Infertility and reproductive rights after the COVID-19 pandemic.

Coronavirus disease 2019 (COVID-19) was declared a pandemic on 11 March 2020 by the World Health Organization, halting the principal income activities worldwide. The International Monetary Fund predicts that the imminent economic recession will be worse than the global financial crisis of 2008, which severely affected the economy of Southern European countries such as Greece, Italy and Spain. There was then an abysmal drop in the Spanish yearly population growth curve as families could not afford to have children in that economic context; this only worsened the already existing demographic problems in that Spain has a constantly ageing population and one of the lowest fertility indicators in Europe. Taking into consideration that female age is the most important independent variable of success at the time of conception, probably thousands of potentially fertile couples were lost while waiting for more promising circumstances. With the COVID-19 pandemic a similar situation is being faced, where reproductive rights are imperiled by not being able to choose when to have children due to economic coercion. Therefore, governments worldwide should take measures to palliate the possible sociodemographic crisis that will follow the economic recession and try to ease the burden that many families might face during the following years.

Coronavirus disease 2019 (COVID-19) was declared a pandemic on 11 March 2020 by the World Health Organization (WHO). Since then, many societies, led by their respective governments, have been fighting to reduce the number of infected cases – the famous slogan of ‘flatten the curve’. The main purpose of this is to avoid the collapse of health systems, especially intensive care units, by implementing social distancing policies, lockdowns of the general population and/or a reduction of non-essential activities. While the economy of many countries remains at stake due to the paralysis of their principal income activities, the SARS-CoV-2 virus that causes COVID-19 keeps spreading worldwide. At the time of writing, on 6 May 2020, approximately 3.74 million cases of COVID-19 had been reported in 212 countries and territories (Worldometers, 2020). The impact of COVID-19 on the global economy remains a subject of debate as this will depend mostly on international government decisions and policy making; however, the climate looks ripe to produce an economic recession, and the International Monetary Fund is predicting that its impact might be worse than that of the global financial crisis (IMF, 2020).

Demographically speaking, it is important to take into consideration that the collapse of an economy undoubtedly means a peak in unemployment rate and, consequently, a decline in birth rate. Many couples cannot afford to have children in such an economic context due to the costs involved in their nutrition, education and well-being. Southern European societies, especially Greece, Italy and Spain, were severely affected by the global financial crisis of 2008. Furthermore, Spanish society is considered to be an ageing population, with a median age of 44.9 years, although this is not far from the European median of 42.9 years (Eurostat, 2020). The 2008 financial crisis therefore became both economic and sociodemographic, especially in the countries mentioned above, where the proportion of gross domestic product (GDP) destined for household/family aid was already below the European mean. Although in 2017 the European Community invested on average 2.3% of GDP in the form of household/family aid, Spain only invested 1.2% (Eurostat, 2020). Importantly, the Spanish fertility indicator is 1.32 children per woman, also below the European mean of 1.6, and is the second lowest fertility indicator in Europe after Malta (Eurostat, 2020).

During the 2008 global financial crisis, Spain experienced an unfavourable environment for providing independence for young people, greatly hindering the possibility of creating family nuclei with descendants. The yearly growth rate of the Spanish population fell from 1.57% in 2007 to –0.33% in 2013, returning to equal the European population yearly growth rate of 1% in 2018 (Worldometers, 2020). This suggests that many fertile couples decided to postpone parenthood for economic reasons. Therefore, a longer ‘waiting-list-for-conception’ emerged. This list contained mainly women or couples who could not achieve a pregnancy, a condition known as primary or secondary infertility depending on whether or not a previous pregnancy had been achieved. However, an increasing number of additional categories added to this: fertile women who wanted to have children but considered themselves too young to do so – so-called normative infecundity – and fertile women who wanted to conceive but postponed this as they did not meet the optimal conditions, either familial and/or economic, to bear the implied costs. As the years of economic crisis went by, the list of categories grew.

As female age is the most important independent variable of success at the time of conception, is it not absurd to assume that thousands of fertile couples were lost on the waiting list during the time over which the Spanish economic recession lasted. In addition, poor ovarian reserve as a result of ovarian ageing is the main reason why patients seek help from assisted reproductive medicine. In July 2018 in Spain, there were 1,414,000 women between 30 and 34 years of age, 52% of whom were, according to the (Spanish Statistical Office 2020), childless. Elective infecundity, or choosing not to have children, represents up to 5% of Spanish women (Spanish Statistical Office, 2018), which leaves approximately 600,000–630,000 potentially fertile women who might be considering motherhood as a future option. Nevertheless, if another economic recession hits Spain, this population will have an increased risk of subfertility. This is also not to mention the approximately 480,000 childless Spanish women between 35 and 40 years of age who will be close to reaching a point of biological infertility in that possible context.

Despite the fact that there is currently no evidence relating SARS-CoV-2 infection to impediments in the reproductive potential of either men or women (Tesarik, 2020), there might be a link to short- and mid-term increases in global infertility. Actions to alleviate the constant demographic decline should be considered as a long-term investment. This current pandemic menaces millions of lives worldwide, and its economic hangover will shackle human rights while imperilling the demographic make-up of countries internationally by decreasing short- and mid-term birth rates.

Although the WHO has already recognized infertility as a global health issue (World Health Organization 2020), the context of an imminent economic recession also threatens reproductive rights per se, as they ‘rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of reproductive health’ (World Health Organization 2010). Therefore, it is not overstating the situation to predict that the economic impact that will follow the pandemic will exert pressure on the desired family planning of couples and single women, postponing the ideal time of conception. Consequently, governments are morally obliged to take measures in accordance with this situation in order to ease the burden that many couples might face during the coming recession and to avoid ultimately undesired childless family units.

Europe has the highest proportion of countries aiming to increase fertility in their societies. Up to 66% of European countries have adopted policies that include baby bonuses, flexible work schedules, parental leave and tax incentives (United Nations 2018). Supporting aids and subsidies directed towards family benefits, such as financial support for families and children, or other social areas such as health and housing, might be considered by policy makers in order to palliate demographic declines (United Nations 2018). However, assisted reproductive technology (ART) may also contribute to alleviating the impact that the economic recession might have on fertility. For example, elective preservation of fertility could be considered to be a plausible option when attempting to maintain individuals’ reproductive rights and overcome the age burden that threats ovarian reserve and oocyte quality (ASRM, 2018). Similarly, embryo cryopreservation could also be an option in order to postpone childbearing. Therefore, we suggest that governments should investigate easing access to these techniques for couples or women who desire them, especially considering that, according to the Spanish Fertility Society Registry, approximately 8.5% of the births that occurred in Spain during 2017 were conceived via ART. As a final remark, reproductive rights are human rights and, as mentioned before, they are all about the ‘when’ and ’how’.