Open research questions in Reproductive Health and Technologies

What the literature leaves open

• WHAT IS KNOWN ALREADY: Most European countries impose national limits on the number of offspring or families per donor, but these limits vary widely and are not always enforced.

  ESHRE position paper: international limits on the number of offspring per gamete donor · 2026 · DOI

• Our study has documented the prevalence, accumulation and age gradient of adverse reproductive experiences. Although individual findings may align with existing expec- tations, the joint analysis of adverse reproductive experiences and births provides insights that go beyond isolated event perspectives. In this final section, we outline the implications of our integrated approach and highlight promising directions for future research. Most importantly, adverse reproductive experiences should be more systemat- ically incorporated into data collections, empirical research and theory on fertility. These experiences appear today to be largely peripheral to demographic research on fertility. Infertility has received growing attention and can be seen as a forerunner in re-introduc- ing physiological and biological constraints into the study of the proximate determinants of fertility. Our findings demonstrate that extending this perspective to include miscar- riage and abortion is essential for a more complete understanding of reproductive behav- iour, particularly in contexts characterised by delayed childbearing and heightened exposure to reproductive barriers. Along these lines, our results suggest that the commonly cited notion of “fertility post- ponement” does not fully capture the range of reproductive experiences observed in age- ing societies. At the individual level, postponement typically implies deliberate timing decisions and assumes that postponed childbearing will eventually be realised. The results point to substantial heterogeneity in reproductive processes that challenges this assumption. The absence of a birth over a 10-year period does not necessarily indicate a lack of reproductive activity. Many women – and their partners – may have actively attempted to conceive but experienced only adverse reproductive events. In our sample, a notable pattern consists of childless women who reported infertility or pregnancy loss without any subsequent birth; in the oldest age group, this applies to up to one-quarter of respondents. For these women, the concept of postponement appears insufficient. Instead, their experiences are better described as forms of “fertility disruption”, as their reproductive outcomes reflect physiological and psychological barriers rather than delib- erate delay. This distinction raises important questions for future research, including about how fertility “postponers” differ from those who experience fertility disruption. https://doi.org/10.1553/p-3fdh-k3g2 24 Nadja Milewski and Jasmin Passet-Wittig Current demographic theories of fertility predominantly emphasise social, institutional and policy-related factors, such as gender equity, work-family reconciliation and family support policies, while giving comparatively limited attention to biological and health- related constraints. However, empirical evidence shows that infertility does not automati- cally translate into having fewer children than intended, which raises questions about who is able to compensate for infertility and under what conditions, and what role ART plays in this context. These questions are closely linked to micro-level processes: adverse repro- ductive experiences such as infertility or miscarriage can act as life course disruptions that affect wellbeing and shape subsequent trajectories, e.g. through union instability, altered partnership dynamics or a reduced willingness to pursue parenthood due to anticipated psychological or physical burdens. At the same time, infertility and miscarriage share many risk factors, and the use of ART may itself be intertwined with subsequent adverse reproductive experiences, and be shaped by physiological, financial, ethical, cultural or personal considerations. At the macro level, our findings highlight age as a central risk factor for the occurrence of adverse reproductive experiences and their associations with birth outcomes. While much demographic research continues to focus on policy levers aimed at facilitating child- bearing, a more systematic integration of reproductive barriers into fertility theory may help to explain why such policies often have limited effects on fertility levels in late fertility societies. Incorporating these dimensions would refine existing models of the proximate determinants of fertility and provide a more realistic account of reproductive decision-making under conditions of delayed childbearing. Further theoretical and empir- ical progress in this direction critically depends on the availability of data that capture adverse reproductive experiences. The pairfam study and recent data collections in other European countries (Beaujouan et al., 2025; Minello, 2025) demonstrate that respondents in demographic surveys are willing to report on these sensitive experiences and may even value their recognition.

  Reproductive disruptions in fertility research: Conceptual re-integration and evidence from Germany · 2026 · DOI

• Background: Analysing fertility alone is insufficient with respect to understanding individual reproductive trajectories since reproductive experiences are interconnected across the lifespan and may be influenced by other reproductive events that affect both the tempo and the quantum - especially within the context of fertility postponement.

  Exploring the full spectrum of reproductive experiences · 2026 · DOI

• Multifactorial aetiology of infertility underlines the need for early identification, targeted counselling and intervention along with lifestyle modification strategies. The findings of the present study have important implications for both clinical practice and public health strategies. 1. Policy-level interventions: Integrating infertility screening and counselling within existing maternal and reproductive health programs could support early identification and management of at-risk couples. Routine infertility risk assessment should be incorporated into primary healthcare with particular emphasis on early identification of modifiable risk factors such as smoking, obesity, and delayed care-seeking. Early screening, targeted counselling, and timely referral at the primary healthcare level can help reduce delays in seeking treatment and improve reproductive outcomes. 2. Community-based strategies: Community-based awareness programs tailored to identified risk factors can play an important role in early detection and prevention. Frontline health workers such as Accredited Social Health Activists (ASHAs) and Auxiliary Nurse Midwives (ANMs) can be trained to provide awareness on Patel et al. Discover Public Health (2026) 23:990 Page 13 of 14 reproductive health, promote healthy lifestyle practices, encourage early consultation for infertility, and facilitate timely referral to specialised services. Existing platforms such as Village Health and Nutrition Day (Mamta Divas) can be utilised to generate awareness regarding infertility and its risk factors. 3. Clinical practice implications: In tertiary care settings, clinicians should actively screen couples for infertility risk factors using a brief risk assessment checklist. This would facilitate early identification of high-risk couples and enable targeted counselling and timely interventions. 4. Future research: Further multicentric, longitudinal, community-based research involving a comprehensive evaluation of both male and female partners is recommended. Such studies will help generate region-specific evidence to inform targeted interventions and strengthen infertility care services at the primary healthcare level in India.

  A comparative study of factors associated with primary and secondary infertility among women attending a tertiary care hospital in Western India · 2026 · DOI

• The NSFG is a cross-sectional dataset and does not include information on wom- en’s age at diagnosis or how long they have had their condition, nor is there infor- mation on severity, treatment, or other aspects of their condition that could impact fertility and quality of life. This precludes identifying specific experiences related to reproductive health conditions that could be impacting fertility decision-making, such as severe pain, frustration with providers, or difficulty in maintaining intimacy in relations. Information about reproductive health conditions is based on women’s self-reports and thus are likely to be underestimates of the true prevalence of such conditions. Further, as a cross-sectional survey, fertility goals are measured at only a single point in time and may change over the life course; they may also differ Women’s Reproductive Health Conditions and Fertility Goals1 3 10 Page 16 of 20 before and after being diagnosed with a reproductive health condition. Finally, we are unable to observe which women go on to fulfill their fertility goals.

  Women’s Reproductive Health Conditions and Fertility Goals · 2026 · DOI

• This review should be interpreted in light of certain con- siderations. Not all countries within the MENA region were represented, as inclusion was dependent on the availability of published data and relevant sources, which may influence the generalizability of the findings. Addi- tionally, while the review integrates insights from the literature and expert-informed perspectives, it does not include direct patient input, which may limit the repre- sentation of lived experiences. Furthermore, although a structured and comprehensive literature search was con- ducted, a formal quality assessment of included studies was not performed. Finally, the available literature from the MENA region remains limited, with relatively few studies and often small sample sizes, which may affect the robustness and generalizability of the conclusions. Ata et al. Middle East Fertility Society Journal (2026) 31:55 Supplementary Information The online version contains supplementary material available at h t t p s : / / d o i . o r g / 1 0 . 1 1 8 6 / s 4 3 0 4 3 - 0 2 6 - 0 0 3 4 1 - 1 . Supplementary Material 1.

  Bridging the Gap: barriers to infertility treatment in the Middle East and North Africa (MENA) region and expert recommendations for enhanced access · 2026 · DOI

• This study is subject to several limitations. First, the four indicators developed for com- parative analysis were limited to the specific variables available within the NSFG. Conse- quently, these measures do not reflect the full range of indicators that have been used to estimate unrealised fertility. Second, the results reflect the fertility goals and outcomes of a specific cohort of U.S. women and may not be generalisable to men, gender-diverse indi- viduals or populations in different cohorts or social contexts. Nevertheless, by explicitly comparing four indicators within a single nationally representative dataset, the study results demonstrate significant heterogeneity in estimates of unrealised fertility and provide a rep- licable framework for comparative studies in other contexts. Second, the reproductive health determinants of unrealised fertility should be interpreted with caution, as infertility and pregnancy loss are often underreported in surveys (Lindberg and Scott, 2018). Similarly, as many reproductive health conditions go unrecognised or undiagnosed, knowledge of the impact of reproductive health factors on desired and achie- ved fertility is limited. The reproductive health characteristics analysed in the present study reflect those of women aged 40–49 and may not have been present earlier in the life course when most women initiate childbearing. Future surveys and novel data collection efforts (Nobles et al., 2026) that track fertility goals prospectively and document a broad range of social and reproductive health experiences would allow for a more accurate assessment of how various factors influence the achievement and revision of fertility goals.

  The meaning and measurement of unrealised fertility: A comparison of measures among women aged 40–49 in the United States · 2026 · DOI

• A convenience sampling technique was utilized for this study, with participants selected based on their attendance at the fertility clinic during the data collection period. This approach was adopted due to the practical constraints of clinic workflow, allowing all eligible women present on designated study days to be consecutively invited until the target sample size was obtained. While convenience sampling is frequently used in clinical settings, it is a non- probability method that introduces inherent selection bias [17]. Consequently, the findings may not be fully generaliz- able to all women experiencing infertility, particularly those who do not attend or cannot access tertiary-level healthcare facilities. Such women may differ systematically in their knowledge, attitudes, health-seeking behaviour, and eco- nomic circumstances, which may influence IVF uptake. Eligibility was determined using clearly defined selection criteria. Women attending the fertility or general Obstetrics and Gynaecology clinics who provided informed consent were included in the study. Exclusion criteria comprised pregnant women, individuals who declined participation, and those who had participated in the pilot study. The instru- ment was pilot-tested among 15 women (representing 10% of the target sample) at a private fertility facility. This pre- liminary phase enabled refinement of the terminology to Page 3 of 14 181 ensure cultural and linguistic appropriateness for the local population.

  Understanding the Uptake of In-Vitro Fertilization (IVF) and Determinants Among Women in Sub-Saharan Africa: Evidence from Nigeria · 2026 · DOI

• The application of AI across reproductive health domains, including screening, diagnosis, decision support, and service delivery, is expanding rapidly and is often linked to progress towards universal access to sexual and reproductive healthcare and reproductive rights (24, 25, 38). However, the integration of algorithmic decision making into these sensitive areas introduces to autonomy, equity, privacy, complex challenges relating accountability, and legal risk (28–31). These challenges are particularly pronounced in reproductive health, where decision making is intimate, socially embedded, and shaped by restrictive laws, stigma, and unequal access to care. Framing these challenges through the Healthcare 5.0 paradigm provides a basis for moving from descriptive ethics to governance focused analysis. Healthcare 5.0 emphasises human centricity, adaptability, ethical by design principles, and system level accountability within interconnected health ecosystems (20, 21, integrated with a 23). In this paper, this perspective reproductive justice framework, which foregrounds structural inequality, power, and the conditions shaping reproductive autonomy and access to care (22). Together, these frameworks for understanding how provide a algorithmic systems operate as socio-technical systems, in which data practices, model design, institutional use, and regulatory oversight interact to shape outcomes over time, particularly in constrained or legally restrictive contexts. complementary lens is Figure 1 presents this integrated framework as a conceptual synthesis for reproductive health AI governance. It illustrates how Healthcare 5.0 principles intersect with reproductive justice to define governance priorities, positioning dimensions autonomy, fairness, privacy, accountability, and contextual sensitivity as interdependent system level requirements rather than isolated ethical concerns (20–22). This perspective also institutional highlights gaps approaches, including limited explainability, weak bias auditing, insufficient protection of sensitive reproductive data, unclear accountability structures, and limited adaptation to local legal and sociocultural conditions. Accordingly, the sections that follow apply this integrated framework to examine how risks emerge, identify governance gaps, and clarify the oversight, design constraints, and institutional responsibilities required for equitable deployment of reproductive health AI.

  Regulating algorithmic tools in reproductive health: ethical and legal challenges · 2026 · DOI

• RAISING THE EVIDENCE BAR Addressing the “add-on phenotype” requires fundamental shifts in how the medical field evaluates and adopts new technologies. Below are a few relevant points. RIGOROUS PRE-ADOPTION EVALUATIONS Expensive technologies intended to improve patient-important outcomes must undergo adequately powered validation studies before being integrated into standard IVF cycle protocols. This does not mean that all research must be a prospectively randomized study of thousands of patients; such a recommendation is unrealistic for IVF, which is completely excluded from U.S. federal funding. But it means that every change to routine practice must be declared to the public and must be described as “experimental” until an authoritative body under widely accepted study criteria concluded one of the following: The new addon should no longer be considered experimental (because studies of varying evidence levels have determined there is sufficient likelihood of specifically described outcome benefits), or the new practice did not produce expected outcome benefits after adequate time as an “experimental” procedure, and, should remain “experimental” or should no longer be used. After all, IVF itself was once an experimental procedure supervised by Institutional Review Boards. And only once IVF had achieved minimum expected results, did ASRM and other authoritative bodies declare the procedure no longer experimental. In short, the IVF field needs better regulation, preferably by its own professional organizations, such as ASRM, or, if they do not establish recommended practices, by the government, as is the case in the U.K. Moreover, regulatory bodies and/or medical advisory societies should retroactively review every major clinical change introduced to IVF since 2010, when fresh embryo transfer rates in the U.S. plateaued, if their costs exceed a certain threshold. In addition, every new potential addon should be prospectively evaluated before being put into clinical practice. ENHANCED REGISTRIES There currently exists no better tool for evaluating a country’s IVF performance than a well-designed national registry. Clearly, in this sense, the SART registry is the leading registry in the world; enhancing it with artificial intelligence (AI) will certainly make it even more powerful in the near future. Access to these registries must be significantly eased because, at least for both the U.S. Centers for Disease Control (CDC) registry and the ASRM/SART registry, the bureaucratic hurdles are unacceptable. In addition, post-market- TRANSPARENCY FOR PATIENTS Professional societies could adopt a regulatory model similar to that of the Human Fertilisation and Embryology Authority (HFEA), which is charged with overseeing all IVFrelated matters in the U.K.

  Paying more for no better outcome: The add-on crisis in modern medicine – using infertility treatment as the primary example · 2026 · DOI

• Current IVF practices are in need of radical reforms at multiple levels. Critical peer reviews of published papers are designed to remove business interests from the IVF literature. Enhanced post-marketing surveillance should provide much more transparent communications with patients about evidence quality and costs. Reimbursement policies should reward demonstrated value. These steps promote a professional culture that balances innovation with restraint.

  Paying more for no better outcome: The add-on crisis in modern medicine – using infertility treatment as the primary example · 2026 · DOI

• The paper notes that regulatory approaches have developed in an 'ad hoc, responsive way' but does not provide a systematic methodology for how regulators can prospectively use this typology of models to anticipate technological and social developments in reproductive donation beyond DTCGT, such as emerging biotechnologies or changing family structures.

  Conceptualizing Reproductive Donation: Developing Models of Egg and Sperm Donation and the Implications for Regulating Information Giving · 2026 · DOI

• The paper establishes that donors, recipient couples, and donor-conceived people have divergent interests regarding information disclosure in reproductive donation, but does not provide empirical comparison of how these stakeholder preferences align or conflict across the five proposed models or how regulatory frameworks should weigh competing interests when no consensus exists.

  Conceptualizing Reproductive Donation: Developing Models of Egg and Sperm Donation and the Implications for Regulating Information Giving · 2026 · DOI

• The paper identifies that the HFEA and other regulators launched consultations in 2022-2023 to respond to DTCGT challenges in reproductive donation but does not analyze the actual outcomes, recommendations, or policy changes resulting from these consultations or how different regulatory frameworks (UK anonymity-default versus US identity-release models) are operationalizing responses.

  Conceptualizing Reproductive Donation: Developing Models of Egg and Sperm Donation and the Implications for Regulating Information Giving · 2026 · DOI

• The paper notes that the network model of reproductive donation recognizes 'wider donor relations' and the importance of donor-conceived people accessing identifying information before age 18, but does not provide specific empirical data on how donor-conceived individuals at different developmental stages process, utilize, or are affected by accessing donor identity information obtained through both regulated and unregulated channels.

  Conceptualizing Reproductive Donation: Developing Models of Egg and Sperm Donation and the Implications for Regulating Information Giving · 2026 · DOI

• The paper identifies that Direct-to-Consumer Genetic Testing (DTCGT) is circumventing regulatory prohibitions on donor identity disclosure in reproductive donation, but does not investigate empirical mechanisms of how frequently this occurs, which populations are most affected, or what specific genetic databases or platforms are enabling this circumvention across different jurisdictions.

  Conceptualizing Reproductive Donation: Developing Models of Egg and Sperm Donation and the Implications for Regulating Information Giving · 2026 · DOI

• The paper proposes a typology of five models of reproductive donation (bioscientific, clinical, family, person, and network models) but does not empirically test which model(s) are most ethically defensible or how regulators should prioritize between competing models when implementing information-giving policies. Comparative ethical analysis across jurisdictions using these models as a framework is needed.

  Conceptualizing Reproductive Donation: Developing Models of Egg and Sperm Donation and the Implications for Regulating Information Giving · 2026 · DOI

• Since modern research on infertility in sociology is focused mainly on women, men are excluded from the fertility equation, although studies show that men also suffer from infertility, but research for men is insufficient, since in domestic sociological studies very little has been studied the experience of infertility from the point of view of men.

  Male experience of infertility: a sociological analysis of male points of view · 2023 · DOI

• Significance of the study the data and research presented in the article are scientific and new, since models of forced childlessness of men of reproductive age have not been studied in domestic sociology before, therefore, for a deeper understanding of this problem, it is important to study the infertile experience of men.

  Male experience of infertility: a sociological analysis of male points of view · 2023 · DOI

• However, research on the impact of ART on completed fertility is limited and the extent to which delayed births are realized later in life through ART is not well understood.

  Projecting the Contribution of Assisted Reproductive Technology to Completed Cohort Fertility · 2023 · DOI

• Little is known about whether and how parents of TGD youth consider fertility-related implications when making medical decisions about pubertal suppression treatment.

  Fertility Considerations in Parental Decision-Making about Pubertal Suppression Treatment for Their Transgender and Gender-Diverse Children · 2022 · DOI

• Medically assisted reproduction (MAR) plays an increasingly important role in the realization of fertility intentions in advanced societies, yet the evidence regarding MAR-conceived children's longer-term well-being remains inconclusive.

  The Well-Being of Adolescents Conceived Through Medically Assisted Reproduction: A Population-Level and Within-Family Analysis · 2022 · DOI

• Although IVF and egg freezing have received much scholarly attention, the pivotal role of financialization in the fertility (preservation) sector remains understudied.

  The speculative turn in IVF: egg freezing and the financialization of fertility · 2020 · DOI

• However, when it comes to the most controversial topic, germline genome editing (GGE), there is no consensus on whether this technology has any substantial advantages over existing procedures such as embryo selection after in vitro fertilization (IVF) and preimplantation genetic diagnosis (PGD).

  Germline genome editing versus preimplantation genetic diagnosis: Is there a case in favour of germline interventions? · 2019 · DOI

• Many of the instances of discrimination described in this book were limited to the decision of one physician, who was often successfully sued, while another ART provider was identified and used.

  The New Eugenics: Selective Breeding in an Era of Reproductive Technologies by Judith Daar · 2017 · DOI

Most-cited papers in Reproductive Health and Technologies

• Prevalence of infertility and help seeking among 15 000 women and men · Human Reproduction · 2016 · 344 citations
• Fertility intentions · Demographic Research · 2013 · 321 citations
• Reproductive wish in transsexual men · Human Reproduction · 2011 · 288 citations
• ESHRE guideline: routine psychosocial care in infertility and medically assisted reproduction—a guide for fertility staff: Figure 1 · Human Reproduction · 2015 · 285 citations
• Prevalence of depressive and anxiety disorders in an assisted reproductive technique clinic · Human Reproduction · 2004 · 277 citations
• The Impact of Infertility on the Psychological Well-Being, Marital Relationships, Sexual Relationships, and Quality of Life of Couples: A Systematic Review · Journal of Sex & Marital Therapy · 2014 · 271 citations
• ART in Europe, 2019: results generated from European registries by ESHRE · Human Reproduction · 2023 · 258 citations
• Pregnancy established in an infertile patient after transfer of a donated embryo fertilised in vitro. · BMJ · 1983 · 255 citations
• Revised guidelines for good practice in IVF laboratories (2015) · Human Reproduction · 2016 · 254 citations
• Time to pregnancy and semen parameters: a cross-sectional study among fertile couples from four European cities · Human Reproduction · 2002 · 245 citations

Most recent work

• Consentful Lights: Designing for Consent when Sharing Intimate Fertility Data · 2026
• Toward individualistic reproduction: Solving the fertility crisis could require a further marginalization of men · Politics and the Life Sciences · 2026
• Conceptualizing Reproductive Donation: Developing Models of Egg and Sperm Donation and the Implications for Regulating Information Giving · Journal of Law, Medicine & Ethics · 2026
• Attachment in lesbian and gay parent families: a systematic review, theoretical advancements, and a 10-year research agenda · Attachment & Human Development · 2026
• Women’s Reproductive Health Conditions and Fertility Goals · Population Research and Policy Review · 2026
• Memorable Messages in Response to Queer Miscarriage Disclosure: How Dominant Discourses About Reproductive Health Shape and Silence · LGBTQ+ Family An Interdisciplinary Journal · 2026
• Why we need to teach everyone about reproductive health · Health Education Journal · 2026
• Legal Safeguards in Surrogacy: Clinical Permission and Informed Consent in the Indian Context · International Journal of Advanced Research in Science Communication and Technology · 2026
• Paying more for no better outcome: The add-on crisis in modern medicine – using infertility treatment as the primary example · Journal of IVF-Worldwide · 2026
• Requisitos para descarte e compensação de doadores no contexto da reprodução humana assistida: recomendação internacional europeia e norte-americana · Vigilância Sanitária em Debate · 2026

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