Table Of ContentFVV in ObGyn, 2013, 5 (2): 161-175 Vision
The Walking Egg Project: Universal access to infertility care –
from dream to reality
W. Ombelet1,2,3
1Department of Obstetrics and Gynaecology, Ziekenhuizen Oost-Limburg, Schiepse Bos, 6, 3600 Genk, Belgium, 2Faculty
of Medicine and Life Sciences, Hasselt University, Agoralaan, 3590 Diepenbeek, Belgium, 3President of “The Walking
Egg non-profit organization”
Correspondence at: [email protected].
Abstract
Childlessness and infertility care are neglected aspects of family planning in resource-poor countries, although the
consequences of involuntary childlessness are much more dramatic and can create more wide ranging societal
problems compared to Western societies, particularly for women. Because many families in developing countries
completely depend on children for economic survival, childlessness has to be regarded as a social and public health
issue and not only as an individual medical problem.
In the Walking Egg Project we strive to raise awareness surrounding childlessness in resource-poor countries and
to make infertility care in all its aspects, including assisted reproductive technologies, available and accessible for
a much larger part of the world population.
We hope to achieve this goal through innovation and research, advocacy and networking, training and capacity
building and service delivery. The Walking Egg non-profit organization has chosen a holistic approach of repro-
ductive health and therefore strengthening infertility care should go together with strengthening other aspects of
family planning and mother care.
Right from the start The Walking Project has approached the problem of infertility in a multidisciplinary and
global manner. It gathers medical, social, ethical, epidemiological, juridical and economical scientists and experts
along with artists and philosophers to discuss and work together towards its goal.
We recently developed a simplified tWE lab IVF culture system with excellent results. According to our first cost
calculation, the price of a single IVF cycle using the methodologies and protocols we described, seems to be less
than 200 Euros.
We realize that universal access to infertility care can only be achieved when good quality but affordable infertility
care is linked to effective family planning and safe motherhood programmes. Only a global project with respect to
sociocultural, ethical, economical and political differences can be successful.
Key words: Assisted reproduction, developing countries, infertility care, intrauterine insemination, IVF, medical
education, one-step diagnostic phase, resource-poor countries, simplified IVF, sociocultural factors.
Rationale - Background The infertility experience has significant negative
effects on the individual woman and man as well as
Infertility is a global reproductive health problem: it the couple and the broader family (Greil, 1997).
has been estimated that 8 to 12% of the couples Consequences of infertility are numerous: stress,
worldwide are infertile. The large majority of child- depression, low-self esteem, guilt, marital problems,
less couples are residents of developing countries and sexual problems. So far infertile people in the
(DC). A silent population of more than 180 million Western countries and the resource-poor countries
couples worldwide is facing the consequences of have something in common. However the differ-
childlessness day by day (Rutstein and Iqbal, 2004; ences are emerging mainly for two reasons: (a)
Boivin et al., 2007). socio cultural values surrounding procreation and
161
ombelet(Egg).indd 161 1/07/13 14:17
infertility and (b) availability of infertility treat- (Dhont, 2011a, 2011c). Studies have shown that
ments. HIV was up to 3 times more prevalent in childless
Consequences of involuntary childlessness are couples compared with fertile couples in the same
usually more dramatic in DC when compared to population (Nabaitu et al., 1994). Moreover, ex-
Western societies, particularly for women. Often, panded access to antiretroviral therapy (ARVs) im-
the woman is blamed for the infertility, even when a plies that HIV+ people have increased hopes to live
male factor is involved. Negative psychosocial con- longer and healthier lives, which also has been as-
sequences are severe: childless women are fre- sociated with an increased chance to bear children.
quently stigmatised, isolated, ostracized, disinherit- HIV+ males could have a child that is HIV- with the
ed and neglected by the entire family and even the assistance of sperm washing procedures commonly
local community (Papreen et al., 2000; Van Balen used in assisted reproductive procedures such as in-
and Gerrits, 2001; Daar and Merali, 2002; Dyer et trauterine insemination (IUI) and in-vitro fertiliza-
al., 2002a, 2002b, 2004, 2005; Van Balen and Bos, tion (IVF).
2009; Gerrits and Shaw, 2010). This may lead to Despite the high infertility prevalence and the
physical and psychological violence, polygamy, severe economical consequences of childlessness in
and even into suicide. Infertile women - and men - DC, infertility care remains a low priority area for
are marginalized, disadvantaged and disempow- local health care providers and community leaders.
ered. As many families – and elderly people in par- It has been marginalized and neglected by health
ticular - in DC completely depend on children for care authorities despite its high prevalence and un-
economic survival, childlessness in DC becomes an met need (Fathalla et al., 2006; Ombelet, 2011).
important social and public health issue and not According to MDG5 (Millennium Development
only an individual medical problem (Ombelet et al., Goal 5) universal access to reproductive care,
2008; Dhont, 2011a, 2011b; Ombelet, 2011). In the including both contraceptive and infertility care,
last two decades the manifold consequences of in- should be adopted by the year 2015. Until today,
fertility, most significant within DC, at personal, nothing has been done to help childless couples in
conjugal, family and community levels, and finan- developing countries and according to a recent
cially, have been well documented (Inhorn, 2003; questionnaire none of the international organiza-
Van Balen and Bos, 2009; Van Balen and Gerrits, tions, NGOs and foundations is planning to do so in
2001). These studies have also shown that the way the forthcoming years (Ombelet, 2011).
people experience, explain and deal with infertility Till now, infertility care in most DC has been
is strongly related with their sociocultural and eco- fragmented between public and private spheres. In-
nomic life circumstances as well with the availabil- adequate or complete lack of rules and regulations
ity and non-availability of health care options. concerning treatment conditions and commercial
The most important reasons for infertility in DC interests may lead to unethical practices (Guilhem,
are (1) the high incidence of sexually transmitted 2001). Overall, very little is known about actual
diseases (STDs) - which affects both men and w omen practices and results within clinics providing infer-
- and (2) pregnancy-related infections, due to unsafe tility services in DC.
abortions and home deliveries in unhygienic
circumstances, mainly in rural areas. The Walking Egg non-profit organization
The high prevalence of genital infections in de-
veloping countries is commonly compounded by a The Walking Egg npo has opted for a multidisci-
complete lack of diagnosis together with incom- plinary and global approach towards the problem of
plete, inappropriate or no intervention at all. Yet, infertility (Dhont, 2011b). The main goal of the
severe male infertility due to STDs and female in- Walking Egg Project is to raise global awareness
fertility due to tubal block can only be treated by surrounding childlessness, and to make infertility
“expensive” assisted reproductive technologies care in all its aspects universally available and ac-
(ART), which are not available at all or only within cessible. Therefore we need to change and optimise
reach of those (the happy few) who can afford it, the whole set-up of infertility care in terms of avail-
mostly only in private settings (Ombelet et al., ability, affordability and effectiveness (Ombelet
2008). and Campo, 2007).
Reduced fecundity in HIV-infected individuals To realize this objective a number of actions are
has been described before (Brocklehurst and French, planned including the following: (1) to raise aware-
1998; Glynn et al., 2000). Marital instability and ness surrounding the problem of childlessness with-
polygamy, as a reaction to infertility and childless- in (a) the donor community, politicians, funding
ness within the conjugal relationship, may in turn agencies and research organisations through lobby-
increase the spread of HIV-1 infection (and STD’s) ing and publishing, (b) the general population
162 FVV in ObGyn
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through information, education and counselling on be successful, the project has to be global with a
infertility and its consequences, (2) to study the eth- strong sociocultural, ethical and economical com-
ical, sociocultural and economical aspects sur- ponent. It will need the support of a reliable network
rounding the issue of childlessness and infertility of social scientists supporting the project by dis-
care in resource-poor countries, (3) to develop new cussing the various sociocultural, psychological and
methods to make infertility diagnosis and infertility ethical aspects of biomedical infertility care in dif-
treatment including ART accessible for a much ferent DC. This network will be crucial in the intro-
larger part of the population, by (a) simplifying the duction and follow-up of accessible infertility care
diagnostic procedures, (b) simplifying the IVF labo- services in resource-poor countries.
ratory procedures and (c) modifying the ovarian
stimulation protocols for IVF and last but not least Medical
(4) to work together with other organisations and
societies working in the field of reproductive health From a pure medical point of view, our first objec-
to reach the goal of “universal access to infertility tive is the establishment of low-cost “one-stop clin-
care” ics” for the diagnosis of infertility. Simplification of
the ART procedures without loss of quality is our
Research and Innovation second objective. Our final goal is the implementa-
tion of “accessible” infertility services, if possible
Non-medical integrated within health care facilities, providing
good quality family planning services, reproductive
There is an urgent need for more research on socio- health education and high-standard mother care.
cultural, ethical, religious and juridical aspects of
infertility in poor-resource countries. Reliable data The one-stop diagnostic phase
on economical consequences of childlessness in DC
are lacking. Ethical considerations and debates on Standardized investigation of the couple at minimal
this subject are scarce (Pennings et al., 2008, 2009). costs is possible and undoubtedly will enhance the
Legal aspects and rights dealing with the severe likelihood that infertile couples, both men and
consequences of childlessness for women in DC are woman, will come to the infertility centres. How to
almost never mentioned in the literature, and what organize a one-stop diagnostic clinic has been de-
to say about the legal right to have access to infertil- scribed before (Ombelet et al., 2012) and is shown
ity care, agreed upon and mentioned in so many po- in Figure 1.
litical international statements and commitments A questionnaire will be provided to both part-
(Ombelet et al., 2010). ners. This questionnaire can be adapted to the local
In the Walking Egg Project we aim to initiate and situation in the specific locations and countries.
expand an international network of social science Screening for infections and STDs can be done by
research (in broad sense) in these fields. The first using low-cost affordable screening tests which be-
expert-meeting on the “Socio-cultural implications came available recently (Huyser and Fourie, 2010).
of childlessness in developing countries” was orga- Since tubal obstruction associated with previous
nized by The Walking Egg npo in 2009, in coopera- pelvic infections is the most important reason for
tion with ESHRE (European Society of Human Re- infertility in some developing regions, hysterosal-
production and Embryology) and WHO (World pingography and/or hystero-salpingo-contrast-so-
Health Organization). A Monograph with articles of nography are affordable techniques to detect this
most experts was published in “Facts, Views & Vi- problem, easy to perform and without major costs.
sion in ObGyn” (www.fvvo.eu). This Monograph Combining these techniques with an accurate medi-
was distributed to 9000 participants of the annual cal history will identify the majority of women’s
ESHRE meeting in Rome. A second expert-meeting infertility causes, such as ovulatory disorders, uter-
on “Barriers, Access and Ethics of biomedical care ine malformations and tubal infertility. A standard
in resource-poor countries” was held in 2011 and gynaecological and fertility ultrasound scanning of
followed by the publication of another Monograph the uterus and the ovaries can easily be done.
distributed at the Annual ESHRE meeting in Istan- Male factor infertility can be evaluated by a sim-
bul in 2012 (www.fvvo.eu). Participants at the 2011 ple semen analysis (WHO, 2010). Semen analyses
Expert Meeting highlighted the importance of stud- can also be performed by well-trained paramedi-
ies addressing barriers to infertility care, and studies cals, another important advantage for developing
to prepare, assess and follow up the supply and use countries. It is also important to calculate the IMC
of accessible and affordable infertility care in differ- (inseminating motile count). The IMC is the total
ent low-resource contexts. They concluded that, to number of motile spermatozoa after sperm wash
tHe WAlKinG eGG PROJeCt – Ombelet- 163
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Fig. 1. — tWE diagnostic clinic for infertility work-up in a resource-poor setting (tWE = the Walking Egg)
procedure. The IMC is very crucial in selecting is a very cheap and rewarding option. In case of re-
patients for either IUI (intrauterine inseminations), sistance to CC, a low dose ovarian stimulation regi-
IVF (in-vitro fertilization) or ICSI (Intra-Cytoplas- men with gonadotrophins aimed at monofollicular
mic Sperm Injection) (Ombelet et al., 1997, 2012). growth is advisable, although this medication is
Office mini-hysteroscopy to investigate intrauter- more expensive.
ine abnormalities has been simplified in its instru- In case of unexplained and moderate male factor
mentation and technique, so that it can become a infertility and provided tubal patency has been doc-
non-expensive diagnostic technique accessible for umented, intrauterine insemination (IUI) with hus-
every gynaecologist, provided there has been appro- band’s semen in natural cycles or after mild stimu-
priate training (Campo et al., 2005; Ombelet and lation is a excellent first-line treatment without
Campo, 2007). major costs and without expensive infrastructure
All the procedures of the one-day diagnostic clin- (Ombelet et al., 2003; Verhulst et al., 2006). IUI
ic can be performed by a small team of health care programmes can be runned by well-trained para-
providers within a short period of time in an inex- medical staff, another advantage for resource-poor
pensive setting (Ombelet and Campo, 2007). A countries. Controlled ovarian hyperstimulation
flowchart for the tWE (The Walking Egg) diagnos- (COH), with or without IUI, is associated with the
tic clinic is shown in Figure 2. risk of multiple gestations, especially when gonado-
Future studies are planned to assess the reproduc- trophins are used (Gleicher et al., 2000). Appropri-
ibility of ‘one-stop infertility clinics’ in different ate standardized protocols are available to minimize
developing countries. the risk for multiple pregnancies which is even more
important in developing countries because the con-
• Simplified infertility treatment and non-IVF as- sequences of multiple pregnancies can be devastat-
sisted reproduction ing.
If tubal patency is demonstrated in ovulatory wom- • Simplified IVF laboratory procedures
en and if severe male factor subfertility has been
excluded, fertility awareness programmes are an in- Another major challenge is to reduce costs of labo-
expensive and efficient first line approach to infer- ratory procedures, namely fertilization and culture
tility management (Gnoth et al., 2002, 2003). Fertil- of eggs and embryos for IVF. Different options and
ity awareness counselling to couples about the approaches have been developed or are presently
meaning and detection of cervical mucus secretion being field- tested with promising results.
can be given by nurses and paramedical staff work- Intravaginal fertilization and culturing has been
ing in existing reproductive health care centres. used since many years for low cost IVF (Frydman
For ovulatory dysfunction, representing almost and Ranoux, 2008). A tube filled with culture medi-
20 % of female infertility, clomiphene citrate (CC) um containing the oocytes and washed spermatozoa
164 FVV in ObGyn
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is hermetically closed and placed in the vagina. It is tion can be done solely on sonographic criteria with
held intravaginally by a diaphragm for incubation basic inexpensive ultrasound equipment thereby
for 44 to 50 hours. Over 800 cycles cycles have avoiding the need of expensive endocrine investiga-
been published worldwide with a very reasonable tions (Rojanasakul et al., 1994).
clinical pregnancy rate of almost 20 % (Frydman Nevertheless, although very promising results
and Ranoux, 2008). concerning the different steps of IVF are described,
As part of the Walking Egg Project and based on we still have to perform a lot of feasibility studies to
previous findings and experience (Van Blerkom and examine the value of a one-stop diagnostic phase
Manes, 1974; Swain, 2011) we developed a new and to study the value of the simplified tWE lab sys-
simplified method of IVF culturing, called the tWE tem and different low-cost ovarian stimulation pro-
lab method. With this new system, specifically de- tocols in resource-poor settings.
signed for low resource settings, we can avoid the
high costs of medical gases, complex incubation
Service delivery: The implementation of tWE
equipment and infrastructure typical of IVF labora-
pilot- centres in DC
tories in high resource settings.
For insemination of the eggs, we only use 1000-
The ultimate aim of the Walking Egg project is the
5000 motile washed spermatozoa per oocyte, with
implementation of good quality but low-cost infer-
very promising results, which makes this technique
tility centres in DC, if possible and preferable
usable for more the 70% of the actual IVF/ICSI
integrated into existing Reproductive Health Care
population (Genk data, not published).
Centres. Diagnostic and therapeutic procedures and
Since development from insemination to transfer
protocols should be affordable, effective, safe and
is undisturbed and in the same tube until embryo
standardized. Ideally, infertility management should
transfer, we can avoid many problems frequently oc-
be integrated into sexual and reproductive health
curring in regular IVF laboratories, such as unwant-
care programmes.
ed temperature changes, air quality problems etc.
As developing countries differ in their status of
Up to April 2013 twelve healthy babies have
development, three levels of assistance are suggest-
been born after using this technique while a pro-
ed (Sallam, 2008). A level 1 infertility clinic is a
spective study comparing the embryo quality after
basic infertility clinic capable of offering the fol-
using tWE lab versus regular IVF procedures is still
lowing services: basic infertility workout including
ongoing.
semen analysis, hormonal assays, follicular scan-
ning, ovulation induction and IUI. In Level 2 infer-
• Low-cost ovarian stimulation protocols for IVF
tility clinics IVF can be performed as well.
During many expert meetings it was decided that
In order to make infertility care more affordable in
Level 3 infertility clinics capable of offering ICSI,
developing countries, effective, cheap and safe
cryopreservation and operative endoscopy are not
stimulation schemes for intrauterine insemination
part of the Walking Egg Project in the initial phase.
(IUI) and in-vitro fertilization (IVF) need to be
Therefore our first target is the implementation of
established. A review of the literature clearly shows
good quality level 2 centres.
the value and effectiveness of mild ovarian stimula-
Implementation of level 2 services entails the
tion protocols in ART settings (Verberg et al.,
following activities (Sallam, 2008):
2009). The success rates of natural cycle IVF can be
low per cycle due to high cancellation rates because 1. Equipping the clinics: Infertility clinics in devel-
of premature LH rise and premature ovulation. But oping countries should be provided with low-cost
the use of indomethacin to block ovulation helps to and easy serviceable equipment taking into con-
reduce cancellations. Cumulative pregnancy and sideration the local problems often encountered
live birth rates after four consecutive cycles could (e.g. fluctuating voltage, frequent power cuts, un-
reach 46 % and 32% respectively making it a cost- availability of servicing facilities, irregular sup-
effective, safe and patient-friendly option (Nargund ply of consumables, etc...). This may require ne-
et al., 2001). The use of clomiphene citrate (CC), a gotiations with various manufacturers to supply
very cheap oral drug, has been proven in many stud- these tools at affordable prices, particularly if
ies to be an optimal alternative with acceptable re- large quantities are ordered.
sults, minimal side effects and a very low complica- 2. Training the staff: This includes the training of
tion rate (Ingerslev et al., 2001; Nargund et al., the medical, paramedical as well as the adminis-
2007; Verberg et al., 2009; Kato et al., 2012). trative staff. Training courses should tailor to the
Monitoring of follicular development in an IVF local conditions and the possible difficulties en-
cycle, as well as the timing of the hCG administra- countered in developing countries. Table I gives
tHe WAlKinG eGG PROJeCt – Ombelet- 165
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166 FVV in ObGyn
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Table I. — Key categories of the training courses (Ombelet et al., 2012).
• Reproductive health care education basic course
→ Target group: nurses, midwifes
• A general and medical history of and basic clinical examination both partners
→ clinician (medical)
• Screening for infections and STDs
→ clinician (medical, paramedical)
• How to perform and evaluate a hysterosalpingography and/or hystero-salpingo-contrast-sonography
→ clinician (medical, paramedical)
• Standard Operational Procedures for the gynaecological and fertility ultrasound scan
→ clinician (medical, paramedical)
• Basic semenology training course according to WHO 2010 manual
→ laboratory staff (paramedical)
• Sperm washing procedures
→ laboratory staff (paramedical)
• Mini-hysteroscopy
→ clinician (medical)
• Documentation and registration
→ administrative staff (clerical)
an overview of the key topics covered in the tion should be negotiated with the drug manufac-
training courses. Training, quality control, regu- turers and simple treatment protocols should be
lar audit and systems of accreditation and regis- put into action in order to reach the best cost-ef-
tration should be implemented in order to main- fective therapies.
tain appropriate standards of care. Our objective 5. Documentation and registration: We believe
is to organize a one week course for all members that within each pilot-centre on-line data registra-
of the team who are involved in the set-up of a tion of all ART activities is mandatory. Adminis-
pilot-centre, part of the Walking Egg Project. trative staff and (para) medicals have to be aware
This training will need the support of experts in of the importance of correct and trustable data
the field, who are capable to tutor the training registration. The ultimate goal is to offer all pilot-
courses at the highest level in a very short time, centres a similar registration programme, which
taking into account the experience of the trainees should be customer-friendly with a limited but
and the quality of facilities that can be expected sufficient number of items (increased personnel
in the new pilot-centres. compliancy) (Ombelet et al., 2012). Continuous
3. Educating the public: This necessitates estab- monitoring of service activities will be central-
lishing contacts and working relationships with ized, and provide feed-back to clinics for clinical
schools, community leaders, traditional healers and laboratory policy adjustments, information to
as well as the media, producing and distributing couples on clinic performance, and information
educational materials (brochures, posters and to society. Confidence can then be built and
audio-visual material) etc. maintained.
4. Running the services: This should take into con- 6. Psychological and socio-cultural follow-up:
sideration staff salaries, regular purchasing of When implementing low-cost (accessible) infer-
consumables, cost of equipment maintenance, tility services in DC it is extremely important to
cost of investigations, cost of medical interven- study social, psychological, sexual, legal and
tions and the cost of medication. Special servic- ethical aspects of infertility and infertility treat-
ing contracts should be negotiated with the man- ment and take study findings into account when
ufacturers. In addition, simplification of the setting up gender and cultural sensitive infertility
consumables should be taken into consideration services. Considering psychological and socio-
and laboratory reagents and culture media should cultural follow-up the most important aims can
have a long shelf life. Special prices for medica- be summarized as follows:
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Fig. 3. — The tWE strategy from application to implementation (GDP = gross domestic product).
*CosmoGolem: The CosmoGolem, a wooden giant of approximately 4 meters height, aspires to be a helper and savior for all those
who are in need of help, hope and courage, especially children. He stimulates intercultural exchange by travelling all around the world,
sharing his experiences and bridging the gap between cultures (CosmoGolem Project, Koen Vanmechelen). When starting-up a new
pilot-centre a CosmoGolem will be inaugurated at that specific site. (www.koenvanmechelen.be/cosmogolem).
• Informing the design of culture and gender and one year after treatment); their expectations,
sensitive treatment and counseling procedures, experiences and suggestions regarding treatment
ethical guidelines and informed consent forms procedures and aspects of quality of care; and
for the selected pilot-centres. the social repercussions and other social
• Describing the psychological well-being of the implications infertility treatments may have.
infertile women and men along the infertility • Enhancing the level of knowledge and
treatment trajectory (before, during, immediately understanding with regard to socio-cultural,
168 FVV in ObGyn
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Table II. — Implementing accessible infertility care pilot-centres in selected developing countries: recommendations (C Huyser,
personal communication).
1. Risk analysis of the country including GPD, health care expenditures, budget for education, total fertility rate, maternal
and infant mortality rate, etc
2. The community/region should be empowered to support the program (communication channels, …)
3. Selection of patients: one-step diagnostic clinic
4. Some couples have to be referred to a level 3 centre of excellence (if ICSI needed) or to an endoscopic surgery unit
5. Be aware of infectious conditions and STDs
• Aseptic conditions to perform procedures
• Screening of patients
• Prevention of STD transmission
• Unique profiles and risks in different countries
• Semen decontamination methods for sperm processing
6. ART should be designed to be robust, repeatable and efficient
7. Equipment should be basic, sturdy and strong
8. Products should be robust, ready to use and with a long half-life
• Sperm processing materials are best aseptically packaged (set or kit) and stored at room temperature
• Embryo culture media should be robust, short term, pre-packaged in small quantities
• Disposables (pipette tips, screening dishes,….) can be pre-packaged as “a set per patient”
9. Information to the community should be discrete and applicable, taking into account sociocultural and religious differences
10. A training program with regular follow-up / audits should be available for the medical and paramedical staff of the pilot-
centres.
psychical, quality of care and ethical aspects of and (6) the availability of at least one experienced
infertility care in DC. and dedicated gynaecologist and biologist (Fig. 3).
The community/region including the local health
Selection of countries / pilot-centres care authorities should be empowered to support the
program from the beginning. Table II gives an over-
Decision making on infertility treatment in develop- view of the most important recommendations to
ing countries assumes answers to quite a few ques- consider when starting tWE pilot-centres in devel-
tions: How should the infertility problem be de- oping countries.
fined? How often does infertility occur? What is the
income in that specific country and what can be
Selection of patients and IVF protocol
spend on health care? How cheap should IVF be in
order to be accessible to a considerable part of the
population? With what alternative health interven- Figure 4 shows the inclusion and exclusion criteria
tions should infertility treatment be compared? How for the selection of patients, the result of the expert
cost-effective should IVF be in order to compete meeting in Arusha.
with those other interventions? In the initial phase we will only treat childless cou-
In this respect we believe that measurements of ples with specific age-limits.
the (utility-measure oriented) Quality of Life over Whether or not HIV-positive women and men
the infertile life-course in developing countries are should be treated remains a debatable subject. It
urgently needed. was decided that HIV positive women can only be
The selection of countries where the first pilot treated in those countries where antiretroviral thera-
centres are implemented will be based on (1) avail- py is provided, either by the government or by non-
able data on the resources, needs and resource gaps profit organizations.
for infertility services on a national level, (2) per- Since ICSI will not be offered in the initial phase,
centage of GDP spent on education and health care, severe male factor infertility cases are excluded and
(3) the availability of endoscopic surgery facilities referred to a level 3 centre of excellence. We have
in the neighbourhood, (4) a good quality family to consider that in more than 70 % of ART cases our
planning unit, (5) good quality mother care facilities simplified tWE lab method can be successfully used
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due to the low number of spermatozoa needed per study and shows interest for sociological support,
oocyte (see above). before, during and after treatment,
Infertility will likely become one of the more pre-
Advocacy and networking dominant components of future reproductive health
care practice. Taking advantage of information and
Global access to infertility care can only be imple- communication technologies will increase the ef-
mented and sustained if it is supported by local pol- fectiveness and accessibility of health care services,
icy makers and the international community. Many as well as change patient behaviors to seek timely
international organizations have already expressed treatment. As evidence-based affordable solutions
their desire to collaborate including the WHO begin to drive global guidance within both public
(World Health Organisation), ESHRE (European and private health care system solutions, access to
Society for Human Reproduction and Embryology) care for the infertile couple will become one of the
and ISMAAR (International Society for Mild Ap- largest emerging fields in global medicine.
proaches to Assisted Reproduction). We will also
need the media, patient organizations and interested Acknowledgements
politicians to change the existing moral and socio-
cultural beliefs which are isolating and ostracizing I gratefully acknowledge all the experts who were
infertile couples (Fig. 4). involved in the Walking Egg Project since many years
(Rudi Campo, Nathalie Dhont, Danie Franken, Trudie
Gerrits, Carin Huyser, Geeta Nargund, Guido Pennings,
Conclusion
Hassan Sallam, Frank Van Balen, Jonathan Van
Blerkom, Sheryl Vanderpoel, Annie Vereecken, Koen
The magnitude of childlessness in developing coun-
Vanmechelen, and many others).
tries has dimensions beyond its prevalence and aeti-
I also like to thank Nathalie Dhont and Jan Goossens for
ology. Differences between the developed and de-
their critical editorial review and Annelies Thijssen and
veloping world are emerging because of the different Liesbeth Grondelaers for their technical support in pre-
availability in infertility care and different sociocul- paring this manuscript.
tural value surrounding procreation and childless-
ness. There is a growing belief that individual health
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