For millions, the stork never arrives. A new global guideline from the World Health Organization seeks to deliver more than hope—but can it overcome deep-rooted inequities in care?

The numbers are quietly daunting — one in six people of reproductive age will, at some point, face infertility. That puts the inability to conceive on par with common chronic conditions like diabetes or depression—yet it remains cloaked in silence, stigma, and, all too often, inaccessibility.

Last week, the World Health Organization (WHO) issued its first-ever global guideline for making fertility care safer, fairer and—perhaps most radical of all—affordable. The timing is apt.

As birth rates plummet from Seoul to Stockholm, and as medical advances raise hopes for would-be parents, governments are being forced to confront a question once dismissed as a private sorrow: When does the right to reproduce become a public health concern?

“Millions face this journey alone—priced out of care, pushed toward cheaper but unproven treatments, or forced to choose between their hopes of having children and their financial security.” — Dr Tedros Adhanom Ghebreyesus, WHO’s Director-General

The Science of Disappointment

Infertility is a complex adversary. Biologically, it is defined as failure to achieve pregnancy after 12 months or more of regular unprotected sex. The reasons are as varied as human genetics: blocked fallopian tubes, low sperm counts, endometriosis, polycystic ovary syndrome (PCOS), and a host of other diagnoses fill the medical textbooks.

Yet biology tells only part of the story.

Consider this: while roughly one-third of infertility cases are attributed to female factors and another third to male factors, the final third remains “unexplained.” This ambiguity is maddening for patients and clinicians alike.

In the latest 2025 systematic review found that environmental toxins—from air pollution to endocrine-disrupting chemicals common in plastics—may play a growing role, although evidence remains patchy.

Lifestyle factors—smoking, obesity, sexually transmitted infections left untreated—are well-established culprits. Even age, the most predictable risk factor, is poorly understood by many; recent surveys suggest that both men and women overestimate how long their fertility will last.

Some scientists whisper that we are witnessing an “infertility epidemic.” That may be overstated—after all, rising demand for treatment is partly due to later-life childbearing and the proliferation of assisted reproductive technology (ART), not necessarily a true increase in biological infertility.

But as societies grow older and family sizes shrink, the emotional and economic stakes of every lost baby rise correspondingly.

From Barrenness to Biotechnology

Infertility has not always been a medical problem. For most of history, it was a moral failing or a divine curse—visited, conveniently, more often on women than men. The ancient Greeks had their herbal tonics; the Victorians prescribed rest cures and sea air. The 20th century saw science enter the fray, with key milestones that now seem almost quaint.

The first modern fertility clinic opened in 1926 in Vienna (it was promptly shut down by authorities). In 1978, Louise Brown became the world’s first “test-tube baby,” an event greeted with equal parts awe and alarm. In vitro fertilisation (IVF) was soon followed by a cascade of advances—intracytoplasmic sperm injection (ICSI), preimplantation genetic diagnosis (PGD), egg freezing—which have given science unprecedented power over conception.

Yet for most people, the journey remains a gauntlet of waiting rooms, invasive tests and dashed hopes. Success rates for IVF still hover around 30% per cycle for women under 35—and drop sharply with age.

Male infertility remains mired in taboos; in many cultures including in Malaysia, is barely discussed at all. And while some countries subsidise fertility care as a matter of policy, in much of the world it remains a private luxury: one round of IVF can cost twice the average annual household income.

Counting the Cost

Infertility is expensive—in every sense of the word. Direct costs include medications, procedures and endless blood tests; indirect costs mount as couples travel long distances to urban clinics or take time off work for appointments.

For many, the financial burden tips into catastrophe: studies from India and sub-Saharan Africa show families selling land or jewellery to pay for failed treatments.

The WHO’s new guideline does not shy away from this reality. It calls for integrating fertility care into national health systems—not as a boutique service but as part of universal health coverage.

The recommendations are both sweeping and granular: invest in prevention (more sex education; fewer untreated infections); offer evidence-based treatments (not quack remedies); provide ongoing psychosocial support.

The economic argument is compelling. Globally, the fertility business is worth an estimated $25bn—a figure expected to double by 2032.

But as Dr Tedros Adhanom Ghebreyesus, WHO’s Director-General, puts it: “Millions face this journey alone—priced out of care, pushed toward cheaper but unproven treatments, or forced to choose between their hopes of having children and their financial security.” The social costs—depression, anxiety, marital breakdown—are harder to quantify but no less real.

Who Gets to Have Children?

Policy divides are stark. In France, fertility treatment is subsidised by the state; in Britain, access depends on where you live (postcode lotteries mean some women get three cycles on the NHS, others none). In America—the home of free-market medicine—patients pay out-of-pocket unless their employer happens to be unusually generous. In many developing countries including Malaysia, formal fertility care barely exists outside private clinics catering to elites.

These disparities matter—not just morally but demographically. As birth rates tumble below replacement in much of Europe and East Asia, governments fret about shrinking workforces and “missing babies.”

Some have responded by expanding subsidies for ART; others wring their hands over falling family values. Either way, there is growing recognition that infertility is not just a women’s issue or a rich-world problem—it is a question of equity.

The Psychological Toll

Infertility is lonely work. Studies consistently find elevated rates of depression and anxiety among would-be parents; social isolation is common, especially for women. In patriarchal societies, blame falls disproportionately on wives—even when science shows male factors are equally responsible.

WHO’s guideline rightly emphasises the need for ongoing psychosocial support—not just at clinics but in communities and workplaces.

Yet stigma runs deep. As Dr Pascale Allotey of WHO’s Sexual and Reproductive Health Department observes: “Empowering people to make informed choices about their reproductive lives is a health imperative and a matter of social justice.”

That sounds progressive; in practice, changing hearts often proves harder than changing laws.

A Test Tube Half Full

There are reasons for cautious optimism. Greater awareness has led some governments—and insurers—to expand coverage for fertility care. New technologies promise higher success rates at lower cost: researchers are working on AI-based embryo selection tools; cheaper IVF protocols could bring treatment within reach for millions more.

But there are also dangers. The market for unproven supplements and sham therapies is booming—a fact recognised by WHO’s call for evidence-based care. In some countries, commercial surrogacy has become an ethical minefield; elsewhere, restrictive laws force would-be parents abroad in search of services.

And then there are the big unknowns: how will climate change affect sperm counts or egg quality? What are the long-term health effects for children conceived via ART? As always in medicine, today’s solutions may seed tomorrow’s dilemmas.

Looking Ahead

Infertility may never be eradicated; biology is stubborn that way. But it need not remain such a lonely or inequitable fate. By bringing fertility care into the mainstream—not just as a privilege for the wealthy but as a core piece of public health—societies have a chance to narrow one of medicine’s most persistent gaps.

Debates will rage about how much governments should pay; about where science should stop; about whose choices matter most when eggs meet ethics committees. But one thing is clear: in an age obsessed with choice and autonomy, denying people the possibility to start families is neither just nor prudent policy. The stork may be unreliable—but with better science and fairer systems, hope need not be so hard-won.

This article is written by Tony Y, Editor-in-Chief, PP Health Malaysia (PPHM)