Khalifa

Reviewing Infertility Care in Sudan; socio-cultural, policy and

ethical barriersPrepared by: Dina S. Khalifa, MBBS, MRCOG I,

MSc Mohamed A. Ahmed MBBS, MD

Expert meeting,“Socio-cultural and Ethical aspects of Biomedical

infertility care in poor resource countries”Genk-Belgium

21-22 November, 2011

Importance of Bearing babies in a Sudanese Society.

Some regions in Sudan still do not admit that men may contribute to infertility.

Infertility now is more of a concern in Sudanese society.

Infertility is more recognized as a sequel of FGM.

Statistics: Lack of Infertility statistics in Sudan; One study provided prevalence data: ( Elsheikh et al, 2008 )

Prevalence of Infertility in Sudan: 11.5% 1ry: 79.5 % 2ry : 20.5%

Female Factor alone: 37 % 69.5 % due to anovulation; 47.5 % due to hyper prolactinemia Male Factor alone: 20 % Both: 31 % Unknown: 11 %

Infertility, RH & Policy Infertility care outlined in Sudan RH policy as

part component of Family Planning Services.

Public infertility care; Primary Level Consultation Secondary Level Consultation +

Diagnostic tests (Hormones, semen analysis, Hystero-salpingogram) ,+/- Simple ovulation induction.

Tertiary Level All previous + Diagnostic laparoscopy

ART offered at Private level care only.

As a result:

Public Hospital do not have dedicated Infertility Clinics. Couples with infertility complaints go through regular OB/GYN outpatient clinics;

No privacyNo counsellingFemales presenting aloneQuality concerns regarding results of diagnostic

tests

Tertiary level Infertility Care in Sudan:

Khartoum State: (Total population: 5.4 million)

3 public hospitals (out of 12) offer diagnostic laparoscopy;

Souba Teaching Hospital.Khartoum Teaching Hospital.Omdurman Maternity Hospital.

Outside Khartoum State: ( 14 states, Total population: 26.3 million )

Only 4 public hospitals (out of 86) offer diagnostic laparoscopy for infertility;

Mek Nimir University Hospital. Port Sudan Hospital. Medani Hospital.Alfashir Hospital

Traditional healers in infertility care:

First point of consultation in many parts of Sudan.(North and Nouba regions)

Males with infertility are not only seen by gynaecologists and andrologists; dermatologists in addition to skin and venereal diseases they take responsibility for treating male factor infertility wasting valuable time for the couples

National Health Insurance:

Covers all diagnostic tests available at public level hospitals.

Covers induction drugs for ONE cycle IVF/ICSI at private level infertility care.

Any further management out of pocket

Patients from public service repeat all diagnostic tests in clinics.

Any other local health insurance (national or private) does not support any further

management of Infertility.

The Study: Review of barriers to accessibility to ART

services in Sudan.

Findings in Sudan; ART Services recent (2000) ART Services only offered in Private Health

care/ Infertility centres. ART Services All clinics situated in Khartoum

state; 7 functioning, 1 non functioning, 1opening in 2012.

1. Name of centre Year Status1. Sudan Assisted

Reproduction Clinic

2000 Fully Functioning

2. Khartoum RH care Centre


3. Nile fertility Centre


4. Dr. Elsir Abuelhassan Fertility Centre


5. Sudanese- German Fertility Centre

2009 Fully functioning

6. Asia Fertility Centres


7. Janeen fertility Centre


8. Saad Abo Alila Fertility Centre (public)

2008 Non Functioning (low cost IVF donated by Low cost IVF

foundation )9. Ansab Fertility

CentreScheduled for early 2012

All centres currently developing computerized reporting and information systems.

Data for this review was obtained via personal interviews with lead physicians/owners of each centre.

ART service/Procedures Centres offering service• Diagnostic Tools (HSG, Laparoscopy, Fertility hormones, Andrology lab)

ALL (within facility or referred to a partner service)

• IUI ALL• IVF/ICSI ALL ICSI- No IVF• Semen Bank Offered in 5 centre• Embryo Freezing Offered in 5 centre• PGD/PGS Upon request in 1 centre• Sperm Donation Not Offered• Ovum Donation Not Offered• Surrogacy Not Offered

All centres do not have age restriction for ART treatment.

1ry infertility is main type of infertility seen by all clinics; mainly female factor.

2ry infertility and male factor infertility noticeably increasing across centres.

HBV testing is routine for couples receiving ART. No centre refuses further treatment for +ve patients.

HIV testing is obligatory in 2 centres .Others if history suggested. One centre refuses further management if patient is HIV +ve.

Disclosure of any results is to both partners across all centres.

Success rates of ICSI across the centres averages between 25-30% (15-20 IVF/ICSI month).

2 centres commented on an increase of multiparas mothers consulting centres for ICSI mainly for Gender Selection

Average Staffing across centres:

Infertility physicians 2

Embryologists 1

Andrologists 2

Nurses 2

Lab technicians 3

Counsellors 0

Cost of treatment:

Cost of one cycle of ICSI (including drugs) not less than 8,000 SDG ( 2,500 USD). A Sudanese minimum wage is 166 USD/month.

High cost due to high price of unsubsidized fertility drugs to an average Sudanese;

E.g. One vial of hMG = 53 SDG(14 USD)

Ethical issues:

Low knowledge on religious boundaries of services.

If funding for care is available, females have less chance to sustain it if infertility was due to female factor than if it was due male factor. Males have better chances to be supported for a second marriage than support for infertility treatment

Foetal reduction: Maximum ET is 2. If more embryos resulted FR is performed. A religious advisory opinion “Fatwa” was issued permitting the procedure.

Sperm and egg donation- surrogacy: Religiously not acceptable . Not performed in any centre.

Sudanese couples still consult centres outside Sudan;

Seeking better quality and higher success rates.

Herd effect of unsuccessful cases.

Couples with unknown reasons of ART failure.

Common Misconception about infertility/ART

Men that have no problem sexually or fathered children before can not suffer from infertility problems.

IUI is a preference for most couple because is natural, they fear ICSI may border HARAM (Forbidden).

Conceiving by ART is hidden by couples in the society and still feared as a stigma.

Main obstacles to Infertility care in Sudan

Inequity in access to ART services No accreditation body to regulate quality of care or

to survey outcomes of IVF treatments.

No clear training requirements/credentials for physicians to establish private ART centres.

High running cost of centres vs. low number of patients. No government subsidy/support to private fertility centres.

Lack of qualified local trained Staff (Embryologists, nurses).

Recommendations:

Establishing partner satellite Fertility Centres outside Khartoum state to function as;

Do initial workup, ovulation induction, COH & IUI. Referral of ICSI cases to Khartoum for egg

retrieval and embryo transfer.

Sharing of embryologists, embryo and semen banks.

Continuous data collection and reporting from all functioning centres to influence policy and resource allocation changes at the government level as well as to build community confidence in infertility care available in Sudan.

Thank You

Khalifa

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