Mamta Jhunjhun Wala, 42, of Mumbai still remembers the stigma of being unable to bear children for the first 13 years of her marriage. People ask a woman's name—and then, "How many children do you have?" When the woman answers "none," she says, "they don't know what they can talk to you about." Thanks to treatments at Mumbai's Malpani Infertility Clinic, Wala finally conceived a daughter, now 10, and twin boys, now 8. With her doctor, she started a support group to help give other infertile couples the help she wishes she had had, she says. "There were a lot of emotional questions, and support I needed, and there was nobody for me."
Wala is lucky. "It is very, very difficult for people in the United States to deal with [infertility], and yet, when you go to other cultures, it's even more devastating to people," says Dr. David Adamson, president of the American Society for Reproductive Medicine and a board member of the International Federation of Fertility Societies. Worldwide, the World Health Organization says about one in 10 couples experiences difficulty conceiving a child at some point in their lives.
In some developing countries, the consequences of infertility—which can include ostracism, physical abuse and even suicide—are heartbreaking. "If you are infertile in some cultures, you are less than a dog," says Willem Ombelet of the Genk Institute for Fertility Technology in Belgium. Women are often uneducated, so their only identity comes from being moms. "It [infertility] is an issue of profound human suffering, particularly for women," says Marcia Inhorn, professor of anthropology and international affairs at Yale University. "It's a human-rights issue."
The stigma that infertile women face can infiltrate every aspect of life. They may not even be invited to weddings or other important gatherings. "People see them as having a "bad eye" that will make you infertile, too. Infertile women are considered inauspicious," says Inhorn. Other people simply "don't want to have them around at joyous occasions," says Frank van Balen, coauthor (with Inhorn) of "Infertility Around the Globe" and a professor in the department of social and behavioral sciences at the University of Amsterdam. Their reasoning: "they could spoil it," he says.
Often the female takes the blame even when the problem lies with the man, says Inhorn. The women often keep their husband's secret and bear the insults. In Chad, a proverb says, "A woman without children is like a tree without leaves." If a woman doesn't bear children, their husbands may leave them or take new wives with society's blessing. In some Muslim places, women can't go on the street on their own. "If they have a child with them, they can do their errands," says van Balen.
Childlessness can also be an enormous economic problem in developing countries where Social Security, pensions and retirement-savings plans are not the norm. "If you don't have your children, no one looks after you," says Guido Pennings, professor of philosophy and moral science at Belgium's Ghent University. Religion shapes attitudes, too. "People are supposed to go out and populate the earth," says Ian Cooke, director of education for the International Federation of Fertility Societies and cofounder of the Low-Cost IVF Foundation. In the Hindu religion, a woman without a child, particularly a son, can't go to heaven. Sons perform death rituals. Infertile couples worry that without a child, who will mourn for them and bury them? In China and Vietnam, the traditional belief is that the souls of childless people can't easily rest. In India, the eldest son traditionally lights the funeral pyre. In Muslim cultures, the stigma follows childless women even after death: women without children aren't always allowed to be buried in graveyards or sacred grounds.
In Western countries, it has become much more socially acceptable to be childless, and more American women are hitting their 40s without kids, according to the latest census data. By contrast, in many developing countries, women have no careers—just motherhood—to give them their identity. "The notion of child-free living is not considered an acceptable thing for a married couple," says Inhorn. And particularly in Muslim and Hindu areas, she says, adoption "is not an immediate second path."
Legal adoption is "bureaucratically onerous" and often not socially acceptable, says Elizabeth Roberts, assistant professor of anthropology at the University of Michigan, who studied the people of Ecuador. So it's not surprising that even extremely poor people may go into debt trying to conceive. "A family is only a family if there are children, basically," says Roberts. "The biggest stumbling block is money."
Many couples may waste valuable years resorting to "black magic," says Aravinda Guntupalli, a professor at the University of Tübingen in Germany who studied infertility in India. The couples ask so-called sacred people what days they should fast, and they journey to spiritual places. In the tribal area of India where Guntupalli worked, women dry up umbilical cords and sneak them into infertile women's food to try to help them. "They think it creates some fertility juice in the body," she says.
Not surprisingly, infertility treatments are rarely covered by insurance or by government aid. "How do you provide what is clearly a highly technological, sophisticated procedure in a place that doesn't have a lot of money?" says Adamson, a member of the not-for-profit International Committee Monitoring Assisted Reproductive Technologies, a technical adviser to the World Health Organization. Leaders of countries struggling with dirty drinking water, tuberculosis, malaria and AIDS may find IVF expenditures hard to justify.
Infertile couples in developing countries don't publicize the fact that they need help even if they can afford treatment. Children are seen as a gift of the gods, so failure to conceive may be perceived as an indication that someone has sinned or is unworthy. "People aren't willing to go up on [the equivalent of] Oprah Winfrey and say, 'Yes, I'm infertile, and I'm getting treatment'," says Dr. Aniruddha Malpani, an Ob-Gyn who runs the Malpani Infertility Clinic in Mumbai with his wife. "People have actually traveled [for treatment], telling people they're going on holiday," says Inhorn.
Even for couples who do have access to fertility clinics, there are challenges. For example, some cultures consider masturbation evil. Yet it's traditionally the way doctors get semen samples to check a man's sperm count and then to perform IVF. In some cases, doctors can offer condoms that allow a couple to have intercourse and save the sperm. Another cultural hurdle: the Muslim world does not accept egg or sperm donation. "Each child should have a known father and a known mother," explains Inhorn. "Every child must know his own heritage." Adds Adamson: "It's very important to honor and respect the fact that people have these values."
One important approach is to focus on preventing, rather than curing, infertility. A major cause of infertility is untreated reproductive tract infections such as chlamydia and gonorrhea. In places like Africa, the cost of condoms, and taboos against them, contribute to the STD problem. Infection from female genital mutilation adds to the problem. And in some countries, 90 percent of women do not deliver in hospitals, which can also cause complications. And the hospitals they use for birth or abortions aren't always sanitary. Some doctors also believe sperm quality has suffered from toxins like lead, high in Mexico City and Cairo, and dioxin sprayed on crops.
In the developed world, there's sometimes little sympathy for the problem, since the common view is that developing countries are suffering from overpopulation and don't need any more babies. The United Nations projects that the world population will balloon from its current 6.7 billion to 9.1 billion by 2050. But the picture is more complicated than it seems. "We have a fertility paradox in Africa—high fertility rates, and high infertility rates," says Dr. Silke Dyer, an Ob-Gyn in Cape Town and a member of the European Society for Human Reproduction and Embryology task force on developing countries and infertility. (Infertility treatment proponents note that IVF doesn't contribute to overpopulation any more than saving lives with vaccinations does. And both alleviate suffering.)
The good news is that interest in treating infertility around the globe is growing. In 2004, the World Health Organization said people should have access to high-quality services for family planning, including infertility services. Doctors hope to provide $200 to $500 IVF cycles, with cheaper drugs and simplified laboratories, by the end of the year in places like Cape Town and Cairo. Their goal: more happy birth stories, like Wala's.