In the fall of 2010, I was a visiting student at Harvard School of Public Health (HSPH) as it was known back in the day, when I became embroiled in an argument on whether infertility treatment should be offered in India where the pressing problem was overpopulation, that too with many orphans awaiting adoption.
Ten years later, as a Clinical Fellow at Addenbrookes Hospital at the other Cambridge across the pond, there was a sense of déjà vu when I had to re-engage with the same topic at an inter-departmental students’ mixer one evening.
Yet, the prevalence of infertility is higher in low-middle income countries (LMICs), and often highest in regions with the highest fertility rates.
A “demographic paradox”, this results from certain regions being burdened with higher reproductive tract infections and poorer overall health status, as well as reduced access to care, whether for infertility or contraception.
Surely, a demographically disadvantaged couple distraught with childlessness has equal right to healthcare and reproductive autonomy as their counterparts in the developed world?
In fact, there are an estimated 27.5 million couples in India grappling with infertility.
Many of them cannot afford even a single cycle of private sector IVF which, in terms of purchasing power parity converted to US Dollars, costs 51.6% of the average annual GDP per capita, and 166% of the average annual income- the highest in the world.
Consider the following real-life experiences. Smriti G. underwent surgery to remove cysts in both ovaries following which her gynaecologist warned her of possible damage to ovarian reserve. As she did not have immediate plans to conceive, she decided to have her eggs retrieved and frozen to preserve her future fertility. The total cost at a leading private hospital in Mumbai was around ₹4 lakh.
Jaya L. was advised In-vitro fertilization (IVF) by a leading fertility specialist in Calcutta.
She requested the IVF centre to also aspirate her ovarian cyst during the egg retrieval and bill her for it, as only then would her insurance company reimburse the cost of the surgical procedure.
Sonia T. had been consulting allopathic and homoeopathic doctors for 13 years in the hope of conceiving. When she finally overcame personal, societal, and financial inhibition to approach an IVF center in New Delhi, she was already forty years old with severely impaired egg reserve.
These are not isolated instances.
Yet, for long, infertility has been the neglected step-child to champions of universal access to reproductive healthcare.
Thankfully, sustained advocacy has resulted in recently shifting paradigms in thinking and policy- from preventing pregnancy, to achieving pregnancy based on choice and autonomy. Earlier this year, the United Nations Population Fund (UNFPA) India included infertility as a focus area in its publication, ‘Reimagining family planning in India: New Pathways’, hopefully enabling infertile couples to be recognised for who they are- persons with a medical condition who deserve better access to care.
This shift in mindset and national policy is also crucial in the context of India’s total fertility rate (TFR) dropping below replacement levels, which have long-term implications for future workforce diminution and its resultant economic repercussions.
More importantly, India’s commitment to sustainable development goal (SDG) 3.7 —
ensuring universal access to sexual and reproductive healthcare by 2030 — cannot be honoured unless we remove barriers to fertility care for much of its population.
There are different approaches which may be effective to achieve this goal.
Leveraging innovative partnerships to offer fertility treatment free of cost to the deserving is one such approach. We have provided a successful template for this in Kolkata, with the first IVF delivery at the fully subsidized Center of Excellence (COE) in Assisted Reproductive Technology (ART) in October last year.
Established in collaboration between the Government of West Bengal’s IPGMER & SSKM Hospital and the GD Institute for Fertility Research (GDIFR), the COE helmed by noted IVF expert Sudarsan Ghosh Dastidar also aims to train ob-gyn specialists in reproductive medicine state-wide, besides engaging in cutting-edge scientific research.
When free IVF is not feasible, provision of highly subsidized or insurance covered IVF may be life-changing for many families.
Lastly, development of innovative, low-cost technology solutions may provide a quantum leap in improving access to fertility care.
A trans-Atlantic research team has recently made path breaking progress in this
regard which could be a critical enabler for increasing access to fertility care in the Indian context.
Prof Willem Ombelet, a leading member of this group, presented their technology at a landmark international Congress on IVF in Calcutta last month — the Second International Conference on Advances in Reproductive Medicine (ICARM).
Supported by forward thinking political will and smart policy, these solutions may well have lasting impact towards bridging the unmet need for fertility care in India.