UNIVERSAL ACCESS TO INFERTILITY CARE: Perspectives from Africa Fertility Expert Forum 2019 Silke Dyer, FCOG, PhD, University of Cape Town
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ESHRE Capri Workshop Group, Hum Reprod 2001;16:1518–1526 ; International Committee Monitoring ART, unpublished data.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
Wide screen 16:9Page set up: On screen show
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References: Font 11
Other Presentations:
- New York: same
- ESHRE ART utilization: Wide screen page set up