We’re missing the full picture in reproductive choice

14 December, 2020


Written by Andrea Sprockett, Chief Operating Officer at Metrics for Management. She is also passionate about equitable health service delivery.

Despite widespread recognition that reproductive health should embrace the full range of choices including contraception, antenatal and postnatal care, and safe abortion, we, as a community, too often fail to include the other side of the coin. Full reproductive choice should encompass both the ability to prevent, delay, or stop a pregnancy, but also the ability to start it. Yet prevention, diagnosis, and treatment of infertility are conspicuously absent from the reproductive health conversation.

For example, the 2030 Sustainable Development Goals fail to include infertility, despite Health Goal 3’s aim to achieve universal access to sexual and reproductive health care. This neglect for supporting fertility services persists despite data that show it affects an estimated 49 to 186 million people worldwide, or approximately 15% of all couples. For the sake of comparison, the United Nations estimates 142 million individuals have an unmet need for contraception. Despite huge advances in medical technology, its prevalence has not budged, or has even increased slightly, since 1990. Although new techniques are available to prevent, diagnose, and treat infertility, access remains low, and global attention to and concern for infertility has changed little from its low level 20 years ago. Infertility remains a devastating social, psychological, economical, and personal burden, and, for many, results in decreased quality of life. In many cases, we know how to address infertility, and yet it remains an overlooked and neglected disease.

Ethically, individuals and couples dealing with infertility have as much right to choose the timing and spacing of their families as those seeking to limit family size. The two are not antithetical, and should work together as part of a human right to healthcare. As Dr. Mahmoud Fathalla from the World Health Organization (WHO) stated in a 2010 WHO Bulletin, “In a world that needs vigorous control of population growth, concerns about infertility may seem odd, but the adoption of a small family norm makes the issue of involuntary infertility more pressing. If couples are urged to postpone or widely space pregnancies, it is imperative that they should be helped to achieve pregnancy when they so decide, in the more limited time they will have available.” Beyond addressing this human right, we also need to recognize the reproductive injustice that the wealthy are able to access and afford care, while the poor are not, effectively giving wealthy individuals more reproductive agency to address their disease.

While underserved, infertility is not entirely absent from the global development landscape. A few global initiatives, such as the 2012 United Nations Committee on Population & Development resolution or the 2016-2030 Maputo Plan of Action for comprehensive sexual and reproductive health services in Africa include mention of infertility prevention and treatment. In addition, the WHO’s Human Reproduction Programme includes work on infertility. Yet, comparatively little funding is available for infertility services. In 2017, we saw US$11.3 billion committed to sexual and reproductive health, where the vast majority (70%) is allocated to HIV treatment and prevention. Only 16% of this funding went to supporting other critical global health services, including prenatal care, delivery, postnatal care, prevention and management of abortion complications, and safe motherhood activities. Prevention and management of infertility was included within this “other” category, receiving just a fraction of that funding.

Although the general assumption is that treating infertility is expensive, it doesn’t have to be. Ovulation inducing medication can be as low as US$8 in Nigeria, and intrauterine insemination costs around US$135 in India, for example. And the Walking Egg Project, which works to strengthen infertility care by supporting innovation, research, advocacy, capacity building and direct service provision, has worked to develop low-cost IVF treatment costing less than US$240 per procedure.

Infectious diseases, primarily sexually transmitted infections, play a role in both female- and male-factor infertility, as well as poor education, poverty, negative cultural attitudes, age at first marriage, lack of access to contraception or quality delivery services, and unsafe abortion. These challenges should sound familiar, because they overlap with the challenges we are working on in contraception, antenatal/postnatal care, and safe abortion initiatives. That shouldn’t be a surprise. Infertility isn’t a unique reproductive health area; it is simply an underrecognized part of overall reproductive healthcare.

We have seen the negative impacts of COVID-19 globally on sexual and reproductive health, disrupting contraceptive and abortion services despite an unchanged need, leaving many individuals without access to essential care. Individuals seeking infertility services have also been impacted, and these services are no less essential. Yet infertility care, like other services, has been deemed nonessential with several professional organizations across the globe recommending a “moratorium on infertility services” during the pandemic. This has enabled medical facilities to address concerns about limited medical facility capacity, appropriating space and resources for COVID-19 patient treatment. Most countries cancelled all assisted reproductive technology and fertility treatments in the first months of the pandemic. Now, over nine months into the pandemic, some estimate that we may be facing 1-2 more years before we can sufficiently roll out vaccines worldwide and fully return to operations as we’ve once known them. As clinics open back up and begin addressing their backlog of clients, we shouldn’t forget that infertility treatment is often on an unforgiving timeline. These delays in treatment can be devastating when fertility treatment itself can take years and individuals often have a relatively small window of time in which treatments will be most successful. But the pandemic also offers opportunities to rethink global health system approaches to infertility services and to build them back better. As we rebuild and restructure sexual and reproductive health (SRH) services, we can both recognize and integrate infertility care with other SRH services. We can also prioritize the full range of fertility services in financing, policy, and equitable access in a post COVID-19 world. Together we can make the most of this challenging situation to change SRH services in a thoughtful, inclusive, and justice-oriented way.

It’s time to stop ignoring the importance of infertility care, and start working together in the field of sexual and reproductive health to integrate infertility care into broader sexual and reproductive health programs. Let’s stop putting reproductive health care needs into siloes, and come together as a community to meet the full range of an individual’s reproductive health goals and offer complete reproductive choice.


Please note that blog posts are not peer-reviewed and do not necessarily reflect the views of SRHM as an organisation.