Infertility and inequality: a plea for action

The recent global guidelines from the World Health Organization on diagnosis, prevention, and treatment of infertility invites us to consider infertility beyond the traditional framing as a clinical condition, recognizing it as a profound issue of equity. The guideline explicitly states that fertility care should be founded on equity, evidence-based information, and respect for human rights while rejecting stigma or discrimination. In this contribution, we propose a conceptual framework that interprets infertility as a system of layered inequalities operating across global, structural, social, temporal, narrative, and individual dimensions. At the global and system levels, geographical differences, legislative fragmentation, disparities in access, and public-private services imbalances define reproductive opportunities. Social and cultural factors, including unequal access to education, limited fertility awareness, biased representations, and potential stigmatization, further contribute to the marginalization of affected individuals, disproportionately impacting vulnerable and minority groups. Time represents a crucial yet often overlooked determinant of injustice. Its manifestations differ across settings, sparing from delayed access to infertility treatment in resource-limited countries to the growing mismatch between biological reproductive constraints and societal trends toward delayed parenthood in many high-income settings. In this context, technological solutions such as assisted reproduction and elective egg freezing may inadvertently reinforce disparities by shifting responsability to individuals rather than addressing broader barriers, partly sustained by misleading narratives in social media. These dynamics often weigh more on women and ultimately interact to shape the individual experience of infertility. Infertility care requires coordinated action beyond a clinical one. Embracing a public health perspective and ameliorating access to fertility services must become the priority, sustained by investment in fertility education, inclusive narratives, and family-friendly policies, alongside greater harmonization of legislation. Considering infertility as an issue of equity means addressing upstream determinants that influence reproductive opportunities long before individuals seek care. The key question is not only who can access fertility treatment, but who reaches it with a meaningful chance of success. Only through such efforts can the opportunity to pursue one's reproductive goals and build a family, if wished, becomes a reality for many, rather than a privilege for a few.