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1 Progress, No. 63 No. 63 2003 UNDP/UNFPA/WHO/World Assisted reproduction in developing Bank Special Programme of Research, Development and countriesfacing up to the issues Research Training in Human Reproduction (HRP) For millions of couples around the Attitudes to assisted reproduction are Department of Reproductive world, the inability to have children is very much influenced by the specific Health and Research, a personal tragedy. For a significant cultural and social context. Manipula- World Health Organization, proportion of them, the private agony tion of sperm, oocytes and embryos Geneva, Switzerland is compounded by a social stigma, raises numerous questions to which which can have serious and far-reach- there are no easy answers, and which Launched by the World Health ing consequences. It is not surprising often arouse strong emotions. The Organization in 1972, the UNDP/ therefore that the demand for as- article on page 5 outlines some of the UNFPA/WHO/World Bank sisted reproductive technologies ethical and legal issues surrounding Special Programme of (ART) is growing in all regions. But the use of ART, which need to be Research, Development and how can the provision of these tech- discussed openly by all involved par- Research Training in Human nologieswhich are expensive and ties wherever such services are made Reproduction is a global have a success rate of less than available. programme of technical 30%be justified in developing coun- cooperation. It promotes, tries with poorly developed health In the 25 years since the birth of the coordinates, supports, conducts, services that are still struggling with first baby resulting from in vitro ferti- and evaluates research on infectious and chronic diseases, such lization, there have been tremendous reproductive health, with as tuberculosis, malaria and HIV/ advances in scientific techniques and particular reference to the needs AIDS? medical applications of ART. But there of developing countries. are still areas where more research is In 2001, the World Health Organiza- needed. For instance, concerns have tion convened a meeting on Medical, been expressed about the long-term Ethical and Social Aspects of As- development of the child. Experience sisted Reproduction, to examine a in this area is, of necessity, rather INSIDE number of issues surrounding the limited, especially for the newer tech- treatment of infertility, and to learn niques, but the results so far are reas- about country and regional experi- suring. As noted in the article on page ART in developing countries 1 a response to individual need ences with assisted reproduction. 6, however, continued vigilance is or a social priority? ................ 2 Specifically, the objectives of the needed to monitor the long-term out- meeting were (i) to review and assess comes of ART. Regional and country recent developments in ART, (ii) to perspectives ........................... 3 identify unresolved issues in the field, As part of this monitoring effort, and and (iii) to provide recommendations as ART becomes available in more Ethical and legal issues ......... 5 for future research. and more countries, national and in- ternational surveillance systems as- Long-term effects of ART ...... 6 This issue of Progress looks at some sume considerable importance. The National and international of the topics that were covered at the article on page 7 describes some of surveillance of ART ................ 7 meeting, starting with an overview of the difficulties in ensuring that such the situation in developing countries, systems produce reliable and com- New publication ...................... 8 where infertility rates are high and parable data. Box 3 (The Latin Ameri- private ART services are being set up can Registry of Assisted Reproduc- in response to the needs and de- tion) on page 7 describes an attempt mands of individuals. This is followed in Latin America to ensure standard- 1 Vayena E, Rowe P, Griffin PD, eds. Current practices and controversies by a series of short reports from sev- ized reporting from ART centres in a in assisted reproduction: report of a eral regions and countries on the cur- number of countries. WHO meeting. Geneva, World Health rent status of ART services. Organization, 2002. 2 Progress, No. 63 ART in developing countries Progress a response to individual need or a social in Reproductive Health Research priority? Issued quarterly (since 1987) by There are over 186 million couples in are severely limited, where there are the UNDP/UNFPA/WHO/World developing countries alone (exclud- other pressing public health problems Bank Special Programme of ing China) today who are affected by that are not adequately addressed, Research, Development and infertility (both primary and second- and where national goals may include Research Training in Human ary). Rates of infertility vary consider- reducing fertility rates in the popula- Reproduction, Department of ably from country to country; in the tion. In addition, it is argued that Reproductive Health and Re- worst-affected areas, over 25% of resources would be better spent on search, World Health Organiza- couples may be unable to have chil- tackling the causes of much of the tion, 1211 Geneva 27, Switzer- dren. Most of the infertility in develop- infertilitythe reproductive tract in- land. For a free subscription, ing countries is attributable to dam- fections that are not diagnosed or please write to the above age caused by infections of the repro- adequately treated. address. ductive tract, notably gonorrhoea and chlamydial infection. Whatever the merits of the various Editor: Jitendra Khanna arguments, it has to be recognized Writer: Patricia A. Butler In addition to the personal grief and that couples who want children will go suffering it causes, the inability to to great lengths to have them, and have childrenespecially in poor that there will always be providers to © World Health Organization communitiescan create broader make services available to those who 2003 problems, particularly for the woman, can pay for them. Thus, while ART is in terms of social stigma, economic still not easily accessible in develop- This newsletter is not a formal hardship, social isolation, and even ing countriesand is extremely ex- publication of the World Health violence. Various studies have found pensiveit is starting to make an Organization (WHO), and all that childless women in developing appearance. Governments in these rights are reserved by the countries are often abandoned by their countries therefore have a responsi- Organization. The document husband, subjected to violence, or bility to ensure that the services pro- may, however, be freely re- treated as servants by the husbands videdwhether in the public or the viewed, abstracted, reproduced family. In some societies, mother- private sectorare safe and effec- or translated, in part or in whole, hood is the only way for women to tive. The majority of developing coun- but not for sale or for use in improve their status within the family tries where ART is available have not conjunction with commercial and the community. On a practical formally addressed these issues, al- purposes. level, many families in developing though some are considering or using countries depend on children for eco- approaches based on those used in The mention of specific compa- nomic survival. While many people, developed countries, including legis- nies or of certain manufacturers' therefore, would not consider infertil- lation, management guidelines, li- products does not imply that they ity a disease in itself, it can certainly censing, and reporting systems. Oth- are endorsed or recommended be said to be a social and public ers have approached WHO for ad- by the World Health Organization health issue as well as an individual vice on how to handle the introduction in preference to others of a problem. of ART. similar nature that are not mentioned. Errors and omissions It is not surprising, therefore, that The lack of appropriate guidelines excepted, the names of propri- there is a growing demand for serv- and regulations in most developing etary products are distinguished ices that can help infertile couples to countries is a serious drawback in by initial capital letters. conceive. In practice, this means efforts to improve the quality of the ARTartificial insemination, in vitro services provided. In the absence of Articles in this issue are based fertilization, gamete or zygote national legislation, health profession- on a WHO publication with intrafallopian transfer, intracytoplas- als are challenged to implement some named authors and editors (see mic sperm injection, embryo freezing form of self-regulation, giving some footnote on page 1) and do not and donation, and surrogate mother- form of recognition to practitioners necessarily reflect the views of hood (see Box 1 on page 3). The fact who are qualified to perform the pro- the World Health Organization. that these services are expensive cedures and have access to adequate and controversial has not prevented facilities. Centres should be encour- their appearance in developing coun- aged to standardize procedures and tries. equipment and to share their results and expertise in a genuine collabora- This inevitably raises questions about tive effort aimed at raising profes- whether such services are justifiable sional standards and avoiding mis- in a context where health resources use of the technologies. 3 Progress, No. 63 Regional and country perspectives The view

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