Involuntary childlessness: extending fertility treatment to single people and same-sex couples

Currently, the World Health Organisation (WHO) defines infertility as 'a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse' (1). But with the sweeping, progressive, societal changes that have taken place over the last few decades, and in an age where many same-sex couples and single individuals seek to become parents, this definition has become anachronistic.

The WHO has now put forward proposals (2) to redefine infertility to include those men and women who don't have medical issues but wish to become parents and are eligible for treatment (see BioNews 874). These proposals reflect the wider societal change, encapsulated in an influential article published by the Ethics Committee of the American Society for Reproductive Medicine (3), which recognises the ethical duty to treat all those looking to conceive with equal respect.

The WHO proposals have received hostile billing in some quarters. Most agree with the ethical thrust of the argument – that single individuals and same-sex couples should be treated equally to heterosexual couples undergoing fertility treatment. However, some have argued that the WHO's endorsement of a new cohort of infertile people is unrealistic in an era of rationalisation of state funding for fertility treatment. In the UK, with only one in six Clinical Commissioning Groups offering NICE's recommended three cycles of IVF treatment, will a change in definition heighten expectations that are likely to remain unfulfilled? Another more fundamental objection has been raised by some newspapers – they argue that the addition of single individuals and same sex-couples to the NHS queue under the banner of 'infertility', when there is no underlying medical condition in these patients, is simply wrong.

In order to solve this supposed conflict in priorities, it is important to step back and reconsider the issue. While the WHO's aims are laudable and in tune with the march of progress, it incorrectly sets perceptions by including single individuals and same-sex couples within the definition of infertility. There are recognised medical conditions that cause infertility or subfertility, and it is important that we do not unnecessarily medicalise individuals without such conditions. Medicalisation lends itself to the promotion of the most aggressive solutions, when it is our responsibility to assess the least invasive approach for achieving pregnancy for any patient, whether single, heterosexual or homosexual. I believe that, rather than amending the definition, we should create a new subset for those requiring fertility treatment; we should describe this as 'involuntary childlessness'.

The term 'involuntary childlessness' does not diminish the status of this group; rather, this common-sense approach promotes understanding of the distinct issues, a reduction in unwelcome prejudice, and the use of the least invasive treatment available. There may be many single individuals and same-sex couples who suffer from both reproductive disease and involuntary childlessness. It is important for both patients and doctors that these issues are not conflated.

Finally, a better definition would bring the issue of public funding more into focus. When assessed purely on the question of infertility, it is unsurprising that the pie is constantly shrinking, as life-threatening conditions are prioritised. But when we focus on involuntary childlessness – for all, single, heterosexual or homosexual people – it allows us to go beyond the medical world and consider the negative consequences of being prevented from starting a family on individuals, on couples, on our happiness, on our economy, and on our society. If we can re-frame and shift the paradigm of why fertility treatment is needed, we will be better able to convince policymakers that all those looking to have children should be able to access state funding as a fundamental human right. We will be able to go further than mere definitions, and actually deliver fair, equitable access to fertility treatments.