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Perspectives in Global Fertility and Infertility Catherine L. Haggerty, PhD, MPH Assistant Professor of Reproductive Epidemiology University of Pittsburgh Outline Global Reproductive Health Programs, Population Growth, & Fertility Trends Role of Sexually Transmitted Diseases (STDs) in Unintentional Infertility Intentional Control of Fertility Traditional Global Reproductive Health Family planning Maternal and child health programs STD prevention programs Reproductive Health: A Holistic Approach 1994 United Nations sponsored 3rd International Conference on Population Development, Cairo – Safe sex life – Capability and freedom to reproduce – Access to safe, effective, affordable, and acceptable family planning – Access to prenatal and obstetric care – Sexual health: enhanced life and personal relations Total World Population by Country Income Group, 1980, 1998, 2015 http://www.worldbank.org/depweb/english/modules/social/pgr/chart1.html Average Annual Growth Rates by Country Income Group, 1980-2015 http://www.worldbank.org/depweb/english/modules/social/pgr/chart2.html Demographic Transition From: Wikipedia.com Discussion Question: What might explain general declines in birth rates? Declining infant mortality rates in rural areas means less births are needed to result in the same number of children Increases in urban living raises the cost of dependent children Changes in the role of women in societies Improvements in contraceptive technology and availability Life Expectancy World Rates Fertility Rate World Map From: wikipedia.com Discussion Question: Why are Total Fertility Rates Higher in Developing Countries? Developed Countries – Birth control easily accessible – Start families later in life – More children = more education, clothing, and feeding costs Developing Countries – Children assist with labor and elderly care – Lack of access to contraceptives Maternal age and fertility rates Pathogenesis of pelvic inflammatory disease PID 8% U.S. 15% Sweden 32% Northern Territory, Australia Infertility 16 – 40% Chronic Pelvic Pain Recurrent PID Ectopic Pregnancy 17 – 30% 16 - 23% 7 - 8% Pathogenesis of Reproductive Morbidity Following PID Fallopian Tube Obstruction Infertility Fallopian Tube Closure Chronic Pelvic Pain Cilia Damage Recurrent PID Adhesions Ectopic Pregnancy PID Healthy Fallopian Tube From: Mårdh P, Möller B, Paavonen J, Weström L, Krieger J, Rein M. Atlas of Infectious Diseases: Sexually Transmitted Diseases. Edited by Gerald Mandell (series editor), Michael F. Rein. ©1996 Current Medicine, Inc. From: Mårdh P et al. Atlas of Infectious Diseases: Sexually Transmitted Diseases. Ed. Mandell & Rein. 1996 Current Medicine, Inc. Pollack, JD. Trends Microbiol. 1997; 5:413-419 Prevalence of M. genitalium 6% 2% 4% 88% Cervix Endo Both Neither Adapted from CL Haggerty, PA Totten, S Astete, S Hoferka and RB Ness. The role of Mycoplasma genitalium in pelvic inflammatory disease. International Journal of STD & AIDS 2006; Vol. 17, Supplement 1:p. 9, SY5-3, and symposium presentation at the 2006 IUSTI meeting, Paris, France. Relationship between M. genitalium Measured in the Endometrium at Baseline & Endometritis Assessed at Baseline and 30 Days Post Treatment 80 70 60 50 40 30 20 10 0 Mg+ Mg- OR=3.4 OR=3.7 Baseline 30 Days *p<0.05 for all comparisons Percent Endometritis Adapted from CL Haggerty, PA Totten, S Astete, S Hoferka and RB Ness. The role of Mycoplasma genitalium in pelvic inflammatory disease. International Journal of STD & AIDS 2006; Vol. 17, Supplement 1:p. 9, SY5-3, and symposium presentation at the 2006 IUSTI meeting, Paris, France. Relationship between Endometrial M. genitalium & Endometritis among women without N. gonorrhoeae or C. trachomatis 70 60 50 40 30 20 OR=2.4 OR=6.6 Baseline 30 Days Mg+ Mg- 10 0 Percent Endometritis *p<0.05 for all comparisons Adapted from CL Haggerty, PA Totten, S Astete, S Hoferka and RB Ness. The role of Mycoplasma genitalium in pelvic inflammatory disease. International Journal of STD & AIDS 2006; Vol. 17, Supplement 1:p. 9, SY5-3, and symposium presentation at the 2006 IUSTI meeting, Paris, France. Prevalence of M. genitalium among Women presenting with Signs and Symptoms of PID 30 25 20 Percent 15 13 12 9 10 5 0 US Kenya England Frequency of cervical pathogens among 826 West African sex workers 30 26 25 20 16 15 10 5 0 3 C. trachomatis N. gonorrhoeae M. genitalium Adapted from: Pepin J et al. Mycoplasma genitalium: an organism commonly associated with cervicitis among west African sex workers. Sexually Transmitted Infections. 81(1):67-72, 2005 Prevalence of M. genitalium among HIV Seropositive and Seronegative Women in the US and Kenya 20 18 16 14 12 10 8 6 4 2 0 19 14 HIV+ HIV- 5 3 US Kenya Rate of M. genitalium Adapted from: Irwin KL et al. Influence of human immunodeficiency virus infection on pelvic inflammatory disease. Obstetr & Gyn 2000. 95(4):525-34 and Cohen CR et al. Detection of Mycoplasma genitalium in women with laparoscopically diagnosed acute salpingitis. STI 2005. 81(6):463-6. Nomarski microscopy (x100 objective) of sperm incubated in vitro with M.genitalium Svenstrup, H. F. et al. Hum. Reprod. 2003 18:2103-2109; doi:10.1093/humrep/deg392 M. genitalium & Infertility Clausen HF et al, 2001 – TFI patients: Mg seropositive 22.0% – Patients with normal tubes: Mg seropositive 6.3% Percentage with primary infertility in selected sub-Saharan African countries Larsen, U. Int. J. Epidemiol. 2000 29:285-291; doi:10.1093/ije/29.2.285 Copyright restrictions may apply. Percentage with secondary infertility in selected sub-Saharan African countries Larsen, U. Int. J. Epidemiol. 2000 29:285-291; doi:10.1093/ije/29.2.285 Copyright restrictions may apply. Total Infertility Rates (Primary and Secondary) in U.S. and in Regions with High Rates of STDs and Low Access to Care 30 28 25 26 20 15 10 10 5 0 U.S. Sub-Saharan Africa Northern Territory Australia Primary vs. Secondary Infertility in the U.S. and in Regions with High Rates of STDs and Low Access to Care United States Sub-Saharan Africa 30% Primary Secondary 11% 70% Primary Secondary Northern Territory Australia 31% Primary Secondary 69% 89% Effective Reproductive Span Biological Reproductive Span – Bounded by menarche and menopause Social Reproductive Span – Marked by intervals of sexual activity and/or marriage Family Planning Programs Breastfeeding Contraception Abortion Birth Interval Postpartum period – Breastfeeding Time to conception Spontaneous abortion Sw ed en D en m ar k N ig er ia Zi m ba bw e Ch in a an ia R om SA U K U Fr a nc e 100 90 80 70 60 % at Birth 50 40 30 20 10 0 Cz ec h Worldwide Breastfeeding Rates Developed from http://www.lalecheleague.org/cbi/bfstats03.html Deliberate Control of Fertility Postponement/interruption of marriage/sexual relationship Sterilization Contraceptive use Induced abortion Global Contraceptive Rates among Married Couples, 2000 80 76 67 70 60 56 50 40 30 26 20 10 0 Africa Japan Europe North America Unintended Pregnancy 20% in low to middle income countries – Ranges from 3% in Niger, sub-Saharan Africa, to 45% in Latin American Bolivia Consequences – – – – Increased lifetime risk of maternal mortality Unsafe abortion Poor infant health Lower investment in the child Final Discussion Question: What are the barriers to family planning services, particularly in developing countries? Lack of well-run family planning programs Economic cost of access to services – Transportation costs – Supply costs Social costs – Travel by women limited Psychic costs – Societies may offer little social of familial support for low fertility