|Ahead of print publication
Challenges with assisted reproductive technology (ART) in sub-Saharan Africa
Preye O Fiebai, John I Ikimalo
Department of Obstetrics and Gynaecology, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria
|Date of Submission||18-Jun-2022|
|Date of Acceptance||22-Jul-2022|
|Date of Web Publication||05-Sep-2022|
Preye O Fiebai,
Department of Obstetrics and Gynaecology, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State
Source of Support: None, Conflict of Interest: None
Sub-Saharan Africa is one of the regions with the highest prevalence of infertility in the world. Despite the high prevalence of infertility in sub-Saharan Africa, it is the region with the least number of assisted reproductive technology (ART) facilities in the world. The challenges facing the rapid development of ART in sub-Saharan Africa stem from the socioeconomic, political, religious, and cultural background and the ethical issues surrounding the practice of ART. The establishment of ART centers in this subregion is a welcome development because it creates awareness and improves access to care and follow-up with the technological advancements in other regions of the world. However, the society has the responsibility to ensure that the advances made through ART are implemented in a socially responsible and acceptable manner. National governments should address the infrastructural problems such as power, roads, security, manufacturing, importation clearance, and healthcare facilities in their subregions. At the regional levels, training centers should be established across the region for proper formal training for all cadres of ART practitioners—doctors, embryologists, nurses, counsellors, and administrative staff. The governments of the various countries in sub-Saharan Africa should encourage, regulate, and control the practices of ART in line with local sociocultural norms.
Keywords: Assisted reproductive technology (ART), challenges, infertility, regulation
| Introduction|| |
There are more than 186 million people worldwide with infertility, majority of whom live in Central and Eastern Europe, South and Eastern Asia, the Pacific, and sub-Saharan Africa. The sub-Saharan Africa region is the geographical area of the continent that lies south of the Sahara desert. It is made up of 46 out of the 54 African countries with a total population of 1,038,627,178 people. The high rate of infertility across West, Central, and Southern African countries, in contrast to the countries of North Africa, caused demographers to describe these areas as an infertility belt., Paradoxically, the same areas have high fertility rates. Nigeria, for example, has a high rate of infertility ranging from 15.4% in Abakaliki to 26.8% in Lagos. Institutional rates are much higher in all countries even up to 62% in Zimbabwe. In all these studies, secondary infertility is more prevalent than primary infertility unlike in the Western world.
The consequences of not bearing the “fruit of the womb” are enormous for the couple, but are borne more by the woman than the man especially in our environment. These include depression, low self-esteem, sexual dysfunction, violence, abandonment, separation, threats by husband’s relatives, divorce, polygamy, ridicule, stigma, poverty, suicidal tendencies, and death., Infertility is strongly stigmatized in Nigeria, and mothers-in-laws have been shown to be the greatest tormentors of the infertile woman. It has been shown that women who did not have a child after an initial fertility evaluation and treatment are more than twice at risk of committing suicide than women who have at least one child.
The history of traditional and unorthodox ways of looking for the “fruit of the womb” abound in various communities. The use of charms, sacrifices to the deities, gods, and goddesses, and oral and vaginal concoctions which may further damage the reproductive tract are common., Religious groups and churches also manage infertility with special prayer sessions and services including fasting.
A relatively new concept of growing concern in Port Harcourt, Nigeria is “crypto-pregnancy.” Here the woman searching for the fruit of the womb suddenly “delivers” a baby in a facility without an obvious pregnancy. These facility providers when consulted tell the clients that they are already pregnant. Hormonal drugs or steroids are sometimes given to induce amenorrhea and generalized edema. They are warned that the pregnancy is undetectable by ultrasound scan and by the doctors because it is at the back of the abdomen. Eventually, the client is called up (apparently when the desired baby is available) for a phantom labor and delivery. A higher fee is usually charged for male babies.
On July 25, 1978, 41 years ago, Robert Edwards and Richard Steptoe made history with the delivery of the first in-vitro fertilization (IVF) baby called Louise Brown in the UK. This was done by the technique known as IVF and embryo transfer (IVF-ET). This technological advancement of IVF has been described to rival the first man walking on the moon 9 years earlier. This technological revolution changed the entire treatment for most of the hopeless cases of infertility and gave joy to many families. The practice of IVF immediately spread all over the Western world with the refinement of the original procedure and development of newer procedures. This is the treatment now collectively referred to as assisted reproductive technology (ART).
To date, over 8 million children have been born by IVF since the birth of the first baby. However, sub-Saharan Africa has been generally known as the region with the lowest number of ART centers [18-20]. South Africa, Nigeria, and Ghana have been described to have comparative regional success stories. In Africa, IVF was performed in Tygerberg, South Africa in 1983, Nigeria in 1984, Ghana in 1995, Uganda in 2005, Mali in 2010, Tanzania in 2011, and Rwanda in 2013. As at 2018, 40 years after the introduction of the technology, many African countries do not have IVF centers.
It is estimated that one ART center doing 1500 cycles a year can serve a population of 1 million people. Therefore, sub-Saharan Africa would need about 1000 centers but we are no way near this figure.
The challenges facing the rapid development of ART in the sub-Saharan Africa stem from the socio-economic, political, religious, cultural background, and the ethical issues surrounding the practice of ART.
| Challenges|| |
General socio-economic background and knowledge of infertility management
Despite the improvement in healthy life, knowledge, and standard of living in sub-Saharan Africa over the past years, 63% still live in rural areas, 35% of adults are not literate, and 70% of the working adults earn <$3.1 per day. People in this region have little knowledge about human reproduction, infertility, and ART. In 2001, a survey of the health status of women in the entire Niger Delta region of Nigeria found the prevalence of infertility to be 17%. Primary infertility was uncommon and there was very poor knowledge of the causes and treatment of infertility including ART.
Another study was carried out in urban Port Harcourt, Nigeria on perception of infertility and its management. One hundred and fifty (150) adults were surveyed in an area where 58% had tertiary education, 70.7% knew about IVF, all of them expected 100% success rate, and none of them supported surrogacy. This shows that we are still far behind in the knowledge and attitude toward ART. Poor knowledge leads to high default rate and this reduces effectiveness of treatment.
| Conflict and Insecurity|| |
Sub-Saharan Africa is one region that has witnessed the highest number of conflicts. Central African Republic, Sudan, Sierra Leon, Uganda, and Nigeria have all witnessed conflicts and instability, which will make the establishment and sustainability of ART centers challenging. Though the numbers of national conflicts have reduced in the past 15 years, insecurity from kidnapping, armed robbery, and xenophobic attack will make any skilled medical personnel and the few people who can afford ART services to flee the area. In some areas with high incidence of kidnapping, late night consultations and follow-ups are arranged for important dignitaries.
| Religion|| |
Christianity (62.9%) and Islam (30.2%) are the dominant religions in sub-Saharan Africa. The Catholics dominate the Christian religion who do not accept ART, but there is a growing number of Pentecostal Christians who accept ART. The Muslims embrace ART but the predominant Sunni Sect does not accept a third party ART. The minority Shi’ite accept.
| Cultural Challenges|| |
Sub-Saharan Africa societies are deeply rooted in their diverse cultural heritage and societal norms, regarding kinship, importance of genetic and blood ties, and inheritance. The concept of a family being a mother, father, and children that is genetically linked is what is known. The concept of non-coital pregnancy, social parenting, “Google baby” same sex parents, and single by choice parenting are alien. Babies born by those methods and their parents may suffer discrimination and acceptability in the society. Generally, parents who have successful ART treatment like to keep it secret from the society. The secrecy may extend to the child forever despite the recent trend on disclosures.
In some centers, all gamete donations and surrogacy are anonymous. None of the women or men are ready to share this secret with anyone including the children or offspring, and sometimes sisters or relatives help out in third party ART.
| Setting Up|| |
A huge capital investment is required to set up an ART center. Obstetricians with some years of experience and foreign training in IVF were the pioneer practitioners in sub-Saharan African countries. They were all private and located in the major cities of the country. They in turn trained the second generation of practitioners who have expanded the practice to other subregions. Most of the practitioners have undergone self-training as there are no formal training centers in the region. These second-generation practitioners worked with the pioneers for 3–5 years and set up their own centers. Some practitioners go to India for a short course (1–3 months) and set up a center. Others set up a center bringing experts from Europe, India, or other African countries.
Equipment for setting up are costly and manufactured in foreign countries. Maintenance becomes a problem when faults develop and you have to fly in an engineer from that country. This affects the laboratory and eventual success rate. Investment in a second set of equipment as back up becomes inevitable for uninterrupted services.
In recent times, ART centers are being established in public hospitals in Nigeria, seven of them as at 2018. The main aim is to reduce cost and improve access. However, the challenges of power supply, manpower especially embryologists, administrative bottlenecks for consumables, and incessant industrial actions affect services.
| Training|| |
Properly trained embryologists and nurses are lacking in sub-Saharan Africa. The few that are available cannot meet up with the proliferation of new centers. Some leave their primary employers and practice in multiple locations as freelance embryologists or nurses. Some centers in India provide short courses without mastery to practitioners who quickly come to set up or work without proper supervision.
General nurses are often trained on the job to assist in procedures such as giving drugs and patient preparation for ultrasound scan for follicular tracking and egg collection. There is no formal training for nurses in this subregion except in South Africa.
| Drugs and Consumables|| |
The drugs used in ART and majority of the consumables are produced outside the region, in the UK, Europe, India, and USA. These are imported into the countries; therefore, they are subjected to delays at the ports, customs duties, registration, and approval with the relevant agencies. All these add to increasing the cost of treatment. The cold chain cannot be guaranteed due to erratic power supply along this supply chain. All these affect the efficacy, reliability, quality, and there is lack of reliable and uninterrupted supply of drugs and consumables including culture media.
| Number of Embryos Transferred|| |
The ethical issues of number of embryos to transfer are still a contentious issue in sub-Saharan Africa, even though the Western world has now settled for single embryo transfer. Cost, age, and already high prevalence of twining in natural spontaneous pregnancy, lack of facilities for cryopreservation, and long period of infertility are reasons given by practitioners for transferring up to three or four embryos. It has been shown clearly that the complications following multiple pregnancies which may include fetal and maternal mortality are grave and so the advantages of single embryos transfer outweigh those of multiple embryo transfer. It is therefore wiser to invest in facilities and skills for vitrification and cryopreservation of embryos for subsequent single embryo transfer even without stimulation. Whatever happens to the excess embryos is not properly discussed in most centers.
A study we carried out in 2006 showed that 94.4% of women undergoing ART treatment want two to three embryos to be transferred. Only 5.6% want one embryo. Regulation based on consensus is therefore needed in this regard for the sub-Saharan Africans.
| Pelvic and Uterine Pathologies|| |
Huge and multiple uterine fibroids, hydrosalpinx, endometriosis, intrauterine adhesions, and uterine polyps are much more common in the women in sub-Saharan Africa than other regions of the world. Surgical treatment preferably endoscopically may be required before ART treatment. These pathologies affect the cost and acceptability of treatment and the overall success of ART treatment.
Following diagnostic hysteroscopy of 87 women undergoing ART in 3 years, we found that only 23% had normal findings, 64.2% had intrauterine adhesions, 11.5% had polyps, and 3.5% had fetal bones from previous incomplete termination of pregnancies. This is the reason why some people believe that hysteroscopy should be done for all patients prior to ART in sub-Saharan Africa.
| Provision of Limited ART Services|| |
Some clinics set up in sub-Saharan Africa do not provide the full range of ART services. For example, two out of five clinics visited recently in Port Harcourt do not have intracytoplasmic sperm injection capability and none could provide pre-implantation genetic testing. High cost and lack of skills were the reasons for the unavailability of these services. These will affect the success rate and type of treatment available in these centers.
| Power Outages|| |
It is an everyday occurrence to have power fluctuations and outages. These cause damage to equipment, particularly incubators, microscopes, and flow hoods. A comprehensive and reliable power system with backup systems is important for running an ART center. The backups include generating plant, stabilizers, and inverters. A service technician must be available on ground all the time, and there should be a routine maintenance agreement in place.
| Records|| |
There is a general sense of poor record management in the sub-Saharan Africa. Some clients especially donors provide fake names, addresses, and falsified date of birth in order to hide their identity. In most clinics, elaborate information is not obtained and there are incomplete and inappropriately stored records. False results are given out to the public by some centers in order to attract clients. These practices thrive in the absence of national registry and regulations. The absence of registries in many sub-Saharan African countries makes comparison of results with other regions difficult.
The recent concerted efforts by the African Network and Registry for Assisted Reproductive Technology and International Committee Monitoring Assisted Reproductive Technologies to get sub-Saharan Africa countries to the registries are, however, yielding results with the committed partnership with the national associations or societies of ART practitioners like the AFRH.
| Use of Intermediary Agencies for Non-medical Aspects|| |
The non-medical aspects of ART practice such as recruitment, registrations, quality assurance, and legal issues are generally not contracted because of poor knowledge and dearth of registered intermediary agencies with experience in the field. For example, donor and surrogacy agencies exist in some countries but they are few. Unregistered individuals called scouts are presently used to recruit donors. These scouts pose challenges with remuneration and arrest by law enforcement agents for “selling organs.”
| Cost of Treatment|| |
ART services are costly worldwide and poverty is endemic in sub-Saharan Africa. Despite the variation from country to country, only very few people who are well off can afford the treatment, others take a loan, sell properties, or accept support from relatives or churches; payment for treatment is out of pocket except a few with International Health Insurance ranging from $2,500 to $10,000. Donor cycles/surrogacy pays much more. The ART practitioner is often faced with the high operational cost and, at the same time, the dire need to render affordable services to the people. This is always a paradox faced by practitioners in sub-Saharan Africa.
| Lack of Regulation|| |
Apart from South Africa, there is no country in sub-Saharan Africa that has established by law a national regulatory body to register, accredit, and regulate the practice of ART.
In most countries like Nigeria, the ART centers are proliferating very fast, particularly in the past 10 years. Some general medical practitioners and even non-medical persons are setting up clinics, far below practice and ethical standards. There is chaos right now in the practice of ART in many sub-Saharan African countries. The poor and unsuspecting public are vulnerable to the various scams and they need to be protected from serious complication and death.
It is on this note that these urgent recommendations are made to stem the anarchy going on in the practice of ART in the subregion including Nigeria.
| Recommendations|| |
The National Association for practitioners managing infertility including ART should be formed in all the countries in sub-Saharan Africa, and support should be given to countries without such associations. While these associations are formed like in the case of Nigeria, the Association for Fertility and Reproductive Health of Nigeria (AFRH) should immediately embark on self-regulation. Clinics should be registered under the Association, inspected, and accredited to meet the minimum standard for quality assurance and international best practice.
These associations should work with the State Government through the Ministry of Health to conduct various stake holders meeting to come up with guidelines acceptable to the various interest groups for the regulation of ART practice in the state. The Lagos State government in Nigeria has shown the lead by inaugurating the committee on ART regulation in Lagos State on July 12, 2019. This framework or model can be escalated to other states in the country with the religious diversities of the state considered if any.
At the national level in Nigeria, for example, a national dialog with religious bodies, legal practitioners, community leaders, scientists, bioethicists, ordinary citizens, and professional bodies, among others, is urgently needed to input into the Nigerian Fertility Regulatory Authority Bill of 2012, which is yet to be passed by the National assembly. A comprehensive regulatory guideline and enforcement will take care of most of the ethical, religious, and economic challenges faced by the sub-Saharan Africa.
Infertility management should be included in the National Health Insurance Scheme to improve access and community knowledge. Public/private partnership with tertiary hospitals to provide free or subsidized ART treatment for couples with infertility will make the service more accessible.
The national government should address the infrastructural problems such as power, roads, security, manufacturing, importation clearance, and healthcare facilities in the subregion.
At the regional levels, training centers should be established across the region for proper formal training for all cadres of ART practitioners—doctors, embryologists, nurses, counsellors, and administrative staff.
The WACS has approved a center for post fellowship training in infertility and ART program in Abuja. This is a very good step toward strengthening ART practice in sub-Saharan Africa. Similar training centers are urgently needed in all regions for the other professionals in the field.
The ongoing international regional conferences and scientific meeting should be encouraged. The regional registry data analysis should be a major agenda in such meetings to promote and improve access to internationally accepted standards to IVF practice in the sub-Saharan Africa.
| Conclusion|| |
Sub-Saharan Africa is one of the regions with the highest prevalence of infertility in the world. The introduction and rapid development of ART in the management of infertility for 41 years now has improved pregnancy and take-home baby rate for couples who would have been hopeless. Despite the high prevalence of infertility in sub-Saharan Africa, it is the region with the least number of ART in the world. The challenges with the development of ART in this subregion have been highlighted in this lecture.
The proliferation of ART centers in this subregion is a welcome development because it creates awareness and improves access to care and follow-up with the technological advancements in other regions of the world.
The society has the responsibility to ensure that the advances made through ART are implemented in a socially responsible and acceptable manner.
The governments of the various countries in sub-Saharan Africa should encourage, regulate, and control the practices of ART in line with local sociocultural norms.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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