The Italian newspaper Domani and The Why Wait Agenda are continuing their collaboration with a series of reports on the issue of choosing to have children. This second article was published in Italian in Domani on Monday 8 May 2023
When are you going to give us a grandchild? The question – seldom a welcome one – belies the widespread assumption that having children is always a conscious choice: you stop using contraceptives and lo-and-behold, after nine months, a baby is born. And for many, this is exactly how it goes.
Not everyone who doesn't have children is doing so by choice, though, and it's wrong to assume that they don't want any or aren't trying to have any. Silvia underwent a lengthy process of assisted reproduction, including ovarian stimulation and finally in vitro fertilization, to become a mother, a process which spanned five years. Although she wanted three kids, she only has one daughter. «I felt this was one of life's injustices», she says. After going through many medical tests, they could determine that her difficulty in becoming pregnant was twofold: her follicles struggled to turn into oocytes, and the sperm in her husband's semen were not 'energetic' enough.
What does the science say
Infertility is a condition scientifically defined as the absence of conception after twelve months of regular unprotected intended sexual intercourse. «This definition holds a very important concept: you only find out you are an infertile couple when you are trying to have a baby, maybe even after years of trying in which the problem was preventing conception» stresses gynaecologist Andrea Borini. Now director of the 9.baby - GeneraLife network, which groups twelve fertility centres in Italy, Borini has also been president of Sifes Mr, the Italian Society of Fertility and Sterility and Reproductive Medicine.
Invisible infertility
Infertility always catches people off guard. Have we ever stopped to consider, when we congratulate friends on becoming new parents, that the baby may have been born with the help of assisted reproduction? Do the books we read, or the films and series we watch ever present the idea that the children of the main characters could be conceived in a lab instead of resulting from a night of passion?
The truth is, there is no narrative about infertility – except for a few niches that talk about it and are popular with individuals seeking stories that relate to them. For most people, it's invisible: according to a survey led in 2014 by the Italian research institute Censis, 60% of Italians said they knew 'little' or 'nothing' about it. Even when we talk about declining birth rates, we always assume that it results from people making an arbitrary choice – I will have a baby, I won't have a baby – forgetting that bodies are not all the same. They are not all-powerful. And sometimes the desire to have a child is just not enough.
Infertility is a condition unlike any other – it throws us off balance; the feeling that our body is betraying us, that it can't function properly in its most basic task, reproducing itself. The guilt we experience towards our partner, whom we are 'robbing' of the possibility of having children. Grieving the idea of an 'easy' family, in which children arrive quickly. Normally.
One in six struggles with infertility
But infertility is normal too. Increasingly so: a report from the World Health Organisation a few weeks ago revealed that one in six people of childbearing age worldwide are infertile. Within the European Union, the European Society of Human Reproduction and Embryology reported that there are as many as 25 million people of all genders who are infertile.
There should be no stigma attached to it and it should not be kept a secret. On the contrary: «Talking about it as much as possible and trying to normalise the condition of infertile couples would be helpful», Borini reflects: «Instead, couples often feel alone: they generally don't share the journey they are going through even with friends or family, because, even today, they feel the weight of the stigma and are ashamed of the impossibility of conceiving 'naturally».
And besides, a person’s level of fertility is not set in stone. The situation can change over the years: as a basic rule, fertility decreases with the passing of time, but it can also be the case that, once a case is resolved, perhaps thanks to medical assistance, a couple might unexpectedly manage to conceive naturally. In order to dismantle the taboo, it is helpful to share and recount successes and failures, stories with happy endings and stories in which the desire to become parents had to take another form, another path.
Taking care of your own fertility
It is important to know that you can take care of your fertility in a preventative way before you even consider having children. In her book Il segreto della fertilità (“The Secret of Fertility”, Sperling & Kupfer, published for the moment only in Italian), Italian gynaecologist Stefania Piloni, together with journalist Simonetta Basso, outlines a fertility handbook, explaining how hormones and vitamins affect the reproductive system, the negative effects of smoking, alcohol and pollution, and the benefits of a healthier diet, natural remedies, supplements and acupuncture. Piloni, medical director of the Ginecea specialist gynaecology clinic in Milan, is open about the fact that one of the biggest issues for couples is waiting longer to have their first child, which «particularly for women, decreases the chances of conception».
«I was surprised when I went to the doctor looking into why I wasn't getting pregnant and they bluntly said, You know, you're not that young anymore: you're already thirty-three!» Sara recalls: «My close friend's sister had experienced the same issues, so I knew that if the situation did not improve in a year, it was time to look into it. But I thought: this happens to one in a thousand».
As we have seen, though, one out of every six people have gone through this – Sara included, who was thirty-five when she had her child through in vitro fertilisation: «It's not a common topic; only a handful of people bring it up, the tip of the iceberg, so there is very little information out there. Since I have gone through this, I have tried, in my little way, to spread awareness, especially among my friends, and it has proved useful, because several of them have had the same experience».
In Italy, where on average everything is done later than in the rest of Europe – leaving the family home, entering the world of work, gaining stable employment, economic independence, and yes, even having children – defining a person under the age of forty as no longer being young seems absurd. But biologically speaking, that is exactly the case.
Infertility and birth rate
Fertility issues can have many complicated consequences. Infertility can be a source of tension in a couple, and it is not surprising that some studies have identified it as a major cause of divorce. Sometimes one partner wants children more than the other; or they disagree on the roadmap, or whether they should turn to assisted reproduction.
Italy has a very low fertility rate of 1.25 children per woman. The so-called fertility gap, namely the gap between the children we want (an average of two) and the children we have, is abysmal. When we talk about it, we should remember that part of the birth rate decline is involuntary and due to infertility.
Raising consciousness and fertility awareness and running information campaigns, while also promoting good practices and the options offered by science (such as gamete freezing), would be a step in the right direction. Making it easier to access reproductive medicine and shortening the waiting lists at state-run facilities. And above all, undoing the falsehood that having children is easy. There is a silent, ever-growing minority of people who must struggle, turn to science, wait, and often suffer to have even one child. And it is high time these stories come to light, and have their place when discussing the birth rate.