INFERTILITY IN YEMEN.THE FIRST STEPS.

Ishraq DHAIFALAH

INFERTILITY IN YEMENTHE FIRST STEPS

The country of the Queen Sheiba

General information

• It has a population of 16 million with a doubling time of 18,9 years (1994)

• 80% of population lives in rural areas • 0-14 year’s old age group constitutes 52.5 %• Yemen has a total area of 555.000 sqkm.

Excluding Rub-Alkahli• Total literacy is 28%, 64% for male and 36%

for female

Some selected health indicators

• Not established registration system• Life expectancy 47-58• Fertility rate is 7.7 %• It has a crude birth rate of 52.% and a crude

death rate of 21.0% (1994)• Health service covers only 45%

• Infant mortality 75 per 1000• Maternal mortality 800-1000 per 100 000 • Few hospitals, long distance to them, less

qualified staff • 45-49 years aged women have an average of

8 children of which 2 have not survived

IVF IN YEMEN

• „Since children contribute to happiness, they also express love in a relationship, provide a goal in life and give the sense of completion“

• Infertility despite not being an illness, it can cause emotional distress, isolation, unacceptable misunderstood and a feeling of being a shamed

• Infertility is not a priority health problem in Yemen

• No studies done yet to show the percentage of infertility for the whole Yemen yet

• Until now there is only one private IVF center surfing the whole republic started February the year 2000 (16 million population and 7.7 % fertility rate)

Studies and Patients

• Up to date this center have received 5300 patient with an average of 150 new patient/month and follow up of about 400/monthly

• It treats female factors and sever male factors (oligoasthenoteratospermia and azoospermia)

• The center had registered a success rate of 32.6% in IVF-ICSI

• Usually induction, IUI, ICSI, are used as most of the patient are male cases

• The first consecutive 1100 patients presenting to the IVF program in this center, due to any cause of infertility are the only source of information about infertility yet in Yemen

• Routine seminal fluid analysis• Male hormone profiles including (FSH, LH,

PRL and testosterone)• Testicular biopsy when indicated

Methods of investigation and management male factor infertility

Female factor of infertility

• Basic female hormone profile (FSH, LH, oesteradiol at day one and day three of the cycle, PRL and progesterone level during the luteal phase).

• Vaginal ultrasonography • Hysterosalpingiography• Diagnostic and operative laparoscopy as

well as hysteroscopy

Presentation of males

• Male factor infertility is higher than usually seen

• Mechanical (inaccurate timing of intercourse, low semen volume, erectile or ejaculatory dysfunction, anatomical abnormality or physical disability) can benefit from IUI

• Azoospermia (obstructive and nonobstructive as oligo-astheno-terato-zoospermia) can benefit from ICSI

• Obstructive and Non-Obstructive have a strong relation to smoking

• Non-obstructive azoospermia is sometimes related to environmental factors such as insecticides and other chemicals used for plant fertilization as for example Qat. The main bulk of cases came from this group

• Undescended testis is still seen in some cases, some have had operative treatment at late twenties or even early thirties of their life

• Social (whether couple will ask for medical help and if they are motivated to achieve success), nutritional, genetic and environmental causes should be searched

Male factor of infertilitysubgroups distribution

(N=557)Infer. type No. % of male

factor% of the total

groupAzoospermia 246 44.2 22.4 OATS 267 47.9 24.3 Others 41 7.9 3.7Total 557 100 50.4

Presentation of females

• Tubal factors is the major cause it presents about (41.1 %) - pelvic inflammatory disease (PID) early age of marriage, poor education andhygiene - postpartum sepsis home deliveries, poor septic precaution in some medical centers - cases of IUCD

• -Tuberculosis is still seen frequently a rate of 0.09% among people, cure rate is 50% and a death rate is 15 per 100000) - Peritonitis missing early diagnosis as ruptured appendix - Previous ectopic pregnancy late diagnosis and major operations -Previous C/S

• Anovulation is the other major factor of female infertility (37.7 %) -Polycystic ovary syndrome (PCOS) prevalence is not yet known -Hyperprolactinemia it is noticed that it is related to some nutritional factor in Yemen

Female Factor Infertility subgroups distribution (N=404)Infertility Type No. % of female

factor Tubal factor 166 41.1%

PCO Syndrome 151 37.4

Hyper-PRL 42 10.4Cong. anomalies 18 4.4

Others 27 6.7Total 404 100

Outcomes

• Male factor contributes to almost 70 % of cases of infertility in Yemen

• Female factor are mainly due to tubal and anovulatoury causes in equal sheers

• Longer duration of infertility (peak to search of treatment is 7 and 10 for primary 4 and 11 for secondary)

Results

• Main bulk of patients coming to the IVF center in Yemen were due to male factor

• Female factor infertility is related to genital infection most of the time due to tubal block as a consequence of pelvic inflammatory disease (PID) and in particular genital TBC and intra-abdominal adhesions due to recurrent laparatomies

Distribution of different types of infertility (n=1100)

51%37%

4% 8%

Male Factor Female Factor Combined Unexplained

Duration of infertility in Primary & Secondary Infertility group (n=1100)

0

10

20

30

40

50

60

70

80

1 4 7 10 13 16 19 22 25 28

Duration of infertility (years)

No. o

f cas

es

P. InfSec. Inf

Type ofinfertility

Number ofcases

%

Primary 934 78,1

Secondery 166 21,9

Type of infertility Number ofcases

%

Male factor 557 50,4

Female factor 404 36,7

Combined 49 4,5

Unexplained 93 8,4

Causes of infertility in the study group (N= 1100)

Cause of infertility Study (1)

%

N= 472

Study (2) Our Study

N=1100

Ovulatory Failure(PCO*)

21 29 18.9

Tubal Factor 14 16 15.1

Endometriosis 5 7 0.6

Psychosexualproblems

3 4 0.5

Male 24 21 50

Unexplained 26 18 8.5

Incompletelyinvestigated

2 - -

G. tract Cong. anomaly - 5 1.6

Others 5 - 4.5

Total 100 100 100

Study(1) Hull , et al . Population study of causes, treatment and outcome

of infertility. Br Med J 1985 : 291: 1693-1697. Study(2) Smith H. Female

infertility. Mod Med of the Middle East. 1990,6, 62-72

Qat

• Chewing Qat (Khat, Chat), the leaves and shoots of Catha edulis for recreation or alleviate fatigue is a popular custom in several countries of East Africa and South Arabia (it is an exceptional drug in that only the fresh leaves have the desired stimulatory effect).

• It was only until the year 1975 that the most effective substance in Qat was discovered and announced by WHO, some years later Qat has been included in schedule I of the United Nations Convention on Psychotropic Substance and thus put under international control

• It is known as cathinone which produces an amphetamine like stimulant effect, and it is considered as natural amphetamine producing euphorigenic and sympathomimetic like action

• In Yemen about 80-90 % do chew Qat where there is about 40 types of it with different type of effect

• Qat chewers claim varying effects on their sex life. It can cause spermatorrhea and chronic use may lead to impotence

• Release of clear prostatic fluid without much sperm

• Increase in libido which is not sustained by an equal increase of sexual potency

• Social, cultural and economic aspects have to be taken into consideration

• A common effect of Qat is insomnia that some time overcomed by alcohol and sedatives

• Mild euphoria and excitement often accompanied by loquacity or even logorrhea (hypomanic). Withdrawal are limited (lethargy, mild depression, slight trembling and recurrent bad dreams)

• Sympathomimetic effects (mydriasis which a long with a staring look and the brownish stain of the teeth can be considered as a pathognomic for Qat use)

• Arrhythmia and increase of blood pressure • Hyperthermia and dryness of the mouth• The tannins in the digestive system may be a

factor in development of periodontal disease• It reduces birth weight and leads to the

malnutrition