by: Dr. Siladitya Bhattacharya, University of Aberdeen, Scotland U.K.
The FIGO Committee on Reproductive Medicine (FIGO CRM) was established in October, 2009 under the Chairmanship of Dr. David Adamson, (USA). Other Committee members include Siladitya Bhattacharya, Co-chair (UK), John Collins (Canada), Klaus Diedrich (Germany), Silke Dyer (South Africa), Egbert te Velde (Netherlands), Christine Robinson (UK), PC Wong (Singapore) and Fernando Zegers-Hochschild (Chile). The mission of the FIGO CRM is to create access to quality reproductive medical care for women across the world.
The focus is on enhancing in-country capacity in terms of basic fertility management within the developing world by means of The FIGO Fertility Tool Box™. This document provides information to stakeholders about fertility awareness, prevention of infertility and explores ways of overcoming barriers to fertility care, and identifies effective and affordable management pathways.
In deference to the cultural and socioeconomic diversity across different geographical settings, The FIGO RMC Tool Box™ focuses on universal principles (Table 1), and is flexible enough to be customised to meet local needs. Most FIGO member countries practice in relatively low resource environments and few are able to provide universal access to assisted reproductive technologies (ART). The emphasis is therefore on guidance aimed at mid-level health professionals such as nurses, midwives, and general practitioners as well as general obstetricians/gynaecologists rather than fertility specialists. The tools are also relevant to health care commissioners, policy makers and consumers.
The FIGO CRM plan is to test the tools in health care settings in three countries – India, Chile and South Africa. The choice of countries was partly based on an appreciation of their distinctive features in terms of size, diversity, socioeconomic conditions and existing health care services. India is a large country with a well-defined three tier health system but with major inequalities in terms of access to fertility care. The overarching aim of the FIGO CRM’s activities in India is to increase capacity to integrate reproductive medicine education, preventive and comprehensive care into the overall care of women and the healthcare system of the society. The objectives are shown in Table 2. This is an ambitious task and given that there is no core budget from FIGO for in-country work, CRM would need to be creative in terms of seeking support for any initial activity. For this effort to be sustainable, it is vital that local stakeholders take ownership of the initiative.
Areas addressed by CRM Tool kit:
- Justification for helping infertile women and preventing infertility is important
- Overcoming institutional barriers to access to care
- Overcoming personal barriers to infertility care
- Diagnosis of infertility
- Treatment of infertility
- Steps surrounding referral or end of treatment.
- Prevention of infertility
Objectives of FIGO CRM initiative in India:
- To identify and prioritise reproductive medicine needs of women
- To pilot a model of care based on the FIGO Reproductive Medicine toolkit
- To facilitate education, training and capacity-building programs in reproductive medicine
- To encourage integration of facilities and personnel utilized for women’s healthcare into the delivery of reproductive medicine services
- To convince stakeholders that family planning includes the notion of being able to have a family
An initial open meeting was held in Agra (India) in April 2012 at a national Conference of the Indian Society for Assisted Reproduction (ISAR) to canvass opinions of an audience of gynaecologists on how this mission could be accomplished. FIGO CRM was represented by Drs Adamson and Bhattacharya and there was enthusiastic participation by delegates attending the Conference. The general view was that an Indian Task Force should be established involving FIGO CRM representation and including local stakeholders such as representatives from professional organisations such as Federation of Obstetrics and Gynaecological Societies of India (FOGSI), Indian Society of Assisted Reproduction (ISAR) and Indian Fertility Society (IFS). It was felt that it was important to engage with representatives from the Government as well as other groups such as Indian Council for Medical Research (ICMR), the Pharmaceutical Industry and non-governmental organisations (NGOs). A key objective would be to customise and field test The FIGO Fertility Toolbox in a few test areas. Feedback from this exercise would inform the next step in the implementation process.
The next meeting was held in Delhi in December 2012 and involved a smaller core group of invited members suggested by those attending the initial meeting. Attendees included Dr S Bhattacharya from FIGO CRM, academic and non academic obstetrician/gynaecologists including representatives of the professional societies and Public Health Physicians. There was also representation from Indian Council for Medical Research.
The group were supportive of the initiative but were keen to discuss this in context of the local socioeconomic conditions and relevant projects in this field. Some members were aware of ongoing work supported by WHO to produce a fertility guideline for India and a few other South Asian Countries. The potential overlap between this and the goals of the FIGO CRM Task Force were considered. It was felt that as the Toolbox was much less detailed than a guideline or operating manual, the two would be complementary rather than competitive and there would be scope for collaborative work in terms of implementation of the Guideline as well as the toolbox. The toolbox itself was discussed and it was felt that it would require to be modified in order to capture social and biological issues relevant to the Indian context. Thereafter, there was scope for developing a pilot, which could be tested at 1-2 sites in different parts of India. Attendees agreed to come together as members of the FIGO CRM Task Force in India whose activities were presented at the All India Congress of Obstetrics and Gynaecology in January 2012 at which the concept of The FIGO Fertility Toolbox was introduced by Dr David Adamson.
Some of the members of the Task Force members met again in March 2012 at an ISAR meeting in Raipur, India. This meeting was attended by a second member of the FIGO CRM, Dr Silke Dyer and number of in-country members of the Task Force. Attendees highlighted the need for a scoping exercise, prior to a pilot study in 2-3 centres across the country in order to map local availability of services, personnel and resources was highlighted. In terms of management of the group’s activities (Table 3), members suggested that an executive group be formed within the Task Force with representatives from the three national professional organisations – FOGSI, ISAR and IFS.
Proposed activities of FIGO CRM Task Force:
- Mapping existing health infrastructure
- Identification of existing facilities, equipment, personnel, systems and other resources
- Exploration of opportunities for state and non-governmental support
- Customise and use toolbox in 2-3 test sites
- Aim for cost neutral solutions where possible
There is no core budget from FIGO for in-country work and the Task Force will need to be creative in terms of seeking support. Possible sources of support include the Government, non -governmental organisations, the corporate sector, the pharmaceutical industry. Where possible, existing health care infrastructure, personnel and equipment would be used for delivering interventions. Funded meetings on other aspects of women’s health could be used as opportunities for dissemination of information on fertility care as part of a holistic approach to reproductive wellbeing.
The FIGO Fertility Toolbox will be formally unveiled at the FIGO meeting in Rome October 2012. Meanwhile, preparations are underway for a scoping exercise in a few areas in India to capture data on existing health care services including resources, equipment and trained personnel. The aim is to make a start on customising the Toolbox for use in India after its launch in October with a view to piloting it in the first half of 2013.