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, â€œSocio-cultural and Ethical aspects of Biomedical infertility care in poor resource countriesâ€? 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
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;
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)
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
1. Sudan Assisted
Clinic 2. Khartoum RH
care Centre 3. Nile fertility
Centre 4. Dr. Elsir
Centre 6. Asia Fertility
Centres 7. Janeen fertility
Centre 8. Saad Abo Alila
Non Functioning (low cost IVF
Abuelhassan Fertility Centre 5. SudaneseGerman Fertility
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,
Centres offering service ALL (within facility or referred to a partner service)
hormones, Andrology lab) •
ALL ICSI- No IVF
Offered in 5 centre
Offered in 5 centre
Upon request in 1 centre
centres do not have age restriction for ART treatment.
infertility is main type of infertility seen by all clinics; mainly female factor.
infertility and male factor infertility noticeably increasing across centres.
testing is routine for couples receiving ART. No centre refuses further treatment for +ve patients.
testing is obligatory in 2 centres .Others if history suggested. One centre refuses further management if patient is HIV +ve.
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).
centres commented on an increase of multiparas mothers consulting centres for ICSI mainly for Gender Selection
Average Staffing across centres:
Infertility physicians 2
Lab technicians 3
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.
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.
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.
and egg donation- surrogacy: Religiously not acceptable . Not performed in any centre.
couples still consult centres outside
Sudan; Seeking Herd
better quality and higher success rates.
effect of unsuccessful cases.
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).
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).
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.
of embryologists, embryo and semen
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.