With an estimated prevalence of over 80 million worldwide, infertility is a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months of regular unprotected intercourse. Parenthood is an important milestone of life, though the urgency and sensitivity may vary. While India tops the list in the need for parenthood, the awareness of fertility problems is the lowest. In societies like ours where parenthood is mandatory, infertility is a devastating experience with serious far-reaching consequences. Social isolation, stigmatization, domestic violence, separations and divorces are exceedingly common with infertile women. It is a known fact that male factor is responsible for one-thirds of total infertility cases. However, the burden falls disproportionately on women. In countries with limited resources, despite significant implications on quality of life, the resources allocated for infertility prevention and treatment are negligible.

Global access to infertility care is a human right and a case of reproductive equity and social justice. India has a burden of more than 23 million infertile couples. Assisted Reproductive Techniques (ART) is used by <1% of them. This may be attributed to low awareness and accessibility issues, high cost and unacceptability. Even in the metropolitans like Mumbai and Delhi, the demand for fertility treatment is 9 to 12 times higher than the current market.

Understanding the causes of infertility and socio-cultural factors is a critical step for developing treatment strategies and resource allocation to address the huge burden. Developing countries owe their infertility burden largely to reproductive infections (RIs) and tuberculosis which damage the tubes. Nearly half of men and 2/3rds of infertile women in Sub-Saharan Africa have infertility as a sequel of untreated RIs. The number of women with damaged tubes and endometrium as a result of tuberculosis in India is very high. In such a scenario, it is critical to prevent postpartum, postabortal and sexually transmitted infections and treat them in time.

Male infertility contributes to more than half of all infertility cases. While severe male-factor infertility cases are genetically-determined and incurable, they are amenable to treatment through ART. However in developing countries, ART is culturally and religiously unacceptable to many. ART is haunted by social and religious taboos despite a fascinating success story lasting more than 30 years. Besides, ART for the low resource settings is a catastrophic expenditure. People have to travel from villages to urban areas to access infertility care. Travel away from home, the costs attached with that, expensive treatment and absenteeism from work, loans or credits taken for such treatment make a huge economic impact. Besides, many infertile couples waste a lot of time going to quacks and under-qualified healthcare providers. Early referrals to trained specialists would save time and a lot of money. Since there are none or limited services available in the public sector, couples seek ineffective and incorrect therapies. Private sector provides infertility services at a high cost, which is beyond the scope of lower socio-economic strata. It is this stratum that is most vulnerable to infertility through early sexual debut, reproductive infections, unsafe abortions, tuberculosis and no access to health care.

Some positive steps have been taken by international bodies to address the unmet need. The World Health Organization (WHO) recommended that infertility must be considered a global health problem and also recommended development of initiatives like low-cost ART. The United Nations (UN) Program of Action includes the need to incorporate the prevention and treatment of RIs as well as infertility as part of Reproductive Health Services. The European Society for Human Reproduction and Embryology (ESHRE) has created a Task Force for developing countries to explore useful, effective and low-cost approaches to ART. The Walking Egg Project is yet another example to realize affordable infertility care through effective and cheap laboratory procedures like fertilization and culture.

With the support of local policy makers and international community, global access to fertility care can be achieved. Media, non-profit organizations, insurance companies and public-private partnerships have to work hand in hand to change the dismal penetration of infertility treatment in general populations in resource –poor countries. Adequate training of health professionals and early referrals should be promoted. Regular audit of accreditations, continuing medical education and quality control will ensure high-quality ethical treatments. In India only about 1000 gynecologists are actually performing ART procedures for a huge figure of more than 23 million infertile couples. From the present number of around 1,00,000 In Vitro Fertilization (IVF) cycles countrywide, the number is estimated to rise to 2,50,000 and above by the year 2020. The gap has to be bridged. Affordable ART can be achieved by using simpler protocols, clinical acumen rather than expensive lab testing, reducing the burden of pre - ART investigations, and government subsidies on infertility drugs and lab media without necessarily compromising on pregnancy rates.

With a huge burden of infertility, there is an insurmountable gap in access to care, more so in countries with limited resources. While a large chunk of resources are channelized towards family planning, reducing maternal and infant mortality and morbidity, vaccinations, and drugs for people with Human Immunodeficiency Virus, it is important to incorporate ART into comprehensive reproductive health. Spreading awareness about infertility and its treatment, and educating health care providers will go a long way in reducing the burden. The policy makers have to be made aware of the profound mental, physical and social consequences of infertility and also the brilliant success rates of ART. Governments should take initiatives like public-private partnerships and insurance covers for infertility care to improve the penetration of ART. The gravity of the problem is severe and it is high time for action.

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