Reproductive Health Firms See Opportunities In Delayed Childbearing

BMI View: Acquired infertility will increase in Asia as women delay childbearing for various reasons, including greater work commitments and the rising costs associated with raising a child. Combined with high expenditure on healthcare and government funding, this trend will boost opportunities for assisted reproductive technology providers. However, cultural and religious beliefs are downside risks to our view.

According to online news provider VietNamNet Bridge, demand for surrogate births is increasing in Vietnam, but the Ministry of Health and Ministry of Justice remain undecided on the legalisation of such practices. Data from the Ministry of Health showed that 7.7% of Vietnamese couples (or 1mn couples) are dealing with infertility in the country. Highlighting the rising issue of infertility, Tu Du Maternity Hospital in Ho Chi Minh City receives an average of 200-300 patients daily for infertility tests compared with 10 cases a decade ago.

Causes of Infertility

There are many risk factors associated with infertility in women, most of which are genetic in nature such as Turner syndrome and Kallmann syndrome, while some can be acquired over the lifetime such as infertility due to chemotherapy, sexually transmitted diseases, increased body weight, age and smoking. These factors result in various forms of infertility in different anatomic locations such as polycystic ovary syndrome and gonadal dysgenesis, endometriosis, uterine fibroids, cervical stenosis and vaginal obstruction.

Infertility In Asia Pacific

It is difficult to source reliable and up-to-date statistics on infertility for some countries. Statistics from the World Health Organization (WHO) show that the prevalence of infertility remains almost unchanged globally and in South East Asia, although in absolute terms, the number of infertile women increased between 1990 and 2010 due to population growth. [1] We note that the endpoint is to study child birth as an outcome. In contrast, none of the current treatments guarantees a live birth but instead seek to increase the chances of conception.

No Change In Prevalence
Prevalence Of Primary Infertility In South East Asia In Percentage Terms (LHS) And In Absolute Numbers (RHS)

We highlight that the risk of acquired infertility will increase over time, given the lifestyle choices of more developed countries. While statistics are hard to find, BMI highlights that mean age of marriages and the mean age of mothers at first child birth increases with a country's stage of economic development. This is largely linked to a more educated population and increased employment opportunities for women, meaning women tend to delay childbearing in favour of working. For example, in Singapore, the median age of males at first marriage has increased from 28.7 in 2001 to 30.1 in 2011, and for females from 26.0 in 2001 to 27.8 in 2011. This has affected the median age of the first childbearing, which has increased from 28.7 in 2001 to 29.8 in 2011.

Delayed Marriages & First Child Births, Declining Fertility Rates In Asia Pacific
Year Median Age Of Citizens At First Marriage Median Age Of Citizens At First Child-Birth Fertiliy Rate
N/A = data unavailable. Source: BMI, UN, WHO, government websites
Male Female Male Female
Developed Countries
Australia 2001 28.7 26.9 2001 32.3 30 1990-1995 1.9
2011 29.7 28 2011 33 30.6 2011 2
New Zealand 1970 22.9 20.8 1970 N/A N/A 1990-1995 2.1
2011 29.9 28.3 2011 N/A 30 2011 2.2
Japan 1990 30.3 26.9 1975 N/A 25.7 1990-1995 1.48
2011 30.7 29 2011 N/A 30.1 2011 1.38
South Korea 1995 29.3 26.1 1993 N/A 26.23 1990-1995 1.7
2012 32.1 29.4 2010 N/A 30.1 2011 1.36
Singapore 2001 28.7 26 2001 N/A 28.7 1990-1995 1.83
2011 30.1 27.8 2011 N/A 29.8 2011 1.32
Developing Countries
Male Female Male Female
China 1990 23.8 22.1 1990 N/A N/A 1990-1995 2.01
2011 1.58
Philippines 1990 26.3 23.8 1998 N/A 23 1990-1995 4.14
2008 N/A 22.2 2008 N/A 23.2 2011 3.1
Indonesia 1990 25.2 21.6 1990 N/A N/A 1990-1995 2.9
2011 2.09
Thailand 1990 25.9 23.5 1990 N/A N/A 1990-1995 1.99
2003 N/A 23.5 2011 1.56
Malaysia 1991 27.9 24.6 1991 N/A N/A 1990-1995 3.42
2010 28 25.7 2010 N/A N/A 2011 2.61
Vietnam 1989 24.5 23.2 1989 N/A N/A 1990-1995 3.23
2009 25.2 22.4 2009 N/A N/A 2011 1.8

Given that the risk of infertility increases with age, BMI sees opportunities for infertility and infertility-related treatments providers in developed countries in the short to medium term, and in developing countries over the medium to long term as their demographics become similar to those in developed countries. In addition to the need for infertility treatments, we note that populations in developed countries are also better able to afford such infertility treatments, especially for in-vitro fertilisation (IVF), given the expensive nature of IVF treatments.

In addition to higher per capita expenditure on healthcare, governments in developed countries have also provide subsidy for various assisted reproductive technology (ART) treatments as part of their aim of boosting birth rates. For example, in Singapore, the government allows couples to withdraw up to SGD6,000 (US$4747) from Medisave for ART treatments and couples seeking ART treatments in public hospitals can receive up to 75% government co-funding. These subsidies coupled with high health expenditure means high revenues for fertility treatments providers.

List Of Subsidies Available In Selected Asian Countries
Source: BMI, government websites, Merck Serono's Starting Families Asia Study
Singapore 1. Citizens can withdraw SGD6,000 (US$4,747), SGD5,000 (US$3,956) and SGD4,000 (US$3,165) from Medisave for their first, second and third ACT treatments
2. Government to co-fund (35-75%, depending on citizenship) ART treatment cycles for a maximum of three fresh and three frozen cycles
Australia 1. Provides AUD71.40 (US$68.86) (out of the average fee of AUD200 (US$193)) for IVF pre-treatment expenses
2. Medicare provides up to 75% funding for various procedures required under ART including oocytl retrival and preparation of embryos or oocytes for transfer to the female reproductive system.
3. According to IVF Australia, an IVF cycle typically cost AUD8155 (US$7,864) of which patients are expected to pay AUD2,804-AUD3,360 (US$2,703-US$3,240) out of pocket depending on if they have reached Medicare Safety Net
New Zealand The government offers two free treatments to women who meet its eligibility criteria. According to Fertility Associate, over 60% of IVF cycles in NZ are publicly funded
Japan Couples can apply for co-funding of up to:
1. US$1,920/cycle for three cycles in the first year of treatment
2. two cycles in each subsequent year
3. maximum of 10 cycles in the first five years of treatment
South Korea Government to co-fund (approximately 50%) towards the cost of first three IVF cycles, up to 35% for the fourth cycle to qualifying couples.

Downside Risks To Outlook

Despite numerous attempts to boost the birth rate in various countries through different incentives, we note that the TFR remained largely unchanged in countries such as Japan and Singapore, highlighting that the choice of having a child lies largely based on personal preferences and can take into account various factors, in particular the time and cost required for raising a child. Should these couples be diagnosed as infertile, it is unlikely that they will opt for ACT treatments.

In addition, other cultural/religious views may also limit opportunities for ART treatment providers. For example, the Roman Catholic Church only condones procedures that 'assist' conception that will occur naturally, such as intrauterine insemination and gamete intrafallopian tube transfer, but not IVF. Consequently, it is unlikely that IVF treatment will receive much popularity in Philippines, where approximately 80% of the population are Catholic.

[1] Mascarenhas MN, Flaxman SR, Boerma T, Vanderpoel S, Stevens GA (2012) National, Regional, and Global Trends in Infertility Prevalence Since 1990: A Systematic Analysis of 277 Health Surveys. PLoS Med 9(12): e1001356. doi:10.1371/journal.pmed.1001356.