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The story of modern parenthood is increasingly being written in clinics, not bedrooms. Nowhere is this transformation more vivid than in India, where fertility sits at just 1.9 children per woman, a far cry from the 5.8fertility rate¹ that inspired the blockbuster Population Bomb in 1968.² Worlds away from the “hellish” scenario described in that book’s opening passage, India is now home to a booming middle class with a better quality of life. Consider this: 61% of India’s total population will be middle class by 2047, nearly double today’s rate of 31%.³ This economic blossoming has given rise to a vast, growing population of Indians demanding infertility treatments. As a result, the fertility sector has ballooned into a massive economic powerhouse, equipped with state-of-the-art technology,⁴ private-equity backing,⁵ innovative services (including the nation’s first “at home IVF” offering⁶) and surrogacy centers.

Globally, with the discourse on population decline well underway,^7,8 you would be well within reason to think that one of the major issues plaguing governments today is how to boost birthrates. Merits of such thinking aside, given that one in six people worldwide will be over the age of 60 in just five years,⁹ this concept tracks statistically. But what if I told you that the same number of people—one in every six on Earth—are affected by infertility in their lifetime?¹⁰ Still, infertility receives nowhere near the attention or funding of fertility decline or aging despite asking the same fundamental question: How should governments and institutions support people in having the number of children they desire?

The Measurement Challenge

Broadly, infertility is defined as a disease of the male and/or female reproductive system based on a prolonged period of not reaching pregnancy or live birth despite unprotected sex; however, the precise definition and methods used to estimate its frequency vary across research studies.¹¹ The vagueness of some of its components—”prolonged period” (I can just hear demographers scream, “What’s the denominator?!”) and other terms—underscores the first challenge: measurement. If we can’t accurately quantify the problem in simple terms, how can we prioritize it as a problem worthy of time and investment amidst so many competing priorities? How can we measure infertility in a meaningful way?

Thankfully, progress has been made in this arena. A new report on measuring infertility by the World Health Organization (WHO)¹² recommends a specific time period (12 months), suggests targeted methodologies, and even provides guidance for national surveys, including recommended questions that are easily understood across contexts and help with data disaggregation, which can give us more nuanced insights on who is affected. With this comprehensive guidance, we now have the tools in hand to measure infertility more accurately than ever before. Additionally, WHO will be releasing guidelines for the prevention, diagnosis and treatment of infertility on November 28, a massive step forward to guide countries in ensuring equitable, evidence-based care for individuals and couples with infertility.

The Stigma Challenge

Which leads us to the more challenging set of solutions to counter stigma — unspoken yet omnipresent regardless of context. To understand the roots of the stigma around infertility, it is important to understand the power of its converse. Parenthood—and motherhood specifically—still cements social standing in many societies. Often, it is a sociocultural obligation that is linked to inheritance rights, and the failure to achieve it is tied to family shame, marital instability, and more.

Infertility—whether perceived or “real” (more on this distinction later)—is seen as a social and moral failure, particularly borne by women.¹³ Researchers synthesized evidence from Africa¹⁴ to conclude that infertility is not only a medical condition, but a profound social crisis. Their framework for infertility in Africa (below) could be adapted for use in other places, supporting interventions at the individual, interpersonal, institutional, and community levels.

Figure 1: A Framework for Infertility Stigma in Africa

Source: Emmanuel Ekpor et al., “Experience of Infertility-Related Stigma in Africa: A Systematic Review and Mixed Methods Meta-Synthesis,” International Health 17, no. 6 (2025): 903–13.

There is good news in this arena as well. Low- and middle-income countries have been steadily increasing their efforts to address infertility stigma in recent years, with a recent evidence review identifying effective multilevel programs, from supporting men and women in community and church groups to empowering women financially to influencing legislation.¹⁵

The Cost Challenge

That last point is quite possibly the most exciting—and challenging—piece of the puzzle yet. The cost of various assisted reproductive technology (ART) is prohibitive for most (see figure below), broadening existing inequities in health care access. In the United States alone, this could also contribute to the growing debate about which population is declining¹⁶ and who gets to have children when they desire (spoiler alert: more inequities¹⁷). A recent review of patient costs for ART in LMICs found that, in countries where government financing for ART exists, patients spent approximately half of their average annual income on one ART cycle; meanwhile, patients in countries without this support spent double their average annual income. Further, patients in poorer countries were more likely to face higher ART costs, compounding inequities in access to care. Notably, despite potentially catastrophic costs, many still decided to pursue treatment—another illustration of the power of societal pressures around fertility.¹⁸

Figure 2: ART Treatment Cost Ranges Across Regions

Source: Purity Njagi et al., “Financial Costs of Assisted Reproductive Technology for Patients in Low- and Middle-Income Countries: A Systematic Review,” Human Reproduction Open 2023, no. 2 (2023).

Another recent study in LMICs¹⁹  reported this stunning statistic: less than 1.5% of Africa’s population has access to ART. Compare this to South Asia, where countries like India have become models for expanding access to low-cost care.²⁰  How can these innovations cross borders—and not just for the rich?

Earlier, I mentioned there is a distinction between perceived infertility versus “real” infertility. Only the privileged few—with access to clinics and the money and time for care—can afford a “real,” medical fertility diagnosis. Further, the conversation is difficult to broach with one’s partner for fear of shame or worse (see “the stigma challenge” above). Thus, many individuals,  particularly young people, base their infertility on perception, citing their past reproductive or contraceptive behaviors,²¹ a few instances of “missed conceptions” after unprotected sex,²² or even supernatural factors.²³ There is agreement that more needs to be done to promote body literacy among youth and to train providers to counsel clients on myths and misconceptions about infertility. But the reality is that providers don’t have enough time with their patients—and infertility counseling doesn’t often enter the conversation, despite guidelines.²⁴

Promising Futures

Amidst the current fertility panic, two areas emerge as key to helping countries navigate infertility concerns in their populations:

Addressing the Policy Gaps in Infertility Care

One of the recurring themes in research has been the lack of political will to prioritize infertility as a health issue due to competing priorities and dwindling resources. Infertility is more than “just” a health issue—it is a social one. Improving school curricula on body literacy to include discussions on infertility myths and misconceptions can lead to increased contraceptive use (something that many policymakers care about). LMICs grappling with the downstream or imminent concern of low fertility and population decline can look to countries such as South Korea and Japan, which are helping subsidize infertility treatments in insurance plans. Countries with existing ART services need to improve access to high-quality services for all. This may require significant investment (more below), including in improving financing and regulatory frameworks. Many LMICs have ART centers operating without appropriate regulations and guidelines, affecting pricing as well as quality of care. Costs of running ART centers are further influenced by the complexity of the procedures offered and the need for highly skilled staff, equipment, and imported drugs.²⁵ Therefore, closing these policy gaps—from education and subsidization to robust regulation—is essential to ensuring equitable access to necessary, high-quality infertility care for all citizens. Some countries are making progress towards the policy framework for infertility care, with news just this month that Kenya’s National Assembly passed the Assisted Reproductive Technology (ART) Bill, 2022, which attempts to create a legal framework for ART and services such as IVF and surrogacy²⁶.

Investing in Low-Cost Diagnostics and Treatment

Recent, exciting advances in low-cost diagnostics and treatment from infertility would benefit from significant donor investment to test and scale up, including international efforts to bring ART to low-resource settings. For instance, the Walking Egg project²⁷ aims to reach the goal of “global access to infertility care,” the INVOcell—billed as the first FDA-cleared medical device for fertility treatment via intravaginal culture—has shown promise in Colombia and Pakistan,²⁸ and various initiatives from India²⁹ can be adapted for other contexts.

In just the last few months, in separate initiatives, two major donors—the Gates Foundation³⁰ and Pivotal Ventures³¹—have announced a combined $2.6 billion in new funding for work that addresses women’s health issues. While infertility is most certainly not a woman’s issue alone, this is an exciting challenge for innovators, researchers, and governments to think about sexual and reproductive health in broader terms, aligning more than ever with the Lancet-Guttmacher Commission’s vision of sexual and reproductive health and rights for all.³² The time is ripe to invest in advancing low-cost, effective, and affordable infertility treatments for everyone who wants them.