Sallam

Socio-cultural aspects of infertility in Egypt

Hassan N. Sallam, MD, FRCOG, PhD (London)

Professor in Obstetrics and GynaecologyThe University of Alexandria, and

Clinical and Scientific Director, Alexandria Fertility Center, Alexandria,

EgyptWorkshop on “Socio-cultural and ethical aspects of

biomedical infertility care in poor resource countries”, 21-22 November 2011, Genk, Belgium.

1. Egypt – background2. Prevalence of infertility in Egypt

3. Causes of infertility in Egypt 4. Socio-cultural aspects of infertility in

Egypt5. Consequences of infertility in Egypt 6. Current infertility services in Egypt

7. Obstacles to treatment8. Religion and IVF in Egypt

9. Simplifying infertility treatment 10. Regulation of IVF in Egypt

11. Conclusions

Infertility in Egypt

The land and the environment

• Area = 1 million square kilometers

• 2% of Egypt’s land is arable• 6% of the total land area is

inhabited by 97% of the population

General characteristics of the population World bank, 2009)

Characteristic 1985 1990 2001 2009

Population size (million) 31.6 56.3 69.1 83.1 Population growth rate

(%/ yr) 2.37 2.25 1.9 1.8

Life expectancy (yrs) 48.6 62.5 67 70 Adult literacy (%) 48 44 66

Population of Egypt (1882-1996)

0102030405060708090

1882 1907 1927 1947 1966 1986 2009

6.79.7 11.2 12.7 14.2 16.0

19.0

26.130.1

36.6

48.3

59.3

83.1

Population growth actual and projected (in millions) (UNICEF 2002)

0102030405060708090100

1965 1990 2001 2025

31.6

56.3

69.5

95.1

Population of Egypt, 2011

Males = 39,785,675 Females = 39,101,332

Percent distribution of women (15 to 49)

(EDHS 2000)Age (years) Number (x1000)

15-19 5,161 20-24 4,126 25-29 3,399 30-34 2,878 35-39 2,756 40-44 2,222 45-49 2,343 Total 22,884

GDP in billions of US$ in 2011(World bank, 2011)

0

500

1000

1500

2000

2500

Egypt Israel Turkey Italy

2051

735

219 217

World Bank ranking• High income countries

(GDP >12275 US$ per capita)______________________________________

• High middle income countries(GDP 3976 - 12275 US$ per capita)

• Low middle income countries (GDP 1006 - 3975 US$ per capita)

_______________________________________• Low income countries

(GDP <1006 US$ per capita)






11. Conclusions


Prevalence of infertility in Egypt

Prevalence of infertility = 12 %

Primary infertility = 4.3%Secondary infertility = 7.7%Women 15-49 years = 25

millionInfertile women = 3 million

1. WHO-sponsored study, Egyptian Fertility Care Society, 1995 2. Inhorn, Social Science & Medicine 56:

1837–1851, 2003






11. Conclusions


Causes of infertility in Egypt1488 infertile couples

Primary infertility = 70.7%Secondary infertility = 29.3%___________________________

Male infertility = 20.5% Female infertility = 64%

Combined male and female = 12.2% Unexplained infertility = 3.3%

Serour et al, Popul Sci 10:41-58, 1991

0

10

20

30

40

50

60

70

Male Female Combined Unexplained

Causes of infertility in Egypt


20.5%

64%

12.2%

3.3%

Causes of infertility in EgyptMale infertility = 20.6% Azo/oligospermia= 20%Asthenospermia = 40%Teratospermia = 40%

Female infertility = 64%Tubal problems = 42%

Ovulatory disorders = 25.3%Pelvic endometriosis = 5.6%

Cervical factor infertility = 4.2%Multiple factors = 23.4%

Serour et al, Popul Sci 10:41-58, 1991.

Causes of female infertility in Egypt

05

1015202530354045

Tubal Ovulatory Endo-metriosis

Cervical Multiple

Serour et al, Popul Sci 10:41-58, 1991.

42%

25.3%

5.6% 4.2%

23.4%

Causes of infertility in Egypt

Male infertility = 20.6% Tubal problems = 42%

Combined male and female = 12.2% Unexplained infertility = 3.3% _______________________________

Total = 81.1 % may need assisted reproduction







11. Conclusions


Socio-cultural diversity in Egypt

Socio-cultural aspects of infertility in Egypt

• The extended family – interference by in-laws

• The culture of male-baby preference• Economic importance of a large family

• Social importance of a large family• Illiteracy (35%)

• Equating virility to manhood• Religious restriction on adoption

• No gamete donation• Fertility and the inheritance laws

• Non-acceptance of non-traditional families• Moslem/Christian rivalry (the hidden

factor)

Egypt - The extended

family

Discrimination against the female child

This Pakistani mother gave birth to twins. She breast-fed the boy and bottle-fed the girl. The girl died the following day this

picture was taken.

• In treatment• In education• In feeding

Sen AK. Missing women, BMJ 304: 586-7, 1992 Sen A. Missing women – revisited, BMJ

367: 185-6, 2003

The missing females

About 100 million women are missing (44m in China, 37m

in India) due to:• Prenatal sex

selection/abortion• Discrimination against the

female child• Postpartum hemorrhage

Population in thousands

Males Females

World 3 442 851 3 386 510High income 451 069 464 797

Low and Middle income

2 594 306 2 535 000

The missing femalesWorld population by sex in 2008

United Nations Report: Population prospects: the 2008 revision, 2009

Alexandria septuplets 2008

Economical importance of a large family – Harvesting cotton

Illiteracy rate in Egypt = 35%1996 2006

Education Males Females

Males Females

Illiterate (%) 29 50 22 37Read & write

(%)23 15 15 11

Primary (%) 10 8 10 9Intermediate

(%)31 23 42 35

University (%) 7 4 11 8Source: Central Agency for Public Mobilization and Statistics

(CAPMAS)

Equating virility to manhood

Inhorn M. J Men Stud 10(3): 343-59, 2002

Inheritance laws in Egypt

Non-traditional families

Muslim-Coptic rivalry

1. Egypt – fact sheet2. Prevalence of infertility in Egypt





11. Conclusions


Consequences of infertility in Egypt

• Divorce• Polygamy

• Domestic violence: physical, verbal, emotional and economic • Psychological disease/suicide

• Traditional healers/Zar• Economic strain

Divorce in Egypt, 2009

Marriages and divorces in Egypt

Year Marriages

Rate Divorces Rate

2000 592381 9.3 68991 1.12001 457534 7.0 70279 1.12002 510518 7.7 70069 1.12003 537092 7.9 69867 1.02004 550709 7.9 64496 0.92005 522751 7.4 65047 0.92006 522887 7. 3 65461 0.92007 614848 8.5 77878 1.2Source: Central Agency for Public Mobilization and Statistics

(CAPMAS)

Divorce in Egypt• A couple files for divorce every six

minutes • One in five marriages end in divorce

• Courts rule on 240 divorces each day • 7 out of 10 divorces take place within the first 5 years of marriage and 1 out of 3

in the first year• Highest divorce rates among the urban

lower class, the lowest in villagers of Upper Egypt and 95 percent in illiterate couples• There are 2.5 million divorced womenEgypt: A Country Study" published by the Federal

Research Division of the Library of Congress, 1990

Polygamy

Polygamy is allowed under Islamic law and a Muslim man may take as many as

four wives. Yet, the prevalence of this practice is believed to be relatively low. Kurtz (2006) estimates that in 2001 less

than 3 percent of Egyptian men had multiple wives

Kurtz, S. (2006), Polygamy versus Democracy – You can’t have both, The Weekly Standard, 2006, Volume 011,

Issue 36

Polygamy in Egypt in 2008Social status of re-marrying husband

No.

Married (polygamy) 17617

Divorced 19637

Widowers 7328

Total 44582

Source: Central Agency for Public Mobilization and Statistics (CAPMAS)

Infertility: a cause of violence against women

Violence against women

• Physical violence• Sexual violence

• Emotional violence• Verbal violence

• Economic violence

Number of infertile women

233

Experienced domestic violence 97 (41.6%)Psychological torture 50 (51.5%)

Verbal abuse 38 (39.2%)Ridicule 27 (27.8%)

Physical abuse 17 (17.5%)Deprivation 6 (6.2%)

By the husband 47 (48.5%)By female in-laws 31 (32%).

Infertility as a form of VAW

Ameh et al. Niger Med J 16(4):375, 2007

Suicide in Danish women evaluated for fertility problems

Primary infertilityOR = 2.43 (95% CI: 1.38-3.71) *

Secondary infertility (with one child)

OR = 1.68 (95% CI, 0.82-3.41)

Kjaer TK et al. Hum Reprod 26(9):2401-7, 2011

Egyptian gods: Shu (air) separating Geb (earth) from Nut (sky)

The god Min and the goddess Hathor

The sacred birth of Cleopatra, Dendara temple, Upper Egypt

The old Gods still surviveA quartzite sandstone statue of Senusert III stands on the edge of the desert about two

kilometers to the south of temple of Sety I at

Abydos. The figure, the upper half of which is

missing is seated and is used by local women as a fertility charm. They

walk around it clockwise seven times, and then sit

on its lap.

Cleopatra’s pond, Karnak temple, Luxor, Egypt

Visiting the tombs of Sayyeda Zeinab, Sayyeda Zeinab mosque, Cairo

Visiting the Church of Saint Mina, Egypt

El-Seheimy house

Willow tree

Whale bones

The Zar ceremony

Kabsa (a.k.a. mushahara) and threatened fertility in Egypt.

Marcia C. Inhorn

J Soc Sci Med 1994 Aug;39(4):487-505.

Department of Anthropology, Emory University, Atlanta, GA

30322

Mushahra (a.k.a. Kabsa)

Baladi women of Cairo by Evelyn A. Early, Lynne Rienner Publishers, 1993

Forbidden from entering the room of a woman who

has just delivered is someone who:

• Has attended a funeral• Has just circumcised a

boy or a girl• Has just shaven his

beard• Is carrying raw meat

Economic strain on the familyGNI per capita (2010) =

2,440 US$ (i.e. 6.7 US$/day)

Poverty in Egypt (<1.25 US$/day) (2008) =

22% of the population

Cost of one IVF cycle =1,000 – 1,500 US$

Poverty in Egypt

0

5

10

15

20

25

1996 2000 2005 2008

19.4%

16.7%

19.6%

22%

World Bank, 2010






11. Conclusions


IVF centers in Egypt 2011Number of IVF centers

= 82 center

Number of cycles (IVF+ICSI) = 28,000 cycles

Ovulation Induction cycles (In IVF centers) = 23,000

cyclesFerring Egypt, personal communication

Estimated need for IVF/ICSI

Although the need for IVF/ICSI is 3000 cycles per million, the

optimum demand may be 1500 cycles per million per

annum as only 50% of infertile patients seek

infertility treatment (ESHRE Capri Workshop Group 2001)

ESHRE Capri Workshop Group , Hum Reprod 16: 1518-1526, 2001

Access to assisted reproduction 2003

Continent ART Cycles Cycles/millionAsia 199,476 160

Australia/NZ 34,975 1,477Europe 437,694 658

Latin America >21,781 57Middle East 67,354 570

Israel 22,449 3,670North

America148,686 461

Total >932,415 337Nygren et al, ICMART world report 2003. Fertil Steril 95:2209–

22, 2011

IVF in Egypt in 2003Results from 16 centersInitiated cycles = 7,197

Completed cycles = 6,883 IVF cycles = 49

ICSI cycles = 6,834FET started cycles = 495

FET completed cycles = 444PGD cycles = 19

_______________________________Estimated No. of cycles = 23133

Cycles/million = 310/millionNygren et al. ICMART world report on ART 2003. Fertil Steril

95:2209–22, 2011

IVF in Egypt in 2003CPR/Asp IVF = 32.7 %LBR/Asp IVF = 24.5 %CPR/Asp ICSI = 36.7 %LBR/Asp ICSI = 31.4 %CPR/Asp FET = 24.3 %LBR/Asp FET = 17.6 %

LBR/Asp ART fresh = 31.3 %LBR/Asp ART cum = 32.5 %

Babies/Asp fresh ART = 44.7 %Babies/Asp cum ART = 46.1 %Total babies reported = 3177

Total babies estimated = 9531Nygren et al. ICMART world report on ART 2003. Fertil Steril

95:2209–22, 2011

IVF in Egypt in 2003Aspirations = 6883 Transfers = 6092

One embryo transfers = 7.8 %Two embryo transfers = 13.6 %

Three embryo transfers = 53.3 %>3 embryo transfers = 25.3 %

Average no. of embryos transferred = 3.05CPR/Asp = 36.7 %LBR/Asp = 31.3 %

Babies/Asp = 44.7 %Twin pregnancies = 27.7 %Triplet pregnancies = 3.2 %

Nygren et al. ICMART world report on ART 2003. Fertil Steril 95:2209–22, 2011






11. Conclusions


Obstacles to treating infertility in Egypt

• Lack of services• Lack of know how

• Lack of finance• Lack of access to services

• Acceptance of fate (curse from God)

• Bad experience of neighbors• Traditional healers

Nygren and Zegers-Hochschild, Hum Repropd Suppl 1: 5, 2008

Global health spendingDeveloping countries

Developed countries

Global population

84% 16%

Global disease burden

90% 10%

Global health spending

12% 88%

Schieber G. Health financing in developing countries. Economic viewpoint June

2006

Country Percentage of spending share

Low-income countries 29%Lower-middle income

countries42%

Upper-middle income countries

56%

High income countries 65%

Schieber G. Health financing in developing countries. Economic viewpoint June

2006

Public share of total health spending

Funding infertility services in Egypt

• No government re-imbursement

• No private re-imbursement• No insurance re-

imbursement• Totally self-funded

• No charity organizations• Occasional private charity

Budgetary and Human Rights Observatory (BAHRO) 2009

Obstacles to funding infertility projects

• Infertility is not a disease• Infertility is not a serious disease

• Infertility treatment is not effective• Infertility treatment is expensive

• Treating infertility in an overpopulated

country

Reproductive rights• 1968 Teheran Proclamation (International Conference on

Human Rights)• 1994 Cairo International

Conference on Population and Development (ICPD)

• 1995 Beijing Fourth World Conference on Women

• Cook R and Fathalla M. International Family Planning Perspectives 22: 115, 1996

• Fathalla MF. Reproductive rights and reproductive wrongs. Curr Women’s Health Rep.1(3):169-70, 2001

"Reproductive rights rest on the recognition of the basic right of all

couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the

information and means to do so, and the right to attain the highest standard of sexual and reproductive health. They also include the right of all to make

decisions concerning reproduction free of discrimination, coercion and violence."

Cook R and Fathalla M. International Family Planning Perspectives 22: 115, 1996

Access to infertility treatment is a human right

WHO defines reproductive rights as follows:

Reproductive rights rest on the recognition of the basic right of all couples and individuals to

decide freely and responsibly the number, spacing and timing of their children and to have

the information and means to do so, and the right to attain the highest standard of sexual

and reproductive health. They also include the right of all to make decisions concerning

reproduction free of discrimination, coercion and violence

Reproductive rights

Center for Reproductive Rights, International Legal Program, Establishing International Reproductive Rights Norms: Theory for Change, US CONG. REC. 108th CONG. 1 Sess. E2534 E2547 (Rep.

Smith) (Dec. 8, 2003)






11. Conclusions


http://en.loadtr.com/icons_of_Eastern_Christianity-410047.htm

http://en.loadtr.com/Muslim_are_praying-411281.htm

http://en.loadtr.com/Source_Islam-418591.htm

Islam and IVF in Egypt• The Mufti has no judiciary power but

his opinion is respected• Sperm from husband, oocyte from

wife • In an existing relationship

• No gamete donation• No surrogacy so far

• Freezing of gametes and embryos allowed

• PGD and embryo manipulation allowed

• No reproductive cloning

Rizk B. Infertility and Assisted Reproduction. Eds: Rizk et al, 731, 2008

IVF and the Coptic Church

(8-15 million followers)• St. Mark preached Christianity in Egypt• Coptic Orthodox Church of Alexandria became a distinct church body since the

Council of Chalcedon in AD 451• Roots in Egypt with followers world

wide• Pope Shenouda III

Major branches within Christianity

http://en.wikipedia.org/wiki/File:ChristianityBranches.svg

Basilica of San Marco, Venice

IVF and the Coptic Church• H.G. Bishop Gregorios. The Christian Opinion in

IVF and ET. Bisphoric of Higher theological Studies, Coptic Culture and Scientific Research Publications,

Cairo, Egypt, 1988

• H.G. Bishop Moussa. Current medical issues contraception, IVF and cloning Youth Bisphorship,

Cairo, Egypt, 1997 (medical doctor)

• H.G. Bishop Serapion of LA. The View of the Coptic Orthodox Church on IVF. Al-Keraza, Cairo,

Egypt, 1998 (medical doctor)

Rizk B. Infertility and Assisted Reproduction. Eds: Rizk et al, 731, 2008


• IVF is accepted if the oocyte and sperm are taken from the husband and wife, fertilization occurred in vitro with

no doubt about gamete mixing. ET must be performed to the mother who is the

source of the oocytes• Artificial insemination with the

husband’s sperm (AIH) is also acceptedRizk B. Infertility and Assisted Reproduction. Eds: Rizk et al, 731,

2008


• Surrogacy is not accepted • Sex pre-selection is not accepted

• Reproductive cloning is not acceptable

• Therapeutic cloning is acceptable from somatic but not from

embryonic stem cellsRizk B. Infertility and Assisted Reproduction. Eds: Rizk et al, 731,

2008






11. Conclusions


Simplifying IVF/ICSI treatment

• Simplifying stimulation protocols and monitoring techniques

• Simplifying oocyte collection• Simplifying laboratory

techniques• Simplifying embryo transfer

• Simplifying freezing techniques

HMG-only v/s long protocolHMG-only GnRH+HMG P

valueCycles (No) 558 50Pregnancies 165 14

Preg rate/cycle

27.1 % 28 % NS

U/S per cycle 3.5 5.2 NSCancellations 27 (0.5

%)2 (4 %) NS

Cost/cycle US$

1101.82 1558.18 <0.05

OHSS 7 (1.25%) 2 (4%) NSSallam et al. Presented at the 59th PCRS meeting 2011, Palm

Springs, CA, USA






11. Conclusions


Regulation of IVF in Egypt Regulated by the Syndicate of doctors

• Sperm from husband, oocyte from wife • In an existing relationship

• No gamete donation• No surrogacy so far

• Freezing of gametes and embryos allowed• PGD and embryo manipulation allowed

• No reproductive cloning• Counceling and signed informed consent

required






11. Conclusions


Conclusions• Infertility in Egypt is affected by many socio-cultural factors, and can result in

devastating consequences• This may have helped the early

introduction of IVF and ICSI in Egypt• IVF and ICSI are socially, culturally and

religiously accepted• Despite the lower cost of these

techniques in Egypt, the results are satisfactory

• However, accessibility of the patients to these advanced techniques is less than

desirable • Much work needs to be done along these

social, cultural and economic fronts

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