key: cord-0956900-c4mabfn7
authors: Trinchant, Rafael M; Cruz, María; Marqueta, Javier; Requena, Antonio
title: Infertility and Reproductive Rights after COVID-19 pandemic
date: 2020-05-19
journal: Reprod Biomed Online
DOI: 10.1016/j.rbmo.2020.05.007
sha: 0560d9901d86e31dc00b589b7a1b57fc023cc9a4
doc_id: 956900
cord_uid: c4mabfn7

Coronavirus disease 2019 (COVID-19) was declared a pandemic on 11th 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 an abysmal drop of the Spanish yearly population growth curve as families could not afford having children in that economic context, only worsening the already existing demographic problems: 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 we are facing a similar situation, 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 was declared a pandemic on 11th 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 an abysmal drop of the Spanish yearly population growth curve as families could not afford having children in that economic context, only worsening the already existing demographic problems: 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 we are facing a similar situation, 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 th March 2020 by the World Health Organization (WHO). Since then, many societies, led by their respective governments, are fighting to reduce the number of infected cases -the actual famous motto "flatten the curve". The main purpose is avoiding the collapse of health systems and especially intensive care units by implementing social distancing policies, general population lockdowns and/or the reduction of non-essential activities. While the economy of many countries remains at the stake due to the paralysis of their principal income activities, the SARS-CoV-2 virus keeps spreading worldwide. To date, on 6 th May, approximately 3.74 million cases of COVID-19 have been reported in 212 countries and territories (Worldometers, 2020) . The impact of COVID-19 on the global economy remains a subject to debate as it will depend mostly on international government decisions and policymaking, however the climate for an economic recession is propitious and the International Monetary Fund (IMF) predicts its impact might be worse than the global financial crisis (IMF, 2020).

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

During the 2008 global financial crisis, Spain experienced an unfavorable environment for the emancipation of 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, until it equaled the European population yearly growth rate of 1% in 2018 (Worldometers, 2020) . This data suggests that many fertile couples decided to postpone the time of parenthood due to economic reasons. Therefore, a longer waiting-list-to-conception emerged. This list mainly had inscribed women or couples who could not reach a pregnancy, condition known as primary or secondary infertility -whether a previous pregnancy had been achieved or not. However, an increasing number of additional categories were summing up: fertile women who wanted to have children but considered themselves too young to do so; the so-called normative infecundity and fertile women who wanted to conceive but postponed the latter as they did not meet the optimal conditions, either familiar and/or economic, to bear the costs implied. As the years of economic crisis went by, the list extended.

Since 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 in the waiting list during the years that lasted the Spanish economic recession. Plus, poor ovarian reserve due to ovarian aging is the main reason why patients seek aid in assisted reproductive medicine. To date, In Spain, on July 2018, there were 1,414,000 women between 30 and 34 years old, of which, according to the Spanish Statistical Office, 52% were childless. Elective infecundity, or women 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 a future option. Nevertheless, if another economic recession hits Spain, this population will be in an increased risk of subfertility. Not to mention the approximately 480,000 childless Spanish women between 35 and 40 years old, which indeed will be close to reach biological infertility in that possible context.

Despite there is no evidence in the present relating SARS-CoV-2 infection and a hamper in reproductive potential either in men or women (Tesarik J., 2020) , there might be a link to a short and mid-term increased global infertility. Actions in order to palliate the constant demographic decline should be considered as a long-time investment. This current pandemic menaces millions of lives worldwide and its economic hungover will shackle Human Rights while imperiling the demography of countries internationally as it will hinder short and midterm birthrates.

While the WHO already recognized infertility as a Global Health Issue (WHO, 2019), the context of an imminent economic recession threatens reproductive rights per se too, 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" (WHO, 2009) . Therefore, it is not overstated to predict that the economic impact that will follow the pandemic will coerce 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 the above stated in order to ease the burden that many couples might face during the coming recession and to avoid ulterior undesired childless family units.

Europe has the highest proportion of countries pursuing 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 (UN, 2015) . 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 actions to be considered by policymakers in order to palliate demographic decline (UN, 2015) . However, assisted reproductive techniques (ART) may also contribute to alleviate the impact that the economic recession might have on fertility. For example, elective fertility preservation may be considered as a plausible option when attempting to maintain Reproductive Rights of individuals and overcome the age burden that threats ovarian reserve and oocyte quality (ASRM, 2018) . Similarly, embryo cryopreservation can also be a candidate option in order to postpone childbearing. Therefore, we suggest that governments should study easing the access to these techniques to couples or women who desire so, especially considering that approximately 8.5% of births that occurred in Spain during 2017 were conceived via ART, according to the Spanish Fertility Society Registry. As a final remark, Reproductive Rights are Human Rights and, as mentioned before, they are all about the "when" and "how".

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