FERTILITY CARE IN LOW- AND MIDDLE-INCOME COUNTRIES: Training in assisted reproduction in South Africa.

Abstract: Intending parents on the African continent have limited access to quality services for infertility treatment. South Africa is the primary provider of fertility care on the continent, but because specialist training is only available in three public (teaching) hospitals, supported through partnerships with private institutions, there is a shortage of medical staff and waiting times for admission to training programmes can be years. We draw on data from our qualitative research study on assisted reproduction, generated from clinic visits, informal interviews, participation in science meetings, and formal interviews with 117 patients, gamete donors, clinicians, reproductive scientists and others to explore access to and motivation for training. Trainees' reasons for embarking on this specialisation included: concern with limited access to gynaecological and fertility care on the continent; lack of skilled fertility specialists and embryologists; and lack of options for assisted reproduction available to low-income intending parents. Trainee fellows expressed commitment to low-cost IVF models to address the lack of affordable and accessible reproductive health care. Fertility specialists often shared this concern and emphasised the need for trained professionals to expand services. In general, interviewees felt that infertility care and assisted reproduction were regarded as of lesser importance to other reproductive and health problems, despite the extent of infertility and the demand for assisted reproduction technology (ART) on the continent. Lay summary: Countries across the African continent have the highest infertility rate in the world, yet access to diagnosis of cause, treatment and assisted reproductive technology is sparse. Assisted reproduction clinics now operate in several countries, particularly Ghana, Nigeria, Kenya and South Africa. Most support is in the private health system, and few women and men have access to low-cost assisted reproduction services at public hospitals. While clinics, biobanking services and laboratories are sparse, so too is training. We draw on data from a large study on assisted reproduction in South Africa to explore the provision of training. Most training is provided in South Africa, and people from other countries can access this. However, few teaching hospitals provide training, and people face long delays, sometimes years, before they can enrol. The limited opportunities for training seriously impact the capacity of countries to meet the health needs and support the reproductive hopes of many of their populations.