Front Cover
 Title Page
 The family planning association...
 The comprehensive reproductive...
 Overview of the infertility...
 Diagnosing and treating men for...
 Diagnosing and treating women
 Case studies
 The bottom line: Becoming...
 Helping clients resolve ongoing...
 Achievements of the Bhiwandi infertility...
 Remaining challenges
 An experience from Nigeria: Women's...
 The challenge for family planning...
 Lessons learned
 Resumen en Espanol
 Resume en Francais
 Back Cover

Group Title: Quality/Calidad/Qualité
Title: What about us?
Full Citation
Permanent Link: http://ufdc.ufl.edu/UF00088802/00001
 Material Information
Title: What about us? bringing infertility into reproductive health care
Series Title: QualityCalidadQualité
Physical Description: 34 p. : ill. ; 26 cm.
Language: English
Creator: Datta, Bishakha
Population Council
Publisher: Population Council
Place of Publication: New York N.Y
Publication Date: c2002
Subject: Infertility -- India   ( mesh )
Infertility -- Nigeria   ( mesh )
Health Services -- India   ( mesh )
Health Services -- Nigeria   ( mesh )
Genre: bibliography   ( marcgt )
non-fiction   ( marcgt )
Spatial Coverage: Nigeria
Bibliography: Includes bibliographical references.
 Record Information
Bibliographic ID: UF00088802
Volume ID: VID00001
Source Institution: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
Resource Identifier: oclc - 52209035
issn - 1097-8194 ;

Table of Contents
    Front Cover
        Front Cover
    Title Page
        Title Page 1
        Title Page 2
        Page 1
        Page 2
        Page 3
    The family planning association of India
        Page 4
        Page 5
        Page 6
    The comprehensive reproductive health for all project
        Page 7
    Overview of the infertility service
        Page 8
        Page 9
        Page 10
        Page 11
    Diagnosing and treating men for infertility
        Page 12
        Page 13
        Page 14
    Diagnosing and treating women
        Page 15
        Page 16
    Case studies
        Page 17
    The bottom line: Becoming pregnant
        Page 18
        Page 19
    Helping clients resolve ongoing infertility and preventing infertility
        Page 20
        Page 21
        Page 22
    Achievements of the Bhiwandi infertility program
        Page 23
        Page 24
    Remaining challenges
        Page 25
    An experience from Nigeria: Women's health and action research centre
        Page 26
        Page 27
    The challenge for family planning programs: Is infertility too difficult to take on?
        Page 28
    Lessons learned
        Page 29
        Page 30
        Page 31
    Resumen en Espanol
        Page 32
    Resume en Francais
        Page 33
    Back Cover
        Page 34
Full Text





..."- a
ri a


"What About Us?"
Bringing Infertility
Into Reproductive
Health Care

u(,) ililt -' / l (, zliic a publication of
the Population Council, highlights exam-
ples of clinical and educational programs
that bring a strong commitment, as well
as innovative and thoughtful approaches,
to the issue of high-quality care in sexual
and reproductive health. The series is
based on the philosophy that people have
a fundamental right to respectful treat-
ment, information, choice, and follow-up
from reproductive health-care providers.
Q/C/Q documents projects that are mak-
ing important strides in one or more of the
following ways: broadening the choice of
methods and technologies available; pro-
viding the information clients need to make
informed choices; enabling clients to be-
come more effective guardians of their sex-
ual and reproductive health; making inno-
vative efforts to increase the management
capacity and broaden the skills of service
providers at all levels; combining health
care, family planning, and related serv-
ices in an innovative ways; and reaching
underserved and disadvantaged groups.

Projects are selected for documenta-
tion by an advisory group made up of
individuals who have a broad range of
experience with promoting quality of care
in sexual and reproductive health. None
of the projects documented is being
offered as a model for replication. Rather,
each is presented as an unusually cre-
ative example of values, objectives, and
implementation. These are learning expe-
riences that demonstrate the self-critical
attitude required to anticipate clients'
needs and find affordable means to meet
them. This reflective posture is exempli-
fied by a willingness to respond to
changes in clients' needs as well as to the
broader social and economic transforma-
tions affecting societies. Documenting
the critical choices these programs have
made should help to reinforce, in practi-
cal terms, the belief that an individual's
satisfaction with sexual and reproductive
health services is strongly related to the
achievement of broader health and pop-
ulation goals.

d Population Council
The Population Council is an international, nonprofit, nongovernmental institution that seeks to im-
prove the well-being and reproductive health of current and future generations around the world and
to help achieve a humane, equitable, and sustainable balance between people and resources. The
Council conducts biomedical, social science, and public health research and helps build research
capacities in developing countries. Established in 1952, the Council is governed by an international
board of trustees. Its New York headquarters supports a global network of regional and country offices.
Population Council, One Dag Hammarskjold Plaza, New York, New York 10017 USA
tel: (212) 339-0500, fax: (212) 755-6052, e-mail:qcq@popcouncil.org, http://www.popcouncil.org.

Publication of this edition of Quality/Calidad/Qualit6 is made possible by support provided by the
Ford Foundation, and by the Gender, Family, and Development Program of the Population Council.
Statements made and views expressed in this publication are solely the responsibility of the authors
and not of any organization providing support for Q/C/Q. Any part of this document may be repro-
duced without permission of the authors so long as it is not sold for profit.
Cover photograph by Tejal Shah.
Number Thirteen 2002 ISSN: 1097-8194
Copyright 2002 The Population Council, Inc.

by Friday Okonofua

Infertility is a major reproductive health
problem throughout much of the world.'
Its prevalence in industrialized countries
ranges between 6 and 10 percent of wom-
en of reproductive age; in developing
countries, it may be considerably higher.
Sub-Saharan Africa has the highest infer-
tility rate in the world, with prevalence
exceeding 15 percent in many countries.
An area known as the"infertility belt"
stretches through much of Central Africa;
Gabon and Democratic Republic of the
Congo, for example, have infertility rates
in excess of 25 percent (Farley and Bel-
sey 1988). Furthermore, there is increas-
ing evidence that the prevalence of infer-
tility has been rising in many parts of the
world. This rise is largely attributable to
an increased incidence of infections, es-
pecially sexually transmitted infections
(STIs) that impair female fertility. Data
also exist suggesting a decline in sperm
counts in many parts of the world, al-
though the evidence is not conclusive.
The cause of infertility varies to some
degree by region. Studies indicate that
infertility in developed countries is due
mostly to such biological causes as fail-
ure of ovulation (which may sometimes
be related to a woman's age rather than
to endocrine disease) and "unexplained
causes" (Cates et al. 1985; WHO 1987).
By contrast, in developing countries, and
particularly in sub-Saharan Africa, infer-
tility is largely secondary to undiagnosed
or poorly treated STIs (neisseria gonor-
rhea and chlamydia), unsafe abortion,
and substandard obstetric conditions-
all of which are preventable.
Although involuntary childlessness is
a difficult situation for any couple, its

social consequences are most accentu-
ated in developing countries and are gen-
erally more severe for women than for
men. Male infertility is often not acknow-
ledged, and the female partner is typical-
ly held responsible for a couple's child-
lessness. Indeed, in much of Africa, infer-
tility leaves women vulnerable to physi-
cal abuse, ostracism, and severe psy-
chological problems, as well as divorce.
Where resources are available, a com-
bination of conventional treatments and
new reproductive technologies has en-
abled providers to resolve infertility in
more than 50 percent of cases. Unfor-
tunately, in the developing world, most
health programs have fewer options. The
new technologies are either unavailable
or too expensive for the majority of
patients. Few clinics serving the poor
have any trained staff or systematic pro-
tocols with which to provide infertility
services. Furthermore, unlike attitudes in
some Western settings, adopting a baby
is still considered taboo in many devel-
oping country cultures.
Despite the prevalence and serious-
ness of infertility, the population and
reproductive health field has largely
neglected this problem. National poli-
cies and international donor organiza-
tions have been one-sided in their focus
on programs designed to prevent un-
wanted pregnancies. Little emphasis has
been placed on "other kinds" of family
planning, that is, on assisting couples
who are unable to produce children.
Although many countries with a high
rate of infertility also have elevated rates
of unwanted fertility, these two are dis-
tinct issues and each needs specific atten-

Infertility may refer to primary infertility (the woman has never conceived despite extended exposure to
the risk of becoming ..--'i ,ii secondary infertility (inability to conceive despite previous conception), or
pregnancy wastage (ability to conceive but not to produce live, i .l.r,,.. (WHO 1991). Conditions in the
male and/or female partner may contribute to infertility.

tion. Undoubtedly, the principles articu-
lated by the 1994 International Confer-
ence on Population and Development in
Cairo underscore the need to help indi-
viduals achieve their reproductive goals,
and advocate for holistic approaches to
achieving developmental goals.
The time has come to reverse the
neglect of infertility and to press for im-
provement in its prevention and treat-
ment as part of reproductive health care.
This issue of Q/C/Q, with clinic-based
narratives and case reports from India
and Nigeria, illustrates what is involved
in trying to address the problem of infer-
tility in developing countries. In India,
although 10 percent of couples experi-
ence infertility at some time in their lives,
resources for treatment are scarce. In
Bhiwandi (outside Bombay), where in-
fertility care is largely unaffordable in
the private sector and unavailable in the
public sector, the Family Planning Asso-
ciation of India is providing high-quality,
affordable services to infertile couples
under its Bhiwandi-based Comprehen-
sive Reproductive Health for All project.
In Benin City, Nigeria-where the serv-
ice options are similarly limited and the
prevalence of infertility is now rising
above 20 percent-the Women's Health
and Action Research Centre offers com-
prehensive reproductive health care, in-
cluding management of infertility.
Both programs combine education,
counseling, careful history taking, labora-
tory testing, minor pharmacological and
surgical therapies, and referral. Although
a number of clinical and economic fac-
tors translate into limited success rates,
the programs featured in the following
pages are enabling some couples to
realize their dreams of parenthood. The
education and support they provide to
distraught couples is also invaluable.
Although the expense and technical
expertise of full-scale infertility treat-
ment is beyond the capacity of most
organizations, family planning programs

can do a great deal that generally they
are not currently doing for infertile cou-
ples. Family planning programs need to
reexamine their view of infertility and
consider ways to inform their staff and
assist their clients with information and
provide at least rudimentary services.
Such a reorientation would involve men
in reproductive health care, strengthen
efforts to reduce STI and reproductive
tract infection (RTI) rates, and foster
openness toward sexuality issues. Fur-
thermore, by addressing an issue that is
both sensitive and neglected, family
planning programs can win trust from
communities and enhance program use
in developing countries around the
world. By assisting couples who want to
have children as well as those who want
to avoid pregnancy, family planning
programs will finally become worthy of
their name in the truest sense.
A possible framework for incorporat-
ing limited infertility care into a family
planning or reproductive health pro-
gram is provided in the Afterword, at the
end of this issue. Program leaders would
do well to assess how they might adapt
such a framework to help meet urgently
felt needs in their population. There is
little excuse for doing nothing for the
many infertile couples to whom we can
offer some measure of help and hope.

Cates W., T.M.M. Farley, and P.J. Rowe. 1985.
"Worldwide patterns of infertility: Is Africa
different?" Lancet 2(8,455): 596-598.
Farley, T.M.M. and E.M. Belsey. 1988. "The
prevalence of infertility." In African Popu-
lation Conference. Dakar: International
Union for the Scientific Study of Populations
1:2,1.15- 2.1.30.
World Health Organization. 1987. "Infections,
pregnancies, and infertility: Perspectives on
prevention." Fertility and Sterility 47: 964-
968. Geneva: WHO.
1991. Infertility: A Tabulation of Avail-
able Data on Prevalence of Primary and
Secondary Infertility. Geneva: WHO.

by Bishakha Datta

Bhiwandi is like many new towns around
the world-an industrial center to which
poor villagers from other parts of the
country migrate. Located about an hour
outside Bombay, the primarily working-
class population of 50,000-together
with residents in 70 neighboring vil-
lages-finds employment in the power
looms, agriculture, and other industries.
Despite its proximity to Bombay, In-
dia's most cosmopolitan city, the cultur-
al values in this area are predominantly
rural. Although the settlers have left their
homes behind, they have carried their
traditional attitudes with them; central to
these values is that of the role of a wom-
an as wife, mother, and homemaker in
her husband's family. A woman who does
not bear a child, preferably a son, with-
in two years of marriage holds little cul-
tural value.' In addition to the disappoint-
ment she and her husband feel at not
having a wanted child, she often faces
constant jibing from her in-laws, while
her husband may be encouraged to
abandon her and remarry. Although
men are the source of an infertility prob-
lem about as often as women, typically,
a husband's family will not consider that
he may be infertile.
Often, a childless woman is stigma-
tized beyond her immediate household.
She may not be allowed to hold a new-
born relative or even participate in the

child's naming ceremony. "She is called
waanj (barren)" says Pravina Palaye, field
organizer at Family Planning Association
of India in Bhiwandi. "There is a super-
stition that if she touches a baby, the
baby will die." One community survey
in Andhra Pradesh state found that actual
and anticipated rude comments at social
functions forced many infertile married

_ .
Many Bhiwandi residents are recent immigrants from the countryside and
traditional values still shape family life. For example, a man whose wife
does not bear a child may be encouraged to abandon her and remarry.

women into becoming social recluses,
isolated and ashamed (Unisa 1999).
Such a predicament is not rare. About
10 percent of couples in India face infer-
tility at some time in their lives, a figure
consistent with the worldwide incidence

SIndeed, women's health advocate Manisha Gupte has commented that "Having only daughters is ... seen
as a form of childlessness. It's unbelievable, the layers of childlessness you can see in society."
- Roughly one-third of infertility is related to a condition suffered by the female, about one-third is the
result of a male condition, and one-third is of mixed origin.

of infertility (Jeejeebhoy 1998). Yet there
are few resources available to help infer-
tile couples. Basic information (for exam-
ple, about proper timing of intercourse
or avoiding excessive heat to the scro-
tum) would help some couples, but there
are few ways to acquire such informa-
tion. For working-class people, clinical
services for diagnosing and treating infer-
tility are even more difficult to come by.3
In Bhiwandi, the public sector does
not provide infertility care. Services in
the private sector are not only of widely
varying quality but also are well beyond
the financial reach of most couples;
nonetheless, where one's worth is mea-
sured by the birth of a child, women will
go to extraordinary lengths in the effort
to become parents. In desperation to
conceive, some women resort to tradi-
tional approaches, including such pain-
ful ones as placing a heated brick on
their bellies. Other women have fallen
prey to unethical providers, as reported
in a recent article in a Delhi newspaper:

In December 2000, the police arrested
three doctors in southern India for
cheating childless women, charging
them exorbitant fees and making false
claims about their pregnancy. The ar-
rests took place after a woman, Sita-
mahalakshmi, lodged a police com-
plaint about a doctor who had cheat-
ed her of $5,000 by falsely claiming to
have helped her conceive through an
embryo transfer technique. Another
woman, B Ratnakumari, filed a similar
complaint against the same trio. Soon
it became evident that this was a mas-
sive racket in which the three doctors
had connived to dupe as many as 30
gullible women in the last three
months alone. (The Pioneer 2000)

Neither have family planning pro-
grams responded to the needs of infertile
couples. Reproductive health programs
may seem like a logical "home" for
addressing infertility, given the clear
link between infertility, STIs, and basic
reproductive health counseling. Despite
this link and the enormous social con-
sequences of involuntary childlessness,
family planning programs have found it
difficult to make the philosophical leap
to devoting a measure of their limited
resources to helping people reproduce.
The Family Planning Association of In-
dia (FPAI), an affiliate of the International
Planned Parenthood Federation, has be-
gun addressing the problem of infertility
within a broad sexual and reproductive
health mission. The town of Bhiwandi
lies in the region covered by the Bom-
bay branch of FPAI, and in 1996, FPAI
launched one of its most important efforts
there to provide services to infertile cou-
ples: the Comprehensive Reproductive
Health for All project, or, in the Marathi
language, Bahu Vyapak Prajanan Arogya
Seva Sarvansathi Prakalp.

a i i 1 a n ani n
,ssciat i. n f I.-.ia
FPAI, like many family planning organi-
zations around the world, has made
strides toward a comprehensive repro-
ductive health framework since the
1994 International Conference on Popu-
lation and Development held in Cairo.
Yet the Comprehensive Reproductive
Health for All project did not spring fully
formed out of the Cairo agenda. Its seeds
were sown in 1983 when FPAI started a
women's development program in 70
villages in Bhiwandi District. Develop-

The community survey of infertile women reported by Unisa (1999) found that one-fourth of the respon-
dents never sought help, for the most part because such help was too expensive (43 percent) or because
they felt that it was unnecessary (41 percent). More than half of those who sought care had been through
more than one course of treatment. The first choice of treatment was modern medical care (73 percent),
although many women cut their treatment short because of cost; 63 percent also visited at least one holy
place or spiritual healer.

ment theorists had already highlighted
the gender bias in community develop-
ment programs, which generally focus on
men, who are more visible within the
community. "We found that within the
rural integrated projects, men got the
fruits of development, because men are
freer, more educated, and nearer to pow-
er," notes Dr. Seshagiri Rao, who recent-
ly retired as secretary-general of FPAI.

Working from the insight that empower-
ing women can benefit the whole com-
munity and reduce family size, in 1983,
the FPAI Women's Development pro-
gram started setting up mahila mandals
or village-level women's groups. Apart
from teaching rural women about nutri-
tion, hygiene, and safe delivery tech-
niques, the mandal provided a rare op-
portunity for women to explore options
beyond motherhood: literacy, income-
generation, and the entirely alien notion
of standing on one's own feet.
At first, few women responded posi-
tively. Those were the days when the In-
dian government was enforcing the slo-
gan Hum do, hamare do ("We two, our
two") through any means possible, inclu-
ding force. The fear of being sterilized
was deep-rooted in the rural psyche, and
the message of small family size was far
removed from the realities of village life.
Women would agree to come to a ster-
ilization camp-but slip out through the
back door when the time came. Men
were openly dismissive. According to
Pravina Palaye, Bhiwandi field organiz-
er, the village men would ask the health
workers, "If you operate on my wife,
will you come and sleep with me? Will
you come to look after my child?"
Over the years, the mandals built
community trust and began successful-
ly to address local politics, community
development, the needs of young peo-
ple, and other issues. Still, the reproduc-
tive health spotlight stayed focused on

controlling population growth. The tradi-
tional bhajani mandals (groups that sing
devotional songs) composed lyrics about
family planning; newlyweds who agreed

to use condoms or other spacing meth-
ods were publicly congratulated, as were
those who voluntarily chose to be ster-
ilized after having two children.
Infertility treatment was not a feature
of this programmatic landscape. "Every-
thing else [beyond the messages of small
family size and women's empowerment]
was a blind spot," says Dr. Rao. "We did
not see it till we focused on it."
Childless women occasionally asked
for help, but would be treated in an ad
hoc manner. "We would regretfully say,
'We can't help you why don't you
think of adopting?'" says Pravina. She
recalls that at one FPAI community cel-
ebration, a woman approached the FPAI
health worker-and did some plain
speaking. "You'll only do things for those
who have children. What about us?
Can't you do anything for those who
don't have children?"

The 1994 International Conference on
Population and Development had a sig-
nificant impact on family planning pro-
grams in India. In the government pro-
gram, longtime contraceptive quota and

Despite the emotional pain and stigma associated with childlessness, infertile women who begged for assistance were, for decades,
regretfully told that FPAI could not help. The ICPD and IPPF's Charter of Sexual and Reproductive Rights both paved the way for a
more effective response.

incentive programs are gradually giving
way to more voluntary schemes, and
attention is being paid to ways that pro-
grams can effectively involve men as
well as women (Patchauri 2001; Murthy
et al. 2002). FPAI, which in 1994 had
43 clinics across the country, decided
to implement the Cairo agenda in sev-
eral areas, including Bhiwandi, where it
already had a strong community-based
program in place.
The International Planned Parenthood
Foundation's new Charter of Sexual and
Reproductive Rights provided a concep-
tual framework. The Charter identified a
number of rights related to reproductive
health care and has been used to re-
shape IPPF services in several countries.
Some of its provisions have direct impli-
cations for infertile couples. For exam-
ple, the "Right to the Benefits of Scien-
tific Progress" states that "all persons
shall have the benefit of and access to
available reproductive health-care tech-
nology, including that related to infertil-

ity, contraception, and abortion, where
to withhold access to such technology
would have harmful effects on health
and well-being" (IPPF 1996). Other pro-
visions in the Charter include the right
to decide whether to found and plan a
family, to decide whether or when to
have children, and to have the highest
possible quality of health care.
Introducing a new approach is al-
ways easier said than done. Although
international guidelines existed, the
institution had to develop and commit
to its own institutional vision. Dr. Rao
explains, "We didn't know what repro-
ductive health was. It means everything
and nothing. We felt whatever we were
doing was reproductive health. We
needed to change the mindset."
The institution faced both internal and
external resistance. Dr. Sangameshwar
Nagral is the President of the Bombay
branch of FPAI, which officially spon-
sors the Bhiwandi clinic. Dr. Nagral,
who began volunteering with FPAI dur-

ing his student days 50 years ago, also
serves as Vice President of the National
FPAI Volunteer Board. He is currently
active in promoting and supporting the
Bhiwandi project, but admits that he
was initially skeptical, partly because of
the town's demographics: A majority of
residents are migrants or Muslims, two
groups that family planning programs
have had difficulty reaching. "I was sure
we would fail," says Dr. Nagral.
In addition, as Dr. Nagral explains,
the town's private doctors as well as the
Medical Association of Bhiwandi had
strongly opposed the clinic. "The rea-
son was very simple," he says. "There
was fear among the professionals of los-
ing money." External barriers such as
these were negotiated through the sup-
port of eminent local persons, such as
Professor Ganesh Gadre, chairman of
the Bhiwandi project. To build support,
the clinic offered contraceptive technol-
ogy workshops for local doctors, and
developed a plan to refer clients to
them for services not offered at the clin-
ic, in some cases at a reduced fee.
To design the new program, Dr. Rao,
Dr. Nagral, and the Bhiwandi staff turned
to the community. They conducted a
community survey to identify unmet
sexual and reproductive health needs
and to determine the best ways to meet
those needs. Infertility was among the
highest priorities named.

The survey results led to a plan for a
combination of clinical and community
services that would be, according to Dr.

Rao, "our most experimental, most com-
prehensive project." In 1996, with a
three-year grant from the Ford Founda-
tion and support from IPPF's South Asia
regional office, FPAI launched its
Comprehensive Reproductive Health
For All project. Implementing the new
program involved the following steps:
* Recruiting a new breed of staff. The
project required a staff of 20. Many
staff were recruited from within FPAI,
but an effort was made to find per-
sonnel with open minds, or, as Dr.
Rao notes, "without any family plan-
ning baggage."
Training the entire team. The pro-
ject's medical officer was sent to the
Liverpool School of Tropical Hygiene
for clinical training in reproductive
health. In addition, all project staff
were given training in various as-
pects of reproductive health, sexual-
ity, and community participation.
Fostering self-reflection and develop-
ing counseling skills, especially for
sensitive topics like infertility and
sexuality. "When the community is
biased against infertile people, peo-
ple serving them will also share the
bias," explains Dr. Rao. "Many [new
staff] were [also] hesitant to ask ques-
tions about sexuality. The training
slowly dealt with these fears, which
withered away."'
Setting norms and standards, especial-
ly in areas that were new to the orga-
nization, including infertility.5 To en-
sure that women would not automat-
ically carry the blame for causing and
the burden of resolving the problem
of infertility, the organization estab-
lished one overarching principle from
the start: The couple, not the woman
alone, must come for treatment.

Since the start-up period, the clinic has conducted several follow-up training on reproductive health.
For example, in 1997, FPAI provided one-to-two-day follow-up c. .r.-i,, workshops for all staff.
Another such area was HIV testing and treatment. Initially, staff felt that inclusion of these services would
deter other patients from coming to the clinic. FPAI's philosophy, however, focused on the rights of all
clients, and ultimately, the clinic developed special norms regarding confidentiality and treatment.

personnel costs, which amount to 58
percent of the annual budget. The re-
maining 42 percent is met through con-
tributions from the Bombay branch of
FPAI (18 percent) and users (24 percent).
The clinic collects fees for various clin-
ical services (about ten cents for regis-
tration, $12 for an abortion, and more
for more complex procedures); for con-
traceptive methods; and for participat-
ing in skills-development workshops,
such as beautician training.

, i "~rvie ,

f the

-. .

A quick turn down a narrow sidestreet flanked by small shanties leads to
the FPAI clinic-a gray, two-story building with peeling paint.

In October of 1996, the Comprehen-
sive Reproductive Health for All project
began providing services. The clinic,
which previously provided only family
planning services, now offers a range of
services under one roof, including gyne-
cological checkups; antenatal care; first-
trimester abortion; cervical cancer
screening; infertility treatment; contra-
ception; diagnosis and treatment of STIs,
reproductive tract infections, and HIV;
and reproductive health counseling (the
last four services are available for both
men and women). For the most part, the
services are organized into special clin-
ics at designated times of the week.
Infertility appointments are available on
Wednesday and Friday mornings, al-
though male infertility clients may also
attend the general men's clinic on Friday
The annual cost of operating the
comprehensive reproductive health
clinic is US$27,880. Since the initial
three-year grant from the Ford Founda-
tion ended, IPPF pays for the clinic's

If,-rtilit,. S. rvice
My first visit is on a steamy Friday morn-
ing in May. The clinic-still popularly
known as the mahila mandal clinic-is
an arm's length from Bhiwandi's teem-
ing marketplace, where slender mina-
rets, colorful saris, and appetizing sweet-
meats jostle for attention. A quick turn
down a narrow sidestreet flanked by
small shanties leads to the clinic-a
gray, two-story building with peeling
paint. Inside, several couples sit patient-
ly on the wooden benches lining the
waiting area.
Key staff in the infertility program
include Dr. Kalyani Kelkar, a female
gynecologist who sees the women, and
Dr. Ajay Kanbur, an andrologist who
treats the men. Dr. Kelkar worked as a
general practitioner in a neighboring
community and responded to an adver-
tisement for the position. Dr. Kanbur
was expressly interested in working with
FPAI to shift its priorities to include men.
He notes, "As an andrologist, I thought
it would be interesting to be part of the
first full-fledged male clinic in the FPAI
system." Another key staff member is
Pravina Palaye, who has been with the
Bhiwandi program since it began, first
as a typist and then a statistical assistant
before becoming the field organizer.
From the first weeks of operation of
the Comprehensive Reproductive Health

Ajay Kanbur treats men for infertility; his identical
twin brother, Ajit, has also worked at the clinic per-
forming sterilization procedures. Ajay explains,
"Some clients did confuse us. Luckily, Ajit worked
on a different day from me!"

for All project, childless women began
seeking help. By the end of 2001, about
five years later, 717 couples, ranging in
age from 16 to 48, had sought infertili-
ty care at the clinic. Infertility clients
now account for one-tenth of all clients
at the Bhiwandi clinic. Seventy percent
(502 couples) were cases of primary
infertility, and the remainder (215 cou-
ples) were suffering from secondary
infertility. One-third of all infertility
cases are referred by clinic clients; out-
side doctors, field-workers, and govern-
ment agencies are also major sources of
referral. Roughly 25 percent of clients
come from outside the project area.
Close to a third of new clients have
already tried their luck either with tradi-
tional healers, the public health system,
or private practitioners.

Two out of three women first seek help
for infertility at the Bhiwandi clinic with-
out their husbands. Staff conduct an ini-
tial exam for each woman and take her
history whether she comes alone or with
her husband. Although the man may be

the infertile partner (or may have trans-
mitted an infection to his wife that
impaired her fertility), many men find it
difficult to accept their role in infertility.
Dr. Rao describes the despair of a hus-
band who cannot impregnate his wife:
"The man feels he is no longer a man."
The next step is to make a new ap-
pointment for the couple to return to-
gether for a joint counseling session,
and a separate appointment for the man
to begin his own screening and possible
treatment, even if a woman's initial his-
tory indicates that she may be infertile.
"We ensure that no man is left out,"
says Dr. Ajay Kanbur. "It's no use only
investigating the female. Dr. Kelkar adds,
"She has not come here to prove her fer-
tility. They have come here for the baby.
So both should come."
Only about five percent of husbands
refuse to come in with their wives for
infertility testing. In such cases, treat-
ment usually grinds to a halt. "The drop-
out rate is much higher if there is no
cooperation from the husband," ex-
plains Dr. Kelkar.

Unisa (1999) describes infertility as car-
rying, at least in India, "more negative
social, cultural and emotional repercus-
sions for childless women than any other

non-life-threatening condition." Couples
who arrive at an infertility clinic are typ-
ically experiencing a sense of failure,
often with significant emotional stress,
both within the couple and between the

W -,'it a,. the -;,.:ic Componen: ot: of fertility y
Cou:, -'.eling?
Providing emotional support, for example:
Allowing clients to process their feelings (of shame, loss, fear, and hope)
Offering empathetic support
Balancing hope and realistic expectations
Offering accurate and useful information, for example:
Explaining how to identify the fertile time in the cycle
Providing clear descriptions of diagnoses or treatment options and likely outcomes
Enabling clients to make their own decisions, for example:
Whether to undertake certain procedures
When to accept childlessness and consider other options (for example, adoption)
Helping clients resolve conflicts, for example:
Anger toward or guilt on the part of the infertile person
Disagreement between partners about continuing treatment
Coping with pressures from extended family members

couple and the extended family. Further-
more, because diagnosis and treatment
can take a long time and involve rising
and falling hopes, the process of receiv-
ing care can deepen a couple's anxiety.
Nilima Mehta, a consultant and train-
er who works with FPAI, comments, "In-
fertile couples usually come to a coun-
selor with one single goal. To have a
baby." Unfortunately, despite the best
efforts of medical specialists, the major-
ity of couples seeking infertility care will
not achieve pregnancy. In light of that
reality, the only concrete benefit that
most infertility clients can realistically
expect ultimately to take from their ex-
perience with infertility care is greater
knowledge and emotional comfort.
Given the tremendous anxiety typically
associated with infertility, helping cou-
ples achieve greater psychological well-
being is no small matter. Indeed, be-
cause emotional support is the one thing
that providers can promise, high-quality
counseling-something that does not re-
quire specialized medical training or cost-
ly equipment-is one of the most criti-
cal components of an infertility service.
Many family planning clinics and in-
fertility centers have specialized coun-

selors; in some settings, links are also
available to infertility support groups
where couples can share information
and offer each other crucial emotional
support (see box on Infertility Support
Groups). At Bhiwandi, as Dr. Kelkar ex-
plains, "We don't have a separate, pro-
fessionally trained counselor. But this
does not mean there is no counseling.
The staff sit with patients and talk to them.
It is informal, done by many people. "
For infertility clients at the Bhiwandi
clinic, the primary direct caregivers are
physicians. As medical specialists, their
job is to take detailed medical histories,
provide health-related information, and
concentrate on the complex medical
maze of possible diagnoses and treat-
ments that they are trained to consider.
Not surprisingly, these considerable
demands-along with time pressures-
constrain the possibilities for two-way,
open-ended dialogue that characterizes
true counseling and education. Nor are
women routinely taught methods to
confirm whether they are ovulating, or
to identify the fertile time of the cycle.
Instead, more emphasis is given to trans-
mitting critical medical information.
"Counseling" is largely subsumed with-

One element of the initial history is a frank discussion of sexual practices that may affect fertility. If either partner has had inter-
course outside of marriage, follow-up includes testing for the presence or possible sequelae of an STI.

in the processes of taking a history, con- the emotional and educational needs of
ducting follow-up interviews, and pro- infertile couples, both Drs. Kelkar and
viding explanations and instructions. Kanbur clearly provide information and
Although significant strides remain support to their clients. This begins with
to be made at Bhiwandi in attending to communicating to the woman, and then

Locally based support groups enable infertile women and men to share information and
personal experiences, thus increasing their understanding of their own situation and
reducing their feelings of isolation and stigma. Such groups, which have proliferated in
several Western countries, require virtually no financial resources.
In some countries, the local support groups are associated with national organiza-
tions, for example, CHILD in Great Britain and RESOLVE in the United States. In addi-
tion to providing an umbrella for the support groups, these organizations provide infor-
mation and referrals (for example, for treatment or adoption) through hot lines and
websites. They also lobby for expanded access to medical services and promote public
awareness of the impact and extent of infertility.
Support groups may take different shapes and can be formal or informal gatherings.
One published report (Anonymous 1999) about a RESOLVE group described the "strong
emotional impact" of the experience, in terms of the support received by those individ-
uals nu..nliiL: to pursue further treatments as well as for those who "were helped to come
to terms with the fact that .ilil .e'lh technology gives hope, hope is not always realistic."
Contact information for CHILD and RESOLVE: CHILD e-mail: .1.,:., ** ~ lnh1 ,ig uk.l
http://www.child.org.uk/. RESOLVE e-mail: info@resolve.org; http://www.resolve.org.

to her husband and to the extended fam-
ily, the importance of the man's coming
in for screening and treatment.
The doctors also try to establish a
comfortable atmosphere so that the cli-
ent can provide a detailed history with-
out embarrassment. The medical history
is taken separately for the wife and the
husband. Along with inquiries about pre-
vious pregnancies, infections, and sexu-
al patterns, the staff also ask about con-
traceptive history, because occasionally
one member of a couple hopes to re-
verse a sterilization. The history form for
men also includes questions about the
respondent's occupation, because many
industrial workers are exposed to high
temperatures, which may affect sper-
Another critical element of the initial
history and counseling is a frank discus-
sion of sexual practices that may affect
fertility. In speaking with a man, for
example, Dr. Kanbur explains, "We ask
him how often he has sex-either with
someone or by masturbation, to learn
whether he is discharging semen." In the
session with a woman, she is asked about
when during her menstrual cycle sex
takes place, and about sexual dysfunc-
tion.6 Dr. Kelkar adds, "We ask women
if they or their husbands have a history
of intercourse outside marriage." Even
for clients who do not report diagnosed
STIs, a "yes" is taken as an indication of
vulnerability to STIs. Because of the
importance of STIs as a risk factor for
infertility, the clinic tests all male clients
and those females who have a white
cervical discharge or who are consid-
ered vulnerable.
Although the clinic does not routinely
teach women methods of fertility aware-
ness, Dr. Kelkar provides such informa-
tion to selected women. She explains,
for example, that if a couple is having

intercourse infrequently, it is unlikely that
intercourse is coinciding with the exact
period of ovulation. In such cases, she
advises the woman regarding the likely
fertile time of her cycle and advises her
to "have relations" during that period.
Another challenging task is helping
clients understand that the process of
diagnosis and treatment is a slow one.
Dr. Kelkar explains, "Many clients think
they will have only one visit, take med-
icine, and have a child. According to
Sundeep Kadam, a community health
worker with the project, male clients
are particularly impatient. He explains,
"If they don't get results, they change
doctors very quickly." The staff instruct
the clients from the outset about the
extended period that treatment may re-
quire. At the same time, they offer hope
and reassurance.
For those couples who are experienc-
ing stress from extended diagnosis and
treatment, talking can sometimes help.
As Dr. Kelkar comments, "The couple's
life becomes dominated by temperature
charts, blood tests, and endless waiting
in clinics. We have to deal with it."
Nilima Mehta provides occasional
refresher training to FPAI staff. She re-
minds staff that counseling is an enabl-
ing process that helps couples or indivi-
duals make their own decisions, and em-
phasizes that "counselors have to step in
at a stage where medical technology fails
and other options have to be looked at."

a ia .nosing an.;
Tre n en f r
Ife :i ity
The Bhiwandi clinic has a special repro-
ductive health clinic for men that oper-
ates on Friday afternoons when the pow-
er loom factories are closed. Although

6 For a small number of couples, certain psychosexual problems preclude intercourse; for example, a man
may suffer erectile dysfunction (often treatable with Viagra). Also, in parts of India, men may be con-
cerned that semen loss may lead to infertility.

the men's clinic offers other services,
such as STI testing and condom distrib-
ution, 80 percent of the men who come
through the door are seeking infertility
Dr. Kanbur is assisted by two male
community welfare workers, Sundeep
Kadam and B.Y. Yadav. Both have been
with FPAI for more than 15 years, and
were recruited into this project when it
was felt that men were better able to
talk to other men about their reproduc-
tive and sexual health problems. Sun-
deep and B.Y. are primarily responsible
for providing basic education and refer-
rals to men in the community, while Dr.
Kanbur counsels the men in the clinic.
The basic infertility work-up for men,
which costs about 60 percent of the fee
for the same services provided in the
private sector, includes:
screening for gonorrhea, syphilis,
chlamydia, and HIV
two semen analyses, examining
number, morphology, and motility
of sperm, and quality of sperm
blood tests for testosterone levels
a physical exam, with attention to
screening for varicocoeles or ana-
tomical abnormalities (such as
undescended testicle).
For the vast majority of cases (65
percent), staff are not able to identify
any cause of infertility. In part, this is
because access to costly diagnostic
techniques is inadequate. In any case,
diagnosis is a universal challenge in
infertility treatment, regardless of cost.
Among the 35 percent who are clearly
diagnosed, the husband is more often
identified as the infertile partner. The
leading cause of male infertility at the
clinic is oligospermia, defined as fewer

than 20 million sperm per ml. Even
among those men with a diagnosed
problem, treatment effectively raises
sperm counts for only about 20 percent
(see box on Low Sperm Counts).

Just because a woman has convinced her
husband to come to the clinic, his readi-
ness to accept his own potential infertility
is not guaranteed. According to Dr. Kan-
bur, "The Indian male ego is problem
number one. Men do not want to take
responsibility for this. It is difficult for a
man to believe that he is infertile." He
describes the typical male reaction as one
of "hurt, shock, denial, and remarriage."
Sadly, some men face their own infertil-
ity only after they have already aban-
doned their first wives and remarried.
Explains Dr. Kanbur, "When that (strate-
gy) also fails, they know something is
wrong." To avoid this reaction and help a
man acknowledge his role in childless-
ness, Dr. Kanbur insists that his wife be
present when they discuss his treatment.

The Bhiwandi clinic offers artificial in-
semination, using semen samples from

Those who come for other reasons often want to be tested for STIs or have semen-related problems.
Because many of the men attending the clinic are migrant workers who frequent the red-light district, the
clinic routinely seeks their consent to test for gonorrhea, chlamydia, and HIV.

Low SI,-rm Counts

Worldwide, low sperm counts are a major factor in male infertility. Dr. Kanbur explains,
"Excess heat to the testicles is the big culprit. A rise in testicular temperature by even
one degree Fahrenheit can reduce sperm count." One of the most common causes of
elevated testicular temperature is environmental heat. Many men in Bhiwandi work in
factory jobs involving furnaces or ovens; furthermore, they are "overdressed" in under-
wear, pants, and factory overalls. Dr. Kanbur asks some clients "to take a cold water
bath every day, or dip (their) testes in a mug of cold water, to undress when (they go)
to sleep. He says, "Sometimes I even ask them to move temporarily to a cooler job."
Testicular temperature may also be elevated as a result of a varicocoele, a condition
in which drainage from the scrotal veins is poor, generally associated with a varicosity.
According to Walsh et al. (1992), varicocoele is responsible for about 10 percent of male
infertility worldwide. This condition can often be corrected surgically, and Dr. Kanbur
performs varicocoele operations at the clinic. The operation takes about an hour and is
performed under spinal anesthesia. The clinic charges about Rs 4,000 (US $90), includ-
ing surgery, a night's stay, and anesthesia.
Less common causes of thermal oligospermia (both globally and at the clinic) include:
Infection leading to hydrocoele (a reversible condition in which accumulation of
water in the scrotum leads to excess warmth and physical pressure on the testes.
Anatomical abnormalities such as undescended testicles
Tobacco and alcohol use
Low testosterone (sometimes treated at the clinic with synthetic testosterone)
Blockage in the vas deferens (for which the clinic refers the client to another facil-
ity for corrective surgery)
Unfortunately, often oligospermia has no clear origin. Therefore, along with the spe-
cific treatment options mentioned above, the staff suggest several general approaches
to improving sperm counts:
extending intervals between ejaculations to allow sperm counts to build up;
sperm washing (used when the sperm are of low volume but have good motility),
a technique in which sperm are collected, undergo a "wash" that separates healthy
sperm, which are injected directly into the woman's uterus; and
referrals for more sophisticated treatments, such as testicular sperm aspiration and
sperm autopreservation. Autopreservation (essentially capturing and freezing re-
peated semen samples) may be useful in cases when the husband is separated
from his spouse for long periods.

a local private clinic. The samples cost Even those men who elect to use donor
$17 each. Most of the clinic's infertility sperm tend to experience shame, and a
clients, however, give priority to repro- few men do not want even their wives to
during with their own sperm. Before know that another man's sperm are being
trying artificial insemination with donor used. As Dr. Kanbur explains, the doctor
sperm, they will pay for various costly must help the man confront this delicate
techniques that use their own sperm. situation. "As an andrologist, I feel the
Says Dr. Kanbur, "If that doesn't work, woman must know. We get her consent.
then they'll go for donor sperm." Otherwise, we can't impregnate her."

Women's bodies perform a stream of
functions related to reproduction. Among
these functions are ovulation, fostering
the penetration of sperm through the
cervical mucus and opening, transport-
ing a fertilized egg through the fallopi-
an tube, implanting the egg in the endo-
metrium, and continuing maintenance
of the embryo and fetus. Infertility can
result from a difficulty with any of these
functions. The basic infertility work-up
for women includes:
a physical and gynecological exam;
a cervical mucus study;
tests for RTIs and STIs where infec-
tion is suspected;
endometrial histopathology where
pelvic tuberculosis is suspected; and
blood tests for hormone levels as
well as for infections that could
lead to miscarriage.

,, .5E 1~

As with the services for men, the fees
for screening and treating women for in-
fertility are far lower than those charged
in the private sector. For example, an
initial consultation at a private doctor's
office costs about 200 rupees, compared
with 30 rupees (about 10 cents) at the
clinic. Basic laboratory tests cost close
to $2 privately, almost twice the price at
FPAI. The biggest cost difference, how-
ever, is for surgical procedures: 3,500 ru-
pees is charged in the private sector com-
pared with 1,500 rupees at the project.
Some diagnostic tests, however, re-
main beyond the financial reach of
many clients. For example, although a
client may have a tubal blockage ini-
tially diagnosed through laparoscopy, a
hysterosalpingram may be needed to
confirm the diagnosis. Similarly, ultra-
sound may be required to confirm ovu-
lation. Therefore, a greater prevalence
of tubal blockage may exist among
female clients than the staff can diag-
nose definitively. In large part because
the clinic lacks more sophisticated

Infertile women typically experience a sense of shame and failure, and most couples are willing to pay for services in the hopes of
having a child. At the Bhiwandi clinic, infertility accounts for 10 percent of the client load.

Tu i .ulosis ani

Although endometrial-or pelvic-
tuberculosis is rare in developed coun-
tries, it is fairly common in many
developing countries, and particularly
in India, where approximately 10 per-
cent of women with pulmonary TB (or
tubercular lesions in other sites) devel-
op lesions in the reproductive tract.
Pelvic tuberculosis is often a silent dis-
ease, present for 10 to 20 years within
women who remain in apparent
excellent health. Infertility may be one
of the few symptoms of the disease,
and sometimes the only reason the
woman is ever tested for TB.
Infertililty secondary to pelvic TB is
not rare. According to one study, pelvic
TB occurs in about 6 percent of cases
of infertility among Indian women
(Dawn 1995). Another study conduct-
ed in India showed that of 300 women
with tubal infertility, 39 percent had
pelvic tuberculosis, either currently or
in the past (Parikh et al. 1997).
At the Bhiwandi clinic, pelvic TB
may be noted initially during a diag-
nostic laparoscopy. A sample of endo-
metrial tissue is taken by dilitation and
curettage and sent for a histopatholo-
gy test. Although antituberculin drugs
can cure the underlying infection, the
tubal or endometrial scarring leaves
women with little chance of becoming
pregnant; overall, only 5 percent of
women with infertility related to
pelvic tuberculosis ultimately conceive
(SIRM 2002).

technology, only 7 percent of the infer-
tility cases at the Bhiwandi clinic are
diagnosed as the result of a specific
condition suffered by the woman.
Among cases for which a definitive
female diagnosis is possible, the most
common causes of infertility are non-
ovulatory cycles due to hormonal im-
balances and tubal or endometrial scar-
ring from infection. Most commonly,
pelvic infections are the result of an STI
(such as chlamydia or gonorrhea), un-
safe abortion, or tuberculosis. (see box
on Tuberculosis and Infertility).8
The Bhiwandi staff are able to treat
some conditions of female infertility
directly. For example:
Women with endocrine problems
may be treated with fertility drugs to
promote ovulation. Typically, wom-
en are given clomifen citrate.
In cases where the vaginal or cervi-
cal environment appears unrecep-
tive to sperm, the woman may be
inseminated intracervically.
Laparoscopy is performed when a
uterine, tubal, or ovarian abnormal-
ity is suspected that can be visually
diagnosed. Dilitation and curettage
is also performed if indicated.
Other treatments for female infertility
are often more expensive and invasive,
and require referral to another provider.
For women who have been diagnosed
with blocked tubes, and the site of the
blockage has been identified by hystero-
salpingogram, the staff refer the client to
another FPAI facility in Bombay for sur-
gery to resection the tubes.9

SWorldwide, hormonal or endocrine disturbances account for 35 percent of infertility among women;
tubal factors account for 32 percent; and acquired nontubal factors (such as endometrial tuberculosis)
account for 12 percent. Less than 2 percent of female infertility is the result of sexual dysfunction or con-
genital abnormalities. The figures are similar for Asia (Jeejeebhoy 1998).
Because the scarring and blockage from tuberculosis is usually more serious than that which is secondary
to an STI, women with pelvic TB are not usually candidates for tuboplasty. Cases of active endometrial
tuberculosis are sent to tuberculosis treatment centers in the municipal hospital.

Some of the women who continue to
have ovulatory problems or blocked
tubes are candidates for more sophisti-
cated artificial reproduction technolo-
gies, and are ultimately referred to larger
infertility centers. In India today, an in-
fertile couple theoretically has recourse
to a vast array of assisted-conception
technologies, from first-generation tech-
nologies such as in vitro fertilization
(IVF) to newer ones such as gamete
intrafallopian transfer (GIFT) and zygote
intrafallopian transfer (ZIFT).'0 "What-
ever has come to the world has come to
India," says Dr. Kanbur. Of course, Dr.
Kanbur is painfully aware that wealth has
not come to most of his clients, and that
for the most part, those couples who
seek these treatment go into debt to do
so. He and Dr. Kelkar have referred
about 25 couples for more sophisticated
treatments, but they have not been able
to follow them to determine how many
became pregnant.

Among those women who can conceive
but suffer repeat first-trimester mis-
carriage, the problem may stem from
various conditions, including endocrine
imbalance or infection. The four patho-
gens chiefly responsible for early mis-
carriage are known as TORCH: toxo-
plasma, rubella, cytomegalli, and her-
pes. The clinic can diagnose the pres-
ence of these underlying infections; in
the case of toxoplasma, the underlying
infection can be cured. A woman who
has suffered repeat second-trimester mis-
carriages may have cervical impatency,

in which the cervix dilates prematurely.
In such a case, the clinic refers the client
to another center where her cervix can
be stitched early during pregnancy in
the attempt to avoid a repeat loss.

Some cases are easily diagnosed and
treated, such as that of Vijay and
Kalyani Gawli:

Kalyani had become pregnant twice
but miscarried both times within the
first trimester. She and Vijay went to a
private clinic, which charged them
Rs. 1,500 (US$32) for each treatment,
a significant expense for a couple
relying on Vijay's salary from operat-
ing a tractor compression machine.
The treatment failed. Adding to their
dismay was the way the nurses treated
them. Vijay reported, "They told my
wife, 'You can't hold the baby, so what
is the use of trying to conceive?'"
On the recommendation of a pro-
ject field-worker who lives nearby,
Kalyani and Vijay visited the Bhiwandi
clinic, although they live almost 50
kilometers away. At Bhiwandi, a blood
test showed that Kalyani had toxo-
plasmosis, an infection that can be
caused by the proximity to animals.
The clinic prescribed rovamycin, a
medication unrelated to what had
been prescribed at the private clinic.
Within a short time, Kalyani became
pregnant again and was able to carry
the pregnancy to term. Kalyani and
Vijay are the proud parents of two
year-old Yash, whose name means

oIn IVF, the eggs and sperm are left together in an incubator for about 18 hours, then checked for fertil-
ization and further embryonic development. The embryos are then placed in the uterus. In standard GIFT,
laparoscopy is required to place three to six eggs, together with prepared sperm, in the end of the fal-
lopian tubes. Fertilization then occurs in the fallopian tubes iIn r -il, ZIFT is a method of assisted repro-
duction in which the woman's eggs are fertilized in the laboratory using the husband's sperm and are then
placed in the fallopian tubes.

Some cases are fairly easy to diag-
nose, but it is not always clear whether
the treatment will be successful, as was
the case for Vinod and Ashok, two male

During the nine years Vinod and his
wife had failed to conceive, they had
experienced numerous unsuccessful
encounters with private doctors. Then
Vinod heard about the Bhiwandi clin-
ic from a relative. When he first visit-
ed the clinic, his sperm count was 9
million/ml, well below the 20 million
generally considered the minimum for
conception. Upon physical examina-
tion, Dr. Kanbur diagnosed a varico-
coele, and in mid-2000, Vinod under-
went surgery to repair the varicocoele.
In the first year after his surgery, his
sperm count rose to 16 million, but
his wife still did not become pregnant.
At that time, Vinod explained, "At
least there is hope. In other places,
they didn't tell us what the problem is,
but here they tell us. That's why I con-
tinue coming here."(The following
year, Vinod's wife finally conceived.)

Ashok, 40 years old, had difficulty
achieving an erection and was unable
to ejaculate. After nine years of mar-
riage, his wife had not become preg-
nant. At the clinic, Ashok was found
to have a blockage in the ejaculatory
duct. Dr. Kanbur performed endo-
scopic surgery to remove the obstruc-
tion. Although Ashok's sperm count
rose, he was still unable to ejaculate
during intercourse and was referred to
another center for treatment, where
his semen is being procured for artifi-
cial insemination.

Other cases are relatively simple to
diagnose from a medical perspective,
but difficult to treat because of male

Balram and Bhavna Sambre belong to
a tribal community 22 kilometers from
Bhiwandi. When Bhayna did not be-
come pregnant after two years, the
couple suffered ridicule from friends
and relatives. Balram's mother heard
about the Bhiwandi infertility clinic
from her mahila mandal, then told her
son, and the two of them sent Bhayna
for treatment. Staff at the clinic told
Bhayna that her husband must also be
tested, but Balram refused, insisting
that if anything was wrong, it would
be with his wife. His mother agreed
vehemently that infertility is a wom-
an's problem. Finally, the president of
the local mahila mandal met with
both Balram and his mother, practi-
cally coercing them to come with her
and Bhayna to the clinic for Balram to
be tested.
At the clinic, Balram was diag-
nosed with both urinary and repro-
ductive tract infections, as well as a
low semen count. (Bhavna also had
an RTI, but her cervical mucus and
endometrial lining appeared normal.)
Although staff had to contact them to
continue treatment, their infections
were eventually cured and Balram's
semen count increased. Within a year,
Bhayna conceived. The couple has
now referred others for infertility care
at the Bhiwandi clinic.

T e 1-.tto r Lin :
.e corn ig re .,. ant

Unfortunately, the greatest number of
cases are resolved not by conception,
but by a couple's acceptance of their
inability to reproduce. This outcome is
common throughout the world, particu-
larly where resources for more advanced
diagnostic and therapeutic technologies
are scarce.

At the Bhiwandi clinic, among the
717 couples who began treatment be-
tween 1996 and 2001, 75 women (11
percent) successfully conceived, of whom
five miscarried. Interestingly, success
rates are almost the same among cou-
ples who had previously sought help
elsewhere as among those who first
sought care at the Bhiwandi clinic. No
follow-up information is available con-
cerning the outcome of the 25 couples
who were considered candidates for
more sophisticated infertility techniques
and referred to centers in Bombay.

Dr. Kanbur feels strongly that the suc-
cess rate at the Bhiwandi clinic is con-
strained primarily by lack of access to
more advanced reproduction technolo-

gies. He is able, currently, to treat only
20 percent of his male patients success-
fully; with better technology, around 40
percent of men could be treated, he
asserts. The clinic faces a similar con-
straint on treatment for women.
Dr. Kanbur believes such technolo-
gies must be available at all infertility
treatment centers. Of course, many of
the couples who attend the Bhiwandi
clinic are not able to pay for such
expensive new approaches as in vitro
fertilization and egg donation. Nor does
the Bombay branch of FPAI have such
resources. Dr. Kanbur deals month in
and month out with couples who can-
not conceive, and he believes that
many treatments should be provided at
least at subsidized rates. "Patients must
have an equal right to all modes of
treatment, regardless of their income
status," he argues. "Let's get it done."

Dr. Kanbur believes reproductive technologies must be available at all infertility treatment centers, provided at subsidized rates.
"Patients must have an equal right to all modes of treatment, regardless of their income status," he argues.

e c ing liV nts
solve n going

Although the success stories are a
source of great joy for staff as well as for
their clients, to date, the vast majority of
the couples who come to Bhiwandi
have been unable to conceive. The staff
must support clients through the diffi-
cult decision of whether and when to
give up hope. Inevitably, the staff find

..... ......... in redu' ''~
er liitysto j t it tas
ch as is ..-.. '. .and that
reans .. .. Sections
tha '. .. "1.7 .., *,Y

themselves advising those couples for
whom treatment-even costly and inva-
sive procedures in some cases-has not
been successful. Dr. Kanbur sums up
this difficult situation in a straightfor-
ward manner: "At some point we coun-
sel the patients that the treatment is not
working. Usually this is at a point when
their finances or patience runs out,
since this is a slow, long process."

Mahesh and Sandhya Kumwear live in
a Bhiwandi slum area. They had been
married for three years without having
children. Mahesh had had a bilateral
hernia operation. His semen analysis
indicated zero sperm, and a subse-
quent vasography indicated that both
vas deferens were totally blocked. The
staff at Bhiwandi told the couple that
they would not be able to conceive,
but in Bombay they were informed
that the blockage could be removed
surgically. However, the surgery was
expensive and success was not certain.
Over the course of five counseling

sessions back at the Bhiwandi clinic,
during which staff offered consolation,
suggested adoption (which Mahesh and
Sandhya did not choose), and listened,
the couple slowly began to cope with
losing hope of having a child.

FPAI adoption consultant Nilima
Mehta describes the emotional chal-
lenge for clients at this stage. "The final
reconciliation with childlessness comes
as a total shock to most individuals.
'No, this cannot be me,' is the first
response. This slowly gives way to self-
pity and anger: 'Why me?', followed by
acceptance." In most developing coun-
tries, no community-based infertility
support groups such as RESOLVE
(described above), exist but Mehta trains
FPAI staff to help. She says, "At this
moment we can orient them toward
looking at adoption as an option" (see
box on adoption).

,re.. noting
1.i casting g the
Soi mmnunit a ib ut

The biggest challenge in reducing infer-
tility is to prevent it as much as is possi-
ble, and that means preventing the in-
fections that can impair fertility. At the
Comprehensive Reproductive Health
for All project, STI prevention is part of
both clinical and community-aware-
ness activities. In addition to diagnosing
and treating STIs in the clinic (including
routine voluntary testing of every man
who comes through the doors), com-
munity workers conduct educational
sessions on various reproductive health
topics, including STIs.
Sundeep Kadam and B.Y. Yadav coor-
dinate the community component of the
Comprehensive Reproductive Health for

Infertile couples at the Bhiwandi clinic, and indeed throughout India, generally do not
seek to adopt. Usually, they will try costly infertility treatments first. Only when such
methods fail is adoption considered. "It's the last straw," says Dr. Kanbur. "If nothing
else works."
The resistance to adoption is partly a response to legal factors. First, no uniform law
on adoption is in effect in India; each religious community is governed by its own spe-
cific laws in this matter. Although Hindus are allowed to adopt, the laws of most other
religious communities in India disallow or discourage official adoption. Hence, many
Indians can act only as legal guardians to their adoptive children, who are granted the
status of wards.
Bureaucratic obstacles are another inhibiting factor. Couples who are legally eligible
to adopt are usually required to make a formal written application, followed by inter-
views and home visits. They must provide birth certificates, medical reports, recom-
mendations, and extensive documentation of their finances; couples who just scrape
through the income requirement must place a fixed deposit in the child's name to
ensure financial security. The whole process takes close to a year to complete. "This
can, in practical terms, make it difficult to adopt," says Nilima Mehta understatedly,
"even though every family theoretically has a right to parenthood."
Finally, a key factor hindering adoption is cultural. Dr. Kelkar explains that many in-
fertile couples don't want to adopt out of a "fear of society." Part of the stigma sur-
rounding adoption arises because of class differences-adoptive parents tend to be more
affluent, while adoptees are typically from poor families or orphanages. The stigma also
may be partly a projection of the couple's unresolved frustration with their inability to
conceive. Says Mehta, "Couples tend to believe that blood ties are superior to the ties of
love. Socialization makes us believe that there is a deep bond with the umbilical cord.
So people want to go through the physical process of giving birth." For this reason,
Mehta seeks to ensure that couples resolve emotional issues related to their infertility
before adopting.
In recent years, a trend has grown toward informal, noninstitutionalized adoption:
A couple will hand over one of their children to a childless couple in their extended
family. This phenomenon is common in cities and villages and is so much part of the
Indian social landscape that it is not really considered adoption.
According to Nilima Mehta, attitudes are slowly changing: More Indian families are
adopting children formally, and the shame associated with adoption is gradually fading.
Dr. Kelkar remembers one infertile couple adopting an infant girl. The clinic maintains
a list of adoption centers, to which couples are referred based on their income level.

All project. "We teach men about every- most people know almost nothing about
thing related to reproductive health," causes or treatment options. Public
says B.Y., "from the importance of using awareness is zero." Providing informa-
condoms to the need to test themselves tion helps couples identify their own
for STIs-and about infertility. These are need for clinical follow-up.
all delicate issues, but we have to tell We drive through lush rice fields to a
them. After all, it takes two hands to community sexuality education work-
clap, it takes two people to have rela- shop for girls. The women are bent over
tions." Dr. Kanbur adds, "Although infer- in the fields, sowing paddy in square
utility is a devastating fate in the society, patches of iridescent green. The road

ends at Parivali, a small village, where officer, "using articulate women leaders
25 teenage girls have assembled in the as change agents."
village nursery school to meet with the It is an afternoon of learning, punctu-
Bhiwandi staff. This workshop grew out ated by shocked giggles and embarrassed
of suggestions from the male health smiles. Most of these girls are not sent to
worker and the mahila mandal. "Com- school anymore. "If you sit at home,
munity awareness is created via the what do your parents do?" asks health
mahila mandals," says Virupax Ranne- worker Sunanda Gawli. "Get us married
bennur, FPAI's research and evaluation off," is the overwhelming consensus.

S. >r" e of eg er -cu;,.

Technical information alone will make hardly a dent in infection rates, or, for that mat-
ter, in many other sexual and reproductive health outcomes. Achieving better out-
comes will also require forging new, more equitable sexual and personal relationships
between males and females, which will in turn make girls and women less vulnerable
to unprotected or unwanted sex. Therefore, in addition to providing information about
topics such as STIs, the Bhiwandi awareness workshops address issues of gender directly.
These sessions with young people were designed in response to a needs assessment
in Bhiwandi that identified adolescents' lack of opportunity to reflect on values. The
sexual and reproductive health sessions explore issues such as relationships, emotions,
and the relative power and value attributed to boys versus girls. "It's a real challenge to
develop a curriculum that shows them how to deal with emotions such as anger and
shows them how to express or overcome their feelings," says Vaishali Thakur, a coun-
selor at FPAI's Bombay branch. "These issues are not emphasized in (traditional) cur-
ricula on reproductive and sexual health."
In addition to the teen workshops, the community program conducts outreach to
teachers, training for adolescent peer educators, and public education campaigns aimed
at young people. For example, at a workshop on "Our daughters, our assets," 60 teenage
girls and boys learn how a preference for sons has resulted in an adverse male-female sex
ratio in India. "Here, we hear things that our parents never talk about," says one young
Dr. Kanbur sees the community activities as a critical avenue for helping young peo-
ple to challenge existing assumptions about gender. "Men should be more aware of sex-
ual problems," he says. "Men just won't attend the clinic. Men are the superior lot, so
they assume they are normal. The root cause is that we treat our boys and girls differ-
The community-education team also meets with adult women. Among their con-
cerns are reproductive tract infections, although they do not necessarily link this com-
mon problem to a risk of infertility. For example, women explain that during men-
struation, they must use the common well to wash their sanitary cloths (only about 5
percent can afford sanitary napkins), and they feel embarrassed to have the drainage
water turn red in front of others. As a result, they often wear the same cloth for as long
as possible while they await a chance to wash it when no one else is at the well. The
staff explain to the women that the longer they wear the cloth, the greater their chance
of developing or nurturing an infection of the reproductive tract. The staff encourage
the women to put their health first, to wash the cloths well before wearing them, and
to wash them indoors when they have a bath.

The outline of a teenage girl's body is
traced on a bright yellow sheet of paper,
and the girls are asked to map female
body parts within the outline. Although
they are ready to map eyes, ears, and
noses, they have to be coaxed into map-
ping reproductive and sexual organs.
"So what did you do when you got your
first period?" asks Sunanda, as she draws
-and explains-the function of the
uterus. "Told my mother," says one girl.
"And what did she tell you?" "Nothing."
Nothing. It is this absence of informa-
tion from other sources that makes this
sexuality education workshop a unique
learning experience in the lives of young
men and women in rural Bhiwandi. The
Bhiwandi staff focus on both technical
and social issues. Understanding fertili-
ty is part of understanding-and hope-
fully preventing-infertility. Dr. Kelkar
notes, "While explaining menstruation,
we explain when ovulation takes place."
Using a flip chart, Sunanda teaches the
girls about different methods of contra-
ception, including condoms. She asks
them whether they knew about STIs.
Some girls nodded shyly, but were not
sure what they were. Sunanda provides
them with basic information about such
In addition to awareness workshops,
with the help of local mahila mandals,
community-level diagnostic camps are
held to detect ailments that can then be
treated at the clinic. The camps are usu-
ally held in the village anganwadi
(community center) or in someone's
house, and are usually preceded by a
mahila mandal meeting to educate the
women about reproductive health
issues. About 25 to 30 women are
examined in each one-day camp, and
staff provide antenatal checkups, RTI
screening, and (for women older than
30) pap smears. A specific test for infer-
tility is not performed, but some women
are referred through the camps for infer-
tility treatment.

Technical information alone will make hardly a dent in STI rates. In addi-
tion to providing information about topics such as STIs, the Bhiwandi
awareness workshops address issues of gender directly.

In addition to the 70 infants whose par-
ents might otherwise despair of ever
having a family, the Bhiwandi staff can
take pride in a number of broader social
and institutional accomplishments. Some
of these are direct benefits of the infer-
tility clinic, whereas others are gains re-
sulting from the broader comprehensive
reproductive health project of which the
infertility program is a part.

The counseling available at the clinic
has helped hundreds of couples to work

through an overwhelming sense of
shame and tension, and has helped
them to understand that the wife should
not automatically bear blame for not
becoming pregnant. According to Dr.
Kelkar, clinic staff are seeing a change
in men's attitudes and greater mutual
support between husbands and wives.
As a result of community workshops
and of men's seeing that some women
are able to conceive after their husbands
are treated at the clinic, this awareness
is spreading to men in the community.
"It is amazing," says Dr. Rao. "Normally,

"". !. better ;: < ... : :.- the clinic
could teach more women to
,,i :.ti ; ","" :,-J ^ i iI.'..!: t i ': .' a re 1, ,I, : i i I! ....
and .toiki better assist t,._upi, to
* .<"." with their ultimate 'ai -c to
coc eive,

(men) never used to come forward for
testing.... Now more of them are quite
willing to come in." Furthermore, in the
area in and around Bhiwandi where the
staff have been working, no more cases
have been reported of husbands' desert-
ing their wives because they have not

reader Comi unity
Understanding g
The Bhiwandi program has fostered great-
er understanding of infertility throughout
the community. One benefit is that many
infertile couples feel they can speak of
their situation to their friends or family
members instead of suffering in silence.
Dr. Rao believes that the greater open-
ness leads to increasing familial and com-
munity support. "Here, it is not merely
two persons deciding to start a family.
That's a Western concept." In one instance,
a village raised money to treat a man

who had hydrocoele, and could not stand,
work, sleep, or get married as a result.

Increased se of the
hiavv di Clinic
The Bhiwandi clinic enjoys a strong rela-
tionship with the community, because
the clinical program grew out of the
mahila mandals. Clearly, the communi-
ty particularly values an institution that
provides assistance to infertile couples.
As Dr. Rao expresses it, "This treatment
is seen as a pro, a positive. When we do
family planning, we're 'stopping birth,'
which is not seen as a positive."
Furthermore, the infertility clinic has
contributed to the general willingness
of people to seek reproductive health
care. Compared with a service like fam-
ily planning, the successful results of
infertility treatment are visible. Of
course, not all of the increased use of
the Bhiwandi clinic is the result of its
infertility service; the broad array of
reproductive health services that it
offers undoubtedly fosters the rise in
client volume. Professor Gadre believes
that the key to the clinic's success is in
the very name of the project: Compre-
hensive Reproductive Health for All.
Pravina Palaye echoes this view: "When
we started giving all other reproductive
health services, patients started accept-
ing family planning. This is the repro-
ductive health phenomenon." Indeed,
as Table 1 shows, the greatest increase
in client load by far has been in family

En anced Capacity
among g Stal
The Bhiwandi project now relies on a
sophisticated clinical and community-
based provider team. Staff members are
comfortable discussing issues related to
sexual health. Says Pravina, "We used to
feel embarrassed to talk about the penis.

Infertility treatment 194 170 154 107 92 717
Other reproductive health services 508 918 973 412 317 3,128
Family planning 101 646 1,135 992 1,162 4,036
Total 803 1,734 2,262 1,511 1,571 7,881

When we started discussing these things,
the women started talking openly. My
own development happened here."

Five years after having launched the
infertility program, as FPAI continues to
implement the Cairo agenda in its 43
clinics throughout India, the Compre-
hensive Reproductive Health for All
project serves as an institutional model.
The Bhiwandi staff and their colleagues
at FPAI in Bombay take pride in their
accomplishments and look toward the
future. At the same time, they consider
ways they might, with more resources
and time, better meet the needs of the
women and men they serve. Among the
challenges they face are:
staff hope to find the resources to
enable more couples to try assisted-
reproduction technologies. With
more time, staff could follow up
couples referred for these technolo-
gies to determine their success rates.

better resources, the clinic could
assess what might be gained from
more comprehensive education and
counseling. For example, to help
women determine when they are
ovulating, staff might include rou-
tine instruction about standard days

(or "necklace"), temperature, and/or
mucus methods. Providers could
then screen women for anovulation.
It would also help couples time
intercourse (especially important if
one tube is blocked and the oppor-
tunity for fertilization occurs only
once every two months), and give
them some measure of control at a
time when they feel particularly
The program might also strength-
en counseling that would assist
couples to cope with their failure to
conceive. With increased resources,
a staff member could provide such
counseling, start a support group
for infertile couples, or strengthen
adoption counseling. In following
up couples who have been referred
for more sophisticated treatment to
learn about the medical outcomes
of the referral, staff might also be
able to ask and learn about the
emotional costs to clients of trying
costly and invasive procedures
without success vis-a-vis accepting
childlessness without undergoing
these procedures.

To develop stronger links
between awareness and services,
and between the community and
the clinic, the staff are encouraging
the mahila mandals and yuvak man-
dais (voluntary men's groups) to
strengthen their role in community-
based education, health promotion,
and referral.

ri -.,1ce fro,; 1,, -,..ria:
Ss t an cti n s .rc

Throughout sub-Saharan Africa, infertility is a serious reproductive health prob-
lem. Although the Women's Health and Action Research Centre offers compre-
hensive reproductive health care (including family planning, postabortion coun-
seling, testing and treatment for STIs, and general gynecology), as many as 70 per-
cent of the women voluntarily walking into the clinic are seeking help to conceive.
The primary cause of infertility in this region is tubal scarring in women, a conse-
quence of sexually transmitted infections. Low sperm counts (of various origins)
are the next most common cause of infertility in the client population.
To learn more about the problem of infertility locally, WHARC conducted a
population-based prevalence study in 1997, which found that one of five couples
was infertile (that is, the couple had failed to conceive after two years of engaging
in regular sexual intercourse without the use of contraceptives). A second survey
found that women named infertility services as their primary reproductive health
It is not surprising that unwanted childlessness is such a pressing issue. Not
being able to bear children can be a sad and stressful situation anywhere, but in
Nigeria, as in India (and indeed in many countries), the consequences of infertility
are particularly severe for women. Even when the cause is of male origin, the
woman is blamed for childlessness. Her husband may beat her, either as punish-
ment or simply out of frustration. He may choose-or feel pressured by his fami-
ly-to take an additional wife. Frequently, the childless woman is disinherited or
divorced. Among the Ekiti people of southwest Nigeria, a woman who dies with-
out leaving offspring must be buried outside of the city.
In many ways, the WHARC experience parallels that of the Bhiwandi clinic in
India. Half of the infertility clients are referred by other doctors, and many have
already sought help from traditional or religious healers. Usually, the woman first
comes to the clinic by herself. WHARC staff require, however, that her husband
come back with her; in recent years, most men are willing to do so.
At WHARC, along with conducting an extensive history and clinical work-up,
staff teach women how to tell when during the menstrual cycle they are fertile.
Clients learn the calendar method and then how to identify the changes in cervi-
cal mucus during the cycle. Leaflets are available to complement the instruction.
Learning this method has enabled some couples to conceive.
Among women who ovulate infrequently or irregularly, instruction for identi-
fying the time of ovulation so that intercourse may be synchronized can be help-
ful. However, many of the 350 couples who come to WHARC each year need dif-
ferent treatments, including induction of ovulation, varicocoele repair, and tubal

repair. The majority of successful pregnancies have occurred among couples
undergoing ovulation induction, whereas pregnancy rates following tubal repair
have been particular-
ly poor. Among those
who might benefit t
from in vitro fertiliza-
tion, the few with
financial resources
are referred to a clin-
ic in the UK; two out r -
of six of such refer-
rals have resulted in
pregnancy. Finally,
WHARC staff some- i
times counsel clients
to adopt a child. Bab-
ies are available for
adoption in Nigeria,
but, according to Dr. -
Friday Okonofua, Dir-
ector of WHARC,
strong cultural taboos
remain against adop-
in ainst adp Some WHARC clients became pregnant after learning methods of fer-
tion. Also, because utility awareness. Identifying ovulation may be particularly helpful to
the belief is wide- women who have one blocked fallopian tube (and hence, opportunities
spread that the abili- for fertilization and implantation only on alternate cycles).
ty to conceive is controlled by spirits, people maintain hope. They may return to a
traditional healer, but are unlikely to accept the finality of childlessness. To date,
only one couple has adopted.
WHARC is committed to addressing the epidemic of infertility at its root and is
actively engaged in community education to reduce the prevalence of STIs. One
part of that challenge is changing sexual behavior norms and promoting condom
use. Dr. Okonofua is particularly hopeful that the female condom can provide
women with a way to protect themselves when their partners are unwilling to use
a condom. He stresses, however, that some of the problem with stubborn STI rates
is at the provider level. In one study, WHARC found that less than two percent of
STIs are being treated correctly. WHARC is currently training providers ,l: IIug
traditional healers) to improve the quality of STI diagnosis and treatment. Even
with syndromic approaches, providers can improve diagnosis and prescribe drugs
that are more appropriate to particular conditions. A need remains for better edu-
cation concerning condom use and better partner follow-up if treatment is to be
effective. Of course, even with proper diagnosis and treatment, Dr. Okonofua
laments, financial constraints are the biggest problem. Clients often simply cannot
afford to pay for necessary medications.
Although WHARC has not been successful in helping most infertile couples
achieve pregnancy, the fact that they offer any help is of great value to their
clients. The infertile couple takes some comfort from the compassion and efforts
of a health-care provider, and the community values a clinic that honors and
responds to the needs it identifies.

The c 1enge 1for
SFamiy a n ni n

Is jIferiliy TIoo)
I Tto Ta..e 'n?
At one time, both the Family Planning
Association of India and WHARC of
Nigeria felt overwhelmed by the idea of
responding to the problem of infertility.
The demand seemed too great to meet.
The task of building technical know-
how was intimidating. The cost of pro-
viding care could soar out of control.
The relations with local private doctors
might be jeopardized. The institution
itself might lose its focus.
In fact, the demand has been real,
but not beyond control. Trained physi-
cians have joined the clinics and helped
to build the programs. The clinics have
found a workable balance between out-
side support and client fees. The institu-
tions have become strengthened both
internally and within the community.
Although the staff at Bhiwandi and at
WHARC are proud of their accomplish-

By assisting couples who want to have children as
well as those who want to avoid pregnancy, family
planning programs will finally become worthy of
their name in the truest sense.

ments, their efforts to help infertile cou-
ples conceive is, in many ways, an
uphill battle; the trial is even greater for
their clients. Immense personal, techni-
cal, and financial efforts over a long
period translate into few triumphs. Staff
know their job is not, and will never be
an easy one, and they try to face as
squarely as they can a constellation of
related challenges. Despite the long
odds and sometimes wrenching disap-
pointments, these infertility clinics are
happy places. The staff take great satis-
faction from the benefits they have
helped bring about for their clients and
for the communities in which they live.
Understandably, many program lead-
ers feel they lack the resources or space
to provide the range of infertility serv-
ices offered at Bhiwandi and in Benin
City. A number of discrete and highly
valuable services can be offered, how-
ever, that require little in the way of
extra equipment or staff. For example,
as noted above, counselors can teach
women how to tell when they are ovu-
lating, which can help the clinic screen
for anovulation, help women synchro-
nize intercourse with ovulation, and
give clients a desperately needed mea-
sure of control over the process of their
treatment. Clinics can also provide
basic counseling for male partners and
offer simple exams to screen for prob-
lems such as varicocoele. For a useful
framework of discrete services that can
be provided with different levels of
infrastructure and program effort, see
the afterword to this article.
Certainly, every program can wrestle
with the question of what the words
"family planning" really mean. This pro-
cess is both a pragmatic and, ultimately,
a philosophical one. Despite the limits
of their achievement, the staff at Bhi-
wandi and in Benin know that they now
have a better answer for such women as
the one who faced the FPAI field-work-
er some years back and asked, "What
about us?"

FPAI and WHARC have learned several
important lessons as part of their expe-
rience in managing infertility treatment
within a comprehensive reproductive
health framework.
A serious and generally unacknowl-
edged unmet need exists for afford-
able infertility services.
Some infertility services can be of-
fered within the context of typical
family planning clinics (see the after-
word for a framework for incorpo-
rating infertility into family planning
and reproductive health services).
With minimal additional training
for physicians (or specialists who
work at the clinic on a part-time
basis), a program can manage a sig-
nificant number of cases without
referral to costly specialty clinics.
Even in resource-poor settings, cli-
ents are willing to pay for services
because they greatly value help in
overcoming childlessness. A signifi-
cant portion of a clinic's costs can be
covered by fees charged to clients.
Male involvement is essential to ef-
fective infertility treatment and care.
Counseling and education are inte-
gral aspects of treating infertility. In-
fertility services must be conceptu-
alized as a balance between a med-
ical and social model of care.
* Information about causes and pre-
vention of infertility can be incorpo-
rated easily into existing community
education programs on sexual and
reproductive health and gender.
Screening for infertility also dove-
tails effectively with STI screening
and treatment services.
* In light of the low rates of clinical
success in treating infertility, pro-
grams must devise thoughtful indica-
tors to evaluate program effective-
ness. Among valued outcomes may

be that of helping couples to avoid
unnecessary and inaccurate blaming
of one partner and aiding them to
resolve their situation of childlessness
in a manner that they deem helpful.
Offering support and services for in-
fertile couples builds community
support for and use of a reproduc-
tive health program.

Anonymous. 1999. "Notes from a support
group for women over 40 trying to have
their first child." Reproductive Health
Matters 7(13): 89-95.
Dawn, C.S. 1995. Textbook of Gynaecology,
12th edition. Kolkata, India: Dawn Books.
International Planned Parenthood Federation
(IPPF). 1996. Charter on Sexual and Repro-
ductive Rights (Article 10.1). London: IPPF
P.23. Also available at: org/charter/full.htm>
Jeejeebhoy, Shireen. 1998. "Infertility in In-
dia-levels, patterns and consequences:
Priorities for social science research."
Journal of Family Welfare 44(2):15-24.
Murthy, Nirmala, Lakshmi Ramachandar, Pertti
Pelto, and Akhila Vasan. 2002. "Dismantling
India's contraceptive target system: An
overview and three case studies." In
Haberland and Measham (eds.). Responding
to Cairo: Case Studies of Changing Practice
in Reproductive Health and Family
Planning. New York: Population Council.
Pachauri, Saroj. 2001. "Male involvement in
reproductive health care." Journal of the In-
dian Medical Association 99(3): 138-142.
Parikh, F.R. et al. 1997. "Genital tuberculosis:
A major pelvic factor causing infertility in
Indian women." Fertility and Sterility 67(3):
Sher Institute for Reproductive Medicine
(SIRM). 2002. "Pelvic tuberculosis: An un-
common cause of infertility in the United
States (1999-2001)." com/infert/pelvictb.asp>
Unisa, Sayeed. 1999. "Childlessness in Andhra
Pradesh, India: Treatment-seeking and con-
sequences." Reproductive Health Matters
7(13): 54-64.
Walsh, Patrick and M. McDougall. 1992.
C 1,iI.' ii Urology, 6th edition. Philadel-
phia: Saunders.

by Friday Okonofua

Family planning programs can be an
important entry point for couples with
all types of fertility problems-those
who seek to limit their fertility as well
as those wishing to conceive. Without
mounting large-scale and complex
interventions, family planning programs
can play a critical role in preventing
and treating some aspects of infertility
(Rowe 1999). In doing so, they can help
many couples in need directly; involve
men in reproductive health care; help
reduce STI and RTI rates; and win trust
from communities. A possible frame-

work for incorporating limited infertili-
ty care into a family planning or repro-
ductive health program is provided
below. Programs in settings with signif-
icant unmet need for infertility care
may wish to consider which services
they might reasonably begin to deliver.

Rowe, Patrick John. 1999. "Clinical aspects
of infertility and the role of health care
services." Reproductive Health Matters
7(13): 103-110.

Information and counseling related to fertility and infertility should be part of
the constellation of services available at all family planning clinics. Education is
critical for couples to make informed decisions about seeking care, and some
cases of infertility can be largely resolved with information. Family planning pro-
grams can:
tell women who ask about fertility concerns that men may also be infertile
and encourage them to bring their husbands to the clinic for a joint consul-
teach women (including illiterate women) methods of fertility awareness to
help them determine if and when they are ovulating;
talk with couples to ensure that the timing and nature of their sexual activ-
ity can allow for fertilization; and
provide printed information about infertility as well as contraceptive methods.

With proper training, staff can provide some simple but critical infertility treat-
ment services at family planning clinics. These include:
free or low-cost pregnancy testing at flexible or convenient hours. This serv-
ice should be so advertised that it is welcoming to all couples regardless of
their intent. Many women who are trying to become pregnant agonize as
they wait for a late period, or they invest in costly home pregnancy tests.
Providing pregnancy testing would not only provide clinical results for these
women and their partners, but for those with a negative test result, it could
serve as an opportunity for educating and counseling couples trying to con-
semen analysis;
advice for men on how to boost sperm count, such as avoidance of exces-
sive alcohol, tobacco, and tight underwear;
where appropriate and feasible, prescription of ovulatory drugs such as
clomiphene citrate for women with confirmed minor ovulatory problems.

For couples who fail to conceive after initial testing and counseling interven-
tions, programs can (where available):
refer them to higher levels of infertility management;
provide counseling to help them come to terms with their situation or to
consider adoption, and provide the appropriate referrals (to adoption agen-
cies and for further counseling).

Finally, the cooperation of family planning programs in both the clinical and
policy arenas is needed to help reduce the rate of infertility in the future. Such
programs can play an important role in the following ways. They can:
adopt and promote routine screening, testing, and treatment of sexually
transmitted infections that impair fertility;
promote the use of both male and female condoms, using thoughtful
approaches and counseling;
teach women and providers to seek antenatal care and clean delivery to
reduce the risks of pregnancy-related complications;
help improve the quality of abortion and postabortion care, particularly in
settings where unsafe abortion is a significant source of infection and infer-
tility; and
implement community education programs that address popular myths and
attitudes about infertility.

SsLum en :_spanfio
La infertilidad afecta a hasta el 15 por cien-
to de las parejas en los pauses en vfas de
desarrollo. Las consecuencias sociales del
problema son series en sociedades que
valoran a las mujeres principalmente por
su capacidad reproductive y done se las
culpa por cualquier dificultad en la con-
cepci6n. La posibilidad de diagnosticar y
tratar la infertilidad en muchas de esas
sociedades se encuentra fuertemente limi-
tada por la falta de capacitaci6n y recur-
sos. Es mas, las polfticas nacionales y los
donantes internacionales raramente tratan
de ayudar a las parejas que no pueden
concebir. Esta edici6n de Q/C/Q informa
sobre los servicios para la infertilidad ofre-
cidos por dos clfnicas de planificaci6n
familiar en comunidades de bajos ingre-
sos, una en India y otra en Nigeria.
La clfnica de la Asociaci6n de Planifica-
ci6n Familiar de India en Bhiwandi ofrece
servicios para la infertilidad como parte de
sus servicios su agenda en salud reproduc-
tiva. Dado que muchos varones se niegan
a reconocer su propio papel potential en la
infertilidad, la clfnica decidi6 requerir que
la pareja, y no s6lo la mujer, debe some-
terse al examen medico. Durante la entre-
vista clinica, los medicos preguntan sobre
practices sexuales, tipo de trabajo, etc. Para
los hombres, la revision preliminary incluye
pruebas para ITS yVIH, analisis de semen,
y un examen ffsico. El tratamiento puede
incluir educaci6n sobre factors que
afectan la espermatog6nesis, la reparaci6n
del varicocele, e inseminaci6n artificial. El
procedimiento bAsico para mujeres incluye
exAmenes ffsicos y ginecol6gicos, andlisis
del moco cervical, y ensayos hormonales;
entire las intervenciones utilizadas se en-
cuentran la laparoscopia, los firmacos para
la fecundidad y la educaci6n sobre los
perfodos fertiles de la mujer.
Dado que ni los clients ni la clfnica
pueden acceder a tecnologfas sofisticadas,
los doctors no logran diagnosticar o tratar
muchos casos. Sin embargo, 75 de las 717
parejas atendidas entire 1996 y 2001
lograron un embarazo, y 25 mas fueron
derivadas para tratamientos adicionales.
Dado que la infertilidad suele causar
much estr6s, y que las posibilidades de
un tratamiento exitoso son bajas, para mu-
chas parejas el beneficio principal de la
atenci6n consiste en sentirse menos igno-

rantes y mAs c6modos con su situaci6n.
En Bhiwandi los doctors estan a cargo de
la consejerfa sobre infertilidad. Aunque
tratan de ofrecer todo el apoyo y la infor-
maci6n possible, tienen que tender
simultAneamente a varias tareas clfnicas,
por lo cual todavfa quedan oportunidades
para responder mejor a las necesidades
emocionales de los clients.
Con el fin de evitar la infertilidad future,
el program ofrece tratamiento para ITS y
educaci6n comunitaria sobre infecciones,
las relaciones de g6nero y la infertilidad.
Otro logro del program incluyeque jue-
gan los varones mejoras en la imagen
p6blica en la comunidad y aumento en el
uso de todos los servicios de la clfnica.
En Ciudad de Benin, Nigeria, el Centro
de Acci6n e Investigaci6n en Salud de la
Mujer (en ingles, WHARC) empez6 a ofre-
cer servicios para la infertilidad cuando un
studio local encontr6 fndices de infertili-
dad del 20 por ciento, y cuando una en-
cuesta mostr6 que las mujeres considera-
ban que la atenci6n para este problema era
su principal necesidad. Aquf tambi6n el
personal insisted que los varones asistan a la
clfnica. Los indices de 6xito no son altos,
pero tanto los clients como la comunidad
local valoran profundamente el servicio.
El WHARC tambi6n busca tender a la
causa fundamental de la infertilidad-las
ITS. Los dirigentes de la clinica esperan
que las mujeres locales adopten el cond6n
femenino, y estan trabajando con provee-
dores de servicios para mejorar el diag-
n6stico y tratamiento de las ITS.
Los dos programs ofrecen las sigu-
ientes lecciones:
* Existe una important demand insatis-
fecha por los servicios para la infertili-
dad; incluso los clients de bajos recur-
sos estan dispuestos a pagar por dichos
La orientaci6n y la educaci6n, asf como
la participaci6n de los varones, son la
clave para el 6xito.
Los programs de planificaci6n familiar
se pueden convertir en importantes pun-
tos de entrada para parejas con proble-
mas de infertilidad al proveer servicios
limitados. Estos pueden ser la educaci6n
la consejerfa; algunos servicios clfni-
cos; y derivaciones a otros servicios.

La sterilit6 touche jusqu'A 15 pour cent des
couples dans les pays en developpement.
Les consequences sociales sont particuliere-
ment graves dans les soci6tes ou la valeur
des femmes depend en grande parties de
leur capacity reproductrice et ou elles sont
blImees si elles n'arrivent pas a concevoir.
La capacity de diagnostiquer et trailer la
st6rilit6 dans plusieurs de ces contextes est
toutefois entrav6e par le manque de for-
mation et de resources. En effet, les poli-
tiques nationals et les bailleurs de fonds
internationaux donnent rarement de I'aide
aux couples incapables de procr6er. Ce
numero de Quality/Calidad/Qualite d6crit
les services de sterilit6 offers par deux
centres de planification familiale dans des
communautes pauvres en resources, en
Inde et au Nigeria.
La clinique de L'Association de planifi-
cation familiale d'lnde a Bhiwandi a com-
mence a offrir des soins aux personnel
st6riles dans le cadre d'un programme 6lar-
gi de sante de la reproduction. Beaucoup
d'hommes ne reconnaissant pas leur r6le
potential dans la st6rilit6, le centre a d6cide
d'exiger que le couple subisse des tests de
d6pistage. Au course de I'entretien clinique,
les m6decins se renseignent sur les pra-
tiques sexuelles, le type de travail, etc. Les
tests pr6liminaires pour les hommes inclu-
ent le d6pistage des IST et duVIH, un sper-
mogramme et un examen physique. L'6du-
cation sur les facteurs ayant une incidence
sur la spermatogenese, le traitement des
varicoceles et I'insemination artificielle fig-
urent parmi les options de traitement. Le
depistage de base pour les femmes com-
prend les examens physique et gyn6colo-
gique, I'analyse de la glaire et les essais
hormonaux. La laparoscopie, les medica-
ments centre la st6rilit6 et I'education sur
la periode f6conde sont certain des outils
don't disposent les prestataires.
En parties parce que ni les clients ni le
centre medical ne sont en measure de s'of-
frir des technologies sophistiquees, les
medecins ne peuvent pas diagnostiquer
ou traiter beaucoup de cas. Quand meme,
de 1996 a 2001, 75 couples sur 717 ont
r6ussi a obtenir une grossesse. Vingt-cinq
autres ont 6te r6f6res pour un traitement
Vu que la st6rilite peut ktre stressante et
que les chances de reussite du traitement

sont faibles, un advantage des soins pour les
couples est I'augmentation des connais-
sances et du r6confort. A Bhiwandi, les
m6decins sont charges de conseiller les
personnel st6riles. Bien qu'ils s'efforcent de
fournir le plus d'information et de soutien
possible, ils doivent aussi se concentrer sur
une game de tAches cliniques. En con-
sequence, il reste du chemin a faire pour
r6pondre aux besoins motifs des clients.
Pour pr6venir la st6rilit6 future, le pro-
gramme offre le traitement des IST et I'ed-
ucation communautaire sur les infections,
les relations entire les sexes et la fecondite.
D'autres r6alisations du programme com-
prennent une meilleure image du centre
au sein de la communaut6 et un plus grand
recours au centre pour tous les services.
A Benin City, au Nigeria, le Centre d'ac-
tion et de recherche pour la sante des
femmes (WHARC, Women's Health Action
and Research Centre) a commence a offrir
des soins de sterilite quand une etude lo-
cale a revele un taux de prevalence de la
sterility de 20 pour cent, et qu'une enquite
a etabli que les femmes percevaient les
soins de sterility comme leur plus grand
besoin. Ici comme a Bhiwandi, le personnel
doit insisted pour que les maris se presen-
tent au centre medical. Les taux de r6ussite
ne sont pas 6eeves, mais I'aide offerte par le
centre est tris appreciee, tant par les clients
que par la communaute. Le WHARC s'est
aussi engage a s'attaquer a la cause pre-
miere de la sterilit6 : les IST. Les respons-
ables esperent que les femmes adopteront
le preservatif feminin, et ils collaborent
avec les prestataires pour ameliorer le
diagnostic et le traitement des IST.
Les lemons tires de ces deux pro-
grammes sont les suivantes :
* II existe un s6rieux besoin non satisfait de
services de sterilit6 abordables ; mime
les clients pauvres sont prete a payer
pour les services.
* Les conseils, I'education et la participa-
tion des hommes sont des aspects cles
des soins de sterilite.
* Les programmes de planification famil-
iale peuvent devenir un important point
d'entr6e pour les couples ayant des
problhmes de f6condit6 en o(ffr.nii des
services restreints tels que I'education et
les conseils, certain services cliniques
ainsi que des references 6clair6es.

Friday Okonofua is Executive Director
of the Women's Health and Action Re-
search Center, Benin City, Nigeria; Dean
of the School of Medicine, University of
Benin, Benin City, Nigeria; and Adjunct,
Department of International Health,
Karolinska Institute, Stockholm, Sweden.
Bishakha Datta is Programme Director
of Point of View, a nonprofit organiza-
tion in Bombay, India that promotes the
points of view of women through cre-
ative use of media. A journalist by train-
ing, she makes documentary videos and
writes articles, essays, and books on
issues related to sexuality, reproductive
health, and women's rights.

Editor: Debbie Rogow
Research and editorial assistant:
Michelle Skaer
Project editor: Karen Tweedy-Holmes
Designer: Mike Vosika
Translators: Paul Constance (Spanish)
and Jeannette Ndong (French)

Errol Alexis
Gary Barker
Judith Bruce
Susana Galdos
Fran;oise Girard
Nicole Haberland
Judith F. Helzner
Katherine Kurz
Ann Leonard
Ann McCauley
Liz McGrory

Suellen Miller
Isaiah Ndong
Nancy Newton
Saumya Ramarao
Julie Reich
Ann Starrs
Cynthia Steele
Gilbert Vansintejan
Beverly Winikoff
Margot Zimmerman

Drs. Ajay Kanbur and Kelyani Kelkar
37 Prabhu Alley, Near Raka Bhavan, Mandai,
Bhiwandi 421305, Dist. Thane,
Maharashtra, India
Phone: +952522 58752; fpaipsk@sanchar.net.in

Womenes Health ant) Action Rccarch

Dr. Friday Okonofua
4 Alofoje Street, off Uwasota Rd
Box 10231, Ugbowo
Benin City Edo State, Nigeria

We invite your comments and ideas for projects that might be included in future issues
of Quality/Calidad/Qualite. If you would like to be included on our mailing list, please
send an e-mail to: qcq@popcouncil.org. Most past editions are available online at:
www.popcouncil.org/publications. The following are also available in print; single or
multiple copies may be ordered by e-mail:

Celebrating Mother and Child on the
Fortieth Day: The Sfax Tunisia Postpartum
Program (English only), no. 1, 1989.
Man/Hombre/Homme: Meeting Male Re-
productive Health Care Needs in Latin
America (English, Spanish), no. 2, 1990.
Gente Joven/Young People: A Dialogue on
Sexuality with Adolescents in Mexico (Eng-
lish, Spanish), no. 5, 1993.
The Coletivo: A Feminist Sexuality and
Health Collective in Brazil (English, Por-
tuguese), no. 6, 1995.
Doing More with Less: The Marie Stopes
Clinics of Sierra Leone (English only), no. 7,

Introducing Sexuality within Family Plan-
ning: Three Positive Experiences from Latin
America and the Caribbean (English,
Spanish), no. 8, 1997.
Using COPE to Improve Quality of Care: The
Experience of the Family Planning Associ-
ation of Kenya (English, Spanish), no. 9, 1998.
Alone You Are Nobody, Together We Float:
The Manuela Ramos Movement (English,
Spanish), no. 10, 2000.
From Patna to Paris: Providing Safe and Hu-
mane Abortion (English only), no. 11, 2001.
Universal Sexuality Education in Mongolia:
Educating Today to Protect Tomorrow (En-
glish only), no. 12, 2002.

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