One in six people worldwide experiences infertility at some point in their lifetime, according to a World Health Organization (WHO) report containing the first global infertility estimates in over a decade.

Around 17.5% of adults experience infertility with little variation across regions and country income groups. Lifetime prevalence was 17.8% in high-income countries and 16.5% in low- and middle-income countries.

“The report reveals an important truth – infertility does not discriminate,” said WHO director-general Dr Tedros Adhanom Ghebreyesus. “The sheer proportion of people affected shows the need to widen access to fertility care and ensure this issue is no longer sidelined in health research and policy so that safe, effective and affordable ways to attain parenthood are available for those who seek it.”

WHO experts said there is not enough evidence to make a judgement on whether infertility is rising or not. Previous estimates published by WHO in 2012 also did not find evidence of increasing infertility rates.

“We cannot, based on the data that we have, say that infertility is increasing or constant,” said Dr James Kiarie, head of contraception and fertility care at WHO. “Probably the jury is still out on that question.”

WHO researchers defined infertility as the inability to achieve pregnancy after a year of unprotected sexual intercourse.

The report, which reviewed over 130 studies on infertility from 1990 to 2021, provides strong evidence of the global prevalence of infertility. But the fragmented nature of the data held researchers back from being able to disaggregate by factors like age, sex, or cause, making it difficult to assess which populations need to be prioritised for fertility care and what risks should be targeted by policymakers.

“The causes of infertility are varied and often complex, and it is something that both men and women experience,” said Tedros. “Indeed, a wide variety of people, in all regions, may require fertility care.

“Access to sexual and reproductive health services is the primary way for people to have the best chance of having the number of children they desire. However, in most countries, these services are inadequate.”

Out-of-pocket costs and social pressures are where inequalities lie

Infertility rates are similar in all regions around the world, but their economic costs to households are not. Dr Pascale Allotey, Director of Sexual and Reproductive Health and Research at WHO, called the health care costs in poorer countries “catastrophic”.

“The cost of fertility care is an immense challenge for many people, increasing inequity and creating impoverishment and hardship, especially for the poorest households and individuals,” Allotey said. “Millions of people face catastrophic health care costs, making this a serious equity issue and very frequently a medical poverty trap.”

Dr Gitau Mburu, a fertility research scientist at the WHO, said the data analysed in the report showed how much people in countries where children are expected of a family are willing to sacrifice financially to achieve a successful pregnancy.

“In many low- and middle-income countries, a single cycle of in vitro fertilization (IVF) costs more than their average annual per capita income,” Mburu said. “Such extraordinary expenditures … all too often catapult [people] into household poverty as a direct consequence of seeking care for infertility.”

To many women in countries where motherhood is still viewed as their primary role, the consequences of failing to have children can be devastating. The pressure to sacrifice financially to achieve that goal can often feel like an obligation, Allotey said.

Societal pressures

“Procreation comes with a significant societal pressure in countries like mine,” said Allotey, a native of Ghana. “Pregnancy remains critical to the perception of womanhood and of the perception of a couple.”

Failure is often met with stigma, mental health consequences, and in the worst cases domestic violence triggered by the woman’s failure to conceive.

“People with infertility often experience anxiety and depression with ramifications for people’s mental and psychosocial wellbeing,” Allotey said. “There is an increased risk of intimate partner violence associated with infertility as relationships are tested.”

In his closing remarks accompanying the release of the report on Monday, the WHO director-general said the report should be a wake-up call to governments to stop sidelining fertility care.

“For millions around the world, the path to parenthood can be difficult to access, if not impossible,” Tedros said. “It is my hope that governments use this report to develop evidence-based policies and adopt proven solutions, as part of their efforts to strengthen health systems to help people fulfil their fertility intentions and live healthier lives.”

Image Credits: CC, CC.