Is global access to infertility care realistic? The Walking Egg Project

Access to assisted reproductive technologies in sub-Saharan Africa: fertility professionals' views

Across sub-Saharan Africa, there remains disagreement among local expert providers over the best ways to improve access to assisted reproduction in low-income contexts. Semi-structured qualitative interviews were conducted between 2021 and 2023 with 19 fertility specialists and 11 embryologists and one clinic manager from South Africa, Zimbabwe, Namibia, Kenya, Ethiopia and Uganda to explore issues surrounding access and potential low-cost IVF options. Lack of access to ART was variously conceptualised as a problem of high cost of treatment; lack of public funding for medical services and medication; poor policy awareness and prioritisation of fertility problems; a shortage of ART clinics and well-trained expert staff; the need for patients to travel long distances; and over-servicing within the largely privatised sector. All fertility specialists agreed that government funding for public sector assisted reproduction services was necessary to address access in the region. Other suggestions included: reduced medication costs by using mild stimulation protocols and oocyte retrievals under sedation instead of general anaesthetics. Insufficient data on low-cost interventions was cited as a barrier to their implementation. The lack of skilled embryologists on the continent was considered a major limitation to expanding ART services and the success of low-cost IVF systems. Very few specialists suggested that profits of pharmaceutical companies or ART clinics might be reduced to lessen the costs of treatments.

Women's Awareness of Reproductive Health

Background and Objectives: reproductive disorders are a serious global concern in medical, social, and demographic contexts. According to estimates, approximately 10-15% of couples around the world suffer from infertility. Numerous studies have shown that modifiable lifestyle factors, such as a high-fat diet, a postponed decision to start a family, tobacco smoking, alcohol consumption, risky sexual behavior, psychiatric diseases, and chronic stress, have a negative influence on the fertility of women. The main goal of this study is to assess the knowledge of women about reproductive health, infertility risk factors, and causes of infertility and to determine whether the level of this knowledge varies based on sociodemographic variables. Materials and Methods: a survey was conducted among 111 patients who anonymously filled in a questionnaire comprising questions regarding fertility and its deficiencies. The results were analyzed using the Chi-square test and Fisher's test. Results: the survey results indicated that women had a good or very good level of knowledge of the causes of infertility. The obtained test results were statistically significant (p < 0.05), but the studied group did not possess sufficient knowledge of the symptoms characterizing the diseases related to limited fertility (p > 0.05). The level of knowledge on the diagnosis of infertility did not depend on the age of the examined people, their educational level, or personal experience in this field (p > 0.05). The results also revealed that the awareness of women on reproductive health was poor. The studied women had a low level of knowledge of infertility risk factors, and their knowledge did not correlate with age, educational level, or personal experiences. Conclusions: information on the aspects of reproductive health should be widely disseminated through public educational campaigns, aimed at correcting erroneous convictions among women about the risk factors for infertility and assisting them in improving fertility.

Exploring the challenges of public health nurses in the management of infertility in Northern Ghana: a qualitative descriptive study

OBJECTIVE

To explore the challenges public health nurses (PNHs) face in managing infertility in rural settings of the Talensi and Nabdam districts in the Upper East Region of Ghana.

DESIGN

The study adopted a qualitative descriptive design approach where PHNs who worked in rural settings were interviewed using a semistructured interview guide. Thematic analysis was employed to analyse the data.

SETTING

Primary healthcare setting in the Upper East Region of Ghana.

PARTICIPANTS

The study participants were 15 PHNs working in primary health centres with a mean age of 36.9 years (SD=6.40).

RESULTS

This study revealed that couples with infertility issues face challenges in seeking care for their condition. The challenges expressed by the participants that affect individual and couples' access to infertility care were (1) lack of material and human resources, (2) lack of specialists and guides for infertility treatment and (3) inadequate and inconsiderate communication.

CONCLUSION

This study provides evidence of the challenges experienced by PHNs in managing infertility among couples. Adequate measures are therefore required to ameliorate these challenges to improve care provision for couples with infertility.

Pregnancy and pregnancy intention after experiencing infertility: A longitudinal study of women in Malawi

BACKGROUND

Infertility is a common experience among individuals and couples. Infertility may resolve without intervention, but little is known about pregnancy intentions and incidence of pregnancy following infertility, particularly in low-resource settings.

METHODS

Data come from UTHA, a longitudinal cohort study in Central Malawi, with baseline and follow up surveys conducted from 2014-2019 (N = 1,030 reproductive-aged women). We assessed bivariable and multivariable relationships between reported infertility at baseline and subsequent pregnancy and retrospective pregnancy intentions. Pregnancy intention was measured with the London Measure of Unplanned Pregnancy (LMUP), a scale validated in Malawi (Range = 0-12).

RESULTS

Approximately 20% of the sample reported that they had ever experienced infertility (tried to become pregnant for at least two years without conceiving in that time) at baseline. The proportion of women who reported a new pregnancy during the follow up period (mean = 4.3 years) was the same (65%) for women who had and had not experienced infertility. Among women who became pregnant, levels of pregnancy intendedness were similar between women who had and had not experienced infertility. Prospective desire for a/another child at baseline was associated with subsequent pregnancy (AOR: 1.59; 95%CI: 1.06-2.39) and was also associated with higher levels of pregnancy intendedness measured retrospectively (LMUP of 9.4 vs. 8.4).

CONCLUSIONS

Experienced infertility was not associated with differential odds of having a subsequent pregnancy or the intendedness of a subsequent pregnancy. Thus, women who have experienced infertility should be included in family planning programs and research to support all women in achieving their reproductive goals.

Perinatal Outcome of Singletons Born after Using a Simplified Low-Cost IVF Culture System and All Singletons Born in Flanders (Belgium) between 2012 and 2020

BACKGROUND

We developed a simplified IVF culture system (SCS) which has proven to be effective and safe in a selected IVF cohort.

METHODS

Preterm birth (PTB) and low birth weight (LBW) of 175 singletons born after using the SCS, 104 after fresh embryo transfer (ET), and 71 after frozen embryo transfer, were compared with all singletons born in Flanders between 2012 and 2020 conceived after natural conception, ovarian stimulation (OS), and assisted reproduction (IVF/ICSI).

FINDINGS

The proportion of preterm (<37 weeks) births was significantly higher in the case of IVF or ICSI, followed by hormonal treatment, compared to spontaneous pregnancies. There was no significant difference in PTB between SCS and any of the other groups. Concerning the average birth weight we found no significant difference between singletons born after natural conception and SCS. However, a significant difference in average birth weight was found between SCS singletons and singletons born after IVF, ICSI and hormonal treatment, with a significantly higher birth weight in the SCS group. This difference was also observed in the proportion of babies weighing less than 2500 g, with significantly more LBW babies in the IVF and ICSI group compared to the SCS newborns.

INTERPRETATION

Taking into account the small series, PTB and LBW rates in SCS singletons were found to be comparable with singletons born after natural conception. Compared to babies born after ovarian stimulation and IVF/ICSI, SCS singletons had a lower PTB and LBW rates, although the differences were not significant for PTB. Our results confirm previous reports on reassuring perinatal outcomes after using the SCS technology.

Inequities in Medically Assisted Reproduction: a Scoping Review

Infertility has a high prevalence in the USA and health inequities play a large role in access to medically assisted reproduction (MAR). The aim of this study was to identify gaps in research pertaining to inequities in MAR and propose suggestions for future research directions. Searches were performed using MEDLINE and Ovid Embase. Articles that reported on MAR inequities, published between 2016 and 2021 in the USA, and written in English were included. The inequities investigated were adapted from the NIH-designated health disparities populations. Each article's inequity findings were extracted and reported, along with frequencies of inequities. Our sample included 66 studies. The majority of the studies investigated MAR outcomes by race/ethnicity and found that historically marginalized populations had poorer outcomes. LGBTQ + populations were less likely to use MAR or seek infertility care. Most studies found positive correlations with MAR use with income and education. The least commonly studied inequities in our sample were sex and/or gender and rural/under-resourced populations; findings showed that men and people from rural/under-resourced populations were less likely to access MAR. Studies that examined occupational status had varying findings. We suggest that future research be targeted toward: (1) standardizing and diversifying race/ethnicity reporting regarding MAR, (2) the use of community-based participatory research to increase data for LGBTQ + patients, and (3) increasing access to infertility care for men.

Promising Perinatal Outcome after Using a Simplified Low-Cost IVF Culture System Specifically Designed for Resource-Poor Countries

Background: Assisted reproductive techniques services are often not accessible to the majority of infertile couples in Low and Middle Income Countries (LMIC) due to high costs. Lowering IVF laboratory costs is a crucial step to make IVF affordable for a larger part of the world population. We developed a simplified culture system (SCS) which has proven to be effective, and the next step is to prove its safety.Methods: Preterm birth (PTB) and low birthweight (LBW) of 176 singletons born after using the SCS, 105 after fresh embryo transfer (fresh ET), and 71 after frozen embryo transfer (frozen ET) were compared with all IVF/ICSI singletons born in Belgium between 2013 and 2018. When comparing our 105 SCS babies born after fresh ET with all Belgian babies born after conventional IVF only, we also adjusted for 7 risk factors known to influence perinatal outcome, namelythe mother’s age, day of transfer, pituitary inhibition protocol, rank of cycles, number of oocytes retrieved, number of embryos transferred, and gender of the baby.Findings: Before adjustment, we found a significantly higher PTB (10.2% vs. 3.8%, OR 2.852, 95% CI [1.042–7.803], p-value 0.0413) and LBW (9.8% vs. 2.9%, OR 3.692, 95% CI [1.163–11.721], p-value 0.0267) in the conventional IVF group versus SCS after fresh ET. After adjusting for seven risk parameters, these differences remained significant (PTB: OR 2.627, 95% CI [1.013–6.816], p-value 0.0471) and LBW: OR 3.267, 95% CI [1.118–9.549], p-value 0.0305). PTB and LBW between both groups was not significantly different for singletons born after frozen ET. Interpretation: Taking into account the small series, PTB and LBW rates in SCS singletons in FRET cycles are very reassuring and significantly lower compared to babies born after conventional IVF in Belgium. Being aware of its effectiveness, our results offer a good perspective for SCS to become an important tool to implement low-cost IVF in LMIC.

Access to Fertility Care in Geographically Underserved Populations, a Second Look

Infertility has a prevalence of up to 16% worldwide and is on the rise in developed nations, largely due to pursuing childbearing at advanced reproductive ages. Advances in assisted reproductive technology have benefitted socioeconomically advantaged patients disproportionately. High costs of fertility care are largely responsible for this disparity; however, patients in rural areas also face barriers in accessing both gynecology and reproductive endocrinology subspecialty care. Here, focusing on the USA, we discuss fertility care in geographically underserved areas and low-resource settings, and the impact on reproductive outcomes. Increased innovation to improve patient access to fertility care such as assisted reproductive technology is critical for ensuring equity. Remote monitoring is frequently performed by fertility centers, but partnership with local gynecologists has also been demonstrated to be an effective assisted reproductive technology monitoring method. Telehealth is now in mainstream use and the continued application to reduce geographic barriers to infertility patients is imperative. Partnership between local gynecologists and reproductive endocrinology and infertility specialists may improve patient access to fertility care and provide the unique benefits of continuity and ongoing local social support.

Perinatal outcome of babies born after using a simplified IVF culture system versus ICSI with sibling oocytes: a prospective cohort study

RESEARCH QUESTION

Is there a difference in perinatal outcome in the same patient cohort for babies conceived following randomization of sibling oocytes allocated to a simplified IVF culture system (SCS) or intracytoplasmic sperm injection (ICSI) followed by conventional culturing?

DESIGN

The study compared the perinatal outcomes of 367 babies born from 1 January 2013 until 31 December 2020 after using split SCS and ICSI insemination of sibling oocytes in a selected group of normo-responsive women, excluding cases of severe male infertility. Primary outcome measures were preterm birth (PTB; <37 weeks' gestation), low birthweight (LBW; <2.5 kg) and small for gestational age (SGA) as a primary outcome parameter while secondary outcome measures included mean birthweight, mean gestational age, extreme prematurity (<32 weeks), very low birthweight (<1.5 kg), perinatal mortality, multiple pregnancy and Caesarean section rate.

RESULTS

A total of 105 and 103 singleton babies were born after fresh embryo transfer (FRET) and 71 and 50 singletons after frozen embryo transfer (FET) in the SCS and ICSI groups, respectively. For babies born after FRET, the LBW rate was 2.9% (3/105) for SCS and 7.8% (8/103) for ICSI (P = 0.10). LBW occurred in 4.2% (3/71) and 0% (0/50) of babies born after the transfer of cryopreserved-thawed SCS and ICSI embryos, respectively (P = 0.14). The rate of PTB was 3.8% and 6.8% for SCS and ICSI in FRET cycles (P = 0.33), and 8.5% and 6.0% for SCS and ICSI in FET cycles (P = 0.62). One congenital malformation was found in the SCS FET group.

CONCLUSION

There was no difference in perinatal outcome for singleton and twin babies born after SCS and ICSI.

Impact of governmental support to the IVF clinical pregnancy rates: differences between public and private clinical settings in Kazakhstan-a prospective cohort study

OBJECTIVES

Infertility rates have been increasing in low-income and middle-income countries, including Kazakhstan. The need for accessible and affordable assisted reproductive technologies has become essential for many subfertile women. We aimed to explore whether the public funding and clinical settings are independently associated with in vitro fertilisation (IVF) clinical pregnancy and to determine whether the relationship between IVF clinical pregnancy and clinical settings is modified by payment type.

DESIGN

A prospective cohort study.

SETTING

Three private and two public IVF clinics located in major cities.

PARTICIPANTS

Women aged ≥18 seeking first or repeated IVF treatment and agreed to complete a survey were included in the study. Demographical and previous medical history data were collected from a survey, while clinical data from medical records. The total response rate was 14%.

PRIMARY AND SECONDARY OUTCOME MEASURES

Clinical pregnancy was defined as a live intrauterine pregnancy identified by ultrasound scan at 8 gestational weeks. The outcome data were missing for 22% of women.

RESULTS

Out of 446 women in the study, 68.2% attended private clinics. Two-thirds of women attending public clinics and 13% of women attending private clinics were publicly funded. Private clinics retrieved, on average, a higher number of oocytes (11.5±8.4 vs 8.1±7.2, p<0.001) and transferred more embryos (2.2±2.5 vs 1.4±1.1, p<0.001) and had a statistically significantly higher pregnancy rate compared with public clinics (79.0% vs 29.7%, p<0.001). Publicly funded women had on average a higher number of oocytes retrieved and a statistically significantly higher probability of clinical pregnancy (RR=1.23, 95% CI 1.02 to 1.47) than self-paid women, after adjusting for covariates. There was no statistically significant interaction between clinical setting and payment type.

CONCLUSIONS

Private clinics and public funding were independently associated with higher IVF clinical pregnancy rates. There is also a need to further investigate whether the increase in public funding will influence clinical pregnancy rates.

'With the kanyaleng and the help of god, you don't feel ashamed': women experiencing infertility in Casamance, Senegal

While the precarious situation of women with infertility in Sub-Saharan Africa is well documented, little is known about the ways in which such women show agency despite the challenges that infertility brings to their lives. This study provided a holistic understanding of the experiences of women with infertility living in a rural community in Casamance (Senegal), drawing attention towards both suffering as well as agency. Qualitative research methods were used, triangulating life-story interviews, participant observation and informal conversations. Findings showed that all women with infertility experienced emotional challenges. These emotional challenges were intertwined with social stigmatisation and troubled relationships with their families-in-law and within their marriages. However, women with infertility were not passive victims in these circumstances. The study identified several strategies used by women to cope with the challenges of infertility, including organising in kanyaleng groups, treatment seeking, fosterage, looking for religious and social support, becoming (financially) independent, avoidance and ignorance. These findings highlight the complexity of agency within a context of structural violence. Concrete measures to improve the lives of women with infertility should acknowledge the agency of women with infertility and involve such women while developing multi-component approaches addressing inequalities.

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.

Men and infertility in The Gambia: Limited biomedical knowledge and awareness discourage male involvement and exacerbate gender-based impacts of infertility

Introduction

Infertility in Sub-Saharan Africa constitutes an important social and public health problem. Yet, there is a paucity of research on the experiences of men living with infertility, especially in West Africa. This study explored men’s aetiological knowledge, views and experiences of infertility in the West Coast region of The Gambia, West Africa.

Methodology

An explorative qualitative study was conducted among men living in the rural and urban communities of the West Coast region of The Gambia using in-depth interviews. Data collection and analysis were performed concurrently, and thematic data analysis was an iterative process carried out using NVivo 11 Analysis Software.

Results

Gambian men had generally poor knowledge of infertility, allocating it to God, spiritual powers and bodily (biomedical) factors. While societal norms meant that infertility was generally attributed to women, some men allocated male-factor infertility to poor sperm quality and impotence. Infertility threatened participants’ sense of masculinity and resulted in psychosocial distress, including stigma, feelings of isolation, and low self-esteem.

Conclusion

Normative gendered frameworks of infertility result in high levels of female responsibilisation in the Gambian context. Yet men diagnosed with infertility experience significant, often unrecognized, psychological and social distress. We therefore call for increased attention to male-factor infertility, and the promotion of male engagement with infertility-care and services, both of which are essential for successfully addressing infertility and it’s psychosocial consequences in The Gambia.

Disparities in access to effective treatment for infertility in the United States: an Ethics Committee opinion

In the United States, economic, racial, ethnic, geographic, and other disparities prevent access to fertility treatment and affect treatment outcomes. This opinion examines the factors that contribute to these disparities, proposes actions to address them, and replaces the document of the same name, last published in 2015.

Infertility, Perceived Certainty of Pregnancy, and Contraceptive Use in Malawi

Infertility and unintended pregnancy are dual burdens in Malawi, where 41% of pregnancies are unintended and approximately 20% of people report infertility. Although preventing unintended pregnancy has been a focus in public health, infertility has rarely been explored as a factor that may be associated with contraceptive use. Using cross-sectional survey data (2017-2018; N = 749), we report on the prevalence of and sociodemographic characteristics associated with infertility and certainty of becoming pregnant among women in Malawi. We conducted multivariable logistic regressions examining the relationship between infertility, certainty of becoming pregnant, and contraceptive use. Approximately 16% of women experienced infertility, and three-quarters (78%) were certain they could become pregnant within one year. Women who experienced infertility had lower odds of contraceptive use than women who did not (Adjusted Odds Ratio [AOR]: 0.56; 95% Conficence Interval [CI]: 0.39-0.83). Women who said there was "no chance" or they were "unlikely" to become pregnant also had lower odds of contraceptive use compared to women who were certain they would become pregnant (AOR: 0.30; 95% CI: 0.10-0.92). Our findings indicate that experiences and perceptions surrounding fertility are associated with contraceptive use, underscoring their importance in understanding how people manage their fertility to reach their reproductive goals.

The Nairobi Summit and Reproductive Justice: Unmet Needs for People with Infertility

The Nairobi Summit, held in November 2019 and convened by the United Nations Fund for Population Activities, claims to have represented "all nations and peoples, and all segments" of society during its high-level conference. The overall aim of the summit was to mobilize political will and financial commitments that are urgently needed to "finally and fully" implement the 1994 International Conference on Population and Development (ICPD) Program of Action. Despite the recommendation by ICPD to incorporate infertility care in reproductive health services, the new Nairobi Statement largely neglects the topic of infertility. This is particularly troublesome as infertility is a global health problem affecting between 52.6 and 72.4 million couples worldwide, with a high prevalence in low- and middle-income settings. For many people around the world, infertility constitutes an emotional, social, and financial burden, yet appropriate services directed toward preventing and addressing infertility are often inaccessible, unaffordable, or nonexistent. With the impetus of a wider reproductive justice community, we call for the integration of infertility into global reproductive health research and practice, urging policy makers, practitioners, researchers, activists, and funders worldwide to bring focused attention to addressing challenges posed by a lack of safe, effective, and dignified fertility management among those in need.

Access to infertility care in a low-resource setting: bridging the gap through resident and fellow education in a New York City public hospital

PURPOSE

Improving access to care is an issue at the forefront of reproductive medicine. We sought to describe how one academic center, set in the background of a large and diverse metropolitan city, cares for patients with extremely limited access to reproductive specialists.

METHODS

The NYU Reproductive Endocrinology and Infertility (REI) Fellowship program provides a "fellow-run clinic" within Manhattan's Bellevue Hospital Center, which is led by the REI fellows and supervised by the REI attendings of the NYU Langone Health system. A description of the history of the hospital as well as the logistics of the fertility clinic is provided as a logistical template for implementation.

RESULTS

The fellow-run fertility clinic at Bellevue hospital is held on two half days per month seeing approximately 150 new patients per year. The fertility workup, counseling, surgery, as well as ovulation induction, and early pregnancy management are offered within the construct of the fellowship and residency at NYU. Barriers to care and ways to circumvent those barriers are discussed in detail.

CONCLUSION

By utilizing the ambition and construct of the OB/GYN programs, we greatly improve care for an otherwise underserved patient population by offering an efficient and optimal infertility workup and treatment in a population that would otherwise be without care. We utilize the framework of graduate medical education to provide autonomy, experience, and mentorship to both residents and fellows in our programs in an effort to provide a solution to combating inequity in infertility care.

Progesterone induced blocking factor (PIBF) taken in early pregnancy predicts the pregnancy outcome in women undergoing in vitro fertilization procedure

Earlier data suggest a relationship between PIBF concentrations and the outcome of pregnancy. The aim of the study was to compare serum and urine concentrations of PIBF in women with successful pregnancy after IVF with those of women without pregnancy after IVF procedure, and to evaluate the potential relation between PIBF and the outcome of pregnancy. Urine and serum were collected from 120 women, undergoing IVF. 87.5% of patients had primary infertility. 69.2% faced female causes of infertility: 10.8% tubal cause, 11.7% ovulation disorder, and 46.7% other causes of infertility. 30.8% of patients had male factor of infertility. Among non-pregnant women (42) mean concentrations of PIBF in urine and serum were significantly lower (15.8 ng/mL; 148.4 ng/mL) than in women with positive beta HCG value (78) (19.1 ng/mL; 225.9 ng/mL). In 49 patients pregnancy terminated with a term delivery, in 10 patients with pretem delivery, while in 19 patients the pregnancy terminated with a miscarriage. PIBF concentrations in urine (13.9 ± 2.8 ng/mL) and serum (124.6 ± 46.7 ng/mL) samples of women with miscarriage were significantly lower of those with preterm delivery (180.6 ± 54.4 ng/mL; 18.1 ± 4.4 ng/mL) and of those with term delivery (20.4 ± 8.5 ng/mL; 208.7 ± 114.3 ng/mL). Successful pregnancy after IVF procedure is predictable by measuring of urine and serum PIBF concentrations and could be important for predicting of early implantation and pregnancy outcome after IVF procedure and maybe to protect the risk pregnancy.

Access to Infertility Consultations “What Women Tell Us About it”?

Background:

Infertility has been considered as a serious public health problem. Nevertheless, it is still very difficult to assess the epidemiology of this individual and public health problem. On the other hand, promotion of access to infertility treatments must be treated as a priority to national and regional policies.

Objective:

The aim was to evaluate the perception of women concerning the barriers and access to infertility consultations.

Methods:

Socio cultural and economic access to infertility consultations is detached and three municipalities of the northwest of Portugal were chosen as an example of a peripheral country. A quantitative/qualitative study was done with 60 women.

Results:

Three dimensions were evaluated: geographic and structural and functional access, economic access and sociocultural access. The main barriers were mainly identified in the last two dimensions. The economic access was less well evaluated by women bearing the cost of treatment (medication, and concentration of costs in a short period) which is difficult to bear.

Conclusion:

This can justify a greater involvement of the Portuguese Government, by developing policies for the reimbursement of part of the costs. Also, some changes in structural and functional access must be done with special regard to the separation of the infertility consultations from the reproductive medicine section. The setting of the teams, with a follow-up by the same team of health professionals is also needed.

Improving access to ART in low-income settings through knowledge transfer: a case study from Zimbabwe

It may be assumed that infertility is not a problem in resource-poor areas where fertility rates are high. However, evidence overwhelmingly shows that childlessness is highly stigmatized in these settings and that women who are unable to bear children suffer significant social and psychological consequences. The World Health Organization has recommended that infertility be considered a global health problem and stated the need for ART to be adapted to low-resource settings. This paper describes a model for improving access to ART in low-resource settings. Experienced ART health professionals from Australia and Italy representing medical science, embryology, nursing and counselling used knowledge transfer to support a clinician, a laboratory scientist and a nurse to establish an ART service in Harare, Zimbabwe. Support and mentorship provided between October 2016 and December 2017 included: hosting the clinician and the embryologist for the new service in established ART clinics for short periods and providing them with dedicated mentorship and training during their stay; funding an experienced embryologist to travel to Zimbabwe (three times) to oversee the setting up of the lab and provide hands-on embryology training; funding a scientist and a nurse to travel to Zimbabwe to troubleshoot and establish protocols for record keeping and psychosocial care; and contributing approximately AUD $15,000 to the purchase of some equipment. By 31 March 2018, the team at IVF Zimbabwe had performed 166 ART procedures, which at time of writing had resulted in 16 births and 4 ongoing pregnancies. This case study demonstrates that with mentorship and modest financial support from ART experts from high-income settings, health professionals in low-income settings can deliver affordable ART with successful outcomes.

Long noncoding RNA growth arrest-specific 5 promotes proliferation and survival of female germline stem cells in vitro

Female germline stem cells (FGSCs) are proposed to be a key factor for ameliorating female infertility. Previously we have shown that neonatal and adult FGSCs could be isolated and purified from mouse ovarian tissues. The long noncoding (lnc) RNA growth arrest-specific 5 sequence (GAS5) transcribed from mammalian genomes plays important regulatory roles in various developmental processes. However, there is no study on the relationship between GAS5 and FGSC development in vitro. In this study, we showed that GAS5 was highly expressed in the neonatal mouse ovary and was located in both FGSCs and oocytes. GAS5 facilitated FGSC proliferation and promoted their survival in vitro. Moreover, GAS5 also inhibited apoptosis of cultured FGSCs. These findings indicate that GAS5 is a crucial regulator of FGSC development. This might serve as a foundation for a strategy of lncRNA-directed diagnosis or treatment of female infertility.

Assisted reproductive technologies in Ghana: transnational undertakings, local practices and 'more affordable' IVF

The article sketches the origins and development of IVF in Ghana as a highly transnational undertaking. Movements are from and to Africa, involving human beings (providers and users), and also refer to other entities such as technologies, skills and knowledge. None of these movements are paid for using public money, neither are they subsidized by international health organizations. Currently, 'more affordable' IVF is being introduced into Ghana, on initiative of the first Association of Childless Couples of Ghana (ACCOG), in collaboration with the Belgium based non-profit organization the Walking Egg (tWE), representing another form of transnational networking. The article underlines the scarcity of well-trained embryologists in Ghana, which turns the embryologists' expertise and skills into a scarce and precious commodity and guarantees this expertise becomes a major challenge for the directors of the private clinics. Next to local Ghanaian couples, the clinics also attend to transnational reproductive travellers, including women and men from neighbouring countries and Ghanaians in the diaspora returning to their country of origin. Their manifold motivations to cross borders and visit the IVF clinics in Ghana provide insight into the structural conditions impeding or facilitating the use of assisted reproductive technologies at different local sites. Transnational movements also include the flow of new procreation practices (such as surrogacy and the use of donor material), which (re-)shape existing cultural and societal notions regarding kinship and the importance of blood/genetic ties. Finally, the article lists a number of thematic and theoretical issues which require further exploration and studies.

Infertility around the globe: new thinking on gender, reproductive technologies and global movements in the 21st century

BACKGROUND

Infertility is estimated to affect as many as 186 million people worldwide. Although male infertility contributes to more than half of all cases of global childlessness, infertility remains a woman's social burden. Unfortunately, areas of the world with the highest rates of infertility are often those with poor access to assisted reproductive techniques (ARTs). In such settings, women may be abandoned to their childless destinies. However, emerging data suggest that making ART accessible and affordable is an important gender intervention. To that end, this article presents an overview of what we know about global infertility, ART and changing gender relations, posing five key questions: (i) why is infertility an ongoing global reproductive health problem? (ii) What are the gender effects of infertility, and are they changing over time? (iii) What do we know about the globalization of ART to resource-poor settings? (iv) How are new global initiatives attempting to improve access to IVF? (v) Finally, what can be done to overcome infertility, help the infertile and enhance low-cost IVF (LCIVF) activism?

METHODS

An exhaustive literature review using MEDLINE, Google Scholar and the keyword search function provided through the Yale University Library (i.e. which scans multiple databases simultaneously) identified 103 peer-reviewed journal articles and 37 monographs, chapters and reports from the years 2000-2014 in the areas of: (i) infertility demography, (ii) ART in low-resource settings, (iii) gender and infertility in low-resource settings and (iv) the rise of LCIVF initiatives. International Federation of Fertility Societies Surveillance reports were particularly helpful in identifying important global trends in IVF clinic distribution between 2002 and 2010. Additionally, a series of articles published by scholars who are tracking global cross-border reproductive care (CBRC) trends, as well as others who are involved in the growing LCIVF movement, were invaluable.

RESULTS

Recent global demographic surveys indicate that infertility remains an ongoing reproductive problem, with six key demographic features. Despite the massive global expansion of ART services over the past decade (2005-2015), ART remains inaccessible in many parts of the world, particularly in sub-Saharan Africa, where IVF clinics are still absent in most countries. For women living in such ART-poor settings, the gender effects of infertility may be devastating. In contrast, in ART-rich regions such as the Middle East, the negative gender effects of infertility are diminishing over time, especially with state subsidization of ART. Furthermore, men are increasingly acknowledging their male infertility and seeking ICSI. Thus, access to ART may ameliorate gender discrimination, especially in the Global South. To that end, a number of clinician-led, LCIVF initiatives are in development to provide affordable ART, particularly in Africa. Without access to LCIVF, many infertile couples must incur catastrophic expenditures to fund their IVF, or engage in CBRC to seek lower-cost IVF elsewhere.

CONCLUSIONS

Given the present realities, three future directions for research and intervention are suggested: (i) address the preventable causes of infertility, (ii) provide support and alternatives for the infertile and (iii) encourage new LCIVF initiatives to improve availability, affordability and acceptability of ART around the globe.

Assisted reproduction: Ethical and legal issues

Since inception, the use of assisted reproductive technologies (ART) has been accompanied by ethical, legal, and societal controversies. Guidelines have been developed to address many of these concerns; however, the rapid evolution of ART requires their frequent re-evaluation. We review the literature on ethical and legal aspects of ART, highlighting some of the most visible and challenging topics. Of specific interest are: reporting of ART procedures and outcomes; accessibility to ART procedures; issues related to fertility preservation, preimplantation genetic testing, gamete and embryo donation, and reproductive outcomes after embryo transfer. Improvements in ART reporting are needed nationally and worldwide. Reporting should include outcomes that enable patients to make informed decisions. Improving access to ART and optimizing long-term reproductive outcomes, while taking into account the legal and ethical consequences, are challenges that need to be addressed by the entire community of individuals involved in ART with the assistance of bioethicists, legal counselors, and members of society in general.

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.

Coping with infertility: a transcultural perspective

PURPOSE OF REVIEW

To review the most important and interesting articles in infertility published in the last year.

RECENT FINDINGS

This systematic review covers 60 studies published in journals or dissertations in Science Direct and PubMed in the last year, including those related to prevention and treatment as well as related psychosocial services in infertility. We also propose some suggestions about coping with infertility in China.

SUMMARY

Infertility is a multidisciplinary problem that requires medical, social, and political efforts to prevent and offer infertile patients the best diagnostic, therapeutic, and psychosocial services. Cultural factors should be taken into consideration when designing coping strategies.

Low-cost in vitro fertilization: current insights

Despite the development of in vitro fertilization (IVF) more than 30 years ago, the cost of treatment remains high. Furthermore, over the years, more sophisticated technologies and expensive medications have been introduced, making IVF increasingly inaccessible despite the increasing need. Globally, the option to undergo IVF is only available to a privileged few. In recent years, there has been growing interest in exploring strategies to reduce the cost of IVF treatment, which would allow the service to be provided in low-resource settings. In this review, we explore the various ways in which the cost of this treatment can be reduced.

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.