'You cannot do IVF in Africa as in Europe': the making of IVF in Mali and Uganda

Awareness and acceptability of assisted reproductive technology among non-medical tertiary students in a low-resource setting

BACKGROUND

Assisted Reproductive Techniques (ART) have significantly advanced infertility treatment worldwide. However their availability and use in sub-Saharan Africa, remains limited although infertility is highly prevalent, with significant psycho-social challenges including stigma. This study assessed the awareness, attitudes, and perceptions of ART among non-medical tertiary students in Ghana.

METHOD

A cross-sectional study was conducted among non-medical students in tertiary institutions in Ghana. Pre-tested questionnaires were administered to both post-graduate and undergraduate students after obtaining informed consent. Ethical approval was obtained from the Review Board at Community Health Department of the University of Ghana Medical School. The data collected was analyzed using SPSS (version-27) and the results presented using frequency tables, graphs, and charts. significance was P-value below 0.05 was considered statistically significant.

RESULTS

Overall, 196 participants from the two largest universities and other tertiary institutions in Ghana took part in this study. Majority (63.5%) of respondents demonstrated awareness on ART services, but 60.3% showed poor knowledge of the types of ART. Males generally exhibited lower knowledge of ART services compared to females, and knowledge of ART services showed an inverse relationship with age. In-vitro fertilization (IVF) was the most widely recognized and recommended ART technique, known by 65.1% of respondents who were aware of the types of ART. Most participants expressed reluctance to accept or recommend gamete donation due to religious reasons, fear of complications, and a preference for conventional means of procreation.

CONCLUSION

The majority of tertiary students in Ghana are aware of ART for infertility treatment however, many are hesitant toward donor-gamete treatment protocols. Fear of complications and related costs pose major barriers to considering ART among the respondents. Participants unanimously suggested government subsidies and the inclusion of ART under the national health insurance coverage package.

Delayed time to pregnancy and associated factors among pregnant women attending antenatal care in bale zone administrative towns health facilities: multi-center cross-sectional study

BACKGROUND

The desire to conceive and become parents is a fundamental aspect of human life that carries immense personal, emotional, and societal significance. For many couples, achieving pregnancy represents a long-cherished dream, but the journey to parenthood is not always straightforward. The duration it takes to achieve the desired pregnancy can vary significantly among individuals and is influenced by many factors. This study explores the factors that influence the delayed time of pregnancy among women with naturally planned conception.

METHODS

An institutional-based cross-sectional study was conducted from May 1 to May 30, 2023, in public health facilities of Bale Zone administrative towns, Southeast Ethiopia. Using systematic random sampling, 388 women participated in the study and a pretested questionnaire was used to collect data. Bivariate logistic regression was done, and variables with p-values < 0.25 were exported to multivariable logistic regression, and a statistically significant association was declared at p-value < 0.05.

RESULTS

The study revealed delayed time to pregnancy was 18.6% with 95% (CI = 14.67-22.44%). Women's age ≥ 35, (AOR = 2.61; 95%, CI: 1.17-5.82), menstrual irregularity (AOR = 3.79; 95% CI: 1.98-7.25), and frequency of sexual intercourse/week (AOR = 2.15; 95% CI: 1.05-4.41) and women's sexual dysfunction before conception (AOR = 3.12, 95% CI: 1.62-6.01) were significantly associated factors with delayed time to pregnancy at p-value < 0.05.

CONCLUSION

The study revealed a substantial proportion of delayed time to pregnancy. This delayed time to pregnancy was associated with older maternal age, irregular menstrual cycles, coital activity per week, and the women's sexual dysfunction before pregnancy. Consequently, addressing delayed time to pregnancy requires a targeted approach, prioritizing initiatives such as raising awareness, fostering increased frequency of sexual activity per week, exploring interventions for women with irregular menstrual patterns, and challenges related to sexual dysfunction.

Care-seeking for difficulties conceiving in sub-Saharan Africa: findings from population-based surveys in eight geographies

STUDY QUESTION

What is the nature of women's care-seeking for difficulties conceiving in sub-Saharan Africa (SSA), including the correlates of seeking biomedical infertility care at a health facility?

SUMMARY ANSWER

Care-seeking for difficulties getting pregnant was low, much of which involved traditional or religious sources of care, with evidence of sociodemographic disparities in receipt of biomedical care.

WHAT IS KNOWN ALREADY

Nearly all research on infertility care-seeking patterns in SSA is limited to clinic-based studies among the minority of people in these settings who obtain facility-based services. In the absence of population-based data on infertility care-seeking, we are unable to determine the demand for services and disparities in the use of more effective biomedical sources of care.

STUDY DESIGN, SIZE, DURATION

We used cross-sectional, population-based data from the Performance Monitoring for Action (PMA) female survey in eight geographies in SSA, including nationally representative data from Burkina Faso, Côte d'Ivoire, Kenya, and Uganda and regionally representative data from two provinces in the Democratic Republic of the Congo (DRC) (Kinshasa and Kongo Central) and two states in Nigeria (Kano and Lagos). We employed a multi-stage cluster random sampling design with probability proportional to size selection of clusters within each geography to produce representative samples of women aged 15-49. Samples ranged from 1144 in Kano, Nigeria, to 9489 in Kenya. PMA collected these data between November 2021 and December 2022.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We restricted the sample to women who had ever had sex, with analytic samples ranging from 854 in Kano to 8,059 in Kenya, then conducted descriptive and bivariable analyses to examine characteristics of those who sought care for difficulties getting pregnant. Among those who reported seeking care, we conducted bivariable and multivariable logistic regression analyses to determine factors associated with receipt of biomedical services from a health facility. All analyses were conducted separately by geography.

MAIN RESULTS AND THE ROLE OF CHANCE

Our study found low levels of care-seeking for difficulties getting pregnant among sexually active women in eight geographies in SSA, ranging from 3.7% (Kenya) to 15.3% (Côte d'Ivoire). Of this, 51.8% (Burkina Faso) to 86.7% (Kinshasa) involved receipt of biomedical services in health facilities. While many factors were consistently associated with infertility care-seeking from any source across geographies, factors associated with receipt of biomedical care specifically were less pronounced. This may be a result of the highly limited sources of infertility services in SSA; thus, even privileged groups may struggle to obtain effective treatment for difficulties getting pregnant. However, we did observe disparities in biomedical care-seeking in our bivariable results in several geographies, with the wealthiest women, those with more education, and those residing in urban areas generally more likely to have sought biomedical care for difficulties getting pregnant.

LIMITATIONS, REASONS FOR CAUTION

Our data lacked details on the nature of the services received and outcomes, and we do not have information on reasons why women chose the sources they did. Small samples of women who sought care limited our power to detect significant differences in care-seeking by women's characteristics in several geographies.

WIDER IMPLICATIONS OF THE FINDINGS

Infertility and access to appropriate treatment are issues of reproductive health and human rights. While our results do not indicate to what extent use of non-biomedical sources of care is driven by preferences, cost, or lack of accessible services, it is clear from our results and existing literature that more needs to be done to ensure access to affordable, quality, cost-effective infertility services in SSA.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by grants from the Bill & Melinda Gates Foundation (INV009639) and the National Institute of Child Health and Human Development (K01HD107172). The funders were not involved in the study design, analyses, manuscript writing, or the decision to publish. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Chains of extraction: shifting bioeconomies in India and East Africa

Since the early 2000s, India has been a world leading hub for cross border reproductive treatments, in particular surrogacy, with the nation positioning itself as the "mother destination" for transnational commercial surrogacy, offering "First world services at Third world prices". State policies, lack of legal regulation, state of the art medical infrastructure and a steady supply of women ready to take on the role as surrogate mothers against meager remuneration have been key factors behind the Indian success story. Yet, a gradual process of regulation in recent years, culminating in the introduction of the Surrogacy (Regulation) Bill 2020, has forced the industry to reinvent itself in order to maintain its role as a market leader in a booming global bioeconomy. This article takes the 2020 bill as a starting point for an exploration of the key trajectories that the Indian reproductive industry has taken since. This includes moving into new market segments, such as the unregulated practice of oocyte donation, and expanding globally into new geo-political contexts. Through these practices, India has successfully rebranded itself as a world leading "pre-conception assemblage hub" where embryos are assembled and implanted into surrogates who carry their pregnancies to term in countries with no protective legislation. The article begins to map the emerging links between the reproductive industry in India and East Africa - where diasporic networks are mobilized in the creation of new reproductive markets, dominated by Indian IVF providers. In particular, we discuss the current expansion in Kenya, which we situate against the backdrop of the colonial entanglements between the two countries. While the ART industry in Kenya is still young, we suggest that these emerging developments illuminate the effect of the ban on commercial surrogacy in India, which appears to have resulted in a partial relocation to countries that lack regulation, shifting the precarious conditions of surrogates in India to other women, elsewhere, in ways that rearticulate colonial racial hierarchies and migration patterns.

Opening the first and only public in vitro fertilization (IVF) center in sub-Saharan Africa: The experience of Ethiopia

Opening public in vitro fertilization (IVF) center in low‐income countries is feasible and sustainable.

Exploring Muslim Communities' Experiences and Barriers While Accessing Assisted Reproductive Technologies: A Scoping Review of International Literature

This study adopted a scoping review methodology to analyze international literature on the barriers impacting Muslim couples' access to equitable assisted reproductive technologies (ART). A total of 27 studies were included for review. Results show that Muslim communities face several barriers when accessing ART. These include cultural and religious barriers that impacted which aspects of ART couples were open to adopting, diminished quality of care due to low cultural/religious capacity of practitioners, as well as gendered norms which intersect with experiences of ART treatments. Further research, based in western countries, should be conducted to better understand how these contexts can support Muslim patients accessing ART.

'It's about time': policymakers' and health practitioners' perspectives on implementing fertility care in the Gambian health system

BACKGROUND

Infertility is a major health issue worldwide, yet very few examples of interventions addressing infertility in the Global South have been documented to date. In The Gambia, West Africa, infertility is recognised as a burden and the health authorities have included it in several health policies and the new National Reproductive Health Strategy however, a detailed operationalisation plan for fertility care has not yet been established. Here, we aim to understand and document the factors that influence the implementation of fertility care in The Gambia.

METHODS

We conducted 46 semi-structured interviews with policymakers, implementers, and health practitioners in both the public and private sectors from July to November 2021. The interviews were transcribed, anonymised and analysed with NVivo Pro version 1.6.1. The analysis was initially inductive, with themes arising from the coding categorised according to the WHO health systems building blocks framework.

RESULTS

This study identified several barriers to a successful implementation of fertility care in The Gambia, including (i) a lack of routinely collected infertility data; (ii) an absence of financial protection mechanisms for patients, and/or a specific budget for infertility; (iii) limited cooperation between the public and private sectors in the provision of fertility care; and (iv) gaps in fertility care training among health practitioners. Conversely, enablers included: (i) strong national infertility leadership; and (ii) the integration of infertility care within public reproductive health services.

CONCLUSION

The Gambian health system is not yet in the position to support a comprehensive fertility care package in its public health facilities. Several aspects of the implementation of fertility care must be considered in operationalising the health strategy including the systematic collection of infertility data, fertility awareness, and the provision of specialised fertility care training. Furthermore, a stronger partnership between the public and private sectors must be developed. Given the increasing availability of assisted reproductive technologies in the sub-Saharan Africa region, and the tendency to locate these technologies in the private sector, further research is needed to understand and identify the processes underlying the implementation of fertility care and to foster better integration with the existing health system.

[Some present and future ethical dilemmas surrounding advancements in in vitro fertilization.]

The growing field of assisted human reproduction has achieved unimaginable milestones. Its continuous development and the innovations it generates at times pose both ethical and legal dilemmas. This essay aims to elucidate the progressive changes occurring in the realm of the origin of life due to the development of new options and strategies in assisted human reproduction. First, it constructs an interdisciplinary reflection on human nature and the changes society faces from the perspectives of science, ethics, and law, particularly from the perspective of Spain. Second, it provides a brief overview of current or future biomedical techniques in the field of human reproduction. It concludes with a discussion of the need to reflect on the rapid advancement of science in assisted human reproduction.

Availability of services for the diagnosis and treatment of infertility in The Gambia`s public and private health facilities: a cross-sectional survey

Background

Infertility is a long-standing reproductive health issue, which affects both men and women worldwide and it is especially problematic in the Global South. In sub-Saharan Africa, understanding the current availability of diagnostic and treatment services for infertility is important because this could guide health systems to improve access to fertility care for all. Yet, few studies have explicitly started from a health system perspective to grasp the availability and integration of infertility services in sub-Saharan Africa. This quantitative study, the first in The Gambia, West Africa, examines the availability of infertility services in public and private facilities as part of a wider endeavour to improve fertility care policy and practice in the country.

Methods

A cross-sectional survey using Qualtrics was administered to 38 health facilities. The survey was carried out between March and August 2021 and involved closed-ended questions. Data analysis consisted of descriptive statistics and t-tests performed using SPSS version 26.

Results

A total of 25 facilities (66%) offered infertility services, of which 13 (52%) were public and 12 (47%) private. Although the availability of screening tests was similar between health institutions, most diagnostic and treatment services were available only in the private sector. Treatment services included: (i) ovarian stimulation (n = 16, 42%); (ii) reversal of tubal ligation and/or blockage (tuboplasty) (n = 4, 11%); and (iii) intrauterine insemination (n = 3, 8%). Assisted reproductive technologies such as IVF and ICSI were not available in public or private sectors. The Gambian health management information system lacked a dedicated space to capture data on infertility. Reported barriers to integration of infertility services in existing reproductive health services included a lack of specialised training, an absence of national guidance on infertility management, and a shortage of appropriate equipment, supplies, and medication.

Conclusions

The availability of infertility services in The Gambia follows a trajectory that is similar to other SSA countries in which services are mostly obtainable through the private sector. Yet, access to private care is expensive and geographically restricted, which exacerbates inequalities in accessing fertility care for all. Improving the provision of infertility services in the public sector requires systematically capturing data on infertility and investing in the provision of a full-range fertility care package.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08514-0.

The Ethical Standards of Sunni Muslim Physicians Regarding Fertility Technologies that are Religiously Forbidden

This research project is pioneering in that it is the first to provide empirical data regarding the ethical standards of Sunni Muslim physicians toward religiously prohibited reproductive technologies, a topic which is considered taboo in Muslim society. A total of 689 Sunni Muslim physicians rated their acceptance of 14 fertility treatments. They expressed objections to assisted reproductive technologies entailing gender selection, egg, sperm and embryo donation, and surrogacy. The findings show that the Sunni Muslim medical establishment avoids fertility options that are considered in violation of Islamic law, and Sunni Muslim physicians tend to obey religious law.

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.

IVF and other ART in low- and middle-income countries: a systematic landscape analysis

BACKGROUND

Infertility affects 48.5 million couples worldwide with a prevalence estimated at 3.5-16.7% in low- and middle-income countries (LMIC), and as high as 30-40% in Sub-Saharan Africa. ART services are not accessible to the majority of these infertile couples due to the high cost of treatments in addition to cultural, religious and legal barriers. Infertility and childlessness, particularly in LMIC, have devastating consequences, which has resulted in considerable interest in developing affordable IVF procedures. However, there is a paucity of evidence on the safety, efficiency and ability to replicate techniques under different field conditions, and how to integrate more affordable ART options into existing infrastructures.

OBJECTIVE AND RATIONALE

This review was performed to investigate the current availability of IVF in LMIC and which other ART options are under development. This work will unfold the landscape of available and potential ART services in LMIC and is a key element in positioning infertility more broadly in the Global Public Health Agenda.

SEARCH METHODS

A systematic literature search was performed of articles and gray literature on IVF and other ART options in LMIC published between January 2010 and January 2020. We selected studies on IVF and other ART treatments for infertile couples of reproductive age (18-44 years) from LMIC. The review was limited to articles published after 2010, based on the recent evolution in the field of ART practices in LMIC over the last decade. Citations from high-income countries, including data prior to 2010 and focusing on specialized ART procedures, were excluded. The literature search included PubMed, Popline, CINHAL, EMBASE and Global Index Medicus. No restrictions were applied with regard to study design or language. Two reviewers independently screened the titles and abstracts, and extracted data. A search for gray literature was performed using the 'Google' search engine and specific databases (worldcat.org, greylit.org). In addition, the reference lists of included studies were assessed.

OUTCOMES

The search of the electronic databases yielded 3769 citations. After review of the titles and abstracts, 283 studies were included. The full texts were reviewed and a further 199 articles were excluded. The gray literature search yielded 586 citations, most of which were excluded after screening the title, and the remaining documents were excluded after full-text assessment due to duplicate entries, not from LMIC, not relevant or no access to the full document. Eighty-four citations were included as part of the review and separated into regions. The majority of the studies were observational and qualitative studies. In general, ART services are available and described in several LMIC, ranging from advanced techniques in China to basic introduction of IVF in some African countries. Efforts to provide affordable ART treatments are described in feasibility studies and efficacy studies; however, most citations were of low to very low quality. We found no studies from LMIC reporting the implementation of low-cost ART that is effective, accessible and affordable to most of those in need of the services.

WIDER IMPLICATIONS

The World Health Organization is in a unique position to provide much needed guidance for infertility management in LMIC. This review provides insight into the landscape of ART in LMIC in various regions worldwide, which will guide efforts to improve the availability, quality, accessibility and acceptability of biomedical infertility care, including ART in these countries.

Sub-fecundity and associated factors among mothers with natural planned conception attending antenatal care service in Arba Minch Health Facilities

Background

Fecundity is a physiological ability to have children. The inability to get the desired child which was commonly caused by the prolonged time to conceive due to unwanted non-conception period increased from time to time. As a result, many couples are developing psychological, social, and economic problems and unstable life. However, information on fecundity status is limited in Ethiopia context. Therefore, this study aimed to assess the proportion of sub-fecundity and associated factors in Ethiopia context.

Methods

A health institution based cross-sectional study was conducted in Arba Minch health facilities from March 25 to April 25, 2020. By using a systematic sampling method, 539 mothers were selected for the study. Structured questionnaire was used for data collection. A binary logistic regression model was used to identify factors associated with the sub-fecundity. Variables with p-value <0.25 in the bi-variable logistic regression analysis were interred and checked for association in a multivariable logistic regression model. The level of statistical significance was declared at p-value <0.05.

Result

The proportion of sub-fecundity was 17.8% with 95%CI (14.8%-21.3%). Mothers’ age ≥ 30 (AOR = 2.54, 95%CI; 1.18–5.48), partners’ age ≥ 35 (AOR = 2.20, 95%CI; 1.01–4.75), coffee consumption of ≥ 4 cups/day (AOR = 2.93, 95%CI; 1.14–7.53), menses irregularity (AOR = 3.79 95%CI; 2.01–7.14) and coital frequency of 1day/week (AOR = 3.65, 95%CI; 1.47–9.05) were significantly associated with the sub-fecundity.

Conclusion

This study found that a substantial proportion of mothers were sub-fecund. Factors that contributed to the sub-fecundity were pre-pregnancy; mothers’ age, partners’ age, coffee drinking of ≥ 4 cups/day, coital frequency of 1day/week, and menses irregularity. Thus, efforts to prevent sub-fecundity should focus on awareness creation as to plan to conceive at early age, reducing coffee consumption, increasing days of coital frequency per week, and investigating and treating mothers with irregular menses.

The fertile grounds of reproductive activism in The Gambia: A qualitative study of local key stakeholders' understandings and heterogeneous actions related to infertility

Introduction

While several studies have focussed on the experiences of women living with infertility, there is a paucity of information related to understandings, representations and actions of key stakeholders (i.e. organisations and individual actors involved in activities or professional care surrounding infertility) when it comes to infertility in Sub-Saharan Africa. This ethnographic study conducted in The Gambia, West Africa, focuses on how key stakeholders in the country understand infertility, and on their activities to improve the lives of people with infertility.

Methodology

This ethnographic study draws on primary and secondary data for thematic analysis. Primary qualitative data were collected using in-depth interviews, observations, informal conversations and group discussion with various stakeholders (i.e. health care providers and representatives of non-governmental, governmental and international organisations). Sources of secondary data included government and non-governmental reports and media outputs.

Results

Results illustrated that most key stakeholders had a good understanding of the cultural frameworks and social realities of women living with infertility, with less focus on, or awareness of, men’s experiences of infertility. We distinguished three different positions of these actors and organisations, first, the infertility supporters, i.e. those who despite political challenges and a lack of funding, initiated activities to raise awareness about the problems people with infertility are facing and aim to increase access to infertility services. The second are moderate supporters, i.e. those who recognise the problems infertility poses and whose organisations target some of the perceived causes of infertility (i.e. lack of health education and harmful cultural practices). A third group of neutral or moderate opponents consist mainly of formal health care providers who do not consider infertility a current priority, given many competing demands in the resource-constrained healthcare system.

Conclusion

While international donors still largely neglect the emotional and social implications of infertility in Sub-Saharan African countries, some local stakeholders are working to bring services closer to people with infertility. The efforts of these local stakeholders require support and integration, and should include engaging with different groups for widespread sensitisation to reduce stigma and promote attendance to health centres for reproductive health challenges.

Do à la carte menus serve infertility patients? The ethics and regulation of in vitro fertility add-ons

Add-on treatments are the new black. They are provided (most frequently, sold) to patients undergoing in vitro fertilization on the premise that they will improve the chances of having a baby. However, the regulation of add-ons is consistently minimal, meaning that they are introduced into routine practice before they have been shown to improve the live birth rate. Debate on the adequacy of this light-touch approach rages. Defenders argue that demands for a rigorous approval process are paternalistic, as this would delay access to promising treatments. Critics respond that promising treatments may turn out to have adverse effects on patients and their offspring, contradicting the clinician's responsibility to do no harm. Some add-ons, including earlier versions of preimplantation genetic testing for aneuploidy, might even reduce the live birth rate, raising the prospect of desperate patients paying more to worsen their chances. Informed consent represents a solution in principle, but in practice there is a clear tension between impartial information and direct-to-consumer advertising. Because the effects of a treatment cannot be known until it has been robustly evaluated, we argue that strong evidence should be required before add-ons are introduced to the clinic. In the meantime, there is an imperative to identify methods for communicating the associated risks and uncertainties of add-ons to prospective patients.

Review of 10 years of preimplantation genetic diagnosis in South Africa: implications for a low-to-middle-income country

PURPOSE

To evaluate the preimplantation genetic diagnosis (PGD) service, for the period of January 2006 to December 2016, through a South African academic and diagnostic Human Genetics Unit, and to assess the outcomes and cost of PGD.

METHODS

A retrospective review of PGD files available at the Human Genetics Unit was performed. Data was collected from genetic counseling, fertility, and PGD-specific records.

RESULTS

Amongst the 22 couples who had PGD, 42 in vitro fertilisation cycles were completed with 228 embryos biopsied and included in the analysis. Most (59%) of the conditions for which PGD was requested were autosomal recessive. Of the biopsied embryos, 71/228 (31.1%) were suitable for transfer and 41/71 (57.7%) were transferred. Of these, 14/41 (34.0%) successfully implanted and 11/14 (78.6%) resulted in a liveborn infant. The clinical pregnancy rate per embryo transfer was 29.3%. Overall, 10/22 (45.5%) couples had a successful cycle resulting in a liveborn infant. On average, one cycle of PGD costs USD 9525.

CONCLUSIONS

This is the first study to assess the success rates and the cost of PGD in South Africa and provides evidence for the feasibility in a low-to-middle-income country. The success rates in this sample are comparable to those achieved globally. South Africa has the infrastructure and expertise to provide PGD; the limiting factor is the lack of funding initiatives for PGD. Although the sample size was small, the findings from this study will enable genetic counselors to offer couples in South Africa evidence-based and locally accurate information regarding outcomes, success rates, and costs.

Globalised quests for assisted conception: Reproductive travel for infertility and involuntary childlessness

The global movement of people across international borders to undergo assisted reproductive treatment is common, although there is little accurate data. In this article, we synthesise findings from our own empirical research on reproductive travel in addition to a review of clinical, ethical, legal, and regulatory complexities from studies on reproductive travel since 2010. Motivations for travel include legal and religious prohibitions; resource considerations; lack of access to gametes and reproductive assistors; quality and safety concerns; and personal preferences. Higher risks to mothers and children are associated with multiple embryo transfer and subsequent multiple and higher order pregnancies and the average older age of women undertaking reproductive travel. The potential exploitation of other women as providers of oocytes or surrogacy services, the lack of equity in access to assisted reproduction and the ambiguous legal status of children conceived from international reproductive travel are important ethical considerations. A range of significant legal issues remain given variable and limited international regulation. Scholarship on this trade necessarily engages with issues of power and gender, social inequities, global capitalism and the private decision-making of individuals seeking to form families. Research gaps remain given recent changes in the organisation, demands and destinations of the trade.

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.