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Reviewing Infertility Care in Sudan; socio-cultural, policy and ethical barriers Prepared by: Dina S. Khalifa, MBBS, MRCOG I, MSc Mohamed A. Ahmed MBBS, MD Expert meeting, “Socio-cultural and Ethical aspects of Biomedical infertility care in poor resource countries� Genk-Belgium 21-22 November, 2011


Importance of Bearing babies in a Sudanese Society.

Some regions in Sudan still do not admit that men may contribute to infertility.

Infertility now is more of a concern in Sudanese society.

Infertility is more recognized as a sequel of FGM.


Statistics:  Lack of Infertility statistics in Sudan;  One study provided prevalence data: ( Elsheikh et al, 2008 )   

     

Prevalence of Infertility in Sudan: 11.5% 1ry: 79.5 % 2ry : 20.5% Female Factor alone: 37 % 69.5 % due to anovulation; 47.5 % due to hyper prolactinemia Male Factor alone: 20 % Both: 31 % Unknown: 11 %


Infertility, RH & Policy  Infertility care outlined in Sudan RH policy as part component of Family Planning Services. Public infertility care;  Primary Level  Consultation  Secondary Level  Consultation + Diagnostic tests (Hormones, semen analysis, Hystero-salpingogram) ,+/- Simple ovulation induction.  Tertiary Level  All previous + Diagnostic laparoscopy 

 ART

offered at Private level care only.


As a result:  Public

Hospital do not have dedicated Infertility Clinics. Couples with infertility complaints go through regular OB/GYN outpatient clinics;

 No

privacy  No counselling  Females presenting alone  Quality concerns regarding results of diagnostic tests


Tertiary level Infertility Care in Sudan: Khartoum State: (Total population: 5.4 million) 3 public hospitals (out of 12) offer diagnostic laparoscopy;  Souba

Teaching Hospital.  Khartoum Teaching Hospital.  Omdurman Maternity Hospital.


Outside Khartoum State: ( 14 states, Total population: 26.3 million ) Only 4 public hospitals (out of 86) offer diagnostic laparoscopy for infertility;  Mek

Nimir University Hospital.  Port Sudan Hospital.  Medani Hospital.  Alfashir Hospital


Traditional healers in infertility care: ďƒ˜ First

point of consultation in many parts of Sudan.(North and Nouba regions)

ď ˝

Males with infertility are not only seen by gynaecologists and andrologists; dermatologists in addition to skin and venereal diseases they take responsibility for treating male factor infertility wasting valuable time for the couples


National Health Insurance:  Covers

all diagnostic tests available at public level hospitals.  Covers induction drugs for ONE cycle IVF/ICSI at private level infertility care.  Any further management out of pocket  Patients

from public service repeat all diagnostic tests in clinics. Any other local health insurance (national or private) does not support any further management of Infertility.


The Study:  Review of barriers to accessibility to ART services in Sudan. Findings in Sudan;  ART Services  recent (2000)  ART Services  only offered in Private Health care/ Infertility centres.  ART Services  All clinics situated in Khartoum state; 7 functioning, 1 non functioning, 1opening in 2012.


1. Name of centre

Year

Status

1. Sudan Assisted

2000

Fully Functioning

Clinic 2. Khartoum RH

2005

Fully Functioning

care Centre 3. Nile fertility

2010

Fully Functioning

Centre 4. Dr. Elsir

2000

Fully Functioning

2009

Fully functioning

Centre 6. Asia Fertility

2007

Fully Functioning

Centres 7. Janeen fertility

2010

Fully Functioning

Centre 8. Saad Abo Alila

2008

Non Functioning (low cost IVF

Reproduction

Abuelhassan Fertility Centre 5. SudaneseGerman Fertility

Fertility Centre

donated by Low cost IVF




All centres currently developing computerized reporting and information systems.



Data for this review was obtained via personal interviews with lead physicians/owners of each centre.


ART service/Procedures •

Diagnostic Tools (HSG,

Laparoscopy, Fertility

Centres offering service ALL (within facility or referred to a partner service)

hormones, Andrology lab) •

IUI

ALL

IVF/ICSI

ALL ICSI- No IVF

Semen Bank

Offered in 5 centre

Embryo Freezing

Offered in 5 centre

PGD/PGS

Upon request in 1 centre

Sperm Donation

Not Offered

Ovum Donation

Not Offered

Surrogacy

Not Offered


 All

centres do not have age restriction for ART treatment.

 1ry

infertility is main type of infertility seen by all clinics; mainly female factor.

 2ry

infertility and male factor infertility noticeably increasing across centres.

 HBV

testing is routine for couples receiving ART. No centre refuses further treatment for +ve patients.


 HIV

testing is obligatory in 2 centres .Others if history suggested. One centre refuses further management if patient is HIV +ve.

 Disclosure

of any results is to both partners across all centres.

Success rates of ICSI across the centres averages between 25-30% (15-20 IVF/ICSI month).

2

centres commented on an increase of multiparas mothers consulting centres for ICSI mainly for Gender Selection


Average Staffing across centres: 

Infertility physicians  2

Embryologists  1

Andrologists  2

Nurses  2

Lab technicians  3

Counsellors  0


Cost of treatment: ďƒ˜ Cost

of one cycle of ICSI (including drugs) not less than 8,000 SDG ( 2,500 USD). A Sudanese minimum wage is 166 USD/month.

ďƒ˜ High

cost due to high price of unsubsidized fertility drugs to an average Sudanese;

E.g. One vial of hMG = 53 SDG(14 USD)


Ethical issues: ďƒ˜ Low

knowledge on religious boundaries of services.

ďƒ˜ If

funding for care is available, females have less chance to sustain it if infertility was due to female factor than if it was due male factor. Males have better chances to be supported for a second marriage than support for infertility treatment


Foetal reduction: Maximum ET is 2. If more embryos resulted FR is performed. A religious advisory opinion “Fatwa” was issued permitting the procedure.

 Sperm

and egg donation- surrogacy: Religiously not acceptable . Not performed in any centre.


 Sudanese

couples still consult centres outside

Sudan;  Seeking  Herd

better quality and higher success rates.

effect of unsuccessful cases.

 Couples

with unknown reasons of ART failure.


Common Misconception about infertility/ART  Men

that have no problem sexually or fathered children before can not suffer from infertility problems.

IUI is a preference for most couple because is natural, they fear ICSI may border HARAM (Forbidden).

 Conceiving

by ART is hidden by couples in the society and still feared as a stigma.


Main obstacles to Infertility care in Sudan 

Inequity in access to ART services

No accreditation body to regulate quality of care or to survey outcomes of IVF treatments.

No clear training requirements/credentials for physicians to establish private ART centres.

High running cost of centres vs. low number of patients. No government subsidy/support to private fertility centres.

Lack of qualified local trained Staff (Embryologists, nurses).


Recommendations:  Establishing

partner satellite Fertility Centres outside Khartoum state to function as;

Do initial workup, ovulation induction, COH & IUI.  Referral of ICSI cases to Khartoum for egg retrieval and embryo transfer. 

 Sharing

banks.

of embryologists, embryo and semen


ďƒ˜ Continuous

data collection and reporting from all functioning centres to influence policy and resource allocation changes at the government level as well as to build community confidence in infertility care available in Sudan.


Thank You

Khalifa  

presentation on infertility