WHEN TANG RONGXIN began practising in vitro fertilisation (IVF) in Beijing in 2006, she says that fertility clinics felt otherworldly. The procedure seemed "extremely mysterious", she recalls. Two decades on, IVF has become embedded in mainstream medicine. The most revealing change in that time, Ms Tang says, is not only in the science but in the patients themselves. Women in her waiting room are markedly older than those she helped at the start of her career.

That mirrors a broader demographic transformation. Chinese couples are marrying and trying for children later than in previous generations-one reason why infertility has become more of a problem. The share of couples of reproductive age struggling with infertility climbed from around 12% in 2007 to about 18% in 2020. Demand for IVF has surged. The number of assisted-reproduction treatment cycles in China rose from about 236,000 in 2013 to more than 1.1m in 2019. Today China has roughly 600 licensed clinics; assisted-reproductive technologies accounted for around 300,000 births, roughly 3% of the national total in 2022 (the latest year for which data are available). In a country desperate for more babies, even that modest share has drawn official attention.

China's fertility rate is among the lowest in the world: the average Chinese woman has just one child over her lifetime, down from 1.8 in 2017, and far below the 2.1 required to keep the population stable. Policymakers, alarmed that a greying population will leave too few workers to sustain growth and too many old folk to support, have rolled out an increasingly muscular package of pro-birth measures. A nationwide child-care allowance introduced in 2025 pays families 3,600 yuan ($520) a year per child under the age of three. Less subtly, in January condoms became subject to a 13% VAT rate.

These measures come after the central government required assisted reproductive treatments to be added to public insurance schemes in 2022. These are administered and financed locally. More than 1m people received reimbursement for IVF treatment in 2024 alone. By mid-2025 all 31 provincial-level regions had incorporated them into their schemes. An IVF cycle can cost 20,000–50,000 yuan. Some cities also offer grants of up to 10,000 yuan.

Yet demographers doubt that expanding IVF subsidies will raise births substantially. International experience offers little encouragement. Japan and South Korea have spent lavishly on pro-birth policies, including IVF, for decades; neither has achieved a sustained recovery in numbers. In China assisted reproduction would have to expand many times over to shift the fertility rate substantially.

Besides, scaling it up is far from straightforward. As Ms Tang observes, more patients are arriving in their late 30s, when success rates decline sharply. And IVF helps with infertility, not ambivalence about parenthood, thus benefiting only a small group of people, notes Stuart Gietel-Basten of the Hong Kong University of Science and Technology.

In China that limited pool is further narrowed by geographical constraints and the government's own policies. Clinics are concentrated in wealthier cities. From 2023 to mid-2025 more than 53,000 people in Beijing-a municipal area of 22m-had their fertility treatment reimbursed through public insurance. By contrast, in Jilin, a north-eastern province with a similar population, fewer than 6,000 women benefited in the first year after coverage began in 2024. Authoritative data on how many of these women actually bore children are difficult to obtain.

Such disparities reflect the structure of China's health system, explains Karen Eggleston of Stanford University. Because provinces have to cover a big share of their own insurance costs, richer regions reimburse more generously. In poorer ones treatment often remains unaffordable. Ningxia's annual disposable income per person is less than a cycle of treatment might cost. And low reimbursement rates in turn constrain supply. Public hospitals must generate revenue, and where patients cannot cover the shortfall there is little incentive to expand IVF services, says Wang Feng of the University of California, Irvine.

Moreover, access to IVF is tightly regulated by national and provincial rules. Nationally, only heterosexual couples who are married can receive treatment. Few places seem to restrict access based on a mother's age. But rules on egg-freezing are strict. It is permitted only for medical reasons, such as in the event of cancer treatment, and not for healthy women who wish to postpone childbirth. That prevents women who know they want to delay childbearing from freezing eggs while they are younger, even though IVF using younger eggs has a higher success rate.

Access to IVF may yet expand. Officials' demographic worries may, over time, come to outweigh ideological reservations that have limited eligibility, says Mr Wang. In 2023 the province of Sichuan removed a requirement that parents must be married in order to register a child's birth, allowing single mothers to get maternity benefits. That year, too, an adviser to the national government (unsuccessfully) proposed granting unmarried women access to infertility treatments. Although such changes would bring families joy, high subsidies and advanced technologies will not deliver China from demographic decline.