Quality of infertility care in poor-resource areas and the introduction of new reproductive technologies

Introducing assisted reproductive technologies in The Gambia, a survey on the perspectives of Gambian healthcare professionals and medical students

BACKGROUND

Infertility remains a global reproductive health burden with the highest prevalence in low and middle-income countries. In sub-Saharan Africa, the ability to procreate holds great societal importance. Couples, and particularly women, with infertility can face devastating challenges, leading to social stigma, isolation and/or divorce. However, attention to addressing infertility is lacking in sub-Saharan Africa. In The Gambia, where this study is based, little is known about the potential for introduction of assisted reproductive technologies (ART) in the public health sector.

METHODS

A quantitative survey was conducted using detailed questionnaires on infertility services available, staff knowledge, perceived barriers, and personal motivation to support assisted reproductive technologies. Data was collected electronically between April and June 2021 from healthcare providers (n = 70) in eleven health facilities throughout the country, as well as from medical students (n = 55) enrolled at The University of The Gambia.

RESULTS

Basic infertility services were found to be lacking in the rural areas. Furthermore, 39% of staff (n = 27) providing fertility care had not receive any formal training on the topic. However, 91% of staff (n = 64) showed interest in acquiring additional knowledge and had a positive attitude towards supporting the introduction of ART. Perceived challenges of doing so included: (i) the competing importance of other health priorities; and (ii) religious and cultural barriers.

CONCLUSION

This survey highlights that expansion of infertility services is needed, especially in rural areas. Staff perceived the introduction of ART as important, but this should be coupled with specialized training, as most medical staff had not received any formal infertility training. Future care providers (current medical students) showed both interest in ART and reported having received some basic training in infertility management. Given the reported lack of infrastructure and services, additional targeted investment in infertility care, including ART, will be needed to improve reproductive health for all, countrywide.

Barriers and facilitators for the inclusion of fertility care in reproductive health policies in Africa: a qualitative evidence synthesis

BACKGROUND

Infertility affects over 50 million couples worldwide and impacts people's social and emotional wellbeing. In low- and middle-income countries, particularly across Africa, the inclusion of fertility care into reproductive health (RH) policies remains fragmented or non-existent.

OBJECTIVE AND RATIONALE

This review aims to provide a framework for understanding the inclusion (or lack thereof) of fertility care in RH policies in African settings. It synthesizes the barriers and facilitators to such inclusion, with a view to uncovering the positioning of fertility care in broader health systems and on the agendas of key stakeholders such as health policymakers and practitioners.

SEARCH METHODS

A qualitative evidence synthesis was performed, systematically searching papers and grey literature. Searches were conducted in MEDLINE, EMBASE, CINAHL, Web of Science and Scopus between February and April 2020. No date restrictions were applied. Language was limited to publications written in English and French. Two reviewers independently screened titles and abstracts, and extracted data, applying thematic coding. The quality of the included papers was evaluated using The Joanna Briggs Institute Checklist for Text and Opinion Papers.

OUTCOMES

The search identified 744 papers, of which 20 were included. Findings were organized under four cross-cutting categories, namely: perceived importance of infertility; influence of policy context; resource availability and access; and perceived quality of care. Across these categories, key barriers to the inclusion of fertility care in RH policies were limited political commitment, under-recognition of the burden of infertility and high costs associated with ART. Conversely, facilitators comprised specialized training on infertility for healthcare providers, standard procedures for ART safety and guidelines and North-South/South-South collaborations.

WIDER IMPLICATIONS

The inclusion of fertility care in African RH policies depends upon factors that include the recognition of infertility as a disease, strong political engagement and proactivity and affordability of ART through opportunities for partnership with the private sector, which ease costs on the public health system. Further qualitative and quantitative research, including context-specific analysis and in-depth comparative approaches across diverse African countries, will help to delineate differential impacts of local and global factors on fertility care to address this neglected RH issue.

Comparison of self-esteem and depression among fertile and infertile women in a low resource setting

This study aimed to explore the effect of infertility on self-esteem and depression, and to identify the sociodemographic and infertility characteristics associated with self-esteem and depression among infertile women in Ekiti State, Nigeria. Self-esteem and depression were assessed in 100 infertile women and 100 women seeking family planning (controls) using the Rosenberg Self-Esteem Scale (RSES) and Patient Health Questionnaire (PHQ-9), respectively. Infertile women had significantly lower RSES score (19.4 ± 4.5 vs. 20.7 ± 4.4, p=.038) and higher PHQ-9 score (5.1 ± 4.1 vs. 3.8 ± 3.5, p=.023) compared to controls. Among infertile women, marital status, being remarried, duration of infertility, and RSES score were associated with PHQ-9 score on simple linear regression. On multiple linear regression analysis, the RSES score had a negative association with the PHQ-9 score (β= -0.32, p<.001). In conclusion, infertile women have lower self-esteem and higher depression scores. Mental health screening and management should be an integral part of care administered to infertile women.Impact StatementWhat is already known on this subject? Infertility is a global health problem with negative effects on the mental health and quality of life of couples, especially women.What the results of this study add? Infertile women have lower self-esteem and higher depression scores. The prevalence of major depressive disorder (MDD) is higher among infertile women. Longer duration of infertility, older age, ≤6 years of formal education, and low self-esteem are significant associations of MDD among infertile women.What the implications are of these findings for clinical practice and/or further research? Mental health screening and management should be included in the care given to women undergoing evaluation and treatment for infertility. Larger community-based studies evaluating other aspects of mental health among infertile couples are encouraged.

Scoping review of the psychosocial aspects of infertility in developing countries: protocol

INTRODUCTION

Infertility is a widespread social phenomenon. For both women and men, there are several psychosocial issues associated with infertility. Numerous systematic reviews have focused on individuals' psychosocial issues pertaining to infertility, however, these have been conducted in developed countries. Thus, there is a gap in the current literature to analyse individuals' psychosocial issues associated with infertility in developing countries. Given that there are various contextual factors to consider for appropriate interventions to be implemented, it is vital to explore this topic in a developing context.

METHODS AND ANALYSIS

A scoping review will be conducted. A total of 12 databases were identified and a search string including terms related to infertility, psychosocial aspects and developing countries was developed. The inclusion and exclusion of each article will be determined through the guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart. Quantitative and qualitative data will be collated. The findings will summarise existing research on psychosocial aspects of infertility in developing countries and identify gaps in the research corpus.

ETHICS AND DISSEMINATION

Data will not be collected from participants. Instead, data will be extracted from published studies and therefore no ethical approval is required. The findings will be published in a peer-reviewed journal.

Simplified sperm testing devices: a possible tool to overcome lack of accessibility and inconsistency in male factor infertility diagnosis. An opportunity for low- and middle- income countries

Background

Manual semen assessment (MSA) is a key component in a male’s fertility assessment. Clinicians rely on it to make diagnostic and treatment decisions. When performed manually, this routine laboratory test is prone to variability due to human intervention which can lead to misdiagnosis and consequently over- or under- treatment. For standardisation, continuous training, quality control (QC) programs and pricy Computer-Assisted Sperm Analysis (CASA) systems have been proposed, yet, without resolving intra- and inter-laboratory variability. In response, promising simplified sperm testing devices, able to provide cost-effective point-of-care male infertility diagnosis are prospected as a plausible solution to resolve variability and increase access to sperm testing.

Materials and methods

A throughout literature research for semen testing, sperm analysis, smart-phone assisted semen analysis, ‘at-home’ semen testing, male infertility, infertility in developing countries, infertility in low- and middle-income countries (LMIC) and quantitative sperm analysis was performed. A total of 14 articles, specific to ‘at-home’ simplified sperm assessment, were included to treat the core subject.

Results

Continuous training and consistent QC, are sine qua none conditions to achieve accurate and comparable MSA. Compliance does not rule-out variability, nevertheless. Emerging simplified sperm assessment devices are an actual alternative to resolve the lack of standardisation and accessibility to sperm analysis. YO ® , SEEM ® , and ExSeed ® are commercially available, user-friendly smartphone-based devices which can accurately measure volume, sperm concentration (millions/ml) and total motile sperm count. More broadly, by cost-effectiveness, availability, accuracy and convenient application, these devices could effectively select patients for first-line artificial reproduction treatments such as intrauterine insemination.

Conclusions

Accuracy and cost-effectiveness make smart-phone based sperm testing devices a practical and realistic solution to overcome variability in MSA. Importantly, these tools represent an actual opportunity to standardise and improve male subfertility diagnosis and treatment, especially in LMIC. However, before clinical application is possible, guidelines, further testing with special attention on accuracy in washed sperm, availability, cost-benefit and reliability are required.

Reducing the waiting time to initiation of infertility treatment at a tertiary care centre in India

Background

In a low-resource and high-volume setting, it is often felt that patient care cannot be improved within the limitations of existing infrastructure and resources. However, the use of a systematic problem-solving method can bring about significant improvement even in these settings.

Aim

To decrease the mean waiting time from first visit to initiation of infertility treatment by 70% within 4 weeks (1–30 June 2019) for patients coming to the gynaecological outpatient department (OPD).

Methods

We constructed a multidisciplinary quality improvement team consisting of an academic consultant, a senior resident physician, a junior resident physician and a nurse to address the problem of long waiting times to initiation of fertility treatment. We collected baseline data from 10 consecutive women presenting to gynaecological OPD with complaints of infertility by calculating the time between their first visit to the facility and the day of performance of hysterosalpingography (HSG). The average waiting time was found to be 6 months and 25 days (mean=6.85 months; 3.5–10 months). The team used process flow diagrams and fishbone analysis to identify various causes of these long waiting times. The main reason for the delay in starting infertility treatment was that the date for HSG was given only after seeing the endometrial aspiration report (ie, after ruling out endometrial tuberculosis as there is a risk of dissemination of tuberculosis during HSG). Also, HSG was done only once a week during a short 2-hour slot in the fluoroscopy room.

Results

After the implementation of change ideas, there was significant reduction in the waiting period to starting treatment in patients with infertility. After the first change idea, the average waiting period seen in 10 consecutive patients with infertility reduced to 3.25 months, that is, by 51.8% from baseline within a 2-week interval, and there is shift in the run chart diagram. After the second change idea, the waiting time reduced to 2 months, that is, by 70%, seen in the next 10 consecutive patients with infertility within the next 2 weeks’ time. The results were sustained to the average waiting time of 2 months for 6 months without any additional resources.

Conclusion

With a well-organised and conducted quality improvement project and team efforts, the required changes can be brought about in an established conventional healthcare delivery system and improvements can be sustained over a long period of time.

Engagement in Nonbiomedical Practices for Fertility Enhancement: A Scoping Review

Objectives: This scoping review aims to (1) describe the scope and coverage of the body of literature on nonbiomedical practices used for enhancing fertility, (2) summarize and map the existing evidence on the extent and types of nonbiomedical practices used, and (3) examine how the research on this topic has been conducted with particular attention paid to how participants are asked about their use of nonbiomedical practices for fertility enhancement. Design: We conducted a scoping review by which four databases were searched (PubMed, Psychinfo, Socindex, and CINHAL). Articles were screened for inclusion by two researchers through a title and abstract screening followed by a full-text screening. Data were extracted from included articles and results summarized and compared across studies and regions. Results: A total of 32 studies were identified from 16 countries in five regions of the world. The majority of studies were clinic-based, primarily recruiting participants from fertility clinics in urban and suburban areas. More than half of the studies included only women, a few studies included only men, and the remainder of studies included both men and women. Most quantitative studies reported the prevalence of nonbiomedical practice use, which ranged from 8% to 83%; however, there was variation across studies regarding the time frame for which these percentages were derived. Few studies reported on other measures of the extent of use such as duration or frequency. A variety of nonbiomedical practices were identified with biologically based treatments, particularly herbal medicine use, being the most common followed by religious and spiritual interventions. Regional differences were identified. Variation in the wording and format of the question(s) used in survey instruments asking participants about their use of nonbiomedical practices exists and may impact participants' reporting of use. Conclusions: Infertility affects millions of individuals worldwide often with severe social, emotional, and financial consequences. To enhance fertility and, in some cases, overcome infertility, many individuals and couples are engaging in a variety of nonbiomedical practices. This scoping review describes the scope and nature of the existing literature on the use of nonbiomedical practices for fertility enhancement and highlights important gaps and limitations in the conduct of this research. A more comprehensive and inclusive investigation of nonbiomedical practices for enhancing fertility is needed to improve our understanding of how individuals and couples are managing infertility, identify educational and counseling needs, and to improve research related to effectiveness and safety of nonbiomedical practices.

Iranian women's experiences of infertility: A qualitative study

Background

There are concerns and diverse experiences related to infertility and childlessness. The lived experience of infertile people from various cultures needs to be explored.

Objective

The aim of this qualitative study was to explore Iranian women experiences of their infertility.

Materials and Methods

The data comprised interviews about fertility issues in the Persian language with eighteen women, aged 17-45 yr old, who agreed to be interviewed at the Mottahari Infertility Treatment Clinic, affiliated to the Urmia University of Medical Sciences about their fertility problems. They were approached by the researchers at the time of their first visit. The verbatim transcribed interviews were analyzed using deductive conventional content analysis.

Results

The experiences of the informants were conceptualized into four major themes: 1) Shock (subthemes: Disbelief and Denial); 2) Reaction (subthemes: Distress, Guilt, Loss of self-esteem and Sexual reluctance); 3) Processing (subthemes: Internal processing, Avoidance, Marriage at risk, External processing, Stigma caused by the family and Stigma caused by the community) and 4) Reorientation (subthemes: Forgetting, Marriage to saving marriage and Sexual consent).

Conclusion

Infertility can be a challenging condition. Considering that infertility-related issues affect Iranian women more contextual factors is necessary. So, culturally sensitive and gender specific protocols are suggested to provide suitable and about culturally sensitive and gender-specific protocols is a necessity in order to provide suitable care to infertile women.

Culturally adapted depression intervention to manage depression among women with infertility in Ghana

This study tested the feasibility of a culturally adapted depression intervention among women with infertility. Women who were seeking medical treatment for infertility were randomized into treatment and control groups. Data were collected at baseline, 6 weeks, 12 weeks, and 3 months post intervention. General linear mixed model using empirical Bayesian estimates for repeated measures was used. The findings indicate an improvement in the women's psychosocial health in the treatment group as compared with the controls. These findings strongly suggest that the management of these psychosocial problems should be an integral part of the management of infertility.

The effect of infertility-related stress on Chinese infertile females' mental health: The moderating role of marital adjustment

Although the impacts of infertility-related stress on mental health have been testified in the literature, the underlying mechanism between them is still not clear. In response to this issue, 286 Chinese women who were pursuing medical treatment for fertility problems in two state-owned hospitals were invited to complete the survey, including the 7-item Dyadic Adjustment Scale (DAS), the Fertility Problem Inventory (FPI), the 5-item Mental Health Inventory (MHI-5), and demographic variables (e.g., age). The multiple linear regression method (SPSS 16) was used to investigate the impact of infertility-related stress and marital satisfaction on infertile women's mental health. Results showed that the total FPI score-and the specific domains of Social Concern, Relationship Concern, and Rejection of Child-Free Lifestyle in particular-had a significant negative relation with infertile women's mental health and marital satisfaction as a moderator between them. Therefore, the core of marital relationship and specific infertility-related stress should be addressed in psychological intervention programs for people facing infertility in mainland China.

Psychosocial effects of infertility among couples attending St. Michael's Hospital, Jachie-Pramso in the Ashanti Region of Ghana

Objective

Infertility is a life crisis with a wide range of socio-cultural, emotional, physical and financial problems. This study sought to determine the psychosocial effects of infertility among couples attending St. Michael’s hospital, Jachie-Pramso. A descriptive study design was adopted using a quantitative approach. A simple random technique was used to select 100 respondents and a structured closed ended questionnaire was administered to couples who visited the St. Michaels Hospital at Jachie-Pramso.

Results

The study has revealed that the social effects of infertility on couples included exclusion, verbal and physical abuse, divorce as well as stigma. There is high level of despondence among couples who are considered infertile. Reliance on family members for emotional support as well as avoidance of sensitive conversations was the main coping strategies adopted by the couples to cope with their conditions. Infertility has psychological, emotional and social consequences on individuals as well as couples. Families should support infertile individuals in every way that they can so that they will not be isolated.

Demographic analysis of a low resource, socioculturally diverse urban community presenting for infertility care in a United States public hospital

Background

Infertility is a prevalent disease of reproductive health that exerts an impact on an estimated 80 million people worldwide. For many, involuntary childlessness becomes a central and preoccupying issue in their lives, the impact of which is exacerbated by lack of access to basic care and treatment. These effects maybe further magnified among immigrant communities, a growing but highly marginalized population that has been shown in other areas of reproductive health to experience worse health outcomes and delays in access to care. To date, few studies have examined the unique medical and sociocultural considerations of infertility among immigrant populations in the United States.

Methods

Our study is a cross-sectional analysis of women presenting for infertility evaluation at a county hospital serving a low resource, socioculturally diverse largely immigrant communities in comparison to infertile women from a largely affluent population presenting to a high resource, comprehensive fertility center. We employed surveys to evaluate demographics and socioeconomic parameters as well as abstracted data from medical records to obtain infertility diagnoses. Multivariate regression analysis was applied to examine impact of sociocultural factors as predictors of duration of untreated infertility disease burden experienced by patients.

Results

Eighty-seven women were included in our analysis. In the county hospital/low resource clinic (LR), the mean age was 32.9 ± 4.9 vs 36.4 ± 6.3 years in the fee-for-service/high resource clinic (HR). The mean reported duration of infertility in LR and HR patients was 3.4 ± 3.0 vs 2.3 ± 1.5 years. 70% of LR patients were monolingual non-English speakers vs 5.4% of HR patients. 59% of LR patients reported an annual household income of less than $25,000 and 70% did not have a college degree. 81.1% of HR patients reported an income of higher than $100,000, and 81.1% had completed college or graduate school. The most common infertility diagnosis in the LR was anovulation (38%) and tubal factor (28%) compared to diminished ovarian reserve (37.8%) and male factor (51.4%) in the HR. After controlling for age at the initiation of pregnancy attempt, lower education level, lower income, and immigrant status were significantly correlated with a longer duration of infertility.

Conclusions

Women presenting for infertility care to a low resource county medical center represent immigrant communities and are generally of younger age, but with a longer duration of infertility. This study identifies lower educational level, income, and immigrant status as barriers in access to care.

Trends of male factor infertility, an important cause of infertility: A review of literature

Infertility and problems of impaired fecundity have been a concern through ages and is also a significant clinical problem today, which affects 8–12% of couples worldwide. Of all infertility cases, approximately 40–50% is due to “male factor” infertility and as many as 2% of all men will exhibit suboptimal sperm parameters. It may be one or a combination of low sperm concentration, poor sperm motility, or abnormal morphology. The rates of infertility in less industrialized nations are markedly higher and infectious diseases are responsible for a greater proportion of infertility. The present literature will help in knowing the trends of male factor infertility in developing nations like India and to find out in future, various factors that may be responsible for male infertility.

'At the hospital I learnt the truth': diagnosing male infertility in rural Malawi

This paper examines how men's reproductive bodies are problematised in rural northern Malawi as access to biomedically defined diagnoses of the health of men's sperm contribute to the visibility of male infertility. Ethnographic research with infertile and fertile men explored pathways into the sexual health and fertility services offered in district hospitals, men's clinical engagements and masculine imaginaries. The research suggested that men's willingness to be referred for semen analysis is an extension of intensive and persistent help-seeking for childlessness instigated by couples and encouraged by families. Within the laboratory, acceptable social arrangements for semen sample collection are negotiated between male clients and laboratory staff, which emphasise heterosexual and marital virility. Following diagnosis, counselling by clinical officers, without any significant therapeutic interventions, focuses on compassion in marriage. This paper considers: what is the role of semen analysis within public health facilities and why do men participate? How do men experience an infertility diagnosis and what do they and their partners do with this knowledge? In addition, how do these practices shape gendered relationships in families and communities? The analysis builds on Inhorn's (2012) concept of ‘emergent masculinities’ to better understand the connections between male subjectivities, medical technologies and the globalisation of male reproductive health, as they relate to men's lives in rural Malawi.

Promoting reproductive options for HIV-affected couples in sub-Saharan Africa

HIV-affected couples face unique challenges that require access to information and reproductive services to prevent HIV transmission to the uninfected partner and offspring while allowing couples to fulfil their reproductive goals. In regions of high HIV prevalence in sub-Saharan Africa, HIV-affected couples require multipurpose prevention technologies (MPTs) to enhance their reproductive healthcare options beyond contraception and prevention of HIV/sexually transmitted infections (STIs) to include assistance in childbearing. The unique characteristics of the condom and its accepted use in conjunction with safer conception interventions allow HIV-serodiscordant couples an opportunity to maintain reproductive health, prevent HIV/STI transmission, and achieve their reproductive goals while timing conception. Re-thinking the traditional view of the condom and incorporating a broader reproductive health perspective of HIV-affected couples into MPT methodologies will impact demand, acceptability and uptake of these future technologies.

Infertility care and the introduction of new reproductive technologies in poor resource settings

BACKGROUND

The overall prevalence of infertility was estimated to be 3.5-16.7% in developing countries and 6.9-9.3% in developed countries. Furthermore, according to reports from some regions of sub-Saharan Africa, the prevalence rate is 30-40%. The consequences of infertility and how it affects the lives of women in poor-resource settings, particularly in developing countries, has become an important issue to be discussed in reproductive health. In some societies, the inability to fulfill the desire to have children makes life difficult for the infertile couple. In many regions, infertility is considered a tragedy that affects not only the infertile couple or woman, but the entire family.

METHODS

This is a position paper which encompasses a review of the needs of low-income infertile couples, mainly those living in developing countries, regarding access to infertility care, including ART and initiatives to provide ART at low or affordable cost. Information was gathered from the databases MEDLINE, CENTRAL, POPLINE, EMBASE, LILACS, and ICTRP with the key words: infertility, low income, assisted reproductive technologies, affordable cost, low cost.

RESULTS

There are few initiatives geared toward implementing ART procedures at low cost or at least at affordable cost in low-income populations. Nevertheless, from recent studies, possibilities have emerged for new low-cost initiatives that can help millions of couples to achieve the desire of having a biological child.

CONCLUSIONS

It is necessary for healthcare professionals and policymakers to take into account these new initiatives in order to implement ART in resource-constrained settings.

Comparing local perspectives on women's health with statistics on maternal mortality: an ethnobotanical study in Bénin and Gabon

BACKGROUND

According to the World Health Organization (WHO), reproductive health problems are the leading cause of morbidity and mortality for women in Africa. In spite of this scenario and the importance of plants in African health care, limited research has been conducted linking maternal health and plant-based medicine. The objective of our research was to examine how closely Beninese and Gabonese women's health perspectives, medicinal plant knowledge, and plant use practices reflect the statistical causes of maternal mortality.

METHODS

In Bénin (2011) and Gabon (2012), we conducted 87 ethnobotanical questionnaires with the corresponding collection of 800 botanical specimens. We used free-listing analysis, citation frequency and species counts to determine women's top health concerns. We also interviewed 18 biomedical healthcare providers in national hospitals and local clinics.

RESULTS

Informants' perceptions of the main causes of maternal suffering included malaria, infertility, and menstruation and pregnancy concerns. Women were knowledgeable on plants to treat the top causes of maternal morbidity, but knew more plants for conditions such as anemia, infertility, breast milk production, and the maintenance of menstruation and pregnancy. The biomedical staff recognized the role of traditional medicine in their patients' lives and expressed concern for herbal remedies to facilitate birth, but were restricted by national policies on advising on medicinal plant use.

CONCLUSIONS

Plants serve as an entry point to understanding Beninese and Gabonese women's perceptions of common health concerns and local health management strategies. Plant use practices in both countries did not closely parallel the top statistical causes of maternal mortality, but highlighted key issues such as menstruation and infertility as salient health concerns for women. More research is needed on the role of plants in women's gynecological healthcare.

First births with a simplified culture system for clinical IVF and embryo transfer

This study reports the outcome results from a pilot clinical trial using a simplified laboratory method for human IVF. This system reproducibly generates de novo the atmospheric and culture conditions that support normal fertilization and preimplantation embryogenesis to the hatched blastocyst stage without the need for specialized medical-grade gases or equipment. Development from insemination to the hatched blastocyst stage occurs undisturbed in a completely closed system that enables timed performance assessments for embryo selection in situ that, in this study, involved single-embryo transfers on day 3. With the simplified culture system, 8/23 embryos implanted, one miscarried at 8weeks of gestation and seven healthy babies have been born. The methodology and results are discussed with regard to how this simplified system can be adopted worldwide to meet the growing need for accessible and affordable IVF. A common notion concerning the demographics of infertility is that it is largely a phenomenon associated with developed countries, where infertility treatments are commonplace. In fact, most infertile couples reside in developing/low-resource countries where infertility diagnosis and treatment is nonexistent, inaccessible or unaffordable by the vast majority of young men and women in need. The irony of this situation is that bilateral tubal occlusions, for which IVF was originally indicated and is the most effective treatment, is by far the most common cause of their infertility. We have addressed one aspect of this issue, the IVF laboratory, as part of a wider effort by the Walking Egg Project to design and establish small, dedicated centres in developing countries to provide assisted reproduction technologies that are affordable and accessible to a wider proportion of the population in need. The methods for conventional IVF designed to addresses tubal obstructions are relatively simple and free of complex instrumentation and the highly developed infrastructure common to high-resource centres. This simplified IVF system self-generates culture conditions in a closed system. After prolonged preclinical testing, a pilot clinical study was initiated in 2012 in Genk, Belgium. The findings suggest that a significant first step has been achieved in the effort to bring advanced assisted reproduction to developed countries using a low-resource but highly effective IVF system capable of bringing modern reproductive medicine to infertile couples in low-resource societies.

Family physicians' attitude and practice of infertility management at primary care--Suez Canal University, Egypt

INTRODUCTION

The very particular natures of infertility problem and infertility care make them different from other medical problems and services in developing countries. Even after the referral to specialists, the family physicians are expected to provide continuous support for these couples. This place the primary care service at the heart of all issues related to infertility.

THE AIM OF THE WORK

to improve family physicians' attitude and practice about the approach to infertility management within primary care setting.

METHODS

This study was conducted in the between June and December 2010. The study sample comprised 100 family physician trainees in the family medicine department and working in family practice centers or primary care units. They were asked to fill a questionnaire about their personal characteristics, attitude, and practice towards support, investigations, and treatment of infertile couples.

RESULTS

Hundred family physicians were included in the study. They were previously received training in infertility management. Favorable attitude scores were detected among (68%) of physicians and primary care was considered a suitable place for infertility management among (77%) of participants. There was statistically significant difference regarding each of age groups, gender and years of experience with the physicians' attitude. There was statistically significant difference regarding gender, perceiving PHC as an appropriate place to manage infertility and attitude towards processes of infertility management with the physicians' practice.

CONCLUSION

Favorable attitude and practice were determined among the study sample. Supporting the structure of primary care and evidence-based training regarding infertility management are required to improve family physicians' attitude and practice towards infertility management.

Indonesian infertility patients' health seeking behaviour and patterns of access to biomedical infertility care: an interviewer administered survey conducted in three clinics

Background

Indonesia has high levels of biological need for infertility treatment, great sociological and psychological demand for children, and yet existing infertility services are underutilized. Access to adequate comprehensive reproductive health services, including infertility care, is a basic reproductive right regardless of the economic circumstances in which individuals are born into. Thus, identifying and implementing strategies to improve access to assisted reproductive technology (ART) in Indonesia is imperative. The principle objectives of this article are to improve our understanding of infertility patients’ patterns of health seeking behaviour and their patterns of access to infertility treatment in Indonesia, in order to highlight the possibilities for improving access.

Methods

An interviewer-administered survey was conducted with 212 female infertility patients recruited through three Indonesian infertility clinics between July and September 2011. Participants were self-selected and data was subject to descriptive statistical analysis.

Results

Patients identified a number of barriers to access, including: low confidence in infertility treatment and high rates of switching between providers due to perceived treatment failure; the number and location of clinics; the lack of a well established referral system; the cost of treatment; and patients also experienced fear of receiving a diagnosis of sterility, of vaginal examinations and of embarrassment. Women’s age of marriage and the timing of their initial presentation to gynaecologists were not found to be barriers to timely access to infertility care.

Conclusions

The findings based on the responses of 212 female infertility patients indicated four key areas of opportunity for improving access to infertility care. Firstly, greater patient education about the nature and progression of infertility care was required among this group of women. Secondly, increased resources in terms of the number and distribution of infertility clinics would reduce the substantial travel required to access infertility care. Thirdly, improvements in the financial accessibility of infertility care would have promoted ease of access to care in this sample. Finally, the expansion of poorly developed referral systems would also have enhanced the efficiency with which this group of patients were able to access appropriate care.

Affordable ART: a different perspective

BACKGROUND

Although ≈ 10% of the population is affected by infertility, the treatment option of in-vitro fertilisation (IVF) remains unaffordable for the majority of infertile couples. We have initiated a lowcost programme incorporating an uncommonly used, but recognized, ovarian stimulation protocol, together with certain costlimiting initiatives in an established assisted reproductive technology (ART) set up.

METHODS

The medical records of women who underwent the lowcost programme were analysed. Clomiphene citrate 50 mg daily was administered from Day 2 of the cycle and continued till the day of hCG trigger, thus preventing the LH surge. Intermittent doses of human menopausal gonadotrophin 150 IU were administered on alternate days from the 5th day onwards. Oocyte retrieval was carried out once at least two follicles of >18 mm were identified. The cycle was monitored by ultrasound only, with embryo transfer being carried out on Day 3. Clinical outcomes were recorded together with an estimation of the direct costs per cycle. Direct cost calculations did not include professional charges or facility costs.

RESULTS

Of 143 women evaluated, 104 women underwent embryo transfer. The live birth rate and clinical pregnancy rate per embryo transfer were 19 and 22%. The live birth rate per initiated cycle was 14% (20/143). The multiple pregnancy rate was 26% with no case of ovarian hyperstimulation syndrome being recorded. The average direct cost per cycle was US$ 675 for IVF and US$ 725 for an ICSI treatment cycle.

CONCLUSIONS

Using this protocol, together with several costcutting measures, we achieved an acceptable live birth rate per transfer of 19% at a reasonable cost. This approach could be used by established ART centres to provide treatment to couples who cannot afford conventional ART.

Assisted reproduction services provision in a developing country: time to act?

OBJECTIVE

To conduct a survey in a developing country to gauge the extent of subfertility and the current state of assisted reproductive technology (ART) service provision and explore factors limiting access to ART services.

DESIGN

Cross-sectional online survey.

SETTING

The study was co-ordinated at the Aga Khan University Hospital, Nairobi, Kenya.

SUBJECT(S)

One hundred eighty-eight obstetricians and gynecologists registered with the Kenya Obstetrics and Gynecology Society were invited to complete the survey.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

None.

RESULT(S)

A total of 47 responses (25%) were received after completion of the survey. The overall rate of subfertility was 26.1% among the gynecology consultations, with 50% attributed to tubal factors and 15% due to male factors. Assisted reproductive service provision (IVF/intracytoplasmic sperm injection) was severely limited to only three units, despite the reported high rate of tubal disease. The high cost of treatment, patients' limited finances, and limited local services were almost universally cited as the main barriers to ART services in Kenya.

CONCLUSION(S)

The demand for ART in developing countries is not in doubt. Simplified, less costly, and more accessible ART approaches need to be considered in developing countries, even though the benefits and outcomes of such approaches may not be apparent immediately.

A review of management of infertility in Nigeria: framing the ethics of a national health policy

Infertility has recently been construed to be a serious problem in sub-Saharan Africa. This problem seems to be viewed as of low priority with reference to the effective and efficient allocation of available health resources by national governments as well as by international donors sponsoring either research or service delivery in the public health sector. In this paper the problem of infertility in Nigeria is surveyed with a view to assessing the ethical dimension of proposals to manage infertility as a public sector priority in health care delivery. The population/individual and public/private distinction in the formulation of health policy has ethical implications that cannot simply be ignored and are therefore engaged in critically assessing the problem of infertility. Cost-utility analysis (such as Quality Adjusted Life-Year composite index) in the management of infertility in Nigeria entails the need for caution relevant to the country's efforts to achieve Millennium Development Goals. This should remain the case whether the ethical evaluation appeals to utilitarian or contractarian (Rawlsian) principles. The "worst off " category of Nigerians includes (1) underweight children less than 5 years of age, with special concern for infants (0-1 years of age) and (2) the proportion of the population below a minimum level of dietary consumption. The Rawlsian ethic implies that any Federal Ministry of Health policy aimed at establishing public programs for infertility management can be considered a "fair" allocation and expenditure if, and only if, the situation for these two cohorts is not thereby made worse. Nigerian health policy cannot assume this type of increased allocation of its resources to infertility care without it being hard pressed to warrant defensible moral or rational argument.

'Mama and papa nothing': living with infertility among an urban population in Kigali, Rwanda

BACKGROUND

Not being able to procreate has severe social and economic repercussions in resource-poor countries. The purpose of this research was to explore the consequences of female and/or male factor infertility for men and women in Rwanda.

METHODS

Both quantitative and qualitative methods were used. Couples presenting with female and/or male factor infertility problems at the infertility clinic of the Kigali University Teaching Hospital (n = 312), and fertile controls who recently delivered (n = 312), were surveyed about domestic violence, current and past relationships and sexual functioning. In addition, five focus group discussions were held with a subsample of survey participants, who were either patients diagnosed with female- or male-factor fertility or their partners.

RESULTS

Domestic violence, union dissolutions and sexual dysfunction were reported more frequently in the survey by infertile than fertile couples. The psycho-social consequences suffered by infertile couples in Rwanda are severe and similar to those reported in other resource-poor countries. Although women carry the largest burden of suffering, the negative repercussions of infertility for men, especially at the level of the community, are considerable. Whether the infertility was caused by a female factor or male factor was an important determinant for the type of psycho-social consequences suffered.

CONCLUSIONS

In Rwanda, as in other resource-poor countries, infertility causes severe suffering. There is an urgent need to recognize infertility as a serious reproductive health problem and to put infertility care on the public health agenda.

Gender differences and factors associated with treatment-seeking behaviour for infertility in Rwanda

BACKGROUND

This study examines perceptions of infertility causes, treatment-seeking behaviour and factors associated with seeking medical care in an urban infertile population in Rwanda, as well as the response of health providers.

METHODS

Between November 2007 and May 2009 a hospital based survey was conducted among 312 women and 254 male partners in an infertile relationship.

RESULTS

Infertility causes based on a medical diagnosis were mentioned by 24% of women and 17% of men. Male infertility awareness was low in both sexes with 28% of men and 10% of women reporting male-related causes. Seventy-four per cent of women and 22% of men had sought care for their infertility in the past. Seeking treatment in the formal medical sector was associated with higher income, being married and infertility duration of more than 5 years in both sexes. In women, higher education and being nulliparous and in men blaming oneself for the infertility was also associated with seeking formal medical care. Participants reported a wide array of treatments they received in the past, often including ineffective or even harmful interventions.

CONCLUSION

Health authorities should invest in improving information, education and counselling on issues pertaining to causes and treatments of infertility, and in drawing up guidelines for the management of infertility at all levels of health care.

"Trying" times: Medicalization, intent, and ambiguity in the definition of infertility

Researchers studying infertility from the perspective of anthropology and other the social sciences seldom examine the assumptions embedded in the biomedical definition of infertility. Implicit in the biomedical definition is the assumption that people can be divided straightforwardly into those who are trying to conceive and those who are not trying to conceive. If being infertile implies "intent to conceive," we must recognize that there are various degrees of intent and that the line between the fertile and the infertile is not as sharp as is usually imagined. Drawing on structured interview data collected from a random sample of Midwestern U.S. women and from qualitative interviews, we demonstrate that that there is a wide range of intent among those classified as infertile according to the biomedical definition. We explore the implications of this for research.

Assisted reproductive technologies in India: the views of practitioners

BACKGROUND

This article documents the context of Assisted Reproductive Technology/ies (ART) services and providers' perceptions regarding services offered in India. The objective is to facilitate understanding of critical issues and relevant concerns.

METHODS

A postal survey conducted with a sample of 470 gynaecologists and in-depth interviews with 39 gynaecologists in four cities.

RESULTS

ART clinics have proliferated in cities and towns; they are commercialised and the quality of treatment is variable. Most providers perceived that patients lack knowledge about infertility and ART, costs are high, investigations unnecessarily repeated and success rates low. ART providers do not have clear selection criteria, some lack rigorous specialised training and infrastructure and most are deficient in record-keeping and counselling and lack transparency. Monitoring and regulation by appropriate authorities are also lacking.

CONCLUSION

Both providers and regulatory authorities need to look critically at exploitation of patients and commercialisation, excessive costs, lack of information, informed consent, and transparency, counselling, unethical practices, variations in quality of treatment and ensuring proper monitoring and regulation.

Management of infertility in low resource countries

Infertility is a global problem, but the highest prevalence is in low resource countries, particularly in sub-Saharan Africa where infection-related tubal damage is the commonest cause. Most infections causing tubal damage are preventable and assisted conception can treat the infertility. However, assisted conception, despite being available for nearly three decades is either unavailable or inaccessible to most residents of resource poor countries. Infertility has social, economic and personal effects, which go beyond childlessness, and women bear the major brunt of the burden. There is urgent need for a comprehensive sexual and reproductive healthcare initiative involving maternal and child health, safe abortions, family planning and infertility prevention and management. The provision of low cost assisted reproduction for couples in poorly resourced countries also needs to be revisited.

The experience of infertility: a review of recent literature

About 10 years ago Greil published a review and critique of the literature on the socio-psychological impact of infertility. He found at the time that most scholars treated infertility as a medical condition with psychological consequences rather than as a socially constructed reality. This article examines research published since the last review. More studies now place infertility within larger social contexts and social scientific frameworks although clinical emphases persist. Methodological problems remain but important improvements are also evident. We identify two vigorous research traditions in the social scientific study of infertility. One tradition uses primarily quantitative techniques to study clinic patients in order to improve service delivery and to assess the need for psychological counselling. The other tradition uses primarily qualitative research to capture the experiences of infertile people in a sociocultural context. We conclude that more attention is now being paid to the ways in which the experience of infertility is shaped by social context. We call for continued progress in the development of a distinctly sociological approach to infertility and for the continued integration of the two research traditions identified here.

HIV and reproductive health: a South African experience

Acquired immune deficiency syndrome (AIDS), caused by the human immunodeficiency virus (HIV), disproportionately affects Africa whereby the majority of new infections and deaths occur in sub-Saharan Africa. It is the leading cause of death in Africa and a major cause of maternal mortality. HIV/AIDS impacts on every aspect of reproductive health and presents considerable challenges to healthcare systems. Fertility is particularly valued in Africa and voluntary childlessness is unusual. AIDS results in a reduction in both fecundity and fertility, as well as compromising the outcome of pregnancy. The stigma of childlessness is quite profound and impacts both social life and social standing within the community, particularly of the women who are affected. Unfortunately, treatment for infertility is often inadequate and, because of limited resources, is frequently denied to HIV-positive couples. Undoubtedly the challenges in dealing with the HIV/AIDS pandemic in Africa are enormous; however, appropriate solutions are available and these need to be put in place. It is essential that the management of the HIV patient is holistic and takes all needs, including that of fertility, into account.

Right to assisted reproductive technology: overcoming infertility in low-resource countries

This article examines the high prevalence of primary and secondary infertility in low-resource countries. Provision of assisted reproductive technology (ART) to overcome both female and male infertility is in line with the reproductive rights agenda developed at the International Conference on Population and Development (ICPD) in Cairo 15 years ago. In addition to the right to control fertility, reproductive rights must encompass the right to facilitate fertility when fertility is threatened. Facilitation of fertility may require resort to ART, among both men and women. Egypt is highlighted as a positive example of progress in this regard.

Reproductive healthcare systems should include accessible infertility diagnosis and treatment: an important challenge for resource-poor countries

Infertility is a central issue in the lives of many couples who suffer from it. In resource-poor countries the problem of childlessness is even more pronounced compared with Western societies owing to different sociocultural circumstances. It often leads to severe psychological, social, and economic suffering, and access to infertility treatment is often limited to certain procedures and certain costumers. The issue of infertility in resource-poor countries is underestimated and neglected, not only by local governments but also by the international nonprofit organizations. Simplification of the diagnostic and therapeutic procedures, minimizing the complication rate, and incorporating fertility centers into existing reproductive healthcare programs are essential measures to take in resource-poor countries if infertility treatment is to be accessible for a large part of the population. For reasons of social justice, a search for strategies to implement simplified methods of infertility diagnosis and treatment in resource-poor countries is urgently warranted.

The public sector's role in infertility management in India

This objective of this paper is to explore the public sector's role in infertility management in India. It focuses on services available in the public sector, problems faced by and critiques of public sector providers. A postal survey was conducted with a sample of 6000 gynaecologists and in-depth interviews were conducted with 39 gynaecologists in four cities. The role of the public sector in infertility management is weak as even basic investigations and services were limited or incomplete. Inadequate infrastructure, inappropriate management including time management, lack of information and training, absence of clear protocols at all levels, private practice by public health doctors, pre-occupation with other health issues and lack of regulation were the main problems mentioned by providers. Amongst key recommendations are realistic and low-cost management, streamlining and regulating services, counselling of couples, providing information and raising awareness of patients, health personnel and policy makers.

Infertility and the provision of infertility medical services in developing countries

BACKGROUND

Worldwide more than 70 million couples suffer from infertility, the majority being residents of developing countries. Negative consequences of childlessness are experienced to a greater degree in developing countries when compared with Western societies. Bilateral tubal occlusion due to sexually transmitted diseases and pregnancy-related infections is the most common cause of infertility in developing countries, a condition that is potentially treatable with assisted reproductive technologies (ART). New reproductive technologies are either unavailable or very costly in developing countries. This review provides a comprehensive survey of all important papers on the issue of infertility in developing countries.

METHODS

Medline, PubMed, Excerpta Medica and EMBASE searches identified relevant papers published between 1978 and 2007 and the keywords used were the combinations of 'affordable, assisted reproduction, ART, developing countries, health services, infertility, IVF, simplified methods, traditional health care'.

RESULTS

The exact prevalence of infertility in developing countries is unknown due to a lack of registration and well-performed studies. On the other hand, the implementation of appropriate infertility treatment is currently not a main goal for most international non-profit organizations. Keystones in the successful implementation of infertility care in low-resource settings include simplification of diagnostic and ART procedures, minimizing the complication rate of interventions, providing training-courses for health-care workers and incorporating infertility treatment into sexual and reproductive health-care programmes.

CONCLUSIONS

Although recognizing the importance of education and prevention, we believe that for the reasons of social justice, infertility treatment in developing countries requires greater attention at National and International levels.