The public sector's role in infertility management in India

The quality of life of men experiencing infertility: a systematic review

BACKGROUND

Men experiencing infertility encounter numerous problems at the individual, family, and social levels as well as quality of life (QOL). This study was designed to investigate the QOL of men experiencing infertility through a systematic review.

MATERIALS AND METHODS

This systematic review was conducted without any time limitation (Retrieval date: July 1, 2023) in international databases such as Scopus, Web of Science, PubMed, and Google Scholar. The search was performed by two reviewers separately using keywords such as QOL, infertility, and men. Studies were selected based on inclusion and exclusion criteria. The quality of the articles were evaluated based on the Newcastle-Ottawa Scale. In the initial search, 308 studies were reviewed, and after removing duplicates and checking the title and abstract, the full text of 87 studies were evaluated.

RESULTS

Finally, 24 studies were included in the final review based on the research objectives. Based on the results, men's QOL scores in different studies varied from 55.15 ± 13.52 to 91.45 ± 13.66%. Of the total reviewed articles, the lowest and highest scores were related to mental health problems and physical dimensions, respectively.

CONCLUSION

The reported findings vary across various studies conducted in different countries. Analysis of the factors affecting these differences is necessary, and it is recommended to design a standard tool for assessing the quality of life of infertile men. Given the importance of the QOL in men experiencing infertility, it is crucial to consider it in the health system. Moreover, a plan should be designed, implemented and evaluated according to each country's contex to improve the quality of life of infertile men.

Treatment-seeking behaviour among infertile tribal women of Palghar district in India

Background

The tribal culture views health care practices differently from the mainstream. Infertile tribal women practice treatment-seeking behaviour that reflects the community's cultural access to and availability of treatment as well as customs to meet their health care needs. In the environment of rising awareness of infertility and numerous treatment options, this study aims to highlight the infertility treatment-seeking behaviour of tribal communities.

Data and methods

The study employed a mix methods approach to collect data from 153 tribal couples suffering with infertility (interview schedule) and the community (in-depth interviews-14 and focus group discussions-12). The data was analyzed using Stata 13.0, and NVivo 10. Results of the quantitative data were triangulated with qualitative data for writing.

Results

Many treatment options were available for infertility in the community. Generally, traditional healers (98.7%) were preferred over modern healthcare practitioners (35%). Community members usually guided infertile couples for choosing providers. Treatment practices were very different among primary infertile women than sub-fertile. Women frequently discontinued treatment and switched between providers because of unaffordability, poor connectivity, distance, travel time, time constraints, and non-supportive circumstances. The couples were advised to consume herbs, and eat or avoid certain food items, were given massage, burns on the abdomen (dagani), removed black blood (phasani) and other various rituals to appease spirits, get rid of ghosts while offering animal sacrifice, and conducting shidwa ritual. The mean expenditure on treatment was INR 18,374. If treatment did not yield any result, couple resorted to add another wife, divorce, accept childlessness and foster a child.

Conclusion

Local authorities should strive to work towards the socio-economic development of the tribal communities and provide good healthcare services at their doorstep. The infertility problem needs to be understood in the context of poverty, tribal beliefs, and unequal access to healthcare resources.

Investigating different dimensions of infertile women's quality of life: a descriptive cross-sectional study

BACKGROUND

Infertility is a major challenge in the life of women which affects their quality of life. Infertile women's quality of life is a relatively new field of research that has recently been considered by health researchers. However, there has been no standard tool for measuring different aspects of infertile women's quality of life with female factors, and general and specific tools of infertile couples have been used to assess their quality of life. This study, thus, aimed to analyze different aspects of the quality of life of infertile women.

METHODS

This descriptive cross-sectional study was conducted on 320 infertile women referred to a teaching hospital affiliated with Mazandaran University of Medical Sciences and private infertility treatment centers in Sari, Iran. Demographic and fertility characteristics and the quality of life questionnaire for infertile women questionnaire (a 25-item tool was designed which measured 7 factors of psychological effects, sexual life with infertility family and social effects, infertility-related concerns, physical effects, adaptive approaches and factors preventing infertility adaptation), were recruited for data gathering. Data were analyzed using SPSS version 22. Descriptive statistics (percentage, mean, standard deviation), correlation coefficient, independent sample t-test, and multiple linear regression were used. P-values less than 0.05 were considered statistically significant.

RESULTS

The total mean score of infertile women's quality of life was 65.68 ± 8.91%. Findings were indicative of infertile women's quality of life in the dimensions of adaptive approach (70.48 ± 15.02%), psychological (67.88 ± 12.06%), family and social (64.63 ± 10.76%), physical, 63.42 ± 11.36%), inhibitory factors/ factors preventing adaptation (60.98 ± 8.24%), related concerns (51.52 ± 10.21%) and sexual life (40.12 ± 14.28%). According to the final multiple linear regression model, women's education (B = 2.57, p < 0.001), spouse's education (B = 1.56, p = 0.046), economic status (B = 1.64, p < 0.001), age of women (B = -0.62, p < 0.001), age of spouse (B = -0.65, p < 0.001), duration of infertility (B = -0.36, p = 0.024) and duration of marriage (B = -0.39, p = 0.022) were the final predictors of the quality of life score in infertile women of the study.

CONCLUSION

Given that infertility causes extensive changes in individuals, families, and social dimensions of infertile women, it can affect their quality of life. We can take steps to improve the health of infertile women by promoting various dimensions of their quality of life.

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 causes of infertility in women presenting to gynaecology clinics in Harare, Zimbabwe; a cross sectional study

BACKGROUND

Infertility affects 48.5 million couples globally. It is defined clinically as failure to conceive after 12 months or more of regular unprotected sexual intercourse. The contribution of various aetiological factors to infertility differs per population. The causes of infertility have not been assessed in Zimbabwe. Our objectives were to determine the reproductive characteristics, causes and outcomes of women presenting for infertility care.

METHODS

A retrospective and prospective study of women who had not conceived within a year of having unprotected intercourse presenting in private and public facilities in Harare was done. A diagnosis was made based on the history, examination and results whenever these were deemed sufficient. Data was analysed using STATA SE/15. A total of 216 women were recruited.

RESULTS

Of the 216 women recruited, two thirds (144) of them had primary infertility. The overall period of infertility ranged from 1 to 21 years with an average of 5.6 ± 4.7 years whilst 98 (45.4%) of the couples had experienced 2-4 years of infertility and 94 (43.5%) had experience 5 or more years of infertility. About 1 in 5 of the women had irregular menstrual cycles with 10 of them having experienced amenorrhoea of at least 1 year. Almost half of the participants (49%) were overweight or obese. The most common cause for infertility was 'unexplained' in 22% of the women followed by tubal blockage in 20%, male factor in 19% and anovulation in 16%. Of the 49 (22.7%) women who conceived 21(9.7%) had a live birth while 23 (10.7%) had an ongoing pregnancy at the end of follow up. Thirty-seven (17.1%) had Assisted Reproduction Techniques (ART) in the form of Invitro-fertilisation/Intracytoplasmic Sperm Injection (IVF/ICSI) or Intra-Uterine Insemination (IUI). Assisted Reproduction was significantly associated with conception.

CONCLUSION

Most women present when chances of natural spontaneous conception are considerably reduced. This study shows an almost equal contribution between tubal blockage, male factor and unexplained infertility. Almost half of the causes are female factors constituted by tubal blockage, anovulation and a mixture of the two. Improved access to ART will result in improved pregnancy rates. Programs should target comprehensive assessment of both partners and offer ART.

Quality of life among infertile women living in a paradox of concerns and dealing strategies: A qualitative study

Aim

The current work investigated the issues that cause apprehension in infertile women, the effects of this disquiet on their quality of life and the strategies that they adopt in dealing with their concerns.

Design

The qualitative research.

Method

This qualitative research sampled participants from a training centre in Mazandaran University of Medical Sciences and a privately owned infertility centre in Mazandaran Province, north of Iran. Purposive sampling continued until data saturation was reached. We conducted a conventional content analysis of the responses of 30 individuals (15 women with female infertility and 15 key informants) to in-depth and semi-structured in-person interviews on May to November 2019 .

Results

The results uncovered two themes subsuming four categories of issues: The first theme revolves around "infertility concerns," under which "concerns" and "the difficulty and vagueness of treatment" belonged. The second theme was "dealing with infertility," which covered "adaptive strategies" and "inhibitors of reconciliation with perceived infertility."

Detection of genital tuberculosis among women with infertility using best clinical practices in India: An implementation study

BACKGROUND

Diagnosis of genital tuberculosis (TB) as a cause of infertility still remains a diagnostic dilemma for clinicians, as no standard guidelines exist. The recently proposed best practices for genital TB diagnosis have not been evaluated yet in India.

OBJECTIVES

To implement best practices to diagnose and treat likely genital TB as a cause of infertility.

METHODS

Between April 2016 and June 2018, consenting women seen at a tertiary hospital infertility clinic were assessed by thorough TB related clinical history, ultrasonography, tuberculin skin test (TST), and ESR. Those with suspected genital TB underwent laparohysteroscopy. Clinical and laboratory characteristics were compared between likely (microbiologically confirmed or probable TB) and unlikely (possible and no genital TB) genital TB. Fertility outcome was assessed among women initiated on anti-TB treatment (ATT).

RESULTS

Of 185 women seeking infertility care, likely genital TB was identified among 29 (15.7%) women, with 6 (21%) confirmed and 23 (79%) probable genital TB. Compared to unlikely genital TB cases, the likely genital TB group were found to have past history of TB (p < 0.001); positive TST (p = 0.002) and elevated ESR (p = 0.001). Among the likely genital TB group, all 6 confirmed genital TB were started on ATT and 2 (33.3%) conceived. Of 5 probable genital TB started on ATT, 3 (60%) conceived.

CONCLUSION

Approximately 1/6th of women seeking infertility care met the criteria for likely genital TB. Conception among over-half of treated probable genital TB cases provides preliminary evidence that best clinical practices can be utilized, but needs further confirmatory studies.

"In Cycles of Dreams, Despair, and Desperation:" Research Perspectives on Infertility Specific Distress in Patients Undergoing Fertility Treatments

"Emotional distress in infertility" is a broad expression that loosely denotes anxiety, depression, grief, crisis, depleting psychological well-being, and all forms of affective and interpersonal disturbances faced by individuals with infertility. The distress is usually associated with involuntary childlessness as it is an unwelcoming event. The developmental crisis associated with childlessness poses a threat to one's sense of self at all levels (individual, family and social). Distress may begin before or during treatments as a person experiences the loss of control over attaining parenthood, anxiety or dejection after the diagnosis, treatments, its complications particularly its limited success rates. This paper reviews the basic concepts, theoretical models related to infertility specific distress (ISD). It elaborates on the effects of individual and treatment-specific variables on ISD with special highlights gathered from the national and international research.

Burden of Chlamydia trachomatis in India: a systematic literature review

Chlamydia trachomatis (hereafter CT) is Gram-negative, obligate intracellular pathogen. It causes the world's most common non-viral sexually transmitted disease. India is home to the world's greatest burden of infectious diseases, yet information on prevalence rates of CT is scarce. This article systematically reviews the literature for the prevalence rates and testing methods in India. A total of 27 studies were included. Four main patients groups (symptomatic women, infertile women, pregnant women and asymptomatic population groups) could be identified with varying rates of CT (0.1%-32% using PCR, 2.4%-75% using ELISA serology). Most of the studies originated from urban settings, 11 of them from New Delhi. In-house PCR was the most common diagnostic technique used generating the following ranges in prevalence for the four group studies: symptomatic women 10%-50%, pregnant women 0.1%-2.5% and asymptomatic populations 0.9%-24.5%. The rates among infertile women were 9%-68% based on serology results. The prevalence rates featured in this paper are in line with other locations across the Indian subcontinent. This review highlights the extreme heterogeneity in the limited studies available in India on CT and the need for standardized guidelines for diagnosis and management of CT in India. The availability of resources should be considered in the formulation of recommendations.

Capacity Assessment of District Health System in India on Services for Prevention and Management of Infertility

BACKGROUND

Infertility is a neglected service component in the public health-care system in India.

OBJECTIVES

This study aims to assess the availability and practices on prevention and management services for infertility in the district health system.

METHODOLOGY

A cross-sectional survey of selected health facilities and the staff from 12 district hospitals (DHs), 24 community health centers (CHCs), 48 primary health centers (PHCs), and 48 subcenters was conducted using qualitative and quantitative methods. Interviewed staff included 26 gynecologists; 91 medical officers; 91 auxiliary nurse midwife; 67 laboratory technicians; and 84 accredited social health activist workers.

RESULTS

The findings indicate that adequate staff was in place at more than 70% of health facilities, but none of the staff had received any in-service training on infertility management. Most of the DHs had basic infrastructural and diagnostic facilities. However, the majority of the CHCs and PHCs had inadequate physical and diagnostic facilities related to infertility management. Semen examination service was not available at 94% of PHCs and 79% of CHCs. Advanced laboratory services were available in <42% at DHs and 8% at CHCs. Diagnostic laparoscopy and hysteroscopy were available in 25% and 8% of DHs, respectively. Ovulation induction with clomiphene was practiced at 83% and with gonadotropins at 33% of DHs.

CONCLUSION

The district health infrastructure in India has a potential to provide basic services for infertility. With some policy decisions, resource inputs and capacity strengthening, it is possible to provide advanced services for infertility in the district health system.

Quality management systems for your in vitro fertilization clinic's laboratory: Why bother?

Several countries have in recent years introduced prescribed requirements for treatment and monitoring of outcomes, as well as a licensing or accreditation requirement for in vitro fertilization (IVF) clinics and their laboratories. It is commonplace for Assisted Reproductive Technology (ART) laboratories to be required to have a quality control system. However, more effective Total Quality Management systems are now being implemented by an increasing number of ART clinics. In India, it is now a requirement to have a quality management system in order to be accredited and to help meet customer demand for improved delivery of ART services. This review contains the proceedings a quality management session at the Indian Fertility Experts Meet (IFEM) 2010 and focuses on the creation of a patient-oriented best-in-class IVF laboratory.

Perspectives on access to in vitro fertilization in Portugal

OBJECTIVE: To analyze users' reasons for choosing in vitro fertilization treatment in public or private services and to identify their suggestions for improving fertility treatment. METHODS: A qualitative study using an interpretative approach was conducted. Fifteen semi-structured interviews were conducted with patients undergoing in vitro fertilization treatment (nine women, one man and five couples) at home or at their workplace in the districts of Viana do Castelo, Braga, Porto and Lisbon, Portugal, between July 2005 and February 2006. RESULTS: Users evaluated access to in vitro fertilization treatment in public and private services based mainly on their individual experiences and called for more access to less costly, faster and friendlier care with suitable facilities, appropriate time management and caring medical providers. These perceptions were also associated with views on the need for fighting stigmatization of infertility, protecting children's rights and guaranteeing sustainability of health care system. Interviewees sought to balance reduced waiting time and more attentive care with costs involved. The choice of services depended on the users' purchase power and place of residence and availability of attentive care. CONCLUSIONS: Current national policies on in vitro fertilization treatment meet user's demands of promoting access to, and quality, availability and affordability of in vitro fertilization treatment. However, their focus on legal regulation and technical-scientific aspects contrasts with the users' emphasis on reimbursement, insurance coverage and focus on emotional aspects of the treatment. The study showed these policies should ensure insurance coverage, participation of user representatives in the National Council for Assisted Reproductive Technology, promotion of infertility research and certification of fertility laboratories.

Management of infertility in low resource countries

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