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Beijing health authorities will cover some assisted reproduction procedures under medical insurance, but with restrictions still in place, experts believe it will not lift the birth rate much

By Xie Ying , Niu He Updated May.1

After Beijing became the first city to include assisted reproduction technologies (ART) in its medical insurance scheme, experts expressed caution over whether it will help increase the falling birth rate, especially as many restrictions on who can access treatments remain.  

Beijing Municipal Medical Insurance Bureau said that from March 26, 16 types of ART would be covered, meaning Beijing residents could access artificial birth procedures at a much cheaper price.  

“Beijing’s policy is helpful to promote the application of ‘artificial birth,’ reduce the expense for people suffering from infertility and to some extent increase social acknowledgement of ART,” Huang Kuangshi, a researcher at China Population and Development Research Center told NewsChina.  

China is in a fertility crisis. The birth rate has dropped for five straight years, plummeting to 7.5 per 1,000 people in 2021. This is 37.7 percent less than in 2015, when the government started easing strict birth control policies, allowing couples to have a second, then a third child. Despite an uptick in 2016, these policies have had little effect.  

Some experts believe Beijing’s new policy should be extended nationwide, although many regions would struggle with paying for it. And while Beijing health authorities agreed to cover the cost of ART under medical insurance, the rules on who can actually benefit from ART have not changed. Therefore, experts said, the policy’s effect may be more limited than expected. 

Much Cheaper 
The most common forms of ART are artificial insemination or in-vitro fertilization (IVF). 

A survey published in 2021 by Qiao Jie, an academic at Peking University Third Hospital, showed that China’s rate of infertility rose from 12 percent of the total married population in 2007 to 18 percent in 2020. The high cost is off-putting to many. 

According to Li Junguo, an associate chief physician at the Fertility Center of the No.7 Medical Center under the Chinese PLA General Hospital in Beijing, IVF costs from 20,000-40,000 yuan (US$3,168- 6,336) for each round. The cost could double if any of the procedures, such as egg retrieval or embryo culture, fail.  

Li said the decision to cover ART in the city’s health insurance is a positive move. “Many of my patients turned to me after it failed several times at other hospitals. So it’s definitely good news for the patients,” he told NewsChina.  

According to the Beijing Medical Bureau, 16 ART procedures are covered, ranging from 180-5,050 yuan (US$29-800) each. These include two artificial insemination technologies and three third-generation IVF technologies.  

The most common assisted reproduction technologies – like artificial insemination – cost 7,000-8,000 yuan (US$1,109-1,267) on average. Insurance will reduce the cost to the patient by 64 percent. The cost of first- and second-generation IVF will reduce by 56 percent.  

First-generation IVF, or conventional IVF, means fertilizing eggs with processed sperm, which treats infertility caused by ovulation issues. Second-generation IVF deals with male infertility issues by selecting the best sperm to fertilize an egg.  

The benefit is much more obvious if one receives third-generation IVF that mainly targets couples with gene defects. It includes genetic screening, and is also used for older women or those with a history of miscarriage.  

There are three procedures for third-generation IVF included in the insurance –examining an embryo for a single-gene disorder, (5,050 yuan/US$800), genetic testing (3,750 yuan/US$594) per embryo, and blastosphere/blastomere/polocyte biopsy which costs 1,560 yuan (US$247) each.  

As IVF requires culturing a number of embryos, and for some, it takes multiple attempts to retrieve a viable embryo, the new policy will be beneficial.  

“Infertility treatment is a very complicated, costly and time-consuming process, so Beijing’s new policy will reduce patients’ economic burden and enhance their experience, and enable physicians to be freer in treatment,” Li said. 

Parents hold their baby for the first time since her birth in Shenzhen Longgang Central Hospital, June 30, 2020. The baby, born at 580 grams, was discharged from hospital among a few surviving cases of test-tube super premature infants in China

Xu Zaozao, (pseudonym), stands outside Beijing Chaoyang District People’s Court, September 17, 2021. The court has not announced a verdict so far. Xu sued a hospital for the right of single women in China to freeze their eggs

Change in Official Attitude
In a document issued in 1992, China’s former Labor and Social Insurance Ministry said infertility treatments are not covered. But official attitudes have changed, particularly against the backdrop of the decline in population growth.  

According to China’s National Bureau of Statistics (NBS), the number of newborns has seen a sharp decline since 2000. This has been especially marked since 2018 after a small birth boom in 2016 and 2017 prompted by the second-child policy petered out. The NBS said there were 10.62 million babies born in 2021, 1.38 million less than in 2020 and 4.61 million less than in 2018. China’s net population growth in 2021 was only 480,000, 1.56 million less than in 2020. Meanwhile, the number of women aged between 21-35, the most fertile age bracket, dropped by 3 million in 2021 compared to 2020.  

In May 2020, China allowed couples to have three children. But as local governments rushed to launch policies to encourage births, observers found young people were even reluctant to marry, let alone have a child.  

Data from China’s Ministry of Civil Affairs showed that marriages dropped from 13.47 million in 2013 to 8.13 million in 2020. Li Yue and Zhang Xuying, two researchers at the China Population and Development Research Center, published a thesis in Population Journal in July 2021 which found that the age at which Chinese women married for the first time increased by 2.7 years on average between 2006 and 2016, which means giving birth even later, one of reasons behind the growing infertility rate. 

Another issue is the increasing number of abortions. According to China’s National Health Commission, there were more than 9 million abortions in 2018, with 40 percent in people under 24 years old. Physician Li Junguo warned that abortion may cause sterility.  

In October 2020, China’s National Healthcare Security Administration responded to a National People’s Congress (NPC) proposal on including ART into medical social insurance, saying it believed the country was not ready. But some provinces like Zhejiang and Jiangxi have subsidized ART for families whose only child had died.  

The Administration’s attitude softened just one year later when responding to a similar NPC proposal, saying that ovulation stimulation drugs would be covered and it will consider gradually covering safe and mature ARTs whose cost is controllable. Beijing’s latest policy is seen as a breakthrough in this regard.  

“Beijing women get married for the first time on average three years later than the national average,” Wang Guangzhou, a researcher at the Institute of Population and Labor Economics, Chinese Academy of Social Sciences, told NewsChina, adding that Beijing’s infertility rate has risen from less than 0.3 percent to more than 3 percent.  

“It’s just a matter of time before ART is covered by insurance everywhere. There might only be differences in what is covered and how much they decide to reimburse,” Wang said.  

According to Health Insight, a medical care news column under news portal Sina China, Shanghai and some other cities are considering whether to follow Beijing’s lead. 

Given the high and unpredictable costs of ART, the biggest concern is whether local authorities can afford it.  

Beijing has not yet issued detailed rules on reimbursement, including how many rounds of treatment one person can receive, or whether there is an age limit. The success of ART in people over 45 is very low, experts said.  

“We were a bit surprised at Beijing’s new policy,” an insider who is close to the local medical insurance bureau of Shanghai told Health Insight on condition of anonymity. “If the quarterly report for Beijing’s medical insurance is fine after the policy is implemented, it may be promoted nationwide... But it does increase the financial pressure on local medical insurance, given ART’s high cost, so local governments may limit which hospitals and clinics can accept the insurance,” he added.  

Media reported that at least 18 hospitals or clinics in Beijing are permitted to offer ART, but Beijing Medical Insurance Bureau’s statement only listed 15 that were covered by the new insurance rules. 

Bans and Restrictions 
Pressured by the declining birth rate, birth encouragement was a major topic of discussion at this years’ two sessions, China’s annual legislative meetings, held from March 5 to 11 in Beijing. Many NPC delegates and members of the Chinese People’s Political Consultative Conference (CPPCC) put forward proposals to encourage births, including extending maternity leave, compulsory paternity leave for husbands, free kindergarten for a third child, and laws to economically compensate full-time parents. 

A proposal by CPPCC member Hua Yawei that called to allow single women over 30 to have a child, use ART and freeze their eggs triggered hot discussions, with some saying it would allow marriage avoidance when the marriage rate is already low. 
China forbids single woman to freeze their eggs and the prevailing regulation on use of ART issued in 2003 only allows married couples who have not violated the State’s family planning policy to use ART.  

Lifting the ban on single women has come under fierce public scrutiny since 2015 when pop star Xu Jinglei made a personal revelation in an interview with Vista Story which created huge debate in China. Now 48, Xu said that she had frozen her eggs overseas in 2013 when she was 39. She said she wanted better quality eggs in case she wishes to have a child.  

She described it as “the world’s only remedy for regret,” in reference to not having a child earlier.  

In 2020, renowned Chinese sexologist Li Yinhe called to lift the ART and egg freezing ban on single women in an interview with social media Pear Video, triggering a new round of discussion.  

Supporters believe single women should have equality of reproductive rights and that lifting the prohibitions would promote births. Opponents claim people would eschew marriage and it would increase the number of single-parent families, going against traditional values, and promote the sales of eggs and surrogacy, which are illegal in China.  

In February 2021, China’s National Health Commission responded to a CPPCC proposal on lifting the egg freezing ban on single women, delivering three reasons against it. 
The NHC said that unlike retrieving sperm, egg retrieval is invasive and has health risks. Free use of ART will encourage more healthy women to delay childbirth which is medically not good for them. And companies may misuse ART for profit.  

Even married couples are restricted in using ART in China. Third-generation IVF is available only to those with a medical certificate to prove gene defects or who failed previous rounds of IVF. One of the reasons cited is to prevent sex selection. In some parts of the country, especially rural areas, feudalistic beliefs that men are superior to women persist. Third-generation IVF allows sex selection, although ultrasound operators are forbidden from telling parents the sex of their child to prevent sex-selective abortion.  

But many prefer third-generation IVF.  

“First- and second-generation IVF is a bit like opening a blind box, but third-generation excludes gene defects. It raises the success rate and reduces psychological pressure,” An Ya (pseudonym), a 32-year-old woman in Beijing who has chosen a private hospital for third-generation IVF, told NewsChina. Under 35 and without genetic disorders, she is not eligible for this treatment in a public hospital.  

Experts are cautious on whether the new policy will encourage births.  

“Beijing’s policy is an institutional improvement, but we have to observe who the policy influences and how it influences them. After all, it touches on laws and ethical issues,” Wang Guangzhou said.

A technician at Shanxi Human Sperm Bank Assisted Reproductive Lab, Taiyuan, Shanxi Province, December 10, 2010