The search for assisted reproduction: profile of patients seen in the fertility outpatient clinic of a public hospital

OBJECTIVE

To analyze the epidemiological profile of patients treated at the Fertility Outpatient Clinic of a tertiary public hospital in Juiz de Fora.

METHODS

This cross-sectional study analyzed the medical records of 448 patients who sought fertility treatment at a tertiary public hospital. The data collected from the medical records were used to assess the main causes of infertility, find the most frequently performed procedures, and the cases eligible to therapeutic or prophylactic intervention.

RESULTS

Of the 448 patients included in the study, 385 (86%) sought fertility consultation, 49 (10%) came in for repeated miscarriages, and 14 (3%) for other reasons. Of the 438 infertile patients, 280 (63.9%) had primary and 158 (36.1%) had secondary infertility. The top-three conditions of the 295 patients with established diagnoses were chronic anovulation (n=98; 33%); tubal factor infertility (n=86; 29%); and male factor infertility (n=59; 20%).

CONCLUSIONS

Improving care in reproductive health requires a more profound comprehension of the epidemiological profile of patients seeking treatment. There are alternative cost-effective means to contain the development of infertility. Additional expenditure in public healthcare is needed to accommodate the growing number of individuals seeking fertility treatment in Brazil.

Cost and affordability of non-communicable disease screening, diagnosis and treatment in Kenya: Patient payments in the private and public sectors

Introduction

The prevalence of non-communicable diseases (NCDs) is rising in low- and middle-income countries, including Kenya, disproportionately to the rest of the world. Our objective was to quantify patient payments to obtain NCD screening, diagnosis, and treatment services in the public and private sector in Kenya and evaluate patients’ ability to pay for the services.

Methods and findings

We collected payment data on cardiovascular diseases, diabetes, breast and cervical cancer, and respiratory diseases from Kenyatta National Hospital, the main tertiary public hospital, and the Kibera South Health Center—a public outpatient facility, and private sector practitioners and hospitals. We developed detailed treatment frameworks for each NCD and used an itemization cost approach to estimate payments. Patient affordability metrics were derived from Kenyan government surveys and national datasets.

Results compare public and private costs in U.S. dollars. NCD screening costs ranged from $4 to $36, while diagnostic procedures, particularly for breast and cervical cancer, were substantially more expensive. Annual hypertension medication costs ranged from $26 to $234 and $418 to $987 in public and private facilities, respectively. Stroke admissions ($1,874 versus $16,711) and dialysis for chronic kidney disease ($5,338 versus $11,024) were among the most expensive treatments. Cervical and breast cancer treatment cost for stage III (curative approach) was about $1,500 in public facilities and more than $7,500 in the private facilities. A large proportion of Kenyans aged 15 to 49 years do not have health insurance, which makes NCD services unaffordable for most people given the overall high cost of services relative to income (average household expenditure per adult is $413 per annum).

Conclusions

There is substantial variation in patient costs between the public and private sectors. Most NCD diagnosis and treatment costs, even in the public sector, represent a substantial economic burden that can result in catastrophic expenditures.

Practices and ethical concerns regarding preimplantation diagnosis. Who regulates preimplantation genetic diagnosis in Brazil?

Preimplantation genetic diagnosis (PGD) was originally developed to diagnose embryo-related genetic abnormalities for couples who present a high risk of a specific inherited disorder. Because this technology involves embryo selection, the medical, bioethical, and legal implications of the technique have been debated, particularly when it is used to select features that are not related to serious diseases. Although several initiatives have attempted to achieve regulatory harmonization, the diversity of healthcare services available and the presence of cultural differences have hampered attempts to achieve this goal. Thus, in different countries, the provision of PGD and regulatory frameworks reflect the perceptions of scientific groups, legislators, and society regarding this technology. In Brazil, several texts have been analyzed by the National Congress to regulate the use of assisted reproduction technologies. Legislative debates, however, are not conclusive, and limited information has been published on how PGD is specifically regulated. The country requires the development of new regulatory standards to ensure adequate access to this technology and to guarantee its safe practice. This study examined official documents published on PGD regulation in Brazil and demonstrated how little direct oversight of PGD currently exists. It provides relevant information to encourage reflection on a particular regulation model in a Brazilian context, and should serve as part of the basis to enable further reform of the clinical practice of PGD in the country.

Practices and ethical concerns regarding preimplantation diagnosis. Who regulates preimplantation genetic diagnosis in Brazil?

Preimplantation genetic diagnosis (PGD) was originally developed to diagnose embryo-related genetic abnormalities for couples who present a high risk of a specific inherited disorder. Because this technology involves embryo selection, the medical, bioethical, and legal implications of the technique have been debated, particularly when it is used to select features that are not related to serious diseases. Although several initiatives have attempted to achieve regulatory harmonization, the diversity of healthcare services available and the presence of cultural differences have hampered attempts to achieve this goal. Thus, in different countries, the provision of PGD and regulatory frameworks reflect the perceptions of scientific groups, legislators, and society regarding this technology. In Brazil, several texts have been analyzed by the National Congress to regulate the use of assisted reproduction technologies. Legislative debates, however, are not conclusive, and limited information has been published on how PGD is specifically regulated. The country requires the development of new regulatory standards to ensure adequate access to this technology and to guarantee its safe practice. This study examined official documents published on PGD regulation in Brazil and demonstrated how little direct oversight of PGD currently exists. It provides relevant information to encourage reflection on a particular regulation model in a Brazilian context, and should serve as part of the basis to enable further reform of the clinical practice of PGD in the country.

A South African public-private partnership HIV treatment model: viability and success factors

INTRODUCTION

The increasing number of people requiring HIV treatment in South Africa calls for efficient use of its human resources for health in order to ensure optimum treatment coverage and outcomes. This paper describes an innovative public-private partnership model which uses private sector doctors to treat public sector patients and ascertains the model's ability to maintain treatment outcomes over time.

METHODS

The study used a retrospective design based on the electronic records of patients who were down-referred from government hospitals to selected private general medical practitioners (GPs) between November 2005 and October 2012. In total, 2535 unique patient records from 40 GPs were reviewed. The survival functions for mortality and attrition were calculated. Cumulative incidence of mortality for different time cohorts (defined by year of treatment initiation) was also established.

RESULTS

The median number of patients per GP was 143 (IQR: 66-246). At the time of down-referral to private GPs, 13.8% of the patients had CD4 count <200 cell/mm(3), this proportion reduced to 6.6% at 12 months and 4.1% at 48 months. Similarly, 88.4% of the patients had suppressed viral load (defined as HIV-1 RNA <400 copies/ml) at 48 months. The patients' probability of survival at 12 and 48 months was 99.0% (95% CI: 98.4%-99.3%) and 89.0% (95% CI: 87.1%-90.0%) respectively. Patient retention at 48 months remained high at 94.3% (95% CI: 93.0%-95.7%).

CONCLUSIONS

The study findings demonstrate the ability of the GPs to effectively maintain patient treatment outcomes and potentially contribute to HIV treatment scale-up with the relevant support mechanism. The model demonstrates how an assisted private sector based programme can be effectively and efficiently used to either target specific health concerns, key populations or serve as a stop-gap measure to meet urgent health needs.

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.

Indications for in vitro fertilization at a public center for reproductive health in Campinas, Brazil

OBJECTIVE

To assess the sociodemographic profile and gynecologic and obstetric characteristics of women referred to a public reference center in Campinas, Brazil, for in vitro fertilization (IVF).

METHODS

Women referred between April 1, 2008, and October 31, 2009, were eligible for inclusion in a cross-sectional study. Participants were interviewed about sociodemographic characteristics, obstetric and gynecologic history, and etiologic factors resulting in the referral. Preliminary clinical examinations performed elsewhere were evaluated.

RESULTS

A total of 176 women were included, of whom 129 (73.3%) presented with tubal factor infertility. Tubal ligation had been performed in 66 (37.5%) women. Overall, 121 (68.8%) women were aged 30 years old or less, 110 (62.5%) had received more than 8 years of schooling, 123 (69.6%) had had infertility for up to 5 years, and 99 (56.3%) did not have any children. Moreover, 25 (14.2%) women had endometriosis and 25 (14.2%) had a male factor issue. A previous ectopic pregnancy was reported for 20 (11.4%) women and pelvic inflammatory disease for 49 (27.8%).

CONCLUSION

Tubal factor infertility was the most common indication for IVF. Preventive measures are required, in addition to policies that ensure access to high-complexity treatments in the public sector.

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.

Comparative performance of private and public healthcare systems in low- and middle-income countries: a systematic review

INTRODUCTION

Private sector healthcare delivery in low- and middle-income countries is sometimes argued to be more efficient, accountable, and sustainable than public sector delivery. Conversely, the public sector is often regarded as providing more equitable and evidence-based care. We performed a systematic review of research studies investigating the performance of private and public sector delivery in low- and middle-income countries.

METHODS AND FINDINGS

Peer-reviewed studies including case studies, meta-analyses, reviews, and case-control analyses, as well as reports published by non-governmental organizations and international agencies, were systematically collected through large database searches, filtered through methodological inclusion criteria, and organized into six World Health Organization health system themes: accessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiency. Of 1,178 potentially relevant unique citations, data were obtained from 102 articles describing studies conducted in low- and middle-income countries. Comparative cohort and cross-sectional studies suggested that providers in the private sector more frequently violated medical standards of practice and had poorer patient outcomes, but had greater reported timeliness and hospitality to patients. Reported efficiency tended to be lower in the private than in the public sector, resulting in part from perverse incentives for unnecessary testing and treatment. Public sector services experienced more limited availability of equipment, medications, and trained healthcare workers. When the definition of "private sector" included unlicensed and uncertified providers such as drug shop owners, most patients appeared to access care in the private sector; however, when unlicensed healthcare providers were excluded from the analysis, the majority of people accessed public sector care. "Competitive dynamics" for funding appeared between the two sectors, such that public funds and personnel were redirected to private sector development, followed by reductions in public sector service budgets and staff.

CONCLUSIONS

Studies evaluated in this systematic review do not support the claim that the private sector is usually more efficient, accountable, or medically effective than the public sector; however, the public sector appears frequently to lack timeliness and hospitality towards patients.

Affordable ART: a different perspective

BACKGROUND

Although ≈ 10% of the population is affected by infertility, the treatment option of in-vitro fertilisation (IVF) remains unaffordable for the majority of infertile couples. We have initiated a lowcost programme incorporating an uncommonly used, but recognized, ovarian stimulation protocol, together with certain costlimiting initiatives in an established assisted reproductive technology (ART) set up.

METHODS

The medical records of women who underwent the lowcost programme were analysed. Clomiphene citrate 50 mg daily was administered from Day 2 of the cycle and continued till the day of hCG trigger, thus preventing the LH surge. Intermittent doses of human menopausal gonadotrophin 150 IU were administered on alternate days from the 5th day onwards. Oocyte retrieval was carried out once at least two follicles of >18 mm were identified. The cycle was monitored by ultrasound only, with embryo transfer being carried out on Day 3. Clinical outcomes were recorded together with an estimation of the direct costs per cycle. Direct cost calculations did not include professional charges or facility costs.

RESULTS

Of 143 women evaluated, 104 women underwent embryo transfer. The live birth rate and clinical pregnancy rate per embryo transfer were 19 and 22%. The live birth rate per initiated cycle was 14% (20/143). The multiple pregnancy rate was 26% with no case of ovarian hyperstimulation syndrome being recorded. The average direct cost per cycle was US$ 675 for IVF and US$ 725 for an ICSI treatment cycle.

CONCLUSIONS

Using this protocol, together with several costcutting measures, we achieved an acceptable live birth rate per transfer of 19% at a reasonable cost. This approach could be used by established ART centres to provide treatment to couples who cannot afford conventional ART.

Access of people living with HIV to infertility services: perspective of Brazilian healthcare professionals

OBJECTIVE

To evaluate the perspective of professionals in university and public assisted reproductive technology (ART) and HIV/AIDS services in Brazil, on the demand of people living with HIV wishing to conceive.

DESIGN

Mixed qualitative and quantitative, descriptive, cross-sectional and case study.

METHODS

The quantitative component was based on telephone interviews to women's health and HIV/AIDS program managers at state and municipal level. For the qualitative case study, semi-structured interviews were conducted with health professionals of ART and HIV/AIDS services.

RESULTS

Only one university ART service provided care for seropositive couples, but 64% of the HIV/AIDS services at state level and 73% of municipal HIV/AIDS services offered reproductive counseling focused on preventing pregnancy. Difficulty in discussing desire to conceive, lack of political decision and of human and financial resources were the main reasons given by service managers for not offering the opportunity for HIV couples. Lack of appropriate referrals and of updated knowledge on reproductive options were constrains according to the interviews.

CONCLUSION

Desire to reproduce among people living with HIV is poorly addressed in public services in Brazil.