With the Japanese government pledging to expand subsidies and coverage for infertility treatment as part of an effort to slow population decline, the author introduces surprising new findings on the outcomes for Japanese couples who have dropped out from treatment programs.

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Among the major new policy measures embraced by the cabinet of Prime Minister Yoshihide Suga—albeit largely overshadowed by the COVID-19 response—is its plan to make infertility treatment more affordable and accessible. With such moves in mind, I introduce recent research on a seldom-studied topic, childbirth outcomes among couples who discontinued treatment before achieving pregnancy.

Background

The Suga administration is planning to expand subsidies for infertility treatment and to make such treatment eligible for coverage under Japan’s national health insurance beginning April 2022. According to a recent survey by the Ministry of Health, Labor, and Welfare, the cost of one cycle of in vitro fertilization currently ranges from under ¥200,000 to more than ¥1 million, depending on the provider. Under the circumstances, government assistance and expanded insurance coverage could make a big difference for couples seeking treatment.

One factor behind the new policy emphasis is doubtless the growing importance and rising profile of infertility treatment in Japan. According to the National Fertility Survey (Marriage Process and Fertility of Married Couples) conducted by the National Institute of Population and Social Security Research (IPSS), the proportion of married couples who are or have worried about their ability to have children rose from 26.1% in 2002 to 35.0% in 2015. Among childless couples, the share rose from 48.2% in 2002 to 55.2% in 2015.

If we break childless couples down by the wife’s age, we find that a full 42.5% of those in the 30–39 age group currently have fertility concerns, as compared with 21.9% of those aged 20–29 and 14.0% of those aged 40–49. The 2015 survey also found that 18.2% of all respondents had undergone testing or treatment for infertility at some point (up from 12.7% in 2002) and that 28.2% of childless couples had done so (up from 25.5%). In short, fertility concerns are on the rise, and testing and treatment are becoming more common.

Delayed marriage is doubtless a major factor behind this trend. The average age for first marriage among Japanese women rose from 25.3 years in 1987 to 29.1 years in 2015. Older couples are likely to be more anxious about the chances of getting pregnant, fearing that the window of opportunity is closing.

A Neglected Area of Research

Not surprisingly, the majority of studies on infertility treatment are undertaken from a medical standpoint with the aim of establishing the success rate of different treatments under various circumstances. Significant work has also been carried out from the standpoint of nursing science. A substantial body of survey research has already been conducted with a view to identifying the reasons couples drop out from treatment before achieving their goal. Such studies have found that poor communication with medical and nursing staff, the woman’s age, and her mode of employment figure prominently. None of these results are what one would call unexpected.

Recently, I partnered with Emiko Usui (professor, Hitotsubashi University), Marie Hirakawa (graduate student, Hitotsubashi University), and Nahoko Mitsuyama (associate professor, International University of Health and Welfare) on a survey study that approached the subject from a different angle, tracking and analyzing outcomes among fertility-treatment “dropouts.”

Given the large number of people who drop out, no reliable evaluation of the overall merits and drawbacks of fertility treatment is possible unless we look at those who abandon treatment along with those who are continuing it or have completed it successfully. Unfortunately, information on outcomes among treatment dropouts is hard to find. Since infertility treatment is conducted outside the framework of the national health insurance system, medical and billing records are kept separate. Fertility clinics and treatment centers have no need to maintain the records of former patients, let alone follow up on them. In short, the raw data for analysis do not exist.

Apparently, the situation is much the same in other countries. Having carefully reviewed the literature, I came across only one previous study that had tracked the parenthood status of patients after discontinuance of unsuccessful infertility treatment—a French study published in a prestigious international journal in 2008. The authors, who collected their own data from former infertility patients, found that nearly half had achieved parenthood after discontinuing treatment and concluded that “unsuccessful patients should not lose hope.” It should be noted, however, that only one-fourth of those studied had actually achieved live birth; the other one-fourth had become parents via adoption. Furthermore, the study looked only at those who had given up on in vitro fertilization (IVF), excluding those who had dropped out at earlier stages of treatment.

IVF is typically the third and last stage in infertility treatment. In the first stage, timed intercourse (TI), the medical team helps the couple improve their chances for conception by predicting when ovulation is likely to occur on the basis of hormone levels, body temperature, and ultrasound imaging, while counseling the couple on the optimum timing for intercourse. If that fails, the next step is intrauterine insemination (IUI), in which sperm is collected, washed and screened for quality, and then placed directly in the woman’s uterus. The last stage is IVF, in which eggs are retrieved from the woman’s ovaries and fertilized with sperm in a lab to yield embryos that are later transferred to the womb. IVF is considered the most effective form of assisted reproductive technology, but it is also the most expensive. However, since a substantial number of patients drop out at the earlier stages, it would clearly be helpful to know their outcomes as well.

Good Odds of Pregnancy After Discontinuation

In order to determine the pregnancy outcomes for couples who have discontinued treatment at any of these stages, it is necessary to locate patients, ascertain whether they had dropped out and at what stage, and inquire as to their current pregnancy or parenthood status.

With this in mind, we adopted a relatively straightforward approach. We contacted close to 2,000 adults who had previously participated in a nationwide Internet survey conducted by the Institute of Economic Research at Hitotsubashi University and asked them if they had ever undergone infertility treatment. We received affirmative responses from 199, roughly 10% of the total.

As indicated in the table below, 45.7% of those respondents indicated that they (or their wives) had successfully achieved pregnancy during one of the three aforementioned stages of treatment. The remaining 54.3% had abandoned treatment without achieving the desired outcome. These findings confirm the high overall rate of discontinuation among couples undergoing infertility treatment. Interestingly, about half of those who dropped out did so at the first stage, TI.

Chances of Pregnancy During Infertility Treatment and After Discontinuation

a. Timed intercourse.
b. Intrauterine insemination.
c. In vitro fertilization.

Our main focus, however, was outcomes among those who had discontinued treatment. Of the 108 individuals who had dropped out, 66, or roughly 60%, subsequently achieved live birth. The study also found that the frequency was substantially lower among those who advanced as far as IVF before dropping out. This is not surprising, given that only couples who have had considerable trouble conceiving would advance to that stage to begin with. By contrast, more than 70% of those who dropped out during the first stage, TI, subsequently achieved pregnancy. All told, of the 199 respondents who had undergone infertility treatment, 33.2% became pregnant after discontinuing treatment (as compared with 45.7% during treatment). Like the aforementioned French study, the results of our analysis hold out hope for couples who have given up on treatment.

Need for Further Study

We also analyzed the statistical relationship of such factors as age and socioeconomic status to discontinuation, as well as their association with pregnancy outcomes, whether during treatment or after discontinuation. We found that the probability of discontinuation increases, and the chances of an eventual pregnancy fall, as the woman’s age at the start of treatment rises. These results are consistent with common sense and previous research findings.

Given the limited size of the survey sample, the authors stress the need for larger-scale surveys accompanied by in-depth analysis. Along with the aforementioned “message of hope,” the study’s findings indicate that discontinuation does indeed lower the probability of achieving pregnancy, even after controlling for other factors. The need for policy measures aimed at facilitating continued treatment for subfertile couples is undeniable. At the same time, a better grasp of the factors leading to discontinuation and of post-discontinuation outcomes is needed to accurately evaluate the efficacy of treatment and design sound policies in support of couples’ reproductive goals.