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The place of ART in Africa

Serour, Gamal I., MDa,b,; Serour, Ahmed G., MDa,b; El Faysal, Yehia, MDb,c; Islam, Youmna, MDb,c

Global Reproductive Health: July 2019 - Volume 4 - Issue 2 - p e27
doi: 10.1097/GRH.0000000000000027
Brief Report
Open

Since the birth of Louis Brown on July 25th, 1978 through in vetro fertilization, assisted reproductive technology (ART) now is widely used for the treatment of both male and female infertility. Today globally almost 2 million ART cycles are performed every year. Although Africa constitutes 16% of the world population, yet its share of ART is much less than its fair share of 320,000 cycles per year. There are several barriers to the wide application of ART in Africa. These include epidemiological, geographic, financial, and socio-cultured barriers in addition to the health education barrier, restrictive health policy barrier and health systems barrier. In Africa there is an increasing demand for ART. Africa, like many parts in the world, is witnessing a changing life style which affects fertility. In Africa infertility is a medico-socio cultural problem with sex-based sufferings. Furthermore there is a higher prevalence of STIs and postpartum and postabortion infections which contributes to both male and female infertility. This coupled with the fact that treatment of infertility is a human right issue which should not be discriminated on economic, geographic, or racial basis, necessitates finding ways to overcome such disparity in the provision of ART for infertile patients in Africa. The paper discusses the various possible ways to improve availability and access to ART in Africa. The infertile couples in Africa should not suffer the health, psychological, and societal burden of infertility simply because others in the African continent reproduce too many. The 2030 SDGs agenda has envisaged a better future. One where we collectively tear down the barriers and correct disparities, focusing first on those left further behind.

aInternational Islamic Center For Population Studies and Research, Al Azhar University

bThe Egyptian IVF&ET Center

cDepartment of Obst&Gynec, Cairo University, Cairo, Egypt

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Submitted during the IFFS International Symposium, Kampala, Uganda, March 1–2, 2018.

Published online 18 March 2019

Corresponding author. Address: International Islamic Center For Population Studies and Research, Al Azhar University, Cairo 1200, Egypt. Tel.: +(202) 25755869; fax: +(202) 25754271. E-mail address: giserour1@link.net (G.I. Serour).

This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0/

Received August 9, 2018

Accepted September 11, 2018

The Universal Declaration of Human Rights 1948 in its Article 16:1 indicated that men and women of full age, without any limitation due to race, nationality or religion, have the right to marry and found a family. The human right of infertile couples to access infertility treatment, including assisted reproductive technology (ART), is consistent with the 1948 UN Declaration of human rights, the 1994 ICPD Cairo and the 2004 World health Assembly reports.

In Africa infertility is not only a medical problem associated with disability but it is also a socio-cultural and economic problem associated with sex-based sufferings including, fear, guilt, self-blame, depression and helplessness, social violence and isolation, total loss of social status, economic deprivation, disinheritance, increased ST1/HIV risk, starvation/disease/suicide, and intimate partner violence (2015)1,2. In Africa it is often said that infertility leads to a kind of social death of the infertile couple particularly the woman which makes provision of infertility treatment including ART so vital3.

Provision of effective infertility services including ART is consistent with the objectives of the Global Strategy for Women’s Children’s and Adolescents health 2016–2030; no one is left behind. However, there is a distinct inequity in access to ART within and between countries despite the increased demand for ART in Africa4.

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Needs and utilization

In Africa there is a high prevalence of tubal and malefactor infertility due to high prevalence of Sexually Transmitted Diseases (STDs), postpartum, and postabortive infections, tuberculosis, and iatrogenic infertility, increasing the need for ART as it is the most effective treatment in these cases5.

The optimal global need for ART is at least 1500 cycle/mppy6,7. In Sub-Saharan Africa the utilization of ART in 2010 was 87 cycle/mppy compared with 474 cycle/mppy and 900 cycle/mppy for global and Europe utilization, respectively8. In 2014 the contribution of Africa to the 1,647,777 ART cycles reported globally was only 1%9. The minimal optimal need of the 1.25 billion (16% of global population)10 inhabitants in Africa is 1,875000 cycle. Africa’s fair share of the reported global utilization of ART in 2014 is 256,000 cycle (1.647.777X 16/100). Both figures reflect the huge shortage of ART service for the infertile couples in Africa.

Less than one third of Sub-Saharan African nations hosted in vetro fertilization (IVF) clinics (15/48 nations—31% as of 2010)11. The IFFS Surveillances have shown that despite massive global expansion of ART services over the past decade (2005–2014) ART remains inaccessible in many parts of the world, particularly in Sub-Saharan Africa, Eastern Europe, mid-central and Southern Asia, and Latin America11,12. In countries where ART is not sponsored or subsidized by the State or health insurance, as is the case in most of the African countries, most patients will not be able to have access or a complete access to ART and having ART involves a huge financial burden for the couple2,13,14. In countries where ART service exists a large percentage of couples paying for ART out of their pocket will stop after having the first or second ART cycles and before they succeed to have a baby15.When ART service was implemented in Egypt in the private sector 90% of patients felt the cost was too high. A total of 60%–85% of private patients could afford to have the first cycle of ART. However, 60 % of those who did not get pregnant after the first cycle could not afford to have a repeat cycle13,16. In Uganda, with a high infertility prevalence, an IVF service provider run by the Women’s International Hospital relied on foreign doctors from Belgium, Kenya, and Nigeria who flew in and out of the country. This raised the cost and was not sustainable17.

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Barriers in access to ART in Africa

There are several barriers in access to ART in Africa which include:

Epidemiological barriers: in Africa there is lack of population level database that accurately defines the burden of infertility, need for ART, recording, and auditing and difficulties in access to ART service. Only 6 African countries; Cameron, Kenya, Mali, Nigeria, SA, and Senegal could be included in the overall analysis of data by IFFS18 and only 13 African countries participated in the ICMART 2014 report (Benin, Cameron, Egypt, Ghana, Ivory coast, Mali, Mauritius, Morocco, Nigeria, Senegal, SA, Togo, Tunisia)9.

Geographic barrier: disparity of ART services available in different countries exists between the rich and the poor countries, and between urban and rural regions in the same country.

Financial barrier: in Africa there is lack of resources to establish public ART centers and lack of financial coverage of ART service by the States or the private insurance in almost all African countries resulting in substantial out-of-pocket expenses in the private sector, and ART becomes available mostly for the elite and rich couples.

Socio-cultural and religious barrier: cultural, religious, and societal perception of the diagnosis of infertility and acceptance of ART as an effective line of treatment of infertility, is a barrier to access ART in many African countries. A Questionnaire of 257 Women Attending gynecologic clinics in Nigeria has shown that knowledge and awareness of ART service as a treatment of infertility is poor. Only 46 % were aware of ART. In all, 73.5% (of the 46%) would opt for it and 35.6% found the cost was high for them. A total of 31.1% of them did not believe in ART and said only God gives babies and 25.6% thought that ART babies are artificial19.

Lack of health education barrier: limited knowledge of the public, patients, and even health care providers (HCPs) of the magnitude of the problem of infertility, its impact on health and quality of life and its prevention and treatment is a barrier to access ART and increases the need for ART20. Africa is not an exception to the rest of the world in this regards, as shown in previous studies in Sweden and United Kingdom21,22.

Restrictive health policy barrier: many governments in Africa do not recognize infertility as a disease and a cause of disability. Frequently resources are not allocated for establishing and sponsoring ART services. A tacit eugenic view is that infertile people in Africa should be denied treatment, as this contradicts with population control policy. Most philanthropic, NGOs, and international Reproductive Health organizations do not mention or support infertility care in Africa23.

Establishing ART center barrier: establishing ART centers needs expensive imported equipment, disposables, drugs, uninterrupted power supply, quality control and highly trained personnels including reproductive endocrinologists, embryologists, and researchers. In Africa qualified HCPs are usually either not available or migrate to HICs for a better professional career.

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How can we reduce need and improve access to ART in Africa?

Streamline infertility perception

Political leadership, donors, international organizations, philanthropic, NGOs, societies and HCPs should give up the misperception that access to infertility care is a life style choice rather than a Human Right issue24.

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Political commitments

Policymakers should be convinced that health is not merely the absence of disease or infirmity (WHO constitution). Infertility is recognized by WHO and WB as a disease and is the 6 on the list of disability. Infertility sufferings negatively affect population control policy25–27. Adoption of a small family norm makes the issue of involuntary infertility more pressing. If couples are urged to postpone or widely space pregnancies, it is imperative that they should be helped to achieve pregnancy when they so decide25.Policymakers should recognize that infertility care including ART is an integral part of RH care highlighted in SDG 3.74.

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Health education

Health education of the public and HCPs on ART and the impact of age, delayed childbirth, life style, and sexual behavior on fertility will reduce the need and increase acceptability and access to ART.

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Empowerment of women

Women should be empowered to protect themselves from unsafe abortion, Post Partum Infection, Post Abortive Infection, STDs, and HIV. When infertility occurs they are not to suffer from its medical, social or economic consequences.

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Prevention of infertility

In Africa it is important to prevent infertility by preventing and early treatment of Post Partum Infection, Post Abortive Infection, unsafe abortion STDs, iatrogenic infertility, tuberculosis, and schistosomiasis which are among the prevailing causes of infertility in Africa27,28.

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Mobilization of resources

It is often argued that if limited health service resources are utilized to provide expensive ART service, the opportunity is lost for using these resources to provide basic health care needs to the greatest sector of population of the country violating the ethical principle of utility2. However, not providing ART service to the infertile couples would be unjust, unethical, and violates the principle of Human Rights. Every effort should be made to support providing ART and to reduce ART cost2.

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Reducing cost of ART

Reducing ART cost by all possible means is important to increase access to ART in Africa. Simplified culture systems (Ombelet, Belgium)29,30, INVO cell and vaginal IVF incubator (Doody, USA) which consists of fertilization of oocyte(s) and early embryo development in the INVO cell placed into the maternal vaginal cavity for incubation31, soft stimulation protocols and MNCs, charitable and donation projects (Traunson, USA), establishing ART units in public sectors (AZHAR-ART), and Cairo University ART Units, South–South collaboration and training (AZHAR-ART unit) are all measures to decrease cost of and increase access to ART in Africa2.

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Capacity building of African countries

FIGO RMC developed infertility tool box to identify a structured program of advocacy, health education, prevention of infertility, individual and societal support, and access to specialized health professionals to encourage appropriate lifestyle, evidence-based treatment and referral system for infertility treatment32. Al Azhar University ART unit established a training program on ART and management of infertility in developing countries since 2007. An annual workshop is held every year for 40–50 clinicians and embryologists. Ten Workshops were held between 2007 and 2017 in which various international organizations as IFFS, FIGO RMC, ESHRE, WHO, Lubeck University, ICMART, SEUD, and the Egyptian Fertility and Sterility Society participated. More than 500 candidates were trained from 14 developing countries mostly from Africa. These included the following numbers from different countries: 12 from Nigeria, 10 from Sudan, 2 from Uganda, 2 from Tanzania, 2 from Ghana, 2 from Ethiopia, 1 from Kenya, 1 from Zambia, 3 from Libya, 3 from Yemen, 2 from Syria, 2 from SA, and 1 from Qatar. These participants went back to their own countries and established ART units in their institutions. Many of them came back to Al Azhar ART unit, for further training and updating, where they spent periods varying between 2 weeks and 6 months.

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Conclusions

In Africa infertility is a health problem of considerable socio-cultural and economic impact. It needs to be prevented and alleviated by various measures including ART and other EB alternatives where appropriate. In Africa establishing an enabling environment of political commitments, health education, capacity building, low-cost ART, empowerment of women and international collaboration of all stakeholders including WHO, IFFS, FIGO, ESHRE ASRM, Philanthropic, NGOs, regional and national societies, and the private sector are essential to alleviate the sufferings of infertile couples and improve equity and access to ART in Africa.

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Keywords:

Africa; ART; Barriers; Access

Copyright © 2019 The Authors. Published by Wolters Kluwer on behalf of the International Federation of Fertility Societies. All rights reserved.