Reproductive travel to, from and within sub-Saharan Africa: A scoping review

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.

The future of surrogacy: a review of current global trends and national landscapes

The practice of surrogacy is frequently the subject of media, scientific, social, regulatory and policy attention. Although it is, for many, an accepted form of assisted reproduction for those who would otherwise not be able to have children, surrogacy often generates strong feeling, particularly where there is any possibility of exploitation. Therefore, there is disagreement about how it should be regulated. In some countries, surrogacy is prohibited in any form, although this does not stop people using it. In others, it is unregulated but still practised. In some nations it is regulated in either a 'commercial' or an 'altruistic' model. This review article considers the possible regulatory future of surrogacy, initially from a UK perspective considering a recent review of the legal framework in a country where surrogacy works well (although some cross borders to access it), and then through an assessment of global trends and other national perspectives. It concludes that the international regulation of surrogacy, although potentially desirable, is unlikely. This being the case, it would be preferable for individual nations to regulate surrogacy so it can be undertaken in ways that are safe, ethical and protective of the best interests of children, surrogates, intended parents and families.

'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.

Embryonic stem cell differentiation to primordial germ cell like cells by Nigella sativa, Brassica Oleracea and Oenothera biennis extracts

OBJECTIVES

This study aimed to investigate the induction effects of methanolic extracts of Nigella sativa (NiS), Brassica Oleracea (BrO), and Oenothera biennia (Obi) on transgenic embryonic stem cells (ESCs) and to evaluate the ability of germ cells (GCs) production using these pluripotent cells.

METHODS

ESCs were amplified using a feeder layer. Embryoid bodies enzymatically dissociated to single cells and induced the extracts in gelatinized plates. Then RNA extraction and cDNA synthesis were performed. In the presence of appropriate primers, the desired genes were quantitatively evaluated by quantitative polymerase chain reaction (qPCR).

RESULTS

The copies of all genes in the control group showed a decreasing trend during the first to third weeks. Compared to the control group, the expression level of sex determining region Y-box 2 gene (Sox2) showed the highest level. All four evaluated genes increased in all Obi groups compared to the control group. There is also a slight increase in the Nanog homeobox gene (Nanog). Obi extract in different concentrations has increased the expression of the Sox2 gene. Increased expression of this gene along with octamer-binding transcription factor 4 gene (Oct4) and Nanog indicates a condition close to germ cell-like cells (GCLCs).

CONCLUSIONS

According to the results of this study, NiS can increase expression of the Oct4, Sox2, Nanog, and stimulated by retinoic acid gene 8 (STRA8) genes and so increase the hope of GCs production. Storage of cells for 21 days in the presence of the extract compared to 14 days has a negative effect on cell growth and differentiation. The effects of meiosis onset and GCs production can be expected in the presence of some herbal extracts. Optimal utilization of these extracts requires further study in the field of different extracts and fractions of each extract to more effectively and purposefully direct the differentiation of stem cells.

First clinical report of 179 surrogacy cases in the UK: implications for policy and practice

RESEARCH QUESTION

What implications for policy and practice can be derived from outcomes and trends observed across 8 years of a surrogacy programme in two UK-regulated IVF centres (London, Cardiff)?

DESIGN

Retrospective cohort study analysing surrogacy treatments undertaken between 2014 and September 2021.

RESULTS

Surrogacy continues to rise in popularity in the UK despite the inability of those supporting safe and professional practice to advertise to recruit surrogates. In two IVF centres regulated by the Human Fertilisation and Embryology Authority (HFEA), both the number of surrogacy treatments and the proportion of those undertaken on behalf of same-sex male intended parents increased year on year in the period studied. From a cohort of 108 surrogates, 71 babies were born to 61 surrogates (with five pregnancies ongoing) by February 2022. No statistically significant difference in live birth rates (LBR) was observed between the heterosexual couples and same-sex male couples. Sample sizes of single and transgender intended parents were too small (n < 5) to compare. The use of vitrified oocytes in surrogacy treatments has increased year on year, while fresh oocyte use has declined since peaking in 2019. There was no significant difference in LBR between fresh and vitrified oocyte usage across the cohort.

CONCLUSIONS

The number of surrogacy treatments steadily increased, with clear evidence that the proportion of same-sex male couples accessing surrogacy is a major contributor to this growth. Vitrified/warmed oocyte use now outstrips the use of fresh oocytes in the surrogacy treatment cycles studied here. The results represent a strong basis for supporting the liberalization of regulatory reform expected to be introduced in the UK later in 2022.