The B2-InF consortium has gone through extensive scientific literature stating that the fertility rate in Belgium has been declining since 2010. In that year, the fertility rate was 1.85 children per woman, whereas, in 2020, the total fertility rate decreased to 1.55 children per woman (1). Moreover, since 1998, the average age of mothers at birth in Belgium has increased at an average annual rate of almost 0.1 at year (2); it went from 29.1 years at birth in 1998 to 30.8 years at birth in 2020. There are differences among regions, with a significantly higher average age in Brussels (31.9 years) than in Flanders and Wallonia (30.7 years and 30.6 years, respectively).
Regarding legislation, Medically Assisted Procreation (MAP) treatments in Belgium are regulated by the law of 6 July 2007. The ART treatments allowed in Belgium are intrauterine insemination, in vitro fertilization, intracytoplasmic sperm injection, egg and sperm donation, freezing of oocytes, frozen embryo transfer and preimplantation genetic screening. Egg and sperm donation could be anonymous or non-anonymous when agreed between all parties, and embryo donation could be only anonymous (3).
Since 2007, there has been no limit to the number of children born from each sperm donor, however the sperm of one donor cannot lead to births in more than 6 different women or female couples. In addition, it is determined by law the number of embryos that could be transfer to the woman, which has led to a decrease in the incidence of multiple pregnancies in the recent years (4). There is no specific legislation on subrogation but this does not imply that there is no legal framework, in fact, the Belgian Civil Code clearly states that woman who gives birth is the legal mother, “mater semper certa est”. Any surrogacy agreement will in principle be void and not legally enforceable, because it is contrary to public order (it has no valid object or cause), Art 1131 71133 Belgian Civil Code. In addition, all children born through surrogacy in Ukraine, through Ukrainian surrogate are not allowed a Belgian passport. Despite this, it is indeed practised. There remains the possibility of adoption for the determination of filiation in favour of the intended parents. A situation similar to the Spanish one, in fact.
With regard to accessibility, all ART treatments in Belgium are accessible for heterosexual couples, single women, female couples and male couples. Female women can access public funded ART treatments until de age of 43. For non-reimbursed ART treatments, the female age limit is 47 years-old. Because of the wide accessibility to ART treatments, Belgium is considered an ‘open state’ and a frequent destination to access ART procedures for people from other European countries with more restrictive laws (5).
The MAP data from Belgium has been recorded by the Belgian Register for Assisted Procreation (BELRAP) since 1989 (6). According to this registry, 39,489 cycles were performed in 2018 and 5,954 children were born as a result of the use of these techniques (7).
The number of centres that provide ART treatments in Belgium is limited by law (8). These centres are categorized in 2 types: The A-centre, which can diagnose and treat sterility but it does not have a MAP laboratory; and the B-centre, which diagnose and treat sterility with the ability to turn to a MAP laboratory. According to the registry, there are 17 A-centres and 18 B-centres in Belgium. There are no completely private ART centres in Belgium and there is no waiting list in the public sector.
Regarding costs, 6 cycles of ART treatments are publicly funded in Belgium. Medication is partially covered by the patient. In 2018, 77% of ART treatments were covered by the social security system of Belgium (7).
To understand the perception that the young generations have about ART in Belgium, 15 young Belgians were interviewed. When conducting the interviews, one of the interviewees expressed that her couple was pregnant through the use of ART techniques, which is an exclusion criterion for the study. Therefore, the data from this interview was removed and not considered for the analysis. The sociodemographic characteristics of the 14 interviewees analyzed are described in table 2. The average age was 24.8 years old (standard deviation=3.7).
Table 2. Sociodemographic characteristics of the sample in Belgium
| Participants (n=14) | ||
| n | % | |
| Age in years | ||
| 18 – 22 | 4 | 28 |
| 23 – 26 | 5 | 36 |
| 27 – 30 | 5 | 36 |
| Gender | ||
| Male | 8 | 57 |
| Female | 6 | 43 |
| Transgender male to female | 0 | 0 |
| Transgender female to male | 0 | 0 |
| Other | 0 | 0 |
| Sexual Orientation | ||
| Heterosexual | 9 | 64 |
| Homosexual | 3 | 22 |
| Bisexual | 1 | 7 |
| Other | 1 | 7 |
| Occupation | ||
| Student | 5 | 36 |
| Self-employed | 2 | 14 |
| Employed for wages | 5 | 36 |
| Homemaker | 0 | 0 |
| Unemployed | 2 | 14 |
| Unable to work | 0 | 0 |
| Highest educational level achieved | ||
| No schooling completed | 0 | 0 |
| School | 0 | 0 |
| High school | 3 | 21 |
| Bachelor degree | 11 | 79 |
| Doctorate degree | 0 | 0 |
| Residence | ||
| Urban area | 5 | 36 |
| Semi-urban area | 4 | 28 |
| Rural area | 5 | 36 |
| Relationship | ||
| Yes | 7 | 50 |
| No | 7 | 50 |
| Marital status | ||
| Single | 10 | 71 |
| Married or domestic partnership | 4 | 29 |
| Widow | 0 | 0 |
| Divorced | 0 | 0 |
| Separated | 0 | 0 |
| Religious beliefs | ||
| Christian | 5 | 36 |
| Muslim | 3 | 21 |
| Jewish | 1 | 7 |
| Orthodox | 0 | 0 |
| Other | 0 | 0 |
| None | 5 | 36 |
The recruitment of participants was organized by the contracted company based in Belgium. It took place through two recruitment offices, one in the Francophone area and the other one in the Flemish region of , with the ultimate goal to ensure a good distribution between Flanders and Wallonia.
Respondents were very willing to cooperate, spoke openly and answered all the questions. Only one interview with a religious individual woman was slightly more complicated because sexuality and fertility are issues that she would not normally discuss. In this regard, hopefully B2-InF will allow this segment of the population to have complete information readily available to them in the journey of their life.
REFERENCES
- Sharp drop in births in 2020 [Internet]. [cited 2022 Jan 12]. Available from: https://statbel.fgov.be/en/news/sharp-drop-births-2020
- A still declining birth rate and fertility rate [Internet]. 2019 [cited 2022 Jan 12]. Available from: https://statbel.fgov.be/en/news/still-declining-birth-rate-and-fertility-rate
- Pennings G. Belgian Law on Medically Assisted Reproduction and the Disposition of Supernumerary Embryos and Gametes. Eur J Health Law [Internet]. 2007 Jan 1 [cited 2022 Jan 11];14(3):251–60. Available from: https://brill.com/view/journals/ejhl/14/3/article-p251_4.xml
- De Neubourg D, Bogaerts K, Wyns C, Albert A, Camus M, Candeur M, et al. The history of Belgian assisted reproduction technology cycle registration and control: a case study in reducing the incidence of multiple pregnancy. Hum Reprod [Internet]. 2013 Oct 1 [cited 2022 Jan 11];28(10):2709–19. Available from: https://academic.oup.com/humrep/article/28/10/2709/619530
- Merchant J, editor. Access to Assisted Reproductive Technologies: The Case of France and Belgium. New York; 2020.
- BELRAP [Internet]. [cited 2022 Jan 11]. Available from: https://www.belrap.be/Public/Default.aspx?Lg=En
- Anagnostou E, Blockeel MC, Delbaere MA, member Devreker AF, Vandekerckhove MF, Belmans A, et al. Assisted Reproductive Technology National Summary Report Belgium 2018. College of Physicians Reproductive Medicine [Internet]. 2021 [cited 2022 Jan 11]. Available from: www.belrap.be.
- Calhaz-Jorge C, De Geyter C h, Kupka MS, Wyns C, Mocanu E, Motrenko T, et al. Survey on ART and IUI: legislation, regulation, funding and registries in European countries. Hum Reprod Open. 2020 Jan 1;2020(1).