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Infertility in resource-constrained settings: moving towards amelioration

Published:November 30, 2012DOI:https://doi.org/10.1016/j.rbmo.2012.11.009

      Abstract

      It is often presumed that infertility is not a problem in resource-poor areas where fertility rates are high. This is challenged by consistent evidence that the consequences of childlessness are very severe in low-income countries, particularly for women. In these settings, childless women are frequently stigmatized, isolated, ostracized, disinherited and neglected by the family and local community. This may result in physical and psychological abuse, polygamy and even suicide. Attitudes among people in high-income countries towards provision of infertility care in low-income countries have mostly been either dismissive or indifferent as it is argued that scarce healthcare resources should be directed towards reducing fertility and restricting population growth. However, recognition of the plight of infertile couples in low-income settings is growing. One of the United Nation’s Millennium Development Goals was for universal access to reproductive health care by 2015, and WHO has recommended that infertility be considered a global health problem and stated the need for adaptation of assisted reproductive technology in low-resource countries. This paper challenges the construct that infertility is not a serious problem in resource-constrained settings and argues that there is a need for infertility care, including affordable assisted reproduction treatment, in these settings.
      It is often presumed that infertility is not a problem in densely populated, resource-poor areas where fertility rates are high. This presumption is challenged by consistent evidence that the consequences of childlessness are very severe in low-income countries, particularly for women. In these settings, childless women are frequently stigmatized, isolated, ostracized, disinherited and neglected by the family and local community. This may result in physical and psychological abuse, polygamy and even suicide. Because many families in low-income countries depend on children for economic survival, childlessness and having fewer children than the number identified as appropriate are social and public health matters, not only medical problems. Attitudes among people in high-income countries towards provision of infertility care in low-income countries have mostly been either dismissive or indifferent as it is argued that scarce healthcare resources and family planning activities should be directed towards reducing fertility and restricting population growth. However, recognition of the plight of infertile couples in low-income settings is growing. One of the United Nation’s Millennium Development Goals was for universal access to reproductive health care by 2015, and WHO has recommended that infertility be considered a global health problem and stated the need for adaptation of assisted reproduction technology in low-resource countries. In this paper, we challenge the construct that infertility is not a serious problem in resource-constrained settings and argue that there is a need for infertility care, including affordable assisted reproduction treatment, in these settings.

      Keywords

      Infertility: a global health problem

      It is often presumed that infertility is not a problem in densely populated areas where fertility rates are high (
      • Ombelet W.
      Reproductive healthcare systems should include accessible infertility diagnosis and treatment: an important challenge for resource-poor countries.
      ). It is also commonly argued that scarce healthcare resources and family planning activities should be directed towards reducing fertility and restricting population growth (
      • Daar A.S.
      • Merali Z.
      Infertility and social suffering: the case of ART in developing countries.
      ). The current paper challenges the construct that infertility is not a serious problem in resource-constrained settings and argues that there is a need for infertility care, including affordable assisted reproduction treatment, in these settings.
      The wish and expectation to have children is shared by most people in the world (
      • Dyer S.
      The value of children in African countries – insights from studies on infertility.
      ,
      • Holton S.
      • Fisher J.
      • Rowe H.
      To have or not to have? Australian women‘s childbearing desires, expectations and outcomes.
      ,
      • Lampic C.
      • Skoog-Svanberg A.
      • Karlstrom P.
      • Tyden T.
      Fertility awareness, intentions concerning childbearing, and attitudes towards parenthood among female and male academics.
      ,
      • Langdridge D.
      • Sheeran P.
      • Connolly K.
      Understanding the reasons for parenthood.
      ,
      • Peterson B.D.
      • Pirritano M.
      • Tucker L.
      • Lampic C.
      Fertility awareness and parenting attitudes among American male and female undergraduate university students.
      ,
      • Roberts E.
      • Metcalfe A.
      • Jack M.
      • Tough S.C.
      Factors that influence the childbearing intentions of Canadian men.
      ). Infertility, the inability to conceive after a year or more of regular unprotected sexual intercourse (
      • Zegers-Hochschild F.
      • Adamson D.
      • de Mouzon J.
      • Ishihara O.
      • Mansour R.
      • Nygren K.
      • Sullivan E.
      • van der Poel S.
      The international committee for monitoring assisted reproductive technology (ICMART) and the World Health Organization (WHO) revised glossary on ART terminology.
      ), is a global health problem. A review of population-based surveys estimated the international prevalence of infertility to be 9% on average (
      • Boivin J.
      • Bunting L.
      • Collins J.A.
      • Nygren K.G.
      International estimates of infertility prevalence and treatment-seeking: potential need and demand for infertility medical care.
      ). However, prevalence rates of 30–40% are reported in some parts of sub-Saharan Africa (
      • Leke R.J.I.
      • Oduma J.A.
      • Bassol-Mayagoitia S.
      • Bacha A.M.
      • Grigor K.M.
      Regional and geographical variations in infertility: effects of environmental, cultural and socioeconomic factors.
      ). In a study combining data from 47 demographic and health surveys in developing countries (excluding China) it was estimated that, in 2002, more than 186 million ever-married women of reproductive age (15–49) had primary or secondary infertility (

      Rutstein, S.O., Iqbal, H.S., 2004. Infecundity, Infertility, and Childlessness in Developing Countries. DHS Comparative Reports No. 9. ORC Macro and the World Health Organization, Calverton, Maryland, USA.

      ).
      Approximately one-third of cases of couple infertility is due to male factors, one-third to female factors and one-third relates to a combination of male and female factors or has no identifiable cause (
      • Johnson M.H.
      • Everitt B.J.
      Essential Reproduction.
      ). In places with poor access to health care, common preventable causes of infertility include post-partum and post-abortion infections, tuberculosis and untreated sexually transmitted infections (
      • Serour G.
      Medical and socio-cultural aspects of infertility in the Middle East. Infertility in developing countries: funding the project.
      ). Infertility can also be a consequence of infections caused by the practice of female genital mutilation (
      • Obermeyer C.M.
      The consequences of female circumcision for health and sexuality: an update of the evidence.
      ). Although male factors contribute to about half of all cases of infertility, this is rarely acknowledged and women are often held responsible for couples’ inability to conceive (
      • Dhont M.
      • Luchters S.
      • Ombelet W.
      • Vyankandondera J.
      • Gasarabwe A.
      • van de Wijgert J.
      • Temmerman M.
      Gender differences and factors associated with treatment-seeking behaviour for infertility in Rwanda.
      ,
      • Inhorn M.C.
      Global infertility and the globalization of new reproductive technologies: illustration from Egypt.
      ).
      Motivations for parenthood and the perceived meaning of children vary among cultures (
      • van Balen F.
      • Bos H.M.W.
      Infertility, culture, and psychology in worldwide perspective.
      ). In broad terms, in high-income countries the desire for parenthood is expressed as a wish for personal happiness and fulfilment (
      • van Balen F.
      • Trimbos-Kemper T.C.M.
      Involuntary childless couples: their desire to have children and their motives.
      ) and children are said to be valued as they enhance the relationship and are enjoyable (
      • Langdridge D.
      • Sheeran P.
      • Connolly K.
      Understanding the reasons for parenthood.
      ). In resource-poor settings, additional reasons are identified for the wish to have children: the continuation of the family line, compliance with religious and societal expectations, and assurance of security in old age (
      • Okonofua F.E.
      • Harris D.
      • Odebiyi A.
      • Kane T.
      • Snow R.C.
      The social meaning of infertility in Southwest Nigeria.
      ). In a review of studies relating to the value of children to parents and the community in African countries,
      • Dyer S.
      The value of children in African countries – insights from studies on infertility.
      found that ‘children secure conjugal ties, offer social security, assist with labour, confer social status, secure rights of property and inheritance, provide community through re-incarnation and maintaining the family lineage, and satisfy emotional needs’.

      Psychosocial aspects of infertility

      The psychosocial consequences of infertility for couples in high-income countries have been widely described and include increased symptoms of anxiety and depression, loss of self-esteem, relationship difficulties, diminished sexual satisfaction, reduced life satisfaction and social isolation (
      • Boivin J.
      • Griffiths E.
      • Venetis C.A.
      Emotional distress in infertile women and failure of assisted reproductive technologies: meta-analysis of prospective psychosocial studies.
      ,
      • Fisher J.
      • Hammarberg K.
      Psychological and social aspects of infertility in men: an overview of the evidence and implications for psychologically informed clinical care and future research.
      ,
      • Greil A.L.
      Infertility and psychological distress: a critical review of the literature.
      ,
      • Wright J.
      • Allard M.
      • Lecours A.
      • Sabourin S.
      Psychosocial distress and infertility: a review of controlled research.
      ,
      • Kirkman M.
      Thinking of something to say: public and private narratives of infertility.
      ,
      • Kirkman M.
      Infertile women and the narrative work of mourning: barriers to the revision of autobiographical narratives of motherhood.
      ,
      • Greil A.
      • Slauson-Blevins K.
      • McQuillan J.
      The experience of infertility: a review of recent literature.
      ). Although men are adversely affected by infertility, distress is particularly apparent in women (
      • Chachamovich J.
      • Chachamovich E.
      • Ezer H.
      • Fleck M.
      • Knauth D.
      • Passos E.
      Investigating quality of life and health-related quality of life in infertility: a systematic review.
      ).
      Only in the last decade has evidence begun to emerge about how infertility affects the lives of women in low-income countries (
      • van Balen F.
      • Inhorn M.C.
      Introduction interpreting infertility: a view from the social sciences.
      ). During in-depth interviews, 30 women seeking treatment for involuntary childlessness in South Africa testified to the personal suffering caused by their inability to conceive and also to experiences of marital instability, stigmatization and abuse as a result of their childlessness (
      • Dyer S.
      • Abrahams N.
      • Hoffman M.
      • van der Spuy Z.M.
      ‘Men leave me as I cannot have children’: women’s experiences with involuntary childlessness.
      ). An assessment by the same authors of 120 women on first presentation to an infertility clinic, using the Symptom Checklist-90-R (SCL-90-R, a standardized instrument for the measurement of current psychological symptom status;
      • Derogatis L.
      Validity of the SCL-90-R.
      ), confirmed these findings: compared with fertile controls, infertile South African women had significantly higher SCL-90 scores. Furthermore, infertile women who reported that they were in abusive relationships were more distressed than infertile women in non-abusive relationships (
      • Dyer S.J.
      • Abrahams N.
      • Mokoena N.
      • Lombard C.
      • van der Spuy Z.M.
      Psychological distress among women suffering from couple infertility in South Africa: a quantitative assessment.
      ). Suffering among infertile men in South Africa has also been reported (
      • Dyer S.J.
      • Abrahams N.
      • Mokoena N.E.
      • van der Spuy Z.M.
      You are a man because you have children: experiences, reproductive health knowledge and treatment seeking behaviour among men suffering from couple infertility in South Africa.
      ). In a qualitative study describing the meaning of infertility from the perspective of infertile women in Botswana and the strategies they use to deal with infertility, the theoretical framework of ‘denying and preserving self’ was constructed (
      • Mogobe D.K.
      Denying and preserving self: Batswana women’s experiences of infertility.
      ). The denial of self included denial of status as a woman, of immortality, of the experiences of pregnancy and childbirth and of economic and social security. Women also believed that they were being punished by God and their forefathers. Strategies women used to preserve the self were aimed at preventing or reducing the harm inflicted by others as a result of the infertility (
      • Mogobe D.K.
      Denying and preserving self: Batswana women’s experiences of infertility.
      ). Studies conducted in Nigeria and Ghana revealed that women’s treatment in the community, their self-respect and understanding of womanhood depend on motherhood (
      • Hollos M.
      • Larsen U.
      • Obono O.
      • Whitehouse B.
      The problem of infertility in high fertility populations: meanings, consequences and coping mechanisms in two Nigerian communities.
      ) and that women experience social stigma, relationship problems and diminished emotional wellbeing as a result of being infertile (
      • Fledderjohann J.J.
      ‘Zero is not good for me’: implications of infertility in Ghana.
      ). Women in Ghana also described how the blame for infertility is disproportionately attributed to women (
      • Fledderjohann J.J.
      ‘Zero is not good for me’: implications of infertility in Ghana.
      ). In a study of couples in Rwanda, domestic violence, union dissolutions and sexual dysfunction were significantly more common among the 312 infertile couples than among the fertile controls (
      • Dhont M.
      • van de Wijgert J.
      • Coene G.
      • Gasarabwe A.
      • Temmerman M.
      ‘Mama and papa nothing’: living with infertility among an urban population in Kigali, Rwanda.
      ). In-depth interviews with infertile women in Jordan identified four types of adversity related to being infertile: feeling incomplete, the pressure to conceive from the social network, fear of the husband taking another wife to solve the infertility problem, and marital relationship problems (
      • Obeisat S.
      • Gharaibeh M.K.
      • Oweis A.
      • Gharaibeh H.
      Adversities of being infertile: the experience of Jordanian women.
      ). In spite of the one-child policy enforced in China, infertility in that country is associated with considerable psychosocial distress. Approximately one-third of Chinese infertile women who were seeking infertility treatment had impaired psychological wellbeing as measured by the General Health Questionnaire (
      • Goldberg D.
      General Health Questionnaire (GHQ-12).
      ) and, when treatment failed, mental health deteriorated further (
      • Lok H.I.
      • Lee D.T.S.
      • Cheung L.P.
      • Chung W.S.
      • Lo W.K.
      • Haines C.J.
      Psychiatric morbidity amongst infertile Chinese women undergoing treatment with assisted reproductive technology and the impact of treatment failure.
      ). In Taiwan, women in couples with a female cause of infertility were found to have lower self-esteem and less acceptance by in-laws than women in couples where the infertility was identified as caused by a male factor (
      • Lee T.-Y.
      • Sun G.-H.
      • Chao S.-C.
      The effect of an infertility diagnosis on the distress, marital and sexual satisfaction between husbands and wives in Taiwan.
      ). In the Middle East, women’s social status, dignity and self-esteem depend on her ability to procreate; childbearing is regarded as a family commitment (
      • Serour G.
      Attitudes and cultural perspectives on infertility and its alleviation in the Middle East area.
      ). Interviews with infertile women and key informants in the urban slum in Bangladesh revealed that evil spirits and physiological defects were perceived as leading causes of infertility and that childlessness places women at risk of social and familial displacement (
      • Papreen N.
      • Sharma A.
      • Saboin K.
      • Bergum L.
      • Ahsan S.K.
      • Baqui A.H.
      Living with infertility: experiences among urban slum populations in Bangladesh.
      ).
      Taken together, results from these and other studies indicate that the consequences of involuntary childlessness are very severe in low-income countries, particularly for women. In these settings, childless women are frequently stigmatized, isolated, ostracized, disinherited and neglected by the family and local community. This may result in physical and psychological abuse, polygamy and even suicide. Because many families in low-income countries depend on children for economic survival, childlessness and having fewer children than the number identified as appropriate are social and public health matters, not only medical problems.

      Access to infertility health care and patterns of healthcare seeking

      The ‘right of men and women to … the best chances of having a healthy child’ was endorsed at the International Conference on Women held in Beijing in 1995. In 2004 the World Health Assembly adopted the five core points of the WHO sexual and reproductive health package. One of these was the need globally for provision of high-quality services for family planning, including infertility services (
      • Sallam H.
      Infertility in developing countries: funding the project.
      ). This was followed by a stated target to ‘Achieve by 2015, universal access to reproductive health’ as one of the United Nation’s Millennium Development Goals (
      • United Nations
      The Millennium Development Goals.
      ).
      In most high- and middle-income countries, couples who experience infertility can access medical care, including assisted reproduction treatment. It is estimated that up to three-quarters of infertile couples in these settings make use of infertility-related medical care (
      • Boivin J.
      • Bunting L.
      • Collins J.A.
      • Nygren K.G.
      International estimates of infertility prevalence and treatment-seeking: potential need and demand for infertility medical care.
      ). In many European countries and in Australia, the cost is subsidized by government and health insurance schemes (
      • Chambers G.
      • Sullivan E.
      • Ishihara O.
      • Chapman M.G.
      • Adamson D.
      The economic impact of assisted reproductive technology: a review of selected developed countries.
      ). However, in most states in the USA, there are no subsidies and the cost of treatment is exorbitant. In 2002 the average cost of one treatment cycle in 25 countries was US$3518 compared with US$9547 in the USA (
      • Collins J.A.
      An international survey of the health economics of IVF and ICSI.
      ). As a result of the high cost of assisted reproduction treatment in the USA, infertility care is often unattainable for low-income groups such as immigrant Latino patients (
      • Nachtigall R.
      • Castrillo M.
      • Shah N.
      • Turner D.
      • Harrington J.
      • Jackson R.A.
      The challenge of providing infertility services to a low-income immigrant Latino population.
      ).
      In most low-income countries, assisted reproduction services are available in the private sector but they are only accessible to the wealthy elite who can afford to pay (
      • Nachtigall R.D.
      International disparities in access to infertility services.
      ). In no low-income country is the cost of a treatment cycle less than half of an average individual’s annual income (
      • Collins J.A.
      An international survey of the health economics of IVF and ICSI.
      ). After conducting a systematic review of the literature relating to out-of-pocket cost of infertility treatment in developing countries,
      • Dyer S.
      • Patel M.
      The economic impact of infertility on women in developing countries – a systematic review.
      concluded that infertility treatment is prohibitively expensive and that those who invest their scarce resources in infertility treatment risk financial ruin. In Brazil it was found that there is no public access to infertility treatment in 19/25 states (76%) and 26/39 cities (67%); the most commonly stated reasons were ‘lack of any political decision to implement services’ and ‘lack of human and financial resources’ (
      • Makuch M.Y.
      • Petta C.A.
      • Osis M.J.D.
      • Bahamondes L.
      Low priority level for infertility services within the public sector: a Brazilian case study.
      ).
      • Sundby J.
      • Mboge R.
      • Sonko S.
      Infertility in the Gambia: frequency and health care seeking.
      surveyed 800 households in Gambia with a total of 14,239 inhabitants and found that 40% of women who identified as subfertile had sought care in the formal healthcare system where only very basic investigations were offered and few treatment options were available. Furthermore, the treatment alternatives most commonly offered were curettage and cervical electro-cauterization which are unlikely to improve chance of conception and are even potentially harmful. Gambian infertile women more commonly sought help from traditional and spiritual healers than formal health care (
      • Sundby J.
      • Mboge R.
      • Sonko S.
      Infertility in the Gambia: frequency and health care seeking.
      ). In Chad, public demand for infertility care far outstrips availability; gynaecologists in public hospitals require infertility patients to seek private care, implying that infertility care is a luxury (
      • Leonard L.G.
      ‘Looking for children’: the search for fertility among the Sara of southern Chad.
      ).

      Provision of affordable infertility care

      Although attitudes among people in high-income countries towards provision of infertility care in low-income countries have been either dismissive or indifferent, with an emphasis on controlling overpopulation, members of the medical and scientific community increasingly call for action to reduce the global burden of infertility (
      • Gerrits T.
      Biomedical infertility care in low resource countries: barriers and access.
      ,
      • Hovatta O.
      • Cooke I.D.
      Cost-effective approaches to in vitro fertilization: means to improve access.
      ,
      • Ombelet W.
      Reproductive healthcare systems should include accessible infertility diagnosis and treatment: an important challenge for resource-poor countries.
      ,
      • Ombelet W.
      • Campo R.
      Affordable IVF for developing countries.
      ,
      ,
      • Vayena E.
      • Peterson H.B.
      • Adamson D.
      • Nygren K.
      Assisted reproductive technologies in developing countries: are we caring yet?.
      ). Most argue that strategies to improve education about sexual and reproductive health and to prevent infertility are paramount to reduce the prevalence of infertility. As this does not resolve the plight of infertility for those affected by it, others assert that these strategies should be coupled with provision of infertility care, including assisted reproduction treatment (
      • Geelhoed D.W.
      • Nayembil D.
      • Asare K.
      • Schagen van Leeuwen J.H.
      • van Roosmalen J.
      Infertility in rural Ghana.
      ,
      • Makuch M.Y.
      • Petta C.A.
      • Osis M.J.D.
      • Bahamondes L.
      Low priority level for infertility services within the public sector: a Brazilian case study.
      ,
      • Ombelet W.
      • Cooke I.D.
      • Dyer S.
      • Serour G.
      • Devroey P.
      Infertility and the provision of infertility medical services in developing countries.
      ,
      • Sundby J.
      • Mboge R.
      • Sonko S.
      Infertility in the Gambia: frequency and health care seeking.
      ,
      • Vayena E.
      • Rowe P.J.
      • Peterson H.B.
      Assisted reproductive technology in developing countries: why should we care?.
      ), although concern has also been expressed about the use of scarce health resources for high-tech treatment (
      • Sundby J.
      Infertility and health care in countries with less resources: case studies from Sub-Saharan Africa.
      ) and that prevention should be the primary emphasis (
      • van Balen F.
      • Gerrits T.
      Quality of infertility care in poor-resource areas and the introduction of new reproductive technologies.
      ,
      • van Zandvoort H.
      • de Koning K.
      • Gerrits T.
      Viewpoint: medical infertility care in low income countries: the case for concern in policy and practice.
      ). According to
      , the problem of involuntary infertility is made more urgent by family planning policies that rely on voluntary infertility to limit population growth. If, to improve women‘s health and maintain appropriate population growth, couples are to be encouraged to postpone childbearing and plan for widely spaced pregnancies, they need to know that help to achieve pregnancy is available to them if they experience difficulties when they want to conceive.
      To make infertility care accessible to as many people as possible, it is suggested that services for basic infertility investigations (to determine cause of infertility) and simple forms of infertility treatment (such as ovulation induction and artificial insemination) are integrated into existing reproductive health settings (
      • Ombelet W.
      Reproductive healthcare systems should include accessible infertility diagnosis and treatment: an important challenge for resource-poor countries.
      ).
      • Sallam H.
      Infertility in developing countries: funding the project.
      proposed a model with three levels of assistance: (i) a basic infertility clinic offering diagnostic tests and simple forms of infertility treatment; (ii) an advanced clinic where, in addition to the services offered in the basic clinic, IVF (the simplest procedure) and more advanced diagnostic procedures are available; and (iii) a tertiary-level infertility clinic offering specialized assisted reproduction and surgical procedures. Depending on the level of service, funding options include public–private partnership models and partnerships between the World Bank and government, donor agencies, professional societies and the World Health Organization (WHO) (
      • Sallam H.
      Infertility in developing countries: funding the project.
      ).
      In 2001 WHO recommended that infertility be considered a global health problem and stated the need for adaptation of assisted reproduction technology in low-resource countries. In response, simplified protocols have been developed. These use less potent and cheaper drugs to stimulate oocyte development, minimal monitoring, simplified culture systems and less technologically advanced equipment (
      • Aleyamma T.K.
      • Kamath M.S.
      • Muthukumar K.
      • Mangalaraj A.M.
      • George K.
      Affordable ART: a different perspective.
      ,
      • Hovatta O.
      • Cooke I.D.
      Cost-effective approaches to in vitro fertilization: means to improve access.
      ,
      • Ombelet W.
      • Campo R.
      Affordable IVF for developing countries.
      ), thereby drastically reducing the per-treatment cycle cost.
      A crucial part of implementing simplified protocols in low-income countries is that safety and effectiveness are monitored by a body independent of the clinic (
      • Cooke I.D.
      • Gianaroli L.
      • Hovatta O.
      • Trounson A.
      Affordable ART in the Third World: difficulties to overcome.
      ). While lower success rates are expected with simplified protocols, they have been shown to deliver acceptable live birth rates (
      • Aleyamma T.K.
      • Kamath M.S.
      • Muthukumar K.
      • Mangalaraj A.M.
      • George K.
      Affordable ART: a different perspective.
      ). The two most common adverse effects of assisted reproduction treatment are ovarian hyperstimulation syndrome, which is potentially lethal and is caused by fertility drugs, and multiple birth. The risk of these is eliminated in low-cost treatment models through the use of minimal ovarian stimulation and single-embryo transfer (
      • Ombelet W.
      • Campo R.
      Affordable IVF for developing countries.
      ).

      Moving towards amelioration

      While assisted reproduction services are available in the private sector in most low-income countries’ capital cities, only the very wealthy can access them. Initiatives to set up low-cost alternatives available to a broader range of people are emerging. The European Society of Human Reproduction and Embryology (ESHRE) has established the Task Force Developing Countries and Infertility (www.eshre.eu) which has the following objectives:
      (1) To raise awareness surrounding the problem of childlessness in resource-poor countries within the donor community, politicians, funding agencies and research organizations through lobbying and publishing, and the general population through information, education and counselling on infertility and its consequences.
      (2) To study the ethical, socio-cultural and economical aspects of childlessness and infertility care in resource-poor countries.
      (3) To make infertility diagnosis and infertility treatment, including assisted reproduction treatment, available and accessible for a much larger part of the population, by simplifying the diagnostic procedures and simplifying and modifying the ovarian stimulation protocols and the IVF procedures.
      (4) To work together with other organizations and societies working in the field of reproductive health to reach the goal of ‘global access to infertility care’.
      In 2010 The Walking Egg (www.thewalkingegg.com), a not-for-profit foundation promoting accessible and affordable infertility services in developing countries, was established. The Walking Egg collaborates with ESHRE and WHO to make infertility care an integral part of reproductive health care in low-income settings through innovation and research, advocacy and networking, training and capacity building, and service delivery (
      • Ombelet W.
      • van Balen F.
      Future perspectives.
      ).
      Friends of Low-Cost IVF (www.friendsoflcivf.org) is a US-based charity dedicated to alleviating the suffering caused by infertility in resource-poor settings. Friends of Low-Cost IVF was established by international assisted reproduction experts in 2011; its mission is five-fold: (i) to educate both women and men about the prevention of infertility through safe sex and the early treatment of reproductive tract infections; (ii) to establish high-quality infertility care in public hospitals in resource-poor countries and settings in a cost-effective and culturally sensitive manner; (iii) to train local clinicians, scientists and nurses as key personnel in the provision of low-cost IVF services; (iv) to monitor the success of low-cost IVF in terms of live birth rates in resource-poor settings; and (v) to empower infertile couples worldwide by making infertility care affordable, accessible and culturally acceptable.
      While these and other initiatives provide some hope for the goal of alleviating the personal suffering of infertility and improving reproductive health in low-income countries, there are still many social, political, financial and logistic barriers to overcome before this becomes a reality. In-depth interviews with key informants in Bangladesh, including stakeholders from government and non-government organizations, policy makers, donors and public health researchers, revealed that, although the need for infertility services is acknowledged, infertility is not recognized as a priority area in a healthcare system that can provide only the most basic care. Informants also pointed to the lack of technical expertise and infrastructure as barriers for infertility care in Bangladesh (
      • Nahar B.
      Invisible women in Bangladesh: stakeholders’ views on infertility services.
      ). Similar difficulties are identified in other low-income settings such as Sudan, West Africa and Vietnam (
      • Hörbst V.
      ‘You need someone in a grand boubou’ – barriers and means to access ARTs in West Africa.
      ,
      • Khalifa D.S.
      • Ahmed M.A.
      Reviewing infertility care in Sudan; socio-cultural, policy and ethical barriers.
      ,
      • Pashigian M.J.
      The growth of biomedical infertility services in Vietnam: access and opportunities.
      ).
      Although these barriers may seem insurmountable, strategies to move towards amelioration of inequitable access to infertility care have been proposed.
      • Nahar B.
      Invisible women in Bangladesh: stakeholders’ views on infertility services.
      argues that the decisions of policy makers are dependent on donor agencies allocation of funding and because donor agencies’ rely on epidemiological data to determine their funding priorities the psychosocial burden of infertility is not accounted for. She believes that increasing the body of knowledge about the adverse effects of infertility through rigorous research and strong advocacy directed at donor agencies and policy makers will help them see the need to provide funding for infertility care.
      • Khalifa D.S.
      • Ahmed M.A.
      Reviewing infertility care in Sudan; socio-cultural, policy and ethical barriers.
      suggest that decentralization of infertility care and public–private partnerships have the potential to reduce cost and improve accessibility to medical treatment for infertility in countries like Sudan. They recommend that public–private partnerships provide basic infertility investigations and treatment such as ovulation induction and intrauterine insemination in local satellite fertility centres and more technologically advanced treatment such as IVF and intracytoplasmic sperm injection in a centralized service in the capital city. This would in their view improve the quality of the public services and reduce the cost of private services.
      • Hörbst V.
      ‘You need someone in a grand boubou’ – barriers and means to access ARTs in West Africa.
      also believes that the public sector needs to engage with private providers to improve access to infertility care in West Africa. The number of private providers is increasing in West Africa and while they operate according to international standards and have comparable success rates to clinics in high-income countries, they are also aware of and able to accommodate local socio-cultural needs and wishes in their practice. To ensure that more infertile couples can benefit from the experience of established private providers, the public sector should actively involve them in initiatives to deliver affordable infertility care in West Africa (
      • Hörbst V.
      ‘You need someone in a grand boubou’ – barriers and means to access ARTs in West Africa.
      ). The importance of training local healthcare professionals in all aspects of infertility care is emphasized by
      • Ombelet W.
      • van Balen F.
      Future perspectives.
      . They recommend that training programmes run by experts from high-income countries in each of the fields of reproductive medicine, nursing, counselling, embryology and administration would allow local expertise to develop. Well-trained local experts would be able to provide safe, effective and culturally sensitive infertility care to couples in resource poor settings.

      Conclusion

      With the combined efforts of advocacy, training of local health professionals by experts in reproductive medicine from high-income countries, establishment of private–public partnerships and use of low-cost treatment regimes, reproductive health care that includes affordable infertility care is possible in resource-poor settings.

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