UNIVERSAL ACCESS TO INFERTILITY CARE: Perspectives from Africa Fertility Expert Forum 2019

Silke Dyer, FCOG, PhD, University of Cape Town

Nobody

left

behind.

“

”

Sustainable Development GoalsUN Human Development Report, 2016

Accessible

institutionsservices

skills

respectful culturally -sensitive

Available Quality

physicalfinancial

informationnon-

discrimination

(ART) Utilization = realized access

Freedom to access health care, including ART

The Right to Health, Fact Sheet No 31. Office of the United Nations High Commissioner for Human Rights.

Acceptable

scientificeffective

safe

*

*

*

*

*

1129638

106

468

2642

ART utilization: global inequalityART cycles / million population / annum

192

ESHRE Capri Workshop Group, Hum Reprod 2001;16:1518–1526 ; International Committee Monitoring ART, unpublished data.

Outline

1. Access to care

2. Data

3. Collaboration

Universal access

to primary care

to Fertility downregulation only

for those with means

to Assisted Reproductive Technology

for all in need

progressive realization

Indicator for infertility care

ART utilization

Only indicator at global level

Adopt and promote

Report and monitor

Demand: 1500 couples / million population / annum

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

poor

poor

good

good

ART - infertility care

Non-ART infertility care

Uncommon

Uncommon

A

c

c

e

s

s

Demand: 1500 couples /million population

Freedom to access health care

Available * Accessible Acceptable Quality

ART utilization (realized access)

Social determinants of health, e.g.* Gender Education Income

ART practices

ART utilization (2014)Cycles/million population

Full reimbursement

Partial reimbursement

Out-of-pocket payment

*661

*239

*2010

* 7181033

*

Zegers-Hochschild et al, RBMOnline 2018; 37(6):685-692; Fertility Europe and ESHRE. A Policy Audit on Fertility: Analysis of 9 EU countries. 2017.

Source: ART utilisation: ICMART 2014 data; Affordability: Chambers et al, Fertil Steril 2014; 101(1):191-198

Less affordable More affordable

Affordability predictsART utilizationCorrelation

coefficient

=0.626

Argentina

Australia

Austria

Belgium

Brazil

Canada

Czech Republic

Denmark

Finland

France

Germany

Greece

Hungary

Iceland

Ireland

Italy

Japan

Mexico

New Zealand

Poland Portugal

Spain

Sweden

Switzerland

United Kingdom

United States

0

10

00

20

00

30

00

AR

T u

tiliz

ation / m

illio

n p

opu

lation,

2014

50 60 70 80 90 100Affordability (1- net cost of an ART cycle/disposable income (%))

AR

T u

tiliz

atio

n: c

ycle

s /

mill

ion

po

pu

lati

on

(20

14

) Less affordable More affordable

Gender Inequality &ART utilization

Global trends

2002-2012

Source: ART utilisation: ICMART data; Gender Inequality Index: United Nations Human Development Programme

Source: ART utilisation and fresh non-donor single embryo transfer: ICMART 2014 data

ART utilizationpredictsSET practice Correlation

coefficient

=0.715

CameroonGhana

Ivory Coast Mali

Mauritius

NigeriaSenegal

South Africa

TogoIndonesia

Japan

Australia

New Zealand

Albania

Austria

Belarus

BelgiumCzech Republic

Denmark

Estonia

Finland

France

Germany

Greece

Hungary

Iceland

Ireland

Italy Latvia

Lithuania

Macedonia

Montenegro

PolandPortugal

Romania

Russia

Serbia

SloveniaSpain

Sweden

Switzerland

Ukraine

United Kingdom

Argentina

Bolivia

BrazilChile

ColombiaDominican Republic

EcuadorGuatemala

MexicoNicaraguaPanama

Paraguay

PeruUruguayVenezuela

Canada

United States

0

10

00

20

00

30

00

AR

T u

tiliz

ation / m

illio

n p

opu

lation,

2014

0 20 40 60 80Single embryo transfers (%)

AR

T u

tiliz

atio

n: c

ycle

s /

mill

ion

po

pu

lati

on

(20

14

)

Fresh non-donor single embryo transfer (%)

Less affordable More affordableAffordability andSET practiceCorrelation

coefficient

=0.531

Source: ART utilisation: ICMART 2014 data; Affordability: Chambers et al, Fertil Steril 2014; 101(1):1910198

Argentina

Australia

AustriaBelgium

Brazil

Canada

Czech Republic

Denmark

Finland

France

GermanyGreece

Hungary

Iceland

Ireland

Italy

Japan

Mexico

New Zealand

Poland

PortugalSpain

Sweden

Switzerland

United Kingdom

United States

20

40

60

80

Sin

gle

em

bry

o tra

nsfe

rs (

%),

2014

50 60 70 80 90 100Affordability (1- net cost of an ART cycle/disposable income (%))

Sin

gle

emb

ryo

tra

nsf

ers

(%)

1722014, ANARA data (ART cycles/million population)

* *

*

*

*

*

*

***

*

* **

*

*

*

*

**

A

c

c

e

s

s

* 109

*

Low ART utilization

Lack of government attention

Lack of 3rd party funding

Competing health needs

Low reproductive health literacy

Unaffordable

Unregulated

Unknown

Invisible

Strengthen Assisted Reproductive Technology

Together

With data

Develop

Monitor

16 countries - 56 centres

Dyer et al, First results from the African Network and Registry for ART, 2013; RBMOnline 2018, DOI 10.1016/j.rbmo.2018.11.001

www.anara-africa.com

Fresh non-donor IVF & ICSIAge distribution (interim analysis 2015)

0

2500

5000

7500

10000

Age <=34 Age 35-39 Age>=40

Aspirations Pregnancies Deliveries

Nu

mb

er o

f p

roce

du

res

and

ou

tco

mes

55.8%

29.9%

14.3%

Fresh non-donor IVF&ICSI: Number of embryos transferred (2015)

13.2%

44.1%

34.6%

7.3%

0.7%0%

10%

20%

30%

40%

50%

Transfers (n=12,533)

1 Embryo

2 Embryos

3 Embryos

4 Embryos

5 Embryos

MDR

31.7%

Mean number of embryos per transfer =2,38

Bishop et al, Lancet GH 2019; 7:e513-522.

Fresh non-donor IVF&ICSI (South Africa): Outcome by number of embryos transferred

44

.2

18

.9

55

.4

42

.9

32

.5

6.7

1.7

32

.1

32

.4

25

.8

1 EMBRYO ELECTIV E

1 EMBRYO NON -E 2 EMBRYOS ELECTIV E

2 EMBRYOS NON -E 3 EMBRYOS

CPR MDR

n =52 n =408 n =231 n =1323 n =249

21,7% 44,7% 32,5%

Fresh non-donor IVF&ICSI: Gestational age (2015)

7.7

5.3

16.7

7

2.8

41

43

15.1

35.9

44.8

80.2

22-27 weeks 28-32 weeks 33-36weeks >=37 weeks

Twinsn=647

Singletonsn=1579

Triplets+n=39

Agyepong et al, Lancet 2017; 390(10114):2808-2859

Affordable

Patients

Society

Government

Health funders

Training

Infrastructure

Drugs

Public sector

AvailableAcceptable

Effectiveness

Safety

Stimulation

Embryo Culture

3rd party funding

Private-Public P.

Network and data

Improving access to ART

McIntyre D, et al. Health Econ Policy Law 2009;4(Pt 2):179–93.

0 20000 40000 60000 80000

1990

1994

1998

2002

2006

2010

2014

2016

Number of cycles

Data

Procedures

No. of embryos

Multiples

Babies born

Perinatal outcome

Argentina

Uruguay

Costa Rica

Chile

(Paraguay)

(Colombia)

RedLARA: 20th anniversary goal: Better access

Zegers-Hochschild et al, RBMOnline 7 May 2019 Registro Latinoamericano de Reproducción Asistida (RLA). Trends 1990–2014. Available at: http://redlara.com (Last accessed January 2019);

If you want to go fast,

go alone,

If you want to go far,

go together.

—African proverb

ART Centres(16 countries+)

Fertility societies(SASREG)

RedLARA(Fernando Zegers-Hochschild)

ICMART(David Adamson)

Anara Operational Team(Pavs, Liezel, Inge)

NRF

Industry(MERCK, Msd, Ferring)

Reproductive Networks in Africa(ESHRE 2019)

ANARA

Network of ART Centres

&

Data voice of ART in Africa

AFFS

Network of Fertility Societies

SASREG&

ANARA&

AFFS

Ultimate goalFreedom to access health careHuman right to have children

ART utilization: indicator for access to care

Universal access to care: far from being universal

Better access: together and with scientific data

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