Infertility treatment model needs to be rethought

Dr Igno Siebert

According to Dr Zozo Nene, reproductive medicine specialist at Steve Biko Academic Hospital’s reproductive and endocrine unit in the department of obstetrics and gynaecology. She was among reproductive specialists recently approached by the Infertility Awareness Association of South Africa (IFAASA) to offer comment as to perceived weaknesses in fertility treatment within South Africa.

Nene cites primary barriers as:

• lack of knowledge about what fertility services are available;

• access to these services and the associated high cost;

• choices regarding service providers; and

• quality and regulations of these services.

Age shouldn't be an issue

Adding weight to Nene’s sentiments, IFAASA director: strategic relationships and CEO Meggan Zunckel, says:"We need to change the way our society thinks about infertility.

"The time patients spend in the system of non-referral before reaching a fertility specialist has a direct impact on how many treatment cycles will be required and how complex these cycles will be. All couples exhibiting infertility warning signs deserve a full diagnostic investigation with a fertility specialist no matter what their age. We currently sit with a situation where patients in their 20s and 30s are told to just relax, go on holiday and be patient as they are too young to be infertile. The reality is that women and men well under 40 are also distracted by the physical, financial and emotional hardships of this disease."

Financial burden

Added to the emotional and physical toll exacted by infertility is the financial burden carried by many seeking treatment, especially in South Africa. "It is a disease that deserves attention from our government, medical schemes, medical practices and community at large.

"The bottom line is that patients are entitled to be fully informed of their diagnosis which they can use to make an informed decision about their health and future family building options. It is also not for us to decide who can and cannot afford infertility treatment and only refer to fertility specialists based on this premise," she says.

Medical aids must come to the party

Dr Igno Siebert, reproductive medicine specialist at Vincent Pallotti Hospital’s Institute for Reproductive Medicine, says, “Our patients are suffering. One of the biggest issues currently is that neither the public nor private sector systems allow any leeway around the infertility issue. Basic and long overdue in our conversation with medical aids is that help is needed for infertility funding. We are sitting in a developing world with HIV covered by medical aids, yet 10% of patients suffer infertility. If one does not have money, one cannot fund one’s infertility treatments within the private sector. A couple of state hospitals offer in-vitro fertilisation, however patients must self-fund.”

"The diversity of socioeconomic groups that exist mean that the challenges are different in sub-populations, even though the need is universal. This is quite unique, for example HIV and its consequences remain the dominant health concern that consumes most of state-funded healthcare. Fertility conditions exist as direct and indirect consequences, however access to care is limited by the ability to self-fund in many cases. Higher socioeconomic groups primarily present with conditions related to delayed childbearing and stress/lifestyle related disorders," saysDr Nicholas Clark, a reproductive medicine specialist at Medfem Fertility Clinic in Bryanston, Gauteng,

Nene states that patients in the public sector clinics have been trying for a long time to get assistance for their inability to conceive and usually have consulted numerous doctors and gynaecologists. She says they have had multiple surgeries, ranging from unblocking tubes to cleaning the womb, to removal of growths from the uterus. “They have spent a lot of money on remedies and some have consulted traditional healers and spiritual healers,” she says.

"High-income earners have access to fertility services through the private sector. Even then the service is so expensive that the middle-income earners have to take out loans and sell their belongings to afford the service. The low-income group does not have access to this service at all. Even in the three public sector hospitals that provide fertility treatment – Steve Biko Academic Hospital, Groote Schuur Hospital, Tygerberg Hospital – the patient has to pay a portion of the costs, because the drugs are not available in state facilities."

Clark concurs: “South Africa has the most sophisticated treatments that medicine currently offers, available easily and, importantly, very quickly, with well qualified health practitioners at the helm. The problem is that it comes at a price. Fertility in the main is mistakenly viewed as a non-essential medical condition and as a result, treatments are not funded by medical schemes.

Policies

“This current attitude is misguided and ultimately is backed by false economics. Support of therapy would come with regulation and influence over the treatments. Where assisted reproduction is concerned, the primary criticism is the irresponsible generation of multiple pregnancies which ultimately consume the biggest funds both in the private and government sector through obstetric and neonatal care that is generously funded.

"By insisting on single embryo transfer policies, as in the United Kingdom and Australia, for example, and insisting on the use of registered and reputable centres of excellence, the vast waste in generalist dabbling, delayed referral and irresponsible practice would be eliminated to a large degree. Funding would encourage the main flow of patients with medical insurance to these reputable centres, biasing the medical outcomes in favour of less risky singleton pregnancies which would not only benefit the maternal outcome but also the health funders.

“The impact of poor education, limited access to quality information and entrenched medical practices that do not move with the times all hinder the optimal service that could be provided. With fertility, the treatment success window is narrow, so delayed referral is a major hindrance. Service duplication, with its associated costs, is rife and in my opinion completely unnecessary and avoidable."

Cultural beliefs

Cultural variations in beliefs with traditional fixed and often out of touch ideas certainly make for a challenging engagement in some cases and the potential for sub-optimal service. The most common example is the male reluctance to participate in early investigation with a simple test such as semen analysis. It is often the female that will make the first move and subject herself to various examinations and tests. Comprehensive examination and testing of each party is a quick, easy and relatively inexpensive process if done properly, where focused relevant information is gathered in one go.

“Since pregnancy is achieved in only three possible ways, namely natural conception, artificial insemination or in-vitro fertilisation, it would seem sensible that more emphasis is placed on the diagnostic and decision making part of the process as treatment is relatively straight forward in its execution," he says.

Service delivery

Ultimately the patients themselves need to up their knowledge base and seek out fertility specialists that have received further training in reproductive medicine and their infertility centre must be accredited by SASREG. “There should be a scale up of training of specialists and embryologists in South Africa as presently this is a scarce skill. Adequate service delivery will only be realised when every fertility clinic has an HPCSA-registered reproductive medicine specialist and embryologist and is an accredited facility,” says Nene. “It is furthermore important that patients are educated about what the possible causes are for subfertility and what treatment options are available to them”.

She cites male factor infertility as enormously underdiagnosed in the South African population. “There are treatment options for male infertility that only fertility centres can provide, such as testicular aspirations and testicular sperm extraction. Most men are given over the counter testosterone medication, which may be harmful rather than helpful."