It’s National Infertility Awareness Week. You might ask why it’s important. The answer rests in a survey that came out in March 2021 revealing that 40 percent of San Francisco residents struggle with infertility.

Nationwide, about 12 percent of women (and 9 percent of men) between the ages of 15 and 44 have difficulty getting pregnant or carrying a pregnancy to live birth, according to the Centers for Disease Control.

From ancient times to the middle ages, barrenness was addressed with a cocktail of magic and religion. Hippocratic physicians bolstered their infertility treatments — a mix of medications, behavior modifications and the use of probes — by appealing to the deity Asclepius. In Egyptian lore, infertile women had their own infertile goddess, Nephtys. In ancient Hindu texts, special mantras were recited and potions prepared to increase the fecundity of queens and royal women.

The stigma of infertility, through the ages and across cultures, has focused its lens on the childless female body. Women were judged by their ability to reproduce. It was only during the Renaissance period that infertility started to gain recognition as a problem for both genders.

More recently, in 2013, one study found that 30 percent of infertility cases were due to female factors, 20 percent due to male ones and 40 percent due to issues in both partners. Reproductive endocrinologist and co-founder of CCRM Fertility in San Francisco, Dr. Salli Tazuke, corroborated these findings in her own practice, with 40 percent of her cases arising out of complications with women, 35 to 40 percent attributed to men, and many couples having multiple factors.

The causes of infertility are many, including sexually transmitted diseases, environmental and workplace exposures, genetic and physical conditions, and, yes, infectious diseases. But experts agree that not all causes are known.

One of the significant reasons for a rise in infertility over the years, according to Tazuke, are social and behavioral changes. The average couple looking to start a family is in their mid-thirties these days, she remarked. “When people start late, ovaries start aging,” and other health conditions, like endometriosis and fibroids, start rearing their heads. “We cannot fight aging,” Tazuke said, emphasizing that the amount and quality of eggs and sperm decline as the human body ages.

The CDC has labeled infertility a health concern, though many might argue that infertility is not a disease. However, since data and science have confirmed that health conditions cause infertility, and infertility causes significant emotional challenges, there is no doubt that it is a health concern.

“The effects of infertility and its treatment can be devastating and include psychological stress, anxiety and depression,” said Admiral Robin M. Ikeda, deputy director of non-communicable diseases, injury and environment health at the CDC, speaking at a conference in 2014.

Besides increased anxiety and depression, one of the health risks is multiple births. The use of infertility treatments has resulted in twins, triplets and even more (remember Octomom?) simultaneous births, which has “adverse maternal and infant outcomes such as pre-term births,” according to Ikeda.

Moreover, many of the causes of infertility derive from other health conditions, including obesity, diabetes, polycystic ovary syndrome (PCOS) and development of fibroids or non-cancerous tumors that grow in the uterus.

One of the reasons why it’s important to think about infertility as a medical diagnosis is so that there are equitable treatment options available for all. Unfortunately, in many states, many health insurances do not cover, or only partially cover, the cost of infertility treatment.

This can result in high out-of-pocket expenses, which inevitably leads to disparities in treatment access.

Infertility impacts BIPOC women at higher rates. According to one study, Black women are at three times the risk for and likely to have fibroids than white women. Black women are also less likely to access care and treatment for infertility as compared to white women.

Tazuke said that she sees fewer patients from communities of color and that’s largely because of the expense of infertility treatments. Infertility treatment is not mandated to be covered in California. On average, the cost of treatment can range between $15,000 and $20,000, without medications. With medications, an additional $3,000 to $6,000 is the norm. Needless to say, that’s a steep price to pay without a guaranteed outcome.

According to Barbara Collura, president and CEO of RESOLVE, the national infertility association, insurers have often balked at the cost of treatments that result in multiple births, but she adds, “but there’s a baffling, illogical reasoning when you look at that because they’re going to cover the pregnancy, and they’re going to cover those births and so in essence they’re going to cover the consequences of that lack of insurance.”

Experts agree that the goal is a healthy, single birth. Modern science has come a long way and the increased use of single embryo transfer is really showing insurers that a smart use of IVF can be very effective and lower or eliminate those downstream costs for multiple birth outcomes, argued Collura.

The one way to avoid the high costs of infertility treatment is to empower oneself with information. “Access to information on infertility is still behind,” acknowledged Tazuke. But it’s important to be aware of possibilities like medications to enhance ovaries, egg freezing, sperm banking, intrauterine insemination and IVF.

If you’re thinking of having a baby down the road, it’s perhaps wise to consider behaviors that maintain fertility, reduce exposures to environmental hazards — pollutants in air, water, food and health-and-beauty-aids — and perform regular checkups for reproductive health.

With infertility affecting two out of five people in The City, it’s likely that most of us know of someone living with infertility. This is the moment to help break the code of silence and shame and come out in support of our neighbors and friends struggling to start a family. Most importantly, it’s time to ask our legislative leaders to help mandate insurance coverage in the diagnosis and treatment of infertility.