Toward global reproductive justice: a universal framework for evaluating equity and autonomy in in-vitro fertilization policies

BACKGROUND: Equitable and ethical access to in-vitro fertilization (IVF) remains challenging globally. Existing evaluation frameworks often overlook critical dimensions of reproductive justice. This study develops and validates a Universal IVF Justice Framework, designed to systematically evaluate national IVF policies regarding equity and reproductive autonomy. METHODS: We conducted a systematic literature review (PubMed, Scopus; January 1, 2010 to June 11, 2025) to identify key policy dimensions and indicators, followed by expert consultations and pilot testing to ensure reliability. The framework was validated through comprehensive document reviews and double-coding of IVF policies from 24 diverse countries. Visualization tools were created to illustrate outcomes. RESULTS: Analysis revealed three overarching dimensions that shape national IVF policy outcomes: economic and structural conditions, cultural and social contexts, and healthcare system factors. Substantial variation emerged across countries. At the micro-level, country-specific analyses exposed targeted strengths and weaknesses, supporting localized reform efforts. Visualizations such as radar and scatter plots highlighted performance disparities. At the macro-level, high-income countries generally scored higher, driven by broader insurance coverage, inclusive legal protections, and greater geographic access. In contrast, low- and middle-income countries often faced challenges in affordability, rural service delivery, LGBTQ+ inclusivity, and psychosocial support. CONCLUSIONS: The Universal IVF Justice Framework offers an empirically-grounded and ethically informed approach for evaluating IVF policies globally. By clearly identifying policy strengths and critical gaps, it supports evidence-based decision-making and targeted reforms aimed at enhancing equity and reproductive autonomy in IVF services worldwide.