INFERTILITY IN IN YEMEN. THE FIRST STEPS. THE FIRST STEPS. Ishraq DHAIFALAH

Transcription

1 INFERTILITY IN IN YEMEN. THE FIRST STEPS. THE FIRST STEPS Ishraq DHAIFALAH

2 The country of the Queen Sheiba

3 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 sqkm. Excluding Rub-Alkahli Total literacy is 28%, 64% for male and 36% for female

4 Some selected health indicators Not established registration system Life expectancy 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%

5 Infant mortality 75 per 1000 Maternal mortality per Few hospitals, long distance to them, less qualified staff years aged women have an average of 8 children of which 2 have not survived

6 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

7 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)

8 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)

9 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

10 Methods of investigation and management male factor infertility Routine seminal fluid analysis Male hormone profiles including (FSH, LH, PRL and testosterone) Testicular biopsy when indicated

11 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

12 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

13 Azoospermia (obstructive and nonobstructive as oligo-astheno-terato-zoospermia) can benefit from ICSI Obstructive and Non-Obstructive have a strong relation to smoking

14 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

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

16 Male factor of infertility subgroups distribution (N=557) Infer. type No. % of male factor % of the total group Azoospermia OATS Others Total

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

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

19 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

20 Female Factor Infertility subgroups distribution (N=404) Infertility Type No. % of female factor Tubal factor % PCO Syndrome Hyper-PRL Cong. anomalies Others Total

21 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)

22 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

23 Distribution of different types of infertility (n=1100) 4% 8% 37% 51% Male Factor Female Factor Combined Unexplained

24 Duration of infertility in Primary & Secondary Infertility group (n=1100) No. of cases Duration of infertility (years) P. Inf Sec. Inf

25 Type of infertility Number of cases % Primary ,1 Secondery ,9

26 Type of infertility Number of cases % Male factor , 4 Female factor , 7 Combined 49 4,5 Unexplained 93 8,4

27 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*) Tubal Factor Endometriosis Psychosexual problems Male Unexplained Incompletely investigated G. tract Cong. anomaly Others Total Study(1) Hull, et al. Population study of causes, treatment and outcome of infertility. Br Med J 1985 : 291: Study(2) Smith H. Female infertility. Mod Med of the Middle East. 1990,6, 62-72

28 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).

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30 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

31 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 % do chew Qat where there is about 40 types of it with different type of effect

32 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

33 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

34 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)

35 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