Infertility is rising faster in developing countries than in developed nations and has a much more devastating impact, experts warned this week. Speaking in Seville at “Updates in Infertility Treatment (UIT) 2010”, a prestigious bi-annual meeting attended by almost 1000 of the world’s infertility treatment specialists, they called for greater efforts to bring assisted reproduction expertise within the reach of people in poorer countries. A low cost approach that includes some of the latest assisted reproduction techniques (ART) could be made available for as little as $300 per couple treated compared to $10,000 to $12,000 in the US and western Europe, they say.

International Federation of Fertility Societies’ President Professor Basil Tarlatzis, a human reproduction expert of Aristotle University, Thessaloniki, Greece, said an estimated 10 to 12 per cent of the global reproductive-age population overall experienced fertility problems at any one time. Of these only 15 per cent seek help and a mere six per cent overall receive treatment. Even when countries possess sophisticated ART expertise, few provide the optimal 1500 of cycles of IVF per million population per year to tackle infertility. Only Israel meets this target. Some Scandinavia countries and the Netherlands achieve 50 per cent, the UK and other parts of Europe achieve about a third and the US and Japan achieve 10 per cent. Elsewhere, where infertility is a low priority for constrained healthcare resources the figure is 0 or under 1 per cent.

High costs of private treatment, lack of reimbursement by public health funding, restrictive regulatory policies, and cultural and religious taboos, are all a bar to accessing treatment for many people depending on local circumstances, said Dr Luca Gianaroli, a human reproduction expert of Bologna, Italy, who also addressed the UIT 2010 meeting. “Infertility services are not even homogenised in the EU,” he pointed out. According to researchers, an estimated 20 to 25,000 couples per year are thought to be moving from one country to another in their quest for infertility treatment in order to overcome restrictions denying them access in their home state, he said.

The proportion of couples affected by infertility is over three times higher in some developing regions below the so-called “infertility belt” such as sub-Saharan Africa where treatment is most scarce, Prof Tarlatzis believes. “It is a demographic paradox, that the countries with the highest total fertility (birth rates) also have the highest prevalence of infertility.”

The consequences of infertility were far greater in under-developed countries, he added. Whilst in the developed world, infertility is a personal and family tragedy that may lead to self-blame, diminished self-esteem, marital stress and depression, in poorer parts of the world, infertility can result in women being stigmatised, alienated and subjected to domestic violence and polygamous marriages. “Womanhood is defined by motherhood in some regions so infertile women can be seen as ‘cursed’ and are deprived of all social status.”

Prof Tarlatzis pointed out that women in the developing world could still be stigmatised as infertile if they produced fewer than the normally expected number of children, had no sons, or failed to get pregnant soon after marriage.

Infertility in developing countries is compounded by a combination of factors leading to secondary infertility, including poor healthcare provision, non-medically supervised births, unsafe abortions, a lack of sexual health education, female genital mutilation, environmental pollution, but above all by a greater prevalence of inadequately treated infections affecting the reproductive organs of both men and women. For example, 85 per cent of subfertile women in Africa have infection-related infertility compared to 33 per cent in the rest of the world, he said. Infection is usually the result of sexually-transmitted diseases or HIV although TB and schistosomiasis also take their toll on fecundity.

“Managing infertility in developing countries is a big challenge for all of us and should follow two strategies: prevention of avoidable infertility and making available assisted reproductive techniques,” he said. The task of prevention will require development of improved community health services, the early diagnosis and treatment of STDs in men, education on sexual health, the overcoming of cultural prejudices, and the introduction of safe birthing and abortion practices. “For couples already infertile, a mixture of low tech and high tech techniques need to be available but even the latter do not need to be prohibitively expensive,” he added. “Governments and policy-makers need to be convinced that infertility management serves, rather than conflicts with, population control policies. “

Low-cost IVF

A low cost IVF programme devised by a task force of the European Society for Human Reproduction and Embryology (ESHRE) run in collaboration with the World Health Organisation is stimulating efforts to make infertility treatment feasible in developing countries. The Low-cost IVF Foundation, established in 2007, is now using much cheaper treatment options and equipment to manage infertility, said Dr Gianaroli, a Foundation Committee member.

“The foundation aims to demonstrate that material costs for a cycle of IVF can be under $200.” Basic ultrasound equipment rather than the advanced 3D and 4D models available can be used. Expensive hormonal monitoring can be replaced by modest ultrasound techniques, cheaper fertility drugs can be employed (conventional drug treatment methods costing $1000 or more per cycle can be replaced by alternatives costing only $11 per cycle) and simple incubators, not requiring electricity, can be used, saving thousands of dollars. Intrauterine insemination and mild ovarian stimulation are often highly effective, he said. Three pilot clinics each costing a maximum of $20,000 to set up are already functioning with basic equipment. The cost of each course of infertility treatment they provide works out at around $180 – a tiny fraction of private treatment costs in western European countries with sophisticated technologies.

The Foundation is soliciting donations to fund more units and assistance from established high-tech ART establishments in the form of surplus equipment and help with training.

Olwen Glynn Owen