Is Fertility Treatment a Solution to Population Decline?

The latest PET event explored whether assisted conception can address challenges posed by falling birthrates and decreasing population sizes.

Declining birthrates – both in the UK and around the world – are causing concern because, in conjunction with people living longer, they are contributing to ageing societies and demographic change. In fact, on the same day that the event took place, it was reported that a maternity unit in the same London borough as PET's office will close because the birthrate in the area is so low.

Sarah Norcross, director of PET, who chaired the event, mentioned this news story in her introduction and also drew attention to a new section of the PET website which collates BioNews articles relating to population decline and related issues. Norcross introduced the first speaker, Professor Geeta Nargund, who is the lead consultant for reproductive medicine at St George's University Hospitals, London, and medical director of CREATE Fertility and ABC IVF.

Professor Nargund began by outlining some key terms, including the total fertility rate (TFR) of a population – the average number of children born to each woman who lives to the end of her reproductive lifespan. For a population to remain stable without net migration the TFR needs to be 2.1, but in England and Wales, the TFR currently stands at 1.44 – an all-time low. In 2024, the number of deaths exceeded the number of births for the first time in 50 years.

Professor Nargund discussed the recent Economist Impact report Fertility Policy and Practice: A Toolkit for Europe, to which she contributed. She explained how the report saw a panel of experts review evidence and implement a rating system according to the impact that different types of policy could have on birthrates, considering the quality of evidence in each case.

The panel found that the greatest impact would likely be from improving the availability, accessibility and affordability of childcare. However, in joint second place were workplace policies and assisted conception policies.

The evidence reviewed suggested that improving access to assisted conception could raise the TFR by 0.04, and could have the societal benefits of reducing social stigma, improving wellbeing and achieving equity for people affected by infertility. Doing this was also seen as offering a good return on investment, even though the UK is one of the most expensive places to have IVF. This view comes from considering the projected economic activity of each extra person born throughout their lifetimes, and reducing costs associated with multiple births and with mental health issues in people with infertility.

The second speaker, Professor Bart Fauser, is the scientific director of the International Federation of Fertility Societies (IFFS) and emeritus professor of reproductive medicine at Utrecht University, the Netherlands.

Professor Fauser's presentation highlighted international perspectives, explaining that fertility rates are in decline across almost all countries in the Organisation for Economic Cooperation and Development (OECD). He outlined several trends that are contributing to this, most significantly the fact that more people are not having children at all, and those who do have children tend to start their families later in life.

Professor Fauser discussed the IFFS consensus document on declining global fertility rates, of which he is the lead author. This document concludes that having a family (if you want to) is a human right, so countries need to adopt family-friendly policies and make fertility treatment more accessible (including for same-sex couples and single people).

However, Professor Fauser warned that because IVF is not always successful, assisted conception cannot entirely compensate for reductions in birthrate caused by people choosing to have children later in life. There is also a need for better education, to ensure that people are realistic about their chances of becoming parents if they wait longer.

The third speaker, Dr Chris Skedgel, is director of the Office of Health Economics and an honorary research fellow at the University of East Anglia's Health Economics Group.

Dr Skedgel opened his presentation by further exploring the factors that drive the fall in TFR. He pointed out that much of this is directly related to advances in quality of life, and that framing population decline as a crisis can make it easy to overlook this aspect.

For example, more educated women tend – on average – to have fewer children, and countries with higher human development indices have lower rates of childbirth. When child mortality is low and child labour is not practised, it makes sense for parents to have fewer children, and try to give these children the best education and future.

Furthermore, access to contraception and reduced stigma around childlessness make being child-free more of an option. These are advances that should not be wished away.

However, Dr Skedgel added that addressing infertility represents an opportunity to increase the number of births while helping people to achieve their desired family. According to the World Health Organisation, one in six couples are affected by infertility. Dr Skedgel estimated that providing access to fertility treatment might address ten percent of the TFR gap.

He ended by referencing the economist Professor Andrew Scott's 2024 OHE Annual lecture, and the idea that rather than trying to change our demography to make our institutions work, perhaps we should change our institutions to work for an ageing society.

The final speaker – Dr Paul Morland – is a demographer, broadcaster and author of books including No One Left: Why the World Needs More Children and Tomorrow's People: The Future of Humanity in 10 Numbers.

Dr Morland began by contrasting two different interpretations of fertility – biological fertility (the ability to have children) and the TFR (whether people actually have children or not). Biological problems only affect a minority of people, he said, so IVF will only be a small part of the solution.

He outlined factors that he saw as having major effects – dissociation between men and women when it comes to building relationships, cities that are not family-friendly, and the 'propaganda of anti-natalism'. His proposed solution was for governments and societies to build a 'pro-natal' culture, where raising children is seen as a social and civic responsibility. State support for parents sends a message to society about the importance of future generations.

One example discussed by Dr Morland was Israel, which has the highest TFR of any OECD country, at 2.89, well above the replacement rate. Israel's government offers very generous fertility treatment funding, as well as using 'pro-natal' rhetoric.

The audience had plenty of questions for the panel, some of which concerned the way that immigration can play a role in preventing population decline. However, it was pointed out by Dr Skedgel that this can be politically unpopular.

Professor Nargund added that older people are often more resistant to immigrants, so it can be harder for people to come to countries with ageing populations. Dr Morland observed that the number of countries with high birthrates is diminishing, and argued that inviting the most educated or qualified people from other countries is a form of 'biological imperialism'.

There was also discussion about the association between pro-natalism and far-right movements. Dr Morland said one of the best ways to counter this is to explain that population decline is a global issue, and certainly not limited to white populations.

Another issue that came up on several occasions was the idea of improving education about the consequences of delaying family building. The panel agreed that young people need to understand the facts about declining fertility, so they can make free but informed choices.

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PET is grateful to Merck for supporting this event.

The issues that were discussed at this event will be further explored next week, at the free-to-attend PET event Fertility in Flux: What Can State-Funded IVF Do for Population Growth?.

Next week's event is taking place on Wednesday 9 April. Find out more and register here.