Prevalence of infertility in Taiwan

The net reproduction rate (NRR) in Taiwan fell to 1 in 1983 and has been below-replacement fertility since 1984. In 1964, when the island-wide family planning program was promoted, the total fertility rate (TFR) was 5.10 and the NRR was 2.27. The sustained fertility decline, however, began earlier, as in 1995, the TFR was as high as 6.55 and the NRR was 2.82. Taiwan has reached a society of saturated contraception, 92% of women at the age of 35 to 39 years old had contraception experience, and 86% of them were under contraceptive practice at that time, which is a near-saturation level of contraception.

Some people may wonder that since Taiwan’s net reproduction rate has fallen below the replacement level, why the current1.5% birth rate, 0.5% death rate, and natural population growth rate at 1%, which still appeared to be high. This paradox is a temporary consequence of the young populations resulting from previous high birth rates. In other words itcontinues to account for crude birth rates remaining higher than crude death rates despite below-replacement-level fertility rates. Based on the fact that birth and death rates are crude estimations, calculated by multiplying particular age structure with the birth or death rate of that age structure, and then divided by the total midyear population. The birth and death rate in young adults tend to be higher and lower, respectively, therefore, although there is currently a regression in the reproduction rate, the young age structure will lead to continued increase of population in Taiwan.

Since 1984, the net reproduction rate has been below the replacement level in Taiwan, if thedownward trend continues, the population of Taiwan will reach the stage of zero population grown in the future 30 to 40 years and turn into a negative growth. This means an aging society which will lead to lots of social problems and high dependency ratio or lack of labor force.In view of this, on October 23, 1992, the Executive Yuan revised and announcednew population policy by changing the population growth target from "easing population growth" to "maintaining a reasonable population growth", in hope of achieving such goals as returning to the replacement level in early 21st century.

In order to achieve a reasonable population growth in Taiwan in the future, we have implemented the “New family planning” in 1990, before the announcement of new population policy, to encourage youths to marry and have children an appropriate ages in order to increase marriage rate and marital fertility rate, as well as reducing the percentage of single-child-family and assisting the treatments for infertile couples, to reach the goal of TFR at 2.1 or returned to replacement level in the 21st century.

According to the “Maternal and child health and family planning” by WHO in 1991, which containing the analysis of data from 89 countries, revealed the infertility rate ranging from 0.4% to 66.6%, which could be caused by environmental, cultural and socioeconomic factors. For example, Westhoff reported in 1991 that the prevalence of infertility in the United States from 1965 to 1982 was between 13% and 14%, and that those in black people were much higher than in white people.

According to the estimation by Dr. Chii-Ruey Tzeng, the prevalence of infertility in Taiwan is more than 15%, and based on studies by Dr. Esther Shih-Chu, Ho et al, the major cause is fallopian tube factors, followed by endometriosis, and then ovulation and uterine factors. However, according to “Knowledge, Attitude, and Practice of Contraception (KAP)” study by Taiwan family planning institute in 1992, the prevalence of infertility in women of childbearing age is only about 2.60%. This paradox is mainly due todifferences in the mother group and sampling. To obtain comprehensivenational-wide representative data which taking into account the regional difference, we have initiated a national survey of prevalence of infertility. The specific aims are to estimate the prevalence of infertility in couples in each counties and cities,and with different backgrounds; as well as to understand the causes of infertility, and the attitudes, psychological pressure, and medical treatment of infertile couples (including the location, method, cost, time, and results of medical treatment, etc.).

The mother group in this study is all women married in April 1990 in Taiwan. A total of 8759 women were enrolled, however, this might not be the exact number, i.e., the date of marriage registration may not be the actual date of marriage, and is derived from the summation of recordings in each local health centers. The “questionnaire of female fertility in 1996 (the study of prevalence of infertility in Taiwan)” is adopted in this survey, which include basic demographic information (age, religion, ancestral home, work history, household composition, etc.), pregnancy history, contraception history, frequency of sex, living with husband or not, expected number of children and gender preferences, as well as medical examinations and treatments for infertility (such as costs, tests, diagnosis and results, and the possible effects of suspected infertility on women).

No sampling was conducted in this comprehensive survey of single marriage generation. All cases were visited and pre-visit training was conducted for the interviewers. The home visit was conducted on February 4, 1996. 1,820 cases were not performed due to absence of the person in the registered address, unknown new address for those moving to a new house, refused visits, abroad, death, no show up in repeated visits, etc., and 6,939 surveys were conducted, with a response rate of 79.2%. Among them, the 6,688 were complete, and after deducting 304 cases of remarriage, divorce, or remaining as single after the death of husband, 6,384 questionnaires were valid.

From the results of 6,384 valid questionnaires, we found that only 138 people (2.16%) had not been pregnant. For the 386 women who had normal sex and did not take any contraceptive actions in the first year of marriage, the suspected primary infertility in the first year of marriage was 6.41%, and that in the sixth year was 1.95%, suspected recurrent infertility was 3.13%. In the 138 women who had no experience in pregnancy, only two-thirds doubted themselves as infertile, andmost of the responses were seeking for medical treatment, followed by taking folk medicine, and religious relief. There are more female factors than male factors (mostly semen problems), such as fallopian tube factors, endometriosis, cervical inflammation and chronic anovulation.

The most troublesome part was worrying about treatment failure, followed bytime consuming, psychological stress of treatment, lack of knowledge about professional hospital or doctors, the costs, husbands’ unwillingness to cooperate, etc. In terms of assistance from the government, the greatest wish was to incorporate infertility treatment into health insurance or to provide subsidies; the second was to strengthen the infertility consultation and medical propaganda. About 80% of infertile women suffered self-stress, 40% feel guilty and nearly 40% regarded themselves as having health issues.