Perspectives in Global Perspectives in Global Fertility and InfertilityFertility and Infertility

Catherine L. Haggerty, PhD, MPHCatherine L. Haggerty, PhD, MPH

Assistant Professor of Reproductive Assistant Professor of Reproductive EpidemiologyEpidemiology

University of PittsburghUniversity of Pittsburgh

OutlineOutline

Global Reproductive Health Programs, Global Reproductive Health Programs, Population Growth, & Fertility TrendsPopulation Growth, & Fertility Trends

Role of Sexually Transmitted Diseases Role of Sexually Transmitted Diseases (STDs) in Unintentional Infertility(STDs) in Unintentional Infertility

Intentional Control of FertilityIntentional Control of Fertility

Traditional Global Traditional Global Reproductive HealthReproductive Health

Family planningFamily planning

Maternal and child health Maternal and child health programsprograms

STD prevention programsSTD prevention programs

Reproductive Health: A Reproductive Health: A Holistic ApproachHolistic Approach 1994 United Nations sponsored 1994 United Nations sponsored

33rdrd International Conference on International Conference on Population Development, CairoPopulation Development, Cairo– Safe sex lifeSafe sex life– Capability and freedom to reproduceCapability and freedom to reproduce– Access to safe, effective, affordable, Access to safe, effective, affordable,

and acceptable family planningand acceptable family planning– Access to prenatal and obstetric Access to prenatal and obstetric

carecare– Sexual health: enhanced life and Sexual health: enhanced life and

personal relationspersonal 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 TransitionDemographic Transition

From: Wikipedia.com

Discussion Question:Discussion Question:What might explain What might explain general declines in birth general declines in birth rates?rates? Declining infant mortality rates in rural Declining infant mortality rates in rural

areas means less births are needed to areas means less births are needed to result in the same number of childrenresult in the same number of children

Increases in urban living raises the Increases in urban living raises the cost of dependent childrencost of dependent children

Changes in the role of women in Changes in the role of women in societiessocieties

Improvements in contraceptive Improvements in contraceptive technology and availabilitytechnology and availability

Life Expectancy World Rates

Fertility Rate World Map

From: wikipedia.com

Discussion Question: Why are Discussion Question: Why are Total Fertility Rates Higher in Total Fertility Rates Higher in Developing Countries?Developing Countries?

Developed CountriesDeveloped Countries– Birth control easily accessibleBirth control easily accessible– Start families later in lifeStart families later in life– More children = more education, More children = more education,

clothing, and feeding costsclothing, and feeding costs Developing CountriesDeveloping Countries

– Children assist with labor and elderly Children assist with labor and elderly carecare

– Lack of access to contraceptivesLack of access to contraceptives

Maternal age and fertility ratesMaternal age and fertility rates

Pathogenesis of pelvic inflammatory Pathogenesis of pelvic inflammatory diseasedisease

PID

8% U.S.

15% Sweden

32% Northern Territory, Australia

Ectopic Pregnancy

7 - 8%

Recurrent PID

16 - 23%

Chronic Pelvic Pain

17 – 30%

Infertility

16 – 40%

Pathogenesis Pathogenesis of of Reproductive Reproductive Morbidity Morbidity Following PIDFollowing PID

PID

Infertility

Chronic Pelvic Pain

Recurrent PID

Ectopic Pregnancy

Fallopian Tube

Obstruction

Fallopian Tube

Closure

Cilia Damage

Adhesions

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.

Healthy Fallopian TubeHealthy Fallopian Tube

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 Prevalence of M. genitaliumM. genitalium

4%

2%

6%

88%

CervixEndoBothNeither

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 Relationship between M. genitaliumM. genitalium Measured in the Endometrium at Baseline & Measured in the Endometrium at Baseline & Endometritis Assessed at Baseline and 30 Endometritis Assessed at Baseline and 30 Days Post TreatmentDays Post Treatment

0

10

20

30

40

50

60

70

80

Baseline 30 Days

Percent Endometritis

Mg+Mg-

OR=3.4 OR=3.7

*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.

Relationship between Endometrial Relationship between Endometrial M. M. genitaliumgenitalium & Endometritis among & Endometritis among women without women without N. gonorrhoeaeN. gonorrhoeae or or C. C. trachomatistrachomatis

0

10

20

30

40

50

60

70

Baseline 30 Days

Percent Endometritis

Mg+Mg-OR=2.4 OR=6.

6

*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 Prevalence of M. genitalium M. genitalium among Women presenting with among Women presenting with

Signs and Symptoms of PIDSigns and Symptoms of PID

129

13

0

5

10

15

20

25

30

Percent

US Kenya England

Frequency of cervical pathogens among 826 West African sex workers

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

3

16

26

0

5

10

15

20

25

30

C. trachomatis N. gonorrhoeae M. genitalium

Prevalence of Prevalence of M. genitaliumM. genitalium among HIV among HIV Seropositive and Seronegative Women in the Seropositive and Seronegative Women in the US and KenyaUS and Kenya

19

5

14

3

02468

101214161820

US Kenya

Rate of M. genitalium

HIV+HIV-

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.

Svenstrup, H. F. et al. Hum. Reprod. 2003 18:2103-2109; doi:10.1093/humrep/deg392

Nomarski microscopy (x100 objective) of sperm incubated in vitro with M.genitalium

M. genitaliumM. genitalium & & InfertilityInfertility Clausen HF et al, 2001Clausen HF et al, 2001

– TFI patients: Mg seropositive 22.0%TFI patients: Mg seropositive 22.0%– Patients with normal tubes: Mg Patients with normal tubes: Mg

seropositive 6.3%seropositive 6.3%

Copyright restrictions may apply.

Larsen, U. Int. J. Epidemiol. 2000 29:285-291; doi:10.1093/ije/29.2.285

Percentage with primary infertility in selected sub-Saharan African countries

Copyright restrictions may apply.

Larsen, U. Int. J. Epidemiol. 2000 29:285-291; doi:10.1093/ije/29.2.285

Percentage with secondary infertility in selected sub-Saharan African countries

Total Infertility Rates (Primary and Total Infertility Rates (Primary and Secondary) in U.S. and in Regions with Secondary) in U.S. and in Regions with High Rates of STDs and Low Access to High Rates of STDs and Low Access to CareCare

10

2826

0

5

10

15

20

25

30

U.S. Sub-SaharanAfrica

NorthernTerritoryAustralia

Primary vs. Secondary Infertility in Primary vs. Secondary Infertility in the U.S. and in Regions with High the U.S. and in Regions with High Rates of STDs and Low Access to Rates of STDs and Low Access to CareCare

United States

30%

70%

PrimarySecondary

Northern Territory Australia

31%

69%

PrimarySecondary

Sub-Saharan Africa

11%

89%

PrimarySecondary

Effective Reproductive Effective Reproductive SpanSpan

Biological Reproductive SpanBiological Reproductive Span– Bounded by menarche and Bounded by menarche and

menopausemenopause Social Reproductive SpanSocial Reproductive Span

– Marked by intervals of sexual Marked by intervals of sexual activity and/or marriageactivity and/or marriage

Family Planning Family Planning ProgramsPrograms BreastfeedingBreastfeeding ContraceptionContraception AbortionAbortion

Birth IntervalBirth Interval

Postpartum periodPostpartum period– BreastfeedingBreastfeeding

Time to conceptionTime to conception Spontaneous abortionSpontaneous abortion

Worldwide Breastfeeding Worldwide Breastfeeding Rates Rates

0102030405060708090

100

% at Birth

Developed from http://www.lalecheleague.org/cbi/bfstats03.html

Deliberate Control of Deliberate Control of FertilityFertility

Postponement/interruption of Postponement/interruption of marriage/sexual relationshipmarriage/sexual relationship

SterilizationSterilization Contraceptive useContraceptive use Induced abortionInduced abortion

Global Contraceptive Rates among Global Contraceptive Rates among Married Couples, 2000Married Couples, 2000

26

56

6776

0

10

20

30

40

50

60

70

80

Africa Japan Europe NorthAmerica

Unintended PregnancyUnintended Pregnancy

20% in low to middle income countries20% in low to middle income countries– Ranges from 3% in Niger, sub-Saharan Ranges from 3% in Niger, sub-Saharan

Africa, to 45% in Latin American BoliviaAfrica, to 45% in Latin American Bolivia ConsequencesConsequences

– Increased lifetime risk of maternal Increased lifetime risk of maternal mortalitymortality

– Unsafe abortionUnsafe abortion– Poor infant healthPoor infant health– Lower investment in the childLower investment in the child

Final Discussion Question: Final Discussion Question: What are the barriers to What are the barriers to family planning services, family planning services, particularly in developing particularly in developing countries?countries? Lack of well-run family planning Lack of well-run family planning

programsprograms Economic cost of access to servicesEconomic cost of access to services

– Transportation costsTransportation costs– Supply costsSupply costs

Social costsSocial costs– Travel by women limitedTravel by women limited

Psychic costsPsychic costs– Societies may offer little social of familial Societies may offer little social of familial

support for low fertilitysupport for low fertility