July 9, 2008 After 30 years of IVF, the rewards of treatment are still largely confined to industrialised countries and those who can afford it. Now, a Special Task Force of ESHRE has set about the immeasurable task of making fertility treatment more accessible to developing countries through a programme of pilot projects, professional awareness and involvement of government and non-governmental agencies.
The Task Force faces a huge challenge. According to a report just published in a special monograph of the journal Human Reproduction  even the most basic questions about infertility in developing countries cannot yet be answered: how should infertility be defined; how often does it occur; what is the burden-of-disease; what can be spent on health care; how cost-effective should IVF be in order to compete with other interventions . . . and so on.
However, if the task is great, the need is even greater. According to Professor Oluwole Akande from University College Hospital in Ibadan, Nigeria - who spoke at a press conference on Monday 7th July at 12.00 - infertility in developing countries raises problems beyond those known to developed nations. "In poor resource areas," he said, "the need for infertility treatment in general, and IVF in particular, is great. The inability to have children can create enormous problems, particularly for the woman. She might be disinherited, ostracised, accused of witchcraft, abused by local healers, separated from her spouse, or abandoned to a second-class life in a polygamous marriage."
The UN Population Division now estimates that 186 million women of reproductive age in developing countries (excluding China) are infertile, with more than 30% in many African countries unable to have children because of secondary infertility . Six countries in the world have primary infertility rates over 4% - all of them in sub-Saharan Africa, the highest in Cameroon (7.3%) and Central African Republic (10.5%).
The ESHRE Task Force, which is led by gynecologist Dr Willem Ombelet, of Genk, Belgium, proposes three levels of treatment, but its cornerstone is the provision of affordable IVF. Currently, one cycle of IVF treatment in Europe or the USA costs between US$ 5000 and 10,000. A system of low-cost IVF now being pilot-studied in Khartoum and Cape Town (and shortly in Arusha, Tanzania) aims to provide one cycle of IVF for less than $200.
One of the instigators of the low-cost IVF scheme, Professor Luca Gianaroli from the SISMER Reproductive Medicine Unit, in Bologna, Italy, said: "It's a different approach to IVF. We will not be able to treat every type of infertility, but many women with tubal damage as a result of infection can be helped. We're looking at a low-cost scheme and low-cost baby." The scheme has been developed by The Low Cost IVF Foundation, which also aims to provide a complete start-up package of equipment for around $25,000.
The affordable IVF programme, as proposed by Gianaroli and the Foundation, represents level two of a three-level approach to treatment proposed by the task force: level one would offer investigation and IUI in a basic health setting (with semen analysis, hormone assays, follicular scanning and ovulation induction); level two would offer IVF (and diagnostic endoscopy) in a dedicated fertility clinic; and level three would offer ICSI in an advanced IVF unit (with cryopreservation). All three approaches would be developed around existing hospitals and clinics - as is now happening with the pilot schemes.
Said Ombelet: "A universally accessible treatment service is impossible in most developing countries, but a start can be made by integrating low cost treatments into existing family health services, where opportunities exist for contraception, health education, maternity and child care, prevention and treatment of STDs and HIV. We have to make a start, and this is how we're doing it."
But the real challenge, added Ombelet, lies in galvanising the various support agencies in the both the developed world and the developing countries, and that requires health economics data and the will to accommodate infertility treatment within the overstretched lists of healthcare priorities. "People feel uncomfortable talking about it, even indignant," he said. And that, he adds, has been his experience for the past 20 years. "That's why one of the most important aims of this ESHRE Task Force is to battle the silence that exists on the issue of infertility in most developing countries, even among the media and governments. Education in reproductive health is the message we have to take to the politicians, and we have to help them on this."
- A monograph covering the full proceedings of an expert meeting on "Developing Countries and Infertility", held in Arusha, Tanzania, in December 2007, and edited by Willem Ombelet is published this month by the journal Human Reproduction (doi:10.1093/humrep/den176).
- DHS Comparative Report No. 9. Infecundity, Infertility, and Childlessness in Developing Countries; see http://www.measuredhs.com/pubs/pdf/CR
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The above story is based on materials provided by European Society for Human Reproduction and Embryology, via EurekAlert!, a service of AAAS.
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- Habbema et al. Is affordable and cost-effective assisted reproductive technology in low-income countries possible? What should we know to answer the question? ESHRE Monographs, 2008; 2008 (1): 21 DOI: 10.1093/humrep/den203
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