The image is tenacious. That of a sub-Saharan Africa overwhelmed by its demography. Admittedly, the region has the highest fertility rate in the world, with an average of 4.7 children per woman. However, it is also the most affected by infertility: 16.4% of sub-Saharan couples are confronted with it. This is 4 points more than Europeans, as indicated by the latest report from the World Health Organization (WHO), which points out that these alarming figures could be below reality as comprehensive data remains difficult. to compile.
Infertility, defined as the absence of pregnancy after twelve to twenty-four months of regular sexual intercourse, strikes men and women almost equally. It often results, in Africa, from an untreated sexually transmitted infection (STI) or unsafe abortion in women. Men, in addition to being confronted with a collapse in the quality of their sperm as elsewhere in the world, also suffer from STIs, stress, pollution, smoking… In 20% of cases, the origin of infertility remains unknown.
Despite the taboo that still weighs on this pathology, a low-key medical revolution is making its way from Dakar to Kinshasa. Dozens of medically assisted procreation centers (PMA) have been established for several years in urban areas.
“It’s a booming activity, confirms the Ivorian Coulibaly Founzégué Amadou, head of the Inter-African Group for Studies, Research and Application on Fertility (Gieraf), a learned society bringing together twelve African countries. West and Central. In Côte d’Ivoire alone, there are five assisted reproduction centers. Before, they only practiced simple inseminations. Now some are offering intracytoplasmic sperm injection (ICSI), the most sophisticated form of ART [a sperm is forced into an egg, the resulting egg is then transferred to the woman’s uterus] or even GPA [surrogacy]. »
“Resourcefulness”
Obstetrician-gynecologist trained in Russia and France, Djédi Kaba Diakité shows, in his Bamako clinic, pregnancy rates of 40% for couples aged 25 to 35, and up to 20% for those over 40. Even if “about 15% of these pregnancies are terminated before delivery”, specifies the doctor, these figures are higher than the European average, estimated at 33% of success, all age groups combined. “If, in Africa, we manage to reach this rate, it is also because African women most often request the transfer of several embryos, sometimes up to three, explains the doctor. In Europe, it is often only one at a time. »
In fact, twins and triplets represent a third of births in his center since the first IVF performed in 2010. With his team of around fifty people, Djédi Kaba Diakité also performs the puncture, freezing and storage of oocytes and spermatozoa, their culture and then the transfer of embryos. Cumbersome procedures that require high-performance, expensive equipment. And a good dose of ingenuity.
“PMA in Mali is resourcefulness, says the gynecologist. Everything has to be imported. For reagents, I cannot rely on international transport companies, which are slow to deliver. I collect expired or damaged products. I prefer to buy a ticket for Paris or pay one to relatives settled in France to come to Mali. At least they deliver my reagents on time. »
To equip his clinic, he invested 300,000 euros in an incubator, a high magnification microscope and freezers imported from France. Each year, this specialist in tubal surgery also spends 50,000 euros on single-use products such as syringes, conservation kits, reagents… “We use equipment equivalent to that of northern countries. However, we pay them up to five times more because of the import costs and the tariffs of the resellers”, underlines Coulibaly Founzégué Amadou, of Gieraf.
Luxury care
These costs are reflected in the prices of PMA and make it, in Africa, a luxury treatment. Not supported by the State or insurance, the technique is paid at a high price. In Senegal, where the first IVF in French-speaking sub-Saharan Africa was carried out, in 1989, couples pay up to 4 million FCFA (6,100 euros) in private clinics for PMA, i.e. 45 times the average monthly salary, while it is free in France up to the age of 43 and for four IVF maximum. “Women sell their jewellery, their land or go into debt to pay for IVF. It terrifies me because there is a 70% risk of failure,” laments Tidiane Siby.
At 70, this medical biologist with the look of a golfer who works with several gynecologists admires his latest achievement. A building of 3,000 square meters divided into eleven floors nestled in the heart of the administrative district of Dakar. It is in this new ultra-secure headquarters that he is preparing to install his hundred employees. “We have nothing to envy to the European and American centers. Our standing is international,” he boasts as he unveils the state-of-the-art equipment bearing the logo of a Japanese brand, installed in the new PMA unit. In the adjoining room, an engineer examines under a microscope the quality of the spermatozoa collected the day before, before selecting them for fertilization.
The other great pride of the doctor in canvas moccasins remains the semen collection rooms. “Here, we thought about the privacy of men. In a small room with warm colors sits a television screen. It offers pornographic films. “We installed long benches and a shower. Many men practice ritual baths before masturbating to strengthen their seed. We want them to feel at home. »
And the demand, like the supply, continues to grow. Since he converted to PMA fifteen years ago, Gérard Fayemi has given birth to more than 200 children. “Couples come to me as they go to mass: they are waiting for a miracle, assures this obstetrician-gynecologist with a frank smile and the appearance of a high priest, installed in an imposing office planted in the south of Dakar, facing the Atlantic. Now, 18% of consultations relate to reproductive disorders. Young people no longer wait to consult, notes the practitioner. This is important because the survival of their couple is often at stake. »
Possible drifts
Rokhaya Ba Thiam, another figurehead of the Senegalese PMA, has long received in his Dakar office women with blocked tubes or menopausal in their early thirties. From now on, the diagnoses also point to the infertility of the male partner. “It took a long time to convince men to have a spermogram because many find it demeaning. However, cases of severe sperm abnormalities, even at the age of 30, are no longer rare,” she explains.
The objective now for the specialists is to constitute an African sector of the PMA. Because, even if many African couples continue to turn to Spain, Belgium or France to hope to become parents, a reverse movement has taken place in recent years. In France, the biologist Nino Guy Cassuto, who has been training African doctors in PMA since 1996, regularly sends mixed couples to his colleagues on the continent. “Finding black or mixed-race oocytes is almost impossible in France due to the lack of donors. In Côte d’Ivoire or Burkina, these couples can be taken care of for 3,000 euros,” he explains.
PMA made in Africa also attracts Africans living abroad. Faced with the impossibility of bringing their spouse for visa reasons, they take advantage of their stay in their country of origin to freeze their sperm. “As soon as the wife is ready, we inseminate her with the husband’s semen, even in his absence,” says Dr. Fayemi. But the practice is also extremely expensive. In Dakar, the freezing quarter is priced at 200,000 CFA francs (305 euros). As for the vitrification of oocytes, a practice not very widespread in Senegal, it amounts to 600,000 CFA francs (915 euros) for the first year, to which are added 240,000 CFA francs (365 euros) per additional year.
It remains to provide a legal framework for PMA. Under pressure from practitioners who practice without a specific framework, sub-Saharan states are considering bioethical laws for heterosexual married couples. Some doctors are worried about possible abuses due to lack of regulation. In Cameroon, a 62-year-old woman gave birth in 2018 following IVF. A new text has just lowered the maximum age to 55 years. “PMA in Africa must not become a market without safeguards, warns Guy Sandjon, precursor of PMA in Cameroon. Imagine it falling into the hands of rogue doctors with no training and no ethics. There is a risk of ending up with donated gametes that have not been subjected to viral tests with all the dramatic consequences that this entails. »
