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Fertility matters draft


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Fertility matters draft

  1. 1. Fertility Europe Fertility Matters For one in six fertility is an issue
  2. 2. Fertility Matters What is at stake across Europe regarding Fertility for the years to come1 Who we are .................................................................................. 32 Key facts on Fertility ................................................................. 53 Consequences of Infertility........................................................... 74Medically Assisted Reproduction (MAR) ....................................... 95 Ethics .......................................................................................... 116Equality of Access to Treatments ..................................................127 Criteria to ensure Equality of Access to Treatment ....................... 148 Prevention and Education.......................................................... 169 Fertility Europes recommendations.............................................. 18Glossary .......................................................................................21References .................................................................................. 22 Fertility Matters - March 2013 2
  3. 3. Correspondence address: office@fertilityeurope.eu1 Who we areFertility Europe history and values - To build a strong cross border network amongst European patients and healthIn 2008, a small group of European associations professionals in order to achieve the sharinginvolved with fertility issues felt the need to of best practise;establish a uniting European umbrellaorganisation, based on democracy, transparency - To promote societal changes regarding theand being a truly representative body and voice of perception of infertility;those concerned with fertility problems, indiscussions with the policymakers and the media. - To promote education in the area of the protection of reproductive health and a pro- active approach to family planning.A European representativeassociation Special Families CampaignTodayFertility Europe is the largest and most All over Europe, people are struggling to conceiverepresentative association of European and Fertility Europe has the deepest respect fororganisations involved with fertility issues with those in this position. However, although difficultmembers from over 20 European countries. In for some, they can and do move on, and oftenour national organisationswe are all, involved on a create a special family on their own.daily basis with assisting those affected bydifficulties in conceiving. In 2011, Fertility Europe started the Special Families campaign. We have asked those people who have had to go the extra mile to become aOur goals family, to share their story through www.fertilityeurope.euThe fact that so many people across Europe needreliable information on fertility, its protection and The idea is to send a Postcard of Hope, whetherimprovement, and on infertility, its treatment and you are a family with children after treatment,options has led us to work together and we share adopted, naturally conceived after years of trying,four main goals: still waiting for your dream to come true, a family of two or other “special” family.- To improve the rights of those affected by difficulties in conceiving; Fertility Matters - March 2013 3
  4. 4. Within a few months we received hundreds of messages.stories with photographs and strong personal Fertility Europe represents 25 million people who have difficulties in conceiving acrossEurope through 23 patient associations and interest groups in 22 countriesFertility Europe membersBelgium Sdruzhenie Zachatie DenmarkDe Verdwaalde Ooievaar Netwerk Landsforeningen for ufrivilligtFertiliteit Croatia barnlosehttp://www.deverdwaaldeooievaar.b www.lfub.dke/ Association RODA FinlandBulgaria Lapsettomien yhdistys Simpukka ry Czech RepublicIskambebe ADAM France Fertility Matters - March 2013 4
  5. 5. Maia The Netherlands www.infertilitate.com Freya - Vereniging voorGreece Slovak Republic vruchtbaarheidsproblemenKiveli Občianske združenie Norway SwedenOrszágos Lombikbébi Támogató ØNSKEBARN BarnlängtanAlapitvány SwitzerlandIceland Verein Kinderwunsch Poland Nasz Bocian United Kingdom Infertility Network UKCHEN - Patient Fertility Association Portugal Associação Portuguesa de (in) Turkey FertilidadeItaly Çider www.cocukistiyorum.comAmica Romania SOS Infertilitatea2 Key facts on Fertility iThe first successful birth of a "test tube baby", Louise Brown, occurred in 1978. Since that time over five millionindividuals have so far been born worldwide following in vitro fertilisation. Professor Robert G. Edwards, thephysiologist who developed the treatment, was awarded the Nobel Prize in Physiology or Medicine in 2010.For 1 on 6 Fertility is an issue In 2005 the number of MAR treatment cycles in the EU exceeded 400,000 compared toii approximately 200,000 cycles ten years earlier so One in six people worldwide experience some an increase of 100% (see figure 1)form of fertility problem at least once during their iiireproductive lifespanmeaning that a potential 25million EU citizens are estimated to be havingdifficulties in conceiving. v Number of Medically Assisted Reproduction CyclesEurope performs the most cycles of 450000MAR worldwide... 400000 350000iv 300000 Europe leads the world in the number of cycles 250000taking place, initiating approximately 54%of all 200000reported Medically Assisted Reproduction (MAR) 150000treatment cycles. 100000 50000... and faces a constant increase 0 1996 1997 1998 1999 2000 2001 Fertility Matters - March 2013 5
  6. 6. This includes those diagnosed with secondary infertility which is defined as infertility in a couple who already had at least one pregnancy, whetherInfertility is a medical condition that be a pregnancy resulting in the birth of a baby or a pregnancy that has miscarried, resulted in an ectopic pregnancy or led to a decision to terminateInfertility is recognized by the World Health the pregnancy for medical reasons.Organization as a disease and, withoutinvestigations and treatment, this medicalcondition prevents people of reproductive agefrom fulfillingthe life goal of becoming a parent.People should be referred for investigations after 6months and up to 2 years of trying to conceivewith regular intercourse. However if there issomething in their medical history which indicatesa fertility problem e.g. amenorrhoea, or where thefemale is aged 36 or over (given the impact of theage of the female on the success of treatment),investigations and possible treatment should beconsidered sooner.Causes of infertilityvi 20-30% of infertility cases are linked to physiological causes in men, 20-35% to physiological causes in women,and 25-40% of cases are due to a joint problem. In 10-20% no cause is found. Causes of infertility vi Relative frequency of the different causes of infertility The total is greater than 100% because some couples have more than one cause. 28% 24 % defect/dysfunction Endometriosis 21 % Coital failure defects/dysfunction Ovulatory Failure Other male 14 % infertility Fertility Matters - March 2013 Unexplained 6 Mucus 11% Damage Others Sperm Tubal 6% 6% 3% 2%
  7. 7. 3 Its consequencesMost people affected by problems in conceiving find it difficult to deal with, both physically andemotionally. impacting on relationships with partners, family members and friends.Infertility can lead to depression Emotional troublesInfertility is a medical condition which can cause If infertility is prolonged, studies have found thatsevere side effects such as depression. There is a people go through an extremely stressful andwidespread mistaken belief that life continues as emotional experience. Their sense of self, theirbefore. The childlessness, the prolonged identity and the meaning and purpose of life areuncertainty, and the monthly attempts to become challenged.pregnant, sometimes over several years, can affectevery aspect of a person’s life, as well as Fertility Matters - March 2013 7
  8. 8. The experiences of couples who have hadinfertility treatment in the United Kingdom: resultsof a survey performed in 1997:vii Tearfulness 97% Depression/isolation 94% Anger 84% Inadequacy 72% “Having been through infertility myself and benefi Guilt/shame 62% by the patient association, I recognized how involved.” Suicidal feelings 20% Clare Lewis-Jones MBE, Chief Executive, Infertility Networ & Chair of Fertility EuropeSocietal troubles and isolation The role of patient associationsAs the years go by, this is a burden that many Patient associations contribute to the reduction ofpeople bear. People experience an impaired ability anxiety levels by informing those affected of theto function normally in society for long periods of reproductive biology, the pathology and thetime. For some, events such as the announcement treatment options.of pregnancies within close circles, childrensbirthdays, and religious celebrations related to They emphasize the role of counseling and itsnativity, Mothers Day and other similar occasions benefitsas well as the importance of offering it atare extremely distressing, difficult to deal with and an early stage.are a painful reminder of their fertility problems. What society do we want?Medical treatments that can help to resolve thisproblem have been developed. However infertilitycan still be a socially taboo subject. Society is changing, and with it, the average age of conc treatments being undergone by women aged between thePeople often have to face stereotypes, prejudices, important and increasing issue for Europe. We cant ignoremisunderstandings and guilty feelings. Thus some linked to infertility in our society.people do not dare to address this issue withfriends and family. Little by little they become They also offer support groups which provide ansocially isolated, even more so if children are additional forum for the explanation of many areaspresent in their network and neighbourhood. of reproductive medicine and the impact of related technology.Professional troubles They can reduce the sense of isolation by allowing people to meet others with similar problems.The impact of fertility problems on men andwomen may also affect their professional life.They need to take time out from their career forinvestigations and treatment. Fertility Matters - March 2013 8
  9. 9. 4 Medically Assisted Reproduction Some specifics about IVF viii IVF is a process by which an egg is fertilised by sperm in vitro(“in glass”) i.e. outside the body. IVF is a treatment for infertility when other methodsWhat are the different treatments? of assisted reproductive technology have failed. IVFis performed by monitoring a woman’sMedically Assisted Reproduction (MAR) ovulatory process and collecting ovum or ova (eggtreatments include fertilisation in vivo such as or eggs) from the woman’s ovaries and placingsimple hormonal treatments and insemination them with sperm in a fluid medium in a petri dish(Intra-uterine Inseminaton - IUI), as well as in vitro within a laboratory for hopeful fertilisationfertilisation (IVF) and intracytoplasmic sperm resulting in an embryo/s. The embryos obtainedinjection (ICSI). following this procedure are transferred back into the uterus. Fertility Matters - March 2013 9
  10. 10. Additional techniques that are routinely used inMAR include ovarian stimulation to retrievemultiple eggs, ultrasound-guided transvaginaloocyte retrieval directly from the ovaries, egg andsperm preparation, as well as culture and selectionof resultant embryos before embryo transfer backinto the uterus.MAR may also assist in the treatment of maleinfertilitye.g. abnormal sperm.In such cases,intracytoplasmic sperm injection (ICSI) may beused, where a sperm cell is injected directly intothe egg cell. This is used when sperm havedifficulty penetrating the egg. ICSI is also usedwhen sperm numbers are very low.Gamete donationMAR may also be offeredfor those who are notable to use their own gametes (egg and/or sperm)byusing donated gametes. . Fertility Matters - March 2013 10
  11. 11. 5 EthicsAccess to Medically Assisted Reproduction createsa philosophical dilemma regarding the future ofthe children born.In order to raise the issue with public authorities, “I see the need for regulations,the media and the general public, Fertility Europe best practice exchange and ethicsis actively contributing to the bioethical and on European level and identifiedsocietal reflection. huge need for prevention and education.”Our objective is to bring different views andperspectives to these debates bearing in mind our Denisa Priadková, Chair of Občianske združenietireless promotion of progressive policies, effective BOCIAN &Fertility Europe Vice-Chairpractices and universal human rights i.e.1. The right to found a family and to procreate;2. The wellbeing and welfare of children to come;3. Responsibilities of the future parents towards the community;4. The right of deciding to become parents through treatments or not. Fertility Matters - March 2013 11
  12. 12. 6 Equality of Access to Treatment Why should there be equity of access to treatments? Ensure sustainable population growth rates Addressing reproductive care is a challenge that European governments are tackling whilst addressing the maintenance of balanced populations with sustainable population growth rates. However, infertility may be erroneously side lined and is considered to be a low priority on the public health care stage in many European countries. The right to found a family and to European Parliament’sresolution procreate ix The European Parliament notes that infertility is x A recent jurisprudence from the European Court a medical condition which can cause severe side of Justice has stated that Article 8 of the effects such as depression. It points out that European Convention on Human Rights provides infertility is on the increase occurring in a right to respect for one’s “private and family approximately 15 % of people, and therefore calls life, home and his correspondence” and that it on the Member States to ensure the rights of could be applied in case of Medically Assisted those affected to universal access to infertility Reproduction (MAR) because of the special treatment. importance of the right to found a family and to procreate. Examples of disparities across Europe Reimbursement of In Vitro Fertilisation / ICSI across Europe in Public Centers and Number of cycles reimbursedEurope Diverse legislations across across Europe, data provided from the FE members associations, April 2012 xi 19 Member States of the European Union have Number of cycles Number of cycles Countries Laboratory Drugs Consultations Blood specificUltra Sounds legislations in place for MAR. IVF/ICSI In the IUI Czech Rep. 100% 100% 100% remaining 100% 100% 8 countries, MAR is covered by the 6 4 or 3* France 100% 100% 100% general health legislation. Israel, Switzerland, 100% 100% 6 4 to 5 Poland** Croatia and Norway have different legislation in 3 Portugal 100% 69% 100% place. 100% 100% 3 3 Romania*** Slovakia 75% 75% 100% 100% 100% 0 0 to 2 or 3 Sweden 100% 100% 100% 100% 100% 6 0 to 3 UK 0 or 100%**** 0 or 100% 0 or 100% 0 or 100% 0 or 100% 0 to 6 0 to 3 Fertility Matters - March 2013 12 : No reimbursement * Czech Rep.: 4 if the first 2 with SET or 3 without SET ** Poland: will provide from July 2013 on financing for 15,000 couples; both married and unmarried, for up to three in-vitro procedures for three years after other fertility treatments fail.*** Romania: Since 2011 a pilot fund from the Health Ministry funded partially for 800 couples the consultations and IVF procedures (no laboratory, no drugs, no blood reimbursed) and a partial reimbursement for one IVF cycle for a limited number of couple****UK: Depend on the postcode
  13. 13. Quality in MAR As with every medical treatment, MAR has to be a treatment of quality requiring four dimensions, relevant from the patients perspective. 1 Safety A safe treatment avoids the most common risks encountered with MAR such as Ovarian Hyperstimulation Syndrome (OHSS) or multiples pregnancies. These consequences can highly impact both on the mother and/or childrens health. 2 EffectivenessInequality of access to treatment The success rates (pregnancy rate, delivery rate...) of the different MAR treatments are important toThere is inequality of access to fertility treatment thepatientswho need transparent information onright across Europe. Some countries provide well the important procedures they will undergo in– some do not. Inequalities consist of disparity in order to make informed decisions.the treatments which are permitted in somecountries, the eligibility criteria to treatment andin reimbursement policies.In some countries, the 3 Patient centredright of access to fertility treatment does notnecessarily mean that there is also a right to Treatments should be patient centred and notpublic funding of that treatment. technology centred: communication between patients and clinics, counselling, emotionalTreatment reimbursement support,patient involvement and privacy, competence of clinics and staff are elements facilitating the well being of the patient.Fertility treatment is fully reimbursed in somecountries but the number of cycles being fundedvaries. In others, it is only partially reimbursed 4 Accesswith only treatments up to, but not including,MAR such as In Vitro Fertilisation (IVF), being Inequalities consist of the variation of thereimbursed forcing those whose only chance of eligibility criteria being employed to accessconceiving using such treatment into the private treatment, the type of treatments allowed andsector or outside their own country. the disparity in reimbursement. Disparities in MAR process Fertility Matters - March 2013 13
  14. 14. 7 Criteria to ensure Equity of Access to TreatmentAccess to Medically Assisted Reproductiontreatments should be governed by the same Clinical effectiveness is the ability of a procedureprinciples as other health services, namely needs or treatment to achieve the desired result.assessment, clinical effectiveness and cost Specifically, how well a particular test or treatmenteffectiveness. works when used in the real world, rather than in carefully controlled clinical trial. ClinicalIt is inequitable for fertility patients to be subject to effectiveness is not the same as efficacy.widen access criteria - arising perhaps from socialvalue judgement - which cannot be fully justified. Ingeneral, the main eligibility criteria for access toMAR treatments are the age of the female, thecouples’ marital status (married or legally livingtogether), and the existence of previous childrenfrom the current or a previous relationship.Health need assessmentHealth needs assessmentis a systematic and equal Cost effectivenessmethod for reviewing the health issues faced by apopulation, leading to agreed priorities andresource allocation that will improve health and Cost effectiveness is a type of economic evaluationreduce inequalities. used to determine the best use of money available for medical care. Value for money. A test or treatment is said to be cost-effective if it leadsClinical effectiveness Fertility Matters - March 2013 14
  15. 15. to better result than would otherwise be achievedby using the resources in other ways. Fertility Matters - March 2013 15
  16. 16. 8 Prevention and EducationThis subject is about two issues gathered as one, Governments which promote and support birthpromoting prevention to Europe’s politicians and control should equally inform the public of the riskpolitical institutions, and educating the public to their fertility from delaying having a child.about the causes of infertility. Governments should also work towards familyIndeed the importance of the prevention of friendly environments, to make sure delayinginfertility has not been of great enough parenthood is not the only answer for men andsignificance to governments, health agencies and women who have not found a balancedsocial organisations dealing with fertility. professional, social or economical situation.European governments need to be more active inpromoting public prevention of infertility.Infertility needs to be considered a medical Infertility is equally shared by bothcondition as much in need of support as otherchronic conditions which attract funding and for genderswhich there are prevention campaigns. The general public need to know that infertility isIn fact preventive measures can start before not solely a woman’s problem and that 45-70 % ofconception, maybe even before the time people cases are caused by either male factors or joint xiirealize they wish to have children. But preventive factors . As such infertility is a problem shared bythinking might also be important for couples who both partners and therefore both genders.intend to have children much later in life. Education on the causes of infertility must includeLifestyle choices can impact on future fertility. If information for men on reproductive health andpeople are aware of this they may consider what can impact on their fertility. To do thislifestyle changes which could help their fertility in effectively, fertility must be separated out fromthe future. virility to show it has nothing to do with masculinity.How to protect infertility The best place to start educating people on what impacts on their fertility and the causes of infertility is with teenagers and young adults, asOne method of prevention should include they are the potential parents of the future, andinformation on the types of fertility disorders, the infertility will be a major concern for a largepossibilities of detection, chances and risks of proportion of them without that education. Anytreatments, their psychosocial and ethical context. education curriculum about reproduction mustThis knowledge is essential for informed decision- include a component on infertility to ensuremaking and to overcome the dilemma such informed decision-making.decisions may cause. Fertility Matters - January 2013 16
  17. 17. Infertility NetworkUKs educational leaflet on Lifestyles impacting on future fertilitySexually transmittedinfections Anabolic steroidsThe prevention of sexually transmittedinfection is vital for health in general; it is Anabolic steroids, which menimportant that the public is aware this is a sometimes take to improve theirminority cause of infertility and can be performance in sports and boostlinked to less than 10 % of causes. muscle, may lead to serious fertilityHowever in countries which do not provide problems. They can cause the testiclessexual education the amount of infertility to shut down completely, and thecases caused by sexually transmitted effects are not always reversible.diseases seems to be higher than incountries which apply such programs. Recreational drugs Recreational drugs, even those which you may think are not particularly Delaying parenthood harmful such as cannabis, may have an impact on both male and female fertility. Little is done to advise young adults about the effects of delaying parenthood which is a major cause of fertility problems. Fertility in women drops dramatically from their mid 30’s as well in men. Weight In addition, the intervening years exposes Weight problems can affect your them and their partners to longer periods of fertility if you are very overweight or risk such as (i) Changes in egg quality and underweight. Obesity is linked to number; (ii) Changes in quality of sperm; (iii) ovulation problems for women and Potential to make a normal embryo may be with lower sperm counts for men. less good; (iv) Fibroids and early pregnancy Being very underweight is not good for losses which also could have a your fertility either; women need some detrimentaleffect on their fertility. body fat in order to produce eggs normally.Eating disorders Excess or binge drinkingEating disorders can lead to fertility Excess or binge drinking can make itproblems. Women who are anorexic often harder to conceive for both men andfind that their periods stop, and this can have women, affecting sperm and egga lasting impact even if a woman is able to production.maintain a normal weight in the future.Bulimia is linked with polycystic ovarysyndrome, a condition which affects the way Smokingwomen’s ovaries work. Smoking is known to be detrimental to Fertility Matters - January 2013 17 fertility. Women who smoke are twice as likely to have fertility problems as those who don’t and also often have a shorter reproductive life as they tend to have an earlier menopause
  18. 18. 9 Towards a European Pact to address ReproductiveHealth: Recommendations by Fertility EuropeOne in six people across Europe experience some form of fertility problem at least once during theirreproductive life span, meaning that a potential 25 million EU citizens are estimated to be having difficulties inconceiving. Infertility is recognized as a disease by both world and regional agencies such as the World HealthOrganization. Over the last 35 years medically assisted reproduction techniques have been developed fromsimple hormone treatments and artificial insemination up to and including in vitro fertilisation (IVF). Over 5million people have been born worldwide thanks to IVF.Ethics men i.e. women and men past the natural age of conceiving to become parents.1 People have the basic right to decide on the number of children they have, and when they have them. Theresponsibility of couples and individuals in theexercise of this right should take into accountthe needs of their living and future children,as well as their responsibilities towards thecommunity. 4 In relation to welfare of the child, both society and the medical profession2 There are different ways of resolving should take into account not only the involuntary childlessness, a full range of life expectancy and current state of health of Medically Assisted Reproduction the person, but also their expected futuretreatments, as well as adoption. Those state of health and the known physical andaffected should also have the option of psychological demands of being a parent.deciding against these treatments andalternatives and decide to live a life withoutchildren. Both options can bring a happy andfulfilled life. 5 Donation of gametes on commercial basis is ethically unacceptable.3 There are known risks in pregnancy in relation to age and therefore more information and national communitydebate is required before decisions about Access to Careassisting not only older women but also older Fertility Matters - January 2013 18
  19. 19. 6 Infertility is a medical condition and a health need and it should be covered as such by national social insurancesystems. document ensuring that the risks and benefits of treatment are described in a balanced, evidence-based framework, and appropriate warnings are given when that evidence is inadequate to assess the efficacy7 The inclusion of a full range of Medically Assisted Reproduction (MAR) treatments in the provision of basichealth care at least partially depends on thegeneral level of welfare in society. or safety of specific drugs, devices or procedures. 12 Access to psychological counselling should be offered in the framework of fertility8 Fertility investigations and treatment should be reimbursed across Europe, and treatments of proven benefit topatients should be made available, investigations and treatments. People should be offered implications counseling, particularly if their treatment includes the use of donated gametes and embryos. Theyirrespective of the patients income and place should be informed about any potential longof residence. term risks and psychological, social and medical ramifications.9 To avoid unjustified discrimination the principles of needs assessment, cost effectiveness and clinical effectivenessshould be used to determine the level of Prevention and Educationreimbursement for all assisted reproductionpossibilities.Safe and Quality 13 Public prevention of infertility has been inadequate to date and governments have a responsibility to promote unbiased rational information about all causes, implications and treatments options to help remove the myths andTreatments misunderstandings.10 People with difficulties in conceiving should be given accurate information in a range offormats and languages on all assisted 14 Male infertility needs to be highlighted as contributing to half of the causes. Infertility can no longer be considered a “woman’s” problem.reproduction possibilities, as well as adoptionand a life without child, as well as beingallowed to accept or to reject the diagnosis ortreatment without discrimination. 15 Education of the next generation about infertility and implications needs to start now. its11 19 Those undergoing MAR as well as those donating gametes should sign an informed consent Fertility Matters - January 2013
  20. 20. 16 Patients associations across Europe should be recognized as a driving force behind multi-stakeholders prevention campaigns to makeeducation programmes happen. Fertility Matters - January 2013 20
  21. 21. xiii GlossaryAssisted Reproduction Technology (ART): all treatments that include in vitro handling of humangametes (eggs and sperm) and embryos to establish a pregnancy – often called MAR (MedicallyAssisted Reproduction)Delivery rate: number of deliveries per 100 cycles (aspiration or embryo transfer cycles)Embryo: the product up to eight weeks after fertilisation, later it is called a foetusEmbryo donation: transfer of an embryo that did not originate from the recipient and her partnerEndometriosis: condition where endometrial tissue grows in areas other than the uterine cavityFertilisation: a sperm penetrates the egg leading to a combination of genetic material resulting in afertilised eggGamete: a reproductive cell, egg in females and sperm in malesInfertility: a disease of the reproductive system defined by the failure to conceive after 12 months ofregular unprotected sexual intercourseIntracytoplasmic sperm injection (ICSI): process by which an egg is fertilised by injecting a singlesperm into the eggIntrauterine Insemination (IUI): the insemination of washed semen directly into the uterusIn vitro fertilisation (IVF): fertilisation of an egg by sperm in a laboratory dish Fertility Matters - January 2013 21
  22. 22. Referencesi Press Release on the Official site of the Nobel Prize (2010) fact sheet June 2010 from the European Society for Human Reproduction andEmbryology (ESHRE). According to Eurostats 2008:48,7 % of the 497,4 millions EU citizens are between 14 and 49 years old :14-25 y. old (12,5 % ); 25-49 y. old (36,2%) = 242 millions1/6 of 242 millions = 40,3 millions.A potential of 25 millions EU citizens are estimated to be have difficulties in conceiving. Comparative Analysis of Medically Assisted Reproduction in the EU: Regulation andivTechnologies European Society for Human Reproduction and Embryology (ESHRE).[2].pdfv ART in Europe, Publications from 1997 to 2006, ESHRE ART fact sheet June 2010 from the European Society for Human Reproduction andviEmbryology (ESHRE). Kerr J. et al. (1999) The experiences of couples who have had infertility treatment in theviiUnited Kingdom : results of a survey performed in 1997. Human Reprod. Vol 14 : 934-938.viii Wikipedia Resolution on the demographic future of Europe from the European Parliament (2008). European Court of Justice: Case of S.H. and others v. Austria judgment 1 April 2010. Comparative Analysis of Medically Assisted Reproduction in the EU: Regulation andxiTechnologies European Society for Human Reproduction and Embryology (ESHRE).[2].pdfxi 20-30% of infertility cases are linked to physiological causes in men, 20-35% tophysiological causes in women, and 25-40% of cases are due to a joint problem. In 10-20%no cause is found.Report from the University of Bristol, Department of Obstetrics &Gynaecology by Professor Michael Hull: brief summary taken from an extensive reviewpublished in Human Reproduction in 1992. Law evasion and unequal access to treatment leads to cross-border reproductive care:xiiShenfield et al. (in press, 2009) Shenfield, F., de Mouzon, J., Pennings, G., Ferraretti, A.P.F., Fertility Matters - January 2013 22
  23. 23. Andersen, A.N., de Wert, G., Goossens, V. And Van den Eede, B., on behalf of the ESHRETaskforce on cross border reproductive care 2009. ESHRE Assisted Reproduction Technology (ART) Glossaryxiii Fertility Matters - January 2013 23