Fertility Matters

Fertility Europe

For one in six fertility is an issue

Fertility Matters

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

1 Who we are..............................................................3

2 Key facts on Fertility................................................3

3 Consequences of Infertility.......................................3

4 Medically Assisted Reproduction (MAR)....................3

5 Ethics......................................................................3

6 Equality of Access to Treatments..............................3

7 Criteria to ensure Equality of Access to Treatment....3

8 Prevention and Education........................................3

9 Fertility Europe's recommendations..........................3

Glossary....................................................................3

References................................................................3

Correspondence address: office@fertilityeurope.eu

1 Who we are

Fertility Europe history and values

In 2008, a small group of European associations involved with fertility issues felt the need to establish a uniting European umbrella organisation, based on democracy, transparency and being a truly representative body and voice of those concerned with fertility problems, in discussions with the policymakers and the media.

A European representative association

Today Fertility Europe is the largest and most representative association of European organisations involved with fertility issues with members from over 20 European countries. In our national organisations we are all, involved on a daily basis with assisting those affected by difficulties in conceiving.

Our goals

The fact that so many people across Europe need reliable information on fertility, its protection and improvement, and on infertility, its treatment and options has led us to work together and we share four main goals:

- To improve the rights of those affected by difficulties in conceiving;

- To build a strong cross border network amongst European patients and health professionals in order to achieve the sharing of best practise;

- To promote societal changes regarding the perception of infertility;

- To promote education in the area of the protection of reproductive health and a pro-active approach to family planning.

Special Families Campaign

All over Europe, people are struggling to conceive and Fertility Europe has the deepest respect for those in this position. However, although difficult for some, they can and do move on, and often create a special family on their own.

In 2011, Fertility Europe started the Special Families campaign. We have asked those people who have had to go the extra mile to become a family, to share their story through www.fertilityeurope.eu

The idea is to send a Postcard of Hope, whether you are a family with children after treatment, adopted, naturally conceived after years of trying, still waiting for your dream to come true, a family of two or other “special” family.

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

Fertility Europe members

Belgium De Verdwaalde Ooievaar Netwerk Fertiliteit http://www.deverdwaaldeooievaar.be/

Bulgaria Iskambebe www.iskambebe.bg

Sdruzhenie Zachatie

www.zachatie.org/

CroatiaAssociation RODA www.roda.hr

Czech RepublicADAM http://www.adamcr.cz/

DenmarkLandsforeningen for ufrivilligt barnlose www.lfub.dk

FinlandLapsettomien yhdistys Simpukka ry http://www.simpukka.info/

France

Maia http://www.maia-asso.org/ GreeceKiveli www.kiveli.gr/

HungaryOrszágos Lombikbébi Támogató Alapitvány http://www.lombikbebialapitvany.hu/

IcelandTilvera www.tilvera.is

IsraelCHEN - Patient Fertility Association http://www.amotatchen.org/

Italy Amica Cicogna www.amicacicogna.it/

The NetherlandsFreya - Vereniging voor vruchtbaarheidsproblemen http://www.freya.nl/

Norway

ØNSKEBARN http://www.onskebarn.no/

PolandNasz Bocian http://www.nasz-bocian.pl/

PortugalAssociação Portuguesa de (in) Fertilidade www.apfertilidade.org

RomaniaSOS Infertilitatea www.infertilitate.com

Slovak RepublicObčianske združenie BOCIAN http://www.bocianoviny.sk/

SwedenBarnlängtan www.barnlangtan.com/

SwitzerlandVerein Kinderwunsch http://www.kinderwunsch.ch/

United KingdomInfertility Network UK

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

http://www.infertilitynetworkuk.com/ Turkey Çiderwww.cocukistiyorum.com

2 Key facts on Fertility

i

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

For 1 on 6 Fertility is an issue

iiOne in six people worldwide experience some form of fertility problem at least once during their reproductive lifespan meaning that a potential iii25 million EU citizens are estimated to be having difficulties in conceiving.

Europe performs the most cycles of MAR worldwide...

ivEurope leads the world in the number of cycles taking place, initiating approximately 54% of all reported Medically Assisted Reproduction (MAR) treatment cycles.

... and faces a constant increase

In 2005 the number of MAR treatment cycles in the EU exceeded 400,000 compared to approximately 200,000 cycles ten years earlier so an increase of 100% (see figure 1)

v

Infertility is a medical condition

Infertility is recognized by the World Health Organization as a disease and, without investigations and treatment, this medical condition prevents people of reproductive age from fulfilling the life goal of becoming a parent.

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

This includes those diagnosed with secondary infertility which is defined as infertility in a couple who already had at least one pregnancy, whether that be a pregnancy resulting in the birth of a baby or a pregnancy that has miscarried, resulted in an ectopic pregnancy or led to a decision to terminate the pregnancy for medical reasons.

1996 1997 1998 1999 2000 2001 2002 2003 2004 20050

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Number of Medically Assisted Reproduction Cycles in Europe 1996-2005

Causes of infertility

vi20-30% 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.

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Causes of infertilityvi Relative frequency of the different causes of infertility

The total is greater than 100% because some couples have more than one cause.

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3 Its consequences

Most people affected by problems in conceiving find it difficult to deal with, both physically and emotionally.

Infertility can lead to depression

Infertility is a medical condition which can cause severe side effects such as depression. There is a widespread mistaken belief that life continues as before. The childlessness, the prolonged uncertainty, and the monthly attempts to become pregnant, sometimes over several years, can affect every aspect of a person’s life, as well as impacting on relationships with partners, family members and friends.

Emotional troubles

If infertility is prolonged, studies have found that people go through an extremely stressful and emotional experience. Their sense of self, their identity and the meaning and purpose of life are challenged.

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

vii

Tearfulness 97%

Depression/isolation 94%

Anger 84%

Inadequacy 72%

Guilt/shame 62%

Suicidal feelings 20%

Societal troubles and isolation

As the years go by, this is a burden that many people bear. People experience an impaired ability to function normally in society for long periods of time. For some, events such as the announcement of pregnancies within close circles, children's birthdays, and religious celebrations related to nativity, Mothers Day and other similar occasions are extremely distressing, difficult to deal with and are a painful reminder of their fertility problems.

Medical treatments that can help to resolve this problem have been developed. However infertility can still be a socially taboo subject.

People often have to face stereotypes, prejudices, misunderstandings and guilty feelings. Thus some people do not dare to address this issue with friends and family. Little by little they become socially isolated, even more so if children are present in their network and neighbourhood.

Professional troubles

The impact of fertility problems on men and women may also affect their professional life. They need to take time out from their career for investigations and treatment.

“Having been through infertility myself and benefited directly from the support offered by the patient association, I recognized how important that support is and got involved.”

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

The role of patient associations

Patient associations contribute to the reduction of anxiety levels by informing those affected of the reproductive biology, the pathology and the treatment options.

They emphasize the role of counseling and its benefits as well as the importance of offering it at an early stage.

They also offer support groups which provide an additional forum for the explanation of many areas of reproductive medicine and the impact of related technology.

They can reduce the sense of isolation by allowing people to meet others with similar problems.

4 Medically Assisted Reproduction

What society do we want?

Society is changing, and with it, the average age of conception with the largest number of treatments being undergone by women aged between the ages of 30 and 39. Infertility is an important and increasing issue for Europe. We can't ignore the impact of all the consequences linked to infertility in our society.

What are the different treatments?

Medically Assisted Reproduction (MAR) treatments include fertilisation in vivo such as simple hormonal treatments and insemination (Intra-uterine Inseminaton - IUI), as well as in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI).

Some specifics about IVF

viiiIVF is a process by which an egg is fertilised by sperm in vitro (“in glass”) i.e. outside the body. IVF is a treatment for infertility when other methods of assisted reproductive technology have failed. IVF is performed by monitoring a woman’s ovulatory process and collecting ovum or ova (egg or eggs) from the woman’s ovaries and placing them with sperm in a fluid medium in a petri dish within a laboratory for hopeful fertilisation resulting in an embryo/s. The embryos obtained following this procedure are transferred back into the uterus.

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

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

Gamete donation

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

5 Ethics

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

In order to raise the issue with public authorities, the media and the general public, Fertility Europe is actively contributing to the bioethical and societal reflection.

Our objective is to bring different views and perspectives to these debates bearing in mind our tireless promotion of progressive policies, effective practices and universal human rights i.e.

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

2. The wellbeing and welfare of children to come;

3. Responsibilities of the future parents towards the community;

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

10 Fertility Matters - March 2013

Denisa Priadková, Chair of Občianske združenie BOCIAN & Fertility Europe Vice-Chair

“I see the need for regulations, best practice exchange and ethics on European level and identified huge need for prevention and education.”

Examples of disparities across Europe Reimbursement of In Vitro Fertilisation / ICSI across Europe in Public Centers and Number of cycles reimbursed across Europe, data provided from the FE members associations, April 2012

Countries Laboratory Drugs Consultations Blood Ultra Sounds Number of cycles IUI

Number of cycles IVF/ICSI

Czech Rep. 100% 100% 100% 100% 100% 6 4 or 3*France 100% 100% 100% 100% 100% 6 4 to 5

Poland** 3Portugal 100% 69% 100% 100% 100% 3 3

Romania***Slovakia 75% 75% 100% 100% 100% 0 0 to 2 or 3Sweden 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

: 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

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.

European Parliament’s resolution

ixThe European Parliament notes that infertility is a medical condition which can cause severe side effects such as depression. It points out that infertility is on the increase occurring in approximately 15 % of people, and therefore calls on the Member States to ensure the rights of those affected to universal access to infertility treatment.

The right to found a family and to procreate

xA recent jurisprudence from the European Court of Justice has stated that Article 8 of the European Convention on Human Rights provides a right to respect for one’s “private and family life, home and his correspondence” and that it could be applied in case of Medically Assisted Reproduction (MAR) because of the special importance of the right to found a family and to procreate.

Diverse legislations across Europe

xi19 Member States of the European Union have specific legislations in place for MAR. In the remaining 8 countries, MAR is covered by the general health legislation. Israel, Switzerland, Croatia and Norway have different legislation in place.

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Inequality of access to treatment

There is inequality of access to fertility treatment right across Europe. Some countries provide well – some do not. Inequalities consist of disparity in the treatments which are permitted in some countries, the eligibility criteria to treatment and in reimbursement policies. In some countries, the right of access to fertility treatment does not necessarily mean that there is also a right to public funding of that treatment.

Treatment reimbursement

Fertility treatment is fully reimbursed in some countries but the number of cycles being funded varies. In others, it is only partially reimbursed with only treatments up to, but not including, MAR such as In Vitro Fertilisation (IVF), being reimbursed forcing those whose only chance of conceiving using such treatment into the private sector or outside their own country.

Quality in MAR

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

1 Safety

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

2 Effectiveness

The success rates (pregnancy rate, delivery rate...) of the different MAR treatments are important to the patients who need transparent information on the important procedures they will undergo in order to make informed decisions.

3 Patient centred

Treatments should be patient centred and not technology centred: communication between patients and clinics, counselling, emotional support, patient involvement and privacy, competence of clinics and staff are elements facilitating the well being of the patient.

4 Access

Inequalities consist of the variation of the eligibility criteria being employed to access treatment, the type of treatments allowed and the disparity in reimbursement.

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Disparities in MAR process

7 Criteria to ensure Equity of Access to Treatment

Access to Medically Assisted Reproduction treatments should be governed by the same principles as other health services, namely needs assessment, clinical effectiveness and cost effectiveness.

It is inequitable for fertility patients to be subject to widen access criteria - arising perhaps from social value judgement - which cannot be fully justified. In general, the main eligibility criteria for access to MAR treatments are the age of the female, the couples’ marital status (married or legally living together), and the existence of previous children from the current or a previous relationship.

Health need assessment

Health needs assessment is a systematic and equal method for reviewing the health issues faced by a population, leading to agreed priorities and resource allocation that will improve health and reduce inequalities.

Clinical effectiveness

Clinical effectiveness is the ability of a procedure or treatment to achieve the desired result. Specifically, how well a particular test or treatment works when used in the 'real world', rather than in carefully controlled clinical trial. Clinical effectiveness is not the same as efficacy.

Cost effectiveness

Cost effectiveness is a type of economic evaluation used to determine the best use of money available for medical care. Value for money. A test or treatment is said to be 'cost-effective' if it leads to better result than would otherwise be achieved by using the resources in other ways.

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8 Prevention and Education

This subject is about two issues gathered as one, promoting prevention to Europe’s politicians and political institutions, and educating the public about the causes of infertility.

Indeed the importance of the prevention of infertility has not been of great enough significance to governments, health agencies and social organisations dealing with fertility.

European governments need to be more active in promoting public prevention of infertility. Infertility needs to be considered a medical condition as much in need of support as other chronic conditions which attract funding and for which there are prevention campaigns.

In fact preventive measures can start before conception, maybe even before the time people realize they wish to have children. But preventive thinking might also be important for couples who intend to have children much later in life.

Lifestyle choices can impact on future fertility. If people are aware of this they may consider lifestyle changes which could help their fertility in the future.

How to protect infertility

One method of prevention should include information on the types of fertility disorders, the possibilities of detection, chances and risks of treatments, their psychosocial and ethical context. This knowledge is essential for informed decision-making and to overcome the dilemma such decisions may cause.

Governments which promote and support birth control should equally inform the public of the risk to their fertility from delaying having a child.

Governments should also work towards family friendly environments, to make sure delaying parenthood is not the only answer for men and women who have not found a balanced professional, social or economical situation.

Infertility is equally shared by both genders

The general public need to know that infertility is not solely a woman’s problem and that 45-70 % of cases are caused by either male factors or joint factorsxii. As such infertility is a problem shared by both partners and therefore both genders.

Education on the causes of infertility must include information for men on reproductive health and what can impact on their fertility. To do this effectively, fertility must be separated out from virility to show it has nothing to do with masculinity.

The best place to start educating people on what impacts on their fertility and the causes of infertility is with teenagers and young adults, as they are the potential parents of the future, and infertility will be a major concern for a large proportion of them without that education. Any education curriculum about reproduction must include a component on infertility to ensure informed decision-making.

Infertility Network UK's educational leaflet on

14 Fertility Matters - January 2013

Lifestyles impacting on future fertility

15 Fertility Matters - January 2013

Sexually transmitted infectionsThe prevention of sexually transmitted infection is vital for health in general; it is important that the public is aware this is a minority cause of infertility and can be linked to less than 10 % of causes. However in countries which do not provide sexual education the amount of infertility cases caused by sexually transmitted diseases seems to be higher than in countries which apply such programs.

Delaying parenthoodLittle 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. In addition, the intervening years exposes them and their partners to longer periods of risk such as (i) Changes in egg quality and number; (ii) Changes in quality of sperm; (iii) Potential to make a normal embryo may be less good; (iv) Fibroids and early pregnancy losses which also could have a detrimental effect on their fertility.

SmokingSmoking is known to be detrimental to 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

Excess or binge drinkingExcess or binge drinking can make it harder to conceive for both men and women, affecting sperm and egg

Recreational drugsRecreational drugs, even those which you may think are not particularly harmful such as cannabis, may have an impact on both male and female fertility.

WeightWeight problems can affect your fertility if you are very overweight or underweight. Obesity is linked to ovulation problems for women and with lower sperm counts for men. Being very underweight is not good for your fertility either; women need some body fat in order to produce eggs normally.

Anabolic steroidsAnabolic steroids, which men sometimes take to improve their performance in sports and boost muscle, may lead to serious fertility problems. They can cause the testicles to shut down completely, and the effects are not always reversible.

Eating disordersEating disorders can lead to fertility problems. Women who are anorexic often find that their periods stop, and this can have a lasting impact even if a woman is able to maintain a normal weight in the future. Bulimia is linked with polycystic ovary syndrome, a condition which affects the way women’s ovaries work.

9 Towards a European Pact to address Reproductive

Health: Recommendations by Fertility Europe

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

Ethics

People have the basic right to decide on the number of children they have, and when they have them. The

responsibility of couples and individuals in the exercise of this right should take into account the needs of their living and future children, as well as their responsibilities towards the community.

1

There are different ways of resolving involuntary childlessness, a full range of Medically Assisted Reproduction

treatments, as well as adoption. Those affected should also have the option of deciding against these treatments and alternatives and decide to live a life without children. Both options can bring a happy and fulfilled life.

2

There are known risks in pregnancy in relation to age and therefore more information and national community

debate is required before decisions about assisting not only older women but also older men i.e. women and men past the natural age of conceiving to become parents.

3

In relation to welfare of the child, both society and the medical profession should take into account not only the

life expectancy and current state of health of the person, but also their expected future state of health and the known physical and psychological demands of being a parent.

4Donation of gametes on commercial basis is ethically unacceptable.5

Access to Care

Infertility is a medical condition and a health need and it should be covered as such by national social insurance

systems.6

The inclusion of a full range of Medically Assisted Reproduction (MAR) treatments in the provision of basic

health care at least partially depends on the general level of welfare in society.

7

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Fertility investigations and treatment should be reimbursed across Europe, and treatments of proven benefit to

patients should be made available, irrespective of the patient's income and place of residence.

8To avoid unjustified discrimination the principles of needs assessment, cost effectiveness and clinical effectiveness

should be used to determine the level of reimbursement for all assisted reproduction possibilities.

9Safe and Quality Treatments

People with difficulties in conceiving should be given accurate information in a range

of formats and languages on all assisted reproduction possibilities, as well as adoption and a life without child, as well as being allowed to accept or to reject the diagnosis or treatment without discrimination.

10

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

document ensuring that the risks and benefits of treatment are described in a balanced, evidence-based framework, and that appropriate warnings are given when evidence is inadequate to assess the efficacy or safety of specific drugs, devices or procedures.

11

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

investigations and treatments. People should be offered implications counseling, particularly if their treatment includes the use of donated gametes and embryos. They should be informed about any potential long term risks and psychological, social and medical ramifications.

12

Prevention and Education

Public prevention of infertility has been inadequate to date and governments have a responsibility

to promote unbiased rational information about all causes, implications and treatments options to help remove the myths and misunderstandings.

13Male infertility needs to be highlighted as contributing to half of the causes. Infertility can no

longer be considered a “woman’s” problem.14

Education of the next generation about infertility and its implications needs to start now.15

Patients associations across Europe should be recognized as a driving force behind multi-

stakeholders prevention campaigns to make education programmes happen.

16

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xiiiGlossary

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

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

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

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

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

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

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

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

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

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

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

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References

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

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

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.iv

Comparative Analysis of Medically Assisted Reproduction in the EU: Regulation and Technologies European Society for Human Reproduction and Embryology (ESHRE). http://www.eshre.eu/binarydata.aspx?type=doc&sessionId=q1m1djzhvbgxisyxggghuo55/MAR_for_web[2].pdf

v ART in Europe, Publications from 1997 to 2006, ESHREhttp://www.eshre.eu/page.aspx/1758

vi ART fact sheet J une 2010 from the European Society for Human Reproduction and Embryology

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

vii  Kerr J. et al. (1999) The experiences of couples who have had infertility treatment in the United Kingdom : results of a survey performed in 1997. Human Reprod. Vol 14 : 934-938. viii

Wikipedia http://en.wikipedia.org/wiki/In_vitro_fertilisationix

Resolution on the demographic future of Europe from the European Parliament (2008).http://www.europarl.europa.eu/sides/getDoc.do?pubRef=-//EP//NONSGML+COMPARL+PE-392.248+01+DOC+PDF+V0//EN&language=ENx

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

Comparative Analysis of Medically Assisted Reproduction in the EU: Regulation and Technologies European Society for Human Reproduction and Embryology (ESHRE). http://www.eshre.eu/binarydata.aspx?type=doc&sessionId=q1m1djzhvbgxisyxggghuo55/MAR_for_web[2].pdf

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

xii Law evasion and unequal access to treatment leads to cross-border reproductive care: Shenfield et al. (in press, 2009) Shenfield, F., de Mouzon, J., Pennings, G., Ferraretti, A.P.F., Andersen, A.N., de Wert, G., Goossens, V. And Van den Eede, B., on behalf of the ESHRE Taskforce on cross border reproductive care 2009.xii

xiii ESHRE Assisted Reproduction Technology (ART) Glossaryhttp://www.eshre.eu/ESHRE/English/Guidelines-Legal/ART-glossary/page.aspx/1062