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Tropical Medicine and International Health volume 6 no 7 pp 563±569 july 2001

Viewpoint: Medical infertility care in low income countries: the case for concern in policy and practice1 Helma van Zandvoort1, Korrie de Koning2 and Trudie Gerrits3 1 Department of Gynaecology and Obstetrics, Pasteur Hospital, Oosterhout, The Netherlands 2 International Health Department, Royal Tropical Institute, Amsterdam, The Netherlands 3 Medical Anthropology Unit, University of Amsterdam, Amsterdam, The Netherlands

Summary

Based on published, `grey' and anecdotal information, this paper explores some aspects of infertility, its medical treatment and their burden in poor countries. Many cases of infertility result from sexually transmitted infections (STI) and unsafe abortion and there is no doubt that their prevention and adequate treatment are of utmost importance, especially as effective infertility treatment, if any, comes at a high price for the consumer, materially as well as physically. Medical infertility interventions are apt to fail a free market of provision because of major information asymmetry. This renders patients in lowresource countries prone to exploitation, potentially damaging practices and waste of their savings. The authors argue that in countries struggling with limited funds and a range of pressing public health problems, public investment in infertility treatment should not have priority. But governments should take an active role in quality control and regulation of treatment practice, as well as invest in counseling skills for lower-level reproductive health staff to achieve rational referral of patients. keywords consumer interests, exploitation, infertility, infertility treatment, policy correspondence Helma van Zandvoort, Bergsingel 72 a, 3037 GH Rotterdam, The Netherlands. E-mail: helma.zandvoort@wxs.nl

Introduction The 1994 International Conference on Population and Development (ICPD) has put infertility care on the agenda of health care planners worldwide: prevention and treatment of infertility were, in the ICPD Programme of Action, explicitly acknowledged as basic elements of reproductive health care. Whilst sexually transmitted infections (STI) control and family planning and, indirectly, prevention of infertility have been part of integrated sexual and reproductive health programmes, infertility treatment has hardly been addressed in most poor countries. Meanwhile sociological and anthropological research on the subject of infertility has revealed an impressive amount of grief and suffering among those affected by or fearing infertility, often 1 This article is based on the MPH-thesis `Medical infertility care in low resource countries: the case for concern in policy and practice' by Helma van Zandvoort, written at the 36th International Course in Health Development (ICHD), KIT, Amsterdam, the Netherlands, June 2000.

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resulting in prolonged and relentless care-seeking, particularly by women. There is evidence that medical infertility care plays an important role in fertility-seeking strategies and that hi-tech interventions such as assisted reproductive techniques have found a market in developing countries. Without pretending to be comprehensive, this paper discusses infertility and its medical treatment, making use of published information identi®ed in a MEDLINE search, books and grey literature, at times mixed with anecdotal information. The limited information available does not provide an accurate picture of the situation in each lowresource country. But it does highlight general points of concern about the content and context of provision of treatment in these countries that deserve to be taken into account by policy makers and health care planners. Burden Reliable quanti®cation of the problem of infertility in terms of prevalence is dif®cult, but extensive quantifying efforts

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have provided gross estimates: worldwide, 8±12% of couples are thought to experience some sort of infertility problem during their reproductive lives (WHO 1992). But what do infertility problems mean for the individual and for the health services? Studies from the Netherlands (Oddens et al. 1999), Japan (Chiba et al. 1997), Canada (Newton et al. 1999) and the USA (Whiteford & Gonzalez 1995) have con®rmed that infertility and dif®culties when attempting to conceive impose a considerable psychosocial burden on the couples involved. Considering that this evidence has been derived from societies where fertility is valued but voluntary childlessness is becoming an accepted alternative to motherhood, one can imagine a considerable burden of infertility in the developing world, where children are known to be highly valued (Whiteford & Gonzalez 1995; Mgalla & Boerma 2001) and where many countries are characterized as `pro-natalist'. Research on the subject gives support to the general statement that it is women who bear the largest burden of infertility: in many countries their female identity, social status and security depend on their ability to produce children. Failure to comply with the norm of fertility, in a culture where more than 90% of women become mothers, is known to have serious consequences. Reported are feelings of anxiety, depression, worthlessness, guilt, grief, jealousy, possible domestic violence and disrespect (Inhorn 1994; Gerrits et al. 1999; Upton 1999). These alone can have a large impact on a woman's quality of life, but reported social consequences, i.e. divorce and resultant loss of social security and support, may be even more devastating (Cain 1986; Inhorn 1994; Boerma et al. 1996; Pearce 1999; Mgalla & Boerma 2001), especially for poor women (Winston 1991). The male perspective on infertility in developing countries has been relatively neglected in research and, if not underestimated, has certainly not been fully understood. In various societies childless men are not treated as equal to fathers (Inhorn 1994; Gerrits et al. 1999; Mgalla & Boerma 2001). This social stigma is high, but men can and do disguise their problem by claiming children elsewhere or allowing their partner to have sex with another man, for example a relative (Sundby 1999). There are reports from Zimbabwe and Tanzania (Hellum 1999; Gijssels et al. 2001), supported by anecdotal reports from Cameroon and Uganda, which suggest that male infertility is handled with discretion in order to protect male dignity. This hampers medical infertility management when it keeps men from taking part in the diagnostic process, and as a result, women may persistently seek and undergo treatment while their husbands are the cause of the problem (Inhorn 1994; Sundby et al. 1998; Bhatti et al. 1999). 564

In industrialized countries large percentages of couples seek medical advice for perceived infertility (Hirsch & Mosher 1987; van Balen et al. 1995; Schmidt & Munster 1995a, b). Cross-sectional studies in The Gambia (Sundby et al. 1998) and India (Unisa 1999) have given evidence of similar patterns in help-seeking behaviour: 40±75% of couples sought medical advice. In several other countries, infertility and related complaints such as menstrual disorders (Roth Allen 2001) are reported to impose a serious burden on health services in terms of patient load (Katz & Katz 1987; Sundby et al. 1998), gynaecologists reportedly spending a sizeable proportion of their time in infertility care (Okonofua 1996). In Nigeria, South Africa and Zimbabwe infertility patients reportedly consume a large proportion of reproductive health service resources: up to one-third of either family planning or gynaecological consultations relate to complaints of infertility, and patients are often, without counselling, unnecessarily referred to higher care levels (Rowe 1999). In Latin America, Africa and Asia 30±35% of couples seek medical care within 2 years and another 30% within 4 years of unsuccessful attempts to achieve pregnancy (Rowe et al. 1997). Women speci®cally are persistent care seekers in medical as well as traditional sectors: they often consult more than one provider at a time, sometimes for a considerable amount of years, thus having interventions duplicated unnecessarily and wasting their own and the services' ®nite resources (Katz & Katz 1987; FeldmanSavelsberg 1994; Inhorn 1994; Gerrits 1997; Sundby et al. 1998; Bhatti et al. 1999; Liamputtong 1999; Unisa 1999). While much about the epidemiology of causes is unknown (Lumley 1998) there is evidence that a large proportion of infertility, reportedly up to 64% in Africa (Okonofua 1996), is related to infections that cause damage to the genital tract and thus potentially impair or preclude fertility (Otolorin et al. 1987; Evers & Heineman 1997). STIs especially cause a high overall burden, particularly in sub-Saharan Africa (Adler et al. 1998). They can affect both female and male fertility (WHO 1975; Population Reports 1984; Jejeebhoy 1998; Okonofua 1999), increase the risk of infection complicating delivery and vaginal operative procedures (Plummer et al. 1987; Boerma et al. 1996) and are thus held responsible for a signi®cant part of the burden of infertility. Iatrogenic pelvic infections come next in importance, especially those complicating unsafe abortion. Although several developing countries have introduced more liberal abortion laws in the past 20 years, many women still have to resort to unsafe abortion, resulting in an estimated 80 000 deaths annually (WHO 1997; Berer 2000). On top of this, 20±30% of unsafe abortions lead to reproductive tract infections, ã 2001 Blackwell Science Ltd


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20±40% of which result in permanent damage and consequent infertility (Okonofua 1994; WHO 1997). Treatment Whilst prevention, although indirect, is being emphasized through STI control, family planning and, increasingly, post-abortion care in reproductive health programmes, content and context of fertility treatment have hardly been addressed. What can be expected from medical treatment in terms of desired result is limited by the fact that fertility is a chance event, determined by many factors (Perrin & Sheps 1964). Under normal fertile conditions, the probability of conception in any 1 month is about 25%; cumulative pregnancy rates are 85±93% at the end of the ®rst year and 93% to almost 100% at the end of the second year of trying (Speroff et al. 1994; Evers & Heineman 1997). Subfertility, a state between normal and absolute impaired fertility or sterility, can be dealt with rationally: combining medical history, female age, length of the period during which she tried to become pregnant and results of basic medical examinations of the couple, subfertility can be graded into moderate and severe categories with corresponding prognoses for spontaneous pregnancy (Eimers et al. 1994; Evers & Heineman 1997): 71% of moderately and 21% of severely subfertile couples conceive spontaneously within 2 years; 95% of moderately and 45% of severely subfertile couples conceive within 5 years (Evers & Heineman 1997). In summary, many subfertile couples should allow themselves more time. In the past two decades, medical infertility treatment has advanced rapidly and new reproductive techniques have been introduced. Few treatment interventions have been proven effective in improving impaired chances of conception in cases of subfertility. Ovulation induction therapy, in case of ovulation disorders, is effective in about 80% of eligible patients and is, in western countries, reported to potentially achieve 6-month cumulative pregnancy rates of 45±80% (Evers & Heineman 1997). Intrauterine insemination (IUI), the timed transfer of `washed', i.e. specially prepared sperm into the uterus, can improve chances of conception in certain cases of cervical hostility, male subfertility and longer-term infertility of unknown cause. Insemination with frozen-thawed donor sperm in cases of severe male subfertility potentially achieves a 12-month cumulative pregnancy rate of 65% (Speroff et al. 1994; Evers & Heineman 1997). Effective surgical repair of tubal damage depends on special surgical techniques, skills of the surgeon, age of the patient and, last but not least, the extent of tubal damage.

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Considering the heterogeneity of the group of patients who could potentially bene®t, it is impossible to generalize effectiveness. At any rate tubal surgery has not proven effective in case of severe damage (Evers & Heineman 1997). The incidence of severe damage in absence of microsurgical techniques explains why this form of treatment reportedly has a low yield in Africa (Okonofua 1999). Assisted reproductive technologies (ART) like in vitro fertilization (IVF) have, since their introduction, come to be applied in cases of subfertility and infertility of different causes. Their clinical potential is based on control of the fertilization process by hyperstimulation of egg production, egg retrieval directly from the ovary and exposure of eggs to fertilization in vitro, in cases of severe male subfertility enhanced by injection of the sperm into the egg (ICSI): Crucial barriers in access for the male to the female gamete are thus bypassed and the timing of fertilization is optimized. Data from western Europe and the USA indicate potential pregnancy rates of 15±25% per treatment cycle. But rates in these western conditions vary greatly by laboratory, duration and cause of infertility and female age, i.e. case mix (Brownlee et al. 1994; Evers & Heineman 1997; Cramer et al. 2000). Effective treatment, if at all, comes at a high price. First, there is a material price to consider, as there is no such thing as `low-tech' treatment: with the exception of assessing the medical history and a basic microscopic sperm analysis, all diagnostic and treatment interventions require a certain degree of technology and advanced equipment. To arrive at a correct diagnosis and to treat patients safely and effectively, treatment centres need to have surgical (vaginal) ultrasound, specialized laboratory facilities and skilled, specialized providers. Effective treatment thus requires high investments translating into costly treatment, culminating in the case of ART where establishment of a unit, equipped according to international standard, costs between US$400 000 and 500 000 (Serour 1991; Lancaster 1991; Mor-Yosef 1995; Okonofua 1996). Although patients in developing countries spend much money on different treatments (Inhorn 1994; Unisa 1999), the cost of assisted reproduction precludes its use for most who need it (Inhorn 1994; Hellum 1999). Apart from the material, the emotional price needs to be considered. Research from industrialized (Chiba et al. 1997; Lukse & Vacc 1999; Newton et al. 1999; Oddens et al. 1999) and developing countries (Inhorn 1994; Boonmongkon 1999; Sundby 1999) shows that treatment implies a serious emotional burden, particularly for women. This is aggravated by long duration of treatment and experiences of treatment failure, especially in ART,

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where the decision to stop treatment becomes dif®cult when every cycle offers a new chance (Hull et al. 1992; Heitman 1999). And there is a physical price to pay. Interventions are strenuous, ovulation induction and IVF are associated with increased incidence of twins and higher order multiple pregnancies. This is a highly undesirable complication, especially in developing countries, and more probable in the absence of proper monitoring means and equipment and by indiscriminate transfer of multiple embryos after IVF. The risk of potentially life-threatening complications of ART, like Severe Ovarian Hyperstimulation Syndrome (SOHSS), has to be taken into account. Secondary and tertiary prevention require optimal monitoring and management conditions, under which, in the West, SOHSS still occurs in 0.1±0.2% of treatment cycles (Evers & Heineman 1997). Lastly, although not yet quanti®able, pro-fertility drugs may have long-term adverse effects (Becker & Nachtigall 1994). Negative potential Some interventions, historically applied in case of infertility, have been identi®ed as ineffective and potentially harmful. An example is dilatation and curettage (D & C) for which there is no rationale in infertility work-up or treatment and which can even cause damage (Taylor & Graham 1982; Speroff et al. 1994). D & C still plays a role in infertility diagnosis and treatment in many developing countries (Sundby et al. 1998; Bhatti et al. 1999; Sundby 1999), perhaps because where patients have come to perceive a procedure as desirable and affordable, providers are under pressure of patients' demand (Blackwell et al. 1987; Inhorn & Buss 1993). Demand is also provider-induced: because the procedure involves comparatively low investment and skills that are relatively easy to acquire, a great many providers rely on D & C for income (Sundby 1999). Under such conditions rationalization of the practice is obviously not in the providers' interest. While the nature of medical care is that patients do pay in return for treatment, materially but also psychologically or physically, `the thin line between exploitation and legitimate treatment has been violated when substandard or unnecessary care is rendered' (Blackwell et al. 1987). Provision of care by an uncontrolled market with forpro®t providers (Blackwell et al. 1987; Inhorn & Buss 1993; Sundby 1999) facilitates exploitation of infertility patients. Patients are emotionally vulnerable and willing to buy anything that is said to give them a chance of conception (Inhorn 1994; Bharadwaj 2000). They cannot make a well-informed decision on treatment when the 566

options are complicated and information may be biased or incomplete (Inhorn 1994; Bhatti et al. 1999; Unisa 1999). ART, especially, has a high potential for exploitative use because of its hi-tech nature, having become `a multibillion dollar industry worldwide' in which clinicians, medical researchers and pharmaceutical companies have their stake (Heitman 1999). Although there is evidence suggesting that many developing countries have facilities for assisted conception, the information that is made available is insuf®cient to determine the role of ART in terms of the number of clinics involved, the number of cycles and its effectiveness in these countries (Wang 1989; Olatunbosun et al. 1990; Lancaster 1991; WHO 1992; Inhorn 1994; Nwagfor 1994; Rojanasakul 1994; Anand Kumar 1996; Boonmongkon 1999; Hellum 1999; Okonofua 1999). In 1987 only 40% of IVF units made their results publicly available (WHO 1992), and reporting remains incomplete. In the 1999 Second Organon World Survey of Assisted Conception on IVF-ICSI, data could only be obtained from 32 of the 48 countries where Organon companies were active. Remarkably, the reported number of 3 414 cycles in the Netherlands was, in fact, 12 500. The dearth of information on infertility treatment practices is worrying considering that the number of private forpro®t units has increased dramatically in recent years (Inhorn 1999) and that networks of units have been set up (Lancaster 1991) which may be operated by pharmaceutical companies. Conclusion Effective and safe medical infertility treatment is expensive for both provider and consumer ± materially, psychologically, physically ± and the birth of a healthy baby cannot be guaranteed because conception and pregnancy remain chance events. Because of its high cost, infertility treatment cannot be provided by the public sector in poor countries. But public investment in the ®rst and secondary levels of care, in order to establish an effective referral system, should be considered. Staff could be trained in screening patients by simple investigation and medical history to make a prognosis of spontaneous pregnancy, and in counselling and giving simple advice. Keeping in mind that many couples seek help early, i.e. within 2±4 years, counselling on spontaneous chances could potentially reduce unnecessary referral, treatment and waste of patients' and services' resources. As they are inextricably linked with family planning, STI control and other reproductive health problems, prevention and treatment of infertility illustrate the case for ã 2001 Blackwell Science Ltd


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integration of these services in order to provide comprehensive, more effective reproductive health care. Efforts to control STI and increase uptake of family planning could be enhanced by pointing out the deleterious consequences of STI and unsafe abortion for fertility, by advocating safe abortion, and by providing sympathetic post-abortion care and counselling (Ketting & Visser 1994). Medical infertility treatment is a classic case for market failure because of major information asymmetry. In poor countries especially, patients need to be protected from exploitation, damaging practices and waste of their savings (Baird 1995). Quality assurance, of facilities as well as providers, is essential, which requires that standards of care be de®ned, providers accredited, practices licensed, and services constantly monitored by a neutral authority (Wagner & St Clair 1989; WHO 1990; Robertson 1997; Steinberg et al. 1998). Reporting of treatment outcomes, complications and effectiveness rates, adjusted for casemix, should be mandatory to allow consumers to make informed choices (WHO 1990; Stephenson & Wagner 1993; Steinberg et al. 1998). Regulation of practice and rational referral can, in an established market, be expected to meet with resistance from the stakeholders: Patients will expect and demand to be treated, as their social problems are not solved by being advised to await spontaneous pregnancy and providers who bene®t from treatment will ®nd rationalization of practice not to be in their interest. Hence regulatory and quality measures must be preceded and accompanied by giving realistic information to the wider public on matters of fertility, infertility, treatment potential and what to look for when choosing a provider. Mass media (Bharadwaj 2000) and health educators could achieve this in an interactive way. The media could play an important role in initiating discussion on matters of prevention, stigma, societal perception and, last but not least, alternative coping mechanisms. Anticipated resistance should not keep governments and health authorities from setting and enforcing rules and regulations: `not doing anything is a policy that means that the market will drive the availability of the technology' (Baird 1995). In view of the public interests at stake this seems a situation to be avoided at some cost. References Adler M, Foster S, Grosskurth H, Richens J & Slavin H (1998) Sexually Transmitted Infections: Guidelines for Prevention and Treatment. Health and Population Occasional Paper, DFID, London. Anand Kumar TC (1996) Legislation on reproductive technologies in India. Human Reproduction 11, 685.

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