Please note: This archive was last updated in 2005.

RHO archives : Topics : Infertility

Overview/Lessons Learned

Introduction

Between 8 and 12 percent of couples around the world have difficulty conceiving a child at some point in their lives, and in some areas that figure reaches one-third or more of couples. In developing countries, high levels of infertility may drain limited resources from health care systems as infertile couples repeatedly seek help for often insoluble problems. The social stigma of infertility weighs especially heavily on women, who bear the sole blame for barren marriages in many developing countries and may face divorce as a result.

Levels and causes of infertility

Infertility affects an estimated 60 to 80 million women and men worldwide—the vast majority of whom live in developing countries. The prevalence of infertility varies widely both between and within countries. In sub-Saharan Africa, for example, national rates range from 7 to 29 percent among women aged 20 to 44, while rates for different ethnic groups within Namibia range from 14 to 32 percent. What accounts for this variation in prevalence? Everywhere, there is a core of about 5 percent of couples who suffer from anatomical, genetic, endocrinological, and immunological problems that cause infertility. The remainder, whose numbers vary widely, are infertile largely because of preventable conditions, including:

  • Sexually transmitted, infectious, and parasitic diseases such as Chlamydia, tuberculosis, and schistosomiasis;
  • Health care practices and policies, especially unhygienic obstetric practices and unsafe abortions;
  • Exposure to potentially toxic substances in the diet or environment, such as arsenic and pesticides; and
  • Socio-cultural factors, such as close-cousin marriage, female genital mutilation, and patterns of sexual behavior.

While women's fertility problems have been more fully investigated than men's problems, men are the sole cause or a contributing factor to infertility in more than half of couples.

The leading preventable cause of infertility in developing countries is pelvic inflammatory disease (PID), which can scar the fallopian tubes, either blocking them completely or damaging the mucosa and cilia needed for them to function. PID is a common sequela to Chlamydia, gonorrhea, and other reproductive tract infections. It may also follow postpartum and postabortion infections. Prompt treatment of PID reduces but does not eliminate the risk of infertility.

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Evaluating and treating infertile couples

Overburdened clinics in developing countries often take a haphazard approach to evaluating infertile couples. Health providers may offer advice or treatments without conducting a complete evaluation, sometimes without even seeing both partners. A complete work-up should always include exhaustive histories and physical examinations of both partners as well as charts of the woman's menstrual cycles. Further procedures, such as a postcoital test or a test of tubal patency, depend upon the availability of equipment and trained personnel.

Even in low-resource settings, clinics can offer several relatively easy and inexpensive infertility treatments, including drugs to induce ovulation, antibiotics to treat sexually transmitted infections (STIs), artificial insemination with either the husband's or a donor's sperm, and counseling on how to maximize the chances of conception, for example, by timing intercourse. Surgical techniques also have shown some success in repairing tubal scarring and other abnormalities of the reproductive organs.

In developing and developed countries alike, however, attention is increasingly shifting to in vitro fertilization and other advanced technologies that recover mature ova, fertilize them in the laboratory, and then reimplant them. These techniques allow women with irreversible tubal damage to bear children and also are becoming the treatment of choice for male factor infertility. Critics question, however, whether these costly technologies, which benefit few couples, are appropriate in low-resource settings. Even in industrialized countries, cost-benefit analyses have concluded that infertile couples should first try traditional treatments before turning to assisted reproduction.

Lessons learned

For infertility, prevention is far more cost-effective than treatment. Developing countries can reduce the prevalence of infertility by:

  • Controlling RTIs by educating people about RTIs, including their link with infertility; promoting the use of condoms; counseling high-risk individuals; promptly treating infected individuals and notifying their partners; and increasing access to RTI services (see RHO Reproductive Tract Infections);
  • Preventing postpartum infections by training traditional birth attendants to use hygienic obstetric techniques and to refer potentially complicated deliveries to clinics;
  • Preventing postabortion infections by promoting effective contraception, offering treatment for postabortion complications, and, where the law allows, increasing access to safe pregnancy termination services.
  • Controlling endemic diseases by reducing the incidence of diseases like tuberculosis and schistosomiasis and promptly treating infected individuals.

Health facilities in developing countries can treat infertile couples effectively without adding substantially to existing health care costs by:

  • Insisting that men be evaluated as well as women;
  • Conducting thorough work-ups, accompanied by sensitive counseling, to avoid inappropriate treatments and to discourage couples from seeking help at multiple facilities;
  • Selecting treatments based on their probable results and costs to conserve resources;
  • Advising couples about the timing of intercourse and other behaviors, such as smoking and drinking alcoholic beverages, that can affect the odds of conception; and
  • Counseling couples so they can cope with the social and psychological burdens of infertility and, if appropriate, quit treatment and consider non-medical options such as adoption.

Family planning clinics can play an important role by:

  • Reassuring clients that family planning methods do not cause infertility;
  • Educating people about infertility to dispel local beliefs blaming infertility solely on women, to persuade individuals to seek early treatment for STIs, and to encourage infertile couples to seek help before their problems become untreatable; and
  • Offering basic infertility evaluations and treatment to demonstrate the clinic's commitment to helping people achieve their personal reproductive goals.

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