Fertility in Latin America: The Development Crisis No Ministry Claims as Its Own

by José Luis Cárdenas Tomažič / Constanza Salas

Some figures take a generation to become public policy. The decline in fertility across Latin America is one of them. For years, we interpreted it as good news, and in large part it was: fewer adolescent pregnancies, more years of schooling, and greater female labor force participation. Yet the speed of this demographic shift has outpaced our governments’ ability to understand its implications.

Latin America is experiencing the fastest demographic transition in the world. And while we continue debating whether this trend represents a triumph or a crisis, we are overlooking the one question that clearly demands a public policy response: how many people in our countries want to have children but cannot? That gap, between desired children and achievable children, is not a matter of cultural preference. To a large extent, it is a healthcare access problem that we have chosen not to fund.

A Global Phenomenon with Two Extremes

The Global Burden of Disease analysis published in The Lancet projects that by 2050, approximately 155 out of 204 countries will not reach the fertility level required to sustain their populations, and by 2100 this condition will affect 97% of them (GBD 2021 Fertility and Forecasting Collaborators, The Lancet, 2024). It foresees a world divided in two: high fertility concentrated in Sub-Saharan Africa, accounting for more than half of global births, while the rest of the world ages rapidly.

 

At the opposite end are South Korea and several countries in Southern Europe and East Asia. The novelty is that Latin America has already joined this group. According to its vital statistics, Chile’s total fertility rate stands at approximately 0.99 children per woman, placing it firmly in ultra-low fertility territory. Argentina, Uruguay, Cuba, and Costa Rica are following similar trajectories.

And this is not limited to smaller countries. Brazil went from 2.32 children per woman in 2000 to 1.57 in 2023, according to population projections from the Brazilian Institute of Geography and Statistics (IBGE) based on the 2022 Census. In 2024, the country recorded 2.38 million births, a 5.8% decrease from the previous year, the steepest decline in two decades and the sixth consecutive annual drop. Mexico reached 1.60 children per woman and registered 1.67 million births in 2024, 8.5% fewer than in 2023 and nearly 30% below 2015 levels, according to INEGI. The region’s two largest economies, representing more than half of its population, are now below replacement level. This is no longer merely a Southern Cone phenomenon.

This is not simply a healthcare statistic. It is a fiscal, pension, and labor market indicator. Fewer contributors per retiree, fewer students entering schools, and a smaller workforce two decades from now. Finance ministries across the region continue building long-term projections on demographic assumptions that are becoming obsolete faster than they can be updated.

Why Parenthood Is Postponed, and What Happens When It Is

The reasons are numerous, and none are medical in origin: housing costs, job insecurity, the absence of care systems, working schedules incompatible with parenting, and an unequal distribution of domestic responsibilities that continues to fall disproportionately on women. The result is a steady increase in the age at which people seek to have their first child.

This is where biology enters the equation, transforming a social issue into a clinical one. The Latin American Registry of Assisted Reproduction illustrates this shift clearly: women aged 40 years or older now account for 35.7% of all treatment cycles in the region, while women aged 34 and younger represent only 24% (Zegers-Hochschild et al., Reproductive BioMedicine Online, 2025). We are arriving late. And arriving late means lower treatment effectiveness, more treatment cycles, higher costs, and greater frustration.

The composition of this fertility decline is equally revealing. In Brazil, analysis of live birth trends shows that the decrease was concentrated among adolescents and younger women with lower educational attainment, while births among older women increased (Coutinho & Souza, Revista Brasileira de Estudos de População, 2024). In other words, unintended fertility declined while postponed fertility increased. The first is a public health achievement. The second is a clinical demand that health systems will have to address.

It is also important to dismantle a persistent misconception: infertility is not exclusively a women’s issue. Clinical evidence attributes approximately one-third of cases to female factors, one-third to male factors, and one-third to combined or unexplained causes (Raperport et al., The Obstetrician & Gynaecologist, 2026; Agarwal et al., The Lancet, 2021). Moreover, the male component is deteriorating. The most comprehensive meta-analysis available documents a 51.6% decline in sperm concentration between 1973 and 2018 and is the first to confirm this trend in both South and Central America (Levine et al., Human Reproduction Update, 2023). A healthcare system that evaluates only women is examining, at best, one-third of the problem.

The Access Map: Legislation Matters More Than Need

While infertility affects approximately 17.5% of the adult population across all world regions (World Health Organization, 2023), access to treatment is distributed very unevenly.

The regional registry documents that the use of assisted reproductive technologies ranges from 643.3 cycles per million inhabitants in Uruguay to just 28.8 in Guatemala (Zegers-Hochschild et al., Reproductive BioMedicine Online, 2025). A twenty-two-fold difference within the same region. Moreover, all of Latin America remains far below the threshold of 1,500 annual cycles per million inhabitants, an international benchmark originally established by the European Society of Human Reproduction and Embryology (ESHRE) and subsequently adopted by the Latin American Network of Assisted Reproduction (REDLARA) as the minimum level required to adequately meet demand.

The correlation is not mysterious. Uruguay has had an Assisted Human Reproduction Law and public funding since 2013. That same year, Argentina enacted Law 26,862, mandating comprehensive coverage across public, social security, and private healthcare systems without discrimination based on marital status or sexual orientation, the most advanced framework in the region. At the other extreme, Chile, despite having the lowest fertility rate in Latin America, lacks both specific legislation and public funding for high-complexity fertility treatments. In Colombia, access is often resolved through individual legal actions.

An additional coincidence should concern policymakers: the region’s two largest countries also have the weakest regulatory frameworks. In Brazil, assisted reproduction is primarily governed by professional council resolutions rather than legislation, with minimal public provision despite concentrating the highest absolute volume of treatment cycles in Latin America. In Mexico, there is no specific federal legislation, and successive legislative initiatives remain unresolved. Scale without rules does not create access. It creates a market.

The pattern is unmistakable: where legislation and public funding exist, access follows; where they do not, treatment becomes a market commodity available only to those who can afford it or litigate for it. That is the exact opposite of what Universal Health Coverage is intended to achieve.

The same principle applies to family-support policies. Uruguay established a National Integrated Care System, and several countries have expanded shared parental leave and childcare services. These are pieces of the same puzzle. Financing fertility treatment accomplishes little if, after becoming a parent, individuals face a country without adequate care infrastructure.

The Argument Finance Ministries Understand

Here lies the point that regional debates often overlook. Reproductive medicine is one of the very few healthcare interventions whose fiscal return has been explicitly quantified, with remarkably consistent results across countries.

An analysis of Taiwan’s 2021 in vitro fertilization subsidy reform estimated a return of 5.6 monetary units for every unit invested, measured through net lifetime tax contributions from individuals born as a result of treatment, and a gross return of 21.8 times the original investment when measured through total tax contributions (Chen et al., Human Reproduction, 2025). Generational accounting models applied in Europe have reached similar conclusions for years (Connolly et al., Human Reproduction, 2009).

In the language of a Ministry of Finance: funding assisted reproduction is not an operating expense. It is an investment with measurable returns in the future tax base and pension system. When the same analysis notes that health authorities frequently treat infertility as a lower priority and ration its financing, it is describing exactly what is happening across Latin America.

This leads to an uncomfortable conclusion: fertility policy is not solely the responsibility of Ministries of Health. It also involves:

• Finance, because it determines the future contributor and taxpayer base;
• Labor, because female labor force participation depends on motherhood not being economically penalized;
• Social Development, because care systems are the material foundation that makes parenting possible.

The most revealing indicator is not found in a hospital but in a classroom. In Mexico, preschool enrollment declined from 4.93 million children in the 2016-2017 academic year to 4 million in 2024-2025, a reduction of nearly one million children in just eight years. As long as every ministry views the issue as someone else’s responsibility, no meaningful policy response will emerge.

What Needs to Be Done

The agenda is practical and requires no reinvention.

First, visibility: measure and publish how many people require treatment, how many gain access, and what outcomes they achieve through comparable national registries. Without data, the debate will remain anecdotal.

Second, explicit health benefits: incorporate reproductive medicine into formal healthcare benefit packages using clear clinical criteria, defined limits, and health technology assessment frameworks, just as with any other medical intervention.

Third, comprehensive diagnosis: evaluate the couple as a whole, not only the woman.

Fourth, integrated support policies: align healthcare coverage with care systems, parental leave, and labor-market flexibility, because treatment without these supports only solves half the problem.

Latin America does not have a birth rate problem. It has a growing gap between the number of children people say they want and the number they are ultimately able to have. We are managing that gap as if it were a private matter. It is not. It is a public policy decision that we have already made through inaction.

The real question is how many more years will pass before we recognize that access to reproductive healthcare is not a luxury for a privileged few, but a fundamental condition for sustainable development.

References:

Agarwal A, Baskaran S, Parekh N, et al. Male infertility. Lancet. 2021;397(10271):319-333. doi:10.1016/S0140-6736(20)32667-2.

Chen MJ, Kotsopoulos N, Yen AMF, Lin KT, Connolly MP. Estimating the public economic gains in Taiwan from in vitro fertilization (IVF) subsidy changes implemented in 2021. Hum Reprod. 2025;40(2):328-334. doi:10.1093/humrep/deae271.

Connolly M, Gallo F, Hoorens S, Ledger W. Assessing long-run economic benefits attributed to an IVF-conceived singleton based on projected lifetime net tax contributions in the UK. Hum Reprod. 2009;24(3):626-632. doi:10.1093/humrep/den435.

Coutinho RZ, Souza IVM. A transição da fecundidade no Brasil: investigação sobre os efeitos das crises exógenas nas tendências recentes de queda do número de nascidos vivos. Rev Bras Estud Popul. 2024;41:e0283. doi:10.20947/s0102-3098a0283.

ESHRE Capri Workshop Group, Connolly M, Hoorens S, Chambers GM. The costs and consequences of assisted reproductive technology: an economic perspective. Hum Reprod Update. 2010;16(6):603-613. doi:10.1093/humupd/dmq013.

GBD 2021 Fertility and Forecasting Collaborators. Global fertility in 204 countries and territories, 1950-2021, with forecasts to 2100: a comprehensive demographic analysis for the Global Burden of Disease Study 2021. Lancet. 2024;403(10440):2057-2099. doi:10.1016/S0140-6736(24)00550-6.

Levine H, Jørgensen N, Martino-Andrade A, et al. Temporal trends in sperm count: a systematic review and meta-regression analysis of samples collected globally in the 20th and 21st centuries. Hum Reprod Update. 2023;29(2):157-176. doi:10.1093/humupd/dmac035.

Raperport C, et al. Unexplained infertility: an update. The Obstetrician & Gynaecologist. 2026. doi:10.1111/tog.70037.

Zegers-Hochschild F, Crosby JA, Musri C, et al; Latin American Network of Assisted Reproduction. Assisted reproductive technologies in Latin America: the Latin American Registry, 2021. JBRA Assist Reprod. 2025;29(1):167-190. doi:10.5935/1518-0557.20240107.

Zegers-Hochschild F, Crosby JA, Musri C, Petermann-Rocha F, et al; Latin American Network of Assisted Reproduction. Assisted reproductive technologies in Latin America: the Latin American Registry, 2022. Reprod Biomed Online. 2025.