Transcript Epidemiology of Spontaneous Abortion and Infertility

Perspectives in Global
Fertility and Infertility
Catherine L. Haggerty, PhD, MPH
Assistant Professor of Reproductive Epidemiology
University of Pittsburgh
Outline



Global Reproductive Health Programs,
Population Growth, & Fertility Trends
Role of Sexually Transmitted Diseases
(STDs) in Unintentional Infertility
Intentional Control of Fertility
Traditional Global
Reproductive Health

Family planning

Maternal and child health programs

STD prevention programs
Reproductive Health: A
Holistic Approach

1994 United Nations sponsored 3rd
International Conference on
Population Development, Cairo
– Safe sex life
– Capability and freedom to reproduce
– Access to safe, effective, affordable, and
acceptable family planning
– Access to prenatal and obstetric care
– Sexual health: enhanced life and personal
relations
Total World Population by Country Income Group, 1980, 1998, 2015
http://www.worldbank.org/depweb/english/modules/social/pgr/chart1.html
Average Annual Growth Rates by
Country Income Group, 1980-2015
http://www.worldbank.org/depweb/english/modules/social/pgr/chart2.html
Demographic Transition
From: Wikipedia.com
Discussion Question:
What might explain general
declines in birth rates?
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Declining infant mortality rates in rural areas
means less births are needed to result in the
same number of children
Increases in urban living raises the cost of
dependent children
Changes in the role of women in societies
Improvements in contraceptive technology
and availability
Life Expectancy World Rates
Fertility Rate World Map
From: wikipedia.com
Discussion Question: Why are Total
Fertility Rates Higher in Developing
Countries?

Developed Countries
– Birth control easily accessible
– Start families later in life
– More children = more education, clothing,
and feeding costs

Developing Countries
– Children assist with labor and elderly care
– Lack of access to contraceptives
Maternal age and fertility rates
Pathogenesis of pelvic inflammatory disease
PID
8% U.S.
15% Sweden
32% Northern
Territory, Australia
Infertility
16 – 40%
Chronic
Pelvic Pain
Recurrent
PID
Ectopic
Pregnancy
17 – 30%
16 - 23%
7 - 8%
Pathogenesis of
Reproductive
Morbidity
Following PID
Fallopian
Tube
Obstruction
Infertility
Fallopian
Tube
Closure
Chronic
Pelvic Pain
Cilia
Damage
Recurrent
PID
Adhesions
Ectopic
Pregnancy
PID
Healthy Fallopian Tube
From: Mårdh P, Möller B, Paavonen J, Weström L, Krieger J, Rein M. Atlas of
Infectious Diseases: Sexually Transmitted Diseases. Edited by Gerald Mandell
(series editor), Michael F. Rein. ©1996 Current Medicine, Inc.
From: Mårdh P et al. Atlas of Infectious Diseases: Sexually Transmitted Diseases.
Ed. Mandell & Rein. 1996 Current Medicine, Inc.
Pollack, JD. Trends
Microbiol. 1997; 5:413-419
Prevalence of
M. genitalium
6%
2%
4%
88%
Cervix
Endo
Both
Neither
Adapted from CL Haggerty, PA Totten, S Astete, S Hoferka and RB Ness. The role of Mycoplasma
genitalium in pelvic inflammatory disease. International Journal of STD & AIDS 2006; Vol. 17,
Supplement 1:p. 9, SY5-3, and symposium presentation at the 2006 IUSTI meeting, Paris, France.
Relationship between M. genitalium Measured in
the Endometrium at Baseline & Endometritis
Assessed at Baseline and 30 Days Post Treatment
80
70
60
50
40
30
20
10
0
Mg+
Mg-
OR=3.4
OR=3.7
Baseline
30 Days
*p<0.05 for all comparisons
Percent Endometritis
Adapted from CL Haggerty, PA Totten, S Astete, S Hoferka and RB Ness. The role of Mycoplasma
genitalium in pelvic inflammatory disease. International Journal of STD & AIDS 2006; Vol. 17,
Supplement 1:p. 9, SY5-3, and symposium presentation at the 2006 IUSTI meeting, Paris, France.
Relationship between Endometrial M.
genitalium & Endometritis among women
without N. gonorrhoeae or C. trachomatis
70
60
50
40
30
20
OR=2.4
OR=6.6
Baseline
30 Days
Mg+
Mg-
10
0
Percent Endometritis
*p<0.05 for all comparisons
Adapted from CL Haggerty, PA Totten, S Astete, S Hoferka and RB Ness. The role of Mycoplasma
genitalium in pelvic inflammatory disease. International Journal of STD & AIDS 2006; Vol. 17,
Supplement 1:p. 9, SY5-3, and symposium presentation at the 2006 IUSTI meeting, Paris, France.
Prevalence of M. genitalium among
Women presenting with Signs and
Symptoms of PID
30
25
20
Percent 15
13
12
9
10
5
0
US
Kenya
England
Frequency of cervical pathogens among 826 West
African sex workers
30
26
25
20
16
15
10
5
0
3
C. trachomatis
N. gonorrhoeae
M. genitalium
Adapted from: Pepin J et al. Mycoplasma genitalium: an organism commonly associated with cervicitis
among west African sex workers. Sexually Transmitted Infections. 81(1):67-72, 2005
Prevalence of M. genitalium among HIV Seropositive
and Seronegative Women in the US and Kenya
20
18
16
14
12
10
8
6
4
2
0
19
14
HIV+
HIV-
5
3
US
Kenya
Rate of M. genitalium
Adapted from: Irwin KL et al. Influence of human immunodeficiency virus
infection on pelvic inflammatory disease. Obstetr & Gyn 2000. 95(4):525-34
and Cohen CR et al. Detection of Mycoplasma genitalium in women with
laparoscopically diagnosed acute salpingitis. STI 2005. 81(6):463-6.
Nomarski microscopy (x100 objective) of sperm incubated in vitro with
M.genitalium
Svenstrup, H. F. et al. Hum. Reprod. 2003 18:2103-2109;
doi:10.1093/humrep/deg392
M. genitalium & Infertility

Clausen HF et al, 2001
– TFI patients: Mg seropositive 22.0%
– Patients with normal tubes: Mg
seropositive 6.3%
Percentage with primary infertility in selected sub-Saharan African countries
Larsen, U. Int. J. Epidemiol. 2000 29:285-291; doi:10.1093/ije/29.2.285
Copyright restrictions may apply.
Percentage with secondary infertility in selected sub-Saharan African countries
Larsen, U. Int. J. Epidemiol. 2000 29:285-291; doi:10.1093/ije/29.2.285
Copyright restrictions may apply.
Total Infertility Rates (Primary and Secondary)
in U.S. and in Regions with High Rates of STDs
and Low Access to Care
30
28
25
26
20
15
10
10
5
0
U.S.
Sub-Saharan
Africa
Northern
Territory
Australia
Primary vs. Secondary Infertility in the
U.S. and in Regions with High Rates of
STDs and Low Access to Care
United States
Sub-Saharan Africa
30%
Primary
Secondary
11%
70%
Primary
Secondary
Northern Territory Australia
31%
Primary
Secondary
69%
89%
Effective Reproductive Span

Biological Reproductive Span
– Bounded by menarche and menopause

Social Reproductive Span
– Marked by intervals of sexual activity
and/or marriage
Family Planning Programs
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Breastfeeding
Contraception
Abortion
Birth Interval
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Postpartum period
– Breastfeeding
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Time to conception
Spontaneous abortion
Sw
ed
en
D
en
m
ar
k
N
ig
er
ia
Zi
m
ba
bw
e
Ch
in
a
an
ia
R
om
SA
U
K
U
Fr
a
nc
e
100
90
80
70
60
% at Birth 50
40
30
20
10
0
Cz
ec
h
Worldwide Breastfeeding Rates
Developed from http://www.lalecheleague.org/cbi/bfstats03.html
Deliberate Control of Fertility
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Postponement/interruption of
marriage/sexual relationship
Sterilization
Contraceptive use
Induced abortion
Global Contraceptive Rates among
Married Couples, 2000
80
76
67
70
60
56
50
40
30
26
20
10
0
Africa
Japan
Europe
North
America
Unintended Pregnancy

20% in low to middle income countries
– Ranges from 3% in Niger, sub-Saharan Africa, to
45% in Latin American Bolivia
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Consequences
–
–
–
–
Increased lifetime risk of maternal mortality
Unsafe abortion
Poor infant health
Lower investment in the child
Final Discussion Question:
What are the barriers to family
planning services, particularly
in developing countries?
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Lack of well-run family planning programs
Economic cost of access to services
– Transportation costs
– Supply costs
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Social costs
– Travel by women limited
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Psychic costs
– Societies may offer little social of familial support
for low fertility