Despite modern advances, global infertility rates remain stubbornly high. Estimating that infertility affects more than 10 percent of cisgender women worldwide, the World Health Organization reports an ongoing "child wish" among roughly 186 million reproductive-aged women who grapple with infertility in developing countries.
As infertility takes on global proportions, which nations bear the brunt of this challenge? And how has the advent of coronavirus-related restrictions reshaped fertility treatment access?
How Are Global Infertility Rates Calculated?
The definition of infertility varies widely, defying consistent evaluation and monitoring. Still, the WHO offers an equation-based global framework for tracking infertility. The organization tallies the number of sexually active women ages 15 to 49 who are not pregnant; who are using contraception or lactating; or who have tried unsuccessfully to conceive for two years. This numerator is then divided by the total number of sexually active women with those same characteristics to arrive at an infertility rate.
The WHO also notes that subfertility is seldom monitored and likely underreported.
Key Regional Differences
In 2012, PLOS Medicine published a landmark study of global infertility that tracked data from 1990–2010. Worldwide infertility rates in 2010, the most recent year available, remained largely unchanged compared with the previous two decades. The notable differences in infertility statistics worldwide were declines in primary infertility in South Asia and drops in primary and secondary infertility in sub-Saharan Africa.
Infertility rates remain highest in South Asia, sub-Saharan Africa, North Africa, the Middle East, central Europe, Eastern Europe and central Asia, reports the analysis of 277 demographic and reproductive health surveys from 190 countries.
In the developing world, the high prevalence of infertility among certain western, central and southern African countries may be viewed more broadly in the context of health equity and access. For example, the same PLOS Medicine study found that infertility in these countries may be linked in part to conditions that more commonly go untreated, including reproductive tract infections, gonorrhea and chlamydia. To a lesser extent, infections from obstetric methods may also play a role.
The fertility risks of unsafe abortions — both from the procedure itself and complications afterward — cannot be ignored in these regions of Africa, PLOS Medicine continues. Cultural norms, stigma and a lack of accessible healthcare facilities often block women from seeking reproductive healthcare.
In more industrialized regions, key factors affecting infertility rates include delayed childbearing, infectious or environmental agents, genetic abnormalities and certain reproductive diseases, according to a 2019 white paper issued by the Centers for Disease Control and Prevention. The report found that tubal infertility affects 18 percent of U.S. couples who have tried assisted reproduction. As in the developing world, tubal infertility in the United States typically results from chronic pelvic inflammatory disease, which often stems from an untreated sexually transmitted infection (STI).
Elsewhere in the developed world, Entre Nous: The European Magazine for Sexual and Reproductive Health finds evidence of a growing phenomenon of involuntary childlessness in Europe as more couples postpone childbearing until beyond their reproductive years.
Global Infertility in Focus
Infertility defies a singular explanation. Instead, it is rooted in an interplay of physiological, genetic, environmental and social determinants.
The WHO calls for ongoing research to address these myriad factors, including investigations to help prevent recurrent miscarriages, reduce pregnancy complications and lower the number of preterm births. The organization also recommends a renewed push to halt the transmission of STIs and suggests that the chief target of these efforts should be in developing countries where reproductive healthcare access is inadequate and the global burden of infertility remains the highest.
Furthering assisted reproductive therapies may also remedy global infertility rates, the WHO adds. Expanded access to IVF, for example, may help to address male factor fertility, prevent the transmission of STIs and offer effective options for patients who postpone parenthood until later in life.
COVID Pauses Assisted Reproduction
Prior to the SARS-CoV-2 pandemic, fertility centers worldwide conducted more than 2.5 million cycles of IVF, per a 2019 summary of global regional IVF registries published in Reproductive Biomedicine Online.
After the WHO declared COVID a pandemic, professional organizations including the European Society of Human Reproduction and Embryology and the American Society for Reproductive Medicine called for a temporary moratorium on certain assisted reproduction treatments until the virus's effect on maternal and fetal health was better understood.
Pandemic-related restrictions drew a sharp rebuke from the International Committee Monitoring Assisted Reproductive Technologies, which called for continuing fertility services: "The right of [people] to...build their families, despite this pandemic, must be respected as an expression of hope in the midst of fear and despair."
As the virus continued its global march, infertility services were not deemed an essential medical service among three-quarters of 97 countries surveyed by the International Federation of Fertility Societies. Closed facilities cited either a government mandate (33.1 percent), voluntary decision (32 percent) or professional guidance (30.1 percent) as the reason for the pause in services.
The survey further revealed that a scattering of just 14 countries across Africa, Latin America, Asia, the Middle East and Europe remained open for fertility services during the pandemic. Of the clinics still active in those locales, fertility therapy remained limited. One-third reported performing diagnostic testing, 24 percent performed IVF in select circumstances and 11 percent offered intrauterine inseminations.
As global infertility rates remain largely intractable, the reopening of assisted reproduction services and increasing access to these therapies may help more patients achieve parenthood. Clinicians can also look to new avenues of research to uncover effective methods of addressing the complex factors underpinning global infertility rates.
