Perspectives in Global Perspectives in Global Fertility and Fertility and Infertility Infertility Catherine L. Haggerty, PhD, MPH Catherine L. Haggerty, PhD, MPH Assistant Professor of Reproductive Assistant Professor of Reproductive Epidemiology Epidemiology University of Pittsburgh University of Pittsburgh
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Perspectives in Global Fertility and Infertility Catherine L. Haggerty, PhD, MPH Assistant Professor of Reproductive Epidemiology University of Pittsburgh.
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Perspectives in Global Perspectives in Global Fertility and InfertilityFertility and Infertility
Catherine L. Haggerty, PhD, MPHCatherine L. Haggerty, PhD, MPH
Assistant Professor of Reproductive Assistant Professor of Reproductive EpidemiologyEpidemiology
University of PittsburghUniversity of Pittsburgh
OutlineOutline
Global Reproductive Health Programs, Global Reproductive Health Programs, Population Growth, & Fertility TrendsPopulation Growth, & Fertility Trends
Role of Sexually Transmitted Diseases Role of Sexually Transmitted Diseases (STDs) in Unintentional Infertility(STDs) in Unintentional Infertility
Intentional Control of FertilityIntentional Control of Fertility
Traditional Global Traditional Global Reproductive HealthReproductive Health
Family planningFamily planning
Maternal and child health Maternal and child health programsprograms
STD prevention programsSTD prevention programs
Reproductive Health: A Reproductive Health: A Holistic ApproachHolistic Approach 1994 United Nations sponsored 1994 United Nations sponsored
33rdrd International Conference on International Conference on Population Development, CairoPopulation Development, Cairo– Safe sex lifeSafe sex life– Capability and freedom to reproduceCapability and freedom to reproduce– Access to safe, effective, affordable, Access to safe, effective, affordable,
and acceptable family planningand acceptable family planning– Access to prenatal and obstetric Access to prenatal and obstetric
carecare– Sexual health: enhanced life and Sexual health: enhanced life and
personal relationspersonal relations
Total World Population by Country Income Group, 1980, 1998, 2015
Discussion Question:Discussion Question:What might explain What might explain general declines in birth general declines in birth rates?rates? Declining infant mortality rates in rural Declining infant mortality rates in rural
areas means less births are needed to areas means less births are needed to result in the same number of childrenresult in the same number of children
Increases in urban living raises the Increases in urban living raises the cost of dependent childrencost of dependent children
Changes in the role of women in Changes in the role of women in societiessocieties
Improvements in contraceptive Improvements in contraceptive technology and availabilitytechnology and availability
Life Expectancy World Rates
Fertility Rate World Map
From: wikipedia.com
Discussion Question: Why are Discussion Question: Why are Total Fertility Rates Higher in Total Fertility Rates Higher in Developing Countries?Developing Countries?
Developed CountriesDeveloped Countries– Birth control easily accessibleBirth control easily accessible– Start families later in lifeStart families later in life– More children = more education, More children = more education,
clothing, and feeding costsclothing, and feeding costs Developing CountriesDeveloping Countries
– Children assist with labor and elderly Children assist with labor and elderly carecare
– Lack of access to contraceptivesLack of access to contraceptives
Maternal age and fertility ratesMaternal age and fertility rates
Pathogenesis of pelvic inflammatory Pathogenesis of pelvic inflammatory diseasedisease
PID
8% U.S.
15% Sweden
32% Northern Territory, Australia
Ectopic Pregnancy
7 - 8%
Recurrent PID
16 - 23%
Chronic Pelvic Pain
17 – 30%
Infertility
16 – 40%
Pathogenesis Pathogenesis of of Reproductive Reproductive Morbidity Morbidity Following PIDFollowing PID
PID
Infertility
Chronic Pelvic Pain
Recurrent PID
Ectopic Pregnancy
Fallopian Tube
Obstruction
Fallopian Tube
Closure
Cilia Damage
Adhesions
From: Mårdh P, Möller B, Paavonen J, Weström L, Krieger J, Rein M. Atlas of Infectious Diseases: Sexually Transmitted Diseases. Edited by Gerald
From: Mårdh P et al. Atlas of Infectious Diseases: Sexually Transmitted Diseases. Ed. Mandell & Rein. 1996 Current Medicine, Inc.
Pollack, JD. Trends Microbiol. 1997; 5:413-419
Prevalence of Prevalence of M. genitaliumM. genitalium
4%
2%
6%
88%
CervixEndoBothNeither
Adapted from CL Haggerty, PA Totten, S Astete, S Hoferka and RB Ness. The role of Mycoplasma genitalium in pelvic inflammatory disease. International Journal of STD & AIDS 2006; Vol. 17, Supplement 1:p. 9, SY5-3, and symposium presentation at the 2006 IUSTI meeting, Paris, France.
Relationship between Relationship between M. genitaliumM. genitalium Measured in the Endometrium at Baseline & Measured in the Endometrium at Baseline & Endometritis Assessed at Baseline and 30 Endometritis Assessed at Baseline and 30 Days Post TreatmentDays Post Treatment
0
10
20
30
40
50
60
70
80
Baseline 30 Days
Percent Endometritis
Mg+Mg-
OR=3.4 OR=3.7
*p<0.05 for all comparisons
Adapted from CL Haggerty, PA Totten, S Astete, S Hoferka and RB Ness. The role of Mycoplasma genitalium in pelvic inflammatory disease. International Journal of STD & AIDS 2006; Vol. 17, Supplement 1:p. 9, SY5-3, and symposium presentation at the 2006 IUSTI meeting, Paris, France.
Relationship between Endometrial Relationship between Endometrial M. M. genitaliumgenitalium & Endometritis among & Endometritis among women without women without N. gonorrhoeaeN. gonorrhoeae or or C. C. trachomatistrachomatis
0
10
20
30
40
50
60
70
Baseline 30 Days
Percent Endometritis
Mg+Mg-OR=2.4 OR=6.
6
*p<0.05 for all comparisons
Adapted from CL Haggerty, PA Totten, S Astete, S Hoferka and RB Ness. The role of Mycoplasma genitalium in pelvic inflammatory disease. International Journal of STD & AIDS 2006; Vol. 17, Supplement 1:p. 9, SY5-3, and symposium presentation at the 2006 IUSTI meeting, Paris, France.
Prevalence of Prevalence of M. genitalium M. genitalium among Women presenting with among Women presenting with
Signs and Symptoms of PIDSigns and Symptoms of PID
129
13
0
5
10
15
20
25
30
Percent
US Kenya England
Frequency of cervical pathogens among 826 West African sex workers
Adapted from: Pepin J et al. Mycoplasma genitalium: an organism commonly associated with cervicitis among west African sex workers. Sexually Transmitted Infections. 81(1):67-72, 2005
3
16
26
0
5
10
15
20
25
30
C. trachomatis N. gonorrhoeae M. genitalium
Prevalence of Prevalence of M. genitaliumM. genitalium among HIV among HIV Seropositive and Seronegative Women in the Seropositive and Seronegative Women in the US and KenyaUS and Kenya
19
5
14
3
02468
101214161820
US Kenya
Rate of M. genitalium
HIV+HIV-
Adapted from: Irwin KL et al. Influence of human immunodeficiency virus infection on pelvic inflammatory disease. Obstetr & Gyn 2000. 95(4):525-34 and Cohen CR et al. Detection of Mycoplasma genitalium in women with laparoscopically diagnosed acute salpingitis. STI 2005. 81(6):463-6.
Svenstrup, H. F. et al. Hum. Reprod. 2003 18:2103-2109; doi:10.1093/humrep/deg392
Nomarski microscopy (x100 objective) of sperm incubated in vitro with M.genitalium
M. genitaliumM. genitalium & & InfertilityInfertility Clausen HF et al, 2001Clausen HF et al, 2001
– TFI patients: Mg seropositive 22.0%TFI patients: Mg seropositive 22.0%– Patients with normal tubes: Mg Patients with normal tubes: Mg
seropositive 6.3%seropositive 6.3%
Copyright restrictions may apply.
Larsen, U. Int. J. Epidemiol. 2000 29:285-291; doi:10.1093/ije/29.2.285
Percentage with primary infertility in selected sub-Saharan African countries
Copyright restrictions may apply.
Larsen, U. Int. J. Epidemiol. 2000 29:285-291; doi:10.1093/ije/29.2.285
Percentage with secondary infertility in selected sub-Saharan African countries
Total Infertility Rates (Primary and Total Infertility Rates (Primary and Secondary) in U.S. and in Regions with Secondary) in U.S. and in Regions with High Rates of STDs and Low Access to High Rates of STDs and Low Access to CareCare
10
2826
0
5
10
15
20
25
30
U.S. Sub-SaharanAfrica
NorthernTerritoryAustralia
Primary vs. Secondary Infertility in Primary vs. Secondary Infertility in the U.S. and in Regions with High the U.S. and in Regions with High Rates of STDs and Low Access to Rates of STDs and Low Access to CareCare
Developed from http://www.lalecheleague.org/cbi/bfstats03.html
Deliberate Control of Deliberate Control of FertilityFertility
Postponement/interruption of Postponement/interruption of marriage/sexual relationshipmarriage/sexual relationship
SterilizationSterilization Contraceptive useContraceptive use Induced abortionInduced abortion
Global Contraceptive Rates among Global Contraceptive Rates among Married Couples, 2000Married Couples, 2000
26
56
6776
0
10
20
30
40
50
60
70
80
Africa Japan Europe NorthAmerica
Unintended PregnancyUnintended Pregnancy
20% in low to middle income countries20% in low to middle income countries– Ranges from 3% in Niger, sub-Saharan Ranges from 3% in Niger, sub-Saharan
Africa, to 45% in Latin American BoliviaAfrica, to 45% in Latin American Bolivia ConsequencesConsequences
– Increased lifetime risk of maternal Increased lifetime risk of maternal mortalitymortality
– Unsafe abortionUnsafe abortion– Poor infant healthPoor infant health– Lower investment in the childLower investment in the child
Final Discussion Question: Final Discussion Question: What are the barriers to What are the barriers to family planning services, family planning services, particularly in developing particularly in developing countries?countries? Lack of well-run family planning Lack of well-run family planning
programsprograms Economic cost of access to servicesEconomic cost of access to services