The Bhutanese Leading the way.
For many couples in Bhutan, the desire to have a child is deeply tied to family expectations, social belonging, and emotional well-being. Yet, an increasing number of couples find themselves unable to conceive naturally, often facing not only medical challenges but also social stigma and emotional distress.
As infertility emerges as a growing public health concern, the healthcare system has begun offering medical interventions to support affected couples. One such intervention is Intrauterine Insemination (IUI), a fertility treatment currently available at the Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), providing hope to couples struggling to conceive a child.
Introduction of IUI at JDWNRH
JDWNRH began offering IUI services in 2016 as a part of the Ministry of Health’s (MoH) broader efforts to strengthen infertility care in the country. The service was established using existing hospital infrastructure, equipment, and personnel, at a cost of less than Nu 1 million.
MoH said the procedure is provided free of charge to couples, in line with Bhutan’s policy of free basic healthcare.
The introduction of IUI was prompted by Bhutan’s declining fertility trends, which raised concerns about reproductive health and population dynamics. MoH said, “As the national referral hospital, JDWNRH was best positioned to introduce this service due to the availability of specialist gynecologists, essential laboratory support, and diagnostic facilities.”
Infertility in Bhutan
Currently, Bhutan does not have a nationally representative estimate of infertility or subfertility rates. While fertility concerns are growing, MoH clarified that existing data does not directly measure infertility.
According to the National Health Survey 2023, Bhutan’s Total Fertility Rate (TFR) has declined to around 2.0, below the replacement level of 2.1. MoH emphasized that a lower TFR reflects fewer births overall and should not be interpreted as a direct indicator of infertility.
Trends in live birth records also show a steady decline. MoH said, “The records show a drop from approximately 15,000 annual live births in 2010 to about 9,000 live births in 2024.”
Causes of Infertility
Based on clinical experience at JDWNRH, infertility is commonly due to a combination of both male and female factors. MoH said, “Among women, tubal-related problems, such as tubal blockage, are frequently observed and are often associated with previous pelvic infections, untreated sexually transmitted infections, postpartum or post-abortion sepsis, or other pelvic conditions.”
Tubal-related problems affect a woman’s fallopian tubes, which are essential for transporting eggs from the ovaries to the uterus. Blockages or damage can prevent fertilization, making conception difficult or impossible.
Male-related causes are also significant and commonly present as abnormal semen parameters. MoH added, “Including low sperm count, reduced motility, or poor sperm quality.”
In many couples, more than one contributing factor is present, highlighting that infertility is a shared condition. “A study conducted at JDWNRH found that 56.6 percent of couples with infertility had primary infertility, while 16.18 percent had tubal-related problems,” MoH shared.
The ministry emphasized that a comprehensive evaluation of both partners is essential for an accurate diagnosis, appropriate treatment, and a better chance of successful conception.
Who Seeks IUI: Age and Patient Trends
According to MoH, most women seeking IUI services at JDWNRH are in their early to mid-30s and often come after several years of struggling to conceive.
Many couples initially try to conceive naturally or pursue basic treatments at lower-level health facilities before being referred to JDWNRH. MoH said, “By the time they seek IUI services, a significant number of women are already approaching an age where fertility naturally begins to decline, which can affect treatment outcomes.”
Men’s fertility also changes with age, though the decline is usually more gradual. Starting around the mid-30s to 40s, sperm quality can decrease, with lower sperm count and reduced motility.
Women aged 36 and above have accessed IUI services at JDWNRH, but MoH said their overall success rate remains comparatively low. While some pregnancies are achieved in this age group, outcomes are generally less favorable than for younger women. Factors contributing to reduced success include age-related biological limitations, delays in seeking treatment, and other contextual barriers.
IUI Demand and Service Delivery
MoH mentioned that on average, five to seven couples seek IUI services at JDWNRH each month, although this can rise to around 15 in certain months due to referrals, increased awareness, or personal and medical timing considerations.
MoH highlighted that this fluctuation reflects both the growing demand for assisted fertility services and the pressure on limited specialist, laboratory, and medicine resources.
The introduction of IUI has provided couples with a cost-effective and minimally invasive fertility treatment option.
However, the ministry shared that there are several challenges remaining.
MoH said that the human resource constraints, particularly the shortage of trained laboratory personnel for semen preparation and the need for specialized training for gynecologists, affect service delivery.
Services are continuing with support from a faculty member from KGUMSB, and plans are underway to train two laboratory personnel in the next fiscal year.
The availability of fertility medicines such as letrozole and human chorionic gonadotropin (hCG) is also limited, as they are not part of the routine essential medicines list and require special approval. “However, we are considering adding this as part of the essential medicines list once In Vitro Fertilization (IVF) services are initiated,” MoH said.
IUI Outcomes
According to the ministry, in the early years of service, including 2016 and 2018, no pregnancies were recorded, reflecting both the initial phase of the programme and the inherent limits of IUI.
From 2017 onwards, pregnancies were documented through IUI services almost every year, gradually improving as clinical experience grew. MoH said, “The number of pregnancies recorded was one in 2017, two each in 2019 and 2020, four in 2021, two in 2022, four in 2023, two in 2024, and three between January and September 2025.”
MoH mentioned that while these numbers are modest, they align with international experience, where IUI generally has lower success rates compared to more advanced reproductive technologies.
The ministry highlighted the importance of early referrals, careful patient selection, and the potential role of advanced treatments like IVF for couples who do not conceive after multiple IUI cycles.
Globally, IUI success rates range from 10 to 20 percent per cycle, influenced by age and the cause of infertility. At JDWNRH, recent data indicate the success rate remains below 20 percent.
Looking ahead, MoH explained that all new medical technologies undergo a Health Technology Assessment (HTA) to ensure safety, effectiveness, and alignment with national priorities.
The HTA for IVF at JDWNRH has been completed, laying the groundwork for expanding advanced fertility care. “A comprehensive proposal has already been submitted, reflecting strong institutional commitment and preparedness,” MoH said.
The ministry shared that once endorsed by the High-Level Committee, IVF services will be established at JDWNRH, providing families in Bhutan access to specialized fertility treatment within the national health system. There are also plans to expand IUI services to other dzongkhags in the future, responding to the growing demand for assisted fertility care.
