Background: Infertility is a global health problem that carries a high social and economic burden.Assisted reproductive technology (ART) has been developed in mainland China for over 30 years. We aimed to evaluate the accessibility and equity of distribution of ART facilities in mainland China from 2006 to 2018, and quantify the population with reduced geographic access to ART services.Method: A retrospective study was conducted to describe the trend and analyze the equity of distribution of ART clinics in 2006ART clinics in , 2012ART clinics in , and 2018. Coverage rates were calculated by city and by population. Size of population living in areas with different regional choice of ART services was identi ed. The Gini coe cients were calculated to measure the equity of the distribution of ART clinics.Results: There were 85 ART clinics (not counting arti cial insemination clinics) in mainland China in 2006China in , 356 in 2012China in , and 498 in 2018 The coverage rate of ART clinics was increased signi cantly (P 0.05). Eastern China had the most extensive coverage, followed by the central region, while the western region had the least coverage (P 0.05). At the end of 2018, 171.4 million people in 47 cities had no access to in vitro fertilization (IVF) clinics, but had access to at least one arti cial insemination clinic in their own cities. There were still 354.9 million people (25.4% of the population) living in 148 cities without any ART clinics, indicating that 179.5 million people of reproductive age had no access to ART services.

Background: Infertility is a global health problem that carries a high social and economic burden. Assisted reproductive technology (ART) has been developed in mainland China for over 30 years. We aimed to evaluate the accessibility and equity of distribution of ART facilities in mainland China from 2006 to 2018, and quantify the population with reduced geographic access to ART services.Method: A retrospective study was conducted to describe the trend and analyze the equity of distribution of ART clinics in 2006, 2012, and 2018. Coverage rates were calculated by city and by population. Size of population living in areas with different regional choice of ART services was identified. The Gini coefficients were calculated to measure the equity of the distribution of ART clinics.Results: There were 85 ART clinics (not counting artificial insemination clinics) in mainland China in 2006, 356 in 2012, and 498 in 2018 . The coverage rate of ART clinics was increased significantly (P＜0.05). Eastern China had the most extensive coverage, followed by the central region, while the western region had the least coverage (P＜0.05). At the end of 2018, 171.4 million people in 47 cities had no access to in vitro fertilization (IVF) clinics, but had access to at least one artificial insemination clinic in their own cities. There were still 354.9 million people (25.4% of the population) living in 148 cities without any ART clinics, indicating that 179.5 million people of reproductive age had no access to ART services. The Gini coefficients for the distribution of IVF clinics in mainland China in 2006, 2012, and 2018 were 0.389, 0.275 and 0,267 respectively, and for the distribution of ART clinics in 2012, and 2018 were 0.222 and 0.213.Conclusion(s): The accessibility of ART clinics in mainland China increased significantly in the twelve years to 2018. The equity of distribution of ART clinics was quite balanced over the country. However, underserved areas still exist, especially in the western region, which has spurred more targeted policies and cost-effective measures to improve the accessibility and availability of ART services in such areas.