Reproductive medicine--an African Perspective.
Reproductive medicine is a subspecialty that includes infertility, gynaecological endocrinology and fertility regulation. It interrelates with medical and paediatric endocrinology, with psychiatry, and with many of the laboratory-based disciplines it accesses. Minimal access surgery is widely used in reproductive medicine and has given us an added dimension for therapeutic intervention.
The tragedy of infertility has been reported and documented over centuries. One in six couples suffer from infertility, and the impact on those affected and their families is considerable. The cause of infertility in Africa is predominantly tubal disease, secondary to sexually transmitted infections, infections following unsafe abortion or postpartum sepsis. This contrasts with the lower prevalence of tubal disease in industrialised countries (35% v. 85% in Africa). (1) The impact of infertility in Africa is a major factor in societal terms. Men and women suffer a loss of social status, isolation and both psychological and physical abuse, and too often a culture of secrecy and blame develops with women bearing the brunt of this victimisation. (2) Research in the Reproductive Medicine Unit in Cape Town has defined and emphasised the impact of involuntary childlessness on South African couples and certainly provides compelling evidence for addressing the need for access to suitable therapy. While the prevention of infection is obviously essential, and would prevent the tubal damage that is so prevalent in Africa, appropriate facilities for investigation and treatment of infertility are also required. These, unfortunately, are largely unavailable in most African public health care facilities. Too often infertility is regarded as an 'add-on' facility and health care provision does not offer appropriate investigation, support and therapy.
Given the numerous competing demands in health care, the above may be understandable but certainly does not address the perceived needs of men and women in Africa. Assisted reproductive technologies (ART) offer the possibility of effective treatment, but these are sadly mainly in the private sector and are unaffordable to the majority of patients we see. This needs to be revisited and it is hoped that, through the World Health Organization, affordable ART will become available in Africa. Obviously the management of infertility must be underpinned by safe motherhood, and it would be indefensible to treat infertility in the absence of appropriate facilities for good maternity care.
The second aspect of reproductive medicine, which should enjoy considerable attention, is that of fertility regulation. Millions of couples worldwide have unmet contraceptive needs, and this is particularly true in Africa. Facilities need to be patient-centred and to offer appropriate education and a wide spectrum of methods. Too often contraceptive services limit the methods that are offered and newer technologies such as the levonorgestrel intra-uterine system are just not accessible to patients in the public health sector. This discrimination on the basis of financial resources is unfortunately a repetitive theme in reproductive medicine.
Newer methods of contraception need to be explored and made available. Research from the Contraceptive Development Network has demonstrated enthusiastic support for hormonal contraception for men, from both men and women. Early studies looking at different possible hormonal regimens are now being developed into multi-centre studies in Europe. (3,4)
The polycystic ovary syndrome (PCOS) is the commonest endocrinopathy in women during the reproductive years. It is a syndrome of reproductive dysfunction and metabolic disorders, and the long-term health consequences are only now being fully realised.
PCOS is the most frequent reason for referral to our Gynaecological Endocrine Service and is important as a cause of anovulatory infertility. It is associated with dyslipidaemia and insulin resistance, but there are very few African data available. All the studies on the prevalence of PCOS have been done in industrialised countries, and although research in this area has been undertaken in South Africa, there are no good prevalence studies. Undoubtedly this is an area that should enjoy attention in the future.
Over the past few decades the AIDS pandemic has impacted on our discipline. It has influenced all aspects of health care in every part of our society and presents its own frightening challenges. In reproductive medicine we have to grapple with the problems of infertility in HIV-positive patients, the dilemmas of altered management because of immunocompromise, and the redistribution of resources to deal with the problems of HIV/AIDS. With effective antiretroviral therapy, HIV infection can be better managed and patients will be able to access realistic therapeutic options.
The 19th World Congress of the International Federation of Fertility Societies being held in Durban will undoubtedly offer us the opportunity to access up-to-date information presented by experts from around the world. It is an opportunity for those of us in South Africa, and indeed in Africa, to interface with our colleagues and it will highlight the contrast in resources between countries. It is hoped that we will take from it many lessons and also the opportunity to develop expertise appropriate to the needs of Africa.
Zephne van der Spuy
Department of Obstetrics and Gynaecology
University of Cape Town and
Groote Schuur Hospital
(1.) Cates W, Farley TMM, Rowe PJ. Worldwide patterns of infertility: Is Africa different? Lancet 1985; 2: 596-598.
(2.) Dyer SJ, Abrahams N, Hoffman M, van der Spuy ZM. 'Men leave as I cannot have children'--women's experiences with involuntary childlessness. Hum Reprod 2002; 17(6): 1663-1668.
(3.) Martin CW, Anderson RA, Cheng L, et al. Potential impact of hormonal male contraception: cross cultural implications for development of novel preparations. Hum Reprod 2000; 15(3): 637-645.
(4.) Anderson RA, van der Spuy ZM, Dada OA, et al. Investigation of hormonal male contraception in African men: suppression of spermatogenesis by oral desogestrel with depot testosterone Hum Reprod 2002; 17(11): 2869-2877.
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|Author:||van der Spuy, Zephne|
|Publication:||South African Journal of Obstetrics and Gynaecology|
|Date:||Apr 1, 2007|
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