Social impacts experienced by women with HIV and infertility in sub-Saharan Africa: A scoping review

BACKGROUND

In Sub-Saharan Africa (SSA), HIV (Human Immunodeficiency Virus) prevalence among reproductive-aged women remains high, and infertility among these women is common. The social consequences for these women are yet to be explored. This scoping review summarises the social consequences of living with HIV and infertility for SSA women.

METHODS

This scoping review of published peer-reviewed literature focused on the intersection of infertility and living with HIV among women in SSA. We followed the PRISMA guidelines for scoping reviews. We searched PubMed, Web of Science and SCOPUS and included all original research reports which met the inclusion criteria; women in Sub-Saharan Africa, living with HIV, and infertility.

RESULTS

Fourteen papers met the inclusion criteria. Both HIV diagnosis and infertility were reported as stigmatising experiences for women who desire to have children. The stigma of infertility had a greater negative impact on women than that of an HIV diagnosis. Familial, community support, and medical intervention were perceived vital to ensure women feel de-stigmatised and in control of their future, even without children.

CONCLUSION

This is the first review demonstrating the social consequences of HIV and infertility on SSA women. Further research and interventions are needed to reduce the social consequences of infertility within SSA.

Trends in the burden of female infertility among adults aged 20-49 years during 1990-2019: an analysis of data from the Global Burden of Disease Study 2019

OBJECTIVES

The aim of this analysis was to investigate the worldwide distribution and trends in the burden of female infertility (FI).

DESIGN AND SETTING

Analysis of cross-sectional data from 1990 to 2019 from the Global Burden of Disease (GBD) Study 2019.

PARTICIPANTS

Adults aged 20-49 years in various geographical regions, Sociodemographic Index (SDI) levels and populations across 204 countries worldwide.

OUTCOME MEASURES

Disability-adjusted life years (DALYs), age-standardised DALY rates and estimated annual percentage changes (EAPCs) for FI over the research period.

RESULTS

The global burden of FI, as measured by DALYs and age-standardised DALY rates among adults aged 20-49 years, exhibited an upward trend from 1990 to 2019. Regions such as Tropical Latin America (EAPC: 3.76, 95% CI 2.76 to 4.77), South Asia (EAPC: 1.74, 95% CI 1.01 to 2.48) and Andean Latin America (EAPC: 8.54, 95% CI 6.79 to 10.32) had higher DALYs. The age-standardised DALY rates notably increased in low-middle-SDI and low-SDI countries, with EAPCs of 1.42 (95% CI 0.76 to 2.10) and 1.25 (95% CI 0.30 to 2.21), respectively. Despite lower overall DALYs in high-SDI countries, they experienced the highest EAPC in DALYs (1.57, 95% CI 1.30 to 1.83) during the period 1990-2019. China and India consistently had the highest DALYs for FI globally in both 1990 and 2019, while Africa and Latin America bore a significantly greater burden of the disease compared with other regions.

CONCLUSION

The GBD Study data on FI among adults aged 20-49 years revealed a rising global trend in FI from 1990 to 2019, with notable variations across different regions.

Association between bacterial vaginosis, Chlamydia trachomatis infection and tubal factor infertility in Bukavu, Democratic Republic of Congo

BACKGROUND

Tubal factor infertility (TFI) is common in sub-Saharan Africa and often secondary to pelvic inflammatory disease (PID). Anaerobes associated with bacterial vaginosis (BV) are also found in PIDs widely dominated by Chlamydia trachomatis (C. trachomatis), whose role in TFI is better demonstrated than that of BV.

OBJECTIVES

To determine the prevalence of BV and C. trachomatis and to investigate the association between BV, C. trachomatis and TFI.

METHODS

We included 137 patients treated for infertility between January 2020 and November 2021. Cases were defined as women with infertility aged 18-45 years presenting with TFI (n = 52), and controls as infertile women in the same age groups without TFI (n = 85). Data on social habits, life style and infertility parameters were collected, and we performed screening for BV and C. trachomatis. Multiple regression was used to measure associations.

RESULTS

The prevalence of BV and C. trachomatis was 42.3% (58/137) and 23.4% (32/137), respectively. BV (61.5% vs 30.6%, p<0.001) and C. trachomatis (48.1 vs 8.2%, p<0.001) were more frequent in cases of TFI. BV and C. trachomatis increased the risk of TFI approximately 4-fold [aOR: 3.77 (1.61-8.83), p=0.002] and 14-fold [aOR: 13.77 (4.59-41.27), p<0.001], respectively.

CONCLUSION

BV and C. trachomatis infection are strongly associated with TFI in Bukavu. Prevention and screening should be implemented to reduce the risk of TFI.

A critical systematic review and meta-analyses of risk factors for fertility problems in a globalized world

Globally, fertility awareness efforts include well-established risk factors for fertility problems. Risks disproportionately affecting women in the Global South, however, are neglected. To address this gap, we conducted a systematic review and meta-analyses of relevant risk factors to examine the association between risk factors and fertility problems. MEDLINE, Embase, Cochrane Library, regional databases and key organizational websites were used. Three authors screened and extracted data independently. Studies assessing exposure to risk (clinical, community-based samples) were included, and studies without control groups were excluded. Outcome of interest was fertility problems, e.g. inability to achieve pregnancy, live birth, neonatal death depending on study. The Newcastle-Ottawa Scale was used to assess study quality. A total of 3843 studies were identified, and 62 were included (58 in meta-analyses; n = 111,977). Results revealed the following: a ninefold risk of inability to become pregnant in genital tuberculosis (OR 8.91, 95% CI 1.89 to 42.12); an almost threefold risk in human immunodeficiency virus (OR 2.93, 95% CI 1.95 to 4.42) and bacterial vaginosis (OR 2.81, 95% CI 1.85 to 4.27); a twofold risk of tubal-factor infertility in female genital mutilation/cutting-Type II/III (OR 2.06, 95% CI 1.03 to 4.15); and postnatal mortality in consanguinity (stillbirth, OR 1.28, 95% CI 1.04 to 1.57; neonatal death, OR 1.57, 95% CI 1.22 to 2.02). It seems that risk factors affected reproductive processes through multiple pathways. Health promotion encompassing relevant health indicators could enhance prevention and early detection of fertility problems in the Global South and disproportionately affected populations. The multifactorial risk profile reinforces the need to place fertility within global health initiatives.

Herpes simplex virus type 2 seroprevalence and associated factors in fertility-treatment-seeking population: A cross-sectional survey in the United Arab Emirates

Background

Herpes simplex virus type 2 (HSV-2) is a common genitally-transmitted viral infection affecting more than 400 million individuals globally. In the United Arab Emirates (UAE), in specific at-risk population groups, the burden of HSV-2 has not been reported. This study investigated the prevalence of HSV-2 IgG antibodies in patients seeking fertility treatment and characterized patients with seropositivity to HSV-2 IgG antibodies.

Methodology

A cross-sectional sample of patients seeking fertility treatment in a major fertility clinic in Abu Dhabi, UAE was surveyed from April to May 2021. Patients were consecutively invited to complete self-administered questionnaires and provide blood for HSV-2 testing. Information on sociodemographics, medical history, and infertility was collected. Serum specimens were screened using an enzyme-linked immunosorbent assay for HSV-2 IgG antibodies detection.

Results

Two hundred and ninety-nine patients were surveyed and provided blood samples. The mean age of the patients was 35.9 ± 6.8 [mean ± standard deviation (SD)] years with 89.3% being women. Sixty-six percent were overweight or obese, 25.0% had at least one chronic comorbidity, and 19.6% reported ever-had genital infection. More than two-thirds (68.3%) of the patients were infertile for ≥ 6 months. Of the 42 infertile males, 69.0% had an abnormal semen analysis. HSV-2 IgG antibodies was detected in 12.4% of patients. The HSV-2 IgG seropositive patients had a higher mean age (39.5 vs. 35.4 years; p < 0.001) compared to seronegative patients. HSV-2 IgG antibodies seropositivity was more common in males (15.6%) than females (12.0%), in patients with secondary (14.1%) vs. primary (9.2%) infertility, or in males with abnormal (10.3%) vs. normal (7.7%) semen.

Conclusion

Exposure to HSV-2 at any time in patients seeking fertility treatment in the UAE was found to be slightly common in more than one out of 10 patients. Tailored health campaigns on HSV-2 prevention are warranted.

Association of Herpes simplex virus I&II infections with rs187084 SNP of TLR9 and male infertility

Since TLR9 recognises unmethylated CpG motifs in viral DNA, its polymorphisms may contribute to the susceptibility to Herpes simplex virus I&II infection. In the present study, to evaluate the role of rs187084 SNP (single nucleotide polymorphism) of TLR9 in Herpes simplex virus I&II infection and male infertility, 103 infertile and 27 fertile blood and semen samples were analysed. We assessed the micro and macro properties of semen specimens and the presence of HSV immunoglobulins. Tetra-primer ARMS PCR was used to detect SNP and to investigate the genotype distribution of TLR9-rs187084 SNPs, and the correlation between polymorphisms of TLR9 gene and male infertility. Moreover, the odds ratio (OR) and 95% confidence intervals were used to estimate the strength of the association. Based on our finding, a significant correlation was observed between HSV infection, agglutination and polymorphism (TT) under dominant (OR = 1.28, 95% CI = 0.94-1.75) and recessive (OR = 0.44, 95% CI = 0.21-0.94) models for the data, which was complied with Hardy-Weinberg equilibrium (HWE) (OR = 2.91, 95% CI = 1.02-8.30). The result showed a significant association between HSV IgM and agglutination in HSV infection (p < .001), and in addition, there were associations between alleles so that rs187084 SNP might be considered as a risk factor for the incidence of HSV infection.

The efficacy of cognitive behavioural therapy on stress, anxiety and depression of infertile couples: a systematic review and meta-analysis

Infertility is considered globally to be a stressful and hard experience that affects the couples psychologically, socially and individually. The aim of this study was to systematically review the effectiveness of cognitive behavioural therapy (CBT) on depression, stress and anxiety in infertile couples. In this systematic review and meta-analysis, databases were searched up to August 2019. Twelve articles were included in the meta-analysis and analysed with Comprehensive Meta-Analysis (CMA) v2. The results of pooled studies showed that the mean scores for depression and anxiety decreased in patients receiving CBT as compared to the control group. The results of three pooled studies showed no significant difference on stress in patients receiving CBT as compared to the control group. The findings of this study provides valuable suggestions for improving mental health status through applying CBT to manage anxiety and depression in infertile couples.

Association between bacterial vaginosis and fecundability in Kenyan women planning pregnancies: a prospective preconception cohort study

STUDY QUESTION

Is bacterial vaginosis (BV) associated with fecundability?

SUMMARY ANSWER

Women with BV may be at increased risk for sub-fecundity.

WHAT IS KNOWN ALREADY

While BV has been associated with poor IVF outcomes, the association between vaginal microbiota disruption and non-medically assisted conception has not been thoroughly explored.

STUDY DESIGN, SIZE, DURATION

Kenyan women with fertility intent were enrolled in prospective cohort that included monthly preconception visits with vaginal fluid specimen collection and pregnancy testing. Four hundred fifty-eight women attempting pregnancy for ≤3 menstrual cycles at enrollment were eligible for this fecundability analysis.

PARTICIPANTS/MATERIALS, SETTING, METHODS

At monthly preconception visits, participants reported the first day of last menstrual period and sexual behavior, underwent pregnancy testing and provided vaginal specimens. Discrete time proportional probabilities models were used to estimate fecundability ratios (FRs) and 95% CI in menstrual cycles with and without BV (Nugent score ≥ 7) at the visit prior to each pregnancy test. We also assessed the association between persistent BV (BV at two consecutive visits) and fecundability.

MAIN RESULTS AND THE ROLE OF CHANCE

Participants contributed 1376 menstrual cycles; 18.5% (n = 255) resulted in pregnancy. After adjusting for age, frequency of condomless sex and study site, BV at the visit prior to pregnancy testing was associated with a 17% lower fecundability (adjusted FR (aFR) 0.83, 95% CI 0.6-1.1). Persistent BV was associated with a 43% reduction in fecundability compared to cycles characterized by optimal vaginal health (aFR 0.57, 95% CI 0.4-0.8).

LIMITATIONS, REASONS FOR CAUTION

Detection of vaginal microbiota disruption using Gram stain and a point-of-care test for elevated sialidase identified a non-optimal vaginal environment, but these non-specific methods may miss important relationships that could be identified by characterizing individual vaginal bacteria and bacterial communities using molecular methods. In addition, results may be subject to residual confounding by condomless sex as this was reported for the prior month rather than for the fertile window during each cycle.

WIDER IMPLICATIONS OF THE FINDINGS

Given the high global prevalence of BV and infertility, an association between BV and reduced fecundability could have important implications for a large number of women who wish to conceive. Multi-omics approaches to studying the vaginal microbiota may provide key insights into this association and identify potential targets for intervention.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by a National Institutes of Health grant (NICHD R01 HD087346-R.S.M.). R.S.M. received additional support for mentoring (NICHD K24 HD88229). E.M.L. was supported by pre- and post-doctoral fellowships (NIAID T32 AI07140, NICHD F32 HD100202). Data collection and management were made possible using REDCap electronic data capture tools hosted at the University of Washington's Institute of Translational Health Science supported by grants from NCATS/NIH (UL1 TR002319). The content of this paper is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. R.S.M. receives research funding, paid to the University of Washington, from Hologic Corporation, and has received honoraria for consulting from Lupin Pharmaceuticals. L.E.M. receives research funding, paid to the University of Washington, from Hologic Corporation, and has received honoraria for service on scientific advisory boards from Hologic and Nabriva Therapeutics.

TRIAL REGISTRATION NUMBER

N/A.

The effects of human immunodeficiency virus, human papillomavirus, herpes simplex virus-1 and -2, human herpesvirus-6 and -8, cytomegalovirus, and hepatitis B and C virus on female fertility and pregnancy

Female infertility may be defined as a woman of reproductive age being unable to become pregnant after a year of regular unprotected sexual intercourse. Social, genetic, endocrine, physiological, and psychological factors as well as lifestyle habits (i.e., smoking and alcohol consumption), either alone or in combination with male factors, are major causes. However, approximately 15-30% of cases of female infertility remain unexplained. Numerous investigations have also indicated that microbiomes play an important role in human reproduction. All parts of the female reproductive system may be influenced by infectious and pathological agents, especially viruses, and these may interfere with reproductive function and so are risk factors for infertility, although in many cases an exact role is unclear. We present an overview of the impact of common viral infections on female reproduction, searching Medline, PubMed, Scopus, and Google scholar databases for potentially relevant studies of viruses known to have a potential effect. Human immunodeficiency virus (HIV), herpes simplex virus (HSV) and human herpesvirus (HHV) increase infertility rates whilst human papillomavirus (HPV), cytomegalovirus (CMV), and hepatitis B and C virus (HBV, HCV) infections mostly lead to higher abortion and miscarriage rates. Moreover, HPV infection is linked to increased tubal infertility, endometriosis, and pelvic inflammatory disease. HPV was the most frequently observed infection and with lower pregnancy rate and foetal death in women undergoing IVF treatments. Assisted reproductive treatment could be a safe and effective approach for HIV and HBV infected women.

Bacterial vaginosis among women with tubal factor infertility in Nigeria

OBJECTIVE

To determine the prevalence of bacterial vaginosis among women with tubal factor infertility.

METHODS

A cross-sectional prospective study of women with tubal factor infertility was conducted at a Nigerian teaching hospital between March and September 2014. An equal number of fertile women attending the family planning clinic were recruited as controls. Interviews were conducted to collect data on sociodemographic characteristics, history and characteristics of vaginal discharge, knowledge, and practices. Bacterial vaginosis was diagnosed using the Amsel criteria. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to determine predisposing factors.

RESULTS

Overall, 178 women with tubal factor infertility were recruited. Bacterial vaginosis was noted in 50 (28.1%) of these women, compared with 14 (7.9%) of 178 fertile women (P < 0.001). Patients with tubal factor infertility had an increased risk of bacterial vaginosis when they were of low socioeconomic class (OR 11.89; 95% CI 5.20-27.69), practiced vaginal douching (OR 19.15; 95% CI 7.26-47.75), used vaginal drying agents (OR 17.04; 95% CI 6.91-43.24), had an early sexual debut (OR 32.08; 95% CI 12.02-88.89), and had a history of sexually transmitted infections (OR 12.42; 95% CI 5.36-29.35).

CONCLUSION

The prevalence of bacterial vaginosis was high among patients with tubal factor infertility. Socioeconomic and cultural factors contribute to the risk of the condition.

Chlamydia trachomatis infection in fertile and subfertile women in Rwanda: prevalence and diagnostic significance of IgG and IgA antibodies testing

BACKGROUND

In many developing countries, little is known about the prevalence of genital Chlamydia trachomatis infections and complications, such as infertility, thus preventing any policy from being formulated regarding screening for C. trachomatis of patients at risk for infertility. The objective of the present study was to determine the prevalence of C. trachomatis and evaluate the diagnostic utility of serological markers namely anti-C. trachomatis IgG and IgA antibodies in women attending an infertility clinic.

METHODS

Serum and vaginal swab specimens of 303 women presenting with infertility to the infertility clinic of the Kigali University Teaching Hospital and 312 fertile controls who recently delivered were investigated. Two commercial species-specific ELISA were used to determine serum IgG and IgA antibodies to C. trachomatis and vaginal swabs specimens were tested by PCR. Hysterosalpingography (HSG) was performed in subfertile women.

RESULTS

The PCR prevalence of C. trachomatis infection was relatively low and did not differ significantly among subfertile and fertile women (3.3 versus 3.8%). Similarly, no significant differences in overall prevalence rates of C. trachomatis IgG and IgA among both groups were observed. The only factor associated with C. trachomatis infection in our study population was age <25 years. The seroprevalence of IgG in both assays (86.4% for ANILabsystems and 90.9% for Vircell) was significantly higher in the group of PCR C. trachomatis-positive women compared with that of PCR-negative women. Evidence of tubal pathology identified by HSG was found in 185 patients in the subfertile group (67.8%). All the serological markers measured in this study had very low sensitivities and negative predictive values in predicting tubal pathology. The specificities for ANILabsystems IgG, Vircell IgG, Anilabsystem IgA and positive C. trachomatis DNA to predict tubal pathology were 84, 86, 95 and 98%, respectively, whereas their respective positive predictive values were 73, 76, 81 and 80%.

CONCLUSIONS

The prevalence of C. trachomatis in our study population in Rwanda appears to be low and women aged <25 years are more likely to have genital infection with C. trachomatis. Since serological testing for Chlamydia shows an excellent negative predictive value for lower genital tract infection, specific peptide-based serological assays may be of use for screening in low prevalence settings. Our data suggest that C. trachomatis is not the primary pathogen responsible for tubal pathology in Rwandan women.

The risk factor profile of women with secondary infertility: an unmatched case-control study in Kigali, Rwanda

Background

Secondary infertility is a common, preventable but neglected reproductive health problem in resource-poor countries. This study examines the association of past sexually transmitted infections (STIs) including HIV, bacterial vaginosis (BV) and factors in the obstetric history with secondary infertility and their relative contributions to secondary infertility.

Methods

Between November 2007 and May 2009 a research infertility clinic was set up at the Kigali University Teaching Hospital in Rwanda. Cases were defined as sexually-active women aged 21-45 years presenting with secondary infertility (n = 177), and controls as multiparous women in the same age groups who recently delivered (n = 219). Participants were interviewed about socio-demographic characteristics and obstetric history using structured questionnaires, and were tested for HIV and reproductive tract infections (RTIs).

Results

Risk factors in the obstetric history for secondary infertility were lack of prenatal care in the last pregnancy, the first pregnancy before the age of 21 years, a history of unwanted pregnancy, a pregnancy with other than current partner, an adverse pregnancy outcome, stillbirth, postpartum infection and curettage. Presence of HIV, herpes simplex virus type 2 (HSV-2), or Treponema pallidum antibodies, and bacterial vaginosis (BV), were significantly more common in women in secondary infertile relationships than those in fertile relationships. The population attributable fractions (PAF%) for obstetric events, HIV, other (STIs), and BV were 25%, 30%, 27%, and 14% respectively.

Conclusions

The main finding of this study is that obstetric events, HIV and other STIs contribute approximately equally to secondary infertility in Rwanda. Scaling up of HIV/STI prevention, increased access to family planning services, improvement of prenatal and obstetric care and reduction of stillbirth and infant mortality rates are all likely to decrease secondary infertility in sub-Saharan Africa.

'Mama and papa nothing': living with infertility among an urban population in Kigali, Rwanda

BACKGROUND

Not being able to procreate has severe social and economic repercussions in resource-poor countries. The purpose of this research was to explore the consequences of female and/or male factor infertility for men and women in Rwanda.

METHODS

Both quantitative and qualitative methods were used. Couples presenting with female and/or male factor infertility problems at the infertility clinic of the Kigali University Teaching Hospital (n = 312), and fertile controls who recently delivered (n = 312), were surveyed about domestic violence, current and past relationships and sexual functioning. In addition, five focus group discussions were held with a subsample of survey participants, who were either patients diagnosed with female- or male-factor fertility or their partners.

RESULTS

Domestic violence, union dissolutions and sexual dysfunction were reported more frequently in the survey by infertile than fertile couples. The psycho-social consequences suffered by infertile couples in Rwanda are severe and similar to those reported in other resource-poor countries. Although women carry the largest burden of suffering, the negative repercussions of infertility for men, especially at the level of the community, are considerable. Whether the infertility was caused by a female factor or male factor was an important determinant for the type of psycho-social consequences suffered.

CONCLUSIONS

In Rwanda, as in other resource-poor countries, infertility causes severe suffering. There is an urgent need to recognize infertility as a serious reproductive health problem and to put infertility care on the public health agenda.