FVV iN obGyN, 2013, 5 (3): 243-246 Viewpoint The importance of being fertile. A call for a more balanced approach towards reproductive health N. DhoNt Genk Institute for Fertility Technology, ZOL hospitals, Schiepse Bos 6, 3600 Genk, Belgium. Correspondence at: [email protected] Abstract The core business of reproductive health care in developing countries is HIV/AIDS, contraception and maternal care and not one single reproductive health care program is dealing with couples unable to reproduce. How strange to have on the one hand the reproductive medicine clinics in the resource rich countries focusing mainly on infertil- ity care and on the other hand reproductive health care programs in resource poor countries not giving one single penny to infertility care. In this paper I am exploring the reasons for this unbalanced situation. It is clear from the facts and figures that infertility affects – often with devastating consequences – the lives of roughly one tenth of couples in developing countries. I argue that the neglect of infertility in the public health debate is caused by a mixture of ignorance (mainly by the international aid community) and tunnel vision, opportunism and a non- enlightened attitude of contempt for individual human rights. The prohibitive cost of IVF is contributing to this neglect as well. At present promising low cost IVF techniques are being developed and could potentially make IVF available at a cost accessible for a much larger part of the world population. With the latter becoming available, there should be no impediment for infertility care to become integrated into mainstream reproductive health care in developing nations. Reproductive rights advocates can no longer justify the systematic exclusion of one tenth of couples from the right to decide freely if, when and how to reproduce. Key words: Reproductive health, reproductive rights, infertility care, developing countries, public health, simplified IVF. Different definitions of reproductive health? Reproductive health, therefore, implies that people are able to have a responsible, satisfying and safe Looking at reproductive health care worldwide one sex life and that they have the capability to repro- cannot help to notice a very warped situation. In the duce and the freedom to decide if, when and how so called developed parts of the world reproductive often to do.’ Hence, there is no reason to assume medicine is a branch of medicine dealing with man- that the WHO excludes infertility from reproductive agement of reproductive problems, with most of the health. reproductive medicine clinics focussing on treating Care of the reproductive processes in all stages of infertility. In the so called developing parts of the life include a wide array of topics such as sexual world the word reproductive health care is more of- education, HIV/STI prevention and care (including ten used, with most of the reproductive health care cervical cancer screening), infertility care, family programs dealing with maternal health and family planning, maternal care (including antenatal care, planning excluding in most cases infertility care. It peri- and postpartum care) post abortion care and seems that reproductive health is defined entirely prevention and care of gender based violence. differently in those two worlds. In most of the resource rich countries with well Therefore let’s have a look first at the definition developed health systems the different aspects of proposed by the World Health Organisation (WHO): reproductive health care are provided by a network ‘Reproductive health addresses the reproductive of general practices, midwifes and gynaecological processes, functions and system at all stages of life. inpatient and outpatient services. Since the second 243 dhont(fertile).indd 243 23/09/13 09:33 half of the twentieth century couples from these Could it be that infertility is not such an issue for well developed areas can carefully plan their fami- people in developing countries? There are a number lies with an availability of an ever increasing array of social research reports on this issue and they all of contraceptive methods and can deliver their well conclude unanimously that infertility is having pro- planned babies in safe and healthy circumstances. found and often devastating effects on the lives of However until the eighties modern medicine did not people involved (Dhont et al., 2011; Dyer et al., have an adequate answer for those incapable to re- 2002, 2004; Gerrits, 1997; Nahar et al., 2000; van produce until the technique of IVF revolutionised Balen and Bos, 2009). The value of children per- the management of infertility. Nowadays reproduc- tains not only to personal happiness and fulfilment tive medicine assists an ever increasing number of but also to wider issues such as the ‘raison d’être’ of infertile couples to produce the so-desired offspring. marriages and partnerships, social status, continuity In many countries these procedures are part of the of family lines, social security, etc.... many authors public health system and funded by tax money. It have argued that the problem of infertility has prob- seems that infertility care has gained an important ably more severe consequences for the affected place in the reproductive health agenda in these couples in resource poor countries than in resource parts of the world. rich countries. The core business of reproductive health care in So we have a serious reproductive health prob- developing countries is HIV/AIDS, contraception lem affecting one in ten couples on average but not and maternal care. Maternal deaths, cervical cancer, one single penny of public or donor money spent on HIV/AIDS, unsafe abortions continue to kill thou- these couples. sands of women every day and many couples also Could it be that local governments are not aware face unwanted or unplanned pregnancies because of of the problem of infertility? I find that hard to unmet needs for contraception. These countries believe since most of them must have somebody in have very weak national health systems and rely the family suffering childlessness and know the often on donor funding for their reproductive health devastation it causes. And what about the interna- programs. A recent survey of the largest internation- tional donor community and the development al reproductive health organisations revealed that organisations are they aware of this problem? I am not one of them dealt with couples unable to repro- afraid that they might not be aware at all. The talk of duce (Ombelet, 2011). the town in these communities, especially those in- How strange to have on the one hand the repro- volved in reproductive health, is the ‘overproduc- ductive medicine clinics in the resource rich coun- tion of children’ and how this might impede the tries focusing mainly on infertility care and on the fight against poverty. I have personally been asked other hand reproductive health care programs in the question a million times by Westerners: ‘Is resource poor countries excluding systematically infertility really a problem in these countries...?’ infertility care. There must be a very good reason Funnily enough it takes only a few minutes, showing for it. simple facts and figures to convince most of these people that it is. There must be good reason for excluding infertil- There is no good reason.... ity care... So ignorance could explain the attitude of the inter- The most obvious reason would be that infertility is national aid community but what about local policy no such problem in developing countries because it makers and researchers in resource poor countries occurs rarely and/or if it does, it is not perceived as all of them too well aware of the devastation infer- problematic. This would obviously justify the use of tility causes. Why there are no African leaders for resources for other matters such as malaria, HIV/ instance pressing for more attention to this prob- AIDS etc... lem? A very obvious reason is that there is no donor But looking at the figures one has to conclude money available for infertility care. Most of the that infertility is anything but less prevalent in re- global health funding has been directed towards the source poor countries, in some regions it is even fight against HIV/AIDS, malaria and TB. Applying more prevalent. Recently, the WHO performed a for these grants can bring a nice cash flow into the systematic analysis of 277 health surveys and country. Money for reproductive health is scarcer estimated that worldwide 48.5 million couples are and if available the issues of maternal mortality and suffering from infertility; half of these couples are family planning are the first in line. There is not living in Sub-Saharan Africa (SSA) and South Asia such a thing as a stream of funding for infertility (Mascarenhas et al., 2012). care. 244 FVV iN obGyN dhont(fertile).indd 244 19/09/13 15:05 And maybe a certain way of thinking which is cases. Up till now the most effective infertility treat- more typical for developing countries could also ment consists of expensive IVF/ICSI technologies contribute to the silence surrounding this problem: which come at a prohibitive cost. It comes to no the idea that the individual has only meaning as part surprise that governments or international aid- of a bigger unity and that the individual needs are organisations are currently not investing in this subordinate to the interests of the group. After all, technique. creating more children in an environment of scarci- However, at present promising low cost IVF ty is not a good idea. But I don’t expect western techniques are being developed and could poten- donors, policy makers and researchers to adhere to tially make IVF available at a cost accessible for a this philosophy which is the opposite of our modern much larger part of the world population. Recently western principle of individual freedom and human a breakthrough was realised with the low cost rights. This western paradigm is reflected by the culture method developed in the Genk Institute for declaration issued by the international conference Fertility Technology (Van Blerkom et al., 2013). A on population and development in Cairo 1994 stat- proof of principle study demonstrated high success ing (UNFPA, 2005): population is not about num- rates with this simplified IVF method, at a cost bers, but about people. Implicit in this rights-based which could be only 10% of current IVF methods. approach is the idea that every person counts. Al- though the right to produce offspring is nowhere to Conclusion be found in this declaration they do mention the right to decide the number of children, as we can I cannot help to believe that one day, if the world find it in the WHO definition mentioned above. If a wakes up to this problem – and if we keep knocking couple decides to have one child but cannot have on the doors with the bare facts and figures I don’t any it seems that their right to decide the number of see why they won’t- and if affordable solutions children is violated. This declaration, signed by become operational, infertility care will become many developing countries went on to inform the integrated into mainstream reproductive health care eight millennium development goals. Millennium in developing nations. This achievement has the development goal five is about improving maternal potential to give dignity not only to more than health (the target is to lower maternal mortality rate) 20 million couples but also to give dignity to repro- and achieve universal access to reproductive health ductive health care programs and organisations. (the target is to decrease unmet need of family Family planning cannot be complete without helping planning, increase contraceptive prevalence rate, to plan families for those who cannot have them. decrease adolescent birth rate and increase antenatal Reproductive rights advocates can no longer justify care coverage). Infertility care is not mentioned in the systematic exclusion of one tenth of couples these millennium development goals at all. from the right to decide freely if, when and how to I believe that the neglect of infertility in the pub- reproduce. lic health debate is caused by a mixture of ignorance and tunnel vision, opportunism and a non-enlight- Acknowledgments ened attitude of contempt for individual human rights. Infertile couples in resource poor countries I would like to thank Jan Goossens for his useful com- face a triple exclusion first from their local commu- ments on this manuscript. nities because an individual has no meaning without family, second from their local governments be- References cause donor cash flows dictate the agenda and not the suffering of individuals and finally they face the Dhont N, van de Wijgert J, Coene G et al. ‘Mama and papa nothing’: living with infertility among an urban population ignorance (or worse maybe: hypocrisy) of the west- in Kigali, Rwanda. Hum Reprod. 2011;26:623-629. ern donor and humanitarian aid community. Dyer SJ, Abrahams N, Hoffman M et al. ‘Men leave me as I But the fight to put infertility on the international cannot have children’: women’s experiences with involun- tary childlessness. 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