Thursday, 4 October 2018

POVERTY IN SUB-SAHARAN AFRICA: IMPLICATION FOR IVF/ICSI

Introduction

Poverty in Sub-saharan Africa can be described as being endemic. Unfortunately, this problem is associated with ignorance, illiteracy, poor hygiene, high prevalence of communicable diseases and generally, components of reproductive ill - health including sexually transmitted diseases. Sexually transmitted diseases account for a significant proportion of the causes of obstructive uropathy.

Male factor Sub-fertility is probably in the region of 40 – 50% despite the reluctance to appreciate and accept same

Causes of Male Sub-fertility
  1. Ineffective coitus (5%) (Mostly mechanical causes) with normal sperm function
i.e. those with normal ejaculation – Erectile dysfunction hypospadia
-         retrograde ejaculation – Bladder neck Surgery, DM, Phenothiazines
-         Ejaculatory failure – anorgasmia, spinal cord injury.
  1. Azospermia (5%)
Pretesticular: - Steroids, Kalman’s Syndrome e.t.c.
Non – Obstructive: - Cryptorchism, orchitis, 47XXY, radiotherapy and Chemotherapy
Obstructive: - vasectomy, epididymorchitis, Chlamydia and G.C.
  1. Sperm autoimmunity (5%): Antisperm Antibodies, Genital infection and Idio- pathic
4.  Semen abnormality   (85%): idiopathic, drug, genetic, varicoele.
         (Sperm dysfunction)
      5. Sperm abnormality   (<1%): Immotile cilia (Katagener Syndrome)

 

Treatment of Male Infertility

Treatable Causes: - Treat the cause
Idiopathic causes (>50%) of cases
      Hormones - GnRh / HmG
                          - Recombinant FSH
                       - Exogenous Testosterone
                       - Anti Oestrogens
         Non – hormonal   therapies
                                        - Kallikrein
                                                    - Antioxidants
                                                    - Vit E
                                                    - Bromocriptine

Non – treatable causes
Management: - If fertility cannot be achieved by other treatments, ART offers possibilities for symptomatic treatment of male infertility (Oligospermia, Azospermia, Globozospermia, and Ashthenozoospermia.e.t.c.

ART methods used in the treatment of Male Infertility
  1. Artificial Insemination with partner’s sperm (I.U.I)
  2. Conventional IVF
  3. High Insemination Concentration IVF
  4. Microdrop IVF
  5. Sperm motility stimulants
  6. Zonal Drilling
7. Partial Zonal Dissection                                                      
  1. Sub-zonal insemination                                                
  2. Intracytoplasmic Sperm injection (I.C.S.I)

The most successful albeit expensive and commonly used of these procedures is I.C.S.I
Indications for ICSI
  1. Previous failed I.V.F. attempt.
  2. Marked depression of semen parameters/ poor quality sperm
-         Sperm Concentration < 5 million / ml
-         Progressive motility  < 10%
-         Normal morphology < 4%
-         Total motile sperm count after sperm preparation < 1 million
  1. Borderline semen parameters
  2. Specific patient groups like the following:-
-         Patients suffering with retrograde ejaculation
-         impotence necessitating electroejaculation
-         severe antisperm antibody problem
-   poor quality thawed sperm (e.g. from testicular cancer patients)
  1. Sperm retrieved from patients with initial diagnosis of azospermia.
  2. In – vitro matured Oocyte (I.V.M)

At the HVC, our ICSI rate in the previous 12- months is 68%, mostly for abnormal sperm parameters. Poverty in my view is a social disorder which makes it very difficult if not impossible for patients to afford the cost of ART. For instance, the case of one of our most recent recipient of The Hope valley Clinic Faith Award” is worth mentioning.

The HVC “Faith Award” is given to a couple who in the Judges opinion is considered to be the most consistent, enduring, hopeful and faithful in terms of number of previous IVF/ ICSI attempts prior to a successful one. By implication, it is considered to be financially burdensome for most couples to afford the cost of IVF/ICSI. It is even more so when they are confronted with the possibility of having to undergo more than one attempt.

On the corollary, the depressed state of our economy and the huge cost involved in setting up an assisted reproductive centre has led to paucity in the availability of such services in the past. At the last count, during our very successful NFS/ IFFS International Conference in Lagos, we were intimated with figures of just about 13 IVF centers in West Africa, most of them in Nigeria. This is nothing compared by any standard to about 83 centres in the UK, more than 75% of them in London and Surburbs.

I therefore implore us to pay purposeful attention to possible remedies that tend to make ART more affordable.

Possible remedies:
  1. Improvement in standard of living
  2. Improved health education at all levels with emphasis on reproductive health.
  3. Increased health sector funding by Government.
  4. Increased activity of N.G.O in all the above.
  5. Sustained activities of ART centers in creating awareness about availabilities of remedies for male factor subfertility
  6. Continuing collaboration between ART centers within and outside Nigeria, especially with low cost of IVF in view.
  7. Continuing specialist training in ART
  8. Political stability vis-à-vis improved health sector planning and strategy.

Conclusion
I have a dream that sometimes in the very near future, Africa shall be free from the recurring bondage of high level of poverty, excruciating reproductive ill health and persistent economic depression.
I wish you all interesting deliberations.

Thank you.

Dr. Michael Ogunkoya
Managing Director, The Hope Valley Fertility Clinic
08033069466

The Hope Valley Fertility Clinic
Plot 31, Block 113, Gbemileke Akinsonwon Street, Opposite Treasure Garden, By Ikate Roundabout, Lekki Phase 1, Lagos-Epe Express Way, Lagos.
08033069499