Perceptions of Medically Assisted Reproduction and Fertility Postponement: Limited Evidence, Critical Questions

Abstract

The number of women using medically assisted reproduction (MAR) is rising in high-income countries. This trend is partly driven by the tendency to delay childbearing, yet infertility treatments cannot compensate for the decrease in reproductive capacity with age. Scholars are currently concerned that the increasing availability of MAR is fuelling the misconception that it can extend reproductive life. High confidence in the success of MAR later in life would then encourage fertility postponement. However, this assumption remains untested, likely due to limited data availability. We examine this using panel survey data from the National Survey of Fertility Barriers, conducted in the United States in 2004–2007 and 2007–2010. Our findings support the technological salience hypothesis, which states that perceptions of MAR would only influence fertility intentions at ages when women are more likely to experience difficulties conceiving. Specifically, women aged 35 or over who have high confidence in the success of MAR when used in the late 30s are less likely to forego childbearing than those with low confidence. Overall, however, perceptions of MAR play a limited role in explaining fertility decisions compared to other socio-demographic characteristics. Nonetheless, taking them into account improves our understanding of how technologies enter the realm of reproductive decision-making, particularly at less fertile ages. In conclusion, we highlight the need for further data collection on this issue, covering more recent periods and countries where births are delayed and MAR availability is increasing.

Introduction

Many countries are introducing population policies aimed at increasing their fertility rates, which have fallen below 1.5 children per woman in many cases (Gietel-Basten et al., 2022). Alongside the usual family policy tools, such as parental leave, child allowances or childcare subsidies, some countries have increased public coverage of medically assisted reproduction (MAR)1 to enable more couples who face infertility issues to have children.2 The demographic impact of MAR increases with its availability, and its contribution to domestic births is substantial in some contexts, ranging between 4 and 7% in 2019 (Devolder & Borisova, 2022; Smeenk et al., 2023).

While this makes MAR an attractive tool for policymakers, improving its availability does not appear to be a long-term solution to support fertility levels (Kocourková et al., 2014; Sobotka et al., 2008; Ziebe & Devroey, 2008). First, the success rate of reproductive technologies is limited. For example, in Australia, it was estimated that 52–65% of women who initiated a treatment would experience a live birth by the fourth ART cycle (Chambers et al., 2017). Second, the demand for infertility treatments is increasing at older reproductive ages due to delayed childbearing (Ben Messaoud et al., 2020; Lazzari et al., 2021). However, the already low success rates of these techniques decline quickly with age, meaning they are only partially effective in compensating for fertility postponement (Choi et al., 2023; Kocourková et al., 2014; Leridon & Shapiro, 2017; Rainer et al., 2011). Third, some scholars argue that promoting assisted reproduction could influence young people’s perceptions of how much time they have to conceive, potentially encouraging them to postpone childbearing and thus reinforcing the decline in fertility (Passet-Wittig & Bujard, 2021; Rainer et al., 2011; Sobotka et al., 2008; Ziebe & Devroey, 2008). This paper examines the existence of this presumed effect by investigating the link between perceptions of MAR success at late reproductive ages and individuals’ fertility intentions, using panel data from the United States (US) which consists of two waves from 2004–2007 and 2007–2010. This is the only survey we identified that allows us to explore this crucial question, indicating the need for further data collection.

Existing Literature

Does Confidence in the Use of MAR Encourage Childbearing Postponement?

According to some scholars, enlarging the availability of MAR techniques ‘might fuel a false perception among the wider public that childbearing can be postponed until late reproductive ages’ (Sobotka et al., 2008, p.96). Such an argument posits that the availability of infertility treatments indirectly influences fertility behaviours (Rainer et al., 2011; Ziebe & Devroey, 2008), through cognitive effects. It assumes that people would anticipate the possibility of using MAR to achieve their desired family size and, as a result, postpone childbearing towards later ages (Passet-Wittig & Bujard, 2021). This assumption also relies on the fact that people tend to have imprecise knowledge about the ages at which it becomes difficult to have a child, both with and without medical interventions (Hammarberg et al., 2017).

In line with this, delays in first marriages and first births were observed following a policy change that made MAR treatments more affordable in Israel (Gershoni & Low, 2021). However, while the causal design of that study suggests a possible direct effect of MAR availability on behaviours, it does not assess the mechanisms behind the change. The notion that people’s perceptions of MAR could alter their fertility decisions, particularly leading to fertility postponement, touches upon reproductive imaginaries and one’s perception of their ability to have children. In this study, we examine the relationship between MAR perceptions and fertility intentions at the individual level, using data representative of the US population.

Do MAR Perceptions Influence Fertility Choices at All Ages?

It is possible that MAR only influences choices and behaviours at ages when people feel concerned by fertility-related topics, a phenomenon termed as technological salience (Johnson & Simon, 2012). This suggests that infertility treatments may influence perceptions and choices only when they are personally relevant, such as when someone experiences infertility or is more at risk of experiencing it. A technological salience effect has been observed in the US, where confidence in MAR varies by women’s characteristics and past reproductive experiences, but only among those who had difficulties conceiving (Johnson & Simon, 2012). In line with this, research on fertility education initiatives shows that information about infertility influences childbearing timing only among people in a partnership (Maeda et al., 2018). Other work from the US suggests the existence of a technological salience effect on family behaviours. Indeed, greater access to infertility treatments through the implementation of insurance mandates, which vary by state, is associated with delays in marriage and childbearing, but only from age 30 (Abramowitz, 2014, 2017). This suggests that MAR availability increases fertility rates at late reproductive ages, but does not affect fertility behaviours at early life-course stages.

In our study, perceptions of MAR may be weakly related to delays in family formation in youth because perceptions of personal reproductive capabilities are somewhat abstract, particularly for individuals who have never tried to conceive (Boivin et al., 2019). In contrast, views regarding MAR may be more associated with people’s fertility decisions when the possible use of infertility treatments is salient to them, notably at late reproductive ages due to the increased likelihood of experiencing difficulties to conceive.

Importance of MAR Perceptions as Compared to Other Factors

Finally, according to some scholars, fertility levels tend to respond downward to increases in MAR availability in high-fertility countries, but not in low-fertility countries (Rainer et al., 2011). Their interpretation is that greater access to MAR may encourage people to delay childbearing in high-fertility contexts where births are not yet postponed to later ages. In contrast, in countries where fertility levels are already low and many births are delayed, the effect of MAR on macro indicators is expected to be marginal.

At the same time, desires and decisions to have children in high-income countries have been extensively found to be influenced by social drivers such as partnership and professional situations (Fahlén and Oláh 2018; Sturm et al., 2023), reproductive histories (Guzzo et al., 2019) and family preferences (Billari et al., 2009; Dommermuth et al., 2011). Fertility intentions also greatly vary depending on life circumstances and age (Albertini & Brini, 2020; Iacovou & Tavares, 2011). Considering this broad range of socio-economic and attitudinal factors throughout the life course, MAR attitudes may not be particularly decisive for fertility intentions.

Research Question and Hypotheses in the US Context

Against the background described above, this paper asks: Does confidence in the effectiveness of MAR when used in one’s late thirties encourage women to delay childbearing? This question holds scientific and social relevance. From a scientific perspective, it addresses a critical gap in research, as, to our knowledge, the micro relationship between MAR perceptions and fertility timing has never been tested using representative populations. By examining this issue, we empirically contribute to theories about how technological confidence may shape fertility behaviours. From a social perspective, understanding this relationship is important for reproductive healthcare policies as systematic delays in childbearing based on MAR confidence could have a negative impact on individuals’ ability to realise their fertility intentions.

We examine this question by testing three hypotheses:

1. Confidence in MAR encourages fertility postponement. Women with positive perceptions of MAR success at late reproductive ages may more often delay childbearing than their counterparts with negative perceptions. Greater confidence in the availability and success of MAR may reduce the perceived urgency to have a child. These women would also be less likely to abandon their desire for a child, as confidence in MAR can support the perceptions that motherhood remains achievable later in life.

2. Perceptions of late MAR success are related to fertility intentions only among women who are themselves in their late 30s (technological salience);

3. Socio-economic drivers of fertility postponement play a greater role in fertility decisions than perceptions of MAR.

We test these three hypotheses in the US context. There, MAR’s contribution to fertility is moderate but on the rise. In 2021, about 2.0% of births resulted from IVF and related techniques (Centers for Disease Control and Prevention 2023). The prominent increase in treatment utilisation has been particularly pronounced in the 40–45 age group, for which the proportion of IVF births went from 17% to 23% between 2010 and 2017 (Tierney & Cai, 2019). The mean age at birth rose from 27.9 in 2004 to 28.3 years old in 2010 and 29.8 years old in 2022 (according to the Human Fertility Database), and births at later ages are gradually becoming more common (Beaujouan, 2023). In this context, the use of planned oocyte cryopreservation (POC), which is among the MAR techniques that are the most likely to compensate for the age-related fecundity decline, has significantly increased over time since the 2010s (Johnston et al., 2021). In light of this, we can expect this parallel increase in both fertility delay and MAR use at the country level to be reflected at the individual level, with confidence in MAR success at late ages encouraging women to delay childbearing (hypothesis 1).

The US federal government plays a minor role in regulating access to MAR. Individual states have the power to pass legislation on assisted reproduction, but only a few have legislated in this area (Frith & Blyth, 2014). This lack of regulation is concomitant with the financialization of medical practice, notably allowing the advertisement of fertility preservation (van de Wiel, 2020), which is an additional reason to expect an encouragement effect of MAR on delayed childbearing (hypothesis 1). On the other hand, there is no federal government reimbursement of treatment costs, although several states provide insurance mandates for fertility treatment coverage (Henne & Bundorf, 2008). Out-of-pocket costs in the US remain substantially higher than in any other high-income country, with only a quarter of the demand for assisted reproduction being met (Chambers et al., 2009). Given that the availability of infertility treatments is limited and highly dependent on women’s financial resources, MAR perceptions and fertility decisions may only be associated when seeking medical help is highly relevant and envisioned by women (hypothesis 2). Finally, Hypothesis 3, which suggests that women’s socioeconomic characteristics are more important than perceptions of MAR for reproductive behaviour, is particularly relevant in the US context. There are significant socioeconomic disparities in fertility timing, with higher-educated women experiencing more pronounced delays in childbearing (Yang & Morgan, 2003). Moreover, because access to MAR is highly stratified by socioeconomic status (Lazzari and Tierney, 2023), the high cost of MAR treatments and limited insurance coverage may limit the importance of MAR perceptions in shaping fertility intentions.

Data and Method

The National Survey of Fertility Barriers (NSFB)

In order to explore whether opinions about MAR might encourage childbearing delay, we study the United States, which is the only country for which we could identify suitable data. We use the National Survey of Fertility Barriers (NSFB), a two-wave panel representative of the female population aged 25–45. This survey investigates psychological, social, and biomedical obstacles to fertility desires. The first wave was conducted in 2004–2007, among 4,794 women and 926 of their partners, and the second wave was in 2007–2010 (2,222 women and 772 partners). Attrition was high, but tests showed it was uniform for our main explanatory variable (confidence in MAR).3

We construct an indicator of confidence in MAR success when used at older ages, called confidence in late MAR hereafter. Overall, these data show widespread acceptance of MAR in the early 2000s. In Wave 1, almost all women strongly agreed or agreed that ‘Medical science can be a big help to women having trouble getting pregnant’ (98%, authors’ own calculation) and that ‘Women who have trouble getting pregnant would benefit from consulting a doctor’ (98%, authors’ own calculation). Confidence in MAR success at late reproductive ages is also high, as a smaller but still large proportion (strongly) agreed that, thanks to these techniques, ‘Women can wait to have a baby until their late thirties and still have a good chance of having a baby’ (90%). This share has not changed across waves. We focus on this indicator.

For fertility intentions, we use the panel dimension of the data. In both waves, women were asked whether they ‘intend to have a baby’. We selected 619 women with positive intentions in Wave 1 who were also asked about their fertility intentions in Wave 2 (three years later). We excluded 25 women who had a miscarriage across waves and were still intending to have a child at Wave 2. 46% of those with positive fertility intentions in Wave 1 had a child between waves or were pregnant in Wave 2, 13% had revised their intentions downwards, and 41% were still intending to have a child. We consider this last category as postponing their fertility plans, as their intentions remain unchanged from one wave to the next, meaning they have not acted on them. The delay may be voluntary or not, and life circumstances, including infertility or a change in partnership, may contribute to it.

Method

The association between the timing of fertility intentions and confidence in late MAR success (at one’s late thirties) is estimated with multinomial logistic models. This type of model predicts categorical outcome variables with more than two categories. Here, it estimates whether women with positive intentions in Wave 1 (a) had a(nother) child before Wave 2 or are pregnant at Wave 2 (realised intentions), (b) had no (additional) child between Waves 1 and 2 and maintain positive fertility intentions (postponed intentions, which is the reference category), and (c) had no (additional) child and no intention to have a child anymore (foregone intentions).

Models control for characteristics that are likely to influence fertility intentions (Billari et al., 2009; Dommermuth et al., 2011; Fahlén & Oláh, 2018; Guzzo et al., 2019; Sturm et al., 2023): age of the respondents (distinguishing between 25–29, 30–34 and 35+), whether respondents are childless, have a tertiary degree, are employed, and are in a partnership. The latter is based on marital status (cohabiting and married women vs. divorcees, widowed and singles). We also control for attitudes regarding family life. Women with more traditional attitudes tend to be more family-prone (Billari et al., 2009; Dommermuth et al., 2011) and, hence, may be more likely to view medical help positively at any age. Traditional attitudes (such as negative views of homosexuality) can also be associated with negative views towards the use of MAR, as shown in Europe (Szalma & Djundeva, 2020). To control for an attitudinal indicator, we rely on a continuous scale available in NSFB, which is based on two items regarding gender norms.4 Finally, models also include a control for perceived infertility. This is positive if women answered ‘yes’ to the following question: ‘Do you think of yourself as someone who has, has had or might have trouble getting pregnant?’. The full model is presented as coefficients (Table 1) and the association between fertility intentions and MAR perceptions is additionally displayed as predicted probabilities (Fig. 1).

Table 1.

Estimation of realised and foregone fertility intentions compared to postponing a birth between waves 1 and 2 (multinomial logit models)

	Realised intentions (vs. postponed)			Foregone intentions (vs. postponed)
	Coeff.	se	p-value	Coeff.	se	p-value
High confidence in MAR success at late reproductive ages (ref=’Low’)	0.284	0.255	–	−0.806	0.306	**
Age group (ref=’25–29’)
30–34	0.893	0.190	***	1.367	0.284	***
35+	0.416	0.210	*	2.434	0.266	***
Has children (ref=’Childless’)	3.524	0.203	***	0.594	0.213	**
Not tertiary educated (ref=’Yes’)	−0.110	0.241	–	0.566	0.281	*
Not in a relationship (ref=’Yes’)	−1.154	0.180	***	0.303	0.225	-
Not employed (ref=’Yes’)	0.345	0.189	–	−1.074	0.298	***
Perceive infertility problems (ref=’No’)	0.222	0.238	–	1.545	0.247	***
Traditional attitude scale	0.035	0.075	–	−0.163	0.093	–
Intercept	−2.703	0.594	***	−1.327	0.747	–
N	446
AIC	1,832.32
Log-Likelihood	−896.16
Pseudo-R²	0.37

NSFB (2004–2007 and 2007–10), women aged 25–45 with positive intentions in Wave 1 and surveyed in both waves.

*** p <.001, ** p <.01, *p.05, - not significant.

Fig. 1.

Predicted probabilities (with confidence intervals) of birth, postponement or foregone fertility intentions between waves 1 and 2, by level of confidence in late MAR. NSFB (2004–2007 and 2007–2010), women aged 25–45 with positive intentions in Wave 1 and surveyed in both waves. The predicted probabilities are calculated with multinomial logistic regressions and presented for women who are tertiary educated, childless, employed, married or cohabitating, without any declared infertility issues, and with average values on the traditional scale. Confidence intervals are at the 5% level

To address hypothesis 2, a second model allows for the effect of MAR perceptions to vary by age group (interaction term), and the results of these interactions are displayed as predicted probabilities (Fig. 2).

Fig. 2.

Predicted probabilities (with confidence intervals) of birth, postponement or forgone fertility intentions between waves 1 and 2, by level of confidence in late MAR success and age (interaction plots). NSFB (2004–2007 and 2007–2010), women aged 25–45 with positive intentions in Wave 1 and surveyed in both waves. The predicted probabilities are calculated with multinomial logistic regressions and presented for women who are tertiary educated, childless, employed, married or cohabitating, without any declared infertility issues, and with average values on the traditional scale. Confidence intervals are at the 5% level

After excluding 10 observations with missing values, the final sample includes 446 women. Data are weighted using survey weights from Wave 2, which correct for attrition.

To address hypothesis 3, we perform a likelihood ratio test, which assesses the significant contribution of each independent variable to the model by estimating and comparing various covariate combinations. In addition, relative importance analysis, by ranking variables according to their contribution to the pseudo-R², calculates how much each of them contributes to the overall model fit (Azen & Traxel, 2009).

Findings

We test whether confidence in MAR success at late reproductive ages in the first wave is associated with whether women have realised their positive fertility intentions between Waves 1 and 2, are postponing a birth or have foregone their fertility plans. This association is tested by holding other factors constant, which are shown in the full model displayed in Table 1.

We first describe the relationship between MAR perceptions and the three outcomes, presented as predicted probabilities in Fig. 1. There are no significant differences in predicted probabilities of postponing for women with high confidence in MAR efficiency at late ages (45.2% [41.0–49.5]) and those with low confidence (44.8% [34.6–55.5]). However, predicted probabilities of having had a child across waves are higher for women with positive MAR perceptions (45.1% [40.7–49.5]) than for women with negative perceptions (33.6% [24.5–44.2]), and conversely for probabilities of abandoning fertility intentions (9.7% [7.5–12.4] vs. 21.5% [14.0–31.5]). In sum, women with high confidence in MAR efficiency when used in the late thirties, in comparison to those with low confidence, are more likely to have realised their fertility intentions and less likely to have abandoned them, while associations with postponement do not significantly differ.

These associations between MAR perception and fertility also vary by age, as presented in Fig. 2 which displays the predicted probabilities of the model with an age-perception interaction. For women aged 25–29, we observe the same patterns as in the overall model: equivalent chances to postpone according to confidence in late MAR success, more births and less abandonment among those with high confidence compared to those with low confidence (Fig. 2a).

Women in their early thirties in Wave 1 have, in general, high probability to become mothers before Wave 2, but those who have greater confidence in MAR have a lower predicted probability of giving birth compared to those with low confidence in MAR (52.3% [45.3–59.2] vs. 73.0% [50.8–87.6]) (Fig. 2b). Variations in postponement are not statistically significant in that age group, although women with positive perceptions of late MAR use exhibit higher predicted probabilities. Abandoning a positive intention to have a child is rare, but slightly more likely among those with greater MAR confidence. At these key reproductive ages, foregoing childbearing may be linked to unobserved characteristics (e.g., partner’s fertility intentions, family-proneness) associated with a greater propensity to adjust their fertility intentions. This difference should also be interpreted cautiously, given the small numbers involved.

Although women aged 35 + are very likely to abandon a positive fertility intention, they are much less likely to do so if they express confidence in the success of late MAR (26.1% [20.8–32.4] of cases, compared to 67.2% [43.4–84.6] for those with negative perceptions, Fig. 2c). Women with greater confidence in late MAR success are more likely to postpone their intentions or to have a birth than women with negative perceptions of MAR, although results are not significant (Fig. 2c).

In summary, the relationship between confidence in late MAR use and whether women have a child, postpone childbearing or forego it, varies by age. For women in their late twenties, high confidence in MAR is associated with postponement and more births, and with less abandonment. For women in their early thirties, having high MAR confidence is associated with having fewer children and a slightly higher rate of abandonment. This may reflect unobserved individual characteristics related to more flexibility in fertility intentions. Finally, among women aged 35 and older with positive intentions at Wave 1, confidence in MAR reduces the likelihood of abandoning those intentions.

Finally, Table 1 displays the results of the multinomial logistic regression model estimating the likelihood of realising and foregoing fertility intentions relative to postponing between Waves 1 and 2, along with other relevant covariates. Among other characteristics, having no employment in Wave 1 is more associated with postponing rather than foregoing fertility intentions. Women who were already mothers were more likely to either have another child or forego their fertility intentions. Those without a partner were more likely to postpone having a child than to have one, but they were not significantly more likely to forego their fertility intentions. Having less than a college education and perceiving infertility issues is positively associated with forgone intentions, while we see no significant link between intentions and traditional attitudes.

According to log-likelihood tests, parity and age have the highest predictive power, followed by perceived infertility and partnership status (Table 2). This is also consistent with the relative importance analysis. MAR perceptions have much lower explanatory power, as they account for only 1.1% of the model variance; however, unlike education and traditional values, their contribution to the model is significant.

Table 2.

Likelihood ratio test and relative importance test assessing the explanatory power of variables

	Log-Likelihood ratio Chi²	Relative importance (%)
Childlessness	463.46***	52.1
Age	132.39***	17.8
Partnership status	54.7***	15.3
Perceived infertility	43.99***	7.3
Employment status	26.24***	4.3
Education	5.53	1.4
Confidence in MAR	11.4**	1.1
Traditional values	4.13	0.7

NSFB (2004–2007 and 2007–10), women aged 25–45 with positive intentions in Wave 1 and surveyed in both waves.

*** p <.001, ** p <.01, *p.05, otherwise not significant.

Conclusion and Implications

We aimed to test whether confidence in MAR’s ability to help women have children in their thirties was associated with delayed fertility intentions at the individual level in the US. The idea is that favourable views of MAR could lead people to believe that they have a longer reproductive lifespan than they actually have.

The analyses lend support to our second hypothesis about the existence of a technological salience effect (Johnson & Simon, 2012). This is hinted by our finding that women at advanced reproductive ages (35+), with positive views of MAR use at late ages, are less likely to forego fertility intentions compared to those with negative perceptions (and instead either have a child or delay childbearing). This hypothesis could gain additional support from the fact that women in their thirties, who are confident in MAR success at older ages, are more likely to postpone their fertility plans than those with negative perceptions of these technologies. However, this finding lacks statistical significance, likely due to small sample size, and warrants replication with higher-quality data. In any case, positive MAR perceptions do not encourage childbearing postponement before women’s thirties, which contradicts hypothesis 1.

Despite the fact that already well-established circumstances, such as parity, relationship statuses or infertility issues, are crucial determinants of childbearing behaviours, MAR perceptions have a significant and independent effect on fertility intentions, but they contribute little to the overall predictive power of the model. Although they appear to be associated with fertility decisions for some ages, this confirms our third hypothesis that socioeconomic aspects are more significant drivers.

Taken together, these results suggest a possible but weak mediating pathway through which MAR availability may partially influence fertility behaviours at advanced ages (Abramowitz, 2017), namely, by reinforcing confidence in reproductive technologies as a reliable backup option when likely to be confronted with the pressure associated with age-related fertility decline. However, this analysis is not causal and cannot properly assess whether the greater availability and use of infertility treatments lead to higher MAR acceptance or whether other factors are at play. In addition to fertility desires or intentions, testing the relationship between confidence in MAR and perception of one’s reproductive lifespan would help illuminate how perceptions of these technologies can shape fertility timing decisions. This is not possible with the available data.5

The question raised in this analysis is relevant to contemporary societies, but our evidence dates back to the 2000–2010s. It is possible that MAR has become a more significant determinant of fertility over time and across age groups. Indeed, there is a high level of trust in reproductive technologies in the US, especially those aimed at addressing age-related infertility, such as planned oocyte cryopreservation. Since the 2010s, both MAR’s contribution to births in the US, particularly at advanced reproductive ages (Tierney & Guzzo, 2023), and the use of oocyte cryopreservation (Johnston et al., 2021) have increased. Undergoing infertility treatments, and particularly egg freezing, has also been heavily promoted as a means to postpone childbearing. In particular, the idea of MAR as a form of ‘fertility insurance’ has gained popularity following endorsement by large companies such as Apple and Facebook (van de Wiel, 2020).

Our analysis only lends limited support to concerns previously raised by scholars (Passet-Wittig & Bujard, 2021; Rainer et al., 2011; Sobotka et al., 2008; Ziebe & Devroey, 2008) that policies designed to improve MAR availability — which are sometimes expected to have a significant impact on fertility levels — may have the unintended consequence of encouraging delayed childbearing. However, while we focus on the US, the tendency for positive perceptions of MAR to encourage postponed fertility may differ in other contexts. Unfortunately, there is a lack of data allowing for cross-country comparison on this topic.6

In conclusion, this work highlights the need to include relevant measures in surveys that allow for cross-country comparisons in more recent periods, to better assess whether the perception of MAR currently influences people’s fertility choices. As births continue to be postponed and the demand for MAR is increasing in high-income countries, clarifying the role of reproductive technologies in fertility decision-making is essential for evidence-based reproductive health policies.

Declarations

Conflict of interest

The authors have no conflict of interest to declare.