Global importance of infertility and its treatment: role of fertility technologies

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Induction of Ovulation with Clomiphene Citrate Versus Clomiphene with Bromocriptine in PCOS Patients with Normal Prolactin: A Comparative Study

INTRODUCTION

Polycystic ovarian syndrome (PCOS) is the main cause of anovulatory infertility. Various combination of drugs have been tried to induce ovulation in PCOS patients with varied result. So, this study was planned to compare the effect of bromocriptine combined with Clomiphene Citrate and Clomiphene Citrate alone, in patients of polycystic ovarian syndrome with normal prolactin level.

MATERIALS & METHODS

On the basis of inclusion and exclusion criteria, seventy four PCOS patients with normal prolactin level (< 20 ng/ml) and BMI between 20-30 were randomly assigned into two groups. One group (n=38) received 50 mg clomiphene citrate (CC) from day3 to day7. The other group (CC+Bcrt) was given 50 mg of clomiphene citrate from day3 to day7 along with 0.8mg of bromocriptine daily for full cycle (n=36). Both the groups were treated for 3 cycles. The outcomes were measured by the hormonal status, follicular size, ovulation rate and pregnancy outcomes.

RESULTS

The serum prolactin level was normal in both the groups before treatment. After 3 cycles the prolactin level decreased in (CC+Bcrt) group (p< 0.01). Follicular development (size >15mm) was observed in 30 patients (78.9%) in CC group and 28 patients (82.3%) in CC+Bcrt group. There was no significant change in hormonal status (LH, FSH and Estradiol) of both the groups. The rate of ovulation was 69.4% in CC group and 75.8% in CC+Bcrt group. During the treatment period, nine patients in CC group and seven patients in CC+Bcrt group became pregnant.

CONCLUSION

There is no added benefit of bromocriptine with clomiphene citrate as compared to clomiphene alone in ovulation induction as well as pregnancy outcomes in PCOS patients with normal prolactin.

Physical activity and body mass index among women who have experienced infertility

INTRODUCTION

The experience of infertility is a common medical condition in the developing countries. The aim of this retrospective epidemiologic study was to determine fertility status and parity in Babol, Iran and then identify physical activity and body mass index (BMI) among women who have experienced infertility.

MATERIAL AND METHODS

A total of 1,081 women aged 20-45 years were selected using cluster sampling. The current physical activity was measured using the original International Physical Activity Questionnaire short form. Lifestyle factors were compared between those who had experienced infertility (n = 168) and the rest of the women. A face-to-face household interview was conducted using a specially designed interview questionnaire.

RESULTS

After adjusting for suspected confounding factors, women with infertility experience had a 4.8-fold increased risk of obesity (OR = 2.02, CI = 0.70, 5.84) and almost a 3.8-fold increased risk of being overweight (OR = 2.11, CI = 0.72, 6.17) compared to women without infertility. No significant differences were found in Met-minutes of sedentary activity, intensity of walking, moderate, vigorous, and total physical activity, self-reported dietary intake, exercise, and level of physical activity between women with and without experience of infertility.

CONCLUSIONS

Since both obesity and infertility are increasing public health issues in Iranian women, more attention should be paid to lifestyle behaviors, especially gaining weight in women who have experienced infertility.

Procreative sex in infertile couples: the decay of pleasure?

BACKGROUND

Infertility represents a major challenge to the emotional balance and sexual life of couples, with long-lasting and gender-specific effects. The objective of this study is to explore personality features of infertile patients and detect possible sexual disorders in couples undergoing infertility treatment.

MATERIALS AND METHODS

In this prospective study 60 infertile couples and 52 fertile control couples were asked to complete standardized and validated questionnaires: the Adjective Check List (ACL) to enquire about personality features and the Female Sexual Function Index (FSFI) or the International Index of Erectile Function (IIEF) to assess sexual functioning of female and male partners. The study population was divided into 3 groups: Group A (N = 30, recently diagnosed infertile couples) Group B (N = 30, infertile couples already undergoing Intrauterine Insemination) and Group C (N = 52, fertile control group).

RESULTS

Infertile patients did not display any distinguishing personality features. Regarding sexual function, men of all the three groups scored higher in both questionnaires (sexual satisfaction, desire and orgasm) than their female partners. Comparing results between groups, Group A male partners obtained lower scores in all the subscales. Women belonging to Group A and Group B showed an impairment of sexual arousal, satisfaction, lubrification and orgasm when compared to fertile controls.

CONCLUSIONS

Even if at the very first stages of infertility treatment no personality disturbances can be detected, the couples' sexual life is already impaired with different sexual disorders according to gender.

Infertility and the provision of infertility medical services in developing countries

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Affordable IVF for developing countries

Worldwide, more than 80 million couples suffer from infertility; the majority are residents of developing countries. Residents of developing countries encounter a lack of facilities at all levels of health care, but especially infertility diagnosis and treatment. Infertility defined as a disease has a much stronger negative consequence in developing countries compared with Western societies. Social isolation, economic deprivation and violence are commonly observed. Tubal infertility due to sexually transmitted diseases, unsafe abortion and post-partum pelvic infections are the main causes of infertility in developing countries. Very often those conditions are only treatable by assisted reproductive technologies. Although preventative measures are undoubtedly the most cost-effective approach, not offering assisted reproduction is not an alternative. This study proposes a specially designed infertility care programme leading to cost-effective simplified assisted reproduction as a valid treatment protocol in developing countries when prevention or alternative methods have failed. Special attention should be given to avoid adverse outcomes such as ovarian hyperstimulation and multiple embryo pregnancy.

International disparities in access to infertility services

OBJECTIVE

To characterize the international availability of infertility services.

DESIGN

A PubMed computer search to identify relevant articles.

SETTING

Academic medical center.

PATIENT(S)

None.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

None.

RESULT(S)

Epidemiological data suggests that approximately 80 million people worldwide are infertile. Most countries in the industrial west have declining fertility rates marked by late marriage, postponed childbearing, and primary infertility. In contrast, in the developing world, there is little voluntary effort to postpone childbearing and early first marriage is common. However, a high prevalence of sexually transmitted infections and infections acquired as a result of inadequate health care result in increased rates of secondary infertility. In developing societies, childlessness is often highly stigmatized and leads to profound social suffering for infertile women in particular, yet most infertile people in the developing world have virtually no access to effective treatment. Internationally, a minority of countries offer IVF, and even where it is available, on average it is prohibitively expensive and utilized by a fraction of those who could benefit from its use.

CONCLUSION(S)

Wide disparities exist in the quality, availability, and delivery of infertility services between the developed and developing nations of the world.

Reproductive health and obstetricians and gynecologists

The art of medicine provides a rare opportunity to understand human values and to contribute toward the well-being of one's fellow humans--women in the case of ob-gyn--a contribution that fits in with the mission of the International Federation of Gynaecology Obstetrics (FIGO). Obstetricians and gynecologists should indeed take it upon themselves to improve conditions for women, since the bond and respect between the two is a significant one. It is obstetricians-gynecologists who can provide the much needed technical information to throw light on justifying services that deal with devastating, debilitating, degenerating, and devaluating situations, such as neglected pregnancy, disregard toward cancer detection, and humiliating genital mutilation. Indeed, this can be termed as "terrorism in ob-gyn," neglected by those who should deal with it. Those in ob-gyn and other medical professions clearly witness gender inequality and its ugly aftermath, a degradation of women's reproductive rights. Ob-gyn must look a little beyond just the lucrative practice of the plain science of obstetrics and gynecology and undertake the responsibility to help and protect the health and life of women around the world. A conscientious doctor cannot practice medicine on women's bodies alone, but must also "practice" against several social evils, the prevention of which is crucial to women's health. Obstetricians and gynecologists can utilize their access to policymakers and health "builders" to carry this brief for women's health, and can urge governments to take a second look at women's rights to ensure that they are on par with the accepted norms of human rights, to be protected and propagated.

Global infertility and the globalization of new reproductive technologies: illustrations from Egypt

Infertility is a problem of global proportions, affecting on average 8-12 percent of couples worldwide. In some societies, however-particularly those in the "infertility belt" of sub-Saharan Africa-as many as one-third of all couples are unable to conceive. Factors causing high rates of tubal infertility in parts of the developing world include sexually transmitted, postpartum, and postabortion infections; however, male infertility, which is rarely acknowledged, contributes to more than half of all cases. Unfortunately, the new reproductive technologies (NRTs) such as in vitro fertilization (IVF), which are prohibitively expensive and difficult to implement in many parts of the developing world, represent the only solution to most cases of tubal and male infertility. Not surprisingly, these technologies are rapidly globalizing to pronatalist developing societies, where children are highly desired, parenthood is culturally mandatory, and childlessness socially unacceptable. Using Egypt as an illustrative case study, this paper examines five of the major forces fueling the global demand for NRTs; these include demographic and epidemiological factors, the fertility-infertility dialectic, problems in health care seeking, gendered suffering, and adoption restrictions. Following this overview, a detailed examination of the implications of the rapid global spread of NRTs to the developing world will be offered. By focusing on Egypt, where nearly 40 IVF centers are in operation, this article will demonstrate the considerable constraints on the practice and utilization of NRTs in a developing country on the "receiving end" of global reproductive technology transfer. The article concludes by stressing the need for primary prevention of infections leading to infertility, thereby reducing global reliance on NRTs.

Antidepressant medications, mood and male fertility

By modulating the activity of central neurotransmitters, psychotropic agents may affect reproductive functioning in men and women. Many neurotransmitters influence the hypothalamic-pituitary-gonadal (HPG) axis and can consequently affect menstrual cycling in women and spermatogenesis in men. Emotional state similarly may disrupt reproductive functioning through the effects of stress hormones on the HPG axis. While some data exist on the relationship between stress and menstrual cyclicity in women of reproductive age, little is known regarding the potential effect of emotional state on reproductive function in men. This paper will review: (1) aspects of male reproductive function that may be vulnerable to medication-induced influences; (2) the impact of emotional state on male reproductive function; and (3) the literature on the possible effects of antidepressant medications on male fertility.