It was a cold and overcast morning in November, but one full of promise for Guo Meiyan and her husband: They would finally get a chance to start a family.
As Guo, 39, was wheeled on a gurney into a hospital room where a doctor transferred her eggs, which had been harvested and fertilized, back into her uterus, she also felt a sense of dread.
“If the transplant is not successful, all the money we spent will be wasted, all the pain I endured will be wasted, and we will have to start over again,” said Guo, who had traveled 125 miles to Beijing from the northern city of Zhangjiakou. She and her husband had been living in hotels to be near the hospital for a month during the final stage of the in vitro fertilization process.
They are among hundreds of thousands of Chinese couples who turn to assisted reproductive technology every year after exhausting other options to get pregnant. They travel from all corners of the country to big cities such as Beijing in the hopes of beating the odds of infertility. Many wait in long lines outside hospitals before sunrise, just for the possibility of a consultation.
Now, the Chinese government wants to make the technology, which it made legal in 2001, more accessible. It has promised to cover some of the cost — typically several thousand dollars for each round — under national medical insurance. It is one of more than a dozen policy measures that Chinese officials are throwing at what they see as a very big problem — a fertility rate so low that China’s population has started to shrink.
China has arrived at this turning point sooner than other countries at its stage of economic development, leading to what some demographers refer to as the curse of “getting old before getting rich.” As fewer babies are born each year and China’s oldest people live longer, the government is being forced to tackle a series of connected challenges — a shrinking labor force, a fledgling pension system and a generation of young people who aren’t interested in having babies.
Subsidizing fertility services such as IVF, a technology that fertilizes eggs with sperm in a lab and transplants an embryo into the womb, is “a big deal,” said Lin Haiwei, CEO at Beijing Perfect Family Hospital, where Guo had her procedure. Patients go to great lengths to pay for fertility services. Some of them pool loans from relatives. Farmers time their appointments with the autumn harvest when they have money to pay.
But even as there is a clear demand for fertility services, Lin said, the number of patients visiting the hospital is lower each year. “The big picture is that people are less willing to have children,” he said.
This is the single biggest challenge facing China as it tries to reverse its falling birthrate. Young people complain about the financial burden of having children and their own economic uncertainty, and push back on traditional ideas about the woman’s role as a caretaker at home. Many have expressed a desire to focus on their careers, while others have embraced a lifestyle known as “double income, no kids.”
Despite this hurdle, officials are trying to push up one of the lowest fertility rates in the world. While experts say it would be nearly impossible for China’s population to start growing again, the country could keep its birthrate steady. Making assisted reproductive technologies accessible to more people would help, just as it has helped in wealthier countries such as Denmark, said Ayo Wahlberg, an anthropologist at the University of Copenhagen.
China recently promised to build at least one facility offering IVF for every 2.3 million to 3 million people by 2025. It currently has 539 medical institutions and 27 sperm banks that have been approved to carry out assisted reproductive technology. Each year these facilities provide more than 1 million cycles of IVF and other assisted fertility services. Around 300,000 babies are conceived.
Experts say these efforts are meaningful ways to help couples who want to have children. If China can scale up the services in an affordable way, it could even be a model for other countries facing similar challenges with infertility. But whether it will do much to change China’s demographic trajectory is another question.
“The problem is that it is putting a Band-Aid on a gushing wound,” said Wahlberg, the author of a book on fertility in China.
For couples including Wang Fang and her husband, IVF changed their lives. Wang went through two rounds of IVF in 2016 before she gave birth to twins in 2017. Her husband’s first marriage ended in divorce because they were unable to have a child.
Wang, a factory worker, and her husband, an electrician, quit their jobs during the pregnancy to prepare for the birth.
When the first round of IVF failed, the couple felt broken. They learned that they might need a sperm donor, something that Wang has kept a secret from the family. Her parents think the couple’s fertility issues were due to her.
“In our hometown, if you don’t have children, you would not be able to hold your head high,” Wang said. The second time they did IVF, the 14-day waiting period to determine if it was successful “felt like a half a century,” she said.
As soon as they learned the outcome, they called everyone. Relatives offered to pitch in with their savings to help cover the costs, which exceeded $22,000, a huge sum for the couple, whose monthly household income was less than $1,200 when Wang and her husband were working.
“IVF is not a one-time deal, and we ran out of our money after several big items, so we had to borrow money to continue,” Wang said. If even some of those costs had been covered by medical insurance, as the government has said it will now start doing, “it would certainly have helped us and relieved some pressure.”
Each round of IVF can cost $5,000 to $12,000, and many couples need to do it as many as four or five times; each round has a success rate of roughly 30%. Under the new government measures, medical insurance would likely cover about half the cost of a round of IVF, said Lin at Beijing Perfect Family Hospital.
The policy has not been put into effect, its details are unclear and a deadly outbreak of COVID could delay things. Still, Lin is optimistic that some version of the policy will be put into place in the coming months.
But he’s also realistic about its impact. “It is certainly hard to expect much growth in our industry when the overall fertility rate and the willingness to have children are shrinking,” Lin said.
China has a complicated relationship with fertility. For three decades, officials restricted families to one child — sometimes through brutal measures.
Today, infertility affects 18% of couples in China, compared with a global average of around 15%. Researchers cite several factors, including the fact that Chinese couples often wait until later to have children and the common use of abortions, which experts have said could affect fertility.
Su Yue, 32, never had a strong desire to have a baby, but her husband and in-laws did. After the couple tried for several years, her mother-in-law gave them money to start IVF treatment. They were successful last year.
Su loves her son, whom she refers to affectionately as “Cookie.” But she said giving birth had cost her job. She had been breastfeeding while working remotely, but then her boss required her to come into the office. As a career-minded millennial, she laments having to resign.
“The most stressful thing about IVF is that I lost my job,” Su said.
Since her transplant, which was successful, in late November, Guo has been taking it easy back at home in Zhangjiakou. The hot pot restaurant that she and her husband own has been busy during the current Lunar New Year period. She still helps out, and she has found time to knit two mattress quilts for the baby.
Mostly, though, she tries to rest in bed, Guo said. “I feel sick and dizzy all the time.”