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RHO archives : Topics : Infertility

Annotated Bibliography

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Managing infertility in developing countries

Bhatti, L.I. et al. The quest of infertile women in squatter settlements of Karachi, Pakistan: a qualitative study. Social Science & Medicine 49:637-649 (1999).
In-depth interviews with 17 infertile urban women in Pakistan found that most sought treatment early, within two years of marriage, and from then on visited various types of providers unceasingly. The women turned first to family doctors and gynecologists. As they grew increasingly desperate, some tried traditional birth attendants, herbal healers, and spiritual healers. The women changed providers frequently, without allowing adequate time for investigation or treatment, because they wanted immediate results, found the cost too great, or disliked cumbersome treatment protocols. Physicians treated infertility as a purely clinical entity and offered the women no counseling. While spouses and in-laws were generally supportive, the social pressure to have children led to stress, depression, and self-imposed social isolation. The women coped with infertility by adopting a child, finding other ways to interact with children, and taking an role in seeking treatment.

Center for Disease Control and Prevention (CDC). "Infertility." In: Family Planning: Methods and Practice: Africa. Atlanta, Georgia: CDC (2000). Available at: www.dec.org/pdf_docs/PNACH981.pdf.
After thoroughly reviewing the epidemiology and causes of infertility in Africa, this chapter discusses how a family planning or primary health clinic can provide infertility services. Family planning programs should stay up-to-date on preventing, diagnosing, and treating STIs and PID; know how contraceptive choice influences the PID risks; conduct public health education on the consequences of untreated STIs; work within the community to ensure that everyone (including youths) have access to early and confidential diagnosis and treatment of STIs; encourage condom use; and help youths identify STI risk factors. The chapter also discusses how to determine whether an infertility evaluation is appropriate based on a couple's age, menstrual patterns, and medical history and outlines an initial, two-visit infertility work-up. At a minimum, family planning programs should educate and counsel patients, gather their medical history, and provide thorough physical exams. Depending on levels of resources and training, family planning programs also may advise on fertility awareness techniques and coital timing, check for asymptomatic STIs, determine whether ovulation takes place, analyze semen, initiate treatment, and/or refer couples to infertility specialists or adoption agencies.

Fiander, A. Infertility: an approach to management in a district hospital in Ghana. Tropical Doctor 20:98-100 (July 1990).
The author offers detailed, practical advice on how to set up an infertility service that can offer effective and appropriate care for infertility with limited resources and technology. The goal is to satisfy the huge demand for infertility services efficiently and to eliminate the haphazard treatment of infertility without establishing a diagnosis or counseling the couple. The management protocol at this Ghanaian hospital requires a series of four visits to establish an accurate diagnosis, counsel the couple, and treat the condition, if possible. Although the limited treatments available have resulted in just a 15 percent pregnancy rate, the infertility service has made important contributions to the community: education and counseling has helped couples cope with their infertility, while growing awareness of women's health problems has encouraged women to seek treatment for STIs and gynecological complaints and to request family planning.

Gerrits, T. Social and cultural aspects of infertility in Mozambique. Patient Education and Counseling 31:39-48 (1997).
Semi-structured interviews with women, providers, and respected community members from the Macua ethnic group in Mozambique found that, in this matrilineal society, female relatives support infertile women in their search for a solution. All infertile women visit traditional, usually herbal healers. If that fails, about half visit the hospital where the treatment is both limited and haphazard. Women generally explain their infertility in traditional terms, as resulting from possession by spirits, witchcraft, or a poor match between the husband's and wife's blood. Most infertile woman reported having extramarital sexual relations to have a child, and more than half had a foster child. All expressed feelings of sadness and jealousy, worried that they would have no children to support them now or in old age, and felt isolated because they were excluded from some important activities and ceremonies.

Kennedy, H. et al. Enabling conception and pregnancy: midwifery care of women experiencing infertility. Journal of Nurse-Midwifery 43(3):190-207 (1998).
This overview of primary midwifery care of infertile women in the U.S. takes a holistic approach to infertility management. It considers the social, psychological, and religious ramifications of infertility, as well as the medical issues. Among the management issues discussed are: the need to take a thorough history from both members of the couple, the potential success of behavioral interventions, and the efficacy of alternative treatments such as herbal therapies.

Okonofua, F.E. et al. The social meaning of infertility in southwest Nigeria. Health Transition Review 7:205-220 (1997).
This article reports on 25 focus-group discussions held with men and women in rural and urban areas of Osun State, Nigeria, where nearly 20 percent of married women aged 15-45 are involuntarily infertile. Nearly all participants, regardless of education, believed in supernatural causes of infertility, such as witchcraft and curses. They also cited youthful promiscuity, abortions, and contraceptive use as causing infertility, along with a wide range of diseases. When prompted, participants recognized that men could suffer from infertility, but male infertility was not mentioned spontaneously. Women usually seek treatment for infertility from religious leaders and traditional healers, since they view it as a supernatural problem. If unsuccessful, women later consult medical practitioners, but there are concerns about the lack of confidentiality in hospitals. In this community, infertile individuals are considered to have failed in some fundamental way. Women, who take the blame for the problem, are cast out by their husbands for infertility and ostracized by the community. The authors call for community education on the true causes and treatment of infertility to dissipate the blame that women carry, to encourage prompt medical treatment, to discourage potentially harmful herbal treatments, and to overcome suspicions of contraceptives. They recommend that infertility treatment be integrated into primary health care.

Papreen, N. et al.. Living with infertility: Experiences among urban slum populations in Bangladesh. Reproductive Health Matters 8(15):33-44 (May 2000).
Interviews with 60 men and 60 women in a predominantly Muslim urban slum in Dhaka, Bangladesh, were conducted to investigate common perceptions of the causes of infertility, impact of childlessness, and where men and women commonly seek care. Both men and women perceived infertility in women to be caused by evil spirits or physical problems and infertility in men to be the result of psychosexual problems and physical problems. The interviewees perceived herbalists and traditional healers to be womens best treatment option. For men, however, remarriage was thought to be the best option, followed by seeking help from herbalists and traditional healers. The authors conclude that programs in Bangladesh will need to work at the community level to dispel myths about the causes of infertility and to provide accurate information about the best places to seek treatment.

Puttemans, P. et al. Reflections on the way to conduct an investigation of subfertility. Human Reproduction 10 (Suppl. 1):80-89 (1995).
In response to the rising demand and high costs of infertility treatment, the authors propose a shortened regimen for evaluating infertile couples. They outline a two-visit regimen suitable both for fertility centers in developed countries and family planning centers in developing countries. The first visit includes an exhaustive history from each partner (covering medical, surgical, social, sexual, fertility, obstetric, contraceptive, and menstrual issues); a sperm sample and physical exam for the man; and a breast and gynecological exam, vaginal ultrasound, and blood sample for the woman. The next visit includes a second sperm sample from the man and a mid-luteal endoscopy of the woman. The authors argue that this approach can conserve resources while offering a complete work-up, an accurate diagnosis, and appropriate treatment.

Rowe, P.J. Clinical aspects of infertility and the role of health services. Reproductive Health Matters 7(13):103-111 (1999).
In 1979, the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction established a Task Force on the Diagnosis and Treatment of Infertility. In addition to researching the prevalence and causes of infertility on a global basis, the Task Force developed a standardized protocol for the investigation and diagnosis of infertile couples at tertiary-level health facilities. Given the growing demand for and cost of infertility services, however, primary and secondary levels of health care also should become involved. A protocol developed in South Africa has nurses and doctors at primary health clinics initially screen infertile couples, take a menstrual history, and conduct general and pelvic exams. Unless the man cooperates, the investigation does not continue. Secondary level health facilities are responsible for basic semen analyses, postocoital tests, endometrial biopsies, testing hormone levels, and managing STIs and lower genital tract infections. Tertiary hospitals do laparascopies, detailed semen analyses, varicocele management, and ovulation induction. A fourth level of care (a specialist unit) can offer IVF, ICSI, and surgery. A primary health care approach to infertility must be tailored to local attitudes and perceptions of infertility and to the structure of the health care system. To meet the growing demand for infertility services in low-resource settings, national policies should be reviewed, services should be organized more rationally, procedures should be adapted and improved, and more efficient referral systems should be developed.

Singh, A.J. Support for infertile couples. World Health Forum 17:176-177 (1996).
This letter to the editor argues that infertility treatment should be offered as an integral part of family planning services in India in order to restore confidence in the health system and foster the acceptance of family planning. The author notes that, in India, couples may seek help for infertility prematurely because it is such a grave social stigma. He argues that public support for infertile couples could help their situation.

Stewart-Smythe, G.W. and van Iddekinge, B. Lessons learned from infertility investigation in the public sector. South African Medical Journal 93(2):141-143 (February 2003). Abstract available at: www.inasp.org.uk/ajol/journals/sam/vol93no2abs.html#3.
This study conducted a retrospective analysis of hospital records of women presenting at Johannesburg Hospital for infertility. Of 206 women, 79 (38.4%) had primary infertility and 127 (61.6%) had secondary infertility. The hysterosalpingogram (HSG) analysis showed only 38 women (18.5%) had fallopian tubes with no blockage. Of the 168 women (81%) with tubal obstruction, 65.5 percent had bilateral obstruction and 16 percent had unilateral obstruction. HSG testing has the benefits of being a simple, low-cost, and reliable method for determining fallopian tube obstruction. In contrast, laparoscopic investigation is costly, complex, and requires anesthesia and hospital admission. Of the 148 male partners in this study, 49 percent had abnormal sperm motility and 82 percent had abnormal sperm morphology upon semen analysis; however, the authors comment that semen analysis is not a realistic option in low-resource settings. Problems with compliance and the complexities of collecting and transporting the samples were frequently experienced. Because assisted reproduction treatments are often limited in developing countries, the authors make several recommendations to reduce costly and time-consuming infertility investigations for both medical staff and patients in the public sector.

Sundby, J. and Jacobus, A. "Health and Traditional Care for Infertility in the Gambia and Zimbabwe." In: Boerma, J.T. and Mgalla, Z., eds.,Women and Infertility in sub-Saharan Africa: A Multi-disciplinary Perspective. Amsterdam: KIT Publishers (2001).
Based on data from the Gambia and Zimbabwe, this chapter explores the barriers that couples face in seeking infertility treatment. Barriers identified include the costs and difficulties associated with getting to centrally located health care centers, the lack of services and medicines available, and the unwillingness of male partners to go for infertility assessment. The authors propose appropriate infertility services that could be made available at each level of a health care system and advocate for increased awareness of harmful treatment practices.

Sundby, J. et al. Infertility in the Gambia: frequency and health care seeking. Social Science and Medicine 46(7):891-899 (1988).
This survey measured both the prevalence of infertility in the Gambia and the extent to which infertile couples sought health care. In-depth interviews with infertile women, traditional leaders, traditional birth attendants, and village health workers supplement the survey findings. Nine percent of the nearly 3,000 women interviewed had some kind of fertility problem. While most had sought help from traditional healers, only 40 percent had visited a modern health care facility. Health centers and hospitals generally failed to do complete work-ups, for example, not examining the husband or omitting important tests. Most cases ended without a clear diagnosis, and the treatments offered often were irrelevant. The authors recommend collaborating with traditional healers, so that infertile clients are referred promptly to the formal health care system; improving the history-taking, screening, and counseling skills of primary health providers; and including basic infertility services in major health centers.

Sundby, J. Infertility in the Gambia: traditional and modern health care. Patient Education and Counseling 31:29-37 (1997).
A survey of a nationally representative sample of 243 infertile women, complemented by 23 in-depth interviews, examined women's perceptions of infertility in the Gambia. The women knew little about the causes of infertility: 80 percent felt that childbirth was God's will. Women's beliefs and actions varied between ethnic groups: the proportion who sought help from the formal health care system (which was viewed as a last resort) ranged from 16 percent to 50 percent. Traditional care was an important alternative for the women: 57 percent had consulted Muslim traditional healers, 53 percent had seen herbalists or other traditional practitioners, 36 percent had visited a sacred place, and 21 percent had joined a traditional fertility organization. Infertile women feared their husbands would take another wife, seek a divorce, or abandon them. Most reported psychosocial suffering, and 43 percent had a foster child.

Unisa, S. Childlessness in Andhra Pradesh, India: treatment-seeking and consequences. Reproductive Health Matters 7(13):54-64 (1999).
Detailed case studies and provider interviews complement data from a community survey of infertility in India. One-quarter of infertile women never sought help, for the most part because of the high cost (43%) or because they felt it was unnecessary (41%). Those who did seek help waited an average of 3 years after their marriage, and over half the women have been through more than one course of treatment. Their first choice of treatment was modern medical care (73%), although many cut their treatment short because they could not afford its high costs. Although 63 percent have visited at least one holy place or spiritual healer (which are cheap, readily available alternatives), most do so only after modern medical treatment fails. Ten percent had adopted a child and 12 percent intended to. While 72 percent of the women reported a harmonious marital relationship, infertility did spur some men to physical abuse or to take another wife. Actual and anticipated rude comments at social functions forced many women into becoming social recluses. They felt isolated and ashamed.

Usmani, F. Report: National Consultation on Infertility Prevention and Management. New Delhi, India: United Nations Population Fund (1999).
This report synthesizes the presentations and discussions from a 1999 UNFPA meeting on how India should address the issue of infertility. Participants were drawn from the Ministry of Health and Family Welfare, government, private sector, and NGO health programs, medical research institutions, and international agencies. The document reviews information on the epidemiology and causes of infertility as they relate to India. Recommendations include greater efforts to prevent infertility, more IEC materials on the issue, clear service delivery guidelines, training of paramedical and medical officers to manage infertile couples, and developing a partnership between private and public sectors. A four-tier system of infertility treatment was proposed, with IEC, counseling, referrals, and support groups offered at the community level. Workers at the sub-health center level would take histories, perform general and external examinations, and make referrals. A weekly infertility clinic at the primary health center level would be set up to conduct systematic infertility evaluations, including the cervical mucus test, semen analysis, basal body temperature, postcoital test, vaginal-smear exam, and STI lab tests. Services at district hospitals would be expanded to include endometrial biopsy, tubal patency tests, and diagnostic laparascopy as well as treatment for varicocele, genital tuberculosis, endometriosis, and luteal deficiency. The most advanced technology would be offered by the private sector.

Van Balen, F. and Gerrits, T.  Quality of infertility care in poor-resource areas and the introduction of new reproductive technologies. Human Reproduction 16(2): 215-219 (2001).
This opinion piece discusses the availability and quality of infertility services in developing countries. The article outlines the medical, socio-cultural, political, and economic components necessary to successfully providing even low-technology and low-cost infertility services. The article covers the emotional burden of childlessness; different cultural responses to childlessness; the benefits and drawbacks to seeking care from traditional healers and Western medical doctors; problems with implementing new reproductive technologies; and the need for formulating policies to address infertility. The author recommends several steps that can be taken to improve services, including advising couples on the timing of intercourse, training staff at all levels of the health care system, involving male partners in the medical evaluation, and raising awareness of STI prevention, harmful practices, misinformation. 

van Zandvoort, H., de Koning, K., and Gerrits, T. Viewpoint: medical infertility care in low income countries: the case for concern in policy and practice. Tropical Medicine and International Health 6(7):563-569 (July 2001).
This commentary summarizes published scientific literature as well as "grey" literature and anecdotal evidence to provide guidance on programs and policies addressing infertility in low-resource countries. The authors conclude that infertility treatments are too costly financially, physically, and emotionally for the public sector in low-resource settings. The authors advocate for investments instead in training of health care providers in simple procedures like taking extensive medical histories and providing appropriate counseling and referrals. Likewise, increased prevention efforts should be focused on the links between infertility and STIs and unsafe abortion practices. Unfortunately, there is a potential for private-sector markets to offer uniformed consumers ineffective, expensive, and potentially harmful treatments. Mass media coverage and regulatory public policies can help provide information and prevent the exploitation of infertile couples.

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Evaluating treatment options in developing countries

Anate, M. and Akeredolu, O. Surgical management of female infertility in Ilorin, Nigeria. East African Medical Journal 72(7):411-414 (1995).
The authors report their experience in treating a series of 317 infertile women with macrosurgery (mostly salpingolysis and salpingostomy) at a Nigerian hospital from 1984 to 1994. Many of the patients had postponed treatment for years and had extensive tubal damage. Because of intense pressure to operate by patients, husbands, and relatives no matter how poor the outlook, it was impossible to select patients for surgery. Each patient was followed for four years after the surgery, during which time 14.2 percent became pregnant. Outcomes were better when the damage and, hence, the surgery were more limited. Despite the low success rate, the authors contend that the hospital should continue to offer surgery for infertility, because infertility due to infection-related tubal damage is so widespread and because the desire for children is so strong.

Cheung, LP. Patient selection for assisted reproductive technology treatments. Hong Kong Medical Journal 6(2):177-183 (2000). Available at: www.hkam.org.hk/publications/hkmj/article_pdfs/hkm0006p177.pdf. Because of concern that assisted reproductive technology (ART) may be overused, this article reviews standard procedures for investigating and managing infertile couples. The author points out that conventional infertility treatments, which are generally safer, less stressful, and more affordable, may also be more appropriate for some couples than ART. The article offers detailed recommendations on treatment choices, depending on the age of the woman, the duration and causes of infertility, the availability and cost of alternative treatments, and their acceptability. The author concludes that ART is appropriate when the chance of conceiving by any other means is unacceptably low or the woman's age leaves insufficient time for other treatments.

Daar, A.S. and Merali, Z. "Infertility and Social Suffering: The Case of ART in Developing Countries." In: Vayena, E., Rowe, P.J., and Griffin, P.D., eds. Current Practices and Controversies in Assisted Reproduction: Report of a WHO Meeting. Geneva: WHO (2002).
This chapter reviews the scope of infertility in developing countries and details the negative social, economic, physical, and psychological consequences of infertility for couples in these settings. The author refutes the two common arguments against investing in ART in developing countries: (1) that developing countries are struggling with issues of overpopulation, so why invest in infertility treatment; and (2) that with scarce resources and competing health needs, investing in infertility treatment should not receive priority. The author argues that the severe suffering caused by infertility justifies an increased need for infertility treatments beyond preventive measures in developing countries.

Devroey, P. et al. Do we treat the male or his gamete? Human Reproduction 13(Suppl. 1):178-185 (1998).
This critical review of the diagnosis and treatment of male factor infertility concludes that conventional treatments of all kinds (including drugs, varicocele correction, and intrauterine insemination) are ineffective and should be abandoned. The authors contend that only intracytoplasmic sperm injection and, to a much lesser extent, in vitro fertilization are effective in treating male infertility.

Giwa-Osagie, O.F. "ART in Developing Countries with a Particular Reference to sub-Saharan Africa." In: Vayena, E., Rowe, P.J., and Griffin, P.D., eds. Current Practices and Controversies in Assisted Reproduction: Report of a WHO Meeting. Geneva: WHO (2002).
This chapter presents an overview of what types of assisted reproductive technologies (ART) are being practiced in sub-Saharan Africa. The authors gathered information through the review of publications, conference abstracts, and media, as well as through site visits and personal communication. In the nine countries included in the article, the main methods being practiced were artificial insemination by husband (AIH), donor insemination (DI), and in vitro fertilization (IVF), although all forms of ART were available to a lesser degree in the region. In Cameroon, Ghana, Nigeria, Togo, and Zimbabwe, centers that offer ART services have been established in collaboration with European, American, or Australian partners. In Benin, Kenya, and Sierra Leone, AIH treatment is offered through private physicians. Collaboration and knowledge-sharing among countries was minimal, with few physicians being aware of similar activities in neighboring countries. Few countries offered services in the public sector, and costs in the private clinics for IVF and related procedures ranged from US$1,200 to US$4,000. The authors comment that while ART has particular relevance for many couples in sub-Saharan Africa, most people have limited access to ART because of prohibitive costs and locations. The authors suggest that access could be increased by implementing social and health insurance, encouraging collaboration between the private and public sectors, and by establishing centers of excellence in the region to offer the opportunity for research as well as provide services as reasonable costs.

Goverde, A.J. et al. Intrauterine insemination of in-vitro fertilisation in idopathic subfertility and male subfertility: a randomised trial and cost-effectiveness analysis. Lancet 355(1):13-18 (2000).
This prospective study randomly assigned 258 couples with idiopathic or male subfertility to one of three treatment programs for a maximum of six cycles: intrauterine insemination (IUI) alone, IUI after mild ovarian hyperstimulation, or in-vitro fertilization (IVF). The pregnancy rate per cycle was higher for IVF (12.2%) that for IUI with or without stimulation (8.7 percent and 7.4%), but the cumulative pregnancy rate for IVF was not significantly better than for IUI. Couples in the IVF group were more likely than others to give up treatment before their maximum of six attempts. The cost per pregnancy resulting in a live birth was lower for IUI (8,423-10,661 Dutch guilders) than IVF (27,409 Dutch guilders). The authors conclude that IUI is less costly and equally effective as IVF for couples with idiopathic or male subfertility.

Guzick, D.S. et al. Efficacy of treatment for unexplained infertility. Fertility and Sterility 70(2): 207-213 (1999).
This retrospective analysis of 45 published reports examined the cost-effectiveness of alternative treatments for unexplained infertility. Pregnancy rates per cycle were 1.3 percent to 4.1 percent without treatment, 3.8 percent for intrauterine insemination (IUI) without any form of ovarian stimulation, 5.6 percent and 7.7 percent for ovarian stimulation with clomiphene citrate and gonadotropins respectively, 8.3 percent for clomiphene citrate and IUI, 17.1 percent for gonadotropins and IUI 20.7 percent for in-vitro fertilization (IVF), and 27 percent with GIFT (gamete intrafallopian transfer). The estimated cost per pregnancy for the most effective options was $10,000 for clomiphene citrate and IUI, $17,000 for gonadotropins and IUI, $40,000 for GIFT, and $50,000 for IVF. The authors conclude that the combination of ovarian stimulation and IUI should be the first line of treatment for unexplained infertility, and that clomiphene citrate is more cost-effective than gonadotropins in this regime.

Inhorn, M.C. Global infertility and the globalization of new reproductive technologies: illustrations from Egypt. Social Science & Medicine 56:1837-1851 (2003).
This article provides an overview of the expansion of new reproductive technologies (NRT) into many developing countries and, using Egypt as an example, discusses many constraints that keep NRT from being a feasible option. NRT is often the only treatment for men suffering from azoospermia or oligospermia, and for women with tubal factor infertility (the main causes of infertility in developing countries). Nevertheless, the author describes four areas that restrict access to NRT at the local level in developing countries: lack of knowledge and education about reproductive biology, class systems, gender dynamics, and local religious restrictions (such as those found in some versions of Islam). The author concludes that because of cultural and economic constraints, NRT will never be a feasible option for most couples experiencing infertility in developing countries. Since infertility has such great consequences to the social, emotional, physical, and economic well-being for many couples, the author argues that the key is to prevent the most significant preventable cause of infertility—reproductive tract infections.

Kamischke, A. et al. Conventional treatments of male infertility in the age of evidence-based andrology. Human Reproduction 13 (Suppl. 1):62-75 (1998).
This critical review of the treatment of male infertility points out that its pathogenesis is unknown, that it is not clear whether physical abnormalities are coincidental or causal, and that conventional therapies rely on speculation and clinical observation rather than systematic clinical trials. The authors argue for evidence-based medicine, discuss the elements of a good clinical trial, and review the evidence for conventional male infertility treatments. They conclude that there is a remarkable lack of evidence for conventional therapies, including varicocele corrections and hormonal treatments.

Karande, V. et al. Prospective randomized trial comparing the outcome and cost of in vitro fertilization with that of a traditional treatment algorithm as first-line therapy for couples with infertility. Fertility and Sterility 71(3):468-475 (1999).
This study randomly assigned 96 U.S. couples newly diagnosed with infertility either to in vitro fertilization (IVF) or to a standard infertility treatment algorithm (six cycles of ovulation induction and intrauterine insemination prior to the use of in vitro fertilization). Pregnancy rates were higher in the group receiving standard treatment than in the IVF group (56% versus 35%), in part because of higher rates of spontaneous pregnancies in non-treatment cycles. Costs were lower in the standard group than in the IVF group: US$16,725 versus $38,021 per pregnancy. The authors conclude that IVF is not an appropriate first-line treatment option for infertile couples.

Kasia, J.M. et al. Laparoscopic fimbrioplasty and neosaplingostomy: experience of the Yaound General Hospital, Cameroon (report of 194 cases). European Journal of Obstetrics & Gynecology and Reproductive Biology 73:71-77 (1997).
The article reports on the effectiveness of endoscopic surgery in a Cameroon hospital to treat tubal lesions causing infertility. During a three-year follow-up period, 27 percent of 194 women who underwent laparoscopic distal tuboplasties became pregnant. There was no significant difference in pregnancy rates by age, primary or secondary infertility, or duration of infertility. The authors conclude that laparoscopy offers better results than laparotomy, as well as shortening the length of hospitalization and reducing the risk of complications and adhesions. Results depend largely on the extent of damage to the fallopian tubes. When assisted reproduction techniques are not available, however, the authors argue that it is appropriate to try laparoscopy even in cases of advanced tubal disease.

Maruyama, M. et al. Pregnancy rates after laparoscopic treatment: differences related to tubal status and presence of endometriosis. Journal of Reproductive Medicine 45(2):89-93 (2000).
This study examined pregnancy outcomes in 186 infertile women after laparoscopic adhesiolysis of tubes and removal of endometriotic lesions. After 18 months, the cumulative pregnancy rate was lower among women who had bilateral tubal adhesions (13.2%) than among women with no tubal adhesions (41.8%) or unilateral tubal adhesions (45.7%). The average time to conception was shorter among women with no tubal adhesions (6.7 months) than women with unilateral tubal adhesions (10.6 months). Pregnancy rates differed depending on the severity of endometriosis among women with unilateral tubal adhesions, but not among women with no tubal adhesions.

Nicholson, R.F. and Nicholson, R.E. Assisted Reproduction in Latin America. Journal of Assisted Reproduction and Genetics 2(9) (1994).
This article reviews the 1992 pregnancy rates achieved by 45 centers in 12 Latin American countries that offer assisted reproduction technology. Their results are comparable to centers in developed countries, with a pregnancy rate per cycle of 19.7 percent for in vitro fertilization (IVF), 30.3 percent for GIFT, and 24.5 percent for other techniques. Rates are higher for younger women and for couples whose infertility is unexplained. The centers had the least success with male factor and tubal factor infertility. The authors' main criticism of these centers is the relatively high number of multiple pregnancies (7.7%), but they expect better management to reduce that rate.

Okonofua, F.E. New reproductive technologies and infertility treatment in Africa [editorial]. African Journal of Reproductive Health 7(1) (April 2003). Available at: www.inasp.info/ajol/journals/ajrh/vol7no1abs.html.
The author comments in his editorial on two recent studies from Nigeria that provide evidence that it is possible to successfully establish new reproductive technologies in low-resource settings. However, the author emphasizes that the technologies were only feasible when provided through private clinics and hospitals, with close collaboration with international partners from the United Kingdom. Overall, the author recommends that, although infertility is a major health problem disproportionately affecting men and women in Africa, scarce public health resources are better spent on prevention of infertility than on investments in high tech treatments that may fail without private sector support.

Okonofua, F.E. The case against new reproductive technologies in developing countries. British Journal of Obstetrics and Gynaecology 103:957-962 (1996).
Using the case of Nigeria as an example, the author argues that establishing centers for in vitro fertilization and other assisted reproductive techniques in developing countries does not make sense. First of all, two short-lived attempts to set up in vitro fertilization centers in Nigeria have demonstrated that, while professional expertise is sufficient, necessary infrastructure and funding are lacking. Secondly, costly reproductive technologies divert money from higher priority health problems for the benefit of only a small number of people. The author concludes that efforts to reduce the incidence of STIs, postpartum infection, and postabortion infection will help more infertile couples at less cost than assisted reproductive technologies, while also improving the general health status of the population.

Ombelet, W. et al. Intrauterine insemination: a first-step procedure in the algorithm of male subfertility treatment. Human Reproduction 10 (Suppl. 1):90-99 (1995).
The authors argue that a combination of ovarian stimulation and intrauterine insemination (IUI) should be the first choice for treating male subfertility. Refined washing techniques to remove prostaglandins, infectious agents, antigenic proteins, and non-motile sperm from semen have increased the effectiveness of artificial insemination. At the same time, IUI increases the chances of success because it bypasses the cervical mucus barrier and increases the density of sperm at the site of fertilization. After reviewing recent experience with the technique, the authors conclude that its success rates are comparable to assisted reproduction methods, while IUI is far easier, non-invasive, and less expensive. The authors outline optimal procedures.

Posaci, C. et al. Tubal surgery in the era of assisted reporductive technology: clinical options. Human Reproduction 14 (Suppl. 1):120-36 (1999).
Microsurgery and laparoscopy have improved the outcomes of tubal surgery in cases of tubal factor infertility. This article reviews the place of tubal surgery in this era of assisted reproductive technologies. The authors examine data on pregnancy rates after adhesiolysis, proximal tubal lesions, distal tubal lesions, and reversal of tubal ligation and compares with IVF. While surgery carries the risk of complications and takes longer than IVF, on average, to produce a pregnancy, it cures the condition so that a woman can have more than one child in the future. IVF is a one-shot procedure. Cost analysis is difficult and varies with countries, but surgery is slightly less expensive. The authors conclude that IVF and tubal surgery are complementary rather than competitive procedure. Adequate selection of patients is key. The authors also state that microsurgery is effective and appropriate for reversal of tubal ligation and proximal tubal obstruction, and laparosocpy for adhesiolysis. IVF should be considered for distal tubal lesions where tubal surgery frequently fails.

Sah, P. Role of low-dose estrogren-testosterone combination therapy in men with oligospermia. Fertility and Sterility 70(4):780-781 (1998).
Over a six-year period, the author tried a low-cost intervention with 14 oligospermic men in India, each of whom had a 3- to 7-year history of infertility and whose wives had normal menstrual cycles with no signs of pelvic inflammation. The men were given low doses of both estrogen and testosterone orally for 4 months. Nine of the 14 men (64%) showed definite improvement in semen quality (count, motility, and morphology); the remainder showed slight improvement. None suffered side effects. The wives of 3 patients (21%) became pregnant within six months of starting the therapy. The author concludes that this approach has promise for poor patients in developing countries who cannot afford costlier treatment.

Sheth, S.S. and Malpani, A.N. Inappropriate use of new technology: impact on women's health. International Journal of Gynecology & Obstetrics 58:159-165 (1997).
Assisted reproductive technology (ART) is one of the examples presented in this article to illustrate the inappropriate use of new technology in medicine. The authors argue that ART remains unaffordable in developing countries in part because of the pressure to mimic western methods. Techniques that could make ART less expensive, such as using the natural cycle and intravaginal culture, have not been explored in developing countries. The authors argue that both physicians and patients should evaluate the benefits of medical technology before using it.

Te Velde, E.R. and Cohlen, B.J. The management of infertility. New England Journal of Medicine 340(3):224-225 (1999).
This editorial argues that, because of the publicity surrounding assisted reproductive technology (ART), infertile couples and physicians underestimate the chances of spontaneous conception and turn to medical treatment too quickly. When couples have not conceived in three years and the female partner is age 30, the monthly fecundity rate is still 4 to 5 percent; in other words, the couple has a 40 percent chance of conceiving over the course of one year. The authors also argue that neither researchers nor infertile couples sufficiently consider the health risks or the financial and emotional impact of the multiple pregnancies associated with ART. They conclude that, in most cases, infertility treatment helps couples conceive sooner, rather than making the difference between conceiving and not conceiving. For those couples who do require treatment, the authors stress the need to minimize multiple births and other complications.

Van Voorhis, B.J. et al. Cost-effective treatment of the infertile couple. Fertility and Sterility 70(6):995-1005 (1998).
This article compares the cost-effectiveness of different infertility treatments. The cost per delivery for in-vitro fertilization (IVF) and related procedures in the United States has dropped to about US$30,000-$45,000. This does not include the high cost of caring for infants born prematurely as a result of the multiple gestations associated with IVF. Despite its expense, IVF is equally or more cost-effective than tubal surgery for women with blocked tubes, because it results in much higher pregnancy rates. Tubal surgery also carries a high risk of ectopic pregnancy. The author concludes that tubal surgery is only appropriate for women with minimal obstructions. For women with unobstructed tubes, intrauterine insemination (IUI) combined with ovarian stimulation results in a lower cost per delivery than IVF, except in cases of low sperm count. For male factor infertility, varicocelectomy and IUI are more cost-effective than IVF. The authors argue that health insurance should cover all forms of infertility treatment, including IVF, to ensure that physicians make cost-effective decisions regarding treatment and to ensure equitable access to care.

Vayena E, Rowe PJ, Peterson HB. Assisted reproductive technology in developing countries: why should we care? Fertility and Sterility 78(1):13-15 (July 2002).
This editorial discusses the advancement of assisted reproductive technologies in developing countries. The authors highlight three critical factors that influence the availability of infertility services: (1) heterogeneity of cultural and religious values and norms, financial resources, and health infrastructures in developing countries; (2) the array of infertility services, from prevention to treatment; and (3) the safety and effectiveness of infertility services provided in developing countries.

Wakeley, KE and Grendys, EC. Reproductive technologies and risk of ovarian cancer. Current Opinion in Obstetrics and Gynecology 12:43-47 (2000).
This review article examines the possibility that drugs used to induce ovulation in infertile women increase their risk of ovarian cancer. Not only do studies yield conflicting results, most also suffer from a number of limitations due to their size, duration, retrospective design, or inability to control for confounding factors. This makes it difficult to counsel infertility patients adequately. It is hoped that three large-scale cohort studies currently under way in the United States will resolve the issue.

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Reducing the psychological burden of infertility

Aghanwa, H. et al. Sociodemographic factors in mental disorders associated with infertility in Nigeria. Journal of Psychosomatic Research 46(2):117-123 (1999).
This study evaluated the mental status of 37 women referred to a Nigerian gynecology clinic for infertility and an equal number of healthy female hospital workers matched by age and marital status. The infertile women suffered from significantly higher levels of psychopathology, especially depression, than the healthy women (29.7% versus 2.7%). The infertile women had no prior history of psychiatric illness so it is likely that their mental problems were complications of infertility. Infertile women were more likely to be diagnosed with mental illness if they were part of a polygamous marriage (63.6% versus 15.4%).

Boivin, J. A review of psychosocial interventions in infertility. Social Science & Medicine 57:2325-2341 (2003).
Although many infertility specialists recommend psychosocial interventions to couples facing infertility problems, little research has been done to evaluate these interventions. In this article the author conducts a review of the available studies on psychosocial interventions in infertility to assess whether (1) psychosocial interventions benefit individuals well-being, (2) psychosocial interventions increase in pregnancy rates, and (3) whether some interventions are more effective than others. Overall, 25 studies were included and 11 met the criteria of being good quality studies. In general, almost all studies benefited the participants’ well-being to a modest degree. Evidence for an increase in pregnancy rates was scant. Only 15 studies looked at pregnancy rates as an outcome but all except one study included couples also undergoing infertility treatments. Therefore it was difficult to assess whether the psychosocial intervention was associated with a subsequent pregnancy or if it was a result of the medical intervention. Overall, 3 studies of better quality using a control group showed a positive effect on pregnancy rates while 5 showed no effect at all. Given the increasing claims that reducing stress can increase a couples’ chance of becoming pregnant, the author emphasizes the need for more research on this critical research question. Finally, a comparative analysis of intervention types suggests that educational interventions (those interventions focusing on providing information and new skills) were more effective than counseling interventions (those interventions focusing on emotional expression and discussion of issues and feelings). Given the popularity of psychosocial interventions for infertile couples and the scarcity of well-controlled studies evaluating the effect of these interventions, the author concludes by calling for more rigorous evaluations of this area.

Boivin, J. et al. Guidelines for counselling in infertility: outline version. Human Reproduction 16(6):1301-4 (June 2001).
This article briefly summarizes counseling guidelines to help fertility clinics provide counseling and increase patient-centered care. Developed and written by a collaborative process, the guidelines were developed to address a range of situations and emotions that couples seeking infertility treatment may experience. Full text of the guidelines is available on the ESHRE website at www.eshre.com.

Domar, A.D. et al. Impact of group psychological interventions on pregnancy rates in infertile women. Fertility and Sterility 73(4):805-811 (2000).
This prospective study recruited 184 women who had been trying to get pregnant for 1 to 2 years and randomly assigned them to cognitive-behavioral group therapy, a standard support group, or a control group that received routine care. The two intervention groups met for two hours each week for ten weeks. Participants in the cognitive-behavioral group received relaxation training, cognitive restructuring, methods for emotional expression, and nutrition and exercise information. Participants in the support groups updated one another on their medical and emotional status and then discussed a different topic each week (e.g., self-esteem or family relationships. After one year, pregnancy rates were significantly higher in the two intervention groups (55% and 54%) than they were in the control group (20%), and this was not due to differences in medical treatment received. The authors conclude that group psychological interventions are efficient and cost-effective interventions for infertility, but further research is needed to discover how they achieve their impact.

Greil, A. Infertility and psychological distress: a critical review of the literature. Social Science & Medicine 45(11): 679-1704 (1997).
This review article covers both the psychological causes and consequences of infertility and analyzes the methodological flaws common to most of the literature. Most researchers have rejected the idea that psychological factors can cause infertility, but there is some evidence that stress may play a role. Studies show that infertility affects self-esteem and stress but does not lead to psychopathology. Infertility is more stressful for women than men, and gender roles shape an individual's experience of infertility more than a couple's actual physical problem. The author believes that infertility can be best understood as a socially defined life crisis and argues that the psychological literature has mistakenly transformed infertility into an individual trait.

Paulson, R. and M. Sauer. Counseling the infertile couple: when enough is enough. Obstetrics & Gynecology 78:462-464 (1991).
This clinical commentary discusses how to counsel couples who, despite treatment, have not achieved a pregnancy. The authors recommend that providers discuss the options of no treatment, adoption, and the use of donor sperm or eggs from the start. They also recommend pauses in treatment, perhaps every 3 to 6 months, for the couple to reassess their options based on the provider's best estimate of their prognosis. The authors conclude that setting time limits and helping patients quit treatment is sometimes the best thing providers can do for infertile couples.

Tarlatzis, I. et al. Psychosocial impacts of infertility on Greek couples. Human Reproduction 8(3):396-401 (1993).
This study reports on 69 women and 18 male spouses attending an infertility clinic in Greece who were interviewed prior to treatment. Women and men responded to the stress of infertility quite differently. Compared with men, women were more likely to feel guilty, angry, and nervous. Women also reported more intense feelings of anxiety and depression than the men. Infertility caused marital and sexual problems in some couples. The authors conclude that infertile couples need psychological counseling.

Tuschen-Caffier, B. et al. Cognitive-behavioral therapy for idiopathic infertile couples. Psychotherapy and Psychosomatics 68:15-21 (1999).
Distress caused by infertility and its medical treatment may impair fertility by increasing marital conflict and sexual dissatisfaction, decreasing the frequency of intercourse, and possibly impairing sperm quality. This pilot study tested the impact of a psychological intervention on 17 infertile couples. The 6-month course of therapy was designed to differentiate between task-oriented and pleasure-oriented sex, to reduce thoughts of helplessness, and to improve marital communication skills. Compared with a control group, couples receiving therapy practiced timed intercourse more reliably, enjoyed greater sexual satisfaction, and experienced less helplessness, marital distress, and problem-focused thoughts. Results also suggest a positive impact on sperm quality and the live birth rate. The authors conclude that infertile couples need training in order to cope with distress and to maintain positive attitudes toward timed intercourse

Whiteford, L. and L. Gonzalez. Stigma: the hidden burden of infertility. Social Science and Medicine 40(1):27-36 (1995).
This article argues that the growth of the medical fertility industry has helped transform infertility from private agony to public stigma. After following 25 middle-class, U.S. women undergoing treatment for infertility over the course of a year, the authors found that infertile women experience shame, guilt, inadequacy, and failure and that they feel isolated and alienated from society. Four detailed case studies illustrate the lived experience of infertility. The authors conclude that infertile women suffer because they accept social norms that define them as defective and the sick role imposed by the medical industry.

Woods, N. et al. Infertility: women's experiences. Health Care for Women International 12:179-190 (1991).
This review covers women's emotional responses to infertility and to the stress of contemporary infertility treatments. Infertility undermines women's self-image and self-esteem, and infertile women experience grief, frustration, and alienation. Over the course of treatment, their feelings and coping mechanisms shift. The authors outline three ways that health care providers can help: by fostering women's self-esteem, by promoting social support networks, and by facilitating the use of coping mechanisms that reduce distress.

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