A call to provide multiple options for women in developing countries

19 05 2009

To the Editor:

I was encouraged to read the article by Vayena et al, which justly addressed the needs of women experiencing infertility in developing countries (1). What is not clear is whether the authors are truly concerned with fairly evaluating “innovative approaches in treatment” (1) or whether they are simply one-sided advocates for assisted reproductive technology (ART).

While I agree with the authors that “advances in ART have increased success rates and decreased complications” (1), multiple pregnancies and small-for-gestational-age infants, along with maternal preeclampsia, gestational diabetes, placenta previa, and cesarean delivery all remain risk factors associated with ART (2).

If a woman’s autonomy is to truly be respected, she should be made aware of all options available to her, including how to optimize natural fertility by understanding her “fertile window” (3). Vaynea et al point out that “there is no published report of implementation of a low-cost IVF protocol and the respective outcomes (1).” Conversely, Stanford et al show that couples treated for infertility with natural procreative technology (NPT) had adjusted pregnancy rates similar to cohort studies of ART (4), with the added benefit of being minimally invasive and resulting in fewer multiple pregnancies. Stanford et al also show that consistent, well-timed intercourse “will result in cumulative pregnancies equivalent to early IVF, over a follow-up period of 1-3 years (5).” While NPT cannot cure all reproductive difficulties, it can treat (rather than bypass) many infertility conditions through both biomarker monitoring by the woman and possible enhancement of ovulation, cervical mucus and/or hormonal production (4). If women’s self-determination is of primary importance, then NPT should be evaluated on the same plane as ART since it has the added benefit of allowing women to be more active participants in their own health care.

Without hesitation, I applaud the authors’ aim to provide equitable access to reproductive health services for couples living in developing countries. However, I would also advocate that proponents of ART closely examine the social context of each country they are assisting; making certain that it is not a patriarchal medical establishment putting pressure on women to use ART but rather a woman’s genuine choice and expression of autonomy.  I concur with Vayena et al that “as efforts move forward” toward developing affordable ART in developing countries, “risk-to-benefit” ratio must be ensured (1). I would expand, however, on Vayena et al’s strictly physical dimension to include the emotional and ethical dimensions that must be also considered for true beneficence to be upheld.

Karen Schliep, MSPH
Department of Family and Preventive Medicine
Division of Public Health
Salt Lake City, Utah

References
1. Vayena E, Peterson HB, Adamson D, Nygren KG. Assisted reproductive technologies in developing countries: are we caring yet? Fertil Steril 2009. In press.

2. Reddy UM, Wapner RJ, Rebar RW, Tasca RJ. Infertility, assisted reproductive technology, and adverse pregnancy outcomes: executive summary of a National Institute of Child Health and Human Development workshop. Obstet Gynecol 2007;109:967-77.

3. Practice Committee of American Society for Reproductive Medicine in collaboration with Society for Reproductive Endocrinology and Infertility. Optimizing natural fertility. Fertil Steril 2008;90:S1-6.

4. Stanford JB, Parnell TA, Boyle PC. Outcomes from treatment of infertility with natural procreative technology in an Irish general practice. J Am Board Fam Med 2008;21:375-84.

5. Stanford JB, Mikolajczyk RT, Lynch CD, Simonsen SE. Cumulative pregnancy probabilities among couples with subfertility: effects of varying treatments. Fertil Steril 2009. In press.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2009.05.040

The authors declined to respond to this letter.

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