and PGT-A)
has undergone a more modest increase.
In 2021, 21% and 10% of the respondents reported thatﬁnancial support was available for PGT-M and PGT-A,
40

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive HealthDiagnostic Evaluation

61%

Fertility Medications

53%

IUI

40%

IVF

50%

ICSI

49%

Assisted Hatching

15%

PGT-M

PGT-A

17%

6%

Chapter 3. Chart 2a. What does insurance coverage or government funding cover?

into private and public funding for ART[1]. Only private ART centres
exist in Albania, Armenia, Bosnia-Herzegovina, Cyprus, Georgia,
Ireland, and Latvia. Residents of Bosnia-Herzegovina, Cyprus, andLatvia are eligible for funding for ART treatments performed in thosecentres. In other countries, including Belgium, Bulgaria, Czech
Republic, Finland, France, Iceland, Moldova, Slovenia, the Unitedrespectively; this can be compared to 14% and 6% of the
respondents who reported support for PGT-M and PGT-A,
respectively, in 2018. Modest progress has also been made infunding for non-medical cryopreservation.
A recent European Society of Human Reproduction andEmbryology (ESHRE) study offered additional details and insights

Donor sperm

16%

Donor ova

17%

Donor embryos

14%

Traditional surrogacy

1%

Gestational carrier using donated ova & commissioning couples sperm

1%

Gestational carrier using commissioning couples ova & sperm

Gestational carrier using donated ova & donated sperm

Chapter 3. Chart 2b. What does insurance coverage or government funding cover?

41

2%

1%

Abstracts. Global Reproductive Health (2022) 7:e58

Fertility preservation of ovarian tissue non-medical indication

Global Reproductive Health0%

Fertility preservation of sperm non-medical indication

2%

Fertility preservation of oocytes non-medical indication

2%

Fertility preservation of testicular tissue non-medical indication

Fertility preservation of embryos non-medical indication

4%

5%

Fertility preservation of ovarian tissue medical indication

23%

Cryo of supernumerary oocytes from an IVF cycle

24%

Fertility preservation of testituclar tissue medical indication

27%

Fertility preservation of embryos medical indication

27%

Fertility preservation of sperm medical indication

31%

Cryo of supernumerary embryos from an IVF cycle

31%

Fertility preservation of oocytes medical indication

32%

Chapter 3. Chart 2c. What does insurance coverage or government funding cover?

Chapter 3. Table 5a
Does insurance coverage or government funding typically cover the following ART services?
Country
Albania
Argentina
Armenia
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
Ecuador
Egypt
Estonia
Ethiopia
FinlandFranceGeorgia

Diagnostic Evaluation

Fertility Medications

Intrauterine insemination

IVF

ICSI

Assisted hatching

No
Yes
Yes
Yes
Yes
No
Yes
No
No
Yes
No
No
No
No
Yes
Yes
No
Yes
Yes
No
Yes
No
Yes
No
No
Yes
Yes
Yes
Yes
No

No
Yes
Yes
Yes
Yes
No
Yes
No
No
No
Yes
No
No
No
No
Yes
No
No
Yes
No
Yes
No
Yes
No
No
Yes
Unknown
Yes
Yes
No

No
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
Yes
No
Yes
No
Yes
No
No
Yes
Unknown
Yes
Yes
No

No
Yes
Yes
Yes
Yes
No
Yes
No
No
No
Yes
No
No
No
No
Yes
No
No
Yes
No
Yes
No
Yes
No
No
Yes
Yes
Yes
Yes
No

No
Yes
Yes
Yes
Yes
No
Yes
No
No
No
Yes
No
No
No
No
Yes
No
No
Yes
No
No
No
Yes
No
No
Yes
Yes
Yes
Yes
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
Unknown
No
No
No
Unknown
Yes
Yes
No

42

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 3. Table 5a(Continued)
Country
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
Iceland
India
Iran
IrelandIsraelItaly
Japan
JordanKazakhstan
Kenya
LatviaLebanon
Libya
Lithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
PolandPortugal
Qatar
Romania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain
Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

Diagnostic Evaluation

Fertility Medications

Intrauterine insemination

IVF

ICSI

Assisted hatching

Yes
No
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
No
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
No
No
Yes

Yes
No
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
No
No
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
No
No
No
No
No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
Yes
No
Yes
No
No
Yes

Yes
No
No
No
Yes
Yes
No
No
Yes
Yes
Yes
Yes
No
No
No
No
Yes
No
Yes
No
Yes
No
No
Yes
No
No
Yes
Yes
No
No
No
No
No
No
No
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
No
No
No
No
Yes
No
Yes
No
No
Yes

Yes
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
No
No
Yes
Yes
No
No
Yes
No
No
Yes
Yes
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
No
No
No
Yes
No
Yes
No
Yes
No
No
Yes

Yes
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
No
No
Yes
Yes
No
No
Yes
No
No
Yes
Yes
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
No
No
No
Yes
No
Yes
No
Yes
No
No
Yes

No
No
No
No
No
Yes
No
No

43

Yes
No
Yes
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Unknown
Yes
Yes
Yes
No
Yes
No
Yes
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 3. Table 5b
Does insurance coverage or government funding typically cover the following ART services?

Country
Albania
Argentina
Armenia
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republicof the Congo
Denmark
Ecuador
Egypt
Estonia
Ethiopia
FinlandFranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
IcelandIndia
IranIsraelItaly
Japan
JordanKazakhstan
Kenya
LatviaLebanon
Libya
Lithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandNigeria
NorwayCryopreservation ofsupernumerary oocytes
from an IVF cycle

Cryopreservation ofsupernumerary embryosfrom an IVF cycle

PGT- Monogenic
disorders

PGT- Aneuploidy

No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No

No
No
Yes
Yes
Yes
No
No
No
No
No
Yes
No
No
No
No
Yes
No
No
Yes
No
No
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No

Unknown
No
No
No
Unknown
Yes
Yes
No
No
No
No
No
No
Yes
No
Unknown
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
No
No
No
Yes
Yes
No
No

UnknownNo
No
Yes
Unknown
Yes
Yes
No
No
No
No
No
No
Yes
No
Unknown
Yes
Yes
Yes
Yes
No
No
No
Yes
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No

Yes
No
No
Yes
Unknown
Yes
Yes
No
No
No
No
No
No
No
No
Unknown
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No

Yes
No
No
No
Unknown
Yes
No
No
No
No
No
No
No
No
No
Unknown

44

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 3. Table 5b(Continued)

Country

Cryopreservation ofsupernumerary oocytes
from an IVF cycle

Cryopreservation ofsupernumerary embryosfrom an IVF cycle

PGT- Monogenic
disorders

No
No
No
No
No
Yes
Yes
No
Yes
No
Yes
No
No
Yes
No
Yes
No
No
No
No
Yes
No
Yes
No
Yes
No
No
No

No
No
No
No
No
Yes
Yes
No
Yes
No
Yes
Yes
Yes
No
No
Yes
No
No
No
No
Yes
No
Yes
No
Yes
No
No
No

No
No
No
No
No
Yes
Yes
No
No
No
Yes
No
No
Yes
No
Yes
No
No
No
No
No
No
Yes
No
No
No
No
No

Panamá
Paraguay
Peru
Philippines
PolandPortugal
Qatar
Romania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain
Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

PGT- Aneuploidy
No
No
No
No
No
No
Yes
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

Chapter 3. Table 5c
Does insurance coverage or government funding typically cover the following ART services?

Country
Albania
Argentina
Armenia
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republicof the Congo

Donor
sperm

Donor
egg

Donor
embryos

Traditionalsurrogacy

Gestational surrogacy
using donated ova andcommissioning male’s sperm

Gestational surrogacy
using commissioning couple’s
ova and sperm

Gestational surrogacy
using donated ova anddonated sperm

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Unknown
No
Yes
No
No
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

45

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 3. Table 5c(Continued)

Country
Denmark
Ecuador
Egypt
Estonia
Ethiopia
FinlandFranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
IcelandIndia
IranIsraelItaly
Japan
JordanKazakhstan
Kenya
LatviaLebanon
Libya
Lithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
PolandPortugal
Qatar
Romania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain
Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States

Donor
sperm

Donor
egg

Donor
embryos

Traditionalsurrogacy

Gestational surrogacy
using donated ova andcommissioning male’s sperm

Gestational surrogacy
using commissioning couple’s
ova and sperm

Gestational surrogacy
using donated ova anddonated sperm

Yes
No
No
No
No
Yes
Yes
No
No
No
No
No
No
Yes
No
Yes

Yes
No
No
No
No
Yes
Yes
No
No
No
No
No
No
Yes
No
Yes

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
Yes
No
No
No
No
Yes
No
No
Yes
No
Yes
No
No
No
No
No
No
Yes
No

No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
Yes
No
No
No
No
Yes
Yes
No
Yes
No
Yes
No
No
No
No
No
No
Yes
No

No
No
No
No
No
Yes
Yes
No
No
No
No
No
No
Yes
No
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
Yes
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
46

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 3. Table 5c(Continued)

Country

Donor
sperm

Donor
egg

Donor
embryos

Traditionalsurrogacy

Gestational surrogacy
using donated ova andcommissioning male’s sperm

Gestational surrogacy
using commissioning couple’s
ova and sperm

Gestational surrogacy
using donated ova anddonated sperm

Uruguay
Venezuela
VietnamZimbabwe

Yes
No
No
No

Yes
No
No
No

Yes
No
No
No

Yes
No
No
No

No
No
No
No

Yes
No
No
No

No
No
No
No

Chapter 3. Table 5d
Does insurance coverage or government funding typically cover the following ART services?
Cryopreservation for fertility preservation for medical
indications
Country

Oocytes

Sperm

Cryopreservation for fertility preservation for non-medical
indications

Embryos Testicular tissue Ovarian tissue Oocytes

AlbaniaNo
No
No
Argentina
Yes
Yes
Unknown
ArmeniaNo
No
No
Australia
Yes
Yes
Yes
Austria
No
No
No
Bangladesh
No
No
No
Belarus
No
No
No
Benin
No
No
No
BoliviaNo
No
No
BrazilNo
No
No
Bulgaria
Yes
No
No
Burkina Faso
Unknown
No
No
Cambodia
No
No
No
Cameroon
No
No
No
Canada
No
No
No
Chile
No
Yes
No
China
No
No
No
Colombia
No
No
No
Costa Rica
Yes
Yes
Yes
Cote d’Ivoire
No
No
No
Czech Republic
No
No
No
Democratic Republic of the Congo
No
No
No
Denmark
Yes
Yes
Yes
Ecuador
No
No
No
Egypt
No
No
No
Estonia
Yes
Yes
Yes
Ethiopia
Yes
Yes
Yes
FinlandYes
Yes
Yes
FranceYes
Yes
Yes
GeorgiaNo
No
No
Germany
Yes
Yes
No
Ghana
No
No
No
GreeceNo
No
No
GuatemalaNo
No
No
Hong Kong (China*)
No
No
No
Hungary
No
No
No
Iceland
Yes
Yes
Yes
India
Unknown Unknown Unknown
Iran
Yes
Yes
Yes
IrelandYes
Yes
Yes
Israel
Yes
Yes
Yes
Italy
Yes
Yes
Yes
Japan
No
No
No
JordanNo
No
No
Kazakhstan
No
No
No
Kenya
No
No
No

No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
Yes
No
No
Yes
Yes
Yes
Yes
No
Yes
No
No
No
No
No
Yes
Unknown

No
Unknown
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
Yes
No
No
Yes
Yes
Yes
Yes
No
Yes
No
No
No
No
No
Yes
Unknown

Yes
Yes
No
No
No
No

Yes
Yes
No
No
No
No
47

Sperm

Embryos Testicular tissue Ovarian tissue

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Unknown Unknown Unknown
Yes
Yes
No
No
No
No
No
No

No
No
No
No
No
No

No
No
No
No
No
No

No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

No
No
No
No
No
No
Unknown

No
No
No
No
No
No
Unknown

No
No
No
No
No
No

No
No
No
No
No
No

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 3. Table 5d(Continued)
Cryopreservation for fertility preservation for medical
indications
Country
LatviaLebanon
Libya
Lithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
PolandPortugal
Qatar
Romania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain
Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

Oocytes
No
No
No
No
Yes
No
Yes
No
No
No
Yes
Yes
No
No
No
No
No
No
No
Yes
Yes
No
No
No
Yes
Yes
No
Yes
No
Yes
Yes
No
No
No
No
No
Yes
Yes
No
No
No
No

Sperm

Cryopreservation for fertility preservation for non-medical
indications

Embryos Testicular tissue Ovarian tissue Oocytes

No
No
No
No
No
No
No
No
Yes
Yes
No
No
Yes
Yes
No
No
No
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
Yes
Yes
No
No
No
No
Unknown Unknown
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
No
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Unknown
Yes
No
No
No
No
No
No
No
No

No
No
Yes
No
Yes
No
Yes
No
No
No
Yes
Yes
No
No
No
No
No
No
No
Yes
Yes
No
No
Unknown
Yes
Yes
No
No
No
Yes
Yes
No
No
No
No
No
Yes
Unknown
No
No
No
No

No
No
No
No
Yes
No
Yes
No
No
No
Yes
Yes
No
No
No
No
No
No
No
Yes
No
No
No
No
Yes
No
No
No
No
Yes
Yes
No
No
No
No
No
Yes
Unknown
No
No
No
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

Sperm
No
No
No
No
No
No
No
No
No
No
No

Embryos Testicular tissue Ovarian tissue
No
No
No
No
No
No
No
No
No
No
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
Unknown Unknown
No
No
Yes
Yes
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

No
No
Yes
No
No
No
No
No
No
No
No

No
No
No
No
No
No
No
No
No
No
No

No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
Unknown
No
No
No
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Unknown
No
No
No
No

remained relatively constant over the past three surveys thatwere performed in 2015, 2018, and 2021. Genetic screening
appears to be gaining greater support. There has also been an
increase in the number of countries, from 18% to 28% over the
past six years, that require a SET procedure as a requirement
for reimbursement.

Kingdom, and Ukraine, patients may be reimbursed for treatments
performed in either private or public ART centres. Other countries
have distinct publicly funded or fully private ART centres.
While current ﬁndings may be more reliable than those collectedin previous years because many of the respondents are now familiar
with the survey and its implications, caution should be taken wheninterpreting the data. There are limitations with respect to thecompleteness and accessibility of the data included in this analysis.

References[1] Calhaz-Jorge C, De Geyter Ch, Kupka MS, et al. Survey on
ART and IUI: legislation, regulation, funding and registries in
European countries: The European IVF-monitoring
Consortium (EIM) for the European Society of Human
Reproduction and Embryology (ESHRE). Human Reprod
Open 2020;1:hoz44.

Summary
As of 2021, respondents from slightly more than half thecountries now provide insurance coverage for ART, and 53%
offer some support for infertility therapy. The proportion ofcountries offering insurance coverage for ART services has
48

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

6. What was/is the status of your ART centre in your country in
relation to the COVID-19 pandemic (open, closed, or other),(before March 2020, March – May 2020, June – December
2020, January – March 2021)?
7. If your ART centre is closed or has limited access for
special circumstances, was the closure mandate by (voluntary, government policy, hospital policy or Professional
Society’s recommendation)?
8. If a mandate to close was imposed, were there any exceptions
made for patients with certain conditions (e.g., gametebanking prior to chemotherapy/ diminished ovarian reserve)(before March 2020, March – May 2020, June – December
2020, January – March 2021)?
9. If a mandate to close ART centres was issued, are youaware of any that have remained open (before March
2020, March – May 2020, June – December 2020, January –March 2021)?
10. Are you providing fertility treatments (all fertility treatment,
limited fertility treatment, telemedicine only, all fertility
stopped, referring to another centre), (before March 2020,
March – May 2020, June – December 2020, January –March 2021)?
11. Are you counseling patients about deferring pregnancy;
obtaining the COVID-19 vaccine while pregnant; notcounseling patients regarding COVID-19, pregnancy orobtaining the COVID-19 vaccine; or obtaining the
COVID-19 vaccine while not pregnant?
Respondents from 73 countries submitted data for this section.
Regarding the ﬁrst question, 81% (59 of 73 countries) regarded
fertility treatment as an essential medical service while 16% (12)did not. Fifty-one percent (37 of 73 countries) offered modiﬁed
fertility treatment during the pandemic while 36 (49%) did not.
Regarding the question, “Were/are fertility treatments regarded as an essential medical service that should continue despite
the COVID-19 pandemic?”, attitudes appeared to change overthe course of the pandemic. Before March 2020, 67% (45 of 67
respondents) answered afﬁrmatively while 33% replied “no”.
Positive responses reached a nadir from March 2020 to May
2020 when only 47% (32) of 67 respondents conﬁrmed that thiswas the case while 52% (35) replied “no”. From June 2020 to
December 2020, the proportion of positive responses increased to80% (55 of 69 countries), while 20% (14 countries) submitted anegative response. Responses from January 2021 to March 2021
were almost unchanged, with 79% (54 out of 68 countries)
answering “yes” and 21% (14 countries) replying “no” (Table 1,
Chart 1).
In response to the question, “Has your country modiﬁed its
policy regarding fertility treatments along with the evolution of
the COVID-19 pandemic?”, 90% (62 of 69 countries) had nopolicy in place before March 2020. By contrast, 52% (36 of 69
respondents) reported suspension of fertility treatments between
March and May 2020 while 48%, (33) had not. Forty-ﬁve percent (32 of 71 countries) reported that they were following
European Society of Human Reproduction and Embryology(ESHRE) or American Society for Reproductive Medicine(ASRM) guidelines for the resumption of infertility services
between June 2020 to December 2020, while 55% (39 countries)
reported that they were not following these guidelines. During themonths of January to March of 2021, 37% (25) of 67 countries
reported that they were following these guidelines, while 63% (42countries) were not.

[2] Adamson D, Zegers F, de Mouzon J. ICMART preliminary
world report 2017. Available at: https://secureservercdn.net/
198.71.233.206/3nz.654.myftpupload.com/wp-content/
uploads/ICMART-ESHRE-WR2017-Preliminary.pdf.

CHAPTER 4: COVID-19 ISSUESIntroduction
On March 11, 2020, when the World Health Organization(WHO) declared that the Coronavirus disease-2019 (COVID-19)
epidemic had become a global pandemic, over 118,000 cases had
already been reported affecting 110 countries, posing the mostprofound public health challenge in over 100 years. All nations
and all aspects of society began to marshal and prioritize theirresources to combat the spread of the virus. The reproductive
healthcare community played a major role in this effort.
Immediately, two unresolved issues became of paramount concern: (1) Did the virus pose unique risks to mothers and theirfetuses, similar to the Zika outbreak ﬁve years earlier, and (2) was
it safe to continue to provide infertility services given the degree of
uncertainty and the potential diversion of limited resources tomore critical aspects of healthcare? Although no authorities
recommended that women avoid conception, within a week of
the WHO pronouncement, several professional societies called
for a moratorium on the provision of both medically assisted
reproduction and assisted reproductive technology (MART andART) at that time[1-3]. IFFS Surveillance conducted its ﬁrst
interim survey from April 21, 2020, through May 8, 2020, in aneffort to assess the impact of these measures. The data submitted
from respondents from 97 countries was published in August
2020[4]. The ﬁndings presented in this section document the follow-up experience one year later. All 11 of the original questions
were utilized for the 2021 online questionnaire which was completed between February 1, 2021, and April 30, 2021.
Analysis of the Survey
The following questions pertaining to the COVID-19 pandemic
were presented to the respondents:
1. Are fertility treatments regarded as an essential medical
service that should continue despite the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or COVID-19
pandemic in your country?
2. Has your country modiﬁed its policy regarding fertility
treatments along with the evolution of the COVID-19
pandemic?
3. Were/are fertility treatments regarded as an essential medical
service that should continue despite the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or COVID-19
pandemic in your country (before March 2020, March –May 2020, June – December 2020, January – March 2021)?
4. Has your country modiﬁed its policy regarding fertility
treatments along with the evolution of the COVID-19
pandemic (before March 2020, March – May 2020, June –December 2020, January – March 2021)?
5. What was/is the status of ART centres in your country in
relation to the COVID-19 pandemic (open, closed, or other),(before March 2020, March – May 2020, June – December
2020, January – March 2021)?
49

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 4. Table 1
Were fertility treatments regarded as an essential medical service that should continue despite the severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) or COVID-19 pandemic in your country?

Country
Albania
Argentina
Australia
Austria
Bangladesh
Belarus
Benin
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republicof the Congo
Denmark
Ecuador
Egypt
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceHong Kong (China*)
Hungary
India
Ireland
Italy
Japan
Kazakhstan
Kenya
LatviaLithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
Romania
RussiaSerbiaSlovenia
South Africa

March - May 2020 (ESHRE/
ASRM guidelines for
suspension of fertility
treatments)

June-December 2020
(ESHRE/ASRM guidelines forresumption of fertility
treatment

January - March
2021

No
Yes
No
Yes
No
Yes
Yes
Yes
No
No
Yes
No
No
Yes
Yes
No
Yes
No
Yes

No
No
Yes
Yes
No
Yes
No
No
Yes
No
Yes
Yes
No
Yes
Yes
Yes
No
Yes
No
No

No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
No

No
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes

No
Yes
No
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes

Yes/No
Yes
No

Yes
Yes
Yes

Yes
Yes
Yes

No
Yes
Yes
Yes
No

Yes
Yes
Yes
Yes
Yes

Yes
Yes
Yes
Yes
Yes

No
Yes
No
No
Yes
Yes
No
No
No

Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes

Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes

No
Yes

Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes

Yes
Yes

Before March 2020

No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No

Yes
Yes
Yes
No
No
Yes
Yes
Yes
No
Yes
No
Yes
Yes
Yes

50

No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 4. Table 1(Continued)

CountrySouth Korea
Spain
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

Before March 2020
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
No
Yes

March - May 2020 (ESHRE/
ASRM guidelines for
suspension of fertility
treatments)

June-December 2020
(ESHRE/ASRM guidelines forresumption of fertility
treatment

January - March
2021

No
No
Yes
No
Yes
No
No
No
Yes
No
No
No
No
No
Yes

No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
No
No
Yes

No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
No
No
Yes

Before March 2020, of the countries that provided speciﬁc “yes”
or “no” responses, 90% (60 of 67) noted that their ART centres wereopen without restrictions. Ten percent (7 countries) reported that theyremained closed or were operating with limited access. Two countries
responded that both circumstances existed. From March 2020 to
May 2020, 75% (48 of 64 countries) had closed their ART centres or
imposed restrictions on access, while 25% (16 countries) had
imposed no restrictions to access. One country noted that both circumstances existed. From June 2020 to December 2020, the situation
had apparently reversed. Eighty-seven percent (53 of 61 countries)
reported that they had lifted restrictions while only 13% (eight
countries) reported that their ART centres remained closed or openwith restricted access. An additional six countries replied “other”,
implying that a different, unspeciﬁed situation existed. From January
2021 to March of 2021, 94% (58 of 62 countries) had lifted
restrictions; only four countries had not yet lifted restrictions. An
additional four countries responded “other” to this question.

When asked about the status of the respondent’s own ART
centre, 86% (60 of 70 respondents) noted that their centres wereopen and without restrictions, while 14% (10 participants)
replied that they were closed or open with limited access. One
respondent selected “both” and another selected “other” foranswers provided before March 2020. By March 2020 to May
2020, 78% (53 of 68) of their ART centres had closed orremained open with limited access and 22% (15 of 68) had not;an additional two replied “other” and one replied “both”.
Between June 2020 to December 2020, 78% (51 of 65 countries)
reported that ART centres were open without restrictions, while
22% (14) remained closed or offered only limited access to services. An additional ﬁve answered “other”. From January 2021
to March 2021, 91% (61 of 67) were open without restrictions,while 9% (six) still had no access or offered services withrestricted access only. An additional three responded “other”(Table 2).

Before March 2020

March - May 2020 (ESHRE/ASRM guidelines for suspension of fertility treatments

67%

47%

June-December 2020 (ESHRE/ASRM guidelines for resumption of fertility
treatment

80%

January - March 2021

79%

Chapter 4. Chart 1. Were fertility treatments considered essential medical treatment that should continue?

51

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 4. Table 2
What is the status of your ART centre in relation to the COVID-19 pandemic?

Country

Before March 2020

Albania

Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Closed or limited access to
special circumstances
Closed or limited access to
special circumstances
Closed or limited access to
special circumstances
Open with no restrictions toaccess to infertility
treatments

Argentina

Australia

Austria

Bangladesh

Belarus

Benin

BrazilBulgaria

Burkina Faso

Cambodia

Cameroon

Canada

Chile

China

Colombia

Costa Rica

Cote d’Ivoire
Czech Republic
Democratic Republicof the Congo
EcuadorMarch - May 2020 (ESHRE/ASRM
guidelines for suspension of fertility
treatments)

June-December 2020 (ESHRE/ASRM
guidelines for resumption of fertility
treatment)

Open with no restrictions to access toinfertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Other

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Closed or limited access to special
circumstances

Closed or limited access to
special circumstances

Other

Closed or limited access to special
circumstances

Closed or limited access to
special circumstances

Closed or limited access to special
circumstances

Closed or limited access to special
circumstances

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Closed or limited access to special
circumstances

Open with no restrictions toaccess to infertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances
Closed or limited access to special
circumstances
Closed or limited access to special
circumstances
Closed or limited access to special
circumstances

Closed or limited access to special
circumstances
Open with no restrictions to access toinfertility treatments
Closed or limited access to special
circumstances
Open with no restrictions to access toinfertility treatments

Closed or limited access to
special circumstances
Open with no restrictions toaccess to infertility treatments
Closed or limited access to
special circumstances
Open with no restrictions toaccess to infertility treatments

52

January - March
2021

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 4. Table 2(Continued)

Country

Before March 2020

Egypt

Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Closed or limited access to
special circumstances
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Other
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Closed or limited access to
special circumstances
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Closed or limited access to
special circumstances
Open with no restrictions toaccess to infertility
treatments
Closed or limited access to
special circumstances

Ethiopia

FranceGeorgia

Germany

Ghana
GreeceGuatemalaHong Kong (China*)
Hungary

India

Ireland

Italy

Japan

Kazakhstan

Kenya

LatviaLithuania

Malaysia
Mali

MexicoMarch - May 2020 (ESHRE/ASRM
guidelines for suspension of fertility
treatments)

June-December 2020 (ESHRE/ASRM
guidelines for resumption of fertility
treatment)

Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Open with no restrictions to access toinfertility treatments
Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments
Other

Open with no restrictions toaccess to infertility treatments
Other

Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Other
Closed or limited access to special
circumstances

Other
Open with no restrictions to access toinfertility treatments

Other
Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Closed or limited access to special
circumstances

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances
Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Closed or limited access to special
circumstances

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Closed or limited access to special
circumstances

Closed or limited access to
special circumstances

53

January - March
2021

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 4. Table 2(Continued)

Country

Before March 2020

Montenegro

Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Closed or limited access to
special circumstances
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Closed or limited access to
special circumstances

MoroccoNamibia

New ZealandNigeria

NorwayPanamá

Paraguay

Peru

Philippines

Romania
RussiaSerbiaSlovenia

South Africa

South Korea

Spain

SwedenSwitzerland

Tanzania

Trinidad & Tobago

March - May 2020 (ESHRE/ASRM
guidelines for suspension of fertility
treatments)

June-December 2020 (ESHRE/ASRM
guidelines for resumption of fertility
treatment)

Closed or limited access to special
circumstances

Other

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Closed or limited access to special
circumstances

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances
Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments
Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments
Open with no restrictions toaccess to infertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Closed or limited access to special
circumstances

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Closed or limited access to special
circumstances

Open with no restrictions toaccess to infertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

54

January - March
2021

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 4. Table 2(Continued)

Country

Before March 2020

Tunisia

Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Closed or limited access to
special circumstances
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Open with no restrictions toaccess to infertility
treatments
Closed or limited access to
special circumstances

TurkeyUgandaUnited Kingdom
United States

Uruguay

Venezuela

VietnamZimbabwe

March - May 2020 (ESHRE/ASRM
guidelines for suspension of fertility
treatments)

June-December 2020 (ESHRE/ASRM
guidelines for resumption of fertility
treatment)

Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Closed or limited access to special
circumstances

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances
Closed or limited access to special
circumstances

Other

Other

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Closed or limited access to special
circumstances

Closed or limited access to special
circumstances

Closed or limited access to
special circumstances

Closed or limited access to special
circumstances

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions to access toinfertility treatments

Open with no restrictions toaccess to infertility treatments

January - March
2021

Chapter 4. Table 3
Are you counseling patients regarding the following?

Country
Albania
Argentina
Australia
Austria
Bangladesh
Belarus
Benin
BrazilBulgaria
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republicof the Congo
Ecuador
Egypt
Ethiopia

Deferring
Pregnancy

Yes
Yes

Obtaining Covid-19
Vaccine while notpregnant

Obtaining Covid-19
Vaccine while
pregnant

Proceeding withpregnancy attempt

Yes
Yes
Yes
Yes

Yes
Yes
Yes
Yes
Yes

Yes
Yes
Yes
Yes
Yes

Yes
Yes
Yes

Yes
Yes

Yes

Yes
Yes

Yes
Yes

Not counseling patients
regarding COVID-19,
pregnancy or COVID-19
vaccine

Yes
Yes
Yes
Yes
Yes
Yes
Yes

Yes

Yes

Yes

Yes

Yes
Yes

Yes
Yes
Yes

Yes

55

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Yes
Yes

Yes

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 4. Table 3(Continued)

Country
FranceGeorgia
Germany
Ghana
GreeceGuatemala
Hungary
India
Ireland
Italy
Japan
Kazakhstan
Kenya
LatviaLithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
Nigeria
NorwayPanamá
Paraguay
Peru
Philippines
Romania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

Deferring
Pregnancy
Yes
Yes

Yes

Yes
Yes
Yes
Yes
Yes
Yes
Yes

Obtaining Covid-19
Vaccine while notpregnant

Obtaining Covid-19
Vaccine while
pregnant

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Yes
Yes

Yes
Yes
Yes
Yes
Yes

Yes
Yes
Yes

Yes
Yes

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Yes
Yes
Yes
Yes
Yes

Yes

Yes
Yes
Yes
Yes

Proceeding withpregnancy attemptNot counseling patients
regarding COVID-19,
pregnancy or COVID-19
vaccine

Yes
Yes
Yes
Yes
Yes

Yes
Yes
Yes
Yes
Yes
Yes
Yes

Yes

Yes
Yes

Yes
Yes

Yes
Yes
Yes
Yes

Yes

Yes

Yes
Yes

Yes
Yes

Yes
Yes

Yes
Yes

Yes

Yes
Yes
Yes
Yes
Yes
Yes

Before March 2020, if their ART centre was closed or operating with limited access, the decision was voluntary (completely
or in part) in 71% (37 of 52 respondents) or per government
policy in 13% (seven of 52). Another three respondents reported
that this was dictated by hospital policy, while 25% (13) reported
that the decision was reached in accordance with professionalsociety recommendations. From March 2020 to May 2020, thedecision was voluntary (completely or in part) in 47% (30 of 64
respondents) or per government policy in 38% (24 of 64).

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Yes

Yes
Yes

Another 14% (nine) reported that this was mandated by hospital
policy while 39% (25) noted that this was prompted by professional society recommendations. By June 2020 throughDecember 2020, the choice was completely or partially voluntaryin 56% (29 of 52 respondents), as per government policy in 21 %(11), as per hospital policy in 13% (seven), or prompted by therecommendations of professional societies for 33% (17). Reports
from January 2021 through March of 2021 indicate that thedecision remained voluntary for 58% (28 of 48 participants), as56

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Healthper government policy for 17% (eight), as per hospital policy infour cases, or suggested by professional society guidelines for
31% (15).
In cases where mandates to close were issued, exceptions forpatients with certain conditions were made 45% (23 of 51) of thecountries surveyed before March 2020, in 65% (40 of 62) of thecountries surveyed between March 2020 and May 2020, 54%(28 of 52) of the countries surveyed from June 2020 to December
2020, and 50% (24 of 48) of the countries surveyed from January
2021 to March of 2021.
When speciﬁcally questioned as to whether the respondents
knew of ART centres that had not followed mandates andremained open, 52% (28 of 54 respondents) reported that they
were aware of such centres before March 2020, 38% (23 of 60)
reporting between March 2020 and May 2020 noted that they
were aware of centres that had not followed mandates, 54% (29of 54) reported this ﬁnding between June 2020 and December
2020, while 54% (28 of 52) reported in January 2021 to March
2021 that they were aware of ART centres that had remained
open despite mandates. Over 85% (60 of 71 centres) were providing complete fertility services before March 2020. The nadir
was reached in March 2020 to May 2020, with only 19% (13 of
69 respondents) still providing complete fertility services. From
January 2021 to March of 2021, 86% (59 of 69 countries)
reported that their ART centres were again offering complete
fertility services. A large proportion of providers were counseling
patients about deferring pregnancy, whether or not to undergo
COVID-19 vaccination while pregnant, and whether to proceedwith attempts at pregnancy (Table 3).

Summary
Before the COVID-19 pandemic, the overwhelming majority of
respondents (81%) regarded fertility treatment as an essential
medical service. Between March 2020 and May 2020, only 47%
still recognized the primacy of fertility care. From June 2020 to
December 2020 this number rebounded to 80%, which likely
reﬂected a greater willingness to resume fertility treatment.
Between March 2020 and May 2020, ART centres in 75% ofcountries worldwide had curtailed all or signiﬁcantly restricted
access to infertility services.
References[1] British Fertility Society. Guidance for the care of fertility
patients during the Coronavirus COVID-19 Pandemic.
Available at: https://www.britishfertilitysociety.org.uk/2020/
03/18/guidance-for-the-care-of-fertility-patients-during-thecoronavirus-covid-19-pandemic/. Accessed May 28, 2020.
[2] ESHRE News. Available at: https://www.eshre.eu/Press-Room/
ESHRE-News#COVID19P2. Accessed May 28, 2020.
[3] American Society for Reproductive Medicine (ASRM).
American Society for Reproductive Medicine (ASRM) PatientManagement and Clinical Recommendations During theCoronavirus (COVID-19) pandemic. Available at: https://www.asrm.org/globalassets/asrm/asrm-content/news-andpublications/covid-19/covidtaskforceupdate1.pdf. Accessed
May 28, 2020.
[4] Ory SJ, Miller KA, Horton M. The global impact of COVID19 on infertility services. Glob Reprod Health 2020;5(2):e43.
[5] Islam N, Jdanov DA, Shlolnikov VM, et al. Effects of covid-19
pandemic on life expectancy and premature mortality in
2020: time series analysis in 37 countries. BMJ 2021;375:
e066768.
[6] Harper S. The impact of the Covid-19 pandemic on global
population ageing. J Popul Ageing 2021; 14:137–142.

Discussion
These data reﬂect the massive disruption that the pandemic has
imposed on the provision of reproductive services together with thesubstantial impact this has had on both patients and their providers.
They also attest to the overall responsiveness of the reproductive
medicine community to calls from public health ofﬁcials, professional organizations, government mandates, and decrees that asked
all centres to follow mitigation strategies for containment of
COVID-19 and delay treatment until risks and the need to allocate
critical healthcare resources could be more fully assessed. The
pandemic has continued to unfold unevenly and has affected different countries at different times and to varying extents. A wide
range of strategies has been deployed by all countries. This in part,reﬂects the variation in resources as well as political and cultural
attitudes and the wherewithal to deal with the crisis.
By the end of 2021, the global death toll due to COVID-19 wasestimated to exceed ﬁve million individuals. While the generationof accurate worldwide incidence and death rates has been hampered by numerous methodologic challenges, by any measure thepandemic has had a profound impact on recent demographic
trends. Reduction in life expectancy for men and women wasreported in 31 of 37 countries evaluated in 2020; this represents
28 million years of life lost[5]. Many countries, including France,
Italy, Spain, and the United States reported a 13–20% fall in birthrates in 2020, representing in some cases the lowest rates reported
in 70 years[6]. It will be many years before the full demographic
impact of the pandemic will be fully appreciated.

Chapter 5: MARITAL STATUS, SAME SEX, AND
SINGLE-PARENTING POLICIESIntroduction
In many countries, ART became available in the 1980s as anindependent clinical service without speciﬁc requirements foraccess and with few measures in place to ensure equal availability
to all. When ART services became more established, many
countries set forth conditions that either limited or ensured accessto groups other than heterosexual married couples. As thenumber of countries with speciﬁc legislation or guidelines in place
continues to expand, the Surveillance study noted a general trend
toward favouring expanded and protected access, especially for
individuals who may not be in a married, heterosexual relationship. The most recent data suggest that this trend may be changing. This chapter addresses the availability and oversight of ART
utilization as it pertains to marital status, sexual orientation, andgender identity.
Analysis of the Survey
The following survey questions were posed to establish whether
there were requirements in place that designated a speciﬁc type of
relationship (i.e., one that was stable, married, and/or heterosexual) to gain access to ART services, and, within that type of57

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Healthrelationship, if services were available and/or if restrictions
existed.
Question 1. To access IVF or ART services in your country,
are a couple or an individual required to be in a recognized or
stable heterosexual relationship? How are these requirements
governed?
Question 2. If there is no requirement for an ofﬁcial or stable
heterosexual union, is IVF or ART services accessible to?
Question 3. Does your country have laws that recognize thesame-sex partner of a person who has used assisted reproduction
as a legal parent of the resulting child?
Question 4. To whom are treatments allowed/permitted?
Question 5. To whom are treatments practised/performed?
Respondents from 80 countries provided complete or partial
answers to the ﬁve questions pertaining to access to ART services.
In response to the question focused on requirements for arecognized or stable relationship in order to access ART services,
44% (35) of 80 countries reported that no such requirement
existed, while 54% (43) noted the existence of such a requirement(Chart 1). In 2019, respondents to the Surveillance survey
reported that 62% (52) of 84 countries had no requirements for arecognized or stable relationship, while 38% (32 countries)
reported that this was a requirement for ART services. This
represents a substantial increase in the number of countries thatnow require this type of relationship as a contingency for accessto ART services. Most European countries responded that they
had no requirements for a recognized relationship in order toprovide access to ART services; exceptions included countries
with federal laws, statutes, or ordinances that establish thisrequirement.
Most countries did require that individuals provided with ART
services must be in a stable heterosexual relationship and that thiswas documented by laws or statutes, oversight by professionalorganizations, or government agencies with relevant jurisdiction.
Of these, 83% (36) of 43 countries reported that this was regulated by federal or national laws, statutes, or ordinances(Table 1). Representatives from Bangladesh, Japan, Jordan,
Malaysia, Mali, the Philippines, and Trinidad and Tobago allnoted that access to ART services was limited to individuals in astable relationship as mandated by professional organizations,cultural practice, or religious decree.
The countries with no requirement for a stable heterosexual
union were surveyed and asked whether services were available toChapter 5. Table 1
To access IVF or ART services in your country are a couple or anindividual required to be in a recognized or stable heterosexual
relationship?
Country

Do not require stable relationship

Albania

Yes

Argentina
Australia
Austria

No requirement
No requirement
No requirement

Bangladesh

Yes

Belarus

Yes

Benin

Yes

Bolivia
BrazilBulgaria
Burkina Faso

No requirement
No requirement
No requirement
No requirement

Cambodia

Yes

Cameroon
CanadaChile

No requirement
No requirement
Yes

China

Yes

Colombia
Costa Rica

No requirement
Yes

Cote d’Ivoire

Yes

Czech Republic

Yes

How are these requirements
governed by?
Federal/National Laws/Statutes/
Ordinances

Professional Organization
Standards/Guidelines
Cultural practice
Religious decree
Federal/National Laws/Statutes/
Ordinances
Federal/National Laws/Statutes/
Ordinances

Federal/National Laws/Statutes/
OrdinancesState/Provincial/Regional Laws/
Statutes/Ordinances
Municipal Laws/Statutes/
Ordinances
Cultural practiceFederal/National Laws/Statutes/
Ordinances
Professional Organization
Standards/Guidelines
Federal/National Laws/Statutes/
OrdinancesState/Provincial/Regional Laws/
Statutes/Ordinances
Federal/National Laws/Statutes/
Ordinances
Federal/National Laws/Statutes/
Ordinances
Federal/National Laws/Statutes/
Ordinances

Democratic Republic No requirementof the Congo

2%

54%

Response

44%

Require stable relationship

Denmark

No requirement

EcuadorNo requirement

Egypt

Yes

Estonia

No requirement

Ethiopia

Yes

Federal/National Laws/Statutes/
OrdinancesState/Provincial/Regional Laws/
Statutes/Ordinances
Religious decree

FranceYes

Georgia

Yes

Federal/National Laws/Statutes/
Ordinances
Federal/National Laws/Statutes/
Ordinances

Unknown

Chapter 5. Chart 1. Requirement for a stable or recognized relationship.

58

Federal/National Laws/Statutes/
OrdinancesAbstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 5. Table 1

Chapter 5. Table 1(Continued)(Continued)

Country
Germany

Ghana

GreeceResponse
Yes

Yes

Yes

How are these requirements
governed by?
Federal/National Laws/Statutes/
OrdinancesState/Provincial/Regional Laws/
Statutes/Ordinances
Federal/National Laws/Statutes/
Ordinances
Professional Organization
Standards/Guidelines
Cultural practice
Religious decree
Federal/National Laws/Statutes/
Ordinances

GuatemalaHong Kong (China*)

No requirement
Yes

Hungary

Yes

IcelandIndia

No requirement
Yes

Iran

Yes

IrelandIsraelNo requirement
Yes

Italy

Yes

Japan

Yes

JordanYes

Kazakhstan

Yes

Kenya
LatviaNo requirement
No requirement

Lithuania

Yes

Federal/National Laws/Statutes/
Ordinances

Malaysia

Yes

Professional Organization
Standards/Guidelines

Mali

Yes

Professional Organization
Standards/Guidelines
Cultural practice

MexicoNo requirement

MoroccoYes

Namibia

No requirement

Netherlands

No requirement

New ZealandNo requirement

Nigeria

No requirement

NorwayNo requirement

Panamá

No requirement

Paraguay
Philippines

No requirement
Yes

Country

Federal/National Laws/Statutes/
OrdinancesState/Provincial/Regional Laws/
Statutes/Ordinances
Federal/National Laws/Statutes/
Ordinances
Federal/National Laws/Statutes/
Ordinances
Federal/National Laws/Statutes/
Ordinances
Federal/National Laws/Statutes/
Ordinances
Federal/National Laws/Statutes/
Ordinances
Professional Organization
Standards/Guidelines
Professional Organization
Standards/Guidelines
Cultural practice
Religious decree
Federal/National Laws/Statutes/
Ordinances

Response

PolandYes

Romania

Yes

RussiaYes

SerbiaSlovenia

No requirement
Yes

South Africa
South Korea

No requirement
Yes

Spain
Sudan

Unknown
Yes

SwedenSwitzerland

No requirement
Yes

Tanzania
Trinidad & Tobago
Tunisia

Unknown
Yes
Yes

TurkeyYes

UgandaUnited Kingdom
United States
Uruguay
Venezuela
Vietnam

No requirement
No requirement
No requirement
No requirement
No requirement
Yes

Zimbabwe

Yes

How are these requirements
governed by?
Federal/National Laws/Statutes/
Ordinances
Federal/National Laws/Statutes/
OrdinancesState/Provincial/Regional Laws/
Statutes/Ordinances
Professional Organization
Standards/Guidelines
Federal/National Laws/Statutes/
Ordinances
Federal/National Laws/Statutes/
Ordinances
Federal/National Laws/Statutes/
Ordinances
Professional Organization
Standards/Guidelines
Federal/National Laws/Statutes/
Ordinances
Federal/National Laws/Statutes/
Ordinances
Cultural practiceFederal/National Laws/Statutes/
Ordinances
Federal/National Laws/Statutes/
Ordinances

Federal/National Laws/Statutes/
Ordinances
Federal/National Laws/Statutes/
Ordinances

single men, single women, male and female same-sex couples,
and/or individuals identifying as transgender or intersex(Table 2). Thirty-ﬁve percent (12) of 35 countries reported accessfor all. In 2019, 25% (13) of 52 countries reported that the samegroups had access to ART services, representing no signiﬁcantchange over the previous three years. Several countries reported
access to single individuals or same-sex couples but responded“unknown” regarding transgender and intersex persons. Elevencountries reported that single women and female same-sex couples had access to ART services but responded “no” or“unknown” when asked about access by single men and samesex male couples. Cameroon, Latvia, and Uganda reported thatsingle women had access to ART services, with all others having“no access”, or “unknown”. Austria and Burkina Faso reported
that there was “no access” to ART services for anyone not instable, heterosexual relationships.
Individuals and same-sex couples had access to various diagnostic and therapeutic interventions (Tables 3a–3d). Twenty-

Federal/National Laws/Statutes/
Ordinances

Professional Organization
Standards/Guidelines
59

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 5. Table 2
If there is no requirement for an ofﬁcial or stable heterosexual union is IVF or ART services accessible to?
Country
Argentina
Australia
Austria
Bolivia
BrazilBulgaria
Burkina Faso
Cameroon
CanadaColombia
Democratic Republic of the Congo
Denmark
EcuadorEstonia
GuatemalaIceland
IrelandKenya
LatviaMexicoNamibia
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
SerbiaSouth Africa
SwedenUgandaUnited Kingdom
United States
Uruguay
Venezuela

Single womenSingle men

Same sex female couples

Same sex male couples

TransgenderIntersex Individuals

Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Yes
Yes
No
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
Unknown
Yes
No
No
Yes
No
Yes
Yes
Yes
Yes
Yes
No
No
Yes
No
Yes
No
Unknown
No
Yes
No
No

Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Unknown
Yes
Yes
Yes
Yes

Yes
Yes
No
Yes
Yes
No
No
No
Yes
Yes
No
No
No
Unknown
Yes
No
No
Yes
No
No
Yes
Yes
Yes
No
No
No
Yes
No
Yes
No
Unknown
No
Yes
No
No

Yes
Yes
Yes
Yes
Yes
Unknown
No
No
Yes
Yes
No
Yes
No
UnknownNo
Yes
Unknown
Yes
No
Yes
Unknown
Yes
Yes
No
Yes
No
Yes
No
Yes
Yes
Unknown
Yes
Yes
Unknown
No

Yes
Yes
Yes
Yes
Yes
Unknown
Yes
No
Yes
Yes
No
Yes
No
UnknownNo
Yes
Unknown
Yes
No
No
Unknown
Yes
Yes
No
Unknown
No
Yes
No
Yes
Yes
Unknown
Yes
Yes
UnknownNo

Chapter 5. Table 3a
Access to diagnostic and therapeutic interventions.
Country

Diagnostic Evaluation

Intrauterine Insemination

Albania
Argentina

Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Not allowed

Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Same Sex Female Married Couple
TransgenderIntersex Individuals

Australia

Austria

Bangladesh

60

Not allowedAbstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 5. Table 3a(Continued)
Country

Diagnostic Evaluation

BelarusSingle Women
Single Men
Intersex Individuals
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Intersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Single Women
Single Men
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderSingle Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Not allowed
Single Women
Single Men
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Not allowed

Benin
Bolivia

BrazilBulgaria

Burkina Faso

Cambodia

Cameroon
CanadaChile

Colombia

Costa Rica
Cote d’Ivoire

Czech Republic
Democratic Republic of the Congo
Denmark

Ecuador
Egypt
Estonia
Ethiopia

61

Intrauterine Insemination
Single Women

Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple

Intersex Individuals

Single Women
Same Sex Female Married Couple
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
Not allowed
Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Single Women
Same Sex Female Married Couple

Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Not allowedAbstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 5. Table 3a(Continued)
Country

Diagnostic Evaluation

Georgia

Germany

Ghana
GreeceGuatemalaHong Kong (China*)

Hungary
Iceland

India
IsraelItaly
JordanKazakhstan
Kenya

LatviaLithuania
Mali
MexicoMoroccoNamibia

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Women
Single Men
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
Single Women
Single Men
Single Women
Single Men
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Single Women
Single Men
Single Women
Single Men
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
62

Intrauterine Insemination
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals

Not allowed
Single Women
Single Women
Same Sex Female Married Couple

TransgenderIntersex Individuals

Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals

Single Women
Single Women
Same Sex Female Married Couple

Not allowed
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Not allowed

Single Women
Same Sex Female Married Couple

Not allowed
Single Women
Single Men
Same Sex Female Married Couple

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 5. Table 3a(Continued)
Country
Netherlands

New ZealandNigeria
NorwayPanamá
Paraguay
Philippines
PolandRomania
RussiaSerbiaSlovenia
South Africa

South Korea

Spain

Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago

Tunisia

Diagnostic Evaluation

Intrauterine Insemination

Same Sex Male Married Couple
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Single Women
Same Sex Female Married Couple
TransgenderSingle Women
Same Sex Female Married Couple
Single Women
Single Men
Single Women
Single Men
Single Women
Single Men
Not allowed
Single Women
Single Women
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Not allowed
Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Single Men
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals

Same Sex Male Married Couple
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women

63

Single Women
Same Sex Female Married Couple
TransgenderSingle Women
Same Sex Female Married Couple
Single Women
Single Men
Not allowed
Not allowed
Not allowed
Single Women
Not allowed
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men

Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals

Not allowed
Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Not allowedAbstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 5. Table 3a(Continued)
Country

Diagnostic Evaluation

TurkeyUgandaNot allowed
Single Women
Single Men
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Intersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Single Women
Single Men
Single Women
Single Men

United Kingdom

United States

Uruguay

Venezuela

VietnamZimbabwe

Intrauterine Insemination
Not allowed
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Intersex Individuals
Single Women
Same Sex Female Married Couple
Single Women
Single Women
Single Men

Chapter 5. Table 3b
Access to diagnostic and therapeutic interventions.
Country

IVF

PGT- Monogenic disorders

PGT- Aneuploidy

Albania
Argentina

Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Same Sex Female Married Couple
TransgenderIntersex Individuals
Not allowed
Single Women
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple

Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Same Sex Female Married Couple
TransgenderIntersex Individuals
Not allowed
Single Women
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple

Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Same Sex Female Married Couple
TransgenderIntersex Individuals
Not allowed
Single Women
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple

Australia

Austria

Bangladesh
Belarus
Benin
Bolivia

Brazil64

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 5. Table 3b(Continued)
Country

Bulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
Colombia

Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
Ecuador
Egypt
Estonia
Ethiopia
Georgia
Germany

Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
Iceland

India
IsraelJordanKazakhstan
Kenya

LatviaLithuania
MexicoIVF

PGT- Monogenic disorders

PGT- Aneuploidy

TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Intersex Individuals
Single Women
Same Sex Female Married Couple
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
Not allowed
Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Single Women
Same Sex Female Married Couple
Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Not allowed
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Not allowed
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Not allowed
Single WomenTransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Intersex Individuals
Single Women
Same Sex Female Married Couple
Single Men
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
Not allowed
Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Single Women
Same Sex Female Married Couple
Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Not allowed
Single WomenTransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Intersex Individuals
Single Women
Same Sex Female Married Couple
Single Men
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
Not allowed
Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Single Women
Same Sex Female Married Couple
Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Not allowed
Single Women

Not allowed
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Not allowed

Not allowed
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Not allowed

Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Not allowed
Single Women

Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Not allowed
Single Women

65

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 5. Table 3b(Continued)
Country

MoroccoNamibia

Netherlands

New ZealandNigeria
NorwayPanamá
Paraguay
Philippines
PolandRomania
RussiaSerbiaSlovenia
South Africa

South Korea
Spain

Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago

Tunisia
TurkeyUgandaUnited Kingdom

IVF

PGT- Monogenic disorders

PGT- Aneuploidy

Single Men
Same Sex Female Married Couple
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Single Women
Same Sex Female Married Couple
TransgenderSingle Women
Same Sex Female Married Couple
Single Women
Single Men
Not allowed
Not allowed
Not allowed
Single Women
Not allowed
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Not allowed
Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Not allowed
Not allowed
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals

Single Men
Same Sex Female Married Couple
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
Not allowed

Single Men
Same Sex Female Married Couple
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
Not allowed

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Single Women
Same Sex Female Married Couple

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Not allowed

Single Women
Same Sex Female Married Couple
Single Women
Single Men
Not allowed
Not allowed
Not allowed
Single Women
Not allowed
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Not allowed
Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Not allowed
Not allowed
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals

Single Women
Same Sex Female Married Couple
Single Women
Single Men
Not allowed
Not allowed
Not allowed
Single Women
Not allowed
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Not allowed
Not allowed66

Not allowed
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Not allowed
Not allowed
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 5. Table 3b(Continued)
Country
United States

Uruguay

Venezuela
VietnamZimbabwe

IVF

PGT- Monogenic disorders

PGT- Aneuploidy

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Intersex Individuals
Single Women
Same Sex Female Married Couple
Single Women
Single Women
Single Men

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Intersex Individuals

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Intersex Individuals

Single Women
Same Sex Female Married Couple
Single Women
Single Women
Single Men

Single Women
Same Sex Female Married Couple
Single Women
Single Women
Single Men

Chapter 5. Table 3c
Access to diagnostic and therapeutic interventions.
Country

Donor Sperm

Donor Egg

Donor Embryos

Albania
Argentina

Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Same Sex Female Married Couple
TransgenderIntersex Individuals
Not allowed
Single Women
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Intersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Single Women
Single Men

Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Same Sex Female Married Couple
TransgenderIntersex Individuals
Not allowed
Single Women
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Intersex Individuals
Single Women
Same Sex Female Married Couple

Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Not allowed

Single Women

Not allowed

Australia

Austria

Bangladesh
Belarus
Benin
Bolivia

BrazilBulgaria
Burkina Faso
Cambodia

Cameroon67

Not allowed
Single Women
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Single Women
Same Sex Female Married Couple

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 5. Table 3c(Continued)
Country

Donor Sperm

Donor Egg

Donor Embryos

CanadaSingle Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
Not allowed
Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Single Women
Same Sex Female Married Couple
Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Not allowed
Single Women

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals

Chile

Colombia

Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
Ecuador
Egypt
Estonia
Ethiopia
Georgia
Germany

Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
Iceland

India
IsraelJordanKazakhstan
Kenya

LatviaLithuania
MexicoMoroccoNamibia

Not allowed
Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Single Women
Same Sex Female Married Couple
Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Not allowed
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Not allowed
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Not allowed
Single Women
Same Sex Female Married Couple
Transgender
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
68

Not allowed
Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Single Women
Same Sex Female Married Couple
Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Not allowed
Single Women

Not allowed
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals

Not allowed
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Not allowed

Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Not allowed
Single Women
Same Sex Female Married Couple
Transgender
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple

Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Not allowed
Single Women
Same Sex Female Married Couple
Transgender
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 5. Table 3c(Continued)
Country

Donor Sperm

Donor Egg

Donor Embryos

Netherlands

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Single Women
Same Sex Female Married Couple
TransgenderSingle Women
Same Sex Female Married Couple
Single Women
Single Men
Not allowed
Not allowed
Not allowed
Single Women
Not allowed
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Not allowed
Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Not allowed
Not allowed
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single WomenIntersex Individuals

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Not allowed

Single Women
Same Sex Female Married Couple
Single Women
Single Men
Not allowed
Not allowed
Not allowed
Single Women
Not allowed
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Men
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Not allowed
Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Not allowed
Not allowed

Single Women
Same Sex Female Married Couple
Single Women
Single Men
Not allowed
Not allowed
Not allowed
Single Women
Not allowed
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals

New ZealandNigeria
NorwayPanamá
Paraguay
Philippines
PolandRomania
RussiaSerbiaSlovenia
South Africa

South Korea
Spain

Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago

Tunisia
TurkeyUgandaUnited Kingdom

United States

Uruguay

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single WomenIntersex Individuals
69

Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Not allowed
Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Not allowed
Not allowed
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single WomenIntersex Individuals

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 5. Table 3c(Continued)
Country

Donor Sperm

Donor Egg

Donor Embryos

Venezuela

Single Women
Same Sex Female Married Couple
Single Women
Single Women
Single Men

Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Single Men

Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Single Men

VietnamZimbabwe

Chapter 5. Table 3d
Access to diagnostic and therapeutic interventions.
Country

Traditional Surrogacy

Albania
Australia

Not allowed

Austria
Bangladesh
Belarus
Benin
Bolivia

Not allowed
Not allowed
Not allowed
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Not allowed
Not allowed
Not allowed
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Not allowed
Single Women

BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Denmark
EcuadorNot allowed
Same Sex Female Married Couple
Not allowed
Not allowed

Egypt
Estonia
Ethiopia
Georgia

Not allowed
Single Women
Not allowed
Not allowed

Gestational Surrogacy using donated ova
and commissioning person’s sperm

Gestational Surrogacy using donated ova
and donated sperm

Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Not allowed
Not allowed
Single Women
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Not allowed
Not allowed
Not allowed
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Not allowed
Single Men
Same Sex Male Married Couple
Not allowed
Same Sex Female Married Couple
Not allowed
Not allowed
Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Not allowed
Not allowed

Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Not allowed
Not allowed
Not allowed
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Not allowed
Not allowed
Not allowed
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Not allowed
Not allowed70

Not allowed
Same Sex Female Married Couple
Not allowed
Not allowed
Single Women
Not allowed
Single Women
Not allowed
Not allowedAbstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 5. Table 3d(Continued)
Country
Ghana
GreeceHong Kong (China*)
Hungary
IcelandIsraelJordanKazakhstan
Kenya

Gestational Surrogacy using donated ova
and commissioning person’s sperm

Gestational Surrogacy using donated ova
and donated sperm

Not allowed

Not allowed

Not allowed
Not allowed
Not allowed
Not allowed

Not allowed
Not allowed
Not allowed
Single Women
Same Sex Female Married Couple
Not allowed
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Not allowed
Not allowed
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Not allowed
Not allowed
Not allowed
Not allowed
Not allowed
Not allowed
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Not allowed
Not allowed
Not allowed
Single Women
Not allowed
Not allowed
Not allowed
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals

Not allowed
Single Women
Not allowed
Not allowed
Not allowed
Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Not allowed
Not allowed
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Not allowed
Not allowed
Not allowed

Traditional Surrogacy

Nigeria

Not allowed
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Not allowed
Not allowed
Not allowed
Not allowed
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Men

NorwayPanamá
Philippines
PolandRomania
SerbiaSlovenia
South Africa

Not allowed
Not allowed
Not allowed
Not allowed
Not allowed
Not allowed
Not allowed
Intersex Individuals

Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom

Not allowed
Not allowed
Not allowed
Single Women
Not allowed
Not allowed
Not allowed
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals

LatviaLithuania
MexicoMoroccoNetherlands

New Zealand71

Not allowed
Not allowed
Not allowed
Intersex Individuals

Not allowed
Not allowed
Not allowed
Single Women
Not allowed
Not allowed
Not allowed
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 5. Table 3d(Continued)
Country
United States

Uruguay
Venezuela
VietnamZimbabwe

Traditional Surrogacy
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single WomenIntersex Individuals
Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Single Men

Gestational Surrogacy using donated ova
and commissioning person’s sperm

Gestational Surrogacy using donated ova
and donated sperm

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Intersex Individuals

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Intersex Individuals

Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Single Men

Single Women
Same Sex Female Married Couple
Not allowed
Single Women
Single Men

Chapter 5. Table 4a
To whom are treatments practised/performed?
Country

Diagnostic Evaluation

Intrauterine Insemination

Argentina

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Intersex Individuals
Intersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderSingle Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Intersex Individuals
Single Women
Single Men
Same Sex Female Married Couple

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Same Sex Female Married Couple
TransgenderIntersex Individuals

Australia

Austria

Belarus

Benin
Bolivia

BrazilBulgaria

Burkina Faso
Cambodia72

Single WomenIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderSingle Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple

Intersex Individuals
Single Women
Same Sex Female Married Couple

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 5. Table 4a(Continued)
Country

Diagnostic Evaluation

CameroonSingle Women
Single Men
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderSingle Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
Intersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Single Women
Single Men
Single Women
Same Sex Female Married Couple
Single Women
Same Sex Female Married Couple
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderSingle Women
Same Sex Female Married Couple
Single Women
Single Men
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
Single Women

CanadaChile

Colombia

Costa Rica
Cote d’Ivoire

Democratic Republic of the Congo
Denmark
EcuadorEstonia
Georgia

Germany
GreeceGuatemalaHong Kong (China*)

Hungary
Iceland

India
IrelandIsrael73

Intrauterine Insemination
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple

Single Women
Single Men
Same Sex Female Married Couple

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

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

TransgenderIntersex Individuals

Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals

Single Women
Single Women
Same Sex Female Married Couple

Single WomenAbstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 5. Table 4a(Continued)
Country

Italy
JordanKazakhstan
Kenya

LatviaLithuania
Mali
MexicoMoroccoNamibia

Netherlands

New ZealandNigeria
NorwayPanamá

Paraguay
Philippines

PolandRomania
RussiaSerbiaSouth Africa

Diagnostic Evaluation

Intrauterine Insemination

Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
Single Women
Single Men
Single Women
Single Men
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Women
Single Men
Single Women
Single Men
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Intersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Single Women
Same Sex Female Married Couple
TransgenderSingle Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
Single Women
Single Men
Single Women
Single Men
Intersex Individuals
Single Women
Single Men
Single Women
Single Women
Single Women
Single Men
Single Women

Same Sex Female Married Couple

74

Intersex Individuals
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women

Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple

Single Women
Single Women
Same Sex Female Married Couple
TransgenderSingle Women
Same Sex Female Married Couple

Single Women
Single Men

Single Women
Single Men
Single Women
Single WomenIntersex Individuals
Single WomenAbstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 5. Table 4a(Continued)
CountrySouth Korea

Spain

SwedenTanzania

Trinidad & Tobago

Tunisia
UgandaUnited Kingdom

United States

Uruguay

Venezuela
VietnamZimbabwe

Diagnostic Evaluation

Intrauterine Insemination

Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Single Women
Single Men
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Intersex Individuals
Single Women
Same Sex Female Married Couple
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals

Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men

75

Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals

Single Women
Same Sex Female Married Couple
Single Women

Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals

Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Intersex Individuals
Single Women
Same Sex Female Married Couple
Single Women

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 5. Table 4b
To whom are treatments practised/performed?
Country

IVF

PGT- Monogenic disorders

PGT- Aneuploidy

Argentina

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single WomenIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderSingle Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Intersex Individuals
Single Women
Same Sex Female Married Couple
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Single Women
Single Men
Same Sex Female Married Couple

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single WomenIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderSingle Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Intersex Individuals
Single Women
Same Sex Female Married Couple

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single WomenIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderSingle Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Intersex Individuals
Single Women
Same Sex Female Married Couple

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
Single Women
Same Sex Female Married Couple

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
Single Women
Same Sex Female Married Couple

Single Women
Same Sex Female Married Couple
Single Women
Same Sex Female Married Couple
Single Women
Single Women
Single Women
Same Sex Female Married Couple
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals

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

Australia

Austria

Belarus
Benin
Bolivia

BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
Colombia

Cote d’Ivoire
Democratic Republic of the Congo
Denmark
EcuadorEstonia
Georgia
Germany
GreeceGuatemalaHong Kong (China*)

Single Women
Same Sex Female Married Couple
Single Women
Single Women
Same Sex Female Married Couple
Single Women
Same Sex Female Married Couple
Single Women
Single Women
Single Women
Same Sex Female Married Couple
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals

76

Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 5. Table 4b(Continued)
Country

IVF

Hungary
IcelandSingle Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Single Women
Same Sex Female Married Couple
Single Women
Same Sex Female Married Couple
Intersex Individuals
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Single Women
Same Sex Female Married Couple
TransgenderSingle Women
Same Sex Female Married Couple
Single Women
Single Men
Single Women
Single WomenIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple

India
IrelandIsraelJordanKazakhstan
Kenya

LatviaMexicoMoroccoNamibia

Netherlands

New ZealandNigeria
NorwayPanamá
Paraguay
Romania
RussiaSerbiaSouth Africa

South Korea
Spain

SwedenPGT- Monogenic disorders

PGT- Aneuploidy

Single Women
Same Sex Female Married Couple
Single Women
Same Sex Female Married Couple
Intersex Individuals
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple

Single Women
Same Sex Female Married Couple
Single Women
Same Sex Female Married Couple
Intersex Individuals
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple

Single Women
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Single Women
Same Sex Female Married Couple
TransgenderSingle Women
Same Sex Female Married Couple
Single Women
Single Men

Single Women
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men

Single Women

Single WomenIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
77

Single Women
Same Sex Female Married Couple
Single Women
Single Men

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 5. Table 4b(Continued)
Country

IVF

Tanzania

Single Women

Trinidad & Tobago

Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Intersex Individuals
Single Women
Same Sex Female Married Couple
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals

UgandaUnited Kingdom

United States

Uruguay

Venezuela
VietnamZimbabwe

PGT- Monogenic disorders

PGT- Aneuploidy

Single Women
Single Men
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Intersex Individuals

Single Women
Single Men
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Intersex Individuals

Single Women
Same Sex Female Married Couple
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals

Single Women
Same Sex Female Married Couple
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals

Chapter 5. Table 4c
To whom are treatments practised/performed?
Country

Donor Sperm

Donor Egg

Donor Embryos

Argentina

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single WomenIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderSingle Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single WomenIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderSingle Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals

Australia

Austria

Belarus
Benin
Bolivia

78

Single WomenIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderAbstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 5. Table 4c(Continued)
Country

Donor Sperm

Donor Egg

Donor Embryos

BrazilSingle Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Intersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Single Women
Same Sex Female Married Couple
Single Women
Same Sex Female Married Couple
Single Women
Same Sex Female Married Couple
Single Women
Same Sex Female Married Couple
Single Women
Single Women
Single Women
Same Sex Female Married Couple
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Single Women
Same Sex Female Married Couple
Single Women
Same Sex Female Married Couple
Intersex Individuals
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Women
Same Sex Female Married Couple
TransgenderSingle Women
Single Men

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Intersex Individuals
Single Women
Same Sex Female Married Couple

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple

Bulgaria
Burkina Faso
Cambodia

Cameroon
CanadaChile
Colombia
Cote d’Ivoire
Denmark
EcuadorEstonia
Georgia
Germany
GreeceGuatemalaHong Kong (China*)
Hungary
Iceland

India
IrelandIsraelJordanKazakhstan
Kenya

LatviaMexicoNamibia

Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Single Men
Same Sex Male Married Couple
Single Women
Same Sex Female Married Couple
Single Women
Same Sex Female Married Couple
Single Women
Same Sex Female Married Couple
Single Women
Single Women

79

Single Women
Same Sex Female Married Couple

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Single Women
Single Women
Same Sex Female Married Couple
Single Women
Same Sex Female Married Couple
Single Women
Same Sex Female Married Couple
Single Women
Single Women

Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals

Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women

Single Women
Same Sex Female Married Couple
Single Women
Same Sex Female Married Couple
Intersex Individuals
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Women
Same Sex Female Married Couple
TransgenderSingle Women
Single Men

Single Women
Same Sex Female Married Couple
Single Women
Same Sex Female Married Couple
Intersex Individuals
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Women
Same Sex Female Married Couple
TransgenderSingle Women
Single Men

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 5. Table 4c(Continued)
Country

Netherlands

New ZealandNigeria
NorwayPanamá
Paraguay
RussiaSerbiaSouth Africa

South Korea
Spain

SwedenTanzania
Trinidad & Tobago

UgandaUnited Kingdom

United States

Uruguay

Venezuela
Vietnam

Donor Sperm

Donor Egg

Donor Embryos

Same Sex Female Married Couple
Same Sex Male Married Couple
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Single Women
Same Sex Female Married Couple
Single Women
Same Sex Female Married Couple
Single Women
Single Men
Single WomenIntersex Individuals
Single Women
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Single Women
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals

Same Sex Female Married Couple
Same Sex Male Married Couple
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men

Same Sex Female Married Couple
Same Sex Male Married Couple
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Same Sex Male Married Couple

Single Women
Same Sex Female Married Couple
Single Women
Single Men
Single WomenIntersex Individuals
Single Women
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Men
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Intersex Individuals
Single Women
Same Sex Female Married Couple
Single WomenTransgenderIntersex Individuals

Single Women
Same Sex Female Married Couple
Single Women
Single Men
Single WomenIntersex Individuals
Single Women
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Intersex Individuals
Single Women
Same Sex Female Married Couple
Single Women
Same Sex Female Married Couple

80

Single Women
Single Men

Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Single Women
Single Women
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Intersex Individuals
Single Women
Same Sex Female Married Couple
Single Women
Same Sex Female Married Couple

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 5. Table 4c(Continued)
Country

Donor Sperm

Donor Egg

Donor Embryos

Zimbabwe

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals

Gestational Surrogacy - using donatedova and commissioning person’s sperm

Gestational Surrogacy - using donatedova and donated sperm

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single WomenIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderSingle Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Intersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Single Men

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals

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

Chapter 5. Table 4d
To whom are treatments practised/performed?

Country

Traditional Surrogacy; i.e., in which thesurrogate mother’s ova are inseminatedwith a prospective parent’s sperm

Argentina

Australia

Belarus
Benin
Bolivia

BrazilCambodia
CanadaChile
Colombia
Cote d’Ivoire
Denmark
EcuadorSingle Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Intersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderSingle Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Intersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Single Women
Same Sex Female Married Couple
Same Sex Female Married Couple
Intersex Individuals

Estonia
GreeceIsraelSingle Women

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

JordanIntersex Individuals

Intersex Individuals
81Intersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderSingle Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Intersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 5. Table 4d(Continued)

Country
Kenya

MexicoNetherlands

Traditional Surrogacy; i.e., in which thesurrogate mother’s ova are inseminatedwith a prospective parent’s sperm
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals

Gestational Surrogacy - using donatedova and commissioning person’s sperm

Gestational Surrogacy - using donatedova and donated sperm

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Same Sex Male Married Couple
Single Women
Single Men
Intersex Individuals
Intersex Individuals

Nigeria

Single Men

SerbiaSouth Africa

Intersex Individuals
Intersex Individuals

Tanzania
Trinidad & Tobago
UgandaUnited Kingdom

Single Women
Single Women
Single Women
Single Men

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Same Sex Male Married Couple
Single Women
Single Men
Intersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Women
Single Women
Single Men

TransgenderIntersex Individuals

TransgenderIntersex Individuals

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Same Sex Female Married Couple
Intersex Individuals
Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals

Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Intersex Individuals

Single Women
Single Women
Single Women
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals
Intersex Individuals

Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals

Same Sex Female Married Couple
TransgenderIntersex Individuals
Single Women
Single Men
Same Sex Female Married Couple
Same Sex Male Married Couple
TransgenderIntersex Individuals

New ZealandUnited States

Uruguay

VietnamZimbabwe82

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Healthseven percent (20) of 73 countries reported that they were permitted to offer diagnostic evaluations to single women, single
men, female same-sex couples, male same-sex couples, andintersex and transgender individuals. Twenty percent (15) provided individuals and same-sex couples with access to all therapeutic modalities, compared to seven countries that reported
similarly in 2019. The other countries that responded reported
that they were permitted to provide ART services primarily tosingle women or same-sex female couples, and usually excluded
single men, male same-sex couples, and intersex and transgenderindividuals. Of the 65 countries responding, there was overall
most access to diagnostic evaluation, (82%) intrauterine insemination and IVF (72%), pre-implantation genetic testing andscreening (67%), donor sperm, oocytes, and embryos (72%,69%, and 63%) regardless of relationship status. Six countries,
Australia, Brazil, Canada, Kenya, United States, and Zimbabwe(representing 9% of 65) reported performing diagnostic evaluations and offering all therapeutic options to single women, single
men, female same-sex couples, male same-sex couples, andintersex and transgender individuals (Tables 4a–4d).
The legal parenting status of the partner of a same-sex couple
was also assessed. More than 70% of respondents indicated that
their country did not recognize the same-sex partner as a legal
parent. This was the case for both female same-sex couples (73%,58 of 80 countries) and male same-sex couples (78%, 62 of 79
countries). Twenty-six percent (21 countries) recognized thepartner as a legal parent in female same-sex couples, but only
19% (15 countries) did so for male same-sex couples. Two
countries responded “unknown” regarding the legal status of thepartner for male same-sex couples. One country responded“unknown” regarding the legal status of the female partner in asame-sex couple (Table 5, Chart 2).

Chapter 5. Table 5
Does your country have laws that recognize the same-sex partnerof a person who has used assisted reproduction as a legal parentof the resulting child?
Country
Albania
Argentina
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
Ecuador
Egypt
Estonia
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
Iceland
India
Iran
IrelandIsraelItaly
Japan
JordanKazakhstan
Kenya
LatviaLithuania
Malaysia
Mali
MexicoMoroccoNamibia
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
Philippines
PolandDiscussion
These results continue to reﬂect substantial differences among
countries’ attitudes with respect to acceptance of “non-traditional” couples and individuals desiring to bear children and theiraccess to ART services, primarily based on differences in culturaland religious preferences. Demand for ART services has been
increasing in many countries in Europe and North America where
delayed childbearing has become the norm and non-marital andnon-heterosexual childbearing has become commonplace. Many
individuals in “non-traditional” roles and/or relationships
require medical assistance to conceive[1]. The 2021 Surveillance
survey revealed that an increasing number of countries are now
requiring the existence of a recognized and/or stable relationshipto gain access to ART services, although the ﬁndings did notsuggest that access to ART services by single men, single women,male and female same-sex couples, as well as transgender andintersex individuals had become more limited. There is evidence
suggesting that, as demand for ART services is increasing, couples
and individuals who do not have access to the desired services in
one country are choosing to travel to countries that offer these
services without restrictions[2]. Utilization of cross-borderreproductive care (CBRC) by single men and women and samesex couples is among the most important drivers of this phenomenon (see Chapter 15) Fertility treatments offered at thesesites may include intrauterine insemination or in vitro fertilization, the use of autologous or donor gametes, and in some cases a
gestational carrier.
83

Same sex partnerof a woman

Same sex partnerof a man

No
Yes
Yes
Yes
No
No
No
Yes
Yes
No
No
Yes
No
Yes
No
No
Yes
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
Yes
No
No
No
No

No
Yes
Yes
Yes
No
No
No
Yes
No
No
No
No
Yes
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Unknown
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
No
No

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 5. Table 5

Summary(Continued)
Country
Romania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain
Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

Same sex partnerof a woman

Same sex partnerof a man

No
No
No
No
Yes
No
Yes
No
Yes
Yes
Unknown
No
No
No
No
Yes
Yes
Yes
No
No
No

No
No
No
No
Yes
No
Yes
No
Yes
Yes
Unknown
No
No
No
No
Yes
Yes
No
No
No
No

The 2021 Surveillance survey revealed for the ﬁrst time that most(54%) of the responding countries limit access to ART services tocouples in recognized and/or stable relationships. However, thesurvey did not identify any trends suggesting that access toinfertility services speciﬁcally for single men, single women, maleand female same-sex couples, or transgender or intersex individuals has become more limited.
The provision of ART services to single women was more
widely accepted and permitted than treatment of single men.
Similarly, ART services for female same-sex couples were more
widely accepted than treatment of male same-sex couples. Of
note, the legal parent status of the partner in a same-sex relationship was not recognized in over 70% of the countries
surveyed.
References[1] Livingston G. Fewer than half of U.S. kids today live in a
‘traditional’ family. 2014. Pew Research Center Web site.
Available at: http://www.pewresearch.org/ fact-tank/2014/12/22/less-than-half-of-u-s-kids-today-live-in-a-traditionalfamily/. Accessed March 19, 2021.
[2] Salama M, Isachenko V, Isachenko E, et al. Cross borderreproductive care (CBRC): a growing global phenomenon
with multidimensional implications (a systematic and criticalreview). J Assist Reprod Genet 2018;35(7):1277–1288.
[3] Ethics Committee of the American Society for Reproductive
Medicine. Access to fertility treatment irrespective of marital
status, sexual orientation, or gender identity: an Ethics
Committee opinion. Fertil Steril 2021;116(2):326–330.
[4] De Wert G, Dondorp W, Shenﬁeld F. ESHRE Task Force on
Ethics and Law 23: medically assisted reproduction in singles,
lesbian and gay couples, and transsexual people. Human
Reprod 2014;29(9):1859–1865.

The opportunity to have and raise children is a universal value
and may be an integral component of one’s identity or relationship. Individuals and couples, regardless of marital status, sexual
orientation, or gender identity can have an interest in childrearing. Current evidence supports the notion that relationshipstatus, sexual orientation, and gender identity do not have an
adverse impact on child welfare or parenting ability[3].
In some jurisdictions, antidiscrimination legislation prohibits
programs from denying fertility services to LGBTQ individuals or
couples. Several international organizations have publishedethical reviews and have afﬁrmed that reproduction is a basic
human right and ART programs should treat all persons equally
without regard to marital status, sexual orientation, or gender
identity[3,4].

CHAPTER 6: REGULATIONS GOVERNING THE
NUMBER OF EMBRYOS TRANSFERRED
Introduction
Although single embryo transfer (SET) has been identiﬁed as theideal and the ultimate standard of care, broad implementation ofthis goal remains an ongoing challenge[1,2]. Multiple pregnancies
with their potential for complications and associated costs remain
the greatest, most prevalent, and best documented risks associated with ART. Although some countries have reduced thenumber of embryos transferred during each ART cycle and haveachieved progress in reducing high-order multiple (HOM) pregnancies, recent data from many parts of the world indicate thatART continues to result in high rates of twin and HOM births[1].
Globally, fewer than 20 countries have fertility centers that are
fully publicly funded and thus able to mandate SET policies.
Many women utilizing ART still prefer to receive more than one
embryo. In many of these cases, the patients believe that multiple
pregnancies are justiﬁed ﬁnancially, often without adequately
considering the substantial problems that may ensue for both themother and the fetus or the short and long-term costs of thesecomplications[3–5].
As many countries have been successful at reducing the number of HOM pregnancies to rates well below those reported from

90%
80%

78%
73%

70%
60%
50%
40%
30%
20%
10%

26%
19%

3%

1%

0%
Male same sex couple
Not recognizedFemale same sex couple
RecognizedUnknown

Chapter 5. Chart 2. Parenting Legal Status of the partner of a same sex couple.

84

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health• Federal/national laws/statutes/ordinances and agency
regulations/oversight;• Federal/national laws/statutes/ordinances and state/provincial/regional laws/statutes/ordinances;• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, municipal laws/statutes/
ordinances, and cultural practice;• State/provincial/regional laws/statutes/ordinances, agency
regulations/oversight, and professional organization standards/guidelines; or• Agency regulations/oversight and professional organization standards/guidelines.
In answer to the question: “If the number of embryos transferred is under governance in your country, is there a penalty for
violation?” 25% percent (10 of 40 countries) responded that
there was a penalty, 42% (17 countries) noted that no penalty
existed, and 33% (13 countries) responded “unknown”. In 2019and 2016, 35% (17 countries) and 24% (17 countries) replied
afﬁrmatively to this question, respectively (Table 1). The various
types of penalties reported included:• Professional reprimands• Financial penalties• Suspension of license• Facility closure• Criminal liability• Loss of license
In response to the question: “What is the maximum numberof embryos allowed to be transferred” (Table 2), the 73
countries in which the respondents provided complete answers
reported that:• For oocytes <35 years of age:
• In nine countries, limited to one embryo;• In 17 countries, limited to two embryos;• In 11 countries, limited to three embryos; and• In 31 countries, not addressed.
Four countries responded “unknown” and one with “no response”.
• For oocytes 35–39 years of age:
• In four countries, limited to one embryo;• In 13 countries, limited to two embryos;• In 17 countries, limited to 3 embryos; and• In 32 countries, not addressed.
Five countries responded “unknown” and two with “no response”.
• For oocytes > 40 years of age:
• In one country, limited to one embryo;• In 11 countries, limited to two embryos;• In 18 countries, limited to three embryos;• In four countries, limited to 4 embryos; and• In 33 countries, not addressed.
Four countries responded “unknown” and two with “noresponse”.
Seventy-nine countries responded to the question regarding theexistence of criteria that addressed the number of embryos to betransferred based on the age of the oocyte recipient.
• Thirty-ﬁve countries answered “yes”, 18 answered “no”, four
responded “unknown”, and 22 responded “not addressed”.
• Seventy-eight countries responded to questions regarding
the existence of criteria that addressed the age of theoocyte donor.
• Thirty-six countries answered “yes”, 15 answered “no”, fouranswered “unknown, and 23 answered “not addressed”.

1995 to 2005, the focus has now shifted to reducing twin pregnancies, as these carry the same associated risks. SET has provento be the most effective strategy for reducing the incidence ofmultiple pregnancies and has gradually been embraced as thestandard of care[2]. Acceptance of SET has met with some resistance despite legislation and funding constraints and professionalorganization guidelines that have established limits on the number of embryos that can be transferred in a single ART cycle[6–8].
Efforts to limit the number of embryos transferred have thus beenless effective than was hoped. Many factors contribute to thisproblem, including patient and physician preferences, ﬁnancial
considerations, competition among ART centres, and an underappreciation of the risks involved in multiple pregnancies. Whileeradicating twin births resulting from ART should be a priority,
time to pregnancy has become a major focus for many fertility
patients. Although recent studies have conﬁrmed that the cumulative pregnancy rate with serial SET exceeds that resulting frommultiple embryo transfers in a single cycle, the former may
require additional ART cycles and an additional ﬁnancial burden
while potentially delaying the time to pregnancy[9].
Analysis of the Survey
Four questions were included in the 2021 survey to assess current
practices regarding the number of embryos transferred in a single
cycle:
1. Are the number of embryos transferred regulated in yourcountry; if so, by what means?
2. If the number of embryos transferred is under governance inyour country, is there a penalty for violation?
3. What is the maximum number of embryos allowed to betransferred?
4. What Is the number of embryos to be transferred based on?
In response to the question “Are the number of embryos
transferred regulated in your country; if so, by what means”,
50% of the respondents (40) from 80 countries conﬁrmed theexistence of guidelines or laws governing the number of embryosthat can be transferred (Table 1, Chart 1). While these results are
similar to those received in 2016 and 2019, in which similar
responses were reported from 59% (from 41 countries) and 56%(from 48 countries) of the surveys, respectively, the current results
suggest an overall decline in regulatory activity. Of the 40
countries that reported the existence of regulations and/or
guidelines, the following was reported:• 48% (19) reported that the number of embryos transferred
was regulated by federal/national laws/statutes/ordinances
only;• 20% (8) reported that the number of embryos transferred wasregulated by professional organization standards/guidelines
only;• Four countries reported that the number of embryos transferred was regulated by federal/national laws/statutes/ordinances and professional organization standards/guidelines;• Two countries reported that the number of embryos transferred was regulated by agency regulations/oversight;• Two countries reported that the number of embryos transferred
was regulated by federal/national laws/statutes/ordinances,
agency regulations/oversight, and professional organization
standards/guidelines; and• Single countries reported that the number of embryos transferred was regulated by either:85

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health
Chapter 6. Table 1

Chapter 6. Table 1
If the number of embryos transferred is under governance in yourcountry, is there a penalty for violation?

(Continued)
Country

GovernanceCountry

Governance

Penalty

IsraelAlbania
Argentina

No
Professional Organization
Standards/Guidelines
No
No
No
Federal/National Laws/
Statutes/Ordinances
No
No
Agency Regulations/OversightProfessional Organization
Standards/Guidelines
Federal/National Laws/
Statutes/Ordinances
No
Federal/National Laws/
Statutes/OrdinancesState/Provincial/Regional Laws/
Statutes/Ordinances
Municipal Laws/
Statutes/Ordinances
Cultural practiceProfessional Organization
Standards/Guidelines
No
No
Federal/National Laws/Statutes/
Ordinances
Agency Regulations/OversightProfessional Organization
Standards/Guidelines
Professional Organization
Standards/Guidelines
Federal/National Laws/
Statutes/Ordinances
No
Federal/National Laws/
Statutes/Ordinances
No

Unknown

Italy
Japan

Professional Organization
Standards/Guidelines
No
Professional Organization
Standards/Guidelines
Federal/National Laws/
Statutes/Ordinances
No
Federal/National Laws/
Statutes/Ordinances
Federal/National Laws/
Statutes/Ordinances
No
No
No
Federal/National Laws/
Statutes/Ordinances
Professional Organization
Standards/Guidelines
No
No
Federal/National Laws/
Statutes/Ordinances
Professional Organization
Standards/Guidelines
State/Provincial/Regional Laws/
Statutes/Ordinances
Agency Regulations/OversightProfessional Organization
Standards/Guidelines
Professional Organization
Standards/Guidelines
No
No
No
No
No
Federal/National Laws/
Statutes/Ordinances
No
Federal/National Laws/
Statutes/Ordinances
Professional Organization
Standards/Guidelines
Federal/National Laws/
Statutes/Ordinances
Professional Organization
Standards/Guidelines
Federal/National Laws/
Statutes/Ordinances
Professional Organization
Standards/Guidelines
Federal/National Laws/
Statutes/Ordinances
No
Federal/National Laws/
Statutes/Ordinances
Federal/National Laws/
Statutes/Ordinances
No
No
No
Federal/National Laws/
Statutes/Ordinances
No
Federal/National Laws/
Statutes/Ordinances
No
Federal/National Laws/
Statutes/Ordinances
No
No
No

Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia

Cameroon
CanadaChile
China

Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republicof the Congo
Denmark
EcuadorEstonia
Ethiopia
FranceGeorgia
Germany

Ghana
GreeceGuatemalaHong Kong (China*)
Hungary

Iceland
India
Iran

IrelandFederal/National Laws/
Statutes/Ordinances
No
Federal/National Laws/
Statutes/Ordinances
Agency Regulations/
Oversight
No
No
Federal/National Laws/
Statutes/Ordinances
Agency Regulations/OversightProfessional Organization
Standards/Guidelines
No
Federal/National Laws/
Statutes/Ordinances
Agency Regulations/OversightNo
Agency Regulations/OversightFederal/National Laws/
Statutes/Ordinances
Professional Organization
Standards/Guidelines
Federal/National Laws/
Statutes/Ordinances
No
Federal/National Laws/
Statutes/OrdinancesState/Provincial/Regional Laws/
Statutes/Ordinances
No

Kazakhstan
Kenya
LatviaNo

Lithuania
Yes

Malaysia
Mali
MexicoMontenegro

Unknown
No

MoroccoNamibia
Netherlands

No

New ZealandNo
Nigeria
NorwayPanamá
Paraguay
Peru
Philippines
PolandUnknown
UnknownNo

Romania
RussiaUnknown
SerbiaUnknown

Slovenia

Unknown

South Africa
South Korea

No

Spain
Sudan
Sweden

Yes

Switzerland

Yes
Unknown

Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom

No

United States
UruguayNo

Venezuela
VietnamZimbabwe

86

PenaltyNo
No
No
Unknown
No

Unknown

Yes

No

No

Unknown
Yes

No
No
Yes
No
Yes
Unknown
Yes

Yes
Yes
UnknownAbstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive HealthFederal/National Laws/Statutes/Ordinances

68%

Professional Organization Standards/Guidelines

38%

Agency Regulations/Oversight

15%

State/Provincial/Regional Laws/Statutes/Ordinances

Municipal Laws/Statutes/Ordinances, Cultural practice8%3%

Chapter 6. Chart 1. How are the number of embryos transferred in your country regulated? (More than one catergory may have been chosen per country).

Chapter 6. Table 2
What is the maximum number of embryos allowed to be transferred in your country?
Country

Oocyte age <35

Oocyte age 35-38

Oocyte age > = 40

Argentina
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
EcuadorEstonia
Ethiopia
Georgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
IcelandIndia

2
Not addressed
Not addressed
Not addressed2
Not addressed
Not addressed2
3
Not addressed3
Not addressed
Not addressed22
Unknown2
Not addressed2
Not addressed
Not addressed2
3
3
Not addressed222
Not addressed3
3
1
Not addressed

Not addressed
Not addressed
Not addressed
Not addressed3
Not addressed
Not addressed3
3
Not addressed3
Not addressed
Not addressed2
3
Unknown2
Not addressed2
Not addressed
Not addressed2
3
3
Not addressed2

Not addressed
Not addressed
Not addressed
Not addressed3
Not addressed
Not addressed
4
3
Not addressed4
Not addressed
Not addressed2
3
Unknown2
Not addressed3
Not addressed
Not addressed3
3

3
Not addressed3
3
2
Not addressed4
Not addressed3
4
2
Not addressed87

Not addressed3

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 6. Table 2(Continued)
Country

Oocyte age <35

Oocyte age 35-38

Oocyte age > = 40

IranIsraelItaly
Japan
Kazakhstan
Kenya
LatviaLithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
PolandRomania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain
Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago
TurkeyUgandaUnited Kingdom
United States
Uruguay
VietnamZimbabwe3
1
Not addressed1

3
2
Not addressed2

Not addressed
Not addressed3
Unknown
Unknown
Not addressed
Not addressed
Not addressed
Not addressed1
1
2
Not addressed
Not addressed
Not addressed1
Unknown2
3
2
1
2
3
Not addressed1
3
Not addressed
Not addressed1
Not addressed2
Not addressed2
Not addressed
Not addressed

Not addressed
Not addressed3
Unknown
Unknown
Not addressed
Not addressed
Not addressed
Not addressed1
1
1
Not addressed
Not addressed
Not addressed2
Unknown2
Unknown3
2
3
3
Not addressed1
3
Not addressed
Not addressed1
Not addressed2
Not addressed2
Not addressed
Not addressed3
3
Not addressed2
2
Not addressed
Not addressed3
Unknown
Unknown
Not addressed
Not addressed
Not addressed
Not addressed2
3
3
Not addressed
Not addressed
Not addressed2
Unknown2
Not addressed32
3
3
Not addressed1
3
Not addressed
Not addressed2
Not addressed3
Not addressed2
Not addressed
Not addressed

Chapter 6. Table 3
Is the number of embryos to be transferred based on?
Country
Albania
Argentina
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China

Age of the Donor Oocyte Recipient

Age of the Oocyte Donor

Quality of the Embryos

Stage of the Embryo

Unknown
Yes
Yes
Not addressed
Not addressed
Yes
Not addressed
Yes
No
Yes
Unknown
Yes
No
Not addressed
Yes
Yes

Unknown
Yes
Yes
Not addressed
Not addressed
Yes
Not addressed
Yes
Yes
Yes
Unknown

Unknown
Yes
Yes
Not addressed
Not addressed
Yes
Not addressed
Yes
Not addressed
Yes
Unknown
Yes
Yes
Not addressed
YesNo

Unknown
Yes
Yes
Not addressed
Not addressed
Yes
Not addressed
Yes
Not addressed
Yes
Unknown
Yes
Yes
Not addressed
Yes
Yes

No
Not addressed
Yes
No
88

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 6. Table 3(Continued)
Country
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
EcuadorEstonia
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
Iceland
India
Iran
IrelandIsraelItaly
Japan
Kazakhstan
Kenya
KuwaitLatviaLithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
PolandRomania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain
Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

Age of the Donor Oocyte Recipient

Age of the Oocyte Donor

Quality of the Embryos

Stage of the Embryo

Yes
Yes
Yes
Yes
No
No
Yes
No
Not addressed
Not addressed
Not addressed
Yes
No
No
Yes
Not addressed
Yes
Yes
Not addressed
Yes
Yes
No
Not addressed
Not addressed
Yes
Yes

Yes
Yes
Yes
Yes
No
No
Yes
No
Not addressed
Not addressed
Not addressed
Yes
No
Yes
Yes
Not addressed
Yes
Yes
Not addressed
Yes
Yes
Yes
Not addressed
Not addressed
Yes
Yes

Yes
Yes
Yes
Yes
No
Unknown
Yes
No
Not addressed
Not addressed
Not addressed
No
Yes
Yes
Yes
Not addressed
Yes
Yes
Not addressed
Yes
Yes
Yes
Not addressed
No
Yes
Yes

Yes
Yes
Yes
No
No
No
Yes
No
Not addressed
Not addressed
Not addressed
No
No
Yes
Yes
Not addressed
Yes
Yes
Not addressed
Yes
Yes
No
Not addressed
No
Yes
Yes

No
Not addressed
Unknown
Unknown
Yes
Yes
Not addressed
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Yes
No
No
Not addressed
No
Yes
Yes
Not addressedNoNo
Not addressed
Not addressed
Not addressed
Not addressed
Not addressedNo
Not addressedNo
Yes
Not addressed
YesNo
Not addressed
Unknown
UnknownYes
Not addressed
Not addressed
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Not addressed
Yes
No
No
Not addressedNoNo
Not addressed
Not addressed
Not addressed
Not addressed
Not addressed
Yes
Not addressed
Yes
Yes
Not addressed
YesNo
Not addressed
Unknown
Unknown
Yes
Yes
Not addressed
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
No
Yes
Yes
Not addressed
YesNo
Not addressed
Not addressed
YesNo
Not addressedNo
Not addressed
Yes
Yes
Not addressed
YesNo
Not addressed
Unknown
Unknown
Yes
Yes
Not addressed
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
No
Yes
No
Yes
Yes
Not addressed
YesNo
Not addressed
Not addressed
YesNo
Not addressedNo
Not addressedNo
Yes
Not addressedYes89

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Healthcurrent legislation on this issue. In contrast, there has been an
increase in the number of countries, from 18% to 28% over the past
six years, that require a SET procedure for reimbursement fromgovernment or private sources (See Chapter 3).

For questions as to whether the quality of the embryos wasconsidered as a legislative determinant, representatives from 80
countries provided the following responses:• Forty-four countries answered “yes”, 12 answered “no”, ﬁve
answered “unknown, and 19 answered “not addressed”.
Regarding the developmental stage (cleavage or blastocyst) of theembryo, representatives from 80 countries responded as follows:• Thirty-nine countries answered “yes”, 18 answered “no”, fouranswered “unknown”, and 19 responded “not addressed”.
Table 3 lists the individual policies of the countries represented byeach respondent together with the number of embryos allowed to
be transferred.

References[1] Adamson GD, Norman RJ. Why are multiple pregnancy
rates and single embryo transfer rates so different globally,
and what do we do about it? Fertil Steril 2020;114(4):680–689.
[2] Kissin DM, Boulet SL, Adashi EY. “Yes, elective singleembryo transfer should be the standard of care” in D.T.
Carrell et al, eds. Biennial Review of Infertility: Springer
International Publishing Switzerland 2015;4:177–187.
[3] Ofﬁce for National Statistics. Statistical bulletin: Childhood,
Infant and Perinatal Mortality in England and Wales: 2013;
March 2015.
[4] Kulkarni AD, Jamieson DJ, Jones HW, et al. Fertility treatments and multiple births in the United States. New Engl J
Med 2013;369(23):2218–2225.
[5] Farquhar C. Avoiding multiple pregnancies in assisted
reproductive technologies: transferring one embryo at a timeshould be the norm. Fertil Steril. 2020;114(4):671–672.
[6] Maheshwari A, Grifﬁths S, Bhattacharya S. Global variations in the uptake of single embryo transfer. Hum Reprod
Update 2011;17(1):107–120.
[7] Peperstraten AV, Hermens R, Nelen W, et al. Perceived
barriers to elective single embryo transfer among IVF professionals: a national survey. Hum Reprod 2008;23(12):2718–2723.
[8] Klitzman R. Deciding how many embryos to transfer:ongoing challenges and dilemmas. Reprod Biomed Soc
Online 2016;3:1–15.
[9] McLernon DJ, Harrild K, Bergh C, et al. Clinical effectiveness of elective single versus double embryo transfer: metaanalysis of individual patient data from randomised trials.
BMJ 2010;341(2):c6945.
[10] Campbell A, Gardner DK, Meseguer M, et al. In vitro fertilization and andrology laboratory in 2030: expert visions.
Fertil Steril. 2021;116(1):4–12.
[11] Loewke K, Cho JH, Brumar C, et al. Characterization of an
artiﬁcial intelligence model for ranking static images of
blastocyst stage embryos. Fertil Steril 2022;117:528–535.
[12] Tran D, Cooke S, Illingworth PJ, et al. Deep learning as apredictive tool for fetal heart pregnancy following timelapse incubation and blastocyst transfer. Hum Reprod
2019;34(6):1011–1018.

Discussion
Evidence from the 2021 IFFS Surveillance survey suggests anoverall decrease in the number of countries that maintain legislation or clinical guidelines that restrict the number of embryosthat can be transferred per cycle to women undergoing ART.
Currently, 50% (40 countries) report the existence of legislation/
guidelines versus 59% (48 countries) and 56% (41 countries) that
did so in 2019 and 2016, respectively. Consistent with thisﬁnding, fewer countries (25% [10 countries] in 2021 versus 35%[17 countries] in 2019 and 24% [17 countries] in 2016) reported
the existence of penalties for non-compliance regarding thenumber of embryos transferred. Paradoxically, the previously
noted trend of more countries mandating SET or otherwise limiting the number of embryos that can be transferred as a condition
for ﬁnancial coverage has continued. These mandates werereported in 28% of countries that provide coverage for thisprocedure (see Chapter 3).
Compared to 2019 data, progress in the actual reduction of thenumber of embryos transferred has remained constant ordecreased since 2019. In 2021, 12% of the countries that
responded to the survey reported mandatory SET for patients<35 years of age, compared to 10% that reported these restrictions in 2019. Similarly, 5% reported mandatory SET for patients
35–39 years of age, compared to 7% that reported theserestrictions in 2019. Likewise, 6.5% reported mandatory SET for
patients > 40 years of age in 2021 compared to 1% in 2019.
While advances in embryo selection methods, preimplantation
genetic testing, and cryopreservation technology have led to
improvements in embryo implantation rates [10-12], these potential advantages have not yet led to wider acceptance of SET.
Criteria used to determine the number of embryos to transfer
were based on the age of the donor-recipient (44% in 2021 versus
37% in 2019), the age of the donor (46% in 2021 versus 36% in2019), the quality of the embryo (55% versus 56% in 2019), andthe stage of embryo development (50% versus 56% in 2019).

CHAPTER 7: CRYOPRESERVATION
Introduction

Summary

Assisted reproductive technology (ART) is an innovative andrapidly evolving ﬁeld. In a relatively short period, many technicalinnovations that began in the laboratory have been implemented
in the clinic. These advances include reﬁned and/or new cryopreservation techniques that have ultimately led to improved
patient outcomes[1,2]. By the late 1990s, the ﬁeld developed a new
focus on vitriﬁcation techniques to mitigate the toxicity associated with previously available cryopreservation solutions[3–5].
The ability to cryopreserve gametes and embryos while avoiding
the damaging effects of ice crystal formation and reagent toxicity

The 2021 data reveal a noticeable decline in the number of countries
reporting the existence of legislation or professional organizationalguidelines that determine the appropriate number of embryos fortransfer in ART. Many countries are not adhering to SET goals
despite evidence suggesting that the cumulative pregnancy rate with
serial SET exceeds that of a single multiple embryo transfer without
the associated risks of fetal and maternal complications. The 2021
data also reveal a reduction in the number of countries imposing apenalty for agencies and providers that are not in compliance with90

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Healththat resulted from slow freezing technologies instilled great conﬁdence in the viability of defrosted specimens.
Cryopreservation is essential to present-day ART treatments.
Originally, cryopreservation was a method used to facilitate thepreservation of supernumerary embryos that remained after atransfer cycle[6]. Today, cryopreservation of sperm, oocytes, andembryos provides patients with the opportunity to preserve
reproductive tissue and thus to defer parenthood until a future
date[7,8].
In 2013, the American Society for Reproductive Medicine(ASRM) removed the “experimental” designation from oocyte
cryopreservation and deemed the technology as the standard ofcare, similar to current technologies used to cryopreserve spermand embryos[9,10]. Cryopreservation of donor oocytes has revolutionized patient access to donor oocytes, as it mitigates thearduous process of selecting a qualiﬁed donor and allows practitioners to provide services at a lower cost with a faster timeline
to pregnancy[11]. Blastocyst culture together with cryopreservation has also facilitated the broad application of preimplantation
genetic testing technologies (PGT)[12]. Cryopreservation of allembryos in conjunction with deferred transfer to more receptive
uterine environments has been shown to result in higher delivery
rates[13].

malignancy) was allowed or permitted. Forty-four percent (35) ofthese countries responded that this procedure was commonly
performed; 13% (10 countries) reported that this was infrequently performed, and one country reported “unknown”.
Seventy-eight percent (62) of 79 countries responded thatoocyte cryopreservation for medical indications (e.g., malignancy) was allowed or permitted. Twenty-six countries (33%)
responded that this procedure was commonly performed, while
20% (16 countries) reported that this was performed only
infrequently. Two countries reported that oocyte cryopreservation was never performed, and three countries replied“unknown”.
Seventy-one percent (56) of 79 countries responded that preimplantation embryo cryopreservation for medical indications(e.g., malignancy) was allowed or permitted. Thirty-seven percent(29) countries reported that this procedure was commonly performed, while 20% (16 countries) reported that this procedure
was performed infrequently. Ten percent (8 countries) reported
that pre-implantation embryo cryopreservation was never performed, while ﬁve countries replied “unknown”.
Sixty-ﬁve percent (51) of the 79 countries that responded to thesurvey reported that cryopreservation of ovarian tissue for
medical indications (e.g., malignancy) was allowed or permitted.
Thirteen percent (10 countries) reported that this procedure wascommonly performed. Twenty-four percent (19 countries)
reported that it was performed infrequently. Twenty-ﬁve percent(20 countries) reported that this was never performed, and ﬁve
countries replied “unknown”.
Sixty-eight percent (68) of the 79 countries that responded tothe survey reported that cryopreservation of testicular tissue for
medical indications (e.g., malignancy) was allowed or permitted.
Fifteen percent (12 countries) reported that this procedure wascommonly performed. Twenty-three percent (18 countries)
reported that it was performed infrequently. Twenty percent (16countries) reported that it was never performed, and ﬁve countries replied “unknown”.
Sixty-ﬁve percent (51) of the 78 countries that responded to thesurvey reported that cryopreservation of sperm for non-medical
indications (e.g., deliberate deferral of childbearing for personalreasons) was allowed or permitted. Twenty-nine percent (23)reported that this procedure was commonly performed. Nineteen
percent (15 countries) reported that it was performed infrequently. Thirteen percent (10 countries) reported that it wasnever performed, and twelve percent (nine countries) replied“unknown”.
Sixty-four percent (50) of the 78 countries that responded tothe survey reported that cryopreservation of oocytes for nonmedical indications (e.g., deliberate deferral of childbearing for
personal reasons) was allowed or permitted. Twenty-nine percent(23 countries) reported that this procedure was commonly performed. Twenty-six percent (20 countries) reported that it was
performed infrequently. Twelve percent (9 countries) reported
that this procedure was never performed, and ﬁve countries
replied “unknown”.
Fifty-three percent (41) of the 78 countries that responded tothe survey reported that cryopreservation of pre-implantationembryos for non-medical indications (e.g., deliberate deferral ofchildbearing for personal reasons) was allowed or permitted.
Twenty-six percent (20 countries) reported that this procedure
was commonly performed. Twenty-three percent (18 countries)
reported that this procedure was performed infrequently.

Analysis of the Survey
Three separate questions were included in the 2021 Surveillance
survey to assess current practices regarding cryopreservation:
1. Is cryopreservation for fertility treatment or fertility preservation of reproductive tissues allowed/permitted or practised/performed in your country?
2. If cryopreservation is allowed/permitted in your country, is it
regulated and how?
3. If cryopreservation or fertility preservation is permitted, whatis the maximum duration of storage (years) allowed?
The following responses were received to the question “Iscryopreservation for fertility treatment or fertility preservation of
reproductive tissues allowed/permitted or practised/performed inyour country?” (Tables 1a–1e).
Eighty-ﬁve percent (67) of 79 countries responded that sperm
cryopreservation for fertility treatment was allowed or permitted.
Fifty-four percent (43) responded that this procedure was commonly performed, 6% (5 countries) reported that this was performed infrequently, and one country reported that it was neverperformed.
Eighty-two percent (65) of 79 countries responded that oocyte
cryopreservation for fertility treatment was allowed or permitted.
Forty-four percent (35) countries responded that this procedure
was commonly performed, while sixteen percent (13) countries
reported that was performed only infrequently. One country
replied “unknown”.
Eighty-one percent (64) of 79 countries responded thatcryopreservation of fertilized oocytes (pre-zygotes to blastocysts) for fertility treatment was allowed or permitted. Fortyeight percent (38) of the countries responded that this procedure
was commonly performed, while 8% (6) reported that it wasinfrequently performed. Four countries reported that this wasnever performed.
Eighty-one percent (64) of the 79 countries that responded tothe survey reported that sperm cryopreservation for medical
indications (e.g., fertility preservation before treatment of a91

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 7. Table 1a
Is cryopreservation for fertility treatment or fertility preservation of reproductive tissues allowed/permitted or practised/performed in yourcountry?
Cryopreservation for fertility treatment
Country

Sperm

Oocytes

Albania

Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Never Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed

Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed

Argentina
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
Ecuador
Egypt
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
Iceland
India
IrelandIsraelItaly
Japan
Kazakhstan
Kenya
LatviaLithuania

Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
92

Fertilized Oocytes (Pre-zygotes to Blastocysts)
Allowed/Permitted
Infrequently Practised/Performed
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Never Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 7. Table 1a(Continued)
Cryopreservation for fertility treatment
Country

Sperm

Oocytes

Malaysia
Mali
MexicoMontenegro
MoroccoNamibia

Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted

Commonly Practised/Performed
Unknown
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted

Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
PolandRomania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain
Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

93

Fertilized Oocytes (Pre-zygotes to Blastocysts)
Commonly Practised/Performed
Commonly Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 7. Table 1b
Is cryopreservation for fertility treatment or fertility preservation of reproductive tissues allowed/permitted or practised/performed in yourcountry?
Cryopreservation for medical indications
Country

Sperm

OocytesPre-implantation embryos

Albania

Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted

Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted

Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Unknown
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted

Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Never Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Unknown
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Unknown
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted

Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Never Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Unknown
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Never Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Never Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Unknown
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted never performed
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed

Argentina
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
Ecuador
Egypt
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
Iceland
India
IrelandIsraelItaly
Japan
Kazakhstan
Kenya
LatviaLithuania

94

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 7. Table 1b(Continued)
Cryopreservation for medical indications
Country

Sperm

OocytesPre-implantation embryos

Malaysia
Mali
MexicoMontenegro
MoroccoNamibia

Commonly Practised/Performed
Commonly Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted

Commonly Practised/Performed
Unknown
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted

Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted

Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Infrequently Practised/Performed

Commonly Practised/Performed
Unknown
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Unknown
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Never Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed

Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
PolandRomania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain
Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted95

Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 7. Table 1c
Is cryopreservation for fertility treatment or fertility preservation of reproductive tissues allowed/permitted or practised/performed in yourcountry?
Cryopreservation for medical indications
Country

Ovarian tissue

Testicular tissue

Albania

Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Never Practised/Performed
Never Practised/Performed

Allowed/Permitted
Never Practised/Performed
Infrequently Practised/Performed

Argentina
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
Ecuador
Egypt
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
Iceland
India
IrelandIsraelItaly
Japan
Kazakhstan
Kenya
LatviaLithuania

Never Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Never Practised/Performed
Never Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Never Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Never Practised/Performed
Unknown
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
96

Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Never Practised/Performed
Allowed/Permitted
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Never Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Never Practised/Performed
Unknown
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Never Practised/Performed

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 7. Table 1c(Continued)
Cryopreservation for medical indications
Country

Ovarian tissue

Testicular tissue

Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
Netherlands

Commonly Practised/Performed
Unknown
Infrequently Practised/Performed
Allowed/Permitted
Never Practised/Performed
Never Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Unknown
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Never Practised/Performed
Unknown
Allowed/Permitted
Infrequently Practised/Performed
Never Practised/Performed
Infrequently Practised/Performed
Never Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Never Practised/Performed

Commonly Practised/Performed
Unknown
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Unknown
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Never Practised/Performed
Commonly Practised/Performed
Unknown
Infrequently Practised/Performed
Never Practised/Performed
Infrequently Practised/Performed
Never Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Never Practised/Performed
Infrequently Practised/Performed

New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
PolandRomania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain
Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

Unknown
Allowed/Permitted
Infrequently Practised/Performed
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted

Allowed/Permitted
Commonly Practised/Performed
Unknown
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted

procedure was never performed, and sixteen percent (twelve
countries) replied “unknown”.
Forty-six percent (36) of the 78 countries that responded to thesurvey reported that cryopreservation of testicular tissue for nonmedical indications (e.g., deliberate deferral of childbearing for
personal reasons) was allowed or permitted. Seven countries
reported that this procedure was commonly performed. Eighteen
percent (14 countries) reported that this procedure was performed infrequently. Forty-one percent (32 countries) reported

Fourteen percent (11 countries) reported that it was never performed, and eight countries replied “unknown”.
Forty-four percent (34) of 77 countries that responded to thesurvey reported that cryopreservation of ovarian tissue for nonmedical indications (e.g., deliberate deferral of childbearing for
personal reasons) was allowed or permitted. Six countries
reported that this procedure was commonly performed. Twelve
percent (9 countries) reported that this procedure was performed
infrequently. Fifty-one percent (39 countries) reported that this97

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 7. Table 1d
Is cryopreservation for fertility treatment or fertility preservation of reproductive tissues allowed/permitted or practised/performed in yourcountry?
Cryopreservation for non-medical indications
Country

Sperm

OocytesPre-implantation embryos

Albania

Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Never Practised/Performed
Never Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Never Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Unknown
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Never Practised/Performed
Never Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Unknown
Allowed/Permitted
Never Practised/Performed
Unknown
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted Infrequently performed
Unknown
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Infrequently Practised/Performed
Commonly Practised/Performed
Unknown

Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Never Practised/Performed
Never Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Never Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Unknown
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Unknown
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Never Practised/Performed
Never Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed

Allowed/Permitted
Infrequently Practised/Performed
Infrequently Practised/Performed

Argentina
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
Ecuador
Egypt
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
Iceland
India
IrelandIsraelItaly
Japan
Kazakhstan
Kenya
LatviaLithuania
Malaysia
Mali

Commonly Practised/Performed
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Never Practised/Performed
Commonly Practised/Performed
Unknown98

Allowed/Permitted
Infrequently Practised/Performed
Never Practised/Performed
Never Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Never Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Unknown
Allowed/Permitted
Commonly Practised/Performed
Never Practised/Performed
Infrequently Practised/Performed
Allowed/Permitted
Unknown
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Never Practised/Performed
Never Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted Never performed
Unknown
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Never Practised/Performed
Commonly Practised/Performed
UnknownAbstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 7. Table 1d(Continued)
Cryopreservation for non-medical indications
Country
MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
PolandRomania
RussiaSerbiaSouth Africa
South Korea
Spain
Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

Sperm

OocytesPre-implantation embryos
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Unknown
Infrequently Practised/Performed
Unknown

Never Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Unknown
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Never Practised/Performed

Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Unknown
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Never Practised/Performed

Never Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted

Infrequently Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted

Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Unknown
Allowed/Permitted
Unknown

99

Never Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Unknown
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Infrequently Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 7. Table 1e
Is cryopreservation for fertility treatment or fertility preservation of reproductive tissues allowed/permitted or practised/performed in yourcountry?
Cryopreservation for non-medical indications
Country

Ovarian tissue

Albania

Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Never Practised/Performed
Never Practised/Performed
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Never Practised/Performed
Never Practised/Performed

Argentina
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
Ecuador
Egypt
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
Iceland
India
IrelandIsraelItaly
Japan
Kazakhstan
Kenya
LatviaLithuania
Malaysia
Mali

Never Practised/Performed
Allowed/Permitted
Allowed/Permitted
Never Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Never Practised/Performed
Never Practised/Performed
Allowed/Permitted
Never Practised/Performed
Never Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Never Practised/Performed
Never Practised/Performed
Allowed/Permitted
Never Practised/Performed
Never Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Never Practised/Performed
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Never Practised/Performed
Unknown
Allowed/Permitted
Never Practised/Performed
Never Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Unknown
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Never Practised/Performed
Commonly Practised/Performed
Unknown
100

Testicular tissue
Allowed/Permitted
Never Practised/Performed
Never Practised/Performed
Allowed/Permitted
Never Practised/Performed
Never Practised/Performed
Never Practised/Performed
Never Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Never Practised/Performed
Allowed/Permitted
Allowed/Permitted
Never Practised/Performed
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Never Practised/Performed
Never Practised/Performed
Allowed/Permitted
Allowed/Permitted
Unknown
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Never Practised/Performed
Never Practised/Performed
Allowed/Permitted
Never Practised/Performed
Never Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Never Practised/Performed
Allowed/Permitted
Unknown
Allowed/Permitted
Never Practised/Performed
Unknown
Allowed/Permitted
Never Practised/Performed
Never Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Unknown
Allowed/Permitted
Allowed/Permitted
Allowed/Permitted
Infrequently Practised/Performed
Never Practised/Performed
Commonly Practised/Performed
UnknownAbstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 7. Table 1e(Continued)
Cryopreservation for non-medical indications
Country

Ovarian tissue

MexicoMontenegro
MoroccoNever Practised/Performed
Allowed/Permitted
Never Practised/Performed

Namibia
Netherlands

Never Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Never Practised/Performed
Unknown
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Never Practised/Performed
Unknown
Unknown
Infrequently Practised/Performed
Never Practised/Performed
Unknown
Never Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Unknown
Never Practised/Performed
Unknown
Never Practised/Performed
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Never Practised/Performed
Never Practised/Performed

New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
PolandRomania
RussiaSerbiaSouth Africa
South Korea
Spain
Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

Never Practised/Performed
Commonly Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Unknown
Allowed/Permitted
Commonly Practised/Performed
Allowed/Permitted
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted

Testicular tissue
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Commonly Practised/Performed
Never Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Never Practised/Performed
Unknown
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Never Practised/Performed
Commonly Practised/Performed
Unknown
Infrequently Practised/Performed
Never Practised/Performed
Unknown
Never Practised/Performed
Allowed/Permitted
Infrequently Practised/Performed
Unknown
Never Practised/Performed
Unknown
Never Practised/Performed
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted
Never Practised/Performed
Never Practised/Performed
Unknown
Allowed/Permitted
Infrequently Practised/Performed
Allowed/Permitted
Commonly Practised/Performed
Infrequently Practised/Performed
Allowed/Permitted
Allowed/Permitted
Never Practised/Performed
Allowed/Permitted• Federal/national laws/statutes/ordinances and agency
regulations/oversight;• Agency regulations/oversight and professional organization standards/guidelines; or• Federal/national laws/statutes/ordinances, municipal
laws/statues/ordinances, and professional organization
standards/guidelines.
• Single countries reported either• Agency regulations/oversight;• Professional organization standards/guidelines and religious decree;• State/provincial/regional laws/statutes/ordinance andprofessional organization standards/guidelines;that it was never performed, and ﬁfteen percent (12 countries)
replied “unknown”.
The following responses were received to the question “Ifcryopreservation is allowed/permitted in your country, is it
regulated and how?”
Fifty-four countries responded to questions regarding the existence of guidelines or laws governing the cryopreservation of sperm
for fertility treatments. The following regulations were reported:• 54% (29) reported federal/national laws/statutes/ordinances only;• 11% (six) reported federal/national laws/statutes/ordinancesand professional organization standards/guidelines; and• 9% (ﬁve ) reported professional organization standards/guidelines.
• Two countries each reported either
101

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health• State/provincial/regional laws/statutes/ordinances andprofessional organization standards/guidelines;• Federal/national laws/statutes/ordinances and state/provincial/regional laws/statutes/ordinances;• Federal/national laws/statutes/ordinances, municipal
laws/statues/ordinances, and professional organization
standards/guidelines;• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, and professionalorganization standards/guidelines;• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, and agency regulations/oversight; or• Federal/national laws/statutes/ordinances, municipal
laws/statues/ordinances, professional organization standards/guidelines, and cultural practice.
• Two countries replied “unknown”.
Forty-eight countries responded to questions regarding theexistence of guidelines or laws governing the cryopreservation of
sperm for medical indications (e.g., malignancy). The following
regulations were reported:• Federal/national laws/statutes/ordinances and state/provincial/regional laws/statutes/ordinances;• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, and agency regulations/oversight; or• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, municipal laws/
statutes/ordinances, and professional organization standards/guidelines• Two countries replied “unknown”.
Fifty-three countries responded to questions regarding theexistence of guidelines or laws governing cryopreservation ofoocytes for fertility treatments. The following regulations werereported:• 57% (30) reported federal/national laws/statutes/ordinances only;• 11% (5) reported federal/national laws/statutes/ordinancesand professional organization standards/guidelines• Three reported federal/national laws/statutes/ordinances andagency regulations/oversight; and• Three reported professional organization standards/guidelines
only.
• Two countries each reported either• Agency regulations/oversight and professional organization standards/guidelines; or• Federal/national laws/statutes/ordinances, municipal
laws/statues/ordinances, and professional organization
standards/guidelines.
• Single countries reported either• Agency regulations/oversight only;• Professional organization standards/guidelines and religious decree;• Federal/national laws/statutes/ordinances and state/provincial/regional laws/statutes/ordinances;• State/provincial/regional laws/statutes/ordinances andprofessional organization standards/guidelines;• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, and agency regulations/oversight; or• Federal/national laws/statutes/ordinances, municipal
laws/statues/ordinances, professional organization standards/guidelines, and cultural practice.
• Two countries replied “unknown”.
Fifty countries responded to questions regarding the existenceof guidelines or laws that govern the cryopreservation of fertilized
oocytes (pre-zygotes to blastocysts) to be used for fertility treatments. The following regulations were reported:• 54% (27) reported federal/national laws/statutes/ordinances
only;• 10% (5) reported federal/national laws/statutes/ordinancesand professional organization standards/guidelines; and• Four reported professional organization standards/guidelines
only.
• Two countries each reported either• Agency regulations/oversight and professional organization standards/guidelines; or• Federal/national laws/statutes/ordinances and agency
regulations/oversight.
• Single countries reported either• Agency regulations/oversight only;• Professional organization standards/guidelines and religious decree;• 54% (26) reported federal/national laws/statutes/ordinances
only;• Four reported federal/national laws/statutes/ordinances andprofessional organization standards/guidelines; and• Four reported professional organization standards/guidelines
only.
• Two countries each reported either• Agency regulations/oversight and professional organization standards/guidelines; or• Federal/national laws/statutes/ordinances and agency
regulations/oversight.
• Single countries reported either• Agency regulations/oversight only;• Professional organization standards/guidelines and religious decree;• Federal/national laws/statutes/ordinances and state/provincial/regional laws/statutes/ordinances;• Federal/national laws/statutes/ordinances, municipal
laws/statues/ordinances, and professional organization
standards/guidelines;• Federal/national laws/statutes/ordinances, professionalorganization standards/guidelines, and cultural practice;• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, and agency regulations/oversight; or• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, and professionalorganization standards/guidelines.
• Three countries replied “unknown”.
Forty-eight countries responded to questions regarding theexistence of guidelines or laws governing cryopreservation ofoocytes for medical indications (e.g., malignancy). The following
regulations were reported:• 50% (24) reported federal/national laws/statutes/ordinances
only;• 10% (5) reported federal/national laws/statutes/ordinancesand professional organization standards/guidelines; and• Four reported professional organization standards/
guidelines only.
102

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health• Two countries each reported either• Agency regulations/oversight and professional organization standards/guidelines;• Federal/national laws/statutes/ordinances and agency
regulations/oversight; or• Federal/national laws/statutes/ordinances, municipal
laws/statues/ordinances, and professional organization
standards/guidelines.
• Single countries reported either• Agency regulations/oversight only;• Professional organization standards/guidelines and religious decree;• Municipal laws/statues/ordinances and professionalorganization standards/guidelines;• Federal/national laws/statutes/ordinances and state/provincial/regional laws/statutes/ordinances;• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, and agency regulations/oversight;• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, and professionalorganization standards/guidelines; or• Federal/national laws/statutes/ordinances, municipal
laws/statues/ordinances, professional organization standards/guidelines, and cultural practice.
• Two countries replied “unknown”.
Forty-four countries responded to questions regarding theexistence of guidelines or laws governing cryopreservation of preimplantation embryos for medical indications (e.g., malignancy).
The following regulations were reported:• 55% (24) reported federal/national laws/statutes/ordinances
only;• Four reported federal/national laws/statutes/ordinances andprofessional organization standards/guidelines; and• Three reported professional organization standards/
guidelines.
• Two countries each reported either• Agency regulations/oversight and professional organization standards/guidelines; or• Federal/national laws/statutes/ordinances and agency
regulations/oversight.
• Single countries reported either• Agency regulations/oversight only;• Professional organization standards/guidelines and religious decree;• Federal/national laws/statutes/ordinances and state/provincial/regional laws/statutes/ordinances;• Municipal laws/statutes/ordinances and professionalorganization standards/guidelines;• Federal/national laws/statutes/ordinances, municipal
laws/statues/ordinances, and professional organization
standards/guidelines;• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, and agency regulations/oversight; or• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, municipal laws/
statues/ordinances, professional organization standards/
guidelines, and cultural practice.
• Two countries replied “unknown”.

Thirty-eight countries responded to questions regarding theexistence of guidelines or laws governing cryopreservation ofovarian tissue for medical indications (e.g., malignancy). The
following regulations were reported:• 53% (20) reported federal/national laws/statutes/ordinances;• 13% (5) reported federal/national laws/statutes/ordinancesand professional organization standards/guidelines;• Four reported professional organization standards/guidelines;
and• Two reported federal/national laws/statutes/ordinances andagency regulations/oversight.
• Single countries reported either• Agency regulations/oversight only;• Agency regulations/oversight and professional organization standards/guidelines;• Federal/national laws/statutes/ordinances and state/provincial/regional laws/statutes/ordinances;• Professional organization standards/guidelines and religious decree; or• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, and agency regulations/oversight.
• One country replied “unknown”.
Forty-one countries responded to questions regarding theexistence of guidelines or laws governing cryopreservation of
testicular tissue for medical indications (e.g., malignancy). The
following regulations were reported:• 53% (22) reported federal/national laws/statutes/ordinancesonly;• 12% (5) reported federal/national laws/statutes/ordinancesand professional organization standards/guidelines;• Three reported professional organization standards/guidelines
only; and• Two reported federal/national laws/statutes/ordinances andagency regulations/oversight.
• Single countries reported either• Agency regulations/oversight only;• Professional organization standards/guidelines and religious decree;• Agency regulations/oversight and professional organization standards/guidelines;• Federal/national laws/statutes/ordinances and state/provincial/regional laws/statutes/ordinances;• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, and agency regulations/oversight;• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, professional organization standards/guidelines, and cultural practice.
• Three countries replied “unknown”.
Thirty-seven countries responded to questions regarding theexistence of guidelines or laws governing cryopreservation of
sperm cryopreservation for non-medical indications (e.g., deliberate deferral of childbearing for personal reasons). The following regulations were reported:• 57% (21) reported federal/national laws/statutes/ordinances
only.
• Two countries each reported either• Professional organization standards/guidelines only;• Agency regulations/oversight and professional organization standards/guidelines;
103Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health• Three reported agency regulations/oversight and professionalorganization standards/guidelines; and• Two reported professional organization standards/guidelines
only.
• Single countries reported either• Federal/national laws/statutes/ordinances and agency
regulations/oversight;• Federal/national laws/statutes/ordinances, municipal
laws/statues/ordinance, and professional organization
standards/guidelines;• Federal/national laws/statutes/ordinances, professionalorganization standards/guidelines, and cultural practice;• Federal/national laws/statutes/ordinances, and state/provincial/regional laws/statutes/ordinances;• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, and agency regulations/oversight;• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, and professionalorganization standards/guidelines; and• Professional organization standards/guidelines and religious decree.
• One country replied “unknown”.
Thirty-seven countries responded to questions regarding theexistence of guidelines or laws governing cryopreservation ofovarian tissue for non-medical indications (e.g., deliberatedeferral of childbearing for personal reasons). The following
regulations were reported:• 54% (13) reported federal/national laws/statutes/ordinances only;• Two reported agency regulations/oversight and professionalorganization standards/guidelines; and• Two reported federal/national laws/statutes/ordinances andprofessional organization standards/guidelines.
• Single countries reported either• Professional organization standards/guidelines only;• Professional organization standards/guidelines and religious decree;• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, and agency regulations/oversight; or• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, and professional organization standards/guidelines.
• One country replied “unknown”.
Twenty-ﬁve countries responded to questions regarding theexistence of guidelines or laws governing cryopreservation of
testicular tissue for non-medical indications (e.g., deliberatedeferral of childbearing for personal reasons). The following
regulations were reported:• 52% (13) reported federal/national laws/statutes/ordinances
only;• Two reported agency regulations/oversight and professionalorganization standards/guidelines;• Two reported federal/national laws/statutes/ordinances andprofessional organization standards/guidelines; and• Two reported professional organization standards/guidelines
only.
• Single countries reported either• Professional organization standards/guidelines and religious decree;• Federal/national laws/statutes/ordinances and professional organization standards/guidelines; or• Federal/national laws/statutes/ordinances, municipal
laws/statues/ordinances, and professional organization
standards/guidelines.
• Single countries reported either• Professional organization standards/guidelines and religious decree• State/provincial/regional laws/statutes/ordinances andprofessional organization standards/guidelines;• Federal/national laws/statutes/ordinances, and state/provincial/regional laws/statutes/ordinances;• Federal/national laws/statutes/ordinances, professionalorganization standards/guidelines, and cultural practice;• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, and agency regulations/oversight; or• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, and professionalorganization standards/guidelines.
• Two countries replied “unknown”.
Thirty-seven countries responded to questions regarding theexistence of guidelines or laws governing oocyte cryopreservation
for non-medical indications (e.g., deliberate deferral of childbearing for personal reasons). The following regulations werereported:• 51% (19) reported federal/national laws/statutes/ordinances
only; and• Four reported federal/national laws/statutes/ordinances andprofessional organization standards/guidelines.
• Two countries each reported either• Professional organization standards/guidelines only;• Agency regulations/oversight and professional organization standards/guidelines; or• Federal/national laws/statutes/ordinances, municipal
laws/statues/ordinances, and professional organization
standards/guidelines;• Single countries reported either• Professional organization standards/guidelines and religious decree;• State/provincial/regional laws/statutes/ordinances andprofessional organization standards/guidelines;• Federal/national laws/statutes/ordinances and state/provincial/regional laws/statutes/ordinances;• Federal/national laws/statutes/ordinances, professionalorganization standards/guidelines, and cultural practice;• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, and agency regulations/oversight; or• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, and professionalorganization standards/guidelines.
• Two countries replied “unknown”.
Thirty-seven countries responded to questions regarding theexistence of guidelines or laws governing pre-implantationembryo cryopreservation for non-medical indications (e.g.,deliberate deferral of childbearing for personal reasons). The
following regulations were reported:• 54% (20) reported federal/national laws/statutes/ordinances;• Four reported federal/national laws/statutes/ordinances andprofessional organization standards/guidelines;
104

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health• Federal/national laws/statutes/ordinances and state/provincial/regional laws/statutes/ordinances; or• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, and agency regulations/oversight.
• Three countries replied “unknown”.
The following responses were received to the question “Ifcryopreservation or fertility preservation is permitted, what is the
maximum duration of storage allowed?” (Table 2a–2c).
Storage of sperm for fertility treatments: Forty-seven percent(37) of the 79 countries that responded to the survey reported that
there were no time limits on storage. Nineteen percent (15countries) reported that storage limits had not been addressed,
and ﬁfteen percent (12 countries) replied “unknown”. Fifteen
countries reported storage limits ranging from two years (onecountry), three years (one country), ﬁve years (two countries),
10 years (nine countries), and 20 years (two countries).
Storage of sperm for non-medical indications: Thirty-eightpercent (30) of the 78 countries that responded to the survey
reported that there were no time limits on storage. Twenty-six
percent (20 countries) reported that storage limits had not beenaddressed, and twenty-one percent (16) countries replied“unknown”. Twelve countries reported storage limits ranging
from two years (one country), ﬁve years (one country), six years(one country), 10 years (seven countries), and 20 years (twocountries).
Storage of sperm for medical indications: Forty-nine percent(38) of the 78 countries that responded to the survey reported that
there were no time limits on storage. Nineteen percent (15)countries reported that storage limits had not been addressed,
and fourteen percent (11 countries) replied “unknown”.
Fourteen countries reported storage limits ranging from two
years (one country), three years (one country), ﬁve years (twocountries), 10 years (six countries), 20 years (two countries), and55 years (one country).
Storage of oocytes for fertility treatment: Forty-three percent (34)of the 79 countries that responded to the survey reported there
were no time limits on storage. Nineteen percent (15 countries)
responded that storage limits had not been addressed, while 15%(12 countries) responded “unknown”. Eighteen countries
reported storage limits ranging from two years (one country),
three years (one country), ﬁve years (two countries), 10 years (10countries), 20 years (three countries), and 49 years (one country).
Storage of oocytes for non-medical indications: Thirty-six
percent (27) of the 74 countries that responded to the survey
reported that there were no time limits on storage. Twenty-eightpercent (21 countries) responded that storage limits had not beenaddressed, while 18% (13 countries) responded “unknown”.
Thirteen countries reported storage limits ranging from two years(one country), ﬁve years (three countries), 10 years (six countries), 20 years (two countries), and 49 years (one country).
Storage of oocytes for medical indications: Forty-seven percent(36) of the 76 countries that responded to the survey reported that
there were no time limits on storage. Twenty-one percent (16)countries responded that storage limits had not been addressed,
while 14% (11 countries) responded “unknown”. Fourteen
countries reported storage limits ranging from two years (onecountry), three years (one country), ﬁve years (two countries),
10 years (four countries), 20 years (two countries), 49 years (onecountry), and 55 years (one country).

Storage of embryos for fertility treatment: Thirty-three percent(26) of the 79 countries that responded to the survey reported that
there were no time limits on storage. Nineteen percent (15)countries responded that storage limits had not been addressed,
while 15% (12 countries) responded “unknown”. Twenty-six
countries reported storage limits ranging from two years (twocountries), three years (one country), ﬁve years (six countries), six
years (one country), 10 years (14 countries), 20 years (onecountry), and 49 years (one country).
Storage of embryos for non-medical indications: Twenty-nine
percent (22) of the 77 countries that responded to the survey
reported that there were no time limits on storage. Twenty-sevenpercent (21 countries) responded that storage limits had
not been addressed, while 22% (17 countries) responded“unknown”. Seventeen countries reported storage limits ranging from ﬁve years (four countries), six years (one country),
10 years (nine countries), 20 years (two countries), and 49 years(one country).
Storage of embryos for medical indications: Thirty-eight percent (29) of the 77 countries that responded to the survey
reported that there were no time limits on storage. Twenty-three
percent (18 countries) responded that storage limits had not beenaddressed, while 15% (12 countries) responded “unknown”.
Eighteen countries reported storage limits ranging from two years(one country), three years (one country), ﬁve years (two countries), 10 years (10 countries), 20 years (two countries), 49 years(one country), and 55 years (one country).
Storage of ovarian tissue for non-medical indications: Thirtytwo percent (24) of the 75 countries that responded to the survey
reported that there were no time limits on storage. Thirty-nine
percent (29 countries) responded that storage limits had not beenaddressed, and 17% (13 countries) responded “unknown”. Ninecountries reported storage limits ranging from ﬁve years (1country), 10 years (four countries), 20 years (three countries), and49 years (one country).
Storage of ovarian tissue for medical indications: Thirty-eightpercent (29) of the 77 countries that responded to the survey
reported that there were no time limits on storage. Thirty-six
percent (28 countries) responded that storage limits had not beenaddressed, and 14% (11 countries) responded “unknown”. Ninecountries reported storage limits ranging from ﬁve years (onecountry), 10 years (12 countries), 20 years (three countries),
49 years (one country), and 55 years (one country).
Storage of testicular tissue for non-medical indications: Thirtyone percent (24) of the 78 countries that responded to the survey
reported that there were no time limits on tissue storage. Thirtytwo percent (25) countries reported that storage limits had notbeen addressed, and 26% (20 countries) responded “unknown”.
Nine countries reported storage limits ranging from ﬁve years(two countries), 10 years (ﬁve countries), and 20 years (twocountries).
Storage of testicular tissue for medical indications: Thirty-nine
percent (31) of the 79 countries that responded to the survey
reported that there were no time limits on tissue storage. Thirty
percent (24 countries) reported that storage limits had not beenaddressed, and 16% (13 countries) responded “unknown”.
Eleven countries reported storage limits ranging from three years(one country), ﬁve years (one country), 10 years (ﬁve countries),
20 years (two countries), and 55 years (one country).
105

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 7. Table 2a
Duration of cryostorage?
Cryopreservation for fertility treatment
Country
Albania
Argentina
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
Ecuador
Egypt
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
Iceland
India
IrelandIsraelItaly
Japan
Kazakhstan
Kenya
LatviaLithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
PolandRomania
RussiaSperm

OocytesUnknown
No Limit
No Limit
No Limit
No Limit
No Limit
3 years
No Limit
No Limit
5 years
Unknown
10 years
5 years
No Limit
No Limit
Not addressed
No Limit
10 years
2 years
No Limit
Unknown
No Limit
No Limit
No Limit
Not addressed
Unknown
Not addressed
Not addressed
No Limit
20 years
No Limit
10 yearsUnknown
20 years
Not addressed
No Limit
No Limit
No Limit
Not addressed
No Limit
Not addressed
No Limit
No Limit
Unknown
Unknown
Not addressed
10 years
10 years
No Limit
No Limit
10 years
No Limit
No Limit
No Limit
Not addressed
No Limit
No Limit
Unknown
Unknown
No Limit

Unknown
No Limit
No Limit
No Limit
No Limit
No Limit
3 years
No Limit
No Limit
5 years
Unknown
10 years
No Limit
No Limit
No Limit
Not addressed
No Limit
10 years
2 years
Not addressed
Unknown
Unknown
No Limit
No Limit
Not addressed
Unknown
Not addressed
Not addressed
No Limit
20 years
No Limit
10 years
10 years
20 years
Not addressed
No Limit
Not addressed
No Limit
Not addressed
No Limit
Not addressed
No Limit
No Limit
Unknown
Unknown
5 years
10 years
10 years
No Limit
No Limit
10 years
No Limit
20 years
No Limit
Not addressed
No Limit
No Limit
Unknown
Unknown
No Limit
106

Fertilized Oocytes(Pre-zygotes to Blastocysts)
Unknown
No Limit
10 years
10 years
No Limit
No Limit
3 years
No Limit
No Limit
5 years
Unknown
5 years
Not addressed
No Limit
No Limit
Not addressed
No Limit
10 years
2 years
Not addressed
Unknown
Unknown
No Limit
No Limit
Not addressed
Unknown
10 years
Not addressed
No Limit
20 years
Not addressed
10 years
10 years
10 years
5 years
No Limit
Not addressed
No Limit
Not addressed
No Limit
Not addressed
No Limit
No Limit
Unknown
Unknown
5 years
6 years
10 years
No Limit
No Limit
10 years
10 years
Not addressed
No Limit
Not addressed
No Limit
No Limit
Unknown
Unknown
No Limit

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 7. Table 2a(Continued)
Cryopreservation for fertility treatment
Country
SerbiaSlovenia
South Africa
South Korea
Spain
Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

Sperm

Oocytes

Not addressed
Not addressed
No Limit
No Limit
No Limit
Unknown
No Limit
10 years
Not addressed
Unknown
10 years
Not addressed
Not addressed
10 yearsUnknown
No Limit
No Limit
Not addressed
No Limit

No Limit
Not addressed
No Limit
No Limit
49 yearsUnknown
No Limit
10 years
Not addressed
Unknown
10 years
Not addressed
Not addressed
10 yearsUnknown
No Limit
No Limit
Not addressed
No Limit

Fertilized Oocytes(Pre-zygotes to Blastocysts)
2 years
5 years
No Limit
5 years
49 yearsUnknown
10 years
10 years
Not addressed
Unknown
10 years
Not addressed
Not addressed
10 yearsUnknown
No Limit
No Limit
Not addressed
No Limit

Chapter 7. Table 2b
Duration of cryostorage?
Cryopreservation for medical indications
Country
Albania
Argentina
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
Ecuador
Egypt
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceGuatemalaSperm
Unknown
No Limit
No Limit
No Limit
No Limit
No Limit
3 years
No Limit
No Limit
5 years
Unknown
10 Years
No Limit
No Limit
No Limit
Not addressed
No Limit
10 Years
2 years
Not addressed
Unknown
No Limit
No Limit
No Limit
Not addressed
Unknown
Not addressed
Not addressed
No Limit
20 years
No Limit

OocytesUnknown
No Limit
No Limit
No Limit
No Limit
No Limit
3 years
No Limit
No Limit
5 years
Unknown
Not addressed
No Limit
No Limit
Not addressed
No Limit
10 Years
2 years
Unknown
No Limit
No Limit
No Limit
Not addressed
Unknown
Not addressed
Not addressed
No Limit
20 years
No Limit
107

Pre-implantation embryos

Ovarian tissue

Testicular tissue

Unknown
No Limit
No Limit
10 Years
No Limit
No Limit
3 years
No Limit
No Limit
5 years
Unknown
10 Years
Not addressed
No Limit
No Limit
Not addressed
No Limit
10 Years
2 years
Not addressed
Unknown
No Limit
No Limit
No Limit
Not addressed
Unknown
Not addressed
Not addressed
No Limit
20 years
Not addressed

Unknown
No Limit
No Limit
No Limit
No Limit
No Limit
Not addressed
No Limit
No Limit
5 years
Unknown
Not addressed
Not addressed
No Limit
No Limit
Not addressed
No Limit

Unknown
Unknown
No Limit
No Limit
No Limit
No Limit
3 years
No Limit
No Limit
5 years
Unknown
10 Years
Not addressed
No Limit
Unknown
Not addressed
No Limit
10 Years
Not addressed
Not addressed
Unknown
No Limit
No Limit
No Limit
Not addressed
Unknown
Not addressed
Not addressed
No Limit
20 years
Not addressed

Not addressed
Not addressed
Unknown
No Limit
Not addressed
No Limit
Not addressed
Unknown
Not addressed
Not addressed
No Limit
20 years
Not addressedAbstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 7. Table 2b(Continued)
Cryopreservation for medical indications
Country
Hong Kong (China*)
Hungary
Iceland
India
IrelandIsraelItaly
Japan
Kazakhstan
Kenya
LatviaLithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
PolandRomania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain
Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

Sperm
Unknown
20 years
Not addressed
No Limit
No Limit
No Limit
Not addressed
No Limit
Not addressed
No Limit
No Limit
Unknown
Unknown
5 years
No Limit
10 Years
No Limit
No Limit
10 Years
Not addressed
No Limit
No Limit
Not addressed
No Limit
No Limit
Unknown
Unknown
No Limit
No Limit
10 Years
No Limit
No Limit
No Limit
Not addressed
No Limit
Not addressed
Unknown
10 Years
Not addressed
Not addressed
55 yearsUnknown
No Limit
No Limit
Not addressed
No Limit

OocytesUnknown
20 years
Not addressed
No Limit
Not addressed
No Limit
Not addressed
No Limit
Not addressed
No Limit
No Limit
Unknown
Unknown
5 years
No Limit
10 Years
No Limit
No Limit
10 Years
Not addressed
No Limit
No Limit
Not addressed
No Limit
No Limit
Unknown
Unknown
No Limit
No Limit

Pre-implantation embryos

Ovarian tissue

Testicular tissue

10 YearsUnknown
10 years
Not addressed
No Limit
Not addressed
No Limit
Not addressed
No Limit
Not addressed
No Limit
No Limit
Unknown
Unknown
5 years
10 Years
10 Years
No Limit
No Limit

Unknown
20 years
Not addressed
No Limit
Not addressed
No Limit
Not addressed
No Limit
Not addressed
No Limit
No Limit
Unknown
Unknown
Not addressed
Not addressed
Not addressed
Not addressed
No Limit

Unknown
20 years
Not addressed
No Limit
Not addressed
No Limit
Not addressed
No Limit
Not addressed
No Limit
No Limit
Unknown
Unknown
Not addressed
No Limit
10 Years
Not addressed
No Limit
10 Years
Not addressed
No Limit
No Limit
Not addressed
No Limit
Unknown
Unknown
Unknown
No Limit
Not addressed
10 Years
No Limit
No Limit
No Limit
Not addressed
No Limit
No Limit
Not addressed
Not addressed
Not addressed
Not addressed
Not addressed
55 yearsUnknown
No Limit
No Limit
Not addressed
No Limit

Not addressed
20 years
No Limit
Not addressed
No Limit
No Limit
Unknown
Unknown
No Limit
Unknown

No Limit
No Limit
49 years
Not addressed
No Limit
No Limit
Not addressed
Unknown
10 Years
Not addressed
Not addressed
55 yearsUnknown
No Limit
No Limit
Not addressed
No Limit

No Limit
No Limit
49 years
Not addressed
10 Years
10 Years
Not addressed
Unknown
10 Years
Not addressed
Not addressed
55 yearsUnknown
No Limit
No Limit
Not addressed
No Limit108

Not addressed
20 years
No Limit
Not addressed
No Limit
No Limit
Unknown
Unknown
No Limit
Not addressed
10 Years
No Limit
No Limit
49 years
Not addressed
No Limit
No Limit
Not addressed
Not addressed
10 Years
Not addressed
Not addressed
55 yearsUnknown
Unknown
No Limit
Not addressed
No Limit

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 7. Table 2c
Duration of cryostorage?
Cryopreservation for non-medical indications
Country
Albania
Argentina
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
Ecuador
Egypt
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
Iceland
India
IrelandIsraelItaly
Japan
Kazakhstan
Kenya
LatviaMalaysia
Mali
MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
PolandRomania
RussiaSerbiaSlovenia

Sperm

Oocytes)Unknown
No Limit
No Limit
Unknown
Not addressed
No Limit
Not addressed
No Limit
No Limit
5 years
Unknown
10 years
Not addressed
No Limit
No Limit
Not addressed
No Limit
10 years
2 years
Not addressed
Unknown
No Limit
No Limit
No Limit
Not addressed
Unknown
Unknown
Not addressed
No Limit
20 years
No Limit
10 years
Not addressed
20 yearsUnknown
No Limit
Not addressed
No Limit
Unknown
No Limit
Not addressed
No Limit
Unknown
Unknown
Not addressed
6 years
10 years
No Limit
No Limit
10 years
Not addressed
No Limit
No Limit
Not addressed
No Limit
No Limit
Unknown
Unknown
Unknown
Not addressed
Not addressed

Unknown
No Limit
No Limit
Unknown
Not addressed
No Limit
Not addressed
No Limit
No Limit
5 years
Unknown
10 years
Not addressed
No Limit
No Limit
Not addressed

Pre-implantation embryos
Unknown
No Limit
10 yearsUnknown
Not addressed
No Limit
Not addressed
No Limit
No Limit
5 years
Unknown
5 years
Not addressed
No Limit
No Limit
Not addressed

10 years
2 years
Not addressed
Unknown
5 years
No Limit
No Limit
Not addressed
Not addressed
Not addressed
Not addressed
No Limit
20 years
No Limit
10 years
Not addressed

Unknown
Not addressed
Not addressed
Unknown
Unknown
No Limit
No Limit
Not addressed
Not addressed
Not addressed
Not addressed
No Limit
20 years
Not addressed
10 years
10 years
10 yearsUnknown
No Limit
Not addressed
No Limit
Unknown
No Limit
Not addressed
No Limit
Unknown
Unknown
5 years
6 years
10 years
No Limit
No Limit
10 years
Not addressed
20 years
No Limit
Not addressed
No Limit
No Limit
Unknown
Unknown
Unknown
Unknown
Unknown

Unknown
No Limit
Not addressed
No Limit
Unknown
No Limit
Not addressed
No Limit
Unknown
Unknown
5 years
Not addressed
Not addressed
No Limit
No Limit
Not addressed
20 years
No Limit
Not addressed
No Limit
No Limit
Unknown
Unknown
Unknown
No Limit
10 years
109

Ovarian tissue
No Limit
No Limit
Unknown
Not addressed
No Limit
Not addressed
No Limit
No Limit
5 years
Unknown
Not addressed
Not addressed
No Limit
No Limit
Not addressed
No Limit
Unknown
Not addressed
Not addressed
Unknown
Unknown
Not addressed
No Limit
Not addressed
Not addressed
Not addressed
Not addressed
No Limit
20 years
Not addressed
10 years
Not addressed
20 yearsUnknown
No Limit
Not addressed
No Limit
Unknown
No Limit
Not addressed
No Limit
Unknown
Unknown
Not addressed
Not addressed
Not addressed
Not addressed
No Limit
10 years
Not addressed
20 years
No Limit
No Limit
No Limit
Unknown
Unknown
Unknown
Not addressed

Testicular tissue
Unknown
Unknown
No Limit
Unknown
Not addressed
No Limit
Not addressed
No Limit
No Limit
5 years
Unknown
5 years
Not addressed
No Limit
Unknown
Not addressed
No Limit
Unknown
Not addressed
Not addressed
Unknown
Unknown
No Limit
No Limit
Not addressed
Unknown
Not addressed
Not addressed
No Limit
20 years
Not addressed
10 yearsUnknown
20 yearsUnknown
No Limit
Not addressed
No Limit
Unknown
No Limit
Not addressed
No Limit
Unknown
Unknown
Not addressed
Not addressed
10 years
Not addressed
No Limit
10 years
Not addressed
No Limit
No Limit
Not addressed
No Limit
Unknown
Unknown
Unknown
Unknown
Not addressed
10 yearsAbstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 7. Table 2c(Continued)
Cryopreservation for non-medical indications
CountrySouth Africa
South Korea
Spain
Sudan
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

Sperm
No Limit
No Limit
No Limit
No Limit
No Limit
10 years
Not addressed
Unknown
Not addressed
Not addressed
Not addressed
10 yearsUnknown
Unknown
No Limit
Not addressed
No Limit

Oocytes)
No Limit
No Limit
49 years
No Limit
10 years
Not addressed
Unknown
Not addressed
Not addressed
Not addressed
10 yearsUnknown
No Limit
No Limit
Not addressed
No Limit

Pre-implantation embryos

Ovarian tissue

Testicular tissue

No Limit
5 years
49 years
Not addressed
10 years
10 years
Not addressed
Unknown
Not addressed
Not addressed
Not addressed
10 yearsUnknown
No Limit
No Limit
Not addressed
No Limit

No Limit
No Limit
49 years
Not addressed
No Limit
10 years
Not addressed
Not addressed
Not addressed
Not addressed
Not addressed
10 yearsUnknown
No Limit
No Limit
Not addressed
No Limit

No Limit
No Limit
No Limit
Not addressed
No Limit
No Limit
Not addressed
Not addressed
Not addressed
Not addressed
Not addressed
10 yearsUnknown
Unknown
No Limit
Not addressed
No Limittechnology and innovation. In 2021, there was no apparentchange from 2018 with respect to the number of countries thatallow or permit cryopreservation of sperm, oocytes, and preimplantation embryos for fertility treatments for medical andnon-medical indications. Similarly, no change was reported
concerning the duration of storage for reproductive tissues permitted since the 2018 Surveillance survey. Ten years continues tobe the average time limit for the storage of reproductive tissue inmost countries that responded to the survey. Findings reported inthis study reveal that more countries report the existence ofguidelines or laws governing cryopreservation of sperm, oocytes,
and preimplantation embryos for fertility treatments or medical
indications in 2021 compared to 2018.

Discussion
Evidence from the 2021 IFFS Surveillance survey reveals that the vast
majority of countries allow or permit cryopreservation of sperm,
oocytes, and preimplantation embryos (85%, 82%, and 81%,
respectively) for fertility treatments and medical indications (81%,78%, and 71%, respectively). Fewer countries allow or permit
cryopreservation of sperm, oocytes, and preimplantation embryos fornon-medical indications (65%, 64%, and 53%, respectively). Morecountries allowed or permitted the cryopreservation of ovarian andtesticular tissue for medical (65% and 68%, respectively) than nonmedical indications (44% and 46%, respectively).
More than half the countries reported that sperm, oocytes, andpreimplantation embryos to be used for fertility treatments, medical
indications, or non-medical indications were either commonly or
infrequently performed. Even fewer of the countries reported thatovarian or testicular tissue cryopreservation for medical indications(37 % and 38%, respectively) or non-medical indications (18% and27%, respectively) was either commonly or infrequently performed.
Most countries reported the existence of guidelines or laws
governing cryopreservation of sperm, oocytes, and preimplantation embryos for fertility treatments or medical indications. Most reported that these procedures were regulated byfederal or national laws, statutes, or ordinances. Fewer countries
reported the existence of guidelines or laws governing cryopreservation of sperm, oocytes, and preimplantation embryos fornon-medical indications.
Most of the countries that responded to the survey reported
that they have not addressed the issue or have no speciﬁc storage
limits for reproductive tissue regardless of utilization. A range ofstorage of limitations was reported (ranging from one to 55 years)
with 10 years as the most common response.

References[1] Rall WF, Fahy GM. Ice-free cryopreservation of mouse embryos
at −196 degrees C by vitriﬁcation. Nature 1985;313(6003):
573–575.
[2] Rienzi L, Garcia C, Maggiulli R, et al. Oocyte, embryo andblastocyst cryopreservation in ART: systematic review andmeta-analysis comparing slow-freezing versus vitriﬁcation
to produce evidence for the development of global guidance.
Hum Reprod Update 2017;23(2):139–155.
[3] Mukaida T, Wada S, Takahashi K, et al. Vitriﬁcation ofhuman embryos based on the assessment of suitable conditions for 8-cell mouse embryos. Hum Reprod 1998;13(10):2874–2879.
[4] Mukaida T, Nakamura S, Tomiyama T, et al. Vitriﬁcation ofhuman blastocysts using cryoloops: clinical outcome of 223
cycles. Hum Reprod 2003;18(2):384–391.
[5] Lane M, Schoolcraft WB, Gardner DK. Vitriﬁcation ofmouse and human blastocysts using a novel cryoloop container-less technique. Fertil Steril 1999;72(6):1073–1078.
[6] Trounson A, Mohr L. Human pregnancy following cryopreservation, thawing and transfer of an eight-cell embryo.
Nature 1983;305:707–709.

Summary
The implementation and utilization of cryopreservation techniques is a critical component of ART as it facilitates the preservation of fertility and involves the highest levels of laboratory
110

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

written legal agreements, and documentation of the deceased’s
intent and consent. Most ART programmes now require consent
from the deceased and concerned parties with wording thatspeciﬁcally addresses the disposition of gametes and embryos
after death. When immediate posthumous reproduction is being
considered, family input is often the only source of informationon the intent and wishes of the deceased. In some countries,
gametes are considered to be a form of individual property suchthat subsequent ownership must be documented in a valid will.
Otherwise, the burden of determining whether an individual may
have truly wished to procreate after death is often left to thecourts. The process of updating relevant legislation remains an
ongoing endeavor for many jurisdictions.
Data addressing posthumous reproduction practices were ﬁrst
presented in the 2004 edition of Surveillance. Reports from 2007
through 2013 included ﬁndings that addressed permissibility andutilisation of posthumous insemination only. In 2018,
Surveillance was expanded to include questions that focused on
posthumous reproduction practices that involved insemination
using frozen sperm and/or frozen ova as well as the possibility of
implanting frozen embryos that were stored by individuals whoare currently deceased.

[7] Practice Committee of the American Society for Reproductive
Medicine. Fertility preservation in patients undergoing gonadotoxic therapy or gonadectomy: a committee opinion. Fertil
Steril 2019;112(6):1022–1033.
[8] Daar J, Benward J, Collins L, et al. Planned oocyte cryopreservation for women seeking to preserve future reproductive potential: an ethics committee opinion. Fertil
Steril 2018;110(6):1022–1028.
[9] Kuleshova L, Gianaroli L, Magli C, et al. Birth following
vitriﬁcation of a small number of human oocytes: casereport. Hum Reprod 1999;14(12):3077–3079.
[10] Practice Committees of the American Society of Reproductive
Medicine and the Society for Assisted Reproductive
Technology. Mature oocyte cryopreservation: a guideline.
Fertil Steril 2013;99(1):37–43.
[11] Cobo A, Meseguer M, Remohí J, et al. Use of cryo-banked
oocytes in an ovum donation programme: a prospective,
randomized, controlled, clinical trial. Hum Reprod 2010;25(9):2239–2246.
[12] Schoolcraft WB, Katz-Jaffe MG. Comprehensive chromosome screening of trophectoderm with vitriﬁcation facilitates elective single-embryo transfer for infertile womenwith advanced maternal age. Fertil Steril 2013;100(3):615–619.
[13] Shapiro BS, Daneshmand ST, Garner FC, et al. Clinicalrationale for cryopreservation of entire embryo cohorts inlieu of fresh transfer. Fertil Steril 2014;102:3–9.

Analysis of the Survey
The 2021 online survey included the following questions:
1. Are there regulations that govern posthumous reproduction
in your country and is posthumous reproduction regulated?
How is posthumous reproduction regulated?
2. What posthumous reproduction treatments are allowed/
permitted or practised/performed in your country?
In 2021, representatives from 69 countries responded to thesequestions. By contrast, 82 countries responded to these questionsin 2018, and 63 provided information for the report publishedin 2016.
Twenty (29%) of the 69 responding countries noted the existence of regulations that addressed posthumous reproduction in
their country, including the collection of sperm and oocytes,
fertilization of frozen ova, and implantation of frozen embryos(Table 1). Similarly, 16 (20%) of 82 countries that responded in2018 reported the existence of some types of regulations. Fortynine (71%) of the 69 respondents to the 2021 survey reported
that no regulations governing posthumous reproduction services
in their countries were currently in existence.
In countries in which regulations existed, posthumous reproduction procedures were covered by federal law, state, regional,
provincial, or municipal laws, agency oversight, standards andguidelines from professional organizations, cultural practice, andreligious decree.
Immediate collection of sperm and ova: Respondents fromnine countries (Canada, Egypt, Hong Kong, Israel, Kazakhstan,
Serbia, Sweden, Switzerland, and Tunisia) reported that
immediate posthumous collection of sperm and ova was permitted. This practice was explicitly addressed by legislation inmost countries. Others discussed the impact of guidelines andstandards from professional organizations. A few countries
reported that this practice was subject to religious decrees.
Delayed posthumous reproduction: Respondents from 60
countries provided data pertaining to the practice of posthumous
reproduction via fertilization using cryopreserved sperm and/or
oocytes or transfer of previously- frozen embryos (Table 2). In the

CHAPTER 8: POSTHUMOUS REPRODUCTION
Introduction
Although posthumous or postmortem reproduction has been
performed for over 60 years, it remains one of the most contentious and controversial topics in ART practice today. There
are many unresolved legal and ethical issues pertaining to therights of the deceased person’s parents, the surviving partner, andany future offspring that may be generated.
Posthumous reproduction involves the use of cryopreserved
gametes or embryos collected while an individual was alive or
immediately after death to be utilised later. Posthumous
reproduction is the general term used to describe two uniquesets of circumstances. Immediate posthumous reproduction
involves the immediate harvesting of gametes from an individual who has suffered brain death but who remains on life
support. Gametes can also be extracted from an individual who
was declared dead within the previous 24 hours. Sperm retrieval beyond 24 hours after death has also been described[1].
By contrast, delayed posthumous conception by artiﬁcial insemination using cryopreserved sperm has been practised sincethe 1950s[2].
There is considerable variation in the acceptance, legality, andutilisation of posthumous reproduction among countries worldwide. With the emergence of more effective cryopreservation
techniques, the indications and applications for this practice have
expanded. Oncology patients are now cryopreserving gametes
and embryos for fertility preservation and delayed embryotransfer via in vitro fertilization (IVF) with or without preimplantation genetic testing (PGT). However, one’s ability toutilise cryopreserved reproductive tissue for postmortem purposes depends on local legislation governing this practice, prior111

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 8. Table 1
Are there regulations that govern posthumous reproduction in your country?
Country

Immediate posthumous collectionof sperm or oocytes
Posthumous sperm insemination

Posthumous inseminationsof frozen ova

Argentina
CanadaFederal/National Laws/Status/
Ordinances

Denmark
Egypt

1. Federal/National Laws/Status/
Ordinances
2. Professional Organization
Standards/Guidelines
3. Religious Decree

GreeceHong Kong (China*)

1. Federal/National Laws/Status/
Ordinances
2. State/Provincial/Regional Laws/
Statutes/Ordinances
3. Agency Regulations/
4. Oversight

Hungary
IcelandIsraelKazakhstan
Netherlands

Federal/National Laws/Status/
Ordinances
Cultural PracticeFederal/National Laws/Status/
Ordinances
Federal/National Laws/Status/
Ordinances
Federal/National Laws/Status/
Ordinances
1. Federal/National Laws/Status/
Ordinances
2. Professional Organization/
Standards/Guidelines
Agency Regulations/OversightFederal/National Laws/Status/
Ordinances

New Zealand
NorwaySerbiaFederal/National Laws/Status/
Ordinances
Federal/National Laws/Status/
Ordinances
1. Federal/National Laws/Status/
Ordinances
2. Professional Organization
Standards/Guidelines
3. Religious Decree
Federal/National Laws/Status/
Ordinances
1. Federal/National Laws/Status/
Ordinances
2. State/Provincial/Regional Laws/
Statutes/Ordinance3. Agency Regulations/ OversightFederal/National Laws/Status/
Ordinances
Federal/National Laws/Status/
Ordinances
1. Federal/National Laws/Status/
Ordinances
2. Professional Organization
Standards/Guidelines
3. Religious Decree
Federal/National Laws/Status/
Ordinances
1. Federal/National Laws/Status/
Ordinances
2. State/Provincial/Regional Laws/
Statutes/Ordinances
3. Agency Regulations/Oversight

Switzerland
Tunisia
United States

Federal/National Laws/Status/
Ordinances
Federal/National Laws/Status/
Ordinances
Federal/National Laws/Status/
Ordinances
1. Federal/National Laws/Status/
Ordinances
2. Professional Organization
Standards/Guidelines
3. Religious Decree
Federal/National Laws/Status/
Ordinances
1. State/Provincial/Regional Laws/
Statutes/Ordinances

2. Agency Regulations/OversightFederal/National Laws/Status/
Ordinances

Federal/National Laws/Status/
Ordinances
Federal/National Laws/Status/
Ordinances
Federal/National Laws/Status/
Ordinances

1. Federal/National Laws/Status/
Ordinances
2. Professional Organization
Standards/Guidelines

1. Federal/National Laws/Status/
Ordinances
2. Professional Organization
Standards/Guidelines
Federal/National Laws/Status/
Ordinances

Federal/National Laws/Status/
Ordinances

Spain
SwedenPosthumous implantationof frozen embryos

Federal/National Laws/Status/
Ordinances
Federal/National Laws/Status/
Ordinances
Federal/National Laws/Status/
Ordinances

Federal/National Laws/Status/
Ordinances
Federal/National Laws/Status/
Ordinances
Federal/National Laws/Status/
Ordinances
1. State/Provincial/Regional Laws/
Statutes/Ordinance
2. Professional Organization
Standards/Guidelines
3. Cultural Practice

Uruguay
Federal/National Laws/Status/
Ordinances

Federal/National Laws/Status/
Ordinances
Federal/National Laws/Status/
Ordinances
Federal/National Laws/Status/
Ordinances
1. State/Provincial/Regional Laws/
Statutes/Ordinances
2. Professional Organization
Standards/Guidelines
3. Cultural Practice
1. Federal/National Laws/Status/
Ordinances
2. Cultural PracticeFederal/National Laws/Status/
Ordinances
Federal/National Laws/Status/
Ordinances
Federal/National Laws/Status/
Ordinances
Federal/National Laws/Status/
Ordinances
1. State/Provincial/Regional Laws/
Statutes/Ordinances
2. Professional Organization
Standards/Guidelines
3. Cultural PracticeFederal/National Laws/Status/
Ordinances

described. Forty-four countries (73%) replied “unknown”,
although none reported that this practice was prohibited.
Fertilization of Frozen Ova: Respondents from 60 countries
provided data that addressed the practice of fertilizing frozen ova.
In the 15 (25%) countries that expressly permit or otherwise
perform posthumous fertilization of cryopreserved oocytes, thepractice is regulated by federal laws, local ordinances, and

16 (27%) countries that expressly permit and/or practice posthumous fertilization, this practice is regulated by federal laws andlocal ordinances, as well as regional and professional society
standards. The one exception was Uruguay; the representativefrom this country noted that posthumous fertilization withcryopreserved sperm is currently being undertaken although nospeciﬁc mechanisms providing oversight or regulation were112

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 8. Table 2
What posthumous reproduction treatments are allowed/permitted or practised/performed in your country?
Country

Posthumous
sperm insemination

Posthumous inseminationof frozen ova

Posthumous transfer
of frozen embryos

Argentina
Australia

Unknown
Practised/Performed

Unknown
Practised/Performed

Austria
Bangladesh
BrazilBurkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceAllowed/Permitted
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Allowed/Permitted
Unknown
Unknown
Unknown
Unknown
Unknown
Allowed/Permitted
Practised/Performed
Unknown
Allowed/Permitted
Unknown
Allowed/Permitted
Practised/Performed
Allowed/Permitted
Practised/Performed
Unknown
Unknown
Allowed/Permitted
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Allowed/Permitted
Practised/Performed
Allowed/Permitted
Practised/Performed
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Allowed/Permitted
Practised/Performed
Allowed/Permitted
Unknown
Unknown
Allowed/Permitted

Allowed/Permitted
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Allowed/Permitted
Unknown
Unknown

Allowed/Permitted
Allowed/Permitted
Practised/Performed
Allowed/Permitted
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Allowed/Permitted
Unknown
Unknown
Unknown
Unknown
Unknown
Allowed/Permitted
Practised/Performed
Unknown
Unknown
Unknown
Allowed/Permitted
Practised/Performed
Unknown

Guatemala
Hungary
India
IrelandIsraelItaly
Japan
Kazakhstan
Kenya
LatviaMalaysia
Mali
MexicoMoroccoNamibia
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
PolandRomania
RussiaSerbiaSouth Africa
Spain
Sudan
Tanzania
Trinidad & Tobago

Unknown
Unknown
Allowed/Permitted
Practised/Performed
Unknown
Unknown
Unknown
Allowed/Permitted
Unknown
Allowed/Permitted
Practised/Performed
Unknown
Unknown
Allowed/Permitted
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Allowed/Permitted
Allowed/Permitted
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Allowed/Permitted
Practised/Performed
Allowed/Permitted
Unknown
Unknown
Allowed/Permitted

113

Unknown
Unknown
Allowed/Permitted
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Allowed/Permitted
Practised/Performed
Allowed/Permitted
Practised/Performed
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Practised/Performed
Allowed/Permitted
Unknown
Unknown
Allowed/Permitted

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 8. Table 2(Continued)
Country

Posthumous
sperm insemination

Posthumous inseminationof frozen ova

Posthumous transfer
of frozen embryos

UgandaUnited States
Uruguay
VietnamZimbabwe

Unknown
Allowed/Permitted
Practised/Performed
Unknown
Unknown

Unknown
Allowed/Permitted
Practised/Performed
Unknown
Unknown

Unknown
Allowed/Permitted
Practised/Performed
Unknown
Unknown

regional or professional society standards. Forty-ﬁve countries(75%) responded “unknown” when questioned about the statusof posthumous fertilization, although none noted outright prohibition of this practice. Australia, South Africa, and Uruguay
noted that the procedure was performed in their countries, but
none cited speciﬁc guidelines or legislation.
Transfer of Frozen Embryos: Respondents from 60 countries
provided data on the transfer of frozen embryos. While thisprocedure is expressly permitted and/or performed in 14 countries (23%), 46 (77%) of the respondents answered “unknown”
to this question. Posthumous embryo transfer is performed inSouth Africa and Uruguay, although no speciﬁc legislation or
permission mechanisms were cited.

CHAPTER 9: GAMETE AND EMBRYO DONATION AND
ANONYMITY OF DONORS
Introduction
Third-party reproduction involves the use of donated gametes(sperm or oocytes) or an embryo or engaging a gestational carrier[1].
Third-party reproduction may be accomplished with Medically
Assisted Reproduction (MAR) (e.g., intrauterine insemination) or
Assisted Reproductive Technology (ART) if in vitro fertilization(IVF) is required. Gamete and embryo donations are well-established in both MAR and ART services; these services have beenutilized more extensively in recent years due to the expanded scopeof medical and non-medical indications for their use. These
encompass services that are provided to infertile patients/couples,
carriers of genetic conditions, and human immunodeﬁciency virus(HIV) serodiscordant couples. They are also provided for nonmedical indications, including single women and men, same-sex
couples, and transgender subjects seeking to become parents.
Sperm donation is used mainly to overcome severe male factor
infertility as well as for other signiﬁcant andrological disorders or
genetic conditions in the male. Sperm donation is also available
for single parents or female same-sex couples.
Oocyte donation requires oocytes from a donor for reproductive or research purposes. This reproductive service has
undergone expanded use in recent years, as many societies havenoted a marked demographic trend toward delayed childbearing
with a resultant shift in the “reproductive window” to an age at
which ovarian follicular depletion may impair female fertility.
Additionally, some couples or individuals elect to use embryos
previously created by IVF that are donated by others. Other
recipients include those who choose to transfer an embryo createdfrom both egg and sperm donation, termed “de-novo” generationof an embryo.
A variety of therapeutic alternatives are currently offered at
different locations around the world for third-party reproduction. However, access to these different technologies differs
widely between countries, even among some with similar ethnic,
cultural, political, and religious traditions.

Discussion
Eighty-two countries provided information on the practice of posthumous reproduction in response to the 2018 surveillance survey. Of
these, 16 (20%) reported the existence of regulations governing
immediate posthumous reproduction. In 2021, 25% (15) of 60
countries provided some regulatory guidance on this matter. Most
countries addressed all three applications involving the use of cryopreserved oocytes, sperm, and embryos. Representatives from Israel
noted that there was permission for sperm and oocyte utilization,although responded “unknown” to the question that addressed theutilisation of cryopreserved embryos. South Africa and Uruguay perform all three procedures but did not note the role of agency oversight.
Summary
Although recent scientiﬁc and medical advances have facilitatedthe retrieval and use of gametes and embryos from individuals
who are deceased, complex moral, ethical, and legal issues remainunresolved. Among these issues, it is not clear who will decide
whether the retrieval and disposition of these reproductive tissues
are appropriate, and under what circumstances.
The 2019 Surveillance data revealed the need to address thesecontroversial and complex legal and ethical issues and to provide
more comprehensive guidance and legislation. In 2021, anddespite its ongoing and more frequent use, only about a quarter ofthe respondents reported the existence of government regulations
and legislation focused on posthumous reproduction

Analysis of the Survey
Thirty-six questions pertaining to gamete and embryo donationand donor anonymity were posed:
1. Is third party reproduction practised/performed in yourcountry?
2. Is third party reproduction allowed/permitted in yourcountry?
3. Are gestational surrogates compensated?

References[1] Gilbert S. Fatherhood from the grave: an analysis of
postmortem insemination. Hofstra Law Rev 1993;22(2):521–565.
[2] Sheﬁ S, Raviv G, Eisenberg ML, et al. Posthumous sperm
retrieval: analysis of time interval to harvest sperm. Hum
Reprod 2006;21(11):2890–2893.
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Global Reproductive Health

Forty-seven percent (30) of the 64 countries responding
reported that a wide variety of third-party options were available.
These included gestational surrogacy using the prospective parents’ gametes, sperm donation, or embryo donation; IVF withdonor sperm or donor oocytes; and embryo donation cycles.
Fifty-three percent (16 of 30 countries responding) reported that
this procedure could be performed with embryos that originatedfrom a previous IVF cycle, while 37% (11 of 30 countries
responding) reported that this was performed by de novo generation of embryos with donor gametes. In some countries, certain treatments are not allowed while in others they are
performed but not regulated. Most of these inconsistencies
involve gestational surrogacy, which is typically either performed
and unregulated or permitted but not performed. This isaddressed in more detail in Chapter 14. Other discrepancies
pertained to embryo donation, which is performed in Denmark,
Kenya, and Paraguay from de novo generated embryos and in
Guatemala and Israel using embryos from a previous IVF cycle,
without regulation. When all embryo donation cycles are considered, 77% (49 of 64 countries) reported performing either orboth procedures, while 69% (44 of 64 countries) cite the existence of relevant regulations (Table 1).
Fourteen countries reported performing IVF with donor
gametes and donor embryos created in a previous IVF cycle.
Another 12 countries perform gamete donation cycles and denovo generation of embryos for donation. Gamete donation andembryo donation either from previous IVF cycles or via de novo
generation are performed in Denmark, Latvia, Panama,Paraguay, Trinidad and Tobago, and Venezuela.
China, Germany, and Japan offer sperm donation only, while
another eight countries offer IVF with donor gametes, but notembryo donation. In Kazakhstan, all procedures considered in
the survey are performed including gamete donation, embryo
donation procedures, cytoplasmic donation, ovarian tissue
donation, and testicular tissue donation.
The frequency of use of these different procedures was further
determined. Performance of sperm, oocyte, and embryo donation
was described as “common” in most countries. However, cytoplasmic donation or ovarian/testicular tissue donation is performed only infrequently and described as “common” in
Kazakhstan, Panamá, and Canada alone (Chart 1).
Regulation of gamete, tissue, or embryo donation was reported by 90 respondents, although 51% (46 countries) left the
response to this question blank. Forty-nine percent, (44 countries) reported the existence of some form of regulation governing
gamete or embryo donation. These included 30% (27 countries)
with federal/national laws. Another 10% (nine countries)
reported regulation of gamete donation via other mechanisms,
including regional/state and municipal laws alone or in combination with guidance from professional organizations. Greece,
Canada, Spain, Hong Kong, and Kazakhstan also maintain regulations governing the donation of reproductive tissue.
Cytoplasmic donation is regulated in Canada and the UnitedStates, while Ghana, South Africa, Canada, Spain, andKazakhstan have regulations that direct the activities of theagencies that recruit and match donors with recipients. Mexico
and Brazil reported regulation of gamete donation through government agencies (Table 1).
Compensation for gamete donors is commonplace and was
veriﬁed for sperm donation in 74% (45) of 61 countries that
responded. Eighty percent (49 of 61 countries) reported

4. Are the qualiﬁcations to be a gestational surrogate based
upon medical, mental health and/or any lifestyle (age andoccupational) criteria?
5. Are traditional surrogates compensated?
6. Are the qualiﬁcations to be a traditional surrogate based
upon medical, mental health and/or any lifestyle (age andoccupational) criteria?
7. Are sperm donors compensated?
8. Are the qualiﬁcations to be a sperm donor based upon
medical, mental health and/or any lifestyle (age and occupational) criteria?
9. Are oocyte donors compensated?
10. Are the qualiﬁcations to be an oocyte donor based upon
medical, mental health and/or any lifestyle (age and occupational) criteria?
11. Are embryo donors compensated?
12. Are the qualiﬁcations to be an embryo donor based upon
medical, mental health and/or any lifestyle (age and occupational) criteria?
13. Are cytoplasm donors compensated?
14. Are the qualiﬁcations to be a cytoplasm donor based upon
medical, mental health and/or any lifestyle (age and occupational) criteria?
15. Are ovarian tissue donors compensated?
16. Are the qualiﬁcations to be an ovarian tissue donor based
upon medical, mental health and/or any lifestyle (age andoccupational) criteria
17. Are testicular tissue donors compensated?
18. Are the qualiﬁcations to be a testicular tissue donor based
upon medical, mental health and/or any lifestyle (age andoccupational) criteria?
19. Are there regulations that govern third party reproduction inyour country?
20. How is gestational surrogacy regulated?
21. How is traditional surrogacy regulated?
22. How is sperm donation regulated?
23. How is oocyte donation regulated?
24. How is embryo donation from a previous IVF cycle
regulated?
25. How is de novo generation of embryos for donation purposes
regulated?
26. How is cytoplasmic donation regulated?
27. How is ovarian tissue donation regulated?
28. How is testicular tissue donation regulated?
29. How are agencies that recruit and match egg donors andrecipients as well as surrogates and gestational carriers
regulated?
30. How often is third party reproduction performed in programs within your country?
31. If compensation (beyond reimbursement) is allowed, (asanswered previously) is there a minimum or a maximum
amount allowed?
32. Have there been any modiﬁcations to legislation or guidelines on anonymity of donors since 2018?
33. Are there practices or regulations that address anonymity inyour country?
34. If yes, who are they regulated by?
35. If not anonymous, what type of information can be allowed/
permitted to be provided to the offspring?
36. If not anonymous, what information is customary toprovide?
115

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Global Reproductive Health

Chapter 9. Table 1
Gamete donor anonymity regulations

Country
Albania
Argentina
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic
Republic of
the Congo
Denmark
Ecuador
Egypt
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong(China*)Hungary
India
Ireland
Italy
Japan
Kazakhstan
Kenya
LatviaLithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Romania
RussiaSerbiaNo PracticesorRegulations
No
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
No
No
Yes
No
No
Yes
Yes
Yes
No
Yes
No

Federal/National
Laws/Statutes/
Ordinances
Yes
No
Yes

Yes
Yes

State/Provincial/
Municipal Laws/
Regional Laws/Statutes/
Statutes/
Ordinances
Ordinances

Yes
No

No

No

No

AgencyRegulations/
Oversight

Professional
Organization
Cultural Religious
Standards/ Guidelines practice decree

No

Yes
No

No

No

Yes

Yes
Yes
Yes

Yes
No

No

Yes

Yes
Yes
Yes

Yes

Yes
Yes

Yes

Yes

Yes

No

No

No

No

No

No

Yes

No

No

No

No

No

No

Yes

Yes
No
No
Unknown
Yes
No
Yes
No
Yes
No
Yes

Yes

Yes

Yes

Yes
Yes
Yes
Yes
No
Yes
No
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
No
No
No
Yes
Yes
No
Yes

Yes

No

No

No
Yes

No

No

No

Yes
Yes

Yes

No

No

No

No

No

Yes

Yes

Yes

Yes

Yes
Yes

No
No

No
No

No
No

No
No

No
No

No
No

No
Yes

No

No

Yes

Yes

Unknown

Unknown

Yes
Yes

No

No

No

Yes

No

No

No
Yes

No
Yes

No
Yes

No

No

No

No

Yes

No

No

No

No

No

No

Yes
Yes

116

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 9. Table 1(Continued)

Country
Slovenia
South Africa
South Korea
Spain
Sudan
SwedenSwitzerland
Tanzania
Trinidad &TobagoTunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

No PracticesorRegulations

Federal/National
Laws/Statutes/
Ordinances

Yes
Yes
Yes
Yes
No
Yes
Yes
No
No

Yes
Yes
Yes
Yes

No
No
Unknown
Yes
Yes
Yes
No
Yes
No

State/Provincial/
Municipal Laws/
Regional Laws/Statutes/
Statutes/
Ordinances
Ordinances

AgencyRegulations/
Oversight

Professional
Organization
Cultural Religious
Standards/ Guidelines practice decree

No

No

No

Yes

No

No

Yes
Yes

No

No

No

No

No

No

Yes
No
Yes

No
No
No

No
No
No

No
No
No

No
Yes
No

No
Yes
No

No
No
No

Yes

No

No

No

No

No

No

2%
3%
72%

Testicular tissue donation
23%
2%
5%
Ovarian tissue donation

72%
22%

Cytoplasmic donation

2%
2%
77%
20%
11%
20%

De novo generation of embryos

58%
12%
31%
32%
29%

Embryo donation from a previous IVF cycle
7%

64%
17%
15%

Oocyte donation
4%

70%
15%
11%

Sperm donation
4%
Commonly used

Infrequently Used

Chapter 9. Chart 1. How often is 3rd party donation performed?

117

Never Performed

UnknownAbstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive HealthIn countries in which donors do not remain anonymous, one ispermitted to provide non-identifying information about thedonor to the offspring in 47% (25) of 53 of the countries
responding. However, only 44% (11 of the 25 that responded
positively) noted that it was customary to do so.
Twenty-six percent (14) of 53 countries responding reported
that data that identiﬁed the donor may be provided, although it
was customary to do so in only 15% (8 of 53 countries). Twentysix percent (14 of 53 countries) reported that non-identifying data
could be conveyed from the offspring to the donor, but only ﬁve
countries reported that this actually occurred. Four of 53
responding countries report that they have the option of providing identifying data from the offspring to the donor, but thispractice is only customary in two countries.

90%
80%

80%
74%

70%
60%
50%
40%
30%
22%
20%
10%
0%
Sperm

Oocytes
Sperm

Oocytes

Embryos
Embryos

Chapter 9. Chart 2. Percentage of countries allowing compensation forgamete or embryo donation.

Discussion
Most of the respondents reported no changes in legislation withrespect to gamete donation and anonymity since the last survey
was conducted in 2019[2,3]. An increase in the number of countries reporting compensation for gamete donors was observed
when the data were compared to previous editions of the survey.
There are still signiﬁcant differences in the type and frequencyof embryo donation procedures permitted and performed as wellas the extent of regulation and its enforcement. This is probably
due to inconsistent knowledge and resources of the authorities aswell as the individual decisions made by prospective parents anddonors.
The issue of anonymity in gamete donation has received more
attention in recent years, as cultural and societal perceptions havefocused on increased awareness of identity rights and issues.
Advances in genetics and the prevalence of widely available
genomic identity platforms have revealed the identities of donors
and offspring throughout much of the world without the involvement of medical personnel. A recent article challenged theconcept of anonymity itself with the introduction of genome
sequencing speciﬁcally targeting donors and recipients[4]. In somecountries, especially in Europe, the United States, and Australia,
there has been a shift toward increasing the amount of information offered to donors, recipients, and offspring, including disclosures of medical and non-medical information to the involved
participants. However, this type of information is provided in lessthan half of the countries surveyed.

compensation for oocyte donation. Over 80% of the respondents
replied positively to questions regarding reimbursement for timeand expenses, while nearly 20% of the countries reported thatcompensation frequently went beyond reimbursement (Chart 2).
Compensation for embryo donation is rare. Eight countries
responded that embryo donors were reimbursed for their timeand expenses. Kazakhstan reported that compensation frequently
went beyond reimbursement for oocyte donors. No countries
reported compensation for ovarian or testicular tissue donors.
No speciﬁc amount for compensation beyond reimbursement
was for compensation was reported by any country for sperm
donation. In the case of oocyte donation, Greece, and Chile bothreported that compensation was set at a maximum of $1,200,
while in Israel this amount was $2,000 (US dollars).
Qualiﬁcations for gamete donors (both male and female)
involved an evaluation of medical and mental health and lifestylefactors in 87% (53) of the 61 countries surveyed. However, theserequirements were reportedly less stringent when applied toembryo donation with 48% (29) of 61 respondents citing their
existence. The United States reported qualiﬁcations for ovarianand testicular tissue donors that were the same as those applied tooocyte or sperm donors.
Sixty-one countries responded regarding changes in legislation
or guidelines that addressed donor anonymity. Cambodia,
Colombia, Mexico, and Serbia reported the recent implementation of mandates that increased the amount of information provided to donors. Eight countries reported recent legislativechanges that resulted in a net increase in the amount of information provided to offspring. Conversely, seven countries
reported changes resulting in legislation that restricted theamount of information provided to donors. Ecuador reported
recent changes that restricted information provided to offspring.
Regarding the implementation of regulations that address gamete
donor anonymity, 55% (41 of 75 countries) responded afﬁrmatively. Regulations were implemented at the federal/national level in
80% (33) of 41 countries that responded, the provincial/state level in
15% (6 of 41 countries), and 7% (3 of 41) at the municipal level.
Colombia, Costa Rica, and Romania maintained both federal andlocal legislation. Twelve percent (ﬁve of 41 countries) reported
oversight by governmental agencies, while an additional 27% (11 of
41 countries) also followed the regulations or guidelines provided byprofessional organizations.

Summary
Gamete donations are increasingly involved in MAR and ART
services. These services are regulated in almost 50% of the countries
surveyed, primarily via federal regulations, but also by regionallaws, local laws, and guidance from professional organizations.
Donated embryos are principally those remaining from previous
IVF cycles. While some embryos are generated de novo fromdonated gametes, this alternative is not permitted in many countries.
Compensation to both sperm and oocyte donors is common; thistrend appears to be increasing. In most countries, compensation isoffered as reimbursement for time and expenses only.
The anonymity historically associated with gamete donation iscurrently undergoing reappraisal. Approximately 20 countries
have reported changes in relevant guidelines, with most resulting
in the expansion of the amount of information offered to both
donors and offspring.
118

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Global Reproductive Healthdeveloped to optimize biopsy procedures at later stages ofdevelopment (e.g., targeting trophectoderm cells from the blastocyst stage embryo) as well as the use of different methods forgenetic analysis. Among these new methods, whole chromosomal
panels are evaluated with Array-Comparative Genomic
Hybridization (aCGH), Next Generation Sequencing (NGS), andreal-time quantitative polymerase chain reaction (rtq-PCR).
These advances have changed the clinical practice of ART but
pose formidable new challenges for genetic counselling because
consistent interpretation and clinical recommendations in casesof inconclusive test results remain problematic. Disposition ofthese inconclusive, often labelled “mosaic” embryos has created aproblem because of the possibly transferring an abnormal
embryo and conveying an adverse reproductive outcome on the
one hand versus not transferring a truly euploid embryo due tothe lack of reassuring PGT-A results. Despite the overall
improved implantation rates achieved with the transfer of euploidembryos that were identiﬁed using second-generation PGT-A,
debate continues as to whether the use of these new technologies
improves overall pregnancy outcomes in all women. Unresolved
issues include the determination of why all euploid embryos do
not implant and the accuracy and safety of the overall approach.
Currently, the available evidence is not sufﬁcient to support theuse of PGT-A in routine practice. The general recommendation isthat use of PGT-A, PGT-M and PGT-SR should be guided by theunique clinical circumstances presented by each couple[4,5].
Micromanipulation has also been used for several investigativeand more controversial applications. These include cytoplasmictransfer, mitochondrial and spindle transfer, and the recently
described CRISPR-Cas9 gene-editing technology. Cytoplasmic
and mitochondrial DNA/spindle transfer are potentially valuable
technologies that could provide an important means of assessing
and improving the viability of suboptimal oocytes and ultimately
improve the chance of live birth following embryo transfer.
However, they are investigative approaches that are currently atthe earliest stages of development. Much work remains to bedone to elucidate their complex underlying mechanisms andestablish their safety proﬁles before their clinical application
becomes possible[6,7]. Likewise, while human genome editing has
the potential to prevent and treat human genetic diseases, it still
faces signiﬁcant safety and ethical concerns before it can bebroadly applied in clinical settings. Among the greatest concerns
is its potential to alter the germline with an incomplete understanding of the complexities involved and with unknown consequences[8–10].
In vitro maturation (IVM) was ﬁrst suggested in the 1990s as apotentially useful application that might improve the yield ofuseful oocytes in women undergoing ART, speciﬁcally whensigniﬁcant numbers of immature oocytes were recovered.
Although its practice is no longer considered experimental, theadoption of IVM in clinical practice has been limited by its
relative inefﬁciency and requisite resource intensity. IVM fromconventional in vitro fertilization (IVF) because oocytes are
retrieved without prior controlled ovarian hyperstimulation(COH). The collected immature oocytes are then maintainedin vitro in enhanced culture environments until maturation iscomplete; this occurs once the metaphase II stage has beenachieved. Potential clinical indications for IVM include patients
electing to undergo oncofertility preservation who are unable tocomplete COH due to timing or medical limitations, patients withresistant ovary syndrome, poor responders, and women with

References[1] Zegers-Hochschild F, Adamson GD, Dyer S, et al. The
International Glossary on Infertility and Fertility Care, 2017.
Human Reprod 2017;32(9):1786–1801.
[2] Ory S, Miller K, Horton M, et al. IFFS Surveillance 2016.
Glob Reprod Health 2016;1:e1.
[3] Allan S, Balaban B, Banker M, et al. International Federationof Fertility Societies’ Surveillance (IFFS) 2019: global trends inreproductive policy and practice. IFFS Surveillance 2019.
Glob Reprod Health 2019;4:e29.
[4] Harper JC, Kennett D, Reisel D. The end of donor anonymity:
how genetic testing is likely to drive anonymous gamete donation out of business. Hum Reprod 2016;31(6):1135–1140.

CHAPTER 10: LABORATORY TECHNIQUES
Introduction
A variety of in vitro laboratory techniques are used in assisted
reproduction technology (ART). Some of these methods are
essential to the successful practice of ART, including micromanipulation techniques such as intracytoplasmic sperm injection (ICSI); embryo biopsy with polar body (PB), cleavage stage,
blastomere, or trophectoderm (TE); and assisted hatching (AH).
Others are considered investigational, including cytoplasmictransfer and mitochondrial and spindle transfer[1].
The introduction of ICSI and the ﬁrst successful pregnancy
achieved using this method in 1991 were transformative events
for ART, as this method enabled many men to produce offspring
who were otherwise unable to achieve biological fatherhood[2].
Over the years, this procedure and the indications for ICSI
treatment have evolved. An increased prevalence of de novo sex
and autosomal chromosome abnormalities were observed amongchildren conceived with ICSI in the decade to follow compared tochildren who were naturally conceived and those conceived via
conventional IVF. While there was no clear explanation for theobserved increase, it may have reﬂected factors including parental
age, pre-existing genetic abnormalities in the selected sperm, oran outcome of the ICSI procedure itself. Considering the very low
frequency of these genetic abnormalities, very large and welldesigned, prospective, controlled unbiased studies with systematic cytogenetic testing will be needed to obtain a more conclusive explanation[3].
Preimplantation genetic testing (PGT) is the general term used
to designate several testing strategies, including PGT for aneuploidy (PGT-A), for single gene/monogenic disorders (PGT-M),
and chromosome structural rearrangements (PGT-SR). Firstgeneration PGT-A involved a single or double blastomere biopsy
from cleavage-stage embryos or the ﬁrst or second polar body
(PB). First PB biopsy provides maternal genetic information only
and cannot detect mitotic division or paternal chromosomal
abnormalities. Fluorescence in-situ hybridization (FISH)_
screening technology introduced additional limitations, as only asmall number of chromosomes could be analysed. The expectation was that higher implantation and live birth rates could beachieved while reducing the incidence of multiple pregnancies(the primary risk associated with ART) if a single euploid embryo
could be reliably identiﬁed and transferred. The ﬁrst generation of
PGT-A, which required a cleavage-stage biopsy and used FISH
for the genetic analysis, proved to be ineffective in improving live
birth rates. The second generation of PGT-A methodologies was119Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Healthoocyte maturation defects. However, IVM techniques are in
infrequent use, even for these selected indications, due to perceived lower clinical success rates and a relative dearth of data
regarding its safety. The unresolved safety issues include theoverall health of the resulting offspring and the possibility of
inducing permanent changes in the expression of imprinted
genes[11,12].

means to regulate ICSI in Egypt in addition to POSGs. In Ethiopia
and Latvia, FNLSOs and agency regulations and oversight(ARO) were a source of regulations for ICSI. In Italy, FNLSO as
well as state, provincial, and regional laws, statutes, or ordinances (SPRLSOs) were used as regulatory mechanisms.
Seventy-three countries reported their experiences with PB
biopsies. PB biopsies were permitted in 66% (48) of 73 countries
and not permitted in 15% (11 countries). Nineteen percent (14)replied “unknown”. By contrast, in 2018, PB biopsy was permitted in 72% (54) of the 75 countries that responded. In 2021,
this method was commonly used in only 7% (ﬁve) of 71 countries, including Germany, Italy, Kazakhstan, Morocco, andNigeria. Respondents from three countries did not respond to thequestion regarding the frequency of PB biopsy use, while 38%(27) noted that it was used infrequently. Another 44% (31)replied that PB biopsy was “never performed” while 11% (8)answered “unknown”.
Regulation of PB biopsy was addressed by respondents from37 countries. Of these, 57% (21) provided no speciﬁc responses.
Fifty-six percent (nine) of the 16 countries that responded cited
regulation of PB biopsy by FNLSOs. PB biopsy is regulated by
POSGs only in Argentina and Japan and by POSGs and RD in
Egypt. AROs were reported by respondents from Latvia and
AROs in addition to FNLSOs were used to regulate PB biopsy
procedures in Greece. In Italy, PB biopsy procedures are regulated
by FNLSOs and SPRLSOs, while both FNLSOs and POSGs areused as regulatory mechanisms in Colombia.
Oversight of blastomere biopsy was addressed in responses
from 73 countries. Blastomere biopsy at the cleavage stage isallowed in 81% (59) of the 73 countries that responded.
Blastomere biopsy is not permitted in 10% (seven) of the 73
countries, including Cameroon, Costa Rica, Japan, Mali, thePhilippines, Romania, and Serbia. Ten percent of respondents
from seven countries, including Côte d’Ivoire, Democratic
Republic of the Congo, Ethiopia, Ghana, Namibia, theNetherlands, and Tanzania replied “unknown”. In 2018, blastomere biopsy was permitted in 79% (61) of the 77 countries that
responded. In 2021, blastomere biopsy was regulated in 57%(21) of 37 responding countries, while no regulations existed in
43% (16 countries). Blastomere biopsy was regulated by
FNLSOs in 52% (11) of 21 responding countries. In Argentina
and Japan, regulation was accomplished by POSGs, while both
POSGs and RD governed the use of this procedure in Egypt.
FNLSOs, POSGs, and CP contributed to regulations governing
this procedure in Cambodia. FNLSOs, SPRLSOs, Municipal
Laws/Statutes/Ordinances (MLSOs), and POSGs were used inGermany, while FNLSOs and SPRLSOs were identiﬁed as regulatory bodies in Italy. Blastomere biopsy was regulated by AROs
in Hong Kong, while both FNLSOs and AROs were used in both
Greece and Latvia. Blastomere biopsy was commonly used in
36% (26) of 72 responding countries, infrequently used in 38%(27 countries), and “never performed” in 24% (17 countries).
TE biopsy was allowed in 86% (64) of the 74 countries that
responded to the survey. This procedure was not permitted infour countries, including Costa Rica, Mali, Romania, and Serbia.
Eight percent (six) of the respondents, including those from
Benin, Côte d’Ivoire, Democratic Republic of the Congo,
Ethiopia, Namibia, and Tanzania) replied “unknown”. By
comparison, in 2018, TE biopsy was permitted in 80% (61) of 76
countries that responded to the survey. In 2021, TE biopsies wereregulated in 62% (23) of 37 countries. Of the 23 countries that

Analysis of the Survey
The following questions were submitted to the respondents:
1. Are these laboratory techniques permitted in your country?
ICSI? Assisted hatching? Cytoplasmic transfer? Polar body
biopsy? Blastomere biopsy? Trophectoderm biopsy? Oocyte
maturation? Mitochondrial transfer? CRISPR-Cas9?
2. Are there regulations that govern laboratory techniques inyour country? For: ICSI? Assisted hatching? Cytoplasmictransfer? Polar body biopsy? Blastomere biopsy? Trophectoderm biopsy? Oocyte maturation? Mitochondrial transfer?
CRISPR-Cas9
3. How is ICSI regulated?
4. How is assisted hatching regulated?
5. How is cytoplasmic transfer regulated?
6. How is polar body biopsy regulated?
7. How is blastomere biopsy regulated?
8. How is trophectoderm biopsy regulated?
9. How is oocyte maturation regulated?
10. How is mitochondrial transfer regulated?
11. How is CRISPR-Cas9 regulated?
12. Which laboratory techniques are performed in your country? ICSI with ejaculated sperm? ICSI with surgically
retrieved sperm? Assisted hatching? Cytoplasmic transfer?
Polar body biopsy? Blastomere biopsy? Trophectoderm
biopsy? Oocyte maturation? Mitochondrial transfer?
CRISPR-Cas9?
Respondents from 74 countries submitted data pertaining tolaboratory techniques for the 2021 Surveillance questionnaire.
These included responses regarding the performance and legal statusof micromanipulation procedures and IVM (Tables 1a–1c).
Micromanipulation techniques addressed in the survey included
ICSI with ejaculated or surgically obtained sperm, PGT with a PB,
blastomere, or TE biopsy; assisted hatching; and cytoplasmictransfer, mitochondrial transfer, and the use of CRISPR-Cas9
technology.
ICSI was permitted in all 74 countries that responded to thesurvey. ICSI was reported to be a common procedure with sperm
recovered following ejaculation in all countries. In 2018, thismanipulation was permitted in 99% of the countries that
responded but performed in all. Eighty-ﬁve percent (62) of 73
countries commonly perform ICSI with surgically retrieved
sperm. The procedure is performed infrequently in 15% (11) of
73 countries.
ICSI was regulated in 68% (25) of 37 countries. By contrast,
32% (12 countries) reported that there were no regulations pertaining to ICSI. This method was regulated by federal or nationallaws, statutes, or ordinances (FNLSOs) in 46% (11) of 24
countries. In Russia, ICSI was also regulated by cultural practice(CP) in addition to FNLSO. In Cameroon and the Netherlands,
FNLSOs were supplemented with professional organization
standards and guidelines (POSGs). In Argentina and India, ICSI
was regulated by POSG only. Religious decree (RD) was used as a120

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 10. Table 1a
Are these laboratory techniques allowed/permitted or practised/performed in your country?
ICSI

Allowed/Permitted

Country
Albania
Argentina
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republicof the Congo
Denmark
Ecuador
Egypt
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
India
Ireland
Italy
Japan
Kazakhstan
Kenya
LatviaLithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
Romania

With ejaculated
spermWith surgically retrieved
sperm

Practised/
Performed

Practised/Performed

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used

Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Infrequently Used
Infrequently Used

Assisted hatching
Allowed/Permitted

Practised/
Performed

Oocyte Maturation
Allowed/Permitted

Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Infrequently Used

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Unknown

Infrequently Used
Commonly Used
Infrequently Used
Infrequently Used
Never Performed
Commonly Used
Never Performed
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Never Performed
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Never Performed
Unknown

Yes
Unknown
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Unknown
Unknown

Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Infrequently Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Infrequently Used
Commonly Used
Commonly Used
Infrequently Used
Infrequently Used
Infrequently Used
Commonly Used
Commonly Used
Infrequently Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used

Unknown
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes

Unknown
Commonly Used
Infrequently Used
Infrequently Used
Infrequently Used
Commonly Used
Commonly Used
Commonly Used
Infrequently Used
Commonly Used
Infrequently Used
Commonly Used
Infrequently Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Infrequently Used
Commonly Used
Infrequently Used
Infrequently Used
Never Performed
Commonly Used
Infrequently Used
Commonly Used
Infrequently Used
Infrequently Used
Commonly Used
Commonly Used
Never Performed
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used

Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Unknown
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Unknown
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Unknown
Yes
No

121

Practised/
Performed
Infrequently Used
Infrequently Used
Infrequently Used
Infrequently Used
Never Performed
Never Performed
Never Performed
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Infrequently Used
Infrequently Used
Infrequently Used
Infrequently Used
Infrequently Used
Commonly Used
Infrequently Used
Commonly Used
Infrequently Used
Unknown

Infrequently Used
Infrequently Used
Infrequently Used
Infrequently Used
Commonly Used
Infrequently Used
Commonly Used
Unknown
Infrequently Used
Infrequently Used
Commonly Used
Commonly Used
Never Performed
Infrequently Used
Never Performed
Never Performed
Unknown
Never Performed
Infrequently Used
Commonly Used
Infrequently Used
Infrequently Used
Never Performed
Infrequently Used
Commonly Used
Infrequently Used
Infrequently Used
Never Performed
Unknown
Infrequently Used
Never Performed

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 10. Table 1a(Continued)
ICSI
With surgically retrieved
sperm

Practised/
Performed

Practised/Performed

Allowed/Permitted

Country
RussiaSerbiaSlovenia
South Africa
South Korea
Spain
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited States
Uruguay
Venezuela
VietnamZimbabwe

With ejaculated
sperm

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used

Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Infrequently Used
Commonly Used
Commonly Used
Infrequently Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used

Assisted hatching
Allowed/Permitted
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Oocyte Maturation

Practised/
Performed
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Infrequently Used
Infrequently Used
Never Performed
Never Performed
Commonly Used
Commonly Used
Infrequently Used
Commonly Used
Infrequently Used
Commonly Used
Commonly Used
Never Performed

Allowed/Permitted
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Unknown
Yes
Yes
Yes

Practised/
Performed
Infrequently Used
Commonly Used
Infrequently Used
Commonly Used
Infrequently Used
Infrequently Used
Infrequently Used
Infrequently Used
Infrequently Used
Commonly Used
Infrequently Used
Infrequently Used
Infrequently Used
Never Performed
Infrequently Used
Commonly Used
Infrequently Used

Chapter 10. Table 1b
Are these laboratory techniques allowed/permitted or practised/performed in your country?
Polar Body Biopsy

Blastomere Biopsy

Trophectoderm Biopsy

Country

Allowed/Permitted Practised/Performed Allowed/Permitted Practised/Performed Allowed/Permitted Practised/Performed

Albania
Argentina
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
Ecuador
Egypt
Ethiopia
FranceGeorgia
Germany
Ghana
Greece

Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Unknown
Yes
Yes
No
No
Yes
Yes
Yes
Yes
No
Unknown
No
Unknown
Yes

Infrequently Used
Infrequently Used
Never Performed
Infrequently Used
Never Performed
Infrequently Used
Never Performed
Never Performed
Infrequently Used
Unknown
Never Performed
Never Performed
Never Performed
Infrequently Used
Infrequently Used
Infrequently Used
Never Performed
Never Performed
Never Performed
Infrequently Used
Unknown
Unknown

Yes
Unknown
Yes
Yes
Yes
Unknown
Yes

Infrequently Used
Never Performed
Infrequently Used
Commonly Used
Never Performed
Never Performed

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
No
Unknown
Yes
Unknown
Yes
Yes
Yes
Unknown
Yes
Yes
Yes
Unknown
Yes
122

Infrequently Used
Infrequently Used
Commonly Used
Infrequently Used
Never Performed
Commonly Used
Never Performed
Commonly Used
Commonly Used
Commonly Used
Never Performed
Never Performed
Never Performed
Infrequently Used
Commonly Used
Infrequently Used
Commonly Used
Never Performed
Never Performed
Unknown
Commonly Used
Commonly Used
Never Performed
Infrequently Used
Commonly Used
Infrequently Used
Never Performed
Infrequently Used

Yes
Yes
Yes
Yes
Yes
Yes
Unknown
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Unknown
Yes
Unknown
Yes
Yes
Yes
Unknown
Yes
Yes
Yes
Yes
Yes

Unknown
Commonly Used
Commonly Used
Commonly Used
Never Performed
Commonly Used
Never Performed
Commonly Used
Commonly Used
Commonly Used
Never Performed
Commonly Used
Never Performed
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Never Performed
Never Performed
Commonly Used
Unknown
Commonly Used
Commonly Used
Never Performed
Infrequently Used
Commonly Used
Infrequently Used
Commonly Used
Commonly Used

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 10. Table 1b(Continued)
Polar Body Biopsy

Blastomere Biopsy

Trophectoderm Biopsy

Country

Allowed/Permitted Practised/Performed Allowed/Permitted Practised/Performed Allowed/Permitted Practised/Performed

GuatemalaHong Kong (China*)
Hungary
India
Ireland
Italy
Japan
Kazakhstan
Kenya
LatviaLithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
Romania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited States
Uruguay
Venezuela
VietnamZimbabwe

Yes
Yes
Yes
Unknown
Yes
Yes
No
Yes
Yes
Yes
Yes
Unknown
No
Yes
Yes
Yes
Unknown
Unknown
Yes
Yes
No
Unknown
Yes
Unknown
No
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Unknown
Unknown
Yes
Yes
Yes
Yes
Yes
Yes
Unknown
Yes

Never Performed

Yes

Infrequently Used
Unknown
Infrequently Used
Commonly Used
Never Performed
Commonly Used
Infrequently Used
Unknown
Never Performed
Unknown
Never Performed
Infrequently Used
Never Performed
Commonly Used
Never Performed
Unknown
Never Performed
Commonly Used
Never Performed
Never Performed
Never Performed
Unknown
Never Performed
Never Performed
Never Performed
Infrequently Used
Infrequently Used
Infrequently Used
Infrequently Used
Infrequently Used
Infrequently Used
Infrequently Used
Never Performed
Never Performed
Infrequently Used
Infrequently Used
Infrequently Used
Infrequently Used
Infrequently Used
Never Performed
Never Performed
Never Performed

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Unknown
Unknown
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Unknown
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Commonly Used
Infrequently Used
Infrequently Used
Infrequently Used
Infrequently Used
Commonly Used
Infrequently Used
Commonly Used
Infrequently Used
Infrequently Used
Infrequently Used
Infrequently Used
Never Performed
Commonly Used
Infrequently Used
Commonly Used
Never Performed
Unknown
Commonly Used
Commonly Used
Infrequently Used
Infrequently Used
Infrequently Used
Commonly Used
Never Performed
Never Performed
Never Performed
Infrequently Used
Infrequently Used
Commonly Used
Commonly Used
Commonly Used
Infrequently Used
Infrequently Used
Never Performed
Infrequently Used
Commonly Used
Commonly Used
Infrequently Used
Infrequently Used
Commonly Used
Commonly Used
Commonly Used
Never Performed

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Unknown
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Unknown
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Commonly Used
Infrequently Used
Infrequently Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Infrequently Used
Commonly Used
Infrequently Used
Infrequently Used
Never Performed
Commonly Used
Infrequently Used
Commonly Used
Never Performed
Unknown
Commonly Used
Commonly Used
Infrequently Used
Commonly Used
Commonly Used
Commonly Used
Commonly Used
Never Performed
Commonly Used
Infrequently Used
Infrequently Used
Commonly Used
Commonly Used
Commonly Used
Infrequently Used
Commonly Used
Never Performed
Infrequently Used
Commonly Used
Commonly Used
Infrequently Used
Commonly Used
Infrequently Used
Commonly Used
Commonly Used
Never Performed

AH is permitted in 92% (68) of 74 countries that responded tothe survey, compared to 90% in 2018. This is not allowed in four
countries, including Cameroon, Egypt, Mali, and Norway. Two
countries, Democratic Republic of the Congo, and Denmark
replied “unknown”. AH was regulated in 46% (17) of 37
countries that responded to the survey. It was regulated by
FNLSOs in 22% (8) of the responding countries and by FNLSOs
and CP in Russia. Regulations governing this procedure areprovided by POSGs in Argentina and Cameroon. Both POSGs
and RD are used to regulate AH in Egypt. FNLSOs and
POSGs are used in the Netherlands while FNLSOs, MLSOs, and
POSGs provide regulation of this practice in Romania. FNLSOs,
POSGs, and CPs regulate AH in Cambodia, while FNLSOs,

regulated this procedure, oversight was accomplished in 48% (11countries) by FNLSOs. In Argentina and Japan, regulation wasprovided by POSGs, while both POSGs and RD governed the useof this procedure in Egypt. FNLSOs, POSGs, and CP provided
oversight in Cambodia. FNLSOs, SPRLSOs, MLSOs, and POSGs
were used in Germany, while FNLSOs and SPRLSOs provided
regulatory oversight of this practice in Italy. TE biopsy wasregulated by AROs in Hong Kong, while FNLSOs and AROs
were used in both Greece and Latvia. TE biopsy was commonlyused in 59% (43) of the 73 responding countries, infrequently
used in 21% (15 countries), and never performed in 16% (12countries). Three countries, including Albania, Democratic
Republic of the Congo, and the Netherlands replied “unknown”.
123Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 10. Table 1c
Are these laboratory techniques permitted in your country?
Cytoplasmic transfer

Mitochondrial Transfer

CRISPRCountry

Allowed/Permitted Practised/Performed Allowed/Permitted Practised/Performed Allowed/Permitted Practised/Performed

Albania
Argentina
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
Egypt
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
India
Ireland
Italy
Japan
Kazakhstan
Kenya
LatviaLithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
Romania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain

Unknown
No
No
Yes
Yes
Yes
Yes
No
Yes
Yes
No
No
Yes
Unknown
No
Unknown
No
Unknown
Unknown
Unknown
Unknown
No
UnknownNo
Yes
No
UnknownNo
Yes
Unknown
No
Unknown
Unknown
No
Unknown
Yes
Yes
Unknown
No
Unknown
No
Unknown
No
No
Unknown
Unknown
No
UnknownNo
Yes
Yes
Unknown
No
No
No
No
No
No
Unknown
No

Unknown
Infrequently Used
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Commonly Used
Never Performed
Unknown
Never Performed
Never Performed
Never Performed
Never Performed
Infrequently Used
Never Performed
Never Performed
Never Performed
Never Performed
Unknown
Unknown
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Unknown
Unknown
Never Performed
Unknown
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Unknown
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Unknown
Never Performed
Infrequently Used
Never Performed
Unknown
Never Performed
Never Performed
Never Performed
Infrequently Used
Never Performed
Never Performed
Unknown
Never Performed

Unknown
No
No
Yes
Yes
Unknown
Yes
No
Yes
Unknown
No
No
No
Unknown
No
Unknown
No
Unknown
Unknown
Unknown
Unknown
No
UnknownNo
Yes
No
UnknownNo
Yes
Unknown
Unknown
Unknown
UnknownNo
No
Yes
Unknown
Unknown
No
Unknown
No
Unknown
No
No
Unknown
Unknown
No
Unknown
No
Unknown
Yes
Unknown
No
No
No
No
No
No
Unknown
No
124

Never Performed
Unknown
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Unknown
Never Performed
Never Performed
Never Performed
Never Performed
Infrequently Used
Never Performed
Never Performed
Never Performed
Never Performed
Unknown
Unknown
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Unknown
Unknown
Never Performed
Unknown
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Unknown
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Unknown
Never Performed
Unknown
Never Performed
Unknown
Never Performed
Never Performed
Never Performed
Infrequently Used
Never Performed
Never Performed
Unknown
Never Performed

No
No
No
Yes
Unknown
Unknown
Yes
Yes
No
Unknown
No
No
Unknown
No
No
Unknown
Unknown
Unknown
No
Unknown
No
No
Unknown
No
Unknown
No
UnknownNo
Yes
Unknown
Unknown
Unknown
UnknownNo
No
Yes
Unknown
No
No
Unknown
Unknown
Unknown
Unknown
No
Unknown
No
No
Unknown
No
Unknown
Yes
Unknown
No
No
No
No
No
No
No
No

Unknown
Unknown
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Infrequently Used
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Unknown
Never Performed
Never Performed
Unknown
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Unknown
Unknown
Never Performed
Unknown
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Unknown
Unknown
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Unknown
Never Performed
Unknown
Never Performed
Unknown
Never Performed
Never Performed
Never Performed
Infrequently Used
Never Performed
Never Performed
Never Performed
Never Performed

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 10. Table 1c(Continued)
Cytoplasmic transfer

Mitochondrial Transfer

CRISPRCountry

Allowed/Permitted Practised/Performed Allowed/Permitted Practised/Performed Allowed/Permitted Practised/Performed

SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited States
Uruguay
Venezuela
VietnamZimbabwe

Yes
No
Unknown
Unknown
No
No
Unknown
No
Unknown
No
Unknown
Yes

Infrequently Used
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Unknown
Unknown
Never Performed
Never Performed
Never Performed

Yes
No
Unknown
Unknown
No
No
Unknown
No
Unknown
No
Unknown
Yes

Infrequently Used
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Unknown
Unknown
Never Performed
Never Performed
Never Performed

No
Unknown
Unknown
Unknown
No
No
Unknown
No
Unknown
No
Unknown
Yes

Never Performed
Unknown
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Unknown
Unknown
Never Performed
Never Performed
Never Performed

Japan. Seventy-six percent (54) of the 71 countries responding
reported that CRISPR-Cas9 technology was never performed,
while another two countries (Brazil and Serbia) reported that it
was used infrequently. Twenty-one percent (15 countries) replied“unknown”.
The 2021 survey included responses from 74 countries thatwere focused on the practice of IVM. IVM was permitted in 85%(63) of 74 countries and not permitted in four countries, including
Cameroon, Egypt, Mali, and Romania. Seven countries replied“unknown”. In 2018, IVM was reported as allowed in 86% (64)of 75 countries that responded. In 2021, 35% (13) of 37
respondents reported the existence of regulations governing IVM
treatment. IVM was regulated by FNLSOs only in 22% (eight) of
the countries that responded to the survey and by FNLSOs,
POSGs, and AROs or by RD and POSGs in several individual
countries. IVM is regulated by POSGs alone in Cameroon and by
POSGs and RD in Egypt. IVM is commonly used in 23% (16) of
69 countries responding, infrequently used in 55% (38), andnever performed in 16% (11 countries).

AROs, and POSGs do so in Colombia. AH was reported to becommon in 59% (43) of 73 reporting countries, used infrequently
in 26% (19 countries), and never performed in 12% (ninecountries). Representatives from both Denmark and Democratic
Republic of the Congo replied “unknown”.
Cytoplasmic transfer was permitted in 21% (15) of 72 countries that responded and expressly prohibited in 43% (31 countries). Thirty-six percent (26 countries) replied “unknown”. In
2018, cytoplasmic transfer was permitted in 23% (17) of 73
countries. In 2021, cytoplasmic transfer is regulated in four
(Bulgaria, Canada, Montenegro, and the United States) of 37
countries that responded to the survey. Regulation is accomplished by FNLSOs in Canada, Montenegro, and the UnitedStates. Cytoplasmic transfer was reported to be in common use
only in Bolivia. Seventy-three percent (52) of the 71 respondents
reported that cytoplasmic transfer was never performed. Seven
percent (5 countries, including Argentina, Chile, Panama, Serbia,
and Sweden reported that it was used only infrequently, while
18% (13 countries) replied “unknown”.
Mitochondrial transfer was permitted in 14% (10) of the 72
countries that responded to the survey and expressly prohibitedin 44% (32 countries. Forty-two percent (30) replied“unknown”. In 2018, mitochondrial transfer was allowed in
21% (15) of the 72 countries that responded. In 2021, 14% (ﬁve)of 37 countries, including Australia, Bulgaria, Canada, China,
and the United States, reported the existence of regulations governing mitochondrial transfer. FNLSOs governed this practice inAustralia, Canada, and the United States, while FNLSOs,
SPRLSOs, and POSGs were the source of regulations in China.
Seventy-six percent (54) of 71 countries reported that mitochondrial transfer was never performed; another three countries(Chile, Serbia, and Sweden) reported that it was used only
infrequently. Twenty percent (14 countries) replied “unknown”.
CRISPR-Cas9 technology was permitted in 10% (seven) of 72
countries that responded, including Paraguay, Bangladesh,
Brazil, Guatemala, Kazakhstan, Zimbabwe, and Bolivia. In 2018,
CRISPR-Cas9 technology was permitted in 22% (16) of 73
countries. In 2021, the procedure was not allowed in 49% (35) of
the countries that responded to the survey; another 42% (30countries) replied “unknown”. CRISPR-Cas9 is regulated by
FNLSOs in three of 37 countries. It is regulated by FNLSOs,
SPRLSOs, and POSGs in China and by SPRLSOs and POSGs in

Discussion
The introduction of new laboratory technologies has been
essential to the success and safety of ART. The techniques
assessed in Surveillance 2022 encompass an array of options fromwell-established micromanipulation tools (e.g., ICSI) to unprovenapplications such as mitochondrial transfer. ICSI is an indispensable tool that was widely adopted after validation, successful
global application, and universal acceptance. This has been thecase for many years. The current survey revealed no signiﬁcantchanges with respect to this procedure.
PGT is a promising technology with successful and validated
applications that include PGT-M and PGT-SR. After an earlier
problematic launch with a technology that was somewhat lessthan successful, PGT-A may now be positioned to be the next
breakthrough. However, successful validation will be of utmost
importance before it can be universally recommended for widespread application. PGT is discussed in greater detail in
Chapter 13.
AH has been performed for over 25 years and can be used forthe selective improvement of embryo implantation rates in speciﬁc circumstances when performed by some laboratories. The
125

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health[2] Rosenwaks Z, Pereira N. The pioneering of intracytoplasmic
sperm injection: historical perspectives. Reproduction 2017;
154(6):71–77.
[3] Berntsen S, Laivuori H, La Cour Freiesleben N, et al. A
systematic review and meta-analysis on the association
between ICSI and chromosome abnormalities. Hum Reprod
Update 2021;27(5):801–847.
[4] Cornelisse S, Zagers M, Kostova E, et al. Preimplantation
genetic testing for aneuploidies (abnormal number of chromosomes) in in vitro fertilisation. Cochrane Database Syst
Rev. 2020;9(9):CD005291.
[5] L’Heveder AP, Jones B, Naja R, et al. Preimplantation
genetic testing for aneuploidy: current perspectives. Semin
Reprod Med 2021;39(1-2):1–12.
[6] Cozzolino M, Marin D, Sisti G. New frontiers in IVF: mdna
and autologous germline mitochondrial energy transfer.
Reprod Biol Endocrinol 2019;17(1):55.
[7] Cohen J, Alikani M. The biological basis for deﬁning bi-parental
or tri-parental origin of offspring from cytoplasmic and spindle
transfer. Reprod Biomed Online 2013;26:535–537.
[8] O’Neill HC, Cohen J. Live births following genome editingin human embryos: a call for clarity, self-control andregulation. Editorial. Reprod Biomed Online 2019;38(2):131–132.
[9] Marchant GE. Global governance of human genome editing:
What are the rules? Ann Rev Genomics Hum Genet 2021;
22:385–405.
[10] van Dijke I, van Wely M, Berkman BE, et al. Should germline
genome editing be allowed? The effect of treatment characteristics on public acceptability. Hum Reprod. 2021;
36(2):465–478.
[11] 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.
[12] De Vos M, Grynberg M, Ho TM, et al. Perspectives on thedevelopment and future of oocyte IVM in clinical practice.
J Assist Reprod Genet 2021;38:1265–1280.
[13] Abbara A, Clarke SA, Dhillo WS. Novel concepts for
inducing ﬁnal oocyte maturation in in vitro fertilization
treatment. Endocr Rev 2018;39(5):593–628.
[14] Richani D, Gilchrist RB. The epidermal growth factor network: role in oocyte growth, maturation and developmental
competence. Hum Reprod Update 2018;24(1):1–14.
[15] Plancha C, Rodrigues P, Marques M, et al. The time is ripe
for oocyte in vitro maturation J Assist Reprod Genet 2021;
38:1281–1283.

lack of clearly deﬁned indications and the necessary experienceamong ART labs has precluded its universal application thus far.
Cytoplasmic and mitochondrial transfer and CRISPR-Cas9
are investigative technologies that may ultimately be used toaddress some of the most challenging clinical problems.
However, these evolving technologies are associated with signiﬁcant potential risks and their use poses unique ethicaldilemmas. None of these modalities are ready for broad clinicalapplication at this time. This is reﬂected in their limited use andacceptance and greater regulatory scrutiny. Results of the recent
questionnaire suggest that access to mitochondrial transfer and
CRISPR-Cas9 may be subject to fewer restrictions, with 21%
and 14% of respondents citing that mitochondrial transfer was
permitted in 2018 and 2021, respectively. Interestingly, thefraction of respondents who reported that CRISPR-Cas9-based
procedures were permitted went from 22% to 10% over thesame interval. These differences may suggest a more cautious
regulatory environment but could also represent sampling
differences.
Oocyte maturation is a critical step for successful IVF.
Recovered oocytes need to be mature, competent, and viable toachieve fertilization and ultimately produce a healthy child.
These fundamental molecular and cellular processes that are
integral to successful IVF take place largely in vivo. Realizationof the true clinical potential of IVM will require additionaltranslational advances. These are likely to be accomplished ﬁrst
in animal models[13,14,15]. Although there have been no signiﬁcant technical advances in IVM technology since the 2018
survey, there may be a continued trend that slightly favours
increased utilisation of IVM when comparing ﬁndings to thosecollected in 2010. Overall responses for the 2021 Surveillance
survey are similar to those received in 2018. Respondents seemto be reticent to adopt IVM in the absence of evidence suggesting
comparable or superior results compared to those obtainedusing conventional IVF.
Summary
Micromanipulation procedures performed on gametes andembryos are essential aspects of ART. The availability of theseprocedures has vastly enhanced the success of ART practice andhas expanded its scope. These advances include a wide array oftechniques that are currently at varying stages of application anddevelopment. Among them, ICSI is a universally available technology that is performed in all responding countries.
Micromanipulation procedures, including ICSI and PGT-M,
are now essential technologies that are widely available in mostcomprehensive ART centres. PGT-A and assisted hatching areuseful adjuncts in some settings, although their speciﬁc indications and overall value remain to be established. The preliminary
experiences with cytoplasmic transfer, mitochondrial transfer,and CRISPR-Cas9 technology are encouraging. However, theseapplications remain under investigation; an accurate assessmentof their true potential, limitations, and risks will be forthcoming.
The 2021 survey results may suggest a more cautious regulatoryenvironment for both mitochondrial transfer and CRISPR-Cas9.

CHAPTER 11: WELFARE OF THE CHILD
Introduction
Concern for the welfare of the child has been an issue of paramount importance since the advent of effective infertility therapy,
most notably since ART became widely available. Follow-up
studies assessing the health, development, and general well-beingof the offspring of infertile couples have been underway sincethese treatments became routinely available. Overall, these studies were intended to address concerns regarding potential
increases in obstetric and neonatal morbidity as well as congenital, chromosomal, or structural anomalies inherited throughReferences[1] Malter HE. Micromanipulation in assisted reproductive
technology. Reprod Biomed Online 2016;32:339–347.
126

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Yes

No

Unknown
89%

11%

Federal/National Laws/Statutes/Ordinances

72%
State/Provincial/Regional Laws/Statutes/Ordinances

17%
11%
80%

Municipal Laws/Statutes/Ordinances

20%

76%
Agency Regulations/Oversight

18%
6%
70%

Professional Organization Standards/Guidelines

15%
15%
70%

Cultural practice

18%
12%
73%

Religious decree20%
7%Chapter 11. Chart 1. Are there practices or regulations that address the welfare of the child?

Chapter 11. Table 1
Are there practices or regulations that address the welfare of the child in your country?

Country
Albania
Argentina
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic
Republic of
the Congo
Denmark
Ecuador
Egypt
Ethiopia
FranceGeorgia
Germany
Ghana
GreecePractices orRegulations
No
No
Yes
No
No
Yes
Yes
Yes
No
Yes
No
Yes
No
No
No
No
Yes
Yes
Yes
No
Unknown

Yes
No
No
Unknown
Yes
No
No
Yes
Yes

Federal/National
Laws/Statutes/
OrdinancesState/Provincial/Regional Municipal Laws/
Laws/Statutes/
Statutes/
Ordinances
Ordinances

AgencyRegulations/
Oversight

Yes

Professional
Organization
Standards/Guidelines

Cultural Religious
practice decree

Yes

Yes
Yes
Yes

Yes

Yes

Yes

Yes
Yes

Yes

Yes

Yes
No
No

Yes

Yes

Yes

No

No

Yes

Unknown

Unknown

Yes

No

No

No

No

No

No

Yes
Yes

No

No

No
Yes

Yes

Yes

Yes

No

Yes

127

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 11. Table 1(Continued)

Country
GuatemalaHong Kong(China*)Hungary
India
Ireland
Italy
Japan
Kazakhstan
Kenya
LatviaLithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
Romania
SerbiaSlovenia
South Africa
South Korea
Spain
SwedenSwitzerland
Tanzania
Trinidad &TobagoTunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

Practices orRegulations

Federal/National
Laws/Statutes/
OrdinancesState/Provincial/Regional Municipal Laws/
Laws/Statutes/
Statutes/
Ordinances
Ordinances

No
Yes
Yes
No
No
Yes
Yes
Yes
No
Unknown
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
No
No
Yes
No
Yes
No
Yes
Yes
Yes
Unknown
Yes
No
No
No
Yes
No
Yes
No
Unknown
No

AgencyRegulations/
Oversight

Professional
Organization
Standards/Guidelines

Cultural Religious
practice decree

Yes
Yes

No

No

No

No

No

No

Yes
No
Yes

No

No

No

Yes

No

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes
Yes

Yes

Unknown

Unknown

Yes

Yes

Yes
Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

Yes

Yes

No

No

No

No

No

Yes
Yes
Yes

Yes
Yes

Yes
Yes

Yes
Unknown

Yes
Yes

No
Unknown

No
Unknown

No

No

No

No

No

No

No

Yes

No

No

Yes

No

No

No

Yes

No

No

No

No

No

No

maternal or paternal pathways as a result of ART[1–4]. Morerecently, these concerns have been extended to include thepotential impact of preimplantation genetic testing (PGT) and theassociations of this procedure with low birth weight and obstetriccomplications including hypertensive disorders and preterm
birth[5]. Parental factors that may contribute to poor outcomes
include background and speciﬁc female or male infertility conditions. A great deal of attention has also been focused on
potential iatrogenic factors, including outcomes associated withovarian stimulation, endometrial preparation, early manipulation of the embryo, and obstetric care. For this reason, closemonitoring of the outcomes of ART is of the highest relevanceand is fundamental to the assessment and counseling of individuals and couples who are undergoing infertility treatment[6].
Although the contributions of “nature” to the welfare of the
future child have received more attention in the scientiﬁc literature than those more closely associated with “nurture”, many
countries have committed resources to the pre- and post-natal
assessment of the environment that will be provided by theintended family. This section of the questionnaire was designed todetermine the current status of the environmental assessment
process on a national level.
128

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 11. Table 2
Are prospective parents asked about the following information?

Country
Albania
Argentina
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic
Republic of
the Congo
Denmark
Egypt
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong(China*)Hungary
India
Ireland
Italy
Japan
Kazakhstan
Kenya
LatviaLithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
Romania
RussiaSerbiaPrevious convictions
related to harming a
childContact with social services A history of violence orregarding care of otherserious discord within thechildrenfamilyDrug oralcoholabuse

The existence of serious
mental or physicalconditions

Risk to the child of aserious medical
condition

Unknown
No
No
No
UnknownNo
Yes
No
Unknown
Unknown
No
Yes
No
No
No
Unknown
Yes
Unknown
Unknown
Unknown
Unknown

Unknown
No
No
No
Unknown
No
No
No
Unknown
Unknown
No
Yes
No
No
No
Unknown
Yes
Unknown
Unknown
Unknown
Unknown

Unknown
No
No
No
UnknownNo
No
Yes
Unknown
Unknown
No
Yes
Yes
No
No
Unknown
Yes
Unknown
Unknown
Unknown
No

Unknown
Yes
Yes
Yes
Unknown
Yes
No
Yes
Unknown
Unknown
No
Yes
Yes
Yes
Yes
Unknown
Yes
Unknown
Unknown
Unknown
No

Unknown
Yes
Yes
No
UnknownNo
No
Yes
Unknown
Unknown
No
Yes
Yes
No
Yes
Unknown
Yes
Unknown
Unknown
Unknown
No

Unknown
Yes
Yes
No
UnknownNo
Yes
Yes
Unknown
Unknown
No
Yes
Yes
No
Yes
Unknown
Yes
Unknown
Unknown
Unknown
No

Unknown
No
Unknown
Unknown
No
No
No
No
Yes
Yes

Unknown
No
Unknown
Unknown
No
No
No
No
Yes
Yes

Unknown
No
Unknown
Unknown
No
No
No
No
Yes
Yes

Unknown
Yes
Unknown
Unknown
Unknown
Yes
Yes
No
Yes
Yes

Unknown
Yes
Unknown
Yes
Unknown
Yes
No
No
Yes
Yes

Unknown
Yes
Unknown
Yes
Unknown
Yes
Yes
No
Yes
Yes

No
No
No
No
No
Yes
Unknown
No
No
No
Unknown
No
Unknown
No
Yes
Yes
No
No
Yes
Unknown
No
No
No
Yes
No
Yes

No
No
No
No
No
Yes
Unknown
No
No
No
Unknown
No
Yes
No
Yes
Yes
No
No
Yes
Unknown
No
No
No
Yes
No
Yes

No
No
No
No
No
Yes
Unknown
No
No
No
Unknown
No
Unknown
No
Yes
Yes
No
No
Yes
Unknown
No
No
No
Yes
No
Yes

Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
No
Unknown
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Unknown
No
No
No
Yes
Yes
Yes

Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
No
Unknown
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Unknown
No
No
No
Yes
Yes
Yes

Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
No
Unknown
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Unknown
No
No
No
Yes
Yes
Yes

129

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 11. Table 2(Continued)

Country
Slovenia
South Africa
South Korea
Spain
SwedenSwitzerland
Tanzania
Trinidad &TobagoTunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

Previous convictions
related to harming a
childContact with social services A history of violence orregarding care of otherserious discord within thechildrenfamilyDrug oralcoholabuse

The existence of serious
mental or physicalconditions

Risk to the child of aserious medical
condition

No
No
Unknown
No
No
No
No
Yes

Yes
No
Unknown
No
No
No
No
Yes

No
No
Unknown
No
No
No
No
Yes

Yes
Yes
Unknown
Yes
Yes
No
Yes
Yes

No
Yes
Unknown
Yes
Yes
No
Yes
Yes

No
Yes
Unknown
Yes
Unknown
Yes
Yes
Yes

No
No
No
Yes
No
Unknown
Yes
Unknown
Yes

No
No
No
No
No
Unknown
No
Unknown
No

No
No
No
Yes
No
Unknown
Yes
Unknown
Yes

Yes
No
No
Yes
Yes
Unknown
Yes
Yes
Yes

Yes
No
No
Yes
Yes
Unknown
Yes
Yes
Yes

No
No
Unknown
Yes
Unknown
Yes
Yes
Yes

18% (six of 33) were from Africa, 18% (six of 33) were from theAmericas and 15% (ﬁve of 33) were from Asia or Australia/New
Zealand. Seventy-six percent (25 of 33) of the respondents fromthese countries reported the existence of federal/national laws or
statutes that addressed these issues; eight and four respondents
reported the existence of provincial/state laws and municipal/
local regulation, respectively. Three countries (Cambodia,
Namibia, and South Africa) maintain both national and provincial laws or statutes. Colombia, Paraguay, Spain, andSweden have national, provincial, and/or local regulations inplace (Chart 1).
Six countries (Colombia, Greece, Hong Kong, Paraguay,
Spain, and the United Kingdom) reported oversight by governmental agencies, while another 13 respondents reported thatprofessional organization guidelines were in place. In Colombia,
Paraguay, and Spain, these issues are addressed by all agencies(i.e., national, state, and local legislation and agencies as well as
professional organizations).

Analysis of the Survey
The following ﬁve questions that addressed the welfare of thechild were included in the 2021 survey:
1. Are there practices or regulations that address the welfare of
the child in your country?
2. If yes, who oversees those regulations?
3. Is a formal assessment of the welfare of the child an obligatory
part of the fertility clinic evaluation of prospective parents?
4. Are prospective parents asked about previous convictions, contact
with social services, a history of violence or serious discord within
the family, drug or alcohol abuse, the existence of a serious mental
or physical condition that might impair their ability to care for achild and risk to the child of a serious medical condition?
5. Can fertility care be declined if there are concerns regarding
the welfare of any potential future child?
The existence of regulations that address the welfare of thechild was reported by 45% (33 of 74) of the respondents. Fortyeight percent (16 of 33) of these respondents were from Europe,

No

Yes

Unknown

12.0%
Can fertility care be declined if there are concerns regarding the welfare of any
potential future children?

62.7%
25.3%

48.6%
Is a formal assessment of the welfare of the child an obligatory part of the fertility
clinic evaluation of the prospective parents?

44.6%
6.8%

Chapter 11. Chart 2. Formal Assessment of the welfare of the child.

130

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Not answered

Yes

Unknown

No

1%
53%

Risk to child of serious medical condition

23%
23%
0%
53%

Existence of serious mental/physical conditions that might impair ability to care for child

20%
27%
0%
58%

Drug or alcohol abuse

22%
20%
0%
22%
24%

History of violence or serious discord within the family

54%
0%
18%

Contact with social service regarding care of other children

24%
58%
0%

Previous convictions related to harming a child

20%
26%
54%

Chapter 11. Chart 3. Are prospective parents asked about the following information?

Respondents from another six countries (Bolivia, Cambodia,
Ghana, Namibia, Mali, and Paraguay) reported that child welfare was monitored by cultural practice; additional monitoring in
the latter four countries took place via religious decree. The
ﬁndings presented in Table 1 describe the different types of regulations that are currently in effect.
When asked whether a formal assessment of the welfare of thechild was an obligatory component of the evaluation of prospective parents by the fertility clinic, 28.4% (21) of 74 respondents responded positively, while more than 60% (45 countries)
responded negatively (Table 2). However, 63% (47 of 74 countries) noted that fertility treatments might be denied if signiﬁcantconcerns about the potential future welfare of the child were
uncovered by the clinic staff (Chart 2). However, another 26% of
the respondents (19 from 74 countries) reported uncertainty as towhether this was truly effective in practice. Twelve percent (ninecountries) reported that there were no such mechanisms in place.
The survey further investigated issues concerning the social
environment, i.e., a history of domestic violence, child abuse, and/or drug/alcohol problems among those seeking infertility treatment. Twenty percent (15 of 74 respondents) reported inquiries
into convictions related to child abuse, 18% (13 of 74 countries)
reported contacts with social services regarding childcare, and
22% (16 of 74) inquired about a history of domestic violence. By
contrast, 58% (43 of 74 countries) reported investigations into
histories of drug or alcohol abuse by prospective parents, while
53% (39 of 74) assessed the potential for serious mental or
physical disorders that would impair their ability to care for achild and the risks to the child presented by a signiﬁcant parental
medical condition (Table 2, Chart 3).

the context of infertility treatment. Most of the positive
respondents were from European countries that maintained
established regulatory bodies designed to monitor these issues.
In practice, 60% of the respondents acknowledged that theindividual clinic was not required to evaluate the child’s social
environment and thus this assessment was most likely not
performed on a routine basis. Despite this, over 60 of the 47
countries surveyed reported that they had the option to denytreatment if child welfare was deemed to be in jeopardy. Theseﬁndings are consistent with previous triennial surveys andsuggest that nearly 40% of the respondents were unable toascertain whether treatment standards were being upheld and/or the viability of the reporting mechanism. This ﬁnding
illustrates the complexity of these issues, in which decisionmaking involves competing rights, disclosure of sensitive
information, state and health authorities’ obligation toprovide child protection, and the demands of prospective
parents willing to pay for this service regardless of the suitability of the socio-cultural environment.
Summary
The ﬁndings presented suggest that there has been little to nochange in the statutory or other oversight over the previous three
years with respect to the assessment and protection of childwelfare in the context of infertility treatment. A few countries
continue to address this issue and provide formal monitoring of
the mental and physical health as well as the socio-culturalenvironment of prospective parents and their offspring.
In countries that do have child welfare provisions in place,these are addressed mainly through federal or local regulation
with oversight provided by government agencies and professionalorganizations. In this setting, clinics often have the option to denytreatment when there is evidence or suspicion of domestic

Discussion
The results of this evaluation revealed that 40% of the countries surveyed undertake formal assessments of child welfare in131Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Healthovercome some of the limitations of previous methods, including
ﬂuorescent in-situ hybridization (FISH), signiﬁcant challenges
remain with respect to its interpretation and clinical utilization.
Because PGT-A reveals the biological gender of the embryo, thismethod has also been utilized for sex selection. Both SFR and
PGT-A have been used with the intent of improving overall success rates and facilitating sex selection. Collectively, the ongoinguse of these methods remains among the most controversial issues
addressed in the current survey.

violence, drug and/or alcohol abuse, or serious mental health or
disabilities that might impair appropriate childcare.
References[1] Lancaster PAL. High incidence of preterm births and early
losses in pregnancy after in vitro fertilisation. Australianin vitro fertilisation collaborative group. Br Med J 1985;291:
1160–1163.
[2] Pandey S, Shetty S, Hamilton M, et al. Obstetric and perinatal
outcomes in singleton pregnancies resulting from IVF/ICSI: asystematic review and meta-analysis. Human Reprod Update2012;185:485–503.
[3] Davies MJ, Moore VM, Willson KJ, et al. Reproductive
technologies and the risk of birth defects. New Engl J Med
2012;366:1806–1813.
[4] Bonduel M, Liebaers I, Deketelaere V, et al. Neonatal data ona cohort of 2889 infants born after ICSI (1991 – 1999) and of
2995 infants born after IVF (1983 –1999). Hum Reprod 2002;
17:671–694.
[5] Zheng W, Yang C, Yang S, et al. Obstetric and neonatal
outcomes of pregnancies resulting from preimplantation
genetic testing: a systematic review and meta-analysis. Hum
Reprod Update 2021;27(6):989–1012.
[6] HFEA Code of Practice 8. Welfare of the Child. Available at:https://portal.hfea.gov.uk/media/1756/2021-10-26-code-of-practice-2021.pdf. Accessed March 27, 2022.

Analysis of the Survey
The following questions were posed in the 2021 questionnaire:
1. Is selective fetal reduction allowed/permitted in your country?
2. Is selective reduction allowed/permitted in your country?
3. If allowed/permitted in your country, are there regulations
that address selective fetal reduction?
4. If yes, who oversees the regulations?
5. Are outcomes of selective reduction monitored and/or
documented?
6. Is sex-selective fetal reduction practised/performed in yourcountry?
7. Is sex-selective fetal reduction allowed/permitted in yourcountry?
8. If allowed/permitted, are there regulations that govern
selective fetal reduction for sex selection in your country?
9. Are there speciﬁc ART/IVF centres or institutions where thesetechniques are only allowed/permitted to be performed?
10. Are these techniques considered experimental or part ofestablished medical practice?
11. During which procedures is sex selection performed?
Respondents representing 75 countries submitted data for thissection. SFR was permitted in 61% (46) of the 75 countries
responding. These ﬁndings were similar to those reported in the2018 survey (i.e., 61%; 47 of 77 countries). Of signiﬁcance wasthe change in status reported by seven countries, including
Cameroon, Hungary, Italy, Latvia, Montenegro, Norway, andSwitzerland. While SFR was reportedly “allowed” in the previous
survey, responses to the current survey include “allowed withconditions” (Table 1, Chart 1).
Twenty-eight percent (21) of 75 countries allow SFR withconditions; most of these responses were from Europe. An
additional 23% (17 countries), predominantly in South America,
reported that SFR was not allowed at all, which was also consistent with previous ﬁndings. Brazil, Columbia, Egypt, theDemocratic Republic of Congo, and Uruguay all reported for theﬁrst time in this survey that SFR is not permitted. Nine countries,
Argentina, Georgia, Ghana, Japan, Kenya, Nigeria, Paraguay,
Tanzania, and Uganda responded that this issue was “notaddressed”. Representatives from Benin, Burkina Faso, and Mali
responded “unknown”.
Overall, 51% (38 countries) reported that SFR was performed.
However, most use it infrequently, except for Bangladesh andGreece where it is used frequently. Representatives from
Germany, who did not report on its use in the previous survey,
now responded that SFR is used infrequently (Chart 2).
Overall, 29% (22 countries) reported the existence of regulations that govern the utilization of SFR (Table 2).
• 50% (11) reported the existence of regulations based onfederal/national laws/statutes/ordinances only;

CHAPTER 12: FETAL REDUCTION AND SEX
SELECTION
Introduction
The transfer of multiple embryos was considered to be essential tosuccess during the early years of ART. This was largely due to the
low likelihood of implantation of a single embryo. However, it
soon became apparent that multiple pregnancies were the single
most prevalent and signiﬁcant risk of ART, posing substantial
risks for both the mother and the infants, most notably thoserelated to prematurity. Selective fetal reduction (SFR), which was
typically performed late in the ﬁrst trimester to reduce the numberof implanted embryos, was adopted in many countries.
Technological advances, including improved embryo selection,
have led to improved implantation and pregnancy rates and havefacilitated a gradual reduction in multiple pregnancies over theensuing decades. As embryo selection technology has improved,
there has been less reliance on SFR to limit the number of
implanted embryos and to mitigate some of the sequelae ofmultiple, most notably, high order multiple (HOM), pregnancies.
Nonetheless, SFR remains a controversial intervention and is stillused extensively, although its availability, acceptance, andapplication vary substantially among countries. While greater
acceptance of single embryo transfer (SET) and expanded utilization mandated by legislation and recommendations of professional societies has resulted in a net reduction in multiple
pregnancies, this has not occurred uniformly[1–3].
The principal advance in embryo selection has been the
adoption of preimplantation genetic testing for aneuploidy (PGTA), which is a method that can be used to select euploid embryos.
PGT-A is frequently performed in conjunction with preimplantation genetic testing for monogenic disorders (PGT-M)
where indicated. Although more recent PGT-A platforms have132

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 12. Table 1
Is selective fetal reduction allowed/permitted and practised/performed in your country?
Country

Allowed/permitted

Practised/performed

Frequency

Albania
Argentina
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
Ecuador
Egypt
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
India
Ireland
Italy
Japan
Kazakhstan
Kenya
LatviaLithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
Romania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain

AllowedNot Addressed
AllowedAllowed with conditions
AllowedAllowedUnknown
AllowedNot allowed
AllowedUnknown
Allowed with conditions
Allowed with conditions
AllowedNot allowed
AllowedNot allowed
Not allowed
Not allowed
AllowedNot allowed
AllowedAllowed with conditions
Not allowed
AllowedAllowed with conditions
Not Addressed
Allowed with conditions
Not Addressed
AllowedNot allowed
Allowed with conditions
Allowed with conditions
AllowedAllowed with conditions
Allowed with conditions
Not Addressed
AllowedNot Addressed
Allowed with conditions
Not allowed
AllowedUnknown
Not allowed
Allowed with conditions
AllowedAllowed with conditions
Allowed with conditions
Allowed with conditions
Not Addressed
Allowed with conditions
Not allowed
Not Addressed
Not allowed
Not allowed
AllowedAllowedAllowed with conditions
AllowedAllowedAllowed with conditions
AllowedYes

Infrequently used

Yes

Infrequently used

Yes
Yes

Frequently used
Infrequently used

Yes

Infrequently used

Yes
Yes
Yes

Infrequently used
Infrequently used
Infrequently used

Yes

Infrequently used

Yes

Infrequently used

Yes

Infrequently used

Yes

Infrequently used

Yes

Infrequently used

Yes

Frequently used

Yes
Yes
Yes

Infrequently used
Infrequently used
Infrequently used

Yes

Infrequently used

Yes

Infrequently used

Yes

Infrequently used

Yes

Infrequently used

Yes

Infrequently used

Yes
Yes

Infrequently used
Infrequently used

Yes

Infrequently used

Yes
Yes
Yes
Yes
Yes
Yes

Infrequently used
Infrequently used
Infrequently used
Infrequently used
Infrequently used
Infrequently used133

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 12. Table 1(Continued)
Country

Allowed/permitted

Practised/performed

Frequency

SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

AllowedAllowed with conditions
Not Addressed
Not allowed
Allowed with conditions
Allowed with conditions
Not Addressed
AllowedAllowedNot allowed
Not allowed
AllowedNot allowed

Yes
Yes

Infrequently used
Infrequently used

Yes
Yes

Infrequently used
Infrequently used

Yes
Yes

Infrequently used
Infrequently used

Yes

Infrequently used

• 27% (six) reported regulations from federal/national laws/
statutes/ordinances, state/provincial/regional laws/statutes/ordinances, and professional organization standards/guidelines;• One country each reported as follows:• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, municipal laws/statutes/
ordinances, professional organization standards/guidelines,
cultural practice, and religious decree• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, municipal laws/statutes/ordinances,and professional organization standards/guidelines;• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, and professional organization standards/guidelines;• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, and agency regulations/oversight; or• Not speciﬁed

Only 36% (26 of 72 countries) reported consistent monitoringor documentation of the outcomes of SFR, including several
European countries, China, and Cambodia. An additional 18%(13 countries) reported that they conduct partial or inconsistentmonitoring, while 33% (24 countries) report no monitoringwhatsoever. While the Russian Federation and China previously
reported inconsistent monitoring and documentation, bothcountries now report consistent monitoring in this survey.
Thirty-three percent (25 of 75 countries) responded that sex
selection is permitted in their countries (Table 3). Sex selection via
PGT-A and/or PGT-M is permitted in 92% (23) of 25 of the
responding countries. Sperm sorting is another sex selection technique that is permitted in addition to PGT-A and PGT-M in sevencountries (Guatemala, Kazakhstan, Kenya, Malaysia, Nigeria,
Panamá, Paraguay, and the United States). By contrast, only sperm
sorting was permitted in Cameroon and the Philippines. Spermsorting is performed for sex selection in 40% (10) of 25 countries. By

Allowed33%

Allowed with conditions

28%

Not Allowed23%

Not addressed

Unknown

12%4%

Chapter 12. Chart 1. Is selective reduction allowed/permitted?

134

Abstracts. Global Reproductive Health (2022) 7:e58

Frequently Used

Unknown• Agency regulations/oversight and professional organization
standards/guidelines;• Federal/national laws/statutes/ordinances, professional organization standards/guidelines, and cultural practice; or• Federal/national laws/statutes/ordinances, state/provincial/regional laws/statutes/ordinances, and agency regulations/oversight.
Kazakhstan reported professional organization standards
and guidelines that regulated sperm sorting. No countries
reported any regulatory bodies providing oversight of SFR forsex selection.
No signiﬁcant differences were observed among various typesof clinics allowed to perform sex selection. Procedures were
performed at small and large private clinics, public and university-based hospitals, and by sole practitioners. Netherlands,
Slovenia, and Sweden were the only countries that did not allow
sex selection or SFR to be performed in private clinics and limited
these procedures to a hospital or university-based setting.
Sixty-six countries responded to the question “Are thesetechniques considered experimental or part of established medical practice”? (Table 4). The following responses were obtained:
For use of PGT-A for sex selection:
Twenty-six percent (17 of 66 countries) responded that PGT-A
was considered an established medical practice.
Two countries responded that PGT-A was considered to beexperimental.
Fifty-seven percent (38) responded “not addressed”.
Fourteen percent (nine) responded “unknown”.
For sperm sorting:
Eleven percent (seven of 62 countries) responded that sperm
sorting was considered an established medical practice.

5%

Infrequently Used

Not performed

Global Reproductive Health

82%

5%

9%

Chapter 12. Chart 2. Is selective reduction performed/practised?

contrast, in the 2019 report, 21 countries reported that sperm
sorting was permitted and four reported that it was in use.
Only 41% (nine of 22 countries) reported having regulations
governing the use of PGT-M in tandem with PGT-A for sex
selection. Six countries (46%) reported that this was regulated byfederal/national laws/statutes/ordinances only, while anotherthree countries reported regulations based on:• Federal/national laws/statutes/ordinances, professional organization standards/guidelines, and cultural practice;• Federal/national laws/statutes/ordinances, agency regulations/oversight, and professional organization standards/guidelines; or• Professional organization standards/guidelines, and religious decree.
Thirty-eight percent (ﬁve of 13 countries) regulate the use of
PGT-A alone for sex selection via:
• Federal/national laws/statutes/ordinances, professional organization standards/guidelines, and religious decree;

Chapter 12. Table 2
If selective fetal reduction is allowed/permitted in your country, are there regulations that address selective fetal reduction?

Country
Belarus
Cambodia
China
FranceGermany
GreeceHong Kong(China*)Hungary
Ireland
Italy
Netherlands
NorwayRomania
RussiaSlovenia
South
Africa
South
Korea
Spain
Switzerland
Tunisia
UnitedKingdom

Federal/National Laws/
Statutes/Ordinances
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

State/Provincial/Regional
Laws/Statutes/Ordinances

Municipal Laws/
Statutes/Ordinances

Yes
Yes

Yes
Yes

AgencyRegulations/
Oversight

Professional Organization
Standards/Guidelines

Culturalpractice

Religious
decree

Yes
Yes

Yes

Yes

Yes
Yes

Yes

Yes
Yes

Yes
Yes

Yes
Yes
Yes
Yes
Yes

Yes
Yes

135

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 12. Table 3
Is sex selection allowed/permitted and practised/performed?
PGT-A for sex selection
Country
Argentina
Australia
Austria
BrazilCambodia
Cameroon
Chile
Colombia
Czech Republic
Denmark
Ecuador
Egypt
Ghana
GuatemalaHong Kong(China*)Hungary
Ireland
Kazakhstan
Kenya
Malaysia
MoroccoNigeria
Panamá
Paraguay
Philippines
SerbiaSpain
Tanzania
UgandaUnited States
Uruguay
Venezuela

Allowed/permitted

Practised/performed

PGT-M performed in tandem withPGT-A for sex selection
Allowed/permitted

Practised/performed

Sperm Sorting
Allowed/permitted

Practised/performed

Allowed/permitted

Practised/performed

Selective fetal
reduction
Allowed/permitted

Practised/performed
Allowed/permitted
Allowed/permitted
Allowed/permitted
Allowed/permitted

Practised/performed

Practised/performed
Allowed/permitted

Allowed/permitted

Practised/performed

Allowed/permitted
Allowed/permitted
Allowed/permitted
Allowed/permitted
Allowed/permitted
Allowed/permitted

Practised/performed
Practised/performed
Practised/performed
Practised/performed
Practised/performed
Practised/performed

Allowed/permitted

Allowed/permitted

Allowed/permitted
Allowed/permitted
Allowed/permitted
Allowed/permitted

Practised/performed
Practised/performed

Allowed/permitted
Allowed/permitted
Allowed/permitted

Practised/performed
Practised/performed
Practised/performed

Practised/performed
Practised/performed
Practised/performed
Practised/performed
Practised/performed
Practised/performed
Practised/performed

Allowed/permitted

Practised/performed
Practised/performed
Practised/performed
Practised/performed
Practised/performed
Practised/performed
Practised/performed

Allowed/permitted
Allowed/permitted
Allowed/permitted
Allowed/permitted
Allowed/permitted
Allowed/permitted

Allowed/permitted

Practised/performed
Practised/performed
Practised/performed

Allowed/permitted

Practised/performed
Practised/performed
Allowed/permitted
Practised/performed
Practised/performed

Practised/performed
Practised/performed

Allowed/permitted

Practised/performed
Practised/performed

Practised/performed

Allowed/permitted

Practised/performed

Allowed/permitted

Allowed/permitted
Practised/performed

Ten percent (six) responded that sperm sorting was considered
to be experimental.
Fifty-six percent (35) responded “not addressed”.
Twenty-three percent (14) responded “unknown”.
For SFR for sex selection:
Ten percent (six of 62 countries) responded that SFR for sex
selection was considered an established medical practice.
One country responded that SFR for sex selection was considered to be experimental.
Sixty-one percent (38) responded “not addressed”.
Twenty-seven percent (17) responded “unknown”.
Overall, 29% (20 of 69 countries) performed sex selection intandem with in vitro fertilization (IVF) cycles, while two of 69
countries (Kenya and Tanzania) performed sex selection intandem with IVF or intrauterine insemination (IUI).
Representatives from the United States responded that sex
selection was performed during an IVF cycle or by
SFR. Cameroon responded that sex selection was performed
solely by SFR.

Discussion
Although SFR has been used to reduce risks associated with
HOM pregnancies and births, its use has always been controversial. HOM pregnancies almost always lead to prematurity
and its associated negative sequelae. Up to 20% of infants withbirth weights under 750 g can develop severe complications suchas cerebral palsy[4]. However, SFR is not without risks, including
the loss of all fetuses following the procedure, incomplete
reduction of the risks associated with HOM pregnancies, and thepotential for adverse psychological consequences[5].
Sex selection has been used by many countries for non-medical (i.e.,“social”) indications such as family balancing or socio-cultural preferences. While sex selection has always been a controversial practice,
it is permitted in several countries. While PGT-A is primarily employed
to select a euploid embryo for transfer, the opportunity to offer andperform sex selection has proven to be irresistible to many clinicians
and prospective parents. The broad availability of these methods,
together with their high accuracy, acceptance, and popularization
through social media channels have served to support this practice[6].
136Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 12. Table 4
Are these techniques considered experimental or part of established medical practice?
Country

PGT-A for sex selection

Albania
Argentina
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
Ecuador
Egypt
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
India
Ireland
Italy
Japan
Kazakhstan
Kenya
LatviaMalaysia
Mali
MexicoMoroccoNamibia
Netherlands
New ZealandNigeria
Panamá
Paraguay
Romania
RussiaSerbiaSouth Africa
Spain
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited States

Not addressed
Unknown
Not addressed
Not addressed
Unknown
Not addressed
Not addressed
Not addressed
Established medical practice
Not addressed
Not addressed
Established medical practice
Not addressed
Not addressed
Not addressed
Not addressed
Established medical practiceUnknown
Established medical practice
Not addressed
Established medical practice
Established medical practice
Established medical practice
Not addressed
Experimental
Not addressed
Unknown
Established medical practice
Not addressed
Established medical practice
Established medical practiceExperimental
Unknown
Not addressed
Not addressed
Unknown
Not addressed
Established medical practice
Not addressed
Not addressed
Established medical practice
Not addressed
Not addressed
Unknown
Not addressed
Not addressed
Established medical practice
Established medical practice
Established medical practice
Not addressed
Not addressed
Not addressed
Not addressed
Not addressed
Not addressed
Not addressed
Not addressed
Not addressed
Not addressed
Not addressed
Not addressed
Established medical practice

Sperm sorting
Not addressed
Unknown
Not addressed
Not addressed
Unknown
Not addressed
Not addressed
Not addressed
Not addressed
Not addressed
Not addressed
Established medical practice
Not addressed
Not addressed
Established medical practice

Selective fetal reduction for sex selection
Not addressed
Unknown
Not addressed
Unknown
Unknown
Not addressed
Not addressed
Not addressed
Established medical practice
Not addressed
Not addressed
Unknown
Not addressed
Not addressed
Unknown

Unknown
Unknown
Not addressed
Unknown

Unknown
Unknown
Not addressed
Unknown

Unknown
Not addressed
Experimental
Not addressed
Unknown
Not addressed
Not addressed
Not addressed

Established medical practice
Established medical practiceExperimental
Not addressed
Unknown
Not addressed
Established medical practice
Not addressed

Experimental
Unknown
Not addressed
Experimental
Unknown
Established medical practice
Established medical practice
Not addressed
Not addressed
Established medical practiceUnknown
Not addressed
Unknown
Not addressed
Not addressed
Established medical practiceExperimental
Not addressed
Not addressed
Unknown
Not addressed
Not addressed
Not addressed
Not addressed
Not addressed
Not addressed
Not addressed
Not addressed
Not addressed
Not addressed
Experimental

Not addressed
Unknown
Not addressed
Not addressed
Unknown
Not addressed
Established medical practice
Not addressed
Not addressed
Established medical practice
Not addressed
Not addressed
Unknown
Not addressed
Not addressed
Not addressed
Unknown
Not addressed
Not addressed
Unknown
Not addressed
Not addressed
Not addressed
Not addressed
Not addressed
Not addressed
Not addressed
Not addressed
Not addressed
Not addressed
Unknown137

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 12. Table 4(Continued)
Country

PGT-A for sex selection

Sperm sorting

Uruguay
Venezuela
VietnamZimbabwe

Not addressed
Established medical practiceUnknown
Unknown

Established medical practiceExperimental
Unknown
Unknown

Selective fetal reduction for sex selection
Not addressed
Not addressed
Unknown
Unknown

is permitted unconditionally in 33% of the responding countries,
while 28% allow it on a conditional basis. In 16% of countries, thestatus of SFR was reported as “unknown” or “not addressed”. Only
four countries responded that SFR for sex selection was permitted.
Twenty-ﬁve countries reported that sex selection by various
procedures is legally permitted. Given its increasing popularity
and availability, access to sex selection using PGT methodologies
is increasingly prevalent and is legally permitted in 23 countries.
The social and religious aspects of this practice remain unexplored. Standard regulations or guidelines for governing one ormore of these practices were reported in ∼43% of 24 countries.

Results of a recent survey indicated that 92% of 493 ART clinics
in the United States surveyed offered PGT-A. Ninety-four percent of
the positive responders performed sex selection for family balancing,
81% did so for patient preference when ART was indicated, and
84% for sex selection alone[7]. Another recent survey utilized a crosssectional-based questionnaire study to assess the attitudes of 1,500
patients regarding sex selection for non-medical reasons. Of interest,
19% responded that sex selection should be strictly prohibited, 39%
considered it acceptable if medically indicated, and 33% believedthat it should be available to anyone requesting it. Religion, educational status, and a desire for children of both genders were identiﬁed
as signiﬁcant predictors for acceptance or rejection of sex selection[8].
Varied and region-speciﬁc cultural, religious, and socioeconomic inﬂuences were found to be the primary drivers of
acceptance or rejection of various sex selection techniques. Thereis evidence for increased utilization of sex selection procedures inseveral countries including Ukraine, the Republic of Korea, andVietnam, where a two-fold increase was reported over the last
decade favouring male sex selection[9,10]. Several Asian, African,
and eastern European countries have longstanding altered sex
ratios, due to a culturally entrenched preference for sons.
There has been substantial controversy regarding the acceptanceof sex selection from several perspectives. Critics have argued thatsex selection is unjust because it makes a judgement of value based
solely on the sex of the unborn child and that the practice of sex
selection perpetuates sexual discrimination. While others havesuggested that allowing family balancing in Western countries
would not disturb the sex ratios due to presumed societal gender
equity, the concept of sex selection predicated on predetermined sex
roles remains unacceptable to others. The impact of sex selection on
ART practice in the United States was illustrated by data collectedfrom 2014 through 2016 that revealed that the male: female sex
ratios of children born to mothers who underwent IVF had shiftedfrom 1.05 to 1.10 following the introduction of PGT[12].
There is some evidence that the utilization of sex selection may bedeclining in some regions. As maternal age has increased globally andART has become more successful with fewer embryos transferred, theneed for SFR (with the option of sex selection) for HOM pregnancies
has declined. Data from the United States suggests that, in contrast to
patient preferences for male offspring observed in the late 1980s andearly 1990s, recent trends reveal that the number of patients who
prefer females is equivalent to those preferring males. Recent datafrom Australia suggest that about 75% of respondents oppose thelegalisation of sex selection through IVF for any reason, including
family balancing[13].

References[1] Banker M, Dyer S, Chambers GM, et al. International
Committee for Monitoring Assisted Reproductive
Technologies (ICMART): world report on assisted reproductive technologies, 2013. Fertil Steril 2021;116(3):741–756.
[2] Practice Committee of the American Society for
Reproductive Medicine and the Practice Committee for theSociety for Assisted Reproductive Technologies. Guidanceon the limits to the number of embryos to transfer: acommittee opinion. Fertil Steril 2021;116(3):651–654.
[3] Available at: https://www.eshre.eu/Guidelines-and-Legal/
Guidelines/Guidelines-in-development/Embryo-transfer.
Accessed October 5, 2021.
[4] Evans MI, Andriole S, Britt DW. Fetal Reduction: 25 Years’
Experience. Fetal Diagn Ther 2014;35:69–82.
[5] Stone J, Eddleman K, Lynch L, et al. A single center experience with1000 consecutive cases of multifetal pregnancy
reduction. Am J Obstet Gynecol 2002;187:1163–1167.
[6] Bracewell-Milnes T, Saso S, Jones B, et al. A systematic
review exploring the patient decision-making factors and attitudes towards pre-implantation genetic testing for aneuploidy andgender selection. Acta Obstet Gynecol Scand 2021;100:17–29.
[7] Capelouto SM, Archer SR, Morris JR, et al. Sex selection for
non-medical indications: a survey of current pre-implantation
genetic screening practices among U.S. ART clinics.
J Assist Reprod Genet 2018;35:409–416.
[8] Salame AA, Nassif J, Ghazeeri GS, et al. The effect of religious background on the attitude towards sex selection.
Eur J Obst Gyn Reprod Biol X 2019;3:100052.
[9] King L, Michael M. No country for young girls: market
reforms, gender roles and pre-natal sex selection in postSoviet Ukraine. J Polit Econ Research Institute. Working
paper series no. 425. Oct 2016. Available at: https://peri.
umass.edu/publication/item/927-no-country-for-younggirls-market-reforms-gender-roles-and-pre-natal-sex-selec
tion-in-post-soviet-ukraine. Accessed October 5, 2021.
[10] den Boer A, Hudson V. Patrilineality, son preference, andsex selection in South Korea and Vietnam. Population andDevelopment Review. 2017;43(1):119–147.

Summary
While there have been some changes regarding access to SFR in a
few countries, no new trends have been reported with respect to its
application. SFR is permitted in 61% of the responding countries,
which is the same proportion that reported this ﬁnding in 2019. SFR
138

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Healthalternative approach, is an analytical strategy that currently employs
microarrays featuring up to 300,000 single nucleotide polymorphisms (SNPs) that are in genetic regions scattered throughout the
genome. The microarray signals are analysed using bioinformatics
tools, providing linkage analysis for virtually every region of interestand theoretically avoiding the need for a patient-speciﬁc custom
setup. However, karyomapping is not feasible in cases with insufﬁciently informative polymorphic markers in the region of interest(e.g., telomeric genes), when an affected reference sample is unavailable, or for the detection of de novo mutations[3].
PGT-A: Aneuploidy is extremely common in human embryos andis one of the main causes of unsuccessful in vitro fertilization (IVF)
cycles. PGT-A is intended to improve implantation and per transfer
pregnancy rates by identifying and selecting embryos without chromosomal abnormalities. Initially performed with FISH, this process
was labor intensive, prone to technical errors, and did not result in afull karyotype, as only seven chromosomes (at most) could be efﬁciently evaluated with this procedure. Moreover, in many cases, twoblastomeres were removed from cleavage stage embryos to compensate for the high no-result rate. The negative consequences
imposed by these limitations were demonstrated by Mastenbroek
et al[4] in their 2007 randomised controlled trial of PGT practice in the
Netherlands. The results of this study revealed that embryo chromosomal testing provided no beneﬁt to IVF outcome.
Two main technical developments that contributed to theimprovement and expansion of PGT practice include (a) the
implementation and standardization of an effective and generally
safe TE biopsy approach capable of sampling 2 – 10 cells at theblastocyst stage[5] and (b) the development of comprehensive testing
platforms for the analysis of all 24 chromosomes in single-cellsamples. These platforms included array Comparative Genomic
Hybridization (aCGH), SNP arrays, and various qPCR methodologies. Because these approaches did not rely on the direct visualization of the analysed cell (as required for FISH) but instead on asoftware-based elaboration of ﬂuorescence signal generated byampliﬁed DNA, they could be employed in multicellular biopsies.
While the transition to genome-wide analysis and NGS did not
result in a signiﬁcant change in diagnostic capabilities, the capacity
to evaluate multiple samples in a single experiment using DNA
barcoding technology has resulted in a signiﬁcant cost reduction.

[11]

Bowman‐Smart H, Savulescu J, Gyngell C, et al. Sex
selection and non‐invasive prenatal testing: a review ofcurrent practices, evidence, and ethical issues. Prenat Diag
2020;40(4):398–407.
[12] Shaia K, Truong T, Pieper C, et al. Pre-implantation genetic
testing alters the sex ratio: an analysis of 91,805 embryotransfer cycles. J Assist Reprod Gen 2020;37(5):1117–1122.
[13] Kippen R, Gray E, Evans A. High and growing disapprovalof sex-selection technology in Australia. Reprod Health
2018;15(1):134.

CHAPTER 13: PREIMPLANTATION GENETIC TESTING
Introduction
The goal of preimplantation genetic testing (PGT) of embryos is toprevent the transmission of pathologic genetic conditions, improveoutcomes, and hasten the time to pregnancy when a healthy euploidembryo has been selected. PGT has been employed clinically since the1990s, initially via the use of ﬂuorescent in situ hybridization (FISH)
techniques applied to individual cells in biopsy specimens from eightcell embryos. Most of the tests that were once performed with FISH
(targeting only 5 – 10 chromosomes) are now carried out via comprehensive chromosome screening (CCS) of the full 24 chromosomes.
The ﬁrst applications of CCS included chromosomal microarray
analysis (CMA) and quantitative polymerase chain reaction (qPCR).
More recently, next generation sequencing (NGS) has replaced mostof these earlier techniques due to the lower costs associated withparallel testing. As a result of these technical improvements, a widearray of genetic features can now be tested which has ultimately
improved the outlook of ART. These strategies include PGT for
aneuploidy (PGT-A), monogenic conditions (PGT-M), and structural
chromosomal rearrangements (PGT-SR). In addition, PGT can now
be employed for HLA matching and to determine an embryo’s risk fordeveloping disorders associated with polygenic traits (e.g., diabetes
and cardiovascular diseases) and late onset pathologies such as cancer.
Originally performed at the cleavage stage of embryonic development,
current guidance recommends that embryo biopsies for all forms of
PGT be performed on trophectoderm (TE) cells at the blastocyst stage.
Compared to previously employed methodologies, this approach
results in more cells for analysis (thus providing more DNA and areduced chance of failed ampliﬁcation) as well as a reduced risk ofharming the embryo since a smaller proportion of the embryo cellmass is removed compared to biopsy at the cleavage stage.

Analysis of the Survey
The following questions were posed in the 2021 Surveillancequestionnaire relevant to PGT:
1. Is PGT practiced performed?
2. Is PGT allowed or permitted?
3. Is PGT-M (monogenic disorders) accepted for use to preventor allow the treatment of disease?
4. Are there speciﬁc institutions or centers where PGT is allowed
or permitted?
5. Are these techniques considered experimental or part ofestablished medical practice?
Fifty-six of 73 responders (76.7%) reported that PGT was practiced in their countries. Of these 56 responders, 50 (89.3%) conﬁrmedthat PGT was permitted by national laws. Based on the responses
from these 50 countries, 46 allowed PGT-M (92.0%), of which 22(47.8%) permitted PGT-M in tandem with PGT-A for sex selection.
Of these respondents, 23 (50.0%) noted the existence of regulationsin their countries that governed PGT-M practice, while 20 (43.5%)
reported an absence of such laws or directives, and three (6.5%)

Assessment of the preimplantation embryo
PGT-M: Preimplantation genetic testing for monogenic disorders(PGT-M) was the ﬁrst clinical genetic application employed onhuman embryos[1]. PGT-M applies to cases in which a couple is
known to be at risk of transmitting an inheritable genetic disorderto their offspring[2]. The assessed risk may be based on anamnesis
and/or an investigation of the family pedigree by a geneticist
because of the previous birth of an affected child. Currently, PGTM entails a biopsy of the embryo and subsequent genetic analysisof the cells collected, often in a specialized laboratory.
From a technical standpoint, the presence of a pathogenic genevariant is typically assessed via targeted ampliﬁcation of a speciﬁcregion that includes the site of a potential mutation. This is followedby mini-sequencing or qPCR-based genotyping of the ampliﬁed
product to identify the genetic variant. Karyomapping, which is an139

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 13. Table 1
Is pre-implantation genetic testing allowed/permitted andpractised/performed?

Yes

No

Unknown
48%

PGT-Aneuploidy

PGT-M
Country
Albania
Argentina
Australia
Austria
Belarus
Bolivia
BrazilBulgaria
Cambodia
CanadaChile
China
Colombia
Czech Republic
Denmark
Ecuador
Egypt
FranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong(China*)Hungary
India
Ireland
Italy
Japan
Kazakhstan
Kenya
LatviaLithuania
Malaysia
MexicoMontenegro
MoroccoNew ZealandNigeria
Panamá
Paraguay
Peru
Philippines
RussiaSouth Africa
South Korea
Spain
SwedenSwitzerland
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited States
Uruguay
Venezuela
VietnamPGT-APractised/
Performed

AllowedPermitted

Practised/
Performed

AllowedPermitted

Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Not answered
Not answered
Yes
Yes
Yes
Not answered
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes

Not answered
Not answered
Yes
No
Yes
Not answered
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not answered
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes

Yes
Yes
Yes
Yes
Yes
Yes
Not answered
Yes
Yes
Yes
Yes
Yes
Not answered
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
No
Not answered
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not answered
Yes
Yes
Yes
Yes
Yes
Not answered
Yes
Yes
Yes

50%
2%

50%
PGT-Monogenic Disorders

43%
7%

Chapter 13. Chart 1. Are there regulations that govern PGT?

replied “unknown”. Among those countries that responded toquestions focused on the existence of regulations, 21 (91.3%) of 23
reported that these activities were governed by federal or nationallaws, statutes, or ordinances; agency regulations and oversight orprofessional organization standards and guidelines were followed in
the remaining two countries. Professional organization standards,
agency regulations, provincial or regional laws were reported by ﬁve(21.7%), four (17.4%), and three (13.0%) of the respondents,
respectively. Municipal statutes and cultural practices were followedin fewer than 5% of the respondent countries. PGT-M, followed by
PGT-A for sex selection is allowed in 22 of the respondent countries.
Of these, 13 (59.1%) respondents declared that no regulations governing this practice were in place, while nine (40.9%) noted thatprovision of this service was regulated by law; these regulations were
implemented at the federal or national level in 77.8% of the
respondent countries (Table 1, Chart 1).
Regarding the use of PGT-M, 89% of the respondents reported
that PGT-M was acceptable when used to prevent the transmission of the disease to the embryo. Fifty-nine percent of respondents supported the use of PGT-M to assist with the generation ofa child intended to provide material help to a diseased sibling,
while 52% responded favorably regarding its use in the case of an
immunologically donor-matched diseased child. The use of PGTM for the generation of a diseased embryo to be used for research
was considered acceptable by only 14.6% of respondents; 85.4%
deemed the procedure to be unacceptable.
PGT-A for aneuploidy is allowed in 43 countries (86%); in 13 ofthese countries (30.2%), PGT-A can be employed for sex selection. Of
the 43 respondents, 20 (46.5%) declared that PGT-A practice wasregulated, while 21 (49.8%) and two (4.7%) respondents noted that
there were no regulations or answered “unknown”, respectively.
Where regulation existed, 17 out 20 countries (85%) reported that
this practice was regulated by federal/national laws, while professional organization standards, agency regulations, provincial andregional laws, or municipal laws were reported by ﬁve (25%), three,
two, and one country, respectively. Among the 13 countries reportingthat PGT-A was allowed for sex selection, ﬁve (38.5%) noted theexistence of speciﬁc regulations while eight (61.5%) stated there nosuch regulations existed. Of the ﬁve positive responses, four provided
details about oversight; two of these respondents noted the existenceof federal or national laws, one reported the existence of provincial orregional laws, and one described agency regulations.
PGT-P for polygenic disorders was allowed in 32 (64%) of thecountries that responded to the survey.
Overall, PGT seems to be equally accessible to patients undergoing treatment at sole practitioner clinics, small and large private
clinics, and private hospitals, as well as university-based and public

Yes
Yes
Yes
Not answered
Yes
Yes
Not answered
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Not answered
Yes
No
Not answered
Yes

140

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 13. Table 2
Are these techniques considered experimental or part of established medical practice?
Country
Albania
Argentina
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Cote d’Ivoire
Czech Republic
Democratic Republicof the Congo
Denmark
Ecuador
Egypt
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
India
Ireland
Italy
Japan
Kazakhstan
Kenya
LatviaLithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandNigeria
Panamá
Paraguay
Philippines
Romania
RussiaSerbiaSouth Africa
South Korea
Spain
SwedenSwitzerland
Tanzania

PGT-M

PGT-A

PGT-M with PGT-A

PGT-A for sex selection

PGT-P

Established medical practice
Established medical practice
Established medical practice
Established medical practiceUnknown
Established medical practice
Not addressed
Not addressed
Established medical practice
Established medical practice
Not addressed
Established medical practice
Not addressed
Established medical practice
Established medical practice
Established medical practice
Established medical practiceUnknown
Established medical practice
Not addressed

Established medical practice
Established medical practice
Established medical practice
Established medical practiceUnknown
Established medical practice
Not addressed
Established medical practice
Established medical practice
Established medical practice
Not addressed
Established medical practice
Not addressed
Established medical practice
Established medical practice
Established medical practice
Established medical practiceUnknown
Established medical practice
Not addressed

Established medical practice
Established medical practice
Established medical practice
Established medical practiceUnknown
Established medical practice
Not addressed
Not addressed
Established medical practice
Established medical practice
Not addressed
Established medical practice
Not addressed
Established medical practice
Established medical practice
Established medical practice
Established medical practiceUnknown
Established medical practice
Not addressed

Not addressed
Unknown
Not addressed
Not addressed
Unknown
Not addressed
Not addressed
Not addressed
Established medical practice
Not addressed
Not addressed
Established medical practice
Not addressed
Not addressed
Not addressed
Not addressed
Established medical practiceUnknown
Established medical practice
Not addressed

Not addressed
Not addressed
Established medical practice
Established medical practiceUnknown
Experimental
Not addressed
Not addressed
Established medical practice
Established medical practice
Not addressed
Established medical practice
Not addressed
Unknown
Not addressed
Not addressed
Established medical practiceUnknown
Unknown
Not addressed

Established medical practice
Established medical practice
Established medical practice
Not addressed
Established medical practice
Established medical practice
Established medical practice
Established medical practice
Established medical practice
Established medical practice
Established medical practiceExperimental
Not addressed
Established medical practice
Established medical practice
Established medical practice
Established medical practice
Established medical practice
Established medical practice
Established medical practice
Not addressed
Established medical practice
Established medical practice

Established medical practice
Established medical practice
Established medical practice
Not addressed
Experimental
Established medical practice
Established medical practice
Established medical practice
Established medical practice
Established medical practice
Established medical practiceExperimental
Not addressed
Established medical practice
Established medical practice
Established medical practice
Established medical practice
Established medical practice
Established medical practice

Established medical practice
Established medical practice
Established medical practice
Not addressed
Experimental
Established medical practiceUnknown
Established medical practice
Established medical practice
Established medical practice
Established medical practiceExperimental
Unknown
Established medical practice
Established medical practiceUnknown
Established medical practice
Established medical practice
Established medical practice

Established medical practice
Established medical practice
Established medical practice
Not addressed
Experimental
Not addressed
Unknown
Established medical practice
Not addressed
Established medical practice
Established medical practiceExperimental
Unknown
Not addressed
Not addressed
Unknown
Not addressed
Established medical practice
Not addressed

Unknown
Established medical practice
Established medical practice
Not addressed
Experimental
Not addressed
Established medical practice
Not addressed
Experimental
Established medical practice

Not addressed
Established medical practice
Established medical practiceExperimental
Established medical practiceUnknown
Not addressed
Established medical practice
Established medical practice
Established medical practice
Established medical practice
Established medical practice
Not addressed
Established medical practiceExperimental
Established medical practice
Established medical practice
Established medical practiceExperimental
Established medical practice
Not addressed

Not addressed
Established medical practice
Established medical practice

Not addressed
Established medical practice
Not addressed

Established medical practiceUnknown
Not addressed
Established medical practice
Established medical practice
Established medical practice
Established medical practice

Not addressed
Unknown
Not addressed
Not addressed
Established medical practice
Established medical practice
Established medical practice

Not addressed
Established medical practice
Established medical practiceExperimental
Established medical practiceUnknown
Established medical practice
Not addressed
Established medical practice
Not addressed

Not addressed
Unknown
Not addressed
Established medical practice

Not addressed
Not addressed
Not addressed
Not addressed

Not addressed
Unknown
Not addressed
Not addressed

Established medical practiceExperimental
Established medical practice
Not addressed

Not addressed
Not addressed
Not addressed
Not addressed

Not addressed
Experimental
Not addressed
Not addressed

Established medical practiceUnknown
Established medical practice
Established medical practice
Established medical practice
Established medical practice
Established medical practice
Not addressed
Established medical practice
Not addressed
Established medical practice
Established medical practice
Established medical practice
Established medical practice
Established medical practice
Not addressed

141

Experimental
Not addressed
Not addressed
Not addressed
Unknown
Established medical practice
Established medical practice
Established medical practiceAbstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 13. Table 2(Continued)
Country
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited States
Uruguay
Venezuela
VietnamZimbabwe

PGT-M

PGT-A

PGT-M with PGT-A

PGT-A for sex selection

PGT-P

Established medical practice
Established medical practice
Established medical practice
Not addressed
Established medical practice
Established medical practice
Established medical practice
Established medical practiceUnknown

Established medical practice
Established medical practice
Established medical practice
Not addressed
Established medical practice
Established medical practice
Established medical practice
Established medical practiceUnknown

Not addressed
Established medical practice
Established medical practice
Not addressed
Established medical practice
Established medical practice
Established medical practiceUnknown
Unknown

Not addressed
Not addressed
Not addressed
Not addressed
Established medical practice
Not addressed
Established medical practiceUnknown
Unknown

Established medical practice
Not addressed
Not addressed
Not addressed
Established medical practice
Established medical practiceExperimental
Established medical practiceUnknown

hospital units. Half of the respondents stated that PGT-M, PGT-A,
and PGT-A for sex selection were performed by ∼50% of providers
in their countries, while ∼45% offered PGT-M and PGT-A only.
Fewer than 5% of the providers performed PGT-M only without
chromosome testing. Ninety-eight percent of the respondents
reported that they considered PGT-M to be an established medical
procedure, compared to 93.2%, 90.7%, and 89.5% who considered PGT-M in tandem with PGT-A for sex selection, PGT-A
alone, and/or PGT-A for sex selection in a similar light. By contrast,
the outlook on PGT-P was signiﬁcantly different. The results of thesurvey revealed that 24.1% of the respondents consider PGT for
polygenic traits to be an experimental procedure (Table 2, Chart 2).

a prenatal diagnostic approach such as amniocentesis or chorionicvillous sampling. However, PGT-M is not equally available
in all countries and there are signiﬁcant differences in accessto the service.
As our understanding of the genetic basis of diseases expands,
PGT-M will likely be used to detect predisposition to a wide range ofphenotypes including those that confer late-onset, highly debilitating, degenerative, or even sub-pathological entities that might
become expressed under fully penetrant conditions[6,7]. For example, in recent years, PGT-M has been increasingly employed to deselect embryos with speciﬁc mutations in BRCA1/2 genes which
increase the risk of breast and ovarian cancer in adult women[8].
Over the last decade, the application of PGT-A has continued
to expand worldwide. In the USA, 20% of IVF cycles incorporate
PGT-A. This is largely due to the application of robust technologies available at a more reasonable price due to parallel processing (i.e., NGS). However, there is ongoing debate regarding
the role of PGT-A in improving reproductive outcomes in IVF
patients.

Discussion
PGT-M for inheritable disorders is carried out with extremely highdiagnostic accuracy and procedural safety. Its ethical acceptability
is further supported by the fact that it can be used to circumvent
affected pregnancies, thus reducing the need for therapeuticterminations after a signiﬁcant mutation has been identiﬁed byExperimental

Established medical practice7%
PGT-Aneuploidy Screening
91%

5%
PGT- Mongenic Disease with Aneuploidy Screening
93%

1%
PGT-Monogenic Disorders
98%

11%
PGT-Polygenic Disorders
34%

Chapter 13. Chart 2. Are PGT techniques considered experimental or established medical practice.

142

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health[2] Capalbo A, Fabiani M, Caroselli S, et al. Clinical validity andutility of preconception expanded carrier screening for the
management of reproductive genetic risk in IVF and general
population. Human Reprod 2021;36(7):2050–2061.
[3] Handyside AH, Harton GL, Mariani B, et al. Karyomapping:a universal method for genome wide analysis of genetic disease based on mapping crossovers between parental haplotypes. J Med Gen 2010;47:651–658.
[4] Mastenbroek S, Twisk M, van Echten-Arends J, et al. In vitro
fertilization with preimplantation genetic screening. N Engl J
Med 2007;357:9–17.
[5] Scott RT, Upham KM, Forman EJ, et al. Cleavage-stage
biopsy signiﬁcantly impairs human embryonic implantation
potential while blastocyst biopsy does not: a randomized andpaired clinical trial. Fertil Steril 2013;100:624–630.
[6] Torkamani A, Wineinger NE, Topol EJ. The personal andclinical utility of polygenic risk scores. Nature Revs Genetics
2018;19:581–590.
[7] Treff N, Zimmerman R, Li J, et al. Validation of simultaneous preimplantation genetic testing (PGT) for aneuploidy,
monogenic, and polygenic disorders. Eur J Med Genet 2019;
62(8):103647.
[8] Narod SA, Foulkes WD. BRCA1 and BRCA2: 1994 andbeyond. Nature Revs Cancer 2004;4:665–676.
[9] Scott RT, Ferry K, Su J, et al. Comprehensive chromosome
screening is highly predictive of the reproductive potential of
human embryos: a prospective, blinded, nonselection study.
Fertil Steril 2012;97:870–875.
[10] Yang Z, Liu J, Collins GS, et al. Selection of single blastocysts
for fresh transfer via standard morphology assessment alone
and with array CGH for good prognosis IVF patients: resultsfrom a randomized pilot study. Mol Cytogenetics 2012;5:24.
[11] Forman EJ, Hong KH, Ferry KM, et al. In vitro fertilization
with single euploid blastocyst transfer: a randomized controlled trial. Fertil Steril 2013;100:100–107.
[12] Dahdouh EM, Balayla J, Garcia-Velasco JA. Comprehensive
chromosome screening improves embryo selection: a metaanalysis. Fertil Steril 2015;104:1503–1512.
[13] Ubaldi FM, Capalbo A, Colamaria S, et al. Reduction ofmultiple pregnancies in the advanced maternal age population after implementation of an elective single embryotransfer policy coupled with enhanced embryo selection:
pre-and post-intervention study. Human Reprod 2015;30:
2097–2106.
[14] Sacchi L, Albani E, Cesana A, et al. Preimplantation genetic
testing for aneuploidy improves clinical, gestational, andneonatal outcomes in advanced maternal age patients
without compromising cumulative live-birth rate. J Assist
Reprod Genetics 2019;36:2493–2504.
[15] Haviland MJ, Murphy LA, Modest AM, et al. Comparisonof pregnancy outcomes following preimplantation genetic
testing for aneuploidy using a matched propensity score
design. Human Reprod 2020;35:2356–2364.
[16] Shamonki MI, Jin H, Haimowitz Z, et al. Proof of concept:
preimplantation genetic screening without embryo biopsy
through analysis of cell-free DNA in spent embryo culture
media. Fertil Steril 2016;106:1312–1318.
[17] Capalbo A, Romanelli V, Patassini C, et al. Diagnostic efﬁcacy of blastocoel ﬂuid and spent media as sources of DNA

Although they are few in number and feature small sample sizes
only, several randomised clinical trials (RCTs) focused on theapplication of PGT-A appear to reach similar conclusions withrespect to sustained implantation and decreased miscarriage rates[9–11]. A meta-analysis of relevant publications suggests that improved
clinical outcomes are observed in patients with normal ovarian
reserve[12]. Retrospective cohort studies have revealed that
improved clinical outcomes are also observed in patients where theincidence of oocyte aneuploidy is higher (i.e., advanced maternalage). In these populations, PGT-A-mediated de-selection of aneuploid embryos results in the combined beneﬁts of increasing overall
embryo implantation rates and reducing the early pregnancy loss
compared to matched controls[13–15]. Conclusive proof awaits large
and properly designed RCTs that are sufﬁciently powered toinvestigate live birth rate per initiated cycle as the primary outcome.
An additional impetus with respect to the application of PGT-A
may come from the development of non-invasive approaches (i.e.,
niPGT). These approaches have been designed to avoid interventions
that have a direct impact on the embryo and to facilitate the implementation of PGT-A in laboratories with limited experience. Current
PGT-A protocols that utilise spent culture media have led to improved
rates of DNA ampliﬁcation compared to those obtained using older
methodologies[16]. However, the wide discrepancies between results
obtained by the different groups suggest that a more robust, validated
approach will be needed[17–19]. Results from current technologies
using spent culture media remain suboptimal results compared tothose obtained from a TE biopsy, which remains the gold standard
for PGT-A assessment. Further improvements in both sample collection and pre-analytical processing may lead to higher diagnostic
yields[20]. The correlation between diagnostic results generated using
niPGT and clinical outcomes as well as evidence of efﬁcacy and costbeneﬁt will require further assessment before this approach can beuniversally applied for PGT-A. An effective and non-invasive means
to perform PGT will undoubtedly represent a milestone achievement
for embryo selection in IVF.
Summary
Surveillance 2022 conﬁrmed that the international reproductive
medical community maintains a strong commitment to PGT. BothPGT-M, and, at a slightly lower rate, PGT-A are recognized as
established medical interventions offered by all types of IVF centres,from sole practitioner clinics to large public hospitals. This isimportant information, given that most of the genetic analysis iscurrently performed by specialized external service providers.
Compared to Surveillance 2019, PGT applications have expanded
to include polygenic traits and factors that may be predisposing tolate-onset pathologies. Although still considered experimental bynearly a quarter of the respondents, the availability of these applications is most likely to increase in the coming years. This scenario
will ultimately require more thorough implementation of regulations at national, local, and agency levels.
Non-invasive approaches to PGT remain a novelty in the ﬁeld.
However, niPGT may soon support further expansion of PGT if it
ultimately generates robust diagnostic output with reasonable
cost-efﬁcacy.
References[1] Handyside AH, Kontogianni EH, Hardy K, et al. Pregnancies
from biopsied human preimplantation embryos sexed by
Y-speciﬁc DNA ampliﬁcation. Nature 1990;344:768–770.
143

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive HealthIf surrogacy involves cross-border parties, laws pertaining tosurrogacy in the location in which this will take place and those in
the domicile of the intended parent(s) both require speciﬁc consideration. A thorough medical assessment of the surrogate
mother and counselling of all parties involved in the arrangement
at the outset is of the utmost importance.
The principal reasons that individuals or couples enter surrogacy arrangements include:
1. Medical reasons affecting a female parent:• The woman is without a functioning uterus but has one orboth ovaries intact. This may include women with congenital absence of the uterus and women who required early
hysterectomy for carcinoma or other reasons.
• The woman has experienced repeated miscarriages orotherwise has remote potential for carrying a baby toterm. This may include women who have undergone
repeated failed cycles of IVF.
• The woman has a medical condition such that pregnancy
may be life-threatening, but whose long-term healthprospects are otherwise good.
2. Non-medical or social reasons, including same-sex couples, or
ongoing single status. Surrogacy in these situations is permitted in a limited number of jurisdictions.

for preimplantation genetic testing in standard clinical conditions. Fertil Steril 2018;110(5):870–879.
[18] Vera-Rodriguez M, Diez-Juan A, Jimenez-Almazan J, et al.
Origin and composition of cell-free DNA in spent medium
from human embryo culture during preimplantation development. Human Reprod 2018;33(4):745–756.
[19] Rubio C, Rienzi L, Navarro-Sánchez L, et al. Embryonic cellfree DNA versus trophectoderm biopsy for aneuploidy
testing: concordance rate and clinical implications. Fertil
Steril 2019;112:510–519.
[20] Rubio C, Navarro-Sánchez L, García-Pascual CM, et al.
Multicenter prospective study of concordance between
embryonic cell-free DNA and trophectoderm biopsies from1301 human blastocysts. Am J Obstet Gynecol 2020;223:
751.e1-751.e13.

CHAPTER 14: SURROGACY
Introduction
Surrogacy is an arrangement in which a woman (the surrogate
mother) becomes pregnant, carries, and gives birth to a child orchildren with the intention of giving him or her to another person
or couple (the intended parent or parents).
The 2021 IFFS Surveillance questionnaire considered both“gestational” and “traditional” surrogacy. Gestational surrogacy,
which is sometimes referred to as “full” or “IVF” surrogacy, refers
to a situation in which gametes from both intended parents (or fromone of the intended parents and a donor egg or sperm) are used tocreate an embryo, which is then implanted into the uterus of thesurrogate mother. Alternatively, a donated embryo created fromgametes that are not related to either the intended parent(s) or surrogate mother can be used. The surrogate mother is geneticallyunrelated to the offspring produced by this latter arrangement,
although she carries the child to term and gives birth to the child.
Traditional surrogacy, sometimes termed “natural” or “partial”
surrogacy, refers to a situation in which the surrogate mother is inseminated with the sperm of a (male) intended parent; thus, the surrogate’s own oocytes are fertilized in vivo. This may involve some form of
reproductive assistance, most often in the form of artiﬁcial or intrauterine insemination (IUI) performed at a fertility clinic. The procedure
may otherwise be performed at home. The resulting child or children
are genetically related to the surrogate mother, as her oocytes are used.
Both forms of surrogacy can be commercial or altruistic. With
commercial surrogacy, the woman is compensated for her medical costs and providing gestational services. This is often limited
to payment for time expended during the treatment and related
expenses. Women offering altruistic surrogacy are typicallycompensated for their medical expenses and in some cases forincome lost while providing the service, although no additional
remuneration is provided.
The laws governing surrogacy are complex and vary among
jurisdictions. Many jurisdictions prohibit commercial surrogacy
or only permit these arrangements under speciﬁc limited circumstances. Several steps must be undertaken for individuals
pursuing surrogacy. Couples considering any type of surrogacy
must initially determine the legal status of this arrangement intheir domicile. Even in countries where surrogacy is lawfully
permitted, full and informed legal advice from someone familiar
with the laws of the country where the treatment will be provided
is essential.

Analysis of the Survey
In the 2021 Surveillance questionnaire, the following questions
regarding surrogacy were posed:
1. Is third party reproduction practised/performed in your country?
2. Is third party reproduction allowed/permitted in your country?
3. Are there regulations that govern third party reproduction inyour country?
4. How is gestational surrogacy regulated?
5. Are gestational surrogates compensated?
6. Are traditional surrogates compensated?
7. How are agencies that recruit and match egg donors andrecipients as well as surrogates and gestational carriers regulated?
8. How often is third party reproduction performed in programs within your country?
9. If compensation (beyond reimbursement) is allowed, is there aminimum or a maximum amount allowed for gestationalsurrogacy: i.e., the surrogate is implanted with an embryo(s)created using the gametes of both prospective parents; or donatedova and commissioning male's sperm; or a donated embryo?
10. Are the qualiﬁcations to be a gestational surrogate based
upon medical, mental health and/or any lifestyle (age andoccupational) criteria?
11. Are the qualiﬁcations to be a traditional surrogate based
upon medical, mental health and/or any lifestyle (age andoccupational) criteria?
Of the 90 countries that participated in the 2021 Surveillance
survey, 79% (71) responded to at least one of the questions pertaining to surrogacy. In 2018, 82% (73) of the 89 participating
countries submitted responses to at least one question pertaining tosurrogacy. In 2016, 95% (62) of the 65 participating countries
submitted relevant data. The variable response rates may reﬂect, atleast in part, the different respondents’ knowledge of surrogacy
regulations and/or practices in their countries of residence.
Of the countries that responded to the question “is surrogacy
permitted or practiced in your country”, 28%, (8) of 29 countries
that responded reported that gestational surrogacy was permitted
144

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Healthand/or practised in speciﬁc circumstances, including those in which
the surrogate was implanted with an embryo or embryos createdfrom the gametes of both prospective parents (i.e., the commissioning couple), from donated ova and commissioning male’s
sperm, or from a donated embryo. Thirty-eight percent (11) of thesecountries reported that both gestational surrogacy and traditionalsurrogacy were permitted and/or practised in speciﬁc circumstances,including those in which the surrogate mother’s ova were fertilizedwith the prospective male parent's sperm (Table 1).
Eighty-three percent, (24) of 29 countries noted the existenceof regulations governing IVF surrogacy in their country (Table 2).
Seventy-nine percent (23) of these countries had regulations
speciﬁcally pertaining to gestational surrogacy. Thirty-four percent (10 countries) reported the existence of regulations governing traditional surrogacy. Four countries (Ghana, South Africa,
Canada, and Spain) reported the existence of regulating agencies
that recruit and match egg donors and recipients as well as surrogates and gestational carriers (Tables 2, 3).
The type of regulation pertaining to gestational surrogacy was
speciﬁed in 23 countries, and demonstrated a variety of different
approaches:• Ten countries reported the existence of only federal/nationallaws/statutes/ordinances;• Two countries reported the existence of a mix of federal/nationallaws/statutes/ordinances, and agency regulations/oversight;• Three countries reported having a mix of federal/nationallaws/statutes/ordinances and professional organization standards/guidelines;• One country reported the existence of a mix of federal/nationallaws/statutes/ordinances, state/provincial/regional laws/statutes/
ordinances, and professional organization standards/guidelines;• One country reported the existence of state laws only;• One country reported a mix of state/provincial/regional laws/
statutes/ordinances and agency regulations/oversight;• One country reported a mix of state/provincial/regional laws/
statutes/ordinances, agency regulations/oversight, and professional organization standards/guidelines;• One country reported a mix of agency regulations/oversightand professional organization standards/guidelines;• Two countries reported the existence of professional standards/guidelines only;• One respondent replied “unknown”.
Four countries that reported the existence of regulations governing the practice of traditional surrogacy noted the existence of
only federal or national laws, statutes, or ordinances. Two countries
reported that this was governed by federal or national laws, statutes
or ordinances, and professional organization standards or guidelines. One country reported the existence of federal or national laws,
statutes or ordinances, state, provincial or regional laws, statutes orordinances, or agency regulations or oversight. One country
reported the existence of federal or national laws, statutes or ordinances, state, provincial or regional laws, statutes or ordinances, or
agency regulations or oversight, in addition to professional organization standards or guidelines (Table 3).
Sixty percent of respondents representing 15 of 25 countries
noted that gestational surrogates were reimbursed for time andexpenses. Twenty percent (ﬁve) reported that gestational surrogates received compensation that exceeded coverage for time andexpenses. Three respondents reported that compensation was not
permitted, and two respondents replied “unknown”. In 2018, 48
countries responded to the survey. At that time, 29% (14) of the

Chapter 14. Table 1
Is surrogacy allowed/permitted or practised/performed?
Country
Albania
Argentina
Australia
Belarus
Benin
Bolivia
BrazilCanadaColombia
Czech Republic
EcuadorGeorgia
Ghana
GreeceHong Kong (China*)
India
IsraelKenya
Malaysia
MexicoNetherlands
New ZealandNigeria
RussiaSouth Africa
South Korea
Tanzania
UgandaUnited Kingdom
United States

Gestational
Surrogacy
Allowed/permitted
Practised/Performed
Practised/Performed
Allowed/permitted
Practised/Performed
Allowed/permitted
Practised/Performed
Allowed/permitted
Allowed/permitted
Practised/Performed
Allowed/permitted
Practised/Performed
Allowed/permitted
Practised/Performed
Practised/Performed
Allowed/permitted
Practised/Performed
Allowed/permitted
Practised/Performed
Allowed/permitted
Practised/Performed
Allowed/permitted
Practised/Performed
Allowed/permitted
Practised/Performed
Allowed/permitted
Allowed/permitted
Practised/Performed
Allowed/permitted
Practised/Performed
Allowed/permitted
Practised/Performed
Practised/Performed
Practised/Performed
Allowed/permitted
Practised/Performed
Allowed/permitted
Practised/Performed
Allowed/permitted
Practised/Performed
Allowed/permitted
Practised/Performed
Allowed/permitted
Practised/Performed
Allowed/permitted
Practised/Performed
Allowed/permitted
Practised/Performed
Allowed/permitted
Practised/Performed
Allowed/permitted
Practised/Performed
Allowed/permitted
Practised/Performed

Uruguay
VietnamZimbabwe

145

Allowed/permitted
Practised/Performed
Allowed/permitted
Practised/Performed

Traditional
Surrogacy

Allowed/permitted
Practised/Performed

Allowed/permitted
Practised/Performed
Allowed/permitted
Practised/Performed

Allowed/permitted
Practised/Performed
Practised/Performed
Allowed/permitted
Practised/Performed
Allowed/permitted
Practised/Performed

Allowed/permitted
Practised/Performed
Allowed/permitted
Practised/Performed
Allowed/permitted
Practised/Performed
Allowed/permitted
Practised/Performed
Allowed/permitted
Practised/Performed

Allowed/permitted
Practised/Performed

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Healthpertaining to gestational surrogacy was collected from 33 countries.
Among these responses, four reported that there were no minimum or
maximum amounts for compensation for gestational surrogacy. Fiftyone percent (17) of the respondents answered that compensation was
not addressed, and 27% (9) responded “unknown”. With respect totraditional surrogacy, 30 countries responded to relevant questions in
2018. Of these responses, two indicated there were no minimum or
maximum amounts for compensation, while one responded repliedthat these limits existed. Sixty-three percent (19) of the respondents
answered that compensation was not addressed and 27% (8)responded “unknown”.
Twenty-ﬁve respondents replied to the query, “are the qualiﬁcations to be a gestational surrogate based upon medical,
mental health, and/or any lifestyle (age and occupational) criteria?” Twenty-four respondents replied “yes”, and one
respondent replied “unknown”. When the same question was
posed regarding traditional surrogates, ten replied “yes” andone respondent replied “no”.
In 2021, respondents from 71 countries provided information
pertaining to the frequency of usage of both gestational and traditional surrogacy. Twenty-one percent (15) reported that gestational surrogacy was in frequent use, while 23% (16) reported that
it was used infrequently. Forty-ﬁve percent (32) reported that
gestational surrogacy was not performed, and 11% (8) replied“unknown”. With respect to traditional surrogacy, no respondents
replied that this was performed commonly, while 19% (13) of 69
respondents noted that it was used infrequently. Sixty-four percent(44) reported that traditional surrogacy was never performed and
17% (12) responded “unknown” (Table 4).
In 2018, respondents from 68 countries provided information pertaining to the frequency of use of both gestational andtraditional surrogacy. Twenty-one percent (14) reported that
gestational surrogacy was in frequent use, while 25% (17)reported that it was used only infrequently. Forty percent (27)indicated that it was never performed and 15% (10) replied“unknown”. With respect to traditional surrogacy, three
respondents reported that it was in frequent use, while 26%(18) reported that it was performed only infrequently. Fifty-one
percent (35) reported that it was never performed and 18% (12)responded “unknown”.

Chapter 14. Table 2
Are there regulations that govern gestational carriers in yourcountry?

Country
Australia
Georgia
GreeceIsraelJapan
BelarusBenin
MexicoNew ZealandTunisia
Vietnam
Ghana
South Africa
BrazilAustria
CanadaColombia
Hong Kong(China*)Netherlands
RussiaSpain
UnitedKingdom
Uruguay
United States

Gestationalsurrogacy

Traditionalsurrogacy

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Yes
Yes
Yes
Yes

Yes
Yes
Yes
Yes

Yes
Yes
Yes
Yes

Yes

Yes
Yes

Agencies which recruitand match surrogates andgestational carriers

Yes
Yes

Yes

Yes

respondents noted that gestational surrogates can be reimbursed
for time and expenses only, while another 29% (14) reported thatno compensation was permitted. Nineteen percent (nine)
respondents reported that compensation beyond reimbursement
was permitted in their countries, while 23% (eleven) replied“unknown”.
Sixty-seven percent (eight) of 12 respondents reported that traditional surrogates were reimbursed for time and expenses, while
one respondent answered that traditional surrogates were compensated beyond reimbursement alone. Two respondents repliedthat compensation was not allowed, and one answered“unknown”. These results can be compared to the 44 responses
received in 2018. At that time, 27% (12) of the respondents notedthat reimbursement for time and expenses was permitted, while four
reported that compensation beyond reimbursement was permitted.
Thirty-four percent (15) indicated that no compensation wasallowed and 30% (13) answered “unknown”.
Only a limited amount of information was submitted that addressed speciﬁc limits on and ranges of compensation for surrogacy services. Regarding gestational surrogacy, respondents from Russia, theUnited States, and India reported that there were no minimum or
maximum levels of compensation. The respondent from Belarus
reported a minimum payment of $10,000 (USD) and a maximum
payment of $25,000 (USD) for this service. The respondent from
Greece reported a maximum level of compensation at $10,000 (USD).
With respect to traditional surrogacy, only the United States reported
there were no minimum or maximum amounts. In 2018, data

Discussion
Surrogacy continues to be one of the most contentious topics in
ART practice. The demand for this service appears to be increasing
despite rising ethical concerns regarding the potential for exploitation of the participants[1]. Although data collected for
Surveillance 2022 regarding surrogacy was more limited than inprevious years, it still appears that most countries have either
established overt prohibitions preventing the use of traditional or
gestational surrogacy or these practices are in infrequent use.
A recent review noted that surrogacy is not permitted in manyof the more economically advanced countries worldwide. Only
altruistic surrogacy is permitted in Australia, Belgium, Canada,
the Czech Republic, Denmark, the Netherlands, and the United
Kingdom[2].
Some countries offer both forms of surrogacy to potential
parent(s) who reside in countries that prohibit or do not offer
surrogacy services or provide them at a prohibitively high cost. In
most countries in which surrogacy is practised, the “birthmother” is considered the legal mother of the child, but legislation
146

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 14. Table 3
If surrogacy is regulated, how is it done?

Gestational
SurrogacyCountry

Federal/National

State/Provincial/
Regional

Australia

Yes

Yes

Austria
Belarus
Benin
BrazilCanadaColombia
Georgia
Ghana
GreeceHong Kong(China*)IsraelJapan
MexicoNetherlands
New ZealandRussiaSouth Africa
Spain
Tunisia
UnitedKingdom
United States
Vietnam
Traditional
Surrogacy

Municipal

Agency Regulations
Oversight

Professional
Organization

Religious
DecreeUnknown

Yes
Yes

Yes
Yes
Yes

Yes

Yes
Yes
Yes
Yes
Yes

Yes
Yes
Yes

Yes
Yes

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Yes
Yes
Yes

Yes

Yes

Yes

Yes

Austria
CanadaHong Kong(China*)Netherlands
RussiaSpain
UnitedKingdom
United States
Uruguay

CulturalPractice

Yes
Yes
Yes

Yes

Yes

Yes
Yes
Yes
Yes
Yes
Yes

Yes
Yes

Yes

Yes

exists that enables the intended parent(s) to become legal parents
following the birth of the child, provided that minimal ethical andlegal requirements are met. Ethical and clinical guidelines havebeen presented in some countries as a mechanism for establishingminimum standards of practice, but they may be differentiallyapplied.

Yes

time and expenses. Compensation beyond simple reimbursement for time and expenses is permitted in very few countries.
Many countries continue to prohibit any form of compensation, or compensation beyond reimbursement for expenses,
citing concerns about commodiﬁcation and exploitation ofchildren, vulnerable women, and reproductive capabilities.
Surrogacy continues to be the subject of intense international
debate regarding the indications for its application and thepotential for exploiting participants. The issue of children
seeking additional information or contact with their birthmothers and gamete donors following surrogacy has also beenrecognised; the rights of these individuals continue to bedebated. This conﬂict was intensiﬁed in 2020 and 2021 when
the COVID-19 pandemic precluded intended parents fromtraveling to the domicile of their surrogates at the time that theirbabies were born.

Summary
Although the 2021 dataset was smaller than that collected in2018, evidence continues to suggest that surrogacy is typicallyregulated in areas where it is practised. Most countries rely on avariety of federal and state laws or statutes as well as othermeans of legal enforcement. The ﬁndings collected also conﬁrm
that gestational surrogacy is permitted and practised more
frequently than traditional surrogacy and monetary compensation is either not permitted or limited to reimbursement for147

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 14. Table 4
How often is surrogacy performed in programs within your country?
Country

Gestational surrogacy

Traditional surrogacy

Albania
Argentina
Australia
Austria
Bangladesh
Belarus
Benin
Bolivia
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
Colombia
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
Ecuador
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
India
IrelandIsraelItaly
Japan
Kazakhstan
Kenya
LatviaLithuania
Malaysia
MexicoMontenegro
MoroccoNamibia
Netherlands
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Romania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain
Sudan
SwedenTanzania
Trinidad & Tobago

Unknown
Infrequently Used
Infrequently Used
Never Performed
Never Performed
Infrequently Used
Never Performed
Infrequently Used
Commonly Used
Never Performed
Never Performed
Never Performed
Infrequently Used
Commonly Used
Commonly Used
Commonly Used
Never Performed
Infrequently Used
Unknown
Never Performed
Infrequently Used
Never Performed
Never Performed
Commonly Used
Never Performed
Infrequently Used
Commonly Used
Infrequently Used
Never Performed
Never Performed
Infrequently Used
Never Performed
Commonly Used
Never Performed
Never Performed
Never Performed
Unknown
Unknown
Never Performed
Unknown
Infrequently Used
Never Performed
Never Performed
Unknown
Infrequently Used
Commonly Used
Commonly Used
Never Performed
Unknown
Unknown
Never Performed
Never Performed
Commonly Used
Never Performed
Never Performed
Commonly Used
Infrequently Used
Never Performed
Never Performed
Never Performed
Infrequently Used
Never Performed

Unknown
Unknown
Never Performed
Never Performed
Never Performed
Never Performed

148

Infrequently Used
Never Performed
Never Performed
Never Performed
Never Performed
Infrequently Used
Infrequently Used
Never Performed
Never Performed
Never Performed
Never Performed
Unknown
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Unknown
Never Performed
Infrequently Used
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Unknown
Never Performed
Unknown
Unknown
Never Performed
Unknown
Infrequently Used
Never Performed
Never Performed
Unknown
Infrequently Used
Infrequently Used
Unknown
Never Performed
Unknown
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Never Performed
Unknown
Never Performed
Never Performed
Never Performed
Infrequently Used
Never Performed

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 14. Table 4(Continued)
Country

Gestational surrogacy

Traditional surrogacy

Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

Never Performed
Never Performed
Commonly Used
Commonly Used
Commonly Used
Infrequently Used
Never Performed
Infrequently Used
Commonly Used

Never Performed
Never Performed
Infrequently Used
Infrequently Used
Infrequently Used
Infrequently Used
Never Performed
Never Performed
Infrequently Used

3. Do people travel from your country to seek assisted reproduction (For lower cost, higher quality, availability, egg donation,embryo donation, sperm donation, gestational or traditionalsurrogacy)?
4. Are there regulations regarding the import of reproductive
tissue into your country (ova, sperm, zygotes)?
5. Are there regulations regarding the export of reproductive
tissue into your country (ova, sperm, zygotes)?
Individuals entering the country seeking lower-cost ART services: Respondents from 73 countries provided data pertaining to
CBRC. The analysis included data from respondents that provided
at least one relevant answer to the issues under consideration.
Seventy-one percent (52) of 73 respondents reported that individuals travel to their country to obtain lower-cost ART services(Table 1, Chart 1). Respondents from another 14 countries reported
that people did not travel to their country for lower-cost ART services. Respondents from seven countries answered “unknown”.
Individuals entering the country seeking higher quality ART
services: Seventy-nine percent (56) of 71 respondents reported
that individuals travel to their country seeking higher quality
ART services. By contrast, respondents from nine countries
reported that individuals do not travel to their country for higherquality ART services. Respondents from another six countries
answered “unknown”.
Individuals entering in search of ART services that are unavailable in their home countries: Seventy-two percent (52) of 72
respondents reported that individuals travel to their country seeking
access to ART services that are not available in their home countries.
Twenty-four percent (17) of 72 respondents reported that individuals do not travel to their country seeking access to ART services
that are unavailable at home. Representatives from three countries(South Korea, Mexico, and Burkina Faso) replied “unknown”.
Individuals entering the country seeking access to donatedeggs: Fifty-seven percent (40) of 70 respondents reported that
individuals travel to their country to gain access to donated eggs.
Forty percent (28) of the respondents reported that potential
recipients from other countries do not travel to their country togain access to donated eggs. Two respondents (from Democratic
Republic of the Congo and South Korea) responded “unknown”.
Individuals entering the country seeking access to donatedembryos: Forty-two percent (29) of 69 respondents noted that people
travel to their country seeking access to donated embryos. Fifty-one
percent (35) of the respondents reported that individuals from othercountries do not travel to their country to gain access to donated

References[1] Ellenbogen A, Feldberg D, Lokshin V. Surrogacy – a worldwide demand. Implementation and ethical considerations.
GREM 2021;2(2):66–73.
[2] Piersanti V, Consalvo F, Signore F, et al. Surrogacy and“Procreative Tourism”. What does the future hold fromthe ethical and legal perspectives? Medicina (Kaunas). 2021;
57(1):47.

CHAPTER 15: CROSS-BORDER REPRODUCTIVE
CARE
Introduction
The term cross-border reproductive care (CBRC) describes thepractice in which citizens of one country travel to obtain ART or
related services in another country. CBRC may also refer to cases
in which gametes and embryos are imported or exported acrossnational borders. CBRC is a contentious, relatively unregulated
practice, making data collection particularly challenging. The
2021 Surveillance questionnaire asked if people travelled to orfrom the respondent’s country to engage in ART, and, if so,whether the motive was to seek lower-cost services, higher quality
services, or services not available in their home country. The
survey also requested information about egg, embryo, and sperm
donation, as well as gestational and traditional surrogacy within
the context of CBRC. Further questions focused on the existenceof regulations applied to either inbound and outbound travellers
wishing to engage in CBRC and information regarding theimportation and exportation of gametes and embryos.
Analysis of the Survey
The following questions were posed in the 2021 questionnaire:
1. Do people travel to your country to seek assisted reproduction(For lower cost, higher quality, availability, egg donation,embryo donation, sperm donation, gestational or traditionalsurrogacy)?
2. Are there regulations that govern cross border reproduction in your country (No regulations, Federal/National
Laws/Statutes/Ordinances, State/Provincial/Regional Laws/
Statutes/Ordinances, Municipal Laws/Statutes/Ordinances,
Agency Regulations/Oversight, Professional Organization
Standards/Guidelines, Cultural practices, Religious decrees
or is it unknown)?
149

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 15. Table 1
Do people travel to your country to seek assisted reproduction?
Country
Albania
Argentina
Australia
Austria
Bangladesh
Belarus
Benin
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republicof the Congo
Denmark
Ecuador
Egypt
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
India
Ireland
Italy
Japan
Kazakhstan
Kenya
LatviaLithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
Romania
RussiaSerbiaSlovenia
South Africa
South Korea

Lower cost ART
services

Higher quality ART
services

Unavailable ART
services

Egg
donation

EmbryodonationSpermdonation

Gestationalsurrogacy

Traditionalsurrogacy

Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Unknown
Unknown
Yes
Yes
Yes
No
Unknown

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Unknown
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Unknown

No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Unknown
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes

Yes
Yes
Yes
No
No
Yes

Yes
Yes
Yes
No
No
No

Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
No
Yes
No
Unknown

Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
No
Unknown

Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
No
Yes
No
Unknown

Yes
No
Unknown
No
No
Yes
No
Yes
No
No
No
Unknown
Yes
No
No
Yes

Yes
No
No
No
No
No
No
No
No
No
No
Unknown
Yes
No
No
No

No
Unknown
No

No
Unknown
No

Unknown
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Unknown
Yes
Yes
No
Yes
No
Yes
Unknown
Yes
Unknown
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes

Unknown
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Unknown

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
Yes
No
No
Yes
Yes
Unknown

Yes
Yes

Unknown
Yes

Yes
Yes

No
Yes

No
No

No
No
Yes
No
Yes
Yes
Yes
Yes
No
Yes
No
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Yes

No
No
Yes
No
Yes
Yes
Yes
Yes
No
Yes
No
No
No
No
Yes
Yes
No
Yes
No
Yes

No
No
Yes
No
Yes
Yes
Yes
Yes
Unknown
Yes
No
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Yes

No
No
Yes
No
Yes
Yes
No
No
No
Yes
No
No
No
No
Unknown
No
No
Yes
No
Yes

No
No
No
No
No
No
No
No
No
No
No
No
No
No
Unknown
No
No
Yes
No
Yes

Yes
Unknown
No
Yes
Yes
Yes
Yes
No
Yes
Yes

Yes
Yes
Yes
Yes
No
Yes
No
No
No
Yes
Yes
Yes
No
Yes
Unknown

No
Yes
Yes
Yes
No
Yes
No
No
No
No
Yes
No
No
Yes
Unknown

No
UnknownNo
Yes
No
Unknown
No
No
No
No
Yes
No
No
No
Unknown

No
Unknown
Yes
Yes
Yes
Unknown
No
No
No
No
Yes
No
No
Yes
Unknown

No
Unknown
Yes
Yes
No
Unknown
No
No
No
No
Yes
No
No
No
No

No
Unknown
No
Unknown
No
Unknown
No
No
No
No
No
No
No
No
No

Yes
Yes
Yes
Yes

150

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 15. Table 1(Continued)
Country

Lower cost ART
services

Higher quality ART
services

Unavailable ART
services

Egg
donation

EmbryodonationSpermdonation

Gestationalsurrogacy

Traditionalsurrogacy

Yes
No
No
Yes
Yes
Yes
Yes
Yes
No
No
Yes
No
Yes
Yes

Yes
No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Unknown
Yes

Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
No
Yes

Yes
No
No
Yes
Yes
No
No
Yes
No
Yes
Yes
No
No
Yes

Yes
No
No
Yes
Yes
No
No
Yes
No
Yes
Yes
No
No
Yes

No
No
No
Yes
No
No
No
Yes
No
Yes
Yes
No
No
Yes

No
No
No
Yes
No
No
No
Yes
No
Yes
No
No
No
Yes

No
No
No
Yes
No
No
No
Yes
No
Yes
Yes
No
No
Yes

Spain
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabweded “unknown” and two respondents replied, “not addressed”.
Individuals leaving the country seeking higher quality ART
services: Sixty-one percent (41) of 67 respondents reported that
individuals travelled from their country to seek higher quality
ART services elsewhere. Twenty-seven percent (18) responded
that individuals did not travel from their country seeking higher
quality ART services; Seven respondents selected “unknown”,
and one respondent replied, “not addressed”.
Individuals leaving in search of ART services that are unavailable in their home countries: Fifty-seven percent (37) of 65
respondents reported that individuals travelled from their country in search of ART services that were currently unavailable.
Twenty-eight percent (18) of the respondents noted that people
did not travel from their country in search of ART services thatwere currently unavailable in their home country. Nine respondents chose “unknown” and one replied, “not addressed”.
Individuals leaving the country seeking access to donated eggs:
Seventy-three percent (48) of 66 respondents reported that individuals travelled from their country to obtain access to donated eggs.
Eighteen percent (12) of the respondents indicated that individuals
did not travel from their countries for access to donated eggs. Five
respondents replied “unknown” and one replied, “not addressed”.
Individuals leaving the country seeking access to donatedembryos: Fifty-seven percent (38) of 67 respondents reported that
individuals travelled from their country to gain access to donatedembryos. Twenty-four percent (16) of the respondents reported
that individuals did not travel from their countries to gain accessto donated embryos. Eighteen percent (12) of the respondents
selected “unknown”, and one answered, “not addressed”.
Individuals leaving the country seeking access to donatedsperm: Sixty-two percent (41) of the respondents from 66 countries reported that individuals travelled from their country toanother country for greater access to donated sperm. Twentyfour percent (16) of 66 respondents replied that individuals did
not travel from their countries to other countries for greater
access to donated sperm. Eight responded “unknown” and one
replied, “not addressed”.
Individuals leaving the country seeking to engage in gestationalsurrogacy: Sixty-seven percent (44) of the respondents from 66
countries reported that individuals travelled from their country toother countries to engage in gestational surrogacy. By contrast,

embryos. Five respondents replied that they did not know whether
individuals travelled to their country seeking embryo donation.
Individuals entering the country seeking access to donated sperm:
Fifty-ﬁve percent (39) of 71 respondents reported that individuals
travelled to their country seeking access to donated sperm. By
contrast, 38% (27) of the respondents noted that individuals
from other countries did not travel to their country seeking accessto donated sperm. Five respondents answered “unknown”.
Individuals entering the country seeking to engage in gestational surrogacy: Twenty-seven percent (19) of the 70 respondents answered afﬁrmatively, while 64% (45) of the respondents
said “no” and six replied “unknown”.
Individuals entering the country seeking to engage in traditional surrogacy: Thirteen percent (9) of 70 respondents
answered afﬁrmatively, while 79% (55) of the respondents
replied “no” and six answered “unknown”.
Individuals leaving the country seeking lower-cost ART services: Fifty-three percent (33) of 62 respondents reported that
individuals travelled from their country to seek lower-cost ART
services elsewhere (Table 2, Chart 1). Thirty-four percent (21) of
the respondents indicated that people did not travel from theircountry seeking lower-cost ART services elsewhere. Six respon-

90%
79%

80%

72%

71%
70%
61%

57%

60%
53%
50%
40%
30%
20%
10%
0%
Lower Cost Services

Higher Quality Services Unavailable ART Services
Incoming

Outgoing

Chapter 15. Chart 1. Incoming and Outgoing Travel for Services.

151

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 15. Table 2
Do people travel from your country to seek assisted reproduction?
Country
Albania
Argentina
Australia
Austria
Bangladesh
Belarus
Benin
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republic of
the Congo
Denmark
Ecuador
Egypt
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
India
Ireland
Italy
Japan
Kazakhstan
Kenya
LatviaLithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
New ZealandNigeria
NorwayPanamá
Paraguay
Philippines
Romania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain
SwedenLower cost ART
services

Higher quality ART
services

Unavailable ART
services

Egg
donation

EmbryodonationSpermdonation

Gestationalsurrogacy

Traditionalsurrogacy

Yes
Yes
Yes
Yes
No

Yes

Yes

Yes

Yes

Yes
No
Yes
Yes

No
Yes
Yes
Yes
Yes
Yes

No

No

No

Yes
Yes
Yes
Yes
Yes
Yes

Yes
Unknown
Yes
Yes
Yes
Yes

Yes
No
Yes
Yes
Yes
No

Yes
Yes

Yes
Yes
Yes
Unknown
Yes
Yes
Yes
No
Yes
No
Yes

Yes
No

Yes
No

Yes
No

Yes
Yes
No
Unknown
Yes
Yes
Yes
Yes
Yes
No
Yes

Yes
Yes
Yes
No
No
Unknown
Yes
Unknown

Yes
Yes

No
No
Yes
Yes
Unknown

Yes
Yes
Yes
Unknown
Yes
Yes
Yes
Yes
Yes
No
Yes

No
Yes

Yes
Yes

Yes
Yes

Yes
Yes
Unknown
No
Yes

No
Yes
Unknown
No
Yes

Yes
Yes
Unknown
No
Unknown

Yes

No

Unknown
Unknown
Yes

Unknown
Unknown
Yes

Yes
Yes
Yes
Yes
Yes
Unknown
Yes
Yes
No
No
Yes
Yes

Unknown
Yes
Yes
Yes
No
Unknown
Yes
Yes
No
No
Yes
Yes

Unknown
Yes
Yes
Yes
Yes
Unknown
Yes
Yes
No
No
Yes
No

Yes
Yes
Yes
Unknown
Yes

Yes

Yes
No
Yes
Yes
UnknownNo
Yes
Unknown
Yes

No
Unknown
Yes
No
Unknown
No
Yes
No
No
Yes
Yes
No
Yes
Unknown
No
No
Yes
No
Yes

Unknown
Yes
Yes
Yes
Yes
Unknown
No
Yes
No
Yes
Yes
No
Yes
Yes
No
No
Yes
Yes
Unknown
Yes
Yes
No
Yes

Unknown
Yes
Yes

No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Not addressed

No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Not addressed

Yes
Yes
Yes
No
Yes
Unknown
Yes
Yes
No
Yes
Yes
No
Unknown
Yes
Yes
Yes
No
UnknownNo
Yes
Not addressed

Yes
No
No
Unknown
Yes
No

Yes
Yes
No
Unknown
No
No

No
No
No
UnknownNo
Yes

Yes
Unknown
Yes
Yes
No
Yes
Yes
No

152

Yes
Yes
Yes
Yes
Yes
Unknown
No
No
Yes
Yes
No
No
Yes
Unknown
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Unknown
Yes
Yes
Yes
Yes
No
No
Unknown
Unknown
Yes
Yes
No
No
Not
Not addressed
addressed
Yes
Yes
Yes
Yes
No
No
Unknown
UnknownNo
No
Yes
Unknown

Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Unknown
Yes
No
Not
addressed
No
YesNo
Unknown
No
Yes

Yes
No
No
Yes
Unknown
Unknown

Yes
Unknown
Yes
Unknown
Yes
UnknownNo
Yes
Unknown
Unknown

Yes
Yes
Yes
No
Unknown
Unknown
Unknown
Yes
Yes
Yes
Yes
Unknown
Unknown
Yes
Yes
Yes
Yes
Yes
Yes
No
Not addressed

Yes
Yes
Unknown
No
Unknown
Unknown
Unknown
Yes
Yes
Yes
Unknown
Unknown
No
Unknown
Yes
Yes
Unknown
UnknownNo
Not addressed

No
Yes
No
Yes
Yes
Yes

No
No
No
Yes
Yes
Yes

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 15. Table 2(Continued)
Lower cost ART
services

Country
Switzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

Higher quality ART
services

Yes
Yes
No
No
No
Yes
Yes
Yes
Not addressed
Yes

Unavailable ART
services

Egg
donation

EmbryodonationSpermdonation

Gestationalsurrogacy

Traditionalsurrogacy

Yes
Yes
UnknownNo

Yes
Yes
Unknown
Yes
Yes

Yes
Yes
Unknown
No
Yes

Yes
Yes
Unknown
Yes
Yes

Yes
Yes
Unknown
Yes
Yes

Yes
Yes
Unknown
No
No

Yes
No
Yes
Yes
Yes
Yes

Yes
Yes
Yes
No
No
Yes

Yes
Yes
Yes
No
No
Yes

Unknown
No
Yes
Yes
No
Yes

Yes
Yes
No
No
Yes
Yes

Yes
Yes
Yes
No
Yes
Yes

Yes
Yes
No
No
Yes
UnknownNo
Yes
Yes
Unknown
Yes

Chapter 15. Table 3a
Are there regulations that govern patients that visit your country seeking treatment?

Country
Albania
Argentina
Australia
Austria
Bangladesh
Belarus
Benin
BrazilBulgaria
Cambodia
Cameroon
CanadaChile
China
Colombia
Cote d’Ivoire
Czech Republic
Democratic
Republic of
the Congo
Ecuador
Egypt
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong(China*)Hungary
India
Ireland
Italy
Japan

No
regulations

Federal/National
Laws/Statutes/
OrdinancesState/Provincial/
Regional Laws/
Statutes/Ordinances

Municipal
AgencyLaws/Statutes/ Regulations/
Ordinances
Oversight

Yes
Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Professional
Organization
Standards/
Guidelines

Cultural Religious
practice decree Unknown

Yes
Yes
Yes
Yes
Yes
Yes
Yes

Yes
Yes
Yes

Yes
Yes
Yes
Yes

Yes

Yes

Yes

Yes

Yes
Yes
Yes
Yes
Yes

Yes
Yes

Yes

Yes

Yes

Yes

Yes

Yes
Yes
Yes

Yes

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Yes

Yes
153

Yes

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 15. Table 3a(Continued)

Country
Kenya
LatviaLithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
New ZealandNigeria
NorwayPanamá
Paraguay
Philippines
Romania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain
SwedenSwitzerland
Tanzania
Trinidad &TobagoTunisia
TurkeyUgandaUnitedKingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

Noregulations

Federal/National
Laws/Statutes/
OrdinancesState/Provincial/
Regional Laws/
Statutes/Ordinances

Municipal
AgencyLaws/Statutes/ Regulations/
Ordinances
Oversight

Professional
Organization
Standards/
Guidelines

Cultural Religious
practice decree Unknown

Yes
Yes

Yes

Yes
Yes
Yes

Yes
Yes

Yes

Yes

Yes
Yes

Yes

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Yes
Yes
Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes
Yes
Yes
Yes

Yes

Yes
Yes
Yes
Yes

Yes

Yes
Yes

Yes
Yes

Yes
Yes

Yes
Yes

Yes
Yes

Yes
Yes

Yes
Yes

Yes
Yes

Yes
Yes

Yes
Yes

Yes
Yes

Yes
Yes

Yes
Yes

Yes
Yes

Yes

fourteen percent (nine) answered “no” to this question, while
18% (12) replied “unknown” and one replied, “not addressed”.
Individuals leaving the country seeking to engage in traditionalsurrogacy: Fifty-one percent (33) of the respondents from 65
countries reported that individuals from their country travelled toother countries to engage in traditional surrogacy. Twenty percent (13) of the respondents replied “no”, 28% (18) responded“unknown”; and one replied, “not addressed”.
Regulation of cross-border reproductive care: Respondents
were asked whether their countries maintained regulations thatgoverned cross-border surrogacy (Table 3a, 3b). Respondents
from 68 countries provided answers to this question. Fifty-fourpercent (37) of the 68 respondents stated that there were no
regulations focused on individuals that visited their country
seeking ART treatment, and likewise no regulations pertaining toindividuals from their countries who sought treatment elsewhere.
Twenty-two percent (15) of the respondents reported that theircountry did have regulations governing visitors who might beseeking ART treatment and 6% (4 respondents) noted that theircountry had regulations that pertained to their residents who
might be seeking treatment elsewhere. Eighteen percent (12) ofthe respondents reported that their countries had regulations thatpertained both to visitors as well as to citizens traveling to othercountries seeking ART treatment.
Countries that reported having provisions in place to address
CBRC relied on federal or national laws, statutes, and ordinances; state or provincial or regional laws, statutes, and ordinances; municipal laws, statutes, and ordinances; agency
regulations and oversight; professional organization standards
and guidelines; cultural practice; and/or religious decrees.
Regulation of the import of oocytes, sperm, and zygotes: Fiftysix percent (41) of 73 respondents reported that regulations
existed that addressed the importation of oocytes into theircountries. Thirty percent (22) of the respondents reported that nosuch regulations existed in their countries, while three answered“unknown” and seven replied “not addressed” (Tables 4 and 5).
154

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 15. Table 3b
Are there regulations that govern citizens that visit other countries seeking treatment?

Country
Albania
Argentina
Australia
Austria
Bangladesh
Belarus
Benin
BrazilBulgaria
Cambodia
Cameroon
CanadaChile
China
Colombia
Cote d’Ivoire
Czech Republic
Democratic
Republic of
the Congo
Ecuador
Egypt
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong(China*)Hungary
India
Ireland
Italy
Japan
Kenya
LatviaLithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
New ZealandNigeria
NorwayPanamá
Paraguay
Philippines
Romania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain
SwedenNoregulation

Municipal Laws/
AgencyStatutes/
Regulations/
Ordinances
Oversight

Professional
Organization
Standards/
Guidelines

Federal/National
Laws/Statutes/
OrdinancesState/Provincial/
Regional Laws/
Statutes/Ordinances

Yes

Yes

Yes

Yes

Yes
Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes
Yes

Yes

Yes

Yes

Cultural Religious
practice decree Unknown

Yes
Yes
Yes
Yes
Yes
Yes
Yes

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Yes
Yes

Yes

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Yes

Yes

Yes
Yes
Yes

155

Yes

Yes

Yes

Yes

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 15. Table 3b(Continued)

Country
Switzerland
Tanzania
Trinidad &TobagoTunisia
TurkeyUgandaUnitedKingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

Noregulation

Federal/National
Laws/Statutes/
OrdinancesState/Provincial/
Regional Laws/
Statutes/Ordinances

Municipal Laws/
AgencyStatutes/
Regulations/
Ordinances
Oversight

Professional
Organization
Standards/
Guidelines

Cultural Religious
practice decree Unknown

Yes
Yes
Yes

Yes

Yes

Yes

Yes

Yes
Yes
Yes
Yes
Yes

Yes

Yes

Yes

Yes

Yes
Yes
Yes
Yes

their respective countries to utilize third-party reproductive
services (e.g., oocytes, 47% versus 57%; sperm 51% versus
55%; embryos 37% versus 40% in 2018 and 2021, respectively). Even fewer reported incoming travel for gestationalsurrogacy (28% versus 27%) and traditional surrogacy (19%versus 13%), in 2018 and 2021, respectively.
A smaller proportion of respondents reported that individuals
travelled from their home country to seek ART services elsewhere.
Among those who did, the motivations included lower cost (65%versus 53%), higher quality (51% versus 61%), and for services thatwere not available in their country of residence (51% versus 57%) in2018 and 2021, respectively. By contrast, there were signiﬁcantly
more reports of individuals traveling elsewhere (as opposed to those
traveling to the respondents’ countries) to obtain donated oocytes,
sperm, or embryos donation; these rates were 73% versus 57% foroocytes, 62% versus 55% for sperm, and 57% versus 40% forembryos, respectively. In 2018, the proportion of respondents
reporting travel by individuals seeking oocytes was 47% versus
65%; for sperm, both 51%; and for embryos, 37% versus 52%,
comparing those traveling elsewhere rather those traveling to the
respondents’ countries of residence, respectively. Interestingly, thesenumbers suggest that travel in 2021 was largely in the reverse
direction from that reported in 2018.
Similarly, a greater fraction of the respondents reported travel toelsewhere (away from their countries of residence) than those traveling to their countries of origin to engage in gestational surrogacy;
67% of respondents reported that individuals travelled out of theircountries of residence to engage in gestational surrogacy (versus
27% reporting inbound travel). Likewise, 51% of the respondents
reported that individuals travelled out of their countries of residence
to engage in traditional surrogacy versus 13% reporting inboundtravel. This pattern was similar to that reported in 2018, in which
57% of the respondents reported that individuals were seeking
gestational surrogacy elsewhere versus 28% reporting inboundtravel, and 46% reporting that individuals traveling elsewhere fortraditional surrogacy, compared to 19% reporting inbound travel.
The respondents also indicated that there was little overall direct
regulation of individuals traveling either to or from their respective
countries to seek ART services, although regulation of the import andFifty-six percent (40) of 72 respondents reported that regulations existed that applied to the importation of sperm into theircountries. Thirty-one percent (22) reported that no such regulations existed in their countries, while three responded“unknown” and seven replied, “not addressed”.
Forty-seven percent (34) of 72 respondents reported that regulations existed that addressed the importation of zygotes into
their countries. Thirty-ﬁve percent (25) of the respondents
reported that no such regulations existed, while ﬁve responded“unknown” and eight replied, “not addressed”.
Regulation of the export of oocytes, sperm, and zygotes: Fortynine percent (36) of 73 respondents reported the existence ofregulations pertaining to the exportation of oocytes from theircountries. Thirty-seven percent (27) of the respondents noted thatno such regulations existed, while two respondents answered“unknown” and eight replied, “not addressed”.
Forty-nine percent (35) of 72 respondents reported the existence ofregulations pertaining to the exportation of sperm from their countries.
Thirty-eight percent (27) reported that no such regulations existed,while two answered “unknown” and eight replied, “not addressed”.
Forty-four percent (32) of 72 respondents afﬁrmed the existence of regulations pertaining to the exportation of zygotes fromtheir countries. Thirty-nine percent (28) reported that no such
regulations existed, while four answered “unknown” and eight
responded, “not addressed”.
Discussion
Overall, a larger proportion of the respondents reported that
individuals and couples travel to the respondents’ respective
home countries seeking ART treatment that was of lower cost,higher quality, or otherwise not available to them in theircountries of residence. Little change was noted between the
responses provided in the 2018 versus 2021 surveys. The 2021
ﬁndings include 75% reporting incoming travel to obtain services at lower cost (versus 71% in 2018), 79% reporting
incoming travel to obtain services of higher quality (versus 79%
in 2018), and 66% reporting incoming travel to obtain services
that were not available in their countries of residence (versus
72% in 2018). Fewer respondents reported incoming travel to156

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 15. Table 4
Are there regulations regarding the import of reproductive tissue into your country?
Country
Albania
Argentina
Australia
Austria
Bangladesh
Belarus
Benin
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
Ecuador
Egypt
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
India
Ireland
Italy
Japan
Kazakhstan
Kenya
LatviaLithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
Romania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain
SwedenSwitzerland

Ova

Spermatozoa

ZygotesNo
Not addressed
Yes
Yes
No
Yes
No
Yes
Yes
No
Yes
No
Yes
Yes
Yes
No
Yes
No
Yes
No
Yes
Yes
Yes
Not addressed
YesNo
Not addressed
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
Yes
Yes
Not addressed
No
No
Yes
Yes
No
Not addressed
Yes
Yes
Yes
Unknown
UnknownNo
Not addressed
Yes
Yes
No
Yes
No
Yes
Yes
No
Yes
No
Yes
Yes
Yes
No
Yes
No
Yes
No
Yes
Yes

No
Not addressed
Yes
Yes
No
No
No
Not addressed
Yes
No
Yes
No
Yes
Unknown
Yes
No
Yes
No
Yes
No
Yes
No

Not addressed
YesNo
Not addressed
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
Yes
Yes
Not addressed
No
No
Yes
Yes
No
Not addressed
Yes
Yes
Yes
Unknown
Unknown

Not addressed
YesNo
Not addressed
Unknown
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
Yes
Yes
Not addressed
No
No
No
Yes
No
Not addressed
Yes
Yes
Yes
Unknown
Unknown157

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 15. Table 4(Continued)
Country
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

Ova

Spermatozoa

ZygotesUnknownYes
Not addressed
Yes
No
Yes
Yes
Yes
No
Not addressed
Yes

UnknownYes
Not addressed
Yes
No
Yes
Yes
Yes
No
Not addressed
Yes

UnknownNo
Not addressed
Yes
No
Yes
Yes
Yes
No
Not addressed
Yes

Ova

Spermatozoa

ZygotesNo
Not addressed
No
No
No
Yes
No
Not addressed
Yes
No
Yes
No
No
Yes
Yes
No
Yes
No
Yes
No
Yes
Yes
Yes
Not addressed
YesNo
Not addressed
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
Yes
No
No
No
Yes

No
Not addressed
No
No
No
Yes
No
Not addressed
Yes
No
Yes
No
No
Yes
Yes
No
Yes
No
Yes
No
Yes
Yes

No
Not addressed
No
No
No
Yes
No
Not addressed
Yes
No
Yes
No
No
Unknown
Yes
No
Yes
No
Yes
No
Yes
No

Not addressed
YesNo
Not addressed
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
Yes
No
No
No
Yes

Not addressed
YesNo
Not addressed
Unknown
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
Yes
No
No
No
Yes

Chapter 15. Table 5
Are there regulations regarding the export of reproductive tissue into your country?
Country
Albania
Argentina
Australia
Austria
Bangladesh
Belarus
Benin
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
Ecuador
Egypt
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
India
Ireland
Italy
Japan
Kazakhstan
Kenya
LatviaLithuania
Malaysia
Mali
MexicoMontenegro

158

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 15. Table 5(Continued)
Country
MoroccoNamibia
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
Romania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

Ova

Spermatozoa

Zygotes

Yes
Yes
No
No
Yes
Yes
Not addressed
No
No
No
Yes
No
Not addressed
Yes
Yes
Yes
Unknown
No
UnknownYes
Not addressed
Yes
No
Yes
Yes
Yes
No
Not addressed
Yes

Yes
Yes
No
No
Yes
Yes
Not addressed
No
No
No
Yes
No
Not addressed
Yes
Yes
Yes
Unknown
No
UnknownYes
Not addressed
Yes
No
Yes
Yes
Yes
No
Not addressed
Yes

Yes
Yes
No
No
Yes
Yes
Not addressed
No
No
No
Yes
No
Not addressed
Yes
Yes
Yes
Unknown
No
UnknownNo
Not addressed
Yes
No
Yes
Yes
Yes
No
Not addressedYesexport of tissue was more prevalent. Nonetheless, several respondents
reported either that no regulations existed or that they were unawareof any existing regulations. The lack of regulation and lack ofknowledge about speciﬁc regulations may be relevant to oocyte,
sperm, and embryo donation and surrogacy stakeholders. This will
also have an immediate impact on the children born as a result of suchpractices, most notably those who may ultimately seek information
about their oocyte or sperm donors or surrogate mothers sometime in
the future. Tracking and reporting of treatment outcomes will also be
more difﬁcult in the absence of a robust regulatory climate. Follow-up
across borders is a considerable challenge.
While these data do not reﬂect actual numbers of CBRC travellers,
they do suggest an increased national awareness of new trends,
including a reversal of the trend noted in 2018 when the participating
countries reported that more individuals were traveling inbound as
opposed to outbound. The currently recorded increase in outboundtravel for CBRC, especially for donor oocytes and embryos, might
reﬂect changes in local access due to the pandemic.
Otherwise, these data do not suggest new trends or any additional signiﬁcant changes in CBRC utilization between 2018 and2021. While the responses may provide some early evidence ofthe effects of the COVID-19 pandemic and its impact on travel for
CBRC services, a more deﬁnitive assessment of this situation
remains to be determined.

questionnaire. Overall, the responses suggested that there werecomparable numbers of patients seeking CBRC at lower cost, perceived higher quality, and with greater access to speciﬁc services. The
ﬁndings from the 2021 report suggested that fewer individuals sought
CBRC speciﬁcally for sperm, egg, or embryo donation, and evenfewer for any type of surrogacy arrangement. A relatively smaller
proportion of respondents reported that patients were traveling fromtheir country for any of these services. The 2021 respondents perceived that a larger proportion of patients sought oocyte, sperm, andembryo donation in other countries than the proportion of those
traveling to their countries seeking these services. This is the reverse of
the pattern reported in 2018. If these ﬁndings are conﬁrmed, they may
reﬂect changes in access, conceivably secondary to shut-downs secondary to the COVID-19 pandemic. More than half of respondents
reported that there were no regulations pertaining to patients traveling to (59%) or traveling from (67%) their countries in search of
CBRC services. These data suggest that a substantial amount of
CBRC is provided, although no data are available regarding theactual volume or the extent of oversight.

CHAPTER 16: HUMAN PRE-IMPLANTATION EMBRYORESEARCH
Introduction
In the United States (US), pre-implantation embryos that are notintended for pregnancy are protected by the federal mandates of
the “Common Rule” at levels that exceed regulations applied tothe use of organs and tissues that have been surgically removed.

Summary
CBRC remains prevalent when comparing ﬁndings from 2018 to
those obtained from the 2021 responses to the Surveillance
159

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Adaptations and interpretations of “Common Rule” governanceappear to have been adopted by local and national regulatory
bodies as templates for the regulation of embryo research internationally. This is reﬂected in the responses included in the 2021
Surveillance survey.
Common Rule regulations emerged after the introduction ofin vitro fertilization (IVF). The two major US bodies charged withoversight of these practices are the Ofﬁce of Human ResearchProtections (OHRP) and the Food and Drug Administration(FDA). Additionally, the National Institutes of Health (NIH), a
primary source of research support, has regulations and policies
that must be followed by all research projects and institutions
funded under their auspices. Subpart A of these regulations,collectively known as the Common Rule, has been adopted andindependently codiﬁed by 14 agencies outside those included
under Health and Human Services (HHS). Its tenets are wellknown to researchers working in both the US as well as in western
Europe and are likely followed by most of the survey respondents,
some of whom trained in these regions of the world.
The questions posed in Surveillance 2021 to the respondents
from 70 countries were based on Common Rule standards. The
questions were designed to highlight embryo research as practised
internationally, inﬂuenced by federal and regional customs, andinterpreted by governments, municipalities, and scholarlycommittees.

countries that allowed therapeutic cloning, 71% (ﬁve countries)
also required speciﬁc approval. Only one country reported that
reproductive cloning of human embryos was allowed and that thispractice did not require speciﬁc approval.
Research involving donated, unused pre-implantationembryos is regulated in 38% (26) of 69 countries. This practice
is not regulated in 41% (28) countries and is banned in 12%(eight countries). Ten percent (seven) respondents replied“unknown” to this question. Stem cell research performed on
donated, unused pre-implantation embryos is regulated in 35%(24) of 68 countries, not regulated in 41% (28 countries), andbanned in 9% (six countries). Fifteen percent (ten) respondents
replied “unknown” to this question. Reproductive cloning isregulated in 31% (22) of 70 countries. It is not regulated in 39%(27 countries) and banned in 21% (15 countries). Nine percent(six countries) replied “unknown”. The practice of therapeuticcloning is regulated in 32% (22) of 69 countries, not regulated in
41% (28 countries), and banned in 17% (12 countries).
Respondents from 10% (seven countries) replied “unknown” tothis question. Likewise, research on embryonic stem cells isregulated in 33% (23) of 70 countries, not regulated in 40% (28countries), banned in 10% (7 countries). Twelve countries(17%) replied “unknown” (Chart 2).
Thirty-ﬁve responses were collected that focused on thedevelopmental age of non-implanted embryos that can be used
for experimentation. Responses ranged from 0 to 52 days, with a
median of six days.
Stem cell research on donated, unused pre-implantationembryos is commonly performed in four of the 68 reporting
countries. It is performed infrequently in 13% (nine countries)
and never performed in 63% (43 countries); 18% (12 countries)
replied “unknown” to this question. Reproductive cloning to
generate a human clone is commonly performed in only one of the
68 countries that responded (Benin). This practice is performed
infrequently in two countries and never performed in 82% (56countries). Nine countries (13%) replied “unknown”. Likewise,
therapeutic cloning is commonly performed in 2 of 68 countries,
infrequently performed in four countries, and never performed in
78% (53 countries). Nine countries (13%) responded“unknown”. Finally, research on embryonic stem cells wascommonly performed in 7% (5 of 68 countries reporting),
infrequently performed in 13% (9 countries), and never performed in 60% (41 countries). Nineteen percent (13 of thecountries reporting) responded “unknown” to this question(Table 1a, 1b, Chart 3).

Analysis of the Survey
Questions posed in the survey included:
1. Is experimentation/research on the pre-implantation embryo
allowed/permitted in your country?
2. Is there a requirement for speciﬁc approval of experimentation/research proposals?
3. Are there regulations that address experimentation?
In your country, up to what age development in days canexperimentation be performed on a developing nonimplanted
embryo?
4. Are clinical or research programmes in your country performing experimentation on the pre-implantation embryo?
Research involving donated, unused pre-implantationembryos is allowed in 30% (22) of the 72 countries that
responded and not allowed in 54% (39); 15% (11 countries)
replied “unknown”. Stem cell research, performed on donated,unused pre-implantation embryos, is allowed in 19% (11) of 59
countries, and is not allowed in 58% (34), while representatives from 24% (14 countries) replied “unknown” to thisquestion. Therapeutic cloning is allowed in 10% (seven) of 72
countries, and not allowed in 74% (53 countries); 17% (12countries) responded “unknown”. Reproductive cloning isallowed in only one of 72 countries and is not allowed in 83%(60 countries); representatives from 15% (11 countries) replied“unknown”. Finally, embryonic stem cell research is allowed in
16% (11) of 71 countries and not allowed in 65% (46). Twenty
percent (14 countries) replied “unknown” to this question(Table 1a, Table 1b, Chart 1).
Of the 22 countries that allow research involving donated,unused pre-implantation embryos, 73% (16) required speciﬁc
approval. Of the 11 countries that allowed research on donated,unused pre-implantation embryos ultimately intended for both stem
cell research and embryonic stem cell research, 64% (seven countries) noted that speciﬁc approval was required. Of the seven

Discussion
The United Nations Declaration on Human Cloning, which
prohibited all forms of human cloning, was passed in 2005 with
84-member nations voting in support, 34 in opposition, and 37
abstaining. No global consensus emerged because of concerns
expressed regarding the interpretation and potential applications of this declaration to various types of cloning. The 2022
Surveillance survey was designed to assess the extent to which
member nations conform to the United Nations resolution
13 years after its passing, rather than seeking responses
regarding speciﬁc research initiatives. As anticipated, nations
that had prior experience with the Common Rule frameworktended to have the most comprehensive infrastructures for the
management of research funds, legislation, publication, and160

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 16. Table 1a
Is experimentation/research on the pre-implantation embryo allowed/permitted and/or practised/performed?
Research on donated unused
pre-implantation embryos

Research on donated unused
pre-implantation embryos for stem
cell research

Embryonic stem cell research

Country

Allowed/Permitted Practised/Performed Allowed/Permitted Practised/Performed Allowed/Permitted Practised/Performed

Albania
Argentina
Australia
Austria
Bangladesh
Belarus
Benin
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
Ecuador
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
India
Ireland
Italy
Japan
Kazakhstan
Kenya
LatviaLithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
Romania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain

No
No
Yes, with restrictions
Yes
UnknownNo
No
Yes, with restrictions
No
No
No
No
Yes, with restrictions
Unknown
No
No
No
No
Yes, with restrictions
No
Unknown
No
Unknown
Yes, with restrictions
No
No
No
Yes, with restrictions
No
Yes, with restrictions
Yes
Yes, with restrictions
No
No
Yes, with restrictions
Yes, with restrictions
Unknown
Yes
No
UnknownNo
No
Yes, with restrictions
No
No
No
Unknown
Yes
Yes
Unknown
Unknown
No
No
No
No
No
No
Yes, with restrictions
Yes, with restrictions

No
Yes, with restrictions
Yes, with restrictions
No
No
No
Yes, with restrictions
Yes, with restrictions
Yes, with restrictions
No
No
No
Yes, with restrictions
No
Unknown
No
No
No
Yes, with restrictions
No
No
No
Yes, with restrictions
UnknownNo
No
Yes, with restrictions
No
Yes, with restrictions
Unknown
Yes, with restrictions
No
No
Yes, with restrictions
Yes
Unknown
No
No
UnknownNo
Yes, with restrictions
Yes, with restrictions
No
No
No
Unknown
No
Unknown
Unknown
No
No
No
Unknown
No
No
No
Yes, with restrictions
Yes, with restrictions

No

Yes
Unknown
No
No
No
No
No
No
Unknown
Unknown
No
No
No
Yes, with restrictions
No
Unknown
No
UnknownNo
No
Yes, with restrictions
No
Yes
Yes, with restrictions
Unknown

Yes, with restrictions
Unknown
No
No
UnknownNo
No
Yes, with restrictions
No
No
No
Unknown
Unknown
Yes, with restrictions
Unknown
Unknown
No
No
No
No
No
Yes

161

No
Yes, with restrictions
No
No
No
No
Yes, with restrictions
Yes, with restrictions
No
No
No
No
Yes, with restrictions
No
Unknown
No
No
No
Yes, with restrictions
No
No
No
Yes, with restrictions
UnknownNo
No
Yes, with restrictions
No
Yes, with restrictions
Unknown
No
No
No
Yes, with restrictions
No
Unknown
No
No
Unknown
No
Unknown
Yes, with restrictions
No
No
No
Unknown
No
Unknown
Unknown
No
No
No
Unknown
No
No
No
Yes, with restrictions
Yes, with restrictions

No
No
No
Unknown
Unknown
No
No
No
No
No
No
No
Yes
Unknown
Unknown
No
No
No
Yes, with restrictions
No
Unknown
No
Unknown
Yes, with restrictions
No
No
No
No
No
No
Yes, with restrictions
No
No
No
No
No
Unknown
Yes
No
UnknownNo
Yes, with restrictions
No
No
No
No
Unknown
No
No
Unknown
No
No
No
UnknownNo
No
Yes, with restrictions
Yes

No
Unknown
No
No
No
No
Yes, with restrictions
No
No
No
No
Yes, with restrictions
No
Yes, with restrictions
No
No
No
Yes, with restrictions
No
No
No
Yes, with restrictions
UnknownNo
No
Yes, with restrictions
No
Yes, with restrictions
Unknown
No
No
No
Yes, with restrictions
No
Unknown
Unknown
No
Unknown
No
Unknown
Unknown
No
No
No
UnknownNo
Yes, with restrictions
Unknown
No
No
No
Unknown
No
No
No
Yes, with restrictions
Yes, with restrictions

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 16. Table 1a(Continued)
Research on donated unused
pre-implantation embryos

Research on donated unused
pre-implantation embryos for stem
cell research

Embryonic stem cell research

Country

Allowed/Permitted Practised/Performed Allowed/Permitted Practised/Performed Allowed/Permitted Practised/Performed

SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

Yes, with restrictions
No
Unknown
Unknown
No
No
No
Yes, with restrictions
Yes, with restrictions
No
No
Yes
No

Yes, with restrictions
No
Unknown
Unknown
No
No
No
Yes, with restrictions
Yes, with restrictions
No
No
Yes
No

Yes, with restrictions
No
Unknown
Unknown
No
No
No

No
No
Yes
No

Yes, with restrictions
No
Unknown
Unknown
No
No
No
Yes, with restrictions
Yes, with restrictions
No
No
Unknown
No

No
Unknown
Unknown
Unknown
No
No
No
Yes, with restrictions
Yes, with restrictions
No
No
Yes
No

Yes, with restrictions
Unknown
Unknown
Unknown
No
No
No
Yes
Yes, with restrictions
No
No
UnknownNo

Chapter 16. Table 1b
Is experimentation/research on the pre-implantation embryo allowed/permitted and/or practised/performed?
Reproductive cloning
Country
Albania
Argentina
Australia
Austria
Bangladesh
Belarus
Benin
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
Ecuador
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceGuatemalaHong Kong (China*)
Hungary
India
Ireland
Italy
Japan
Kazakhstan

Therapeutic cloning

Allowed/Permitted

Practised/Performed

Allowed/Permitted

Practised/Performed

No
No
No
Yes
Unknown
No
No
No
No
No
No
No
No
Unknown
No
No
No
No
No
No
Unknown
No
Unknown
No
No
No
No
No
No
No
No
No
No
No
No
No

No
No
No
No
No
No
Yes, with restrictions
No
No
No
No
No
No
No
No
No
No
No
No
No

No
No
No
Unknown
Unknown
No
No
No
No
No
No
No
No
Unknown
No
No
No
No
Yes
No
Unknown
No
Unknown
No
No
No
No
Yes, with restrictions
No
No
No
No
No
No
Yes, with restrictions
Yes

No
No
No
No
No
No
Yes, with restrictions
No
No
No
No
No
No
No
Unknown
No
No
No
Yes, with restrictions
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

162

No
No
No
UnknownNo
No
Yes, with restrictions
No
No
No
No
No
No
Yes, with restrictions
NoAbstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

Chapter 16. Table 1b(Continued)
Reproductive cloning
Country
Kenya
LatviaLithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
Romania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain
SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

Therapeutic cloning

Allowed/Permitted

Practised/Performed

Allowed/Permitted

Practised/Performed

Unknown
No
No
Unknown
No
No
No
No
No
No
Unknown
No
No
Unknown
No
No
No
No
No
No
No
No
No
No
No
Unknown
Unknown
No
No
No
No
No
No
No
Unknown
No

Unknown
No
No
Unknown
No
No

Unknown
No
No
Unknown
No
No
No
No
No
No
Unknown
No
No
Unknown
No
No
No
No
No
No
No
Yes, with restrictions
No
No
No
Unknown
Unknown
No
No
No
Yes, with restrictions
Yes, with restrictions
No
No
Unknown
No

Unknown
No
No
Unknown
No
No

No
No
No
Unknown
No
Unknown
Unknown
No
No
No
No
No
No
No
No
No
No
No
Unknown
Unknown
No
No
No
No
No
No
No
Unknown
No

Yes

No

No
No
No
Unknown
No
Unknown
Unknown
No
No
No
No
No
No
No
Yes, with restrictions
No
No
No
Unknown
Unknown
No
No
No
Yes, with restrictions
Yes, with restrictions
No
No
Unknown
No

Unknown
30%

Donated unused pre-implantation embryos

54%
15%
19%

Donated unused embryos for stem cell research

58%
24%
16%

Embryonic Stem Cell Research

65%
20%
10%

Therapeutic cloning

74%
17%
1%

Reproductive cloning

83%
15%

Chapter 16. Chart 1. Is experimentation allowed/permitted?

163

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive HealthYes

Unknown

No

Banned31%

Reproductive cloning

9%
39%
21%
32%

Therapeutic cloning

10%
41%
17%
33%
17%

Embryonic stem research

40%
10%
35%
15%

Research on donated unused pre-implantation embryos for stem cell research

41%
9%
38%

Research on donated unused pre-implantation embryos

10%
41%
12%

Chapter 16. Chart 2. Are there regulations that address experimentation?

Commonly Performed

Infrequently Performed

Therapeutic Cloning

Never Performed

3%
6%

78%

13%

Reproductive Cloning

2%
3%

82%

13%

Embryonic Stem Cell Research

7%
13%
19%

Research on donated unused preimplantation embryos

6%

13%
18%

Reference[1] The National Academies of Sciences, Engineering, andMedicine. Second International Summit on Human Genome
Editing: Continuing the Global Discussion. Proceedings of aWorkshop—in Brief. 2019. Available at: https://www.nap.
edu/catalog/25343/second-international-summit-on-humangenome-editing-continuing-the-global-discussion. Accessed
January 26, 2019.

Unknown60%

CHAPTER 17: STATUS OF THE EMBRYO
Introduction

63%

The moral status accorded to the embryo is a core principle governing
the practice of ART and, more recently, the performance of stem cellresearch. There is considerable consensus regarding the relevance of
the universal ethical principles to the practice of ART, including
autonomy, beneﬁcence, non-maleﬁcence, and social justice. However,
the global application of these principles to clinical practice andresearch related to mothers, children, and society is clearly regionspeciﬁc. The unique circumstances in which conﬂicts of interest arise
between these three stakeholders are especially acute when considering actions that may have differential effects on the welfare of theprospective mother and child. Biologists, theologians, and legislatures
have approached this dilemma quite differently and as a result, somelaws and regulations that have a signiﬁcant impact on ART may
predate its advent. Essentially, these issues revolve around the question of and point in time in embryonic or fetal development at which
personhood is conveyed together with its inherent human and legal
rights. Alternatively, some countries address this issue by identifying apoint in time before which a person is considered not to exist. The
signiﬁcant variations via which countries attempt to resolve theseconcerns illustrate some of the most critical differences in the international governance of ART. While some countries provide guidance
for both mother and child, and some for one but not the other, manyothers have not addressed these issues at all.
The 2021 questionnaire posed the following questions:
1. Is there a recognized point in time during human developmentin which a human exists and thus provided human rights?

Chapter 16. Chart 3. How frequently is experimentation performed?

enforcement of standards. Most of the responding countries
now have some form of oversight for this type of research
practice in place.
Summary
The 2021 survey reﬂects a modest increase in research activity
utilising donated, unused embryos, typically with appropriate
restrictions in place. A small but growing number of countries areactively involved in embryonic stem cell research. Most of thecountries involved in this type of research practice have existingoversight that has evolved in part from the Common Rule.
Human pre-implantation embryo research remains a controversial topic. Only a small number of countries are actively
involved in these investigations. With recent advances in theclinical application of stem cell research, a small but growing
number of countries are conducting studies using embryonicstem cells from donated, unused embryos, albeit with restrictions. Human reproductive cloning remains almost universallyprohibited[1].
164Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health
Chapter 17. Table 1

Chapter 17. Table 1
For your country, is there a recognized point in time during humandevelopment at which a human person is considered to exist andthus provided human rights?
Country

Response

Albania
Argentina
Australia
Austria
Bangladesh
Belarus
Benin
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
Ecuador
Egypt
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceGuatemala
Hungary
India
Ireland
Italy
Japan
Kazakhstan
Kenya
LatviaLithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
Romania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain

No
Yes
Unknown
Unknown
No
Unknown
Yes
Yes
No
Unknown
Yes
No
No
Unknown
Yes
No
No
Unknown
No
Unknown
Yes
Yes
Yes
Unknown
Unknown
No
Yes
No
No
Yes
Yes
Unknown
No
Yes
No
No
No
No
No
Unknown
Unknown
Unknown
Yes
No
No
No
Unknown
Unknown
No
Yes
No
Yes
No
No
Unknown
Yes
No
No
Unknown(Continued)

If yes, what is the recognizedtime of existence? (days)

7

40

Country

Response

SwedenSwitzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

No
No
Unknown
Unknown
No
No
Unknown
No
Yes
No
Yes
UnknownNo

If yes, what is the recognizedtime of existence? (days)154
1

2. Through which governing bodies or agencies is this time ofhuman existence determined?
3. Is there a recognized point in time during human development
before which a human person is considered not to exist andthus not provided human rights?
4. Through which governing bodies or agencies is this time ofhuman non-existence determined?

196

182
1
120

Analysis of the Survey
Representatives from 72 countries responded to the ﬁrst question. Of
these, 18 respondents reported that such a point existed and wasformally recognised by their respective countries (Table 1). Ninecountries, including Ecuador, Germany, Guatemala, Hungary, Italy,Montenegro, Paraguay, Slovenia, and Venezuela determined that aperson can be said to exist as early as day one (i.e., immediately after
fertilization). In 2018, 13 countries, recognised day one (post-fertilization) as the ﬁrst day of human existence. None of the respondents tothe 2021 questionnaire cited day 0 (i.e., pre-fertilization) as thedemarcation between existence and non-existence. Interestingly, in the2018 survey, Australia, Greece, Ireland, Spain, and Uruguay recognised personhood as existing pre-fertilization (i.e., day 0). In 2021, six
countries deﬁned human existence as beginning at speciﬁc times,
including gestational day 7 (Brazil), day 40 (Cambodia), day 196(China), day 182 (Denmark), day 120 (Egypt), or day 154 (UnitedStates). In 2018, nine countries reported that they utilised a time point
between gestational days 2 and 126 to recognise personhood. At thattime, the Russian Federation and the United States recognised gestational day 280 as the time at which human rights were conveyed.
Among those countries that have made efforts to deﬁne thestart of human existence, in 2021, only four (Brazil, Cambodia,
Denmark, and the United States) reported the existence of oversight on this matter from federal, state, provincial, or municipal
governing bodies. By comparison, in 2018, 34 countries reported
the existence of federal or national legislation or policies pertaining to the start of human existence. In 2021, only Brazil,
Egypt, and the United States reported that this practice wasinﬂuenced by standards and guidelines provided by professionalorganizations; by contrast, ten countries reported similar ﬁndings
in 2018. Only Cambodia and Egypt cited cultural practices andreligious decrees as having an impact on these decisions. By

1

1
1

1

1

1

1

165

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health
Chapter 17. Table 2

Chapter 17. Table 2
For your country, is there a recognized point in time during humandevelopment before which a human person is considered not toexist, and thus not provided human rights?
Country

Response

Albania
Australia
Austria
Bangladesh
Belarus
Benin
BrazilBulgaria
Burkina Faso
Cambodia
Cameroon
CanadaChile
China
Colombia
Costa Rica
Cote d’Ivoire
Czech Republic
Democratic Republic of the Congo
Denmark
Ecuador
Egypt
Ethiopia
FranceGeorgia
Germany
Ghana
GreeceGuatemala
Hungary
India
Ireland
Italy
Japan
Kazakhstan
Kenya
LatviaLithuania
Malaysia
Mali
MexicoMontenegro
MoroccoNamibia
New ZealandNigeria
NorwayPanamá
Paraguay
Peru
Philippines
Romania
RussiaSerbiaSlovenia
South Africa
South Korea
Spain
SwedenNo
Unknown
Unknown
No
Unknown
Unknown
Yes
Unknown
Unknown
Yes
No
No
Unknown
Unknown
No
No
No
No
Unknown
Yes
No
Yes
Unknown
Unknown
No
No
No
No
No
No
Unknown
No
No
No
No
No
No
No
Unknown
Unknown
Unknown
Unknown
No
No
No
Unknown
Unknown
No
No
No
No
No
No
Unknown
No
No
No
Unknown
Unknown(Continued)

If yes, what is the recognizedtime of non-existence? (days)

7

21

Country

Response

Switzerland
Tanzania
Trinidad & Tobago
Tunisia
TurkeyUgandaUnited Kingdom
United States
Uruguay
Venezuela
VietnamZimbabwe

Unknown
Unknown
Unknown
No
Unknown
Unknown
No
Yes
No
No
UnknownNo

If yes, what is the recognizedtime of non-existence? (days)

154

contrast, 12 and 18 countries noted the inﬂuence of cultural
practices and religious degrees, respectively, in 2018.
In 2021, representatives from 71 countries responded to the third
question, compared to only 66 responses received in 2018. Five of
these representatives reported that their country recognised a
gestational day before which a human could not be considered toexist; this can be compared to the 14 countries that responded
similarly in 2018 (Table 2). The speciﬁed point before which ahuman could be said to exist also varied signiﬁcantly, including
gestational day 7 (Brazil), day 21 (Cambodia), day 182 (Denmark),day 14 (Egypt), and day 154 (United States). In 2018, Ecuador,
Ireland, and Senegal deﬁned this point as gestational day 0, while
representatives from Argentina deﬁned this point as gestational day
1. By contrast, respondents from Canada, Finland, the United
Kingdom, and the United States deﬁned the point before which aperson can be said to exist as gestational day 280, while Egypt,
Kazakhstan, Georgia, Norway, Austria, and Germany deﬁned thistime point within a range, from 41 to 97 days. In 2021, 39 countries
did not recognise a speciﬁc time point at which human existence
begins; 35 countries reported similarly in 2018. In Brazil,
Cambodia, and Denmark, this time point was deﬁned by federal
legislation while in the United States, it was deﬁned by state-levelgovernance. Respondents from Brazil, Cambodia, and the UnitedStates reported that this decision was inﬂuenced by standards provided by professional organizations, while cultural practices inﬂuenced this decision in both in Cambodia and Egypt.

182
14

Discussion
A total of 64, 74, and 72 countries responded to the ﬁrst question in2016, 2019, and 2022, respectively. The number of countries thatreported some level of ofﬁcial documentation of the point at which
personhood is recognised has increased from 18 in 2016 (with 40%
afﬁrmative and negative replies) to 31 in 2019 (with 57% afﬁrmativeand negative replies) and back to 18 in 2022 (with 35% afﬁrmativeand negative replies). The fraction of responses marked “unknown”
ranged from 30% to 27% to 29% over the same time interval.
Sixteen countries that responded to this question in the current report
did not respond in 2019; likewise, 14 countries responded previously
but did not respond to this question in 2022. Of the countries that
responded to the ﬁrst question in all three surveys, 26 provided thesame answer while 30 changed their responses over time. However,none of the respondents reported the enactment of new legislation
166

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Healthalmost midway through the triennial cycle had a profound
impact on all aspects of reproductive care. Only some of theseeffects are captured in this survey. The unique and formidable
challenges faced by those involved in collecting and collating thedata introduced new challenges to the interpretation of theﬁndings. Thus, signiﬁcant changes noted in this report may
represent new trends in reproductive practice and policy, temporary or prolonged effects of the pandemic, or limitations of
the data collection.
Between March and May of 2020, 75% (48) of 64 countries
that responded to our survey had eliminated or imposed signiﬁcant restrictions on access to ART services. By December
2020, 87% of these countries had lifted these restrictions,although many individual centres remained closed. The resultsfrom the 2021 survey were the ﬁrst to show no signiﬁcant overall
increase in the number of ART centres for most countries. The
total increase of 776 ART centres cited was attributed to four
countries, China, India, the Russian Federation, and Spain, eachrecording an increase of more than 100 centres. The remaining
countries reported only modest increases or decreases.
Respondents to the 2021 Surveillance survey noted that someform of regulation of ART, usually conveyed by federal or nationallaws or statutes, existed in 69% of the responding countries. Thiscan be compared to 87% reporting some form of regulation of ART
in 2018 and 57% in 2015; overall, our 2021 ﬁndings revealed theexistence of ART regulations in 15 fewer countries in 2021 than in
2018. Without speciﬁc evidence indicating that speciﬁc laws had
been revoked or substantially altered over the ensuing six years,
these variations may reﬂect differences in sampling methods rather
than new trends. However, the 2021 data did reveal that fewer
countries maintained legislation or professional organisationalguidelines for determining the appropriate number of embryos totransfer per cycle and imposed penalties for failure to comply withsuch guidance. Paradoxically, the 2021 survey results also reported
an increase in the number of countries (from 18% to 28% over the
past six years) that provided ART reimbursement only for single
embryo transfer procedures. Overall, slightly more than half of the
responding countries offer some form of insurance coverage for
ART, with little change reported over the past three surveys. Of the
27% of countries (24) that did report regulatory changes since 2018,
new legislation was primarily directed at providing increased accessto donated gametes and embryos together with more limited accessto surrogacy and cross-border reproductive care (CBRC) services.
Although no speciﬁc trends were identiﬁed that directly limitedaccess to infertility services by single women and men, male andfemale same-sex couples, and transgender or intersex individuals,
the 2021 survey revealed that, for the ﬁrst time, most countries(54%) required a couple to be in a recognised and/or stable
relationship to gain access to ART services. Likewise, treatments
provided to single women remain more widely accepted andpermitted than treatments provided to single men.
This year, several opinions that differed from those provided inprevious surveys were noted. Among these are opinions that
relate to the point during development in utero at which humans
begin to exist and are thus entitled to human rights. The responses
provided might reﬂect whether the respondent focused on the ﬁrst
or latter parts of the questions, or whether he or she responded
based on a moral, religious, scientiﬁc, or legal perspective. Whileno clear trends were identiﬁed, there was no evidence to suggestthat fewer countries had established a point that deﬁned personhood to convey legal status or its inverse, i.e., a point before

that would have an impact on the status of personhood. This
remarkable variation in responses over the past six years may reﬂect
the frames of reference of the individual respondents whose perspectives may vary based on their unique moral, religious, scientiﬁc,and/or legal viewpoints.
Similarly, 65, 66, and 71 countries responded to the third
question in 2016, 2019, and 2022, respectively. This question
was ﬁrst introduced in the 2016 survey. In 2016, 12 countries
speciﬁed a point before which a human person could be considered not to exist (27% afﬁrmative and negative replies), In
2019, 14 countries provided a response to this question (28% of
afﬁrmative and negative replies), while only ﬁve responded (11%of afﬁrmative and negative replies) in 2022. The proportion of
responses stating that this was “unknown” was 44%, 26%, and
38% in 2016, 2019, and 2022, respectively.
There is a deﬁnitive point at which a human exists. All nations
confer human rights at birth, if not before. There are at least ninecountries with constitutional provisions that explicitly recognise‘existence’ from the time of ‘conception’ (a concept that is notuniversally deﬁned), including Costa Rica, Ecuador, Guatemala,
Hungary, Kenya, Paraguay, Peru, Philippines, and Venezuela.
Other countries, such as Albania, Argentina, Germany, and Italy,
have civil laws that deﬁne the ‘beginning of life’ (and thus protection of the embryo) either expressly or implicitly as the time of‘conception’[1]. The Philippines uniquely deﬁnes life beginning atconception (deﬁned as fertilization) and prohibits abortion andembryo research, although IVF is permitted. All the other countries permit IVF and some forms of embryo research as well as
abortion, albeit subject to varying criteria.
The 2016 judgement of the Inter-American Court of Human Rights
upheld the right of women to make ‘personal decisions’ to produce
biological children through IVF as protected under the American
Convention on Human Rights. This judgment has been cited as thelegal precedent that ensures ongoing access to ART in the Americas. In
particular, the court advanced the notion that only “gradual or
incremental protection could be granted to the unborn child”[2].
Summary
Many divergent responses were collected from those who choseto answer the questions focused on human development, humanexistence, and human rights. This may be a reﬂection of whether
the respondent focused on the ﬁrst or later parts of the question as
well as his or her moral, religious, scientiﬁc, and/or legal perspective on this matter. No clear trends were elucidated.
Nevertheless, there was no evidence to suggest an overall decreasein the number of countries that have established time frames fordeﬁning personhood and conveying legal status to fetuses whilestill in utero, or its corollary, i.e., deﬁning the point before whichhumans can be said not to exist. However, as of this report, noneof the responding countries are posing statutory barriers to ART.
The availability of ART continues to expand worldwide.
References[1] Alan, Sonia. Personal communication.
[2] Available at: https://www.corteidh.or.cr/tablas/r35048.pdf.

CHAPTER 18: CONCLUSIONSThe 2022 IFFS Surveillance report is unique in several ways. The
ongoing SARS-CoV-2 (COVID-19) pandemic which began167

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Healthcountries that are actively pursuing embryonic stem cell research.
Existing oversight in the countries that have established guidelines for this practice is typically based on the Common Rule.
Human reproductive cloning is almost universally prohibited.
While there has been some limited change with respect toaccess to SFR, no new trends were noted. SFR is allowed in 61%
of responding countries, which is the same proportion thatreported this ﬁnding in 2019. SFR is unconditionally allowedin 33% of the responding countries, while 28% permit it withconditions. With the increased availability of PGT-A, which iscurrently permitted in 23 countries, access to sex selection
methodologies is expanding. However, SFR for sex selection ispermitted in very few countries.
Surrogacy continues to provoke intense international debate
regarding legitimate indications for its use, concerns regarding thepotential for exploitation, and how to go about handling requested
anonymity. These issues intensiﬁed in 2020 and 2021 when the
COVID-19 pandemic prevented some intended parents from travelingto their surrogates’ domicile once their babies had been born. Where
allowed, surrogacy is usually regulated by a variety of federal and statelaws or statutes with other mechanisms in place to ensure legislative
enforcement. The 2021 data conﬁrmed that gestational surrogacy ismore often permitted and practiced than traditional surrogacy.
Patients continued to seek CBRC services primarily for lower
cost, perceived higher quality, and greater access. Fewer
respondents reported patients using CBRC services for sperm,
egg, or embryo donation, and even fewer for any type of surrogacy. CBRC services were usually sought for speciﬁc therapies
that were unavailable in their home countries. In 2021, more
respondents felt that the proportion of patients that travelled
elsewhere for oocyte, sperm, and embryo donation was greaterthan the fraction of those coming into their countries seeking
these services, thereby reversing the pattern reported in 2018.
These ﬁndings may reﬂect a change in access, perhaps created by
the COVID-19 pandemic shut-downs, although this possibility
awaits further study. Over half of the respondents noted theabsence of regulations addressing patients coming to (59%) or
leaving (67%) their country for CBRC services.
Posthumous reproduction remains a contentious topic. Little
progress has been made toward resolving some of the ongoing
ethical and legal issues. In 2021, about 25% of countries had preexisting legislation governing this procedure, it appears to be
more commonly utilised at this time. The current data reinforce
the urgent global need to address the application and appropriateness of this practice in the setting of greater utilisation withfew relevant regulations and only limited legislation.
The ninth edition of the IFFS’s Surveillance 2022: Global
Trends in Reproductive Policy and Practice chronicles some of
the impact of the COVID-19 pandemic on the performance ofART. There has been an apparent interruption in the expansionof the number of ART centres in most countries and possibly inthe number of countries citing the existence of legislative or
professional governance of ART. Changes were also noted in thistriennium that pertained to the utilisation of donor gametes,
requirements for a stable relationship as a condition for access to
ART services, increased research activity focused on preimplantation embryos, and trends regarding CBRC. The next
survey will likely reveal which of these observations are continuing to evolve and which were transient effects that could bedirectly attributed to the worldwide pandemic.

which a human cannot be said to exist. Currently, no countries
are posing global statutory obstacles to ART. Thus, access continues to expand in many countries.
Little change was reported since 2018 with respect to thestatutory or other forms of oversight that facilitate the protectionof the welfare of the future child based on assessments of individuals seeking infertility treatment. Few countries formallyaddress and monitor the mental and physical health or the sociocultural environment of prospective parents and their offspring.
Almost all aspects of ART are widely available in nearly all
countries surveyed. ICSI is offered universally. Other micromanipulation procedures, for example, PGT-M, are regarded as
essential technologies and are available in all comprehensive ART
centres. PGT-A is recognised as an established medical intervention
and is clearly useful in certain circumstances. PGT-A is performed bymany types of IVF centers, although most outsource the genetic
material to specialised laboratories that perform the analysis.
However, its optimal indications and overall value remain to be
determined. PGT applications have recently expanded to include
screening for polygenic traits which may ultimately be used to
identify predisposing factors for late-onset chronic illnesses. These
applications are considered experimental by 25% of the survey
respondents.
Cryopreservation of gametes and embryos is also regarded as
an essential service. No signiﬁcant changes in the number ofcountries that allowed or permitted cryopreservation of sperm,
oocytes, and/or pre-implantation embryos for fertility treatments
for medical and non-medical indications were found over thethree years since the 2018 study.
The utilisation of donated sperm and/or oocytes with donor
compensation appears to be expanding. The use of these materials
relies on medically assisted reproduction (MAR) or ART treatmentsthat are subject to regulations in nearly 50% of countries that
responded to the survey. These activities are usually controlled byfederal regulations, but others report regional and local laws and arole for guidelines from professional organisations. More countries
have reported the existence of guidelines or laws pertaining tocryopreservation of sperm, oocytes, and preimplantation embryos
for fertility treatments or medical indications compared to information collected in 2019. Embryo donation is also in more frequentuse. These embryos are often donated from a previous IVF cycle, butthey can also be generated “de-novo” from donated gametes. Thislatter option is not permitted in many countries. Donor anonymitythat has historically been offered and maintained for gamete
donation is currently being reassessed. Approximately 20 countries
reported changes in relevant guidelines that expanded the amount of
information provided to donors and offspring.
Ongoing experiences with cytoplasmic transfer, mitochondrialtransfer, and CRISPR-Cas9 technology continue to be encouraging.
However, these applications remain investigative at this time, with
beneﬁts, risks, and limitations that have yet to be determined. The
2021 survey responses to queries about legislation suggest that somecountries have adopted a more cautious approach to mitochondrialtransfer and CRISPR-Cas9 over the past three years.
Other topics still regarded as controversial include human preimplantation embryo research, selective fetal reduction (SFR) andsex selection, surrogacy, CBRC, and posthumous reproduction.
The most recent questionnaire revealed a modest increase inresearch activity focused on human pre-implantation embryos,
using donated unused embryos, most often with speciﬁc restrictions in place. There is also a small but expanding number of168

Abstracts. Global Reproductive Health (2022) 7:e58

Global Reproductive Health

ACKNOWLEDGMENTS
Editorial Board
Sonia Allan, OAM, CF, PhD
Professor of Health Law, Western Sydney University, School of Law
Adjunct Professor, Grifﬁth University
Paula Amato, MD, MCR
Professor, Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, Oregon
Basak Balaban, PhD
IVF Laboratory Director, American Hospital of Istanbul, Istanbul, Turkey
Manish Banker, MD
Medical Director, Nova IVI Fertility, India
Consultant, Nova IVI Fertility Ahmedabad
John Buster, MD
Emeritus Professor, Brown University, Providence, RI
Antonio Capalbo, PhD
Genomic Research Director, Igenomix, Rome, Italy
Professor Michael Chapman, AM
Professor of Obstetrics and Gynaecology, University of New South Wales
Clinical Director IVF Australia, Southern Sydney
Dr. Marcos Horton, MD
Co-Director and Director, ART Laboratory, Pregna Medicina Reproductiva, Buenos Aires, Argentina
Treasurer, IFFS
Kathleen Miller, DHSc
Scientiﬁc Director, IVF Florida Reproductive Associates, Margate, FL, RMA Michigan, Troy, MI and Billings Clinic, Billings, MT
Vice President, MedTech, For Solutions and Chief Scientiﬁc Ofﬁcer, Innovation Fertility, New York, New YorkManaging Editor, Surveillance
Steven J. Ory, MD
IVF Florida Reproductive Associates, Margate, FL
Professor of Obstetrics and Gynecology, Florida International University, Miami, FL
Voluntary Associate Professor of Obstetrics and Gynecology, University of Miami, Miami, Florida
Editor-in-Chief, Surveillance

SPECIAL THANKS
Leila Grass
MedTech For Solutions, New York, New York
Dave Listijono, MBBS, FRANZCOG, PhD
IVFAustralia, UNSW

169