1. Assess the Situation and Treatment of the Infertile Couples in Bangladesh Shameem Akhtar Bangladesh Institute of Research for Promotion of Essential & Reproductive Health and Technologies (BIRPERHT)

2. Objectives The study explores the magnitude of the infertility problem Determine the factors contributory to infertility Ascertain the treatment seeking behavior of infertile couple Assess the treatment facility for infertility provided by the government and private health facility Explore the views of traditional healer regarding infertility management.

3. Methodology Cross sectional design. Multistage simple random sampling. Study Area All division Two district (per division) One Upazilla (per district) 14 District 14 Upazilla Randomly selected

4. Study Population All the married couples of selected upazila within reproductive age (15-49) having following inclusion criteria were enrolled as study respondents. Childless couples Trying for child for the last one year having regular sex without any contraceptives May or may not have history of previous conception/abortion/ miscarriage/ dead fetus Service providers from health care facilities and Traditional healer were enrolled of the study area

5. Sample size Community based listing Health facility mapping A total 1423 wives and 1302 husbands were possible to enroll in the study for data collection. We also interviewed 85 health service providers and 57 traditional healers to know their views about infertility.

6. Average age of marriage of the female respondent was 18.0 years. Average age of marriage of the male respondent was 26.0 years. Mean partnership duration was 8 years Average the couples had wanted a child for 5 years. Magnitude of the infertility Pregnancy and outcome history of secondary infertile couples About 93 were pregnant less than 3 times Pregnant more or equal of 3 times 7 percent. Miscarriage 44 percent Still birth 15 percent Abortion cases 10 percent Alive-birth 45 percent. Primary infertility (61%) Secondary infertility (39%) Key Findings

7. Majority (65 percent) female respondents age was <30 Average age of the women was 27 years Secondary and above level of education of female respondents was 52.3 percent Most of the female respondents were housewife (80.3 percent) Majority male respondents age was 64.2 percent (30-39) Average age of the men was 34 years Secondary and above level of education of male respondents was 62.8 percent Just more than one-third of the male were occupied in business More than half of the respondents monthly family income Tk.5000/- to Tk.9000/- Income was adequate to maintain family household expenditure (50 percent). Selected Background & Reproductive characteristics

8. Male cause of infertility Inability of the men to product sperm (32 percent women and 28 percent men). Small quality of semen/sperm (24 percent women and 26 percent men). Uable to reach the sperm into the vagina (14 percent women and 12 percent men). Female cause of infertility Menstrual problem (56 percent women and 43 percent men). Uterine tumor (24 percent women and 12 percent men). Repeated MR (12 percent women and 7 percent men). Ovary fails to produce ovum (11 percent women and 8 percent men). Knowledge about perceived cause of infertility

9. Disease related infertility Sexually transmitted disease (wives 23 percent and husbands 35 percent). Uterine infection (Wives 28 percent and husbands 24 percent). Infection at lower abdomen (Wives 12 percent and husbands 13 percent). Diabetes (Wives 12 percent and husbands 7 percent).

10. Knowledge about fertility treatment Have knowledge (Wives 63 percent and husbands 52 percent). Have no knowledge (Wives 37 percent and husbands 48 percent). Type of treatment Treatment of irregular menstruation (Wives 80 percent and husbands 69 percent). D&C (Wives 19 percent and husbands 18 percent). RTI/STD (Wives 30 percent and husbands 46 percent). Source of treatment Medical College Hospital (Wives 41 percent and husbands 49 percent). Gynae specialist (Wives 35 percent and husbands 42 percent). Traditional and Spiritual healer (Wives 46 percent and husbands 31 percent). Government health facilities (Wives 60 percent and husbands 65 percent).

11. Woman is responsible for infertility (wife 20 percent and husband 18 percent). Most of the couples blamed both husband and wife for infertility (27 percent wife 36 percent husband). Fortune/fate for their infertility (women 15 percent men 1 percent). Blame for infertility

12. Infect of infertility on conjugal life Familial disharmony/bitter relationship (Wives 43 percent and husbands 40 percent). Family ignorance (Wives 40 percent and husbands 25 percent). Separation husband & wife (Wives 41 percent and husbands 26 percent). Treatment seeking pattern Received treatment (Wives 85 percent and husbands 80 percent). Not received treatment (Wives 15 percent and husbands 20 percent).

13. Source of infertility treatment Type of source* Wives Husbands n=1206%n=1045% Medical college hospital25120.723722.7 District hospital27622.820820.0 Maternal and child welfare center (MCWC) 897.41009.6 Upazila Health Complex867.1827.8 Health and family welfare center (H&FWC) 181.5191.8 Private clinic/hospital40333.434533.0 NGO clinic312.6272.5 Gynae specialist34528.530929.5 MBBS doctor14812.215314.6 Village doctor594.9646.1 Homeopath doctor27422.620419.5 Traditional healer59949.546844.8 Spiritual healer22418.512411.8 *Multiple responses

14. Treatment seeking pattern for infertility; person sought remedy WivesHusbands

15. Took medicine for solve the problem (76 percent wives & 79 percent husbands) Thirty one percent wives received traditional and herbal medicine as compare 26 percent husbands received traditional and herbal medicine. Received counseling (38 percent wives & 37 percent husbands) Investigation (67 percent wives & 71 percent husbands) Type of treatment

16. Response regarding responsible person for infertility Person WivesHusbands n%n% Myself48133.814311 Husbands15310.836027.6 Fortune48734.258945.2 Both1369.616512.7 Illness of mine50.460.5 Illness of husband50.4161.2 None is responsible1289.0161.2 Don’t know282.070.5 Total 1423100.01302100

17. Service provider and traditional healer Service provided RTI/STD 60 percent Mother and Child health care 58 percent Infertility 4 percent Provision of infertility treatment D&C 39 percent RTI 62 percent Semen analysis 41 percent 73 percent opined to create awareness about infertility treatment Traditional healer Infertility treatment given by traditional healer 18 percent Treatment seeker : Female 58 percent Male 11 percent Both 32 percent Arrangement for better treatment 46 percent

18. Lessons learned Infertility is a very sensitive issue as it has negative impact on conjugal disharmony Most of the infertile couples are of younger age group and around sixty percent of them are suffering from primary infertility. Menstrual problem among the women and inability to produce sperm among men are the prime cause of infertility. Majority of the infertile couple blame their fate for infertility A significant part of infertile couples seek treatment from improper place for their infertility Tertiary level hospitals are known as place of proper treatment for infertility by major portion of infertile couples Only few health care facilities have provision of hormonal assay and D&C but not total diagnosis and treatment for infertility.

19. Recommendations: Educate the people about the prevalence and impact of infertility through mass media. Awareness should be built up in the family as well as in the society about the causal factors of infertility Govt. should take initiative to establish infertility unit at govt. health facility at tertiary and district hospital and laboratory facility should be upgraded for infertility diagnosis. Reproductive health programs and clinics may also encourage the women and their partners to seek diagnoses and treatment for the infertility. Infertility treatment should be made available for all at low cost. Proper referral system should be built-up for getting infertility treatment and the service provider at health facility and traditional healer as well as spiritual healer should be trained up about the referral system.

20. Many thanks