The aim of the research was to assess the extent to which the growth in the TFR since 2013 in Czechia has been driven by the increasing use of ART. Despite there being other relevant factors behind the continuous increase in the TFR in Czechia over the last decade, in particular economic growth that ensured stable conditions for young people to start a family and improvements in family policy[25,33], the overall long-term fertility postponement process has resulted in the increased need for the use of ART.
Even though ART cannot compensate for all the fecundity lost by delaying attempts at conceiving[34], our findings confirmed that the increase in the use of ART is relevant when assessing recent fertility trends. The impact of ART on the TFR in Czechia was significant; between 2013 and 2020 the contribution of ART to the TFR increased from 0.045 to 0.058, i.e. from 3.1 to 3.4% of the TFR. As a result, in 2020 the TFR without ART would have been just 1.65 instead of 1.71 with ART.
The contribution of ART to the TFR in Czechia in 2020 (0.058) reached a value between that for the US in 2020 (0.023[23]) and for Australia in 2017 (0.088[9]). This shows the wide variation in the impact of ART on fertility, which reflects differences in the broader social context between the US, Europe and Australia. The US and Australia represent two extremes—from low support for ART in the US, where the use of ART is often expensive even with insurance coverage[23]), to generous and supportive funding with no restrictions based on age, parity or the number of cycles in Australia[9]. Czechia has adopted a typical European legislative approach in which a centralised health insurance system provides the reimbursement of a significant part of ART costs up to a certain female age limit (39 years in 2022) and for a limited number of cycles (3–4). Moreover, the high degree of accessibility of ART together with the high quality and safety of the treatment provided and relatively lower costs have established Czechia as an important target for cross-border reproductive care in the European context. However, potential still remains for increasing accessibility to ART for Czech women via the removal or age extension of the limits set for the reimbursement of ART costs by the health insurance system. Moreover, the debate on extending access to ART beyond heterosexual couples and the right of single women to apply for ART has recently begun to gain momentum[35].
The demographic analysis of fertility by age and parity confirmed that first parity was the driver of the increasing impact of ART on the TFR between 2013 and 2020. Thus, ART has made a contribution to reducing childlessness rather than to increasing family size. The most dynamic increase in ART fertility rates was registered at ages of over 35, which confirmed the significant role of ART in the recovery of fertility at older reproductive ages.
The study also aimed to measure the impact of ART on birth timing via the assessment of the extent to which the increase in ART use has contributed to further delaying childbearing. Czechia is specific in terms of its increasing TFR accompanied by a slowdown in fertility postponement. The mean age of women at birth following ART increased by 0.9 years from 2013 to reach 34.6 years in 2020. Nevertheless, it was not confirmed that the use of ART serves to support the postponement of childbearing. The decomposition analysis results indicated that by 2020, the contribution of ART use to delaying childbearing had diminished to 4%. The increase in the MAB between 2013 and 2020 was mainly attributed to the ongoing nonART postponement of childbearing, accounting for 87% of the increase.
The data enabled us to define how many ART children were born in Czechia. The proportion of ART live births in Czechia in 2020 did not exceed 4%. Our results confirmed that the 5.5% of ART births recently reported for Czechia by Wyns[3] was an overestimation due to the inclusion of births to women who received cross-border reproductive care in Czechia.
Interestingly, in 2013 the Czech ART TFR commenced at the level projected for the US ART TFR up to 2040 (0.048[23]). Thus, our findings confirmed that Czechia was in a unique position in terms of the relatively significant contribution of ART to the quantum of fertility as early as one decade ago (in a similarly way as in Denmark[18]). The impact of ART use on the TFR in Czechia must have increased significantly prior to 2013 when the TFR was below 1.5. The increasing use of ART helped Czechia to escape from the low fertility trap[5]. Interestingly, the availability of ART in Czechia before 2013 was increasing due mainly to the growing number of clinics, since no special policy intervention was recorded regarding ART legislation or costs reimbursement. In addition, prior to 2013, the postponement of childbirth was more pronounced, with the significant contribution of the conflict between family and work partly as a result of insufficient and inadequate developments in family policy and the economic recession[25,36].
The use of ART continued to increase in Czechia from 2013 partly due to improvements in ART reimbursement conditions, i.e. an increase in reimbursed cycles from three to four in 2012. Despite a continuous increase in the ART TFR, the relative contribution of ART to the TFR did not increase significantly since the nonART TFR also increased significantly, reaching a peak of 1.65 in 2018. This coincided with family policy developments, the introduction of the 2017 Family Policy Concept and the inclusion of state support for ART in the Concept. It is evident that ART policy alone is unable to provide a solution to low fertility; rather, it should be included in broadly-conceived long-term policies[5,17,19,21,23]. Therefore, recent policy improvements based on the 2017 Family Policy Concept in Czechia[25] may have acted to retard the increase in the contribution of ART use to the TFR.
Despite the results indicating the recent stabilisation of ART use in Czechia, an increase in demand for ART is likely in the near future, especially concerning women of older and advanced ages. This could lead to a further increase in the use of ART for the following reasons: firstly, changes in ART legislation aimed at expanding its accessibility. Indeed, in 2022 the extension of the age limit for the reimbursement of ART costs from age 39 to 40 was introduced in Czechia, the impact of which can be expected as early as in 2023 in connection with an increase in the contribution of ART to fertility rates at ages 40 and 41. Secondly, any increase in the potential of ART will depend on improvements in success rates and the emergence of alternative treatment options[37]. Thirdly, the Covid-19 pandemic-related uncertainty and the fear of an economic recession[38,39] accompanied by a decrease in family support may result in further delays to childbearing, thus creating an increase in the potential use of ART. Public attitudes towards ART, i.e. the level of its social acceptance, may also play an important role. Szalma and Djundeva[40] determined that the mean age of women at first birth has a statistically significant association with the acceptance of ART at the national level. Thus, the more women postpone the transition to motherhood in society, the more permissive attitudes to ART become. This may be due to the fact that women at later age are more likely to face fertility problems.
ART is only one of the treatment options that can be classified under the broader term of medically assisted reproduction (MAR). MAR for the treatment of infertility also includes more traditional treatments such ovulation induction, with or without intrauterine insemination (IUI)[41]. However, due to the lack of data it is not possible to properly assess the overall effect of MAR treatment on fertility in Czechia. Although the data indicates the additional impact of IUI on fertility in Czechia, i.e. around 0.9% of all live births annually in the period 2016–2018 (IHIS 2021), it is likely that this figure is underestimated since data on IUI is not validated and is based on incomplete evidence. The National Register of Assisted Reproduction does not track IUI or alternative treatment approaches other than ART. To assess in detail the overall effect of MAR on fertility levels, which is undoubtedly greater than the effect of ART alone, it would be necessary to expand the data to include evidence on these treatments and their outcomes.
In summary, the Czech TFR would be significantly lower without births conceived via ART, and childlessness would be more commonplace due to the low recovery of fertility at advanced reproductive ages. Interestingly, the findings also indicated the alleviation of concerns about the potential contribution of ART to the further undesired delay of childbearing. The findings have important implications for family policy. Based on experience in Czechia, it appears to be favourable to include ART policies in the overall policy mix aimed at assisting people to fulfil their reproductive plans. The importance of ART in terms of supporting fertility recovery in the context of delayed childbearing will continue to increase, as indicated by recent demographic trends in some European countries[42].
When interpreting these results, it is important to note two limitations. Firstly, the slightly lower number of births in 2020 may have been influenced by the Covid-19 pandemic. However, ART clinics in Czechia were not closed until March 2020, which was reflected in a reduction in births 9 months later, i.e. in December 2020. Secondly, in some cases, it is possible that women would have had a baby later without the use of ART[30]. However, this would not have translated into the cross-sectional indicators that we observed. Moreover, the number of such births would have been negligible since ART is used mainly by older women concerning whom the likelihood of a natural conception was already significantly reduced[11]. The results clearly showed that the greatest contribution of ART to fertility growth related to older women, for whom time is limited in terms of the chances of having a natural birth.