Perspectives in Global Fertility and Infertility Catherine L. Haggerty, PhD, MPH Assistant Professor of Reproductive Epidemiology University of Pittsburgh.

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1 Perspectives in Global Fertility and Infertility Catherine L. Haggerty, PhD, MPH Assistant Professor of Reproductive Epidemiology University of Pittsburgh

2 Outline Global Reproductive Health Programs, Population Growth, & Fertility Trends Global Reproductive Health Programs, Population Growth, & Fertility Trends Role of Sexually Transmitted Diseases (STDs) in Unintentional Infertility Role of Sexually Transmitted Diseases (STDs) in Unintentional Infertility Intentional Control of Fertility Intentional Control of Fertility

3 Traditional Global Reproductive Health Family planning Family planning Maternal and child health programs Maternal and child health programs STD prevention programs STD prevention programs

4 Reproductive Health: A Holistic Approach 1994 United Nations sponsored 3 rd International Conference on Population Development, Cairo 1994 United Nations sponsored 3 rd 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

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6 Total World Population by Country Income Group, 1980, 1998, 2015 http://www.worldbank.org/depweb/english/modules/social/pgr/chart1.html

7 Average Annual Growth Rates by Country Income Group, 1980-2015 http://www.worldbank.org/depweb/english/modules/social/pgr/chart2.html

8 Demographic Transition From: Wikipedia.com

9 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 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 Increases in urban living raises the cost of dependent children Changes in the role of women in societies Changes in the role of women in societies Improvements in contraceptive technology and availability Improvements in contraceptive technology and availability

10 Life Expectancy World Rates

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12 Fertility Rate World Map From: wikipedia.com

13 Discussion Question: Why are Total Fertility Rates Higher in Developing Countries? Developed Countries Developed Countries –Birth control easily accessible –Start families later in life –More children = more education, clothing, and feeding costs Developing Countries Developing Countries –Children assist with labor and elderly care –Lack of access to contraceptives

14 Maternal age and fertility rates Maternal age and fertility rates

15 Pathogenesis of pelvic inflammatory disease

16 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%

17 Pathogenesis of Reproductive Morbidity Following PID PID Infertility Chronic Pelvic Pain Recurrent PID Ectopic Pregnancy Fallopian Tube Obstruction Fallopian Tube Closure Cilia Damage Adhesions

18 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.Atlas of Infectious Diseases: Sexually Transmitted DiseasesCurrent Medicine, Inc Healthy Fallopian Tube

19 From: Mårdh P et al. Atlas of Infectious Diseases: Sexually Transmitted Diseases. Ed. Mandell & Rein. 1996 Current Medicine, Inc.Atlas of Infectious Diseases: Sexually Transmitted DiseasesCurrent Medicine, Inc

20 Pollack, JD. Trends Microbiol. 1997; 5:413-419

21 Prevalence of M. genitalium 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.

22 Relationship between M. genitalium Measured in the Endometrium at Baseline & Endometritis Assessed at Baseline and 30 Days Post Treatment OR=3.4OR=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.

23 Relationship between Endometrial M. genitalium & Endometritis among women without N. gonorrhoeae or C. trachomatis OR=2.4OR=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.

24 Prevalence of M. genitalium among Women presenting with Signs and Symptoms of PID

25 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

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

27 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

28 M. genitalium & Infertility Clausen HF et al, 2001 Clausen HF et al, 2001 –TFI patients: Mg seropositive 22.0% –Patients with normal tubes: Mg seropositive 6.3%

29 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

30 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

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

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

33 Effective Reproductive Span Biological Reproductive Span Biological Reproductive Span –Bounded by menarche and menopause Social Reproductive Span Social Reproductive Span –Marked by intervals of sexual activity and/or marriage

34 Family Planning Programs Breastfeeding Breastfeeding Contraception Contraception Abortion Abortion

35 Birth Interval Postpartum period Postpartum period –Breastfeeding Time to conception Time to conception Spontaneous abortion Spontaneous abortion

36 Worldwide Breastfeeding Rates Developed from http://www.lalecheleague.org/cbi/bfstats03.html

37 Deliberate Control of Fertility Postponement/interruption of marriage/sexual relationship Postponement/interruption of marriage/sexual relationship Sterilization Sterilization Contraceptive use Contraceptive use Induced abortion Induced abortion

38 Global Contraceptive Rates among Married Couples, 2000

39 Unintended Pregnancy 20% in low to middle income countries 20% in low to middle income countries –Ranges from 3% in Niger, sub-Saharan Africa, to 45% in Latin American Bolivia Consequences Consequences –Increased lifetime risk of maternal mortality –Unsafe abortion –Poor infant health –Lower investment in the child

40 Final Discussion Question: What are the barriers to family planning services, particularly in developing countries? Lack of well-run family planning programs Lack of well-run family planning programs Economic cost of access to services Economic cost of access to services –Transportation costs –Supply costs Social costs Social costs –Travel by women limited Psychic costs Psychic costs –Societies may offer little social of familial support for low fertility