in europe, 157,500 children were born using assisted reproductive technology in 2015, according to the european society of human reproduction and embryology (eshre). but there are major differences in legislation across the old continent. a european directive fixes standards concerning the use of human tissue and cells, but all ethical and legal questions on art remain the prerogative of eu member states. conditions of assisted reproductive technology in different european countries. art authorized for lesbian couples art authorized for single women art authorized for single women and lesbian couples art prohibited for single women and lesbian couples across europe, the legal criteria per availability vary somewhat. in 11 countries all women may benefit; in 8 others only heterosexual couples are concerned; in 7 only single women; and in 2 (austria and germany) only lesbian couples. spain was the first european country to open art to all women, in 1977, the year the first sperm bank was opened there. in france, the right to art is accorded to all women since 2019. in the last 15 years, legislation has evolved quickly. for example, portugal made art available in 2006 with conditions very similar to those in france, before amending the law in 2016 to allow lesbian couples and single women to benefit. italy clarified its uncertain legal situation in 2004 by adopting europe's strictest laws: art is only available to heterosexual couples, married or otherwise, and sperm donation is prohibited. today, 21 countries provide partial public funding for art treatment. the seven others, which do not, are ireland, cyprus, estonia, latvia, luxembourg, malta, and romania. such subsidies are subject to conditions, however. in belgium, a fixed payment of €1,073 is made for each full cycle of the ivf process. the woman must be aged under 43 and may not carry out more than six cycles of art. there is also a limit on the number of transferable embryos, which varies according to age and the number of cycles completed. in france, art is subsidized in full by national health insurance for women up to age 43, with limits of 4 attempts at ivf and 6 at artificial insemination. germany tightened its conditions for public funding in 2004, which caused a sharp drop in the number of art cycles carried out, from more than 102,000 in 2003 to fewer than 57,000 the following year. since then the figure has remained stable. 17 countries limit access to art according to the age of the woman. 10 countries have established an upper age limit, varying from 40 (finland, netherlands) to 50 (including spain, greece and estonia). since 1994, france is one of a number of countries (including germany, spain, and the uk) which use the somewhat vague notion of "natural age of procreation". in 2017, the steering council of france's agency of biomedicine established an age limit of 43 for women using art. 10 countries have no age limit for art. these include austria, hungary, italy and poland. most european countries allow donations of gametes by third parties. but the situations vary depending on whether sperm or eggs are concerned. sperm donations are authorized in 20 eu member states; in 11 of them anonymity is allowed. egg donations are possible in 17 states, including 8 under anonymous conditions. on 12 april, the council of europe adopted a recommendation which encourages an end to anonymity. in the uk, anonymous sperm donations ended in 2005 and children have access to the identity of the donor when they reach adulthood. in france, the principle of anonymous donations of sperm or embryos is maintained in the law of bioethics of 2011, but a new bill under discussion may change the situation. united kingdom in the united kingdom, all patients have the right to preliminary testing, provided free of charge by the national health service (nhs). however, treatment is not widely available on the nhs and there can be long waiting lists. many patients therefore pay for immediate treatment within the nhs or seek help from private clinics. in 2013, the national institute for health and care excellence (nice) published new guidelines about who should have access to ivf treatment on the nhs in england and wales. the guidelines say women aged between 40 and 42 should be offered one cycle of ivf on the nhs if they have never had ivf treatment before, have no evidence of low ovarian reserve (this is when eggs in the ovary are low in number, or low in quality), and have been informed of the additional implications of ivf and pregnancy at this age. however, if tests show ivf is the only treatment likely to help them get pregnant, women should be referred for ivf straight away. this policy is often modified by local clinical commissioning groups, in a fairly blatant breach of the nhs constitution for england which provides that patients have the right to drugs and treatments that have been recommended by nice for use in the nhs. for example, the cheshire, merseyside and west lancashire clinical commissioning group insists on additional conditions: the person undergoing treatment must have commenced treatment before her 40th birthday; the person undergoing treatment must have a bmi of between 19 and 29; neither partner must have any living children, from either the current or previous relationships. this includes adopted as well as biological children; and, sub-fertility must not be the direct result of a sterilisation procedure in either partner (this does not include conditions where sterilisation occurs as a result of another medical problem). couples who have undertaken a reversal of their sterilisation procedure are not eligible for treatment. canada