ESHRE Monographs - recent issues

Contents Page

2008-07-07

Introduction

Ombelet, W. — 2008-07-07

List of participants

2008-07-07

Documentation of infertility prevalence, treatment access and treatment outcomes in developing countries

Nygren, K., Zegers-Hochschild, F. — 2008-07-07

False perceptions and common misunderstandings surrounding the subject of infertility in developing countries

Ombelet, W. — 2008-07-07

Although the consequences of the problem of childlessness are more pronounced in developing countries when compared with Western societies, local health care providers and international organizations pay little attention on this issue. The limited budgets for reproductive health care are mostly restricted to family planning and mother care. The most common misunderstanding is the ‘overpopulation-issue’. It is generally believed that the expected growth of the world population puts a real burden on the issue of infertility treatment in resource-poor countries, although recent UN reports clearly show that in most developing countries the fertility rate is dropping significantly and will fall below the threshold of 2.0 by 2050. It seems that the expected population growth in developing countries in the next decades is rather due to population ageing and not to high fertility rates. Another important issue surrounding infertility in developing countries is the so-called ‘limited resources argument’. Because the problem of childlessness is a major health problem in most developing countries, a re-arrangement of the global reproductive health care budget should be requested from local governments and international organizations taking into account the urgent need for a go-together of more successful family-planning policies and affordable simplified ART methods.

Affordable assisted reproductive technologies in developing countries: pros and cons

Akande, E. O. — 2008-07-07

Infertility in developing countries is pervasive and a serious concern. In addition to the personal grief and suffering it causes, the inability to have children especially in poor communities can create broader problems, particularly for the woman. Infertility services in developing countries span the spectrum from prevention to treatment. From a societal and public health standpoint, prevention is cost–effective and is considered by many governments and public health care providers to be a priority for service delivery. While prevention remains paramount, taken alone it ignores the plight of infertile couples, including those with non-infectious causes of infertility. Two key arguments are frequently used to challenge the development of new reproductive technologies in developing countries: overpopulation and limited resources. Evidence supports the conclusion that there is a compelling need for infertility treatment beyond prevention. In many instances, assisted reproductive technologies (ART) are the last hope or the only means to achieve a child for couples. In an effort to make much needed ART to developing countries accessible and affordable, developing countries should look to public–private partnerships. Governments have a responsibility to ensure safe and effective services including the control of standards for clinical procedures and the regulation of professional practice.

Ethical issues of infertility treatment in developing countries

Pennings, G. — 2008-07-07

The provision of infertility treatment in developing countries is controversial. Reports over the last decades have inculcated in people from Western countries the belief that overpopulation is the major problem of developing countries. This paper will analyse the different arguments advanced for and against providing infertility treatment to resource-poor countries. There are two arguments in favour: reproductive autonomy and the huge burden of infertility in these countries. Pronatalism, which reigns in almost all developing countries, is to a great extent responsible for the devastating effects of infertility. The five arguments against the application of infertility treatment are overpopulation, prioritization of limited resources, prevention rather than cure, justice and equal access and risk of abuse. The importance of a person's reproductive autonomy demands that efforts should be made to enable people to determine how many children to have. This is equally true in developing countries. However, given the enormous difficulties of resource-poor countries to provide even the most basic goods, the contribution by society should be directed mostly at prevention and should depend on a strong cost reduction for assisted reproductive technology.

Is affordable and cost-effective assisted reproductive technology in low-income countries possible? What should we know to answer the question?

Habbema, J. D. F. — 2008-07-07

Decision making on infertility treatment in low-income countries (LIC) assumes answers to quite a few questions: how should the infertility problem be defined? How often does infertility occur? What is the burden-of-disease of infertility? What is the income in LIC, and what can be spend on health care? How cheap should IVF be in order to be accessible to a considerable part of the population? With what alternative health interventions should infertility treatment be compared? How cost-effective should IVF be in order to compete with those other interventions? These questions will be discussed. The emphasis is on the situation in Sub-Saharan Africa (SSA). It is concluded that a place for ART in a health care package is not straightforward. Many of the questions are not or only partially answered. Moreover, cheap and effective ART has yet to be developed and tested. From the limited evidence available for each of the questions, it could be calculated that an IVF cycle should cost between 50 and 75 dollar in order to be a candidate for the inclusion in a health package in SSA. This estimate can easily change considerably when in the future the calculations will be based on thorough research. Thus, a targeted research programme for answering the open questions, especially on quality-of-life implications of infertility in different societies, is the preferred option for facilitating the future evaluation of ART in LIC.

Involuntary childlessness: a neglected problem in poor-resource areas

Van Balen, F. — 2008-07-07

Childlessness is analysed on the individual, the national and the international level. On the individual level five categories of consequences are described: grief and sadness; social isolation and stigma; restricted rights; religious effects and economic aspects. The first category concerns individual feelings and the others are socio-cultural effects in broad-sense. In developing countries childlessness has consequences on individual and socio-cultural level. In the West consequences are mostly restricted to individual feelings. In poor-resource areas there are limited possibilities for modern biomedical treatment. Traditional medicine, with its easy access and cultural acceptation, is a serious ‘competitor’. On the national level there are few incentives and possibilities for development of adequate infertility treatment. Though local and national authorities might be sensitive to the problem, allocation of funds is mostly determined by international agencies, which consider other issues more important. On the international level Western perceptions about the urgency of health issues are still dominant. In the Western world there is little interest and understanding in the problem of ‘barrenness among plenty’ because a focus on population growth reduction and on other problems. Also, the perception of childlessness as an individual problem, makes it difficult to change this attitude. Possibilities for change are discussed.

Infertility-related reproductive health knowledge and help-seeking behaviour in African countries

Dyer, S.J. — 2008-07-07

Data from African countries indicate that men and women attribute infertility to traditional beliefs about health and disease as well as to biomedical causes, although appropriate knowledge of the latter is frequently lacking. Infertility is a dreaded condition and as a result help-seeking is often intense and persistent. Most of the help-seeking is undertaken by women and both traditional and modern biomedical health services are accessed. There are, however, many barriers to effective and affordable biomedical infertility care, many of which are related to poor resources and lack of infrastructure, and as a result the need for infertility treatment is often unmet. Advances in the quality of care require greater commitment to the problem of infertility in African countries, the provision of health education as an integral part of infertility management, the integration of infertility services into reproductive health care programmes and defining the role of assisted reproductive technologies in low resource settings. At the same time the importance of traditional health services in infertility management should be recognized.

Medical and socio-cultural aspects of infertility in the Middle East

Serour, G.I. — 2008-07-07

The Middle East (ME), an area rich in history and tradition with >300 million population, includes 18 heterogeneous countries concerning resources, income per capita, available healthcare services, population density, growth rate, birth rate, total fertility rate and life expectancy. There is a high prevalence of infertility in the ME because of post-partum infection, unsafe abortion, iatrogenic tubal and pelvic infertility, tuberculosis, schistosomiasis and high incidence of male factor infertility. It is argued that in the ME, the solution to the problem of infertility is its prevention, and population control should take precedence over infertility treatment. However, for a successful family planning program and adoption of small family norms, couples should be reassured that they will be helped to achieve pregnancy should they decide so. Prevention and treatment of infertility are of particular significance in ME because a woman social status, her dignity and self-esteem are closely related to her ability to have children. Also there is gender suffering of infertility in the ME. One of the stumbling blocks to acceptance of assisted reproductive technology (ART) as a line of treatment of infertility was the unacceptability to the main religious groups of the involvement of a third party in the act of procreation. Practices of ART in the ME have many common features and little differences. A mechanism had to be found to provide low-cost ART to the needy.

Assisted reproductive technology in Latin America: an example of regional cooperation and development

Zegers-Hochschild, F., Schwarze, J.-E., Galdames, V. — 2008-07-07

BACKGROUND

Since 1990, the Latin American Registry of Assisted Reproduction covers more than 80% of the assisted reproductive technology (ART) cycles performed regionally.

METHODS

130 centers enter their data online, and after collection, it is analyzed and published regionally.

RESULTS

This paper analyses trends in ART procedures initiated between 1990 and 2004, and babies born up to 2005. Overall, the data include 150,000 embryo transfer (ET) cycles, 33,500 deliveries and the birth of 44,978 babies. The yearly increment in initiated cycles is below other regions of the world. The economic, religious and social factors explaining this limited access to ART are discussed. Major trends include: an increase in the age of female partner undergoing treatments; a marked shift towards an increase in the use of ICSI; and a steady increase in the delivery rates per ET reaching 24.6% in IVF/ICSI cycles, and 30.7% in OD cycles. Despite a slight decrease in the mean number of ET (2.9), almost half of all births are either twins or triplets.

CONCLUSIONS

Our region is confronted with two main issues: limited access to those who can afford it; and a high number of embryos transferred resulting in almost 50% of babies born from multiple births.

Infertility in African countries: challenges created by the HIV epidemic

Dyer, S.J. — 2008-07-07

HIV infection and infertility are two common reproductive health disorders in Africa. From the perspective of infertility-related reproductive health care, the HIV epidemic has created several challenges which include reduction of fecundity, depletion of scarce health resources, creation of barriers to infertility treatment and increased suffering. Infertility in turn is a risk factor for HIV acquisition and a possible force in the spread of the HIV epidemic. Recognition of the reproductive health needs and desires of HIV-infected infertile men and women is a prerequisite for addressing these challenges. Subsequent strategies comprise the development of treatment guidelines for low-resource environments and a greater integration of HIV and sexual and reproductive health services. Where resources for infertility treatment are not available, the consequences must be critically assessed.

Modern endoscopic-based exploration of the female reproductive tract: a model for developing countries?

Campo, R., Molinas, C. R. — 2008-07-07

African experience with training courses on sperm examination

Franken, D.R., Aneck-Hahn, N. — 2008-07-07

In conjunction with the World Health Organization’s Department of Health and Research, the Department of Obstetrics and University of Stellenbosch, South Africa presented since 1997 hands-on semenology workshops for 87 health care workers from 16 Sub-Sahara African countries. The programme consists of a five-day workshop, during which participants underwent a pre-training test after which they received intensive hands-on training on sperm concentration, motility, vitality and sperm morphology. Following the workshop, all the participants were enrolled in a continuous quality control programme for sperm morphology. The morphology reading skills of 53 workshop participants that enrolled for the external quality control programme were analysed and classified over an extended period. The reading skills were monitored using 36 slides (18 sets over 48 months). Three participants (5.7%) had a poor standard of reading, 6 participants (11.3%) had a marginal standard of reading and 45 participants had an acceptable reading standard (83%). An external quality control programme can be highly successful, on condition that it is presented continuously with a 3–4 month interval between tests. Our results underline the importance of hands-on training and moreover the crucial role that follow up external quality control programmes plays in the maintenance of a technicians reading skills. This observation can be validated for all semen parameters.

Intrauterine insemination (IUI) as a first-line treatment in developing countries and methodological aspects that might influence IUI success

Ombelet, W., Campo, R., Bosmans, E., Nijs, M. — 2008-07-07

It is generally accepted that intrauterine insemination (IUI) should be preferred to more invasive and expensive techniques of assisted reproduction and be offered as a first-choice treatment in cases of unexplained and moderate male factor subfertility. Scientific validation of this strategy is rather difficult because literature is rather confusing and not conclusive. IUI is proven easier to perform, less invasive and less expensive than other methods of assisted reproduction. Effectivity has been documented in controlled studies under the condition that the inseminating motile count exceeds more than 1 million motile spermatozoa. Risks are minimal, provided the multiple gestation incidence can be reduced to an acceptable level and provided at least one tube is patent. Therefore, in developing countries, reflection on the implementation and use of IUI as a first-line treatment for most cases of non-tubal infertility seems mandatory. The costs are minimal, training is easy, quality control possible and severe complications are almost non-existing. In cases of unexplained infertility or combined male subfertility and ovulatory dysfunction, correction and/or ovarian stimulation with clomiphene citrate (CC) is probably the best strategy from a cost–benefit point of view unless CC-resistancy has been proven in which the use of low-dose gonadotrophins is necessary.

Assisted reproductive technologies: how to minimize the risks and complications in developing countries?

De Sutter, P., Gerris, J., Dhont, M. — 2008-07-07

In 2% of assisted reproductive techniques (ART) cycles complications occur. Some are preventable, some are not. In this paper, we will discuss risks and complications of the standard ‘Western’ approach in ART today and point to some measures to be taken when implementing ART in developing countries, where resources and access to medical care may be limited. Ovarian hyperstimulation syndrome (OHSS, and its thrombo-embolic complications) is responsible for the majority of cycle-related complications, followed by bleeding and infection at oocyte retrieval. ART pregnancies are complicated by first-trimester bleeding more often than spontaneous pregnancies, they are more often ectopic, but the major complication is the very high incidence of multiple pregnancies, when more than one embryo is transferred. OHSS can be prevented by screening patients at risk and by using mild or no stimulation. Simple measures can minimize the risks of bleeding or infection. Obviously single embryo transfer is the only way to avoid multiple pregnancies, which have a highly increased risk for severe maternal and neonatal morbidity and mortality (mainly due to prematurity). Special attention should be given to pre-existing pathologies. Risk minimization of ART in developing countries is not only mandatory from an economical but also an ethical point of view.

Affordable ART services in Africa: synthesis and adaptation of laboratory services

Huyser, C. — 2008-07-07

The aim of this paper is to provide information, opinions and suggestions on affordable laboratory-orientated fertility screening and treatment. Resource management to provide such services in developing countries, basic and advanced assisted reproductive services and assisted reproduction treatment (ART) of patients with sexually transmitted infections are addressed. Alternative viewpoints and parallel thinking should be encouraged to synthesize and adapt first-world ART guidelines and recommendations into safe and workable directives for developing regions. Affordable African ART programmes, devoid of commercialism, can provide essential sexual health screening services en route to safe fertility services for human immunodeficiency virus type-1 (HIV-1) serodiscordant couples (male HIV-positive), who wish to have their own biological child.

INVO: a simple, low cost effective assisted reproductive technology

Frydman, R., Ranoux, C. — 2008-07-07

INVO procedure is a simple and effective infertility treatment that uses a new device, the INVOcell. INVO can be performed in a physician's office or in a satellite facility of an IVF center. The INVO procedure consists of fertilization of oocyte(s) and early embryo development in the INVOcell placed into the maternal vaginal cavity for incubation. The vaginal cavity replaces the complex in vitro fertilization (IVF) laboratory. This study presents the specially designed device, INVOcell that has received CE Certification. INVOcell overcomes the disadvantages of the previously used prototype and makes the procedure simpler and reproducible. INVO is a proven procedure that has demonstrated comparable results to conventional IVF when comparative studies were performed. Over 800 cycles have been published worldwide that showed a clinical pregnancy rate of 19.6%. The INVO technology can be performed in an office setting with minor capital equipment. INVO is a simple low-cost procedure that can be available almost everywhere. INVO allows the treatment of a new population of infertile couples who could not benefit from IVF due to cost and availability. The participation of the patient in the process of fertilization and early embryo development is a psychological benefit that creates a high level of acceptance of INVO.

Four years of IVF/ICSI experience in Kampala (Uganda)

Platteau, P., Desmet, B., Odoma, G., Albano, C., Devroey, P., Sali, E. T. — 2008-07-07

We all know that starting and running an ART clinic is not so easy as some people might perceive from outside. Doing the same thing in the middle of Africa is even more challenging as some evidences in the Western world are not so obvious in this part of the world. We started our clinic in Kampala in 2004. The clinic was a converted apartment from a four flat building. In the beginning, we had difficulties with importing drugs, culture media and consumables; we had the feeling everybody was against us. We overcame multiple power failures, night intruders and a 20% masturbation failure, but once the first IVF/ICSI babies were born, people started to believe in the project. At present, ~250 IVF/ICSI cycles a year are done in batches, we have a successful embryo freezing programme, offer IUI/ICSI for sero discordant HIV couples and have the first babies after IVF, ICSI, testicular biopsy, embryo freezing, oocyte donation and surrogacy in Central Africa. The results are comparable to the ones in the Western world.

Affordable ART and the Third World: difficulties to overcome

2008-07-07

A coherent strategy is required, donors to cover the costs of a business plan and personnel to provide advice and training and the country must be chosen. An urban environment is preferred with a local link, ideally a University Department with an existing ART programme and a willingness to be involved. Premises, a clinician and an embryologist must be identified, appropriate training arranged and excellent communication systems put in place. Apart from arranging equipment and servicing supplies, management systems and transparent data collection processes must be established. The protocol and local variations have to be agreed. The clinic needs to be related to the local health system, referral patterns must be created and screening processes set up to develop a waiting list of suitable patients. The nature of prior treatments must be defined. At some point, there needs to be a visit of an agreed scientific adviser with or without a donor representative. The number of patients treated in an initial cohort and review details should be determined. A longer term programme, the creation of a local professional network and clear relations with the state health system need to be explored. Any of these stages may constitute difficulties to be overcome.

Infertility in developing countries: funding the project

Sallam, H. N. — 2008-07-07

Assisting developing countries in establishing infertility services is not a uniform exercise and depends on the stage of development of each country. Three levels of assistance are suggested: providing basic (level 1), advanced (level 2) or tertiary referral infertility services (level 3). At each of these levels, four activities are needed: equipping the clinics, training the staff, educating the public and running the services. Basic (level 1) clinics can be equipped by international donors, whereas level 2 and 3 clinics can be funded through a partnership between an international scientific body (WHO, ESHRE, etc.) and an international bank (World Bank, African Development Bank, etc.). Training of the medical and paramedical staff should be the responsibility of the non-profit organizations (NPOs) preferably in regional training centers. An awareness campaign is necessary to educate the public and inform them of the range of treatment available in their community and can also be funded by NPOs. Finally, the running cost of the services including the staff salaries, the cost of the investigations and medication should be the responsibility of the local government, although in many countries, this has to come from out of pocket payments.

Reproductive research in non-human primates at Institute of Primate Research in Nairobi, Kenya (WHO Collaborating Center): a platform for the development of clinical infertility services?

2008-07-07

The Institute of Primate Research (IPR; www.ipr.or.ke) is a WHO collaborating center for research in reproductive biology, infectious diseases and ecology/conservation. It includes a fully equipped surgical complex, >5000 square feet of laboratory space, a quarantaine facility, library, conference room, administrative offices, etc. More than 500 primates can be housed at IPR, mainly baboons. Reproductive research at IPR is applied to endometriosis, assisted reproduction, prevention of heterosexual transmission of HIV and includes the investigation of immunocontraceptives and placental retroviruses. Reproductive research capacities of IPR include: videolaparoscopic surgical equipment, surgical experience, endometrial biopsies and uterine flushes, ovarian stimulation, laparoscopic oocyte aspiration, hormonal analyses in baboon blood and urine, sperm assessment, in vitro culture and reproductive immunological investigations. During the last years, simultaneously with the development of baboon IVF, there have been contacts with several Kenyan gynecologists at the level of KEMRI (Kenya Medical Research Institute), KOGS (Kenyan Obstetrical and Gynecological Society), Kenyatta National Hospital and Aga Khan Hospital in Nairobi to develop clinical infertility services including low-budget high-quality IVF in Nairobi. The logic behind this initiative is that the Kenyans trained in non-human primate embryology, and IVF would be natural partners to develop human IVF in Kenya.

Patients' voice

Namusisi, R. S. — 2008-07-07

IVF in developing countries: an artist's view

Vanmechelen, K. — 2008-07-07

Message from the French Ministry of Foreign Affairs

Kouchner, B. — 2008-07-07

Message from the government of Uganda

Sajjabi, A. T. — 2008-07-07

Message from the European Commission: the role of the developed countries, a political issue

Languille, S. — 2008-07-07

Recommendations Arusha-meeting 2007

2008-07-07

Introduction

Pennings, G., Shenfield, F. — 2007-01-18

ESHRE Task Force on Ethics and Law

2007-01-18

Reproductive genetics at the crossroads of ESHRE and ESHG

Geraedts, J. — 2006-09-21

The interface between medically assisted reproduction and genetics: technical, social, ethical and legal issues*

2006-09-21

The interface between assisted reproductive technologies (ART) and genetics comprises several sensitive and important issues that affect infertile couples, families with severe genetic diseases, potential children, professionals in ART and genetics, health care, researchers and the society in general. Genetic causes have a considerable involvement in infertility. Genetic conditions may also be transmitted to the offspring and hence create transgenerational infertility or other serious health problems. Several studies also suggest a slightly elevated risk of birth defects in children born following ART. PGD has become widely practiced throughout the world for various medical indications, but its limits are being debated. The attitudes towards ART and PGD vary substantially within Europe. The purpose of this article was to outline a framework for development of guidelines to be issued jointly by European Society of Human Genetics (ESHG) and European Society of Human Reproduction and Embryology (ESHRE) for the interface between genetics and ART. Technical, social, ethical and legal issues of ART and genetics will be reviewed.