Fertility on a Shoestring - eshre


Fertility on a Shoestring - eshre

NATURE|Vol 442|31 August 2006NEWS FEATUREong>Fertilityong> on a shoestringIVF isn’t something most Westerners associate with Africa. But low-cost methods are urgentlyneeded to treat the misery of infertility rampant on the continent, says Helen Pilcher.Several years ago, Betty Chishava wasthrown out of her family home inHarare, Zimbabwe, because she failedto fall pregnant and didn’t want to sleepwith her husband’s brother. Desperate for anheir and a cure for the stigma of infertility, herhusband Herbert took a new wife. Betty wasleft penniless and alone.Betty’s story is played out in millions ofhomes across sub-Saharan Africa, where upto one-third of couples are infertile 1 and thepressure to produce children is immense. “InAfrica, a woman’s worth is defined by her fertility,”says Chishava. As the years roll by anda couple’s lack of children becomes all tooapparent, personal tragedies turn into publichumiliation and shame. Perceived as evilor cursed, a woman without a child may bebeaten and is commonly ostracized by familyand friends. Some risk the threat of HIV toconceive through sex with multiple partners.Some fake pregnancies and steal newbornbabies. Some just can’t bear it any more andtake their own lives.“If you’re a woman in sub-Saharan Africaand you don’t have a child, you’re worth lessthan a dog,” says fertility specialist WillemOmbelet from the Genk Institute for ong>Fertilityong>Technology in Belgium, who has worked inAfrica for more than two decades.Treatments for infertility are becoming availablein the developing world — but slowly. In1989, little more than a decade after the world’sfirst baby conceived through in vitro fertilization(IVF) was born in Britain, western Africahailed its first IVF success: a boy born at LagosUniversity Teaching Hospital in Nigeria. Sincethen a sprinkling of private fertility clinics hassprung up, offering high-tech treatments fromthe developed world. But the therapy is tooexpensive for most Africans.Initiatives are afoot to make fertility treatmentmore accessible. A number of scientistshave proposed methods for developing simpler,low-cost alternatives to the high-tech“We have toconvince theWestern worldthat infertility inAfrica is a realproblem.”— WillemOmbelet©2006 Nature Publishing Groupdrugs and equipment currently used for fertilitytreatments. And others are working to preventthe sexually transmitted infections thataccount for most cases of infertility. But even ascampaigners strive to make these approaches areality, they face daunting prejudice — in bothAfrica and the wider world.Perhaps the biggest stumbling block is theinsidious conviction (in Western circles) thatsub-Saharan Africa simply cannot have aninfertility problem. “Governments worldwideput money into family planning in the developingworld, but no one wants to focus oninfertility,” says Ombelet. The average couplein that region has five or six children 2 , so manygovernments think that being too fertile shouldbe the focus. And they find it hard to justifyexpensive fertility treatments in settings withfew resources that have more obvious problems,such as malaria and HIV. But scientistssuch as Ombelet insist that the problem needsto be addressed. “Infertility is consistently overlookedin aid and development work,” he says.“We have to convince the Western world thatinfertility in Africa is a real problem.”The sad thing is that much of Africa’s infertilitycould be easily prevented, as infections arethe main cause of infertility on the continent.Infections such as gonorrhoea and chlamydia975A. ROSS/GETTY IMAGES

NEWS FEATURENATURE|Vol 442|31 August 2006S. MAINA/AFP/GETTY IMAGESBundles of joy: Kenya celebrated its first IVF babies last year and clinics are springing up across Africa.often go untreated, spreading to the reproductivetubes where they cause blockages and scarring.The acceptance of one simple thing — thecondom — could change it all.But cost and cultural taboos restrict condomuse. Women, most of whom depend upon menfor economic security, find it hard to negotiatesafe sex and difficult to refuse intercourse;those who do may risk a beating. Less than 2%of married women in Africa use condoms 3 .Bodies such as the World Health Organizationhave programmes aimed at improvinggender equality and the availability of contraception.And results are shortly expected fromclinical trials of microbicide gels, which maybe effective against a range of sexually transmitteddiseases 4 .Botch jobsMeanwhile, the unplanned pregnancies thatresult from a lack of contraception poseanother threat to a woman’s fertility. Generalcontraceptive uptake among women remainslow, averaging 23% across sub-Saharan Africaas a whole, reaching just over 50% in SouthAfrica, and dropping to less than 10% inNigeria 3 . All too often, deliveries and abortionsturn into botch jobs that cause infection,says obstetrician and gynaecologist OsatoGiwa-Osagie from Lagos University TeachingHospital. He says this is the second biggestfactor in the region’s female infertility.Female genital mutilation, which is morecommon in Africa than anywhere else, carriessimilar risks. Up to 140 million womenhave had part or all of their external genitaliaremoved 5 . The practice is usually performedby traditional doctors with crude instrumentsand without anaesthetic. Resulting infectionscan spread internally.Men, of course, can also be infertile. “Butit’s always the women who are blamed,” saysChishava. Male infertility accounts for up to40% of cases of childless couples 6 . Men areusually born with their fertility problems,although infections are also a factor. And yetmale infertility is so taboo that no one willadmit it exists. Families go to great lengthsto cover it up: some resort to the traditionalpractice of getting a husband’s brother toimpregnate his wife, something Chishavarefused to agree to. Most men in Zimbabwe,and some other countries including Nigeria,would rather change their wife than admit toan infertile marriage, she says.Cheap tacticsChanging age-old prejudice is going to take awhile. In the meantime, scientists and doctorsin Africa and elsewhere are turning to IVF andother fertility treatments to help.Africa has a more-than-respectable historyin assisted reproductive technologies(ARTs). After Nigeria’s IVF success in 1989,Giwa-Osagie expected African governmentsto increase public spending on ARTs. “In termsof technology, we were just a few years behindBritain,” he says. But the people with the pursestrings prioritized other health concerns, suchas malaria and diarrhoea. Africa’s public infertilityclinics began to feel the pinch and close“In terms oftechnology, wewere just a fewyears behindBritain in 1989.”— OsatoGiwa-Osagiedown. “The service became very fragmentedand many couples ended up going from doctorto doctor,” says Nigerian fertility specialistRichard Ajayi. Those who could afford it, travelledabroad for treatment.Ajayi and others like him turned to the privatesector for funding. Venture capital secured,in 1999 Ajayi founded the Bridge Clinic inLagos. With its recently founded sister clinicin Port Harcourt, Ajayi’s clinics perform morethan 500 cycles of IVF treatment a year.The Bridge Clinic is a polished outfit withstate-of-the-art laboratories and new equipment;other places have more humble beginnings.In 2003, gynaecologist Edward Sali setup the Kampala Gynaecology, ong>Fertilityong> andMaternity Centre in Uganda. Funds were tight,so Sali turned his bedroom into the laboratory.“We had to move out,” he says.Clinical excellenceThere are now more than two dozen privatefertility clinics scattered across nine or moresub-Saharan African countries. Virtually allforms of ART practised in the West are available,with IVF and artificial insemination by ahusband’s sperm the most common. Thanks inpart to collaboration with sister clinics in thedeveloped world, success rates are approachingthose seen in the West. But there’s a problem— the cost.In Nigeria and other countries in sub-SaharanAfrica, a single IVF treatment costs aroundUS$2,500. But the minimum wage in Nigeria isjust US$52–60 a month 6 and there are a greatmany people scraping by on a dollar a day, orless. This makes IVF and other techniques toopricy for most. Ajayi estimates that only 5–10%of those who could benefit from fertility therapycan afford private treatment.So what is to be done? ong>Fertilityong> expert AlanTrounson from Monash University in Melbourne,Australia, thinks it’s time to go back tobasics. He believes that the cost of IVF couldbe slashed by replacing expensive drugs andhigh-tech equipment with safe, low-cost alternatives.And he’s drawing on experience fromveterinary medicine, paediatrics and the earlydays of IVF to do just that.Normally when a woman undergoes IVF, sheis first injected with hormones called gonadotropins,to help her produce more eggs. Shortlybefore the eggs are harvested, the womanreceives another hormone injection to help theeggs mature. The eggs are then collected usingultrasound guidance, and fertilized in the lab.The work is carried out inside a sterile cabinetcalled a laminar flow hood, before beingtransferred to a humidified, gas-filled incubatorwhere the fertilized eggs are left to dividefor a few days before being implanted.“Over the years, IVF has become tailoredto treat the Harley Street end of the market,”says Trounson. “But there’s no reason it can’tbe tweaked and simplified to create somethingthat is affordable and safe, with a reasonableoutput.”976©2006 Nature Publishing Group

NATURE|Vol 442|31 August 2006NEWS FEATUREBRIDGE CLINICAAP IMAGE/JULIAN SMITHThe Bridge Clinic in Lagos uses high-tech tools, but a converted humidicrib(right) also provides a sterile environment in which to manipulate embryos.Costly hormone injections could bereplaced with cheaper alternatives. Mostwomen use 30 ampoules of gonado tropinper treatment cycle, resulting in about a dozeneggs: the total cost is US$300–450. But thedose could be reduced or replaced with clomiphenecitrate. This drug, which was routinelyused in IVF treatments in the late 1960s, alsostimulates ovulation but produces fewer eggs.And 15 tablets cost about US$1.Softly, softlyCritics of clomiphene citrate caution that it cansometimes damage the uterus lining, makingembryo implantation less likely. But advocatessay that the ‘softer’ drug is less likely to triggerovarian hyperstimulation syndrome, a rare sideeffect of gonadotropin therapy that can causediarrhoea, vomiting and breathing difficulties.In the early 1980s, Trounson managed aroughly 5% live birth rate using clomiphenecitrate, and antenatal care and tissue-culturetechniques have come a long way since then.Research is ongoing, but Ombelet estimates thatthree cycles with clomiphene citrate should beas effective as two cycles with gonadotropins.Slashing the price of drugs means nothing,however, if doctors cannot afford the equipmentneeded to fertilize and nurture the eggs.Western IVF laboratories are replete with technologythat costs tens of thousands of dollars,but much of it can be done away with.In place of the laminar flow hood, Trounsonsuggests using a ‘humidicrib’ — a plastic boxmore commonly usedfor keeping newbornssnug. It’s a tenth ofthe price and can bemodified to create aportable, near sterileenvironment in which to handle embryos.And instead of incubating the embryoswith carbon dioxide from an expensive cylinder,Trounson recommends exhaling acrossthe culture media before sealing it in a plasticbag, a technique commonly used in veterinaryIVF. Then remove the need for an incubatorby dropping the bag containing the the Petridish into a warm water bath. Such ‘submarineincubators’ have been used for cow embryosfor more than a decade. “People didn’t think touse it in an IVF setting because it’s not seen tobe sophisticated enough,” says Trounson.Pilot studies are needed to assess the safetyand efficacy of such low-cost IVF protocols.Unfortunately, a lack of awareness, cash andpolitical push means this is not happening. So“There’s noreason IVF can’tbe tweaked tobe affordable.”— Alan Trounson©2006 Nature Publishing GroupTrounson and others are lobbying hard to putAfrican infertility on the international agenda.Ombelet is organizing a meeting in Arusha,Tanzania, in February 2007, where scientists,clinicians, ethicists, policy-makers and women’sorganizations will draw up a plan of action.And the Nigerian ong>Fertilityong> Society is draftingguidelines on infertility treatments, which ithopes will be accepted by its government.As awareness increases, it is hoped thatgovernment money will trickle back to fundpublic infertility clinics. Such low-cost IVFcould help millions of women. But governmentsupport and publicly funded clinics willmean little if the social stigma is not tackled.“Women have no voice in Africa,” says Ombelet,“so raising the status of women may be thehardest job of all.”Home truthsThat’s where Chishava comes in. When shewas thrown out of her family home, she realizedthat there was a need for female counsellingand education. So six years ago, she setup the Chipo Chedu Society (meaning ‘ourgift’ in her language). The organization aimsto help childless women become financiallyindependent, teaching them practicaland business skills such as batikand bookkeeping. It puts women intouch with medical experts and fightsprejudice through rural workshopson infertility. The society has morethan 500 members and Chishavahopes to see her network spreadacross Africa.Chishava has since been reunitedwith her husband. His second andthird marriages failed to produce children,and he gradually accepted that he wasinfertile. He apologized to Chishava and fullysupports her work. Now 54, Betty is motherto five children — all given to her by familymembers — but she would dearly love to havea child of her own and is intrigued by IVF.Until that happens, Chipo Chedu is her truebaby. “I will only find peace of mind when theprogramme flourishes,” says Chishava. “If myneighbour has no children, then their problemis my problem.”■Helen Pilcher is a science writer based inNottinghamshire, UK.1. Daar, A. S. & Merali, Z. Infertility and Social Suffering:the Case of ART in Developing Countries (World HealthOrganization, 2001); available at http://www.who.int/reproductive-health/infertility/5.pdf2. UNICEF ong>Fertilityong> and Contraceptive Use (2001); availableat http://www.childinfo.org/eddb/fertility/index.htm.4. UN World Contraceptive Use (2003); available athttp://www.un.org/esa/population/publications/contraceptive2003/wcu2003.htm3. Pilcher, H. Nature 430, 138–140 (2004).5. World Health Organization factsheet 241 (2000);available at http://www.who.int/mediacentre/factsheets/fs241/en6. Giwa-Osagie, O. F. ART in Developing Countries withParticular Reference to Sub-Saharan Africa (World HealthOrganization, 2001); available at http://www.who.int/reproductive-health/infertility/6.pdfSee also Editorial, page 957.977A. TROUNSON

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