Infertility care challenges and opportunities in low- and middle-income countries

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We now know that infertility is an alarming modern epidemic affecting more couples than ever. One out of six couples today experience difficulty getting pregnant. People living in low- and middle-income countries (LMICs) face unique challenges when it comes to fertility care; fortunately, there are specific opportunities for infertility care in LMICs.  

Infertility is a condition previously regarded as a woman’s problem, but we now know it affects men equally. The natural approach to treating infertility solves the root causes of infertility by addressing all body systems rather than just focusing solely on the reproductive system. 

From being viewed as just an experimental procedure, IVF has evolved into a beautiful technique encompassing assisted reproductive technology. It is the apex of infertility care globally. Unfortunately, it is not readily available in low- and middle-income countries. Despite the pioneering work of IVF-ET in 1984 by Ashiru and Giwa-Osagie, followed by Accra in 2015, there are still challenges to make infertility services universally available when compared to the high-income countries.  The challenges include:

1. Limited access to care: In many LMICs, access to infertility care is limited due to factors such as a lack of specialized healthcare facilities, trained personnel, and financial constraints. The specialized infertility services are usually located in major cities such as Lagos, Accra, Nairobi, and Kampala. This results in many couples not being able to receive the necessary treatment. 

2. Stigma and cultural beliefs: Infertility is often stigmatized in many cultures, leading to social isolation and psychological distress for couples experiencing infertility. Men find it difficult to accept they have infertility issues. All the blame goes to the women. Cultural beliefs and myths around infertility can also impact willingness to seek treatment and support.

3. Lack of awareness and education: There is often a lack of understanding about infertility causes, treatments, and available services in LMICs. It can lead to delays in seeking care and missed opportunities for early intervention. Increased advocacy has opened up the gates to infertility clinics, even for patients who may have to travel long distances to get treatments such as IVF and ICSI for men with low sperm.

4. Cost of treatment: Infertility treatments can be expensive, and many couples in LMICs may not be able to afford the costs associated with IVF or assisted reproductive technologies (ART). In most LMICs, the average price of IVF-ET is about $4000. The devaluation of the currencies has made the cost equivalent to more than a year’s salary of the middle-class worker. Hence, many would have to sell a car or land for treatment.

5. Limited healthcare infrastructure: LMICs may need more healthcare infrastructure, laboratory facilities, and trained staff to provide comprehensive infertility care, including diagnostic testing and advanced treatments. In Nigeria, for example, just about six public ART Clinics are located in teaching hospitals in state capitals. The rest, well over 180 clinics, are in the private sector. Most other African countries have no public ART clinics. About three African countries, like Uganda, have just one. 

Opportunities

The good news is that despite limited resources, there are opportunities:

1. Advocacy and awareness: Increasing awareness about infertility issues and available treatments through public health campaigns and education programs can help reduce stigma and encourage more couples to seek care. In collaboration with the Merck Foundation, the African Reproductive Care Society (ARCS) has created advocacy and awareness campaigns throughout most African Countries, many of which involve the First Ladies of those countries. At present the IFFS focus is on the More Joy Campaign calling for policy makers to support access to infertility care and for employers to cover ART treatments on their health policies https://www.iffsreproduction.org/morejoycampaign/

2. Training: Investing in training programs for healthcare providers in LMICs to improve their knowledge and skills in infertility care can help expand access to quality services and ensure better patient outcomes. Support from organizations like IFFS, MERCK Foundation training fellowship, and the National Fertility Societies have been a great help. IFFS is a leader in reproductive medicine training offering numerous online and in-person educational activities https://www.iffsreproduction.org/education/

3. Service integration: Integrating infertility care into existing reproductive health services can help reach more needy couples and improve the efficiency of care delivery.

4. Public-private partnerships: Collaborations between public health agencies, non-profit organizations, and private sector entities can help mobilize resources, expertise, and funding to support infertility care programs in LMICs.

5. Research and innovation: Encouraging research initiatives and innovation in infertility care tailored to the needs and resources of LMICs can lead to the development of cost-effective and culturally appropriate solutions.

In conclusion, addressing the challenges and leveraging the opportunities in infertility care in LMICs requires a multi-faceted approach involving stakeholders at various levels, including policymakers, healthcare providers, researchers, and communities. By prioritizing investments in infrastructure, education, and awareness, it is possible to improve access to quality infertility care and support the reproductive health needs of couples in LMICs.

Oladapo A Ashiru,

Chief Medical Director Medical Art Center,

Ikeja, Lagos

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