Please note: This archive was last updated in 2005.

RHO archives : Topics : Infertility

Program Examples

The infertility programs described below illustrate some of the strategies that have been developed to overcome logistical and cost constraints. Their experience also highlights lessons learned in managing infertility in low-resource settings.

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  • Colombia: Offering affordable infertility services at Profamilia.
  • Ghana: Standardizing the evaluation and treatment of infertile couples at Bawku Hospital.
  • India: Integrated infertility and family planning services at the Family Planning Association of India.
  • Pakistan: Managing infertility with limited resources at the Family Planning Association of Pakistan.

Colombia

Profamilia, a non-profit family planning and reproductive health care organization, began offering infertility services in Colombia in 1985. Its leaders believed that helping infertile couples conceive was an important component of family planning - as important as helping fertile couples contracept. The demand for affordable infertility services was great because the Social Security system did not offer any help for infertile couples, while private physicians were too expensive for most Colombians. Profamilia charges US$11 for a consultation, compared with US$70 charged by private physicians in Bogata.

The services have proven extremely popular: in 1997 Profamilia staff conducted almost 6,500 infertility consultations. Infertility services are offered only at Profamilia's nine largest centers, which are located in Colombia's leading cities. Infertile couples from small towns and rural areas travel to these urban centers for evaluation and treatment.

Profamilia staff follow a protocol based on the WHO manual for the standardized investigation and diagnosis of infertile couples (Rowe et al. 1993). Both members of the couple are evaluated in integrated male and female clinics. During the first visit, staff members collect complete histories and perform physical examinations of the man and woman. The second visit includes a sperm analysis and, depending upon its results, a hormone analysis and sonogram of the woman. A diagnostic laparoscopy is performed at a later visit, if necessary. Once a diagnosis is made, the couple is counseled about the cause of their infertility, the kinds of treatments available, and the likelihood of conception.

Profamilia offers a wide range of medical and surgical treatments for infertility, including uterine insemination and the induction of ovulation. Finding economic support for assisted reproductive technology has posed a major challenge for the program, however. Profamilia recently entered into a joint venture with REPROTEC to start a micromanipulation program to treat male factor infertility and is actively looking for grants to launch an in vitro fertilization program. In the meantime, couples who want to pursue in vitro fertilization are referred to a private group.

Lessons learned by Profamilia include:

  • Before launching infertility services, a family planning association must be recognized by the medical community as an organized and efficient program that has the ability to follow technically complex diagnostic and treatment protocols. Profamilia announced its infertility program in letters to university gynecology departments.
  • Many infertility procedures, especially assisted reproductive technology, require extremely expensive equipment and supplies. Family planning associations may want to reduce the cost by forming a joint venture with another organization.

For more information, please contact:
Dr. Juan Carlos Vargas, Calle 34 14-52, Santa f de Bogatá, Colombia
Telephone: 57-1-339-0933; Email: [email protected]

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Ghana

There is heavy demand for infertility services at Bawku Hospital in the Upper East Region of Ghana: over 1,000 infertile patients registered at the hospital over an 18-month period, and many are repeat customers (Fiander 1990). However, the hospital has limited resources, especially physician time and treatment options. In response, physicians established a special infertility clinic and a new management protocol designed to help it operate efficiently. The new infertility service sought to offer such thorough evaluations and counseling that couples would be satisfied with their diagnosis and not seek additional consultations in the years to come.

The Bawku management protocol consists of 4 visits over a 6-month period. During the first visit, providers take the couple's medical and fertility history and conduct some basic tests. Patients with STIs are treated, as are men with an abnormal semen analysis. Women are instructed to keep a simple menstrual calendar for the following 3 months. This calendar is reviewed for evidence of menstrual disorders at the second visit, and it is used to schedule a third visit between the woman's menses. The third visit includes abdominal and pelvic exams and a tubal patency test, after which the provider makes a diagnosis. During the fourth visit, the provider makes sure that the couple understands the diagnosis and prognosis, offers treatment and counseling, and, if expensive tubal surgery is being considered, makes a further investigation of tubal patency.

The impact of the Bawku infertility clinic has been more psychological than actual, given the limited treatments available. Fifteen percent of the patients at Bawku Hospital have become pregnant. Thorough education and counseling has lightened the burden of infertility for the remainder of couples, however. In particular, the knowledge that men also contribute to infertility has eased the pressure on women. The clinic also helps prevent future infertility by encouraging women to seek prompt care for STIs and gynecological complaints.

Lessons learned at Bawku include:

  • A special infertility clinic, separate from general outpatient or gynecological clinics, permits standardized case management and relevant health education talks.
  • Many time-consuming tasks, such as taking histories, counseling, and education, can be delegated to interested and trained non-physicians.
  • A pre-printed questionnaire or management protocol can ensure that all staff members follow a uniform approach to history-taking, examination, and investigation.
  • A treatment protocol can guide non-physicians in prescribing appropriate infertility treatments.
  • Health talks can educate patients about the causes of infertility, the importance of men attending infertility consultations, the menstrual cycle, and the symptoms, prevention, and treatment of STIs.

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India

The Family Planning Association of India (FPAI) began providing infertility services as early as 1952 in an effort to address an important, but neglected aspect of reproductive health. From their start in Mumbai, infertility services were extended to New Delhi, Lucknow, and Hyderabad. Today almost all FPAI clinics provide infertility services.

Counseling is the most important service provided by FPAI. When an infertile couple first registers, they are taught about the process of conception, how to detect ovulation, and possible fertile days so that they can improve their chances of conceiving by timing intercourse. The medical officer also explains the need for various diagnostic tests and, in later visits, informs the couple about the outcome of the investigation and their treatment options. Counseling is an integral component of every visit the couple makes to the clinic.

FPAI medical officers are specially trained to evaluate and treat infertile couples. They attend orientation courses and training programs at the national and local level. They follow FPAI guidelines to ensure that each couple is systematically and thoroughly evaluated. These guidelines are based on the WHO Manual for the Standardized Investigation and Diagnosis of the Infertile Couple (Rowe et al. 1993) and on inputs from FPAI's Medical Advisory Panel.

Because most clinics have very basic laboratory services, medical officers usually refer infertility clients to government and private laboratories for diagnostic tests. FPAI has negotiated discounted fees with these laboratories for couples they refer. Clients can easily afford semen analyses, blood tests, some hormone tests, and sonographic evaluations. Some couples find it too expensive, however, to go for repeat sonography for follicular study.

Once the diagnostic tests are complete, the medical officer scrutinizes the results and in difficult cases consults a senior medical volunteer or honorary before deciding on treatment. If surgery is needed, the couple is referred to a government hospital or private doctor. When couples face a poor prognosis or need sophisticated interventions such as Assisted Reproductive Technology (ART), they are repeatedly counseled about their situation and adoption is discussed along with other treatment options. If the couple chooses adoption, the medical officer supports their decision and refers them to an adoption agency.

FPAI has succeeded in providing infertility services to poor and marginalized people throughout India who have never before had access to such services. For example, many couples registered for infertility at the Comprehensive Reproductive Health for All Project had never sought help elsewhere before coming to FPAI. During 1998, FPAI clinics registered 1,314 new cases of infertility, continued to treat 1,454 existing cases, and reported 87 live births. Infertility services also have encouraged women and men to seek other reproductive health services, such as treatment for reproductive tract infections.

Despite these achievements, FPAI does face some problems in offering infertility services:

  • Little is know about the prevalence and incidence of infertility in India.
  • Misconceptions about infertility and its causes are widespread in most communities.
  • FPAI cannot afford to equip its clinics with good laboratory set ups.
  • Infertile couples must visit multiple facilities for diagnostic tests and treatments.
  • Couples drop out when infertility investigations and treatment become too expensive.

Lessons learned by FPAI include:

  • There is a large, unmet need for infertility services, and they should be an integral part of reproductive health care.
  • Family planning centers can provide infertility services with minimal additional infrastructure and personnel by relying on a strong referral network for specialized services.
  • Infertility services can become self supporting in the long run, although they must be nurtured initially.
  • Infertility services are more effective when they are coupled with an educational component.
  • Regular updating of service providers is essential.
  • Programs must devise appropriate indicators and reporting formats to evaluate infertility services.

For more information, please contact:
Dr. Kalpana Apte, Assistant Medical Director, Family Planning Association of India (FPAI), Bajaj Bhavan, 1st floor, Nariman Point, Mumbai 400021, India
Telephone: 2029080/20248513; Fax: 91-22-2029038/2048513; Email: [email protected]

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Pakistan

The Family Planning Association of Pakistan (FPAP) has offered infertility services at its clinics since the organization's inception in 1958. Today, all 81 family health clinics and 10 family health hospitals in the FPAP system provide infertility services, including counseling, explanation of the fertile period and the timing of intercourse, semen analysis, simple clinical tests (dilatation and insufflation) to assess the patency of the tubes, treatment of reproductive tract infections, and referrals to experts for special treatment. In 1985, with the help of a donor, FPAP was able to establish a special infertility unit at its model clinic in Lahore that also offers diagnostic laparoscopic services.

FPAP staff members who treat infertile couples receive basic training in infertility management. They follow a standard protocol for the diagnosis and treatment of infertility to ensure that every couple is systematically evaluated, accurately diagnosed, and appropriately treated. The number of visits that clients make varies with the cause of their problem and the treatment needed. When couples need histosalpingography, hormonal assays, or other sophisticated tests and treatments that FPAP does not offer, they are referred to government hospitals and private clinics.

There are financial constraints on the provision of every kind of health service in developing countries like Pakistan, including infertility services. FPAP clinics and hospitals charge clients only a minimal registration fee; otherwise, infertility services are provided at no cost to the couple. However, when clients are referred to outside institutions, they are responsible for the cost of the diagnostic tests and for the subsidized fee of the consultant. While there is a strong demand for assisted reproduction and other high technology interventions available in Pakistan, few of FPAP's clients can afford them.

 Despite these financial constraints and FPAP's limited facilities, its infertility services have a satisfactory success rate. In 1997, 4,328 clients sought infertility services at FPAP clinics and hospitals, and about 27 percent of them conceived. These infertility clients represented 1.6 percent of FPAP's total clientele for all health services for the year. Only 393 clients were referred to outside experts for further diagnosis and/or treatment.

During its three decades of experience with infertility services, FPAP has learned that:

  • It is possible to manage many cases of infertility, even when resources are limited.
  • Poor couples need extra services until the baby is delivered.
  • Infertility clients should have complete privacy, with in-laws excluded from the process.
  • Male doctors are essential to motivate men to undergo infertility testing.

For more information about FPAP's infertility services, please contact:
Dr. Huma Qureshi, Senior Director Medical, Family Planning Association of Pakistan, 3A Temple Road, Lahore 54000, Pakistan
Telephone: 92-42-6314215 / 42-6314625; Fax: 92-42-6368692; Email: [email protected]

For information about FPAP's Model Clinic, please contact:
Dr. Mobeen Afzal and Dr. Najmi Shamim, I/C Model Clinic, I/C CSU, 34 Lawrance Road, Lahore, Pakistan
Telephone: 92-42-6304716

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