Since 2008, the volume of Assisted Reproductive Technologies (ART) in Spain has increased by nearly 50%, reaching 149,337 In-Vitro Fertilization (IVF) and 34,100 Intrauterine Insemination (IUI) cycles in 2018 [52, 54]. Spain is the largest European ART provider and fourth globally. [7, 14, 21, 33].
Given that 10–15% of the entire population may suffer from infertility [1, 5], the rise in ART practices can be explained by several factors. ART is becoming more available, affordable, and endurable while providing better outcomes. Additionally, parenthood postponement increases age-related infertility and upsurges demand .
In recent years, Spain enjoyed a sharp increase in the number and quality of ART clinics [52, 54], of which some have become world-leading ART corporations. Nevertheless, Spain has the OECD’s second-highest average maternal age at childbirth [32.1 years in 2017) , and 1.3 children per woman, among the lowest in the world. For a few decades, it has been facing elevated unemployment rates among youngsters and gender-gaps concerning employment, salary, and work contracts. Spaniards are among the oldest in Europe to leave parents’ home [38, 44]. These conditions have ongoingly contributed to marriage1 and pregnancy delay [2, 11, 18, 38]. Spain has the highest proportion in Europe of first births to mothers aged 40 or above (8.8% of total births in 2017) . In 2018, patients older than 40 years received more than 30% of ART cycles, while 57% of these included egg donations. Spain produces more than half the continent’s egg donations [21, 54].
Regulations and public provision largely determine whether the demand for ART is being met [16, 47]. The Spanish law 14/20062 on ART is among the most liberals in Europe. It enables practices with no defined age limit and regulates fertility preservation [4, 12]. A liberal approach towards gamete donations and PGT, and an abundant supply of specialized clinics make Spain one of the world’s most popular destinations for cross-border reproductive care, accounting for about 11% of the country’s ART cycles [51, 54].
ART is an expensive and repetitive treatment with uncertain costs and outcomes. In 2018, average success rates in Spain were 8–27% for a regular cycle, depends on patient’s age, and around 37% for donor-eggs cycles . Costs in private clinics were 700-1,000 Euro for an IUI cycle, 3,500-5,500 Euro for an IVF cycle, up to 9,000 Euros for an egg donation, and up to 10,000 Euro for PGT .
Cost reduction of ART through public funding is often justified by the demographic implications of infertility and its strong impact on the quality of life, not only from a social perspective but also as a source for depression, anxiety and conflict in relationships [19, 32, 41, 46]. Fauser et al.  identified positive attitudes among western European respondents towards some extent of public ART coverage for primary infertility. Additionally, Vida [58, p. 1] argued that “infertility qualifies as an unpredictable incident against which rational agents would choose to insure under ideal conditions and that ART is thereby a matter of collective responsibility”. Chambers et al.  found a positive association between affordability and utilization. Nevertheless, public coverage is important not only to provide equal access but also to reduce the financial burden on young parents . It also serves to moderate the principal-agent problem, in which physicians may potentially lead to commodification and supplier-induced demand by offering unnecessary treatments and add-ons [4, 17,27, 45].
Spanish national health system covers up to three ART cycles for childless couples, up to 40 years for women and 55 for men . However, patients spend around one year on average on waiting lists for public clinics [25, 40], which may delay the potential solution, harm treatment outcomes , and produce distrust. In practice, about 75% of cycles are elaborated by private clinics, which are also responsible for nearly all donor eggs3 and PGT (therefore for the majority of reproductive tourism) [42, 49, 54]. Some private insurance policies cover a limited number of cycles, usually one or two, with few exceptions. Coverage for donor gametes and PGT is limited.
This study examines two topics. First, the effectiveness of public ART services in Spain compared with private services, measured by the time since initiating treatment until achieving pregnancy, accounting for age and some socioeconomic factors. Second, the socio economic determinants of access to ART, referring primarily to financial means derived by employment, income, and wealth. Additionally, education levels are usually associated with both the postponement of childbearing and a larger tendency to seek medical help. Lower socioeconomic background (and education) may be associated with higher infertility levels, while a higher socioeconomic background may be associated with higher tendency to seek medical solutions [9, 19, 20].
This study supplements previous research about diverse public ART policies concerning the balance between public and private care, socioeconomic disparities, and differences in outcome [12, 13, 55]. We applied two statistical models on data extracted from the national Spanish Fertility Survey (SFS), conducted in 2018 by the National Statistics Institute (INE). First, competing risk survival analysis with ‘stopping the treatment’ as the competing event. Second, a Bivariate Probit (Biprobit) model to identify how socioeconomic determinants affect access to services in public and private clinics.
The first model suggested that patients treated exclusively in private clinics had a higher cumulative incidence of becoming pregnant, on average and throughout the treatment, compared with patients who approached public clinics. The second showed evidence for inequality in access based on income, education levels, and marital status. Additionally, it shows that many patients choose private over public. Finally, we developed a broader discussion over the extent of public funding of ART, long waiting periods for public care, unequal medical outcome, and optimization.
1We refer here to marriage or domestic partnership.
2Partially revised by Law 19/2015
3Public clinics provide donor eggs only in exceptional cases of genetic disorders, or early ovarian failure before the age of 35