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Clinical, epidemiological and socio-cultural aspects of infertility in resource-poor settings: evidence from Rwanda

Book - Dissertation

BACKGROUND : Rationale: Infertility is highly prevalent in sub-Saharan Africa (SSA), affecting up to one third of couples in certain areas , but has not received the attention it deserves due to limited resources, policies aimed at reducing population growth and the high cost of modern infertility treatment. Existing data indicate that for SSA infection is the leading cause of infertility. Knowing the modifiable risk factors and their relative contribution to infertility can guide the design of cost-effective prevention measures. The bidirectional link between infertility and HIV deserves special attention because of its important consequences for HIV and reproductive health programs. Few studies have examined the HIV prevalence and sexual behaviours in infertile patients, particularly among couples. In order to improve information, education and counselling on causes and treatments of infertility and to develop guidelines for the management of infertility at all levels of healthcare, knowledge on prevailing perceptions and treatment-seeking behaviour is needed. The inability to conceive has severe consequences for the couples, especially for women, in countries where female identity, social status and security depend on the ability to produce offspring. Initiatives to make infertility care accessible in resource-poor settings are gaining momentum. Mapping the socio-cultural consequences of infertility in these settings is necessary to achieve this goal as few data exist on the socio-cultural consequences of infertility in East-Africa. Objectives: The general objective of this work was to study the clinical, epidemiological and socio-cultural aspects of infertility in Rwanda. More specifically we examined predictors and determinants for different types of infertility (female and male factor, primary and secondary infertility) and their relative contribution, including HIV and other reproductive tract infections (RTIs), past sexual and contraceptive behaviour, obstetric history and lifestyle factors. Secondary objectives included the evaluation of 1) perceptions of infertility causes, treatment-seeking behaviour and factors associated with seeking medical care as well as the response of health providers, 2) consequences of female and/or male factor infertility for men and women and 3) the outcome of infertility investigations and 18 month follow-up of infertile women and their partners in Rwanda. METHODS : Between November 2007 and May 2009 sexually-active women aged 21-45 year presenting with infertility problems at the infertility clinic of the Kigali University Teaching Hospital (n=312), and fertile controls who recently delivered (n=312) were surveyed together with their male partners in an unmatched case-control study. Participants were interviewed about socio-demographic characteristics, medical history, obstetric history, sexual behaviours, sexual functioning and were tested for HIV and RTIs. Infertile couples received also basic infertility investigations and were followed up over an 18 month period. In addition five focus group discussions were held with selected infertile participants. RESULTS : Among the STIs examined, HSV-2 and HIV infection were the most important determinants of infertility for both men and women. For women sexual violence in the past was the third most important determinant. All variables related to STIs and risky sexual behaviour were stronger associated with tubal factor infertility than non tubal factor infertility. This pattern was not observed for male factor infertility. Finally, lifestyle factors cannot predict infertility in Rwanda. Some previously unknown obstetric history predictors were identified for secondary infertility such as lack of prenatal care during the last pregnancy, unwanted pregnancies and stillbirths. A history of unwanted pregnancies was strongly associated with secondary infertility despite the fact that very few women reported an induced abortion. Obstetric events, HIV infection and other STIs all contribute equally to secondary infertility in Rwanda. In contrast with previous reports, we found that higher HIV prevalence in infertile couples is driven by secondary infertile relationships with at least one HIV infected partner in 45% of these couples. Women in secondary infertile relationships were more likely to report high risk sexual behaviour in the past including in the last year and at present than primary infertile and fertile women. Men in both primary and secondary infertile relationships reported more frequently concurrent partners over the last year than fertile men. After performing basic infertility investigations in 224 urban infertile couples, we found a high prevalence of tubal factor (70%) and male factor infertility (64%). Pregnancy rates (16%) were low after conventional therapy. Predictors for tubal infertility in women included a history of rape, early age first intercourse, HIV infection, and a history of STI symptoms in the male partner. Younger women (age 30 or below) and women with an infertility duration of less than 5 years had a significantly higher chance of becoming pregnant. When asked about the cause of their infertility, only one in four of the participants named explanations based on a medical diagnosis, often they constructed their own medical concept and cited witchcraft or God as the cause of their infertility, despite the fact that the majority (65%) of women had previously been exposed to modern medical health care. There is very little awareness of the link of infertility with high risk sexual behaviour and sexually transmitted infections (STIs). Both men and women are unlikely to attribute infertility to the male partner. Women looked for care earlier, more often and from different sources and were more likely to visit traditional healers then men. Participants reported a wide array of treatments they received in the past, often including ineffective or even harmful interventions. The investigation of the psycho-social consequences of infertility in Rwanda demonstrated severe suffering, similar to what is reported in other resource-poor countries. Although women carry the largest burden, the negative repercussions of infertility for men, especially at the level of the community, are considerable. Whether the infertility was caused by a female factor or male factor was an important determinant for the type of psycho-social consequences suffered. DISCUSSION AND CONCLUSIONS : The main limitations of this study are 1) the study population is a selection of infertile couples willing to undergo infertility investigations and of male partners willing to participate (selection bias), 2) the cross-sectional study design is unable to ascertain temporal relationships between infertility and most of the measured exposures and 3) study population is entirely urban. Despite these limitations we can draw some important conclusions and make some recommendations. In addition to the prevention of bacterial STIs, the prevention of HIV and HSV-2 has the potential to prevent an important amount of cases of tubal factor infertility in SSA. Reduced sexual violence and better post rape care has a role to play in infertility prevention, especially in areas with high prevalence of this behaviour. The study on secondary infertility indicated that improved obstetric, neonatal and paediatric care will also have a considerable impact on the rates of infertility and/or childlessness. Finally, efforts to prevent infertility should join hands with efforts to prevent HIV and unintended pregnancies. The safe sex messages used in family planning and HIV programs should teach that unsafe sex does not only increase the risk of acquiring HIV and unintended pregnancies, but can also lead to infertility. The high HIV prevalence among infertile couples indicate that voluntary HIV counselling and testing of infertile couples may identify new HIV infections and increase opportunities for HIV care and prevention. On the other hand, the link between HIV and infertility represent an opportunity and indeed an obligation to put infertility services in place. The study of perceptions and treatment-seeking behaviour of infertile couples identified a need to improve information, education and counselling on causes and treatments of infertility. Our experience with infertility investigations learned that investment in radioscopy equipment and training courses in standardized semen analysis for lab technicians can improve the quality of the diagnostic tools available. The results from both these studies indicated that guidelines for the management of infertility on all levels of healthcare should be drawn up and included in the curriculum of doctors, nurses and midwifes to avoid unnecessary or harmful treatments and to improve counselling on infertility. Since pregnancy rates are low with conventional therapy a call for affordable IVF in resource-poor countries was made. Overall, we can conclude that there is an urgent need for a more holistic approach towards reproductive health services in SSA, one that recognises the importance of reproductive failure and one that provides an integrated package of different services.
Publication year:2011
Accessibility:Closed