Infertility—why the silence?

The most common story of the state of reproductive health in many low- and middle-income countries is one of high rates of fertility, limited access to and low use of contraception, and high unmet need for family planning information and services. Indeed, the evidence on these issues is clear, as shown in many research articles and comments published in this journal. But there's one aspect of reproductive health that's conspicuously side-lined from global health research and policy today—infertility. Though recent data on infertility globally are lacking, it has been estimated that 48 million couples and 186 million individuals worldwide live with infertility. Infertility hasn't always been a neglected global health problem. In September 1994, the International Conference on Population and Development (ICPD), held in Cairo, outlined a bold programme of action that was adopted by 179 countries, including reproductive health actions that integrated both fertility control and the prevention and treatment of infertility. Twenty-five years later, the 2019 Nairobi statement of ICPD25 made no specific mention of infertility, nor did the 2021 high-level Commission report on ICPD25, ‘No Exceptions, No Exclusions: Realizing sexual and reproductive health, rights and justice for all’. Assisted reproduction techniques have advanced considerably since the world's first baby was born through in-vitro fertilisation (IVF) in the UK in 1978, though it is fair to say that these technologies remain inaccessible and unaffordable in many parts of the world today, including high-income countries. In 2007, the European Society for Human Reproduction and Embryology special task force on ‘Developing Countries and Infertility’ held an expert meeting in Arusha, Tanzania, with the monograph stating, “After a fascinating period of almost 30 years of IVF and 15 years of ICSI [intracytoplasmic sperm injection], we must admit that only a small part of the world population benefits from these new reproductive technologies. Time has come to give adequate attention to the issue of infertility in developing countries.” Why has this call for attention not been realised almost 15 years later? Key arguments for the lack of national and international policy interest in fertility care include more pressing concerns around overpopulation and the need for population control, and the scarcity of resources making it difficult to justify investment in expensive fertility treatment in settings with competing public health priorities, such as high burdens of infectious diseases and maternal mortality. Economic burden aside, involuntary childlessness can have devastating social and psychological impacts, with couples and individuals experiencing stigma, shame, ostracism, anxiety, depression, and low self-esteem, particularly in cultures where the continuation of the family name through the birth of a child can secure a marriage, guarantee property and inheritance rights, offer a future source of household income, and provide social security in old age. Women in these settings are particularly at risk of the negative consequences of childlessness. A systematic review and meta-analysis by Yuanyuan Wang et al. published in this month's issue of The Lancet Global Health shows that at least one in three infertile women in LMICs suffered from intimate partner violence over a 12-month period and approximately one in two suffered over their lifetime - with psychological violence being the most common form of IPV, followed by physical violence, sexual violence, and economic coercion. The study also found that infertile women in LMICs were more likely to suffer physical violence and sexual violence over their lifetime than fertile women. In a linked comment, Christine Bourey and Sarah Murray say, “Infertility is not only an issue of reproductive health, but also a social issue that can influence marital, family, and other interpersonal relationships, particularly in settings where childbearing is highly valued and central to ideas of womanhood.” In this era of leaving no-one behind, it is time to bring infertility out of the shadows of reproductive health research and policy. There is a pressing need to shine light on the lived experiences and psychosocial realities of infertility for individuals and couples in resource-poor settings who are particularly vulnerable to abuse and exploitation. As a first step, culturally sensitive awareness campaigns could help reduce the stigma and open dialogues on safe, effective, and affordable ways to attain parenthood for those who seek to. Intimate partner violence among women with infertilityIntimate partner violence (IPV) represents a critical public health problem that impacts mental, physical, and reproductive health throughout the life-course. Infertility is not only an issue of reproductive health, but also a social issue that can influence marital, family, and other interpersonal relationships, particularly in settings where childbearing is highly valued and central to ideas of womanhood. Women experiencing infertility might be socially sanctioned for childlessness or small family sizes in cultures where progeny is among what matters most. Full-Text PDF Open AccessPrevalence of intimate partner violence against infertile women in low-income and middle-income countries: a systematic review and meta-analysisA high prevalence of IPV against infertile women is evident despite heterogeneity across studies. IPV screening, counselling, and structural interventions should be tailored to address this urgent issue at multiple levels of society. Full-Text PDF Open Access