SOS reproductive healthcare: a call for action

Reproductive health is a broad term that encompasses not only the ability to get pregnant and have a child but also involves mental, physical, sexual and social well-being (The World Health Organization, 2023). In fact, choosing when and how to have a child as well as having access to proper information concerning reproductive health is a fundamental human right which is included in the Universal Declaration of Human Rights (The United Nations, 2021). It seems crystal clear that reproductive issues go way beyond infertility which according to a report released by the World Health Organization (WHO) last April affects 1 in 6 adults worldwide (World Health Organization, 2023).

To make matters worse, fertility rates are dropping all over the globe, even in overpopulated countries such as India and China (Vollset et al., 2020). Figures may have declined further due to the COVID-19 pandemic. In addition to affecting individual health, the reduced fertility rates may affect us as economies and social security systems may be compromised as the International Monetary Fund (Doepke, Hannusch, and Kindermann 2022) demonstrated in a recent publication (Doepke, Hannusch, and Kindermann 2022). This may be difficult to grasp as in 2023 the world population reached 8 billion. The fact that human fertility is not great even at its best when female age is below 35 adds to this tricky equation and complicates matters further. Human ovaries do age fast and the situation may worsen when social and cultural changes drive women to postpone pregnancy or decide not to have children at all as their perspectives toward pregnancy and family building shift (Sirard 2022).

Some would argue that on a global scale the decreased fertility rates may have positive outcomes regarding the environment and climate change and aliment production. Climate change in fact holds some responsibility in the reduced fertility rates since it may affect people’s decisions to form a family and have children as extreme changes in the climate occur with drastic effects on the economy, the environment as well as on the male and female reproductive systems (Walsh et al., 2019; van Heerwaarden & Sgrò, 2021; Segal and Giudice 2022). On the other hand, as the population growth dwindles, so does the labor force, the possibility of economic development and the social security systems (Doepke, Hannusch, and Kindermann 2022). Countries such as Brazil which boasted a young population for many years faces for the first time aging according to the last population census (Kirby 2023).

Apparently, the solution to such a conundrum is readily available as assisted reproductive technologies (ART) that are an ever-evolving field with great advancements in the past decades as over 12 million babies have been born with the help of in vitro fertilization (IVF) (f ESHRE, 2023). The costs involved, however, hamper access to the much-needed sophisticated ART treatments which sadly remain the privilege of only a few resulting in increased inequality and stigma (Njagi et al. 2023). In fact, providing fertility care is just one side of the coin as individuals should also be able to prevent infertility. Education and access to family planning services is pivotal as defined by the the 2030 Agenda for Sustainable Development which aims “by 2030 ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes.” (The United Nations)

As far as reproductive healthcare is concerned, there are challenges everywhere you look from provision of care and prevention to funding research and education. An international consensus published in 2021 attempted to define the top ten priorities for future infertility research. The document produced a list of 10 questions for each area which includes male infertility, female and unexplained infertility, medically assisted reproduction, and ethics, access, and organization of care for people with fertility issues (Duffy et al. 2021). To fulfill such an extensive agenda the authors agreed huge international cooperation is mandatory in addition to availability of funds which remains a major obstacle.

Male reproductive health also presents huge challenges as it is often overlooked. Although women frequently carry the burden of fertility treatment on their own, male factor may be accountable for up to 40 percent of the cases (Esteves and Humaidan 2023). Unfortunately studies with male participation are scarce and receive little attention as far as funding and inclusion in the public health agenda are concerned (De Jonge and Barratt, 2019). Moreover, men have poor knowledge on the importance of preconception health and the theme is often ignored by medical societies and governments (Carneiro et al. 2021; Rabiei et al. 2023).

Preconception care is a vital variable in the complex reproductive healthcare equation but unfortunately is often ignored. No one denies that promoting preconception health can potentially improve women’s health and pregnancy outcomes. Evidence-based interventions exist to reduce many maternal behaviors and chronic conditions that are associated with adverse pregnancy outcomes, such as tobacco use, alcohol use, inadequate folic acid intake, obesity, hypertension, and diabetes (Shawe et al. 2015). The father however remains neglected (De Jonge and Barratt, 2019). Data from European (Shawe et al. 2015) and South American (Carneiro et al. 2021) countries show that preconception recommendations offered by both government and medical societies for healthy women and men are heterogeneous, inconsistent while male reproductive health is often disregarded. A large body of evidence corroborates the influence of parental health on the development of diseases in their children, including infertility, obesity and diabetes which may further compromise the health and fertility of future generations (van Heerwaarden et al. 2022). Thus caring for parental health is of utmost importance and should be a priority in the global public health agenda.

The current reproductive health crisis has not gone unnoticed. There have been quite a few documents and guidelines published by major medical associations and organizations such as the WHO, the European Society of Human Reproduction and Embryology (ESHRE), the Latin American Society of Assisted Reproduction, (REDLARA) and the International Federation of Fertility Societies (IFFS). IFFS in fact has just published a consensus paper discussing the reduced global fertility rates and its consequences on reproductive health and family building (Fauser et al. 2023). The paper presents a comprehensive overview of the problem, identifies knowledge gaps and discusses ways to achieve equitable access to fertility care. The authors conclude that although high costs make fertility care inaccessible to most people, the child born from fertility care may bring economic rewards to society that will make whatever expenditure worthwhile. Thus, in addition to developing policies and finding more affordable ART we should aim to bridge the gender gap and provide fertility care to single men and women as well as to the LGBTQ+ community (Fauser et al. 2023).The publication sparked a few commentaries in the media but sadly will soon be forgotten as other news catch the public attention.

Implementing proper care to all is an herculean task. All the above-mentioned facts show we are running out of time and choices. No one seems to doubt anyone is entitled to decide if and when to procreate and if medical interventions are required, they should be available to all. Martin Luther King said “Of all the forms of inequality, injustice in health is the most shocking and inhuman.” Plenty of published studies reveal there is injustice and inequality in reproductive health care (Fauser et al. 2023). Priorities have been defined and enough documents have been published. Research should go on but action is urgently required. The fertility rate is shrinking all over the world and yet most governments choose to look the other way ignoring the huge negative impact it could have on our way of life for years to come including on the economy, social security systems and society as a whole. Collaborative work among countries and medical organizations is crucial so as to develop ways to offer evidence-based preconception and fertility care for everyone. Dr. King also said “Our lives begin to end the day we become silent about things that matter.” There is no doubt reproductive healthcare matters to us all.