Infertility was once a topic rarely discussed, often surrounded by shame and seen as a problem only affecting women. Today, with increased awareness and the availability of medical advances like In Vitro Fertilization (IVF), more couples are finding hope and welcoming healthy babies. ALSO READ: Infertility affects one in six couples globally – WHO In this interview, Dr. Emmanuel Semwaga, an obstetrician, gynecologist, and IVF specialist at Mediheal Diagnostic and Fertility Centre in Kimihurura, explained what causes infertility, how it is treated, the costs involved, and how Rwanda is making progress in providing new options for couples facing fertility challenges. ALSO READ: STIs study related to infertility in offing The excerpts: How long has infertility been recognized as a medical condition? And when did treatment options like IVF become available in Africa, and Rwanda? Infertility has existed for as long as humanity itself. The difference is in awareness and medical treatment. In Africa, infertility wasn’t widely considered a medical condition until recently because dedicated centers didn’t exist. Infertility centers only began appearing around 2000. Yet, medical treatment of infertility dates back decades. The first IVF baby was born in 1978 in the UK, which was a revolutionary moment. Later, in 1992, the IVF technique was modernized in Belgium, improving success rates. So, while infertility isn’t new, the accessibility of treatment options is what’s relatively recent in Africa and Rwanda. Infertility is often perceived as a woman’s issue yet it should be seen as a couple’s problem. Can you explain why? Absolutely. To conceive a child, fusion of two gametes is required, the male sperm and the female egg. Infertility can arise from male factors, female factors, or sometimes both. It’s incorrect and unfair to place blame on only one partner. When couples cannot conceive, both partners must be evaluated because infertility is primarily a couple’s issue. How do medical professionals classify infertility, and what does that mean for couples trying to conceive? We generally classify infertility into two types, primary and secondary. Primary infertility is when a couple has never conceived despite trying regularly for at least a year without protection. Secondary infertility is when a couple who has had at least one pregnancy before tries again but cannot conceive for six months or longer. Secondary infertility is often caused by infections, complications after childbirth, or lifestyle factors that impact fertility after the first pregnancy. It is more common in Rwanda than primary infertility. What are the main causes of infertility that you encounter, and how are they grouped? We categorize the causes of infertility into four broad groups. First are male factors, which include issues like low sperm count, poor sperm motility, abnormal sperm shape, or blockages in the reproductive tract. Second are female factors, such as hormonal imbalances, anatomical abnormalities, and congenital conditions. Third, there are mixed causes, where both partners have fertility issues contributing to the problem. Lastly, we have unexplained infertility, where all tests appear normal, yet conception does not occur. In these cases, we often start with a ‘wait and see’ approach, but if pregnancy still doesn’t happen, we recommend assisted reproductive technologies like IVF or IUI (Intrauterine Insemination). Could you explain the female causes of infertility in detail? Female fertility hinges on the proper functioning of the hypothalamic-pituitary-ovarian axis. The hypothalamus in the brain releases gonadotropin-releasing hormone (GnRH), stimulating the pituitary gland to secrete follicle-stimulating hormone (FSH) and luteinizing hormone (LH). These hormones regulate the ovaries to produce eggs and the hormones estrogen and progesterone. If this balance is disturbed, ovulation can fail. For example, a pituitary tumour called a prolactinoma increases prolactin levels and inhibits ovulation. Some women experience premature ovarian failure, meaning their ovaries stop functioning before age 40. Polycystic ovarian syndrome (PCOS) is another common problem, where eggs remain trapped in follicles and do not mature unless medically stimulated. Anatomical conditions such as endometriosis, where uterine-like tissue grows outside the uterus, often on the ovaries, affect egg quality and ovulation. Adenomyosis involves this tissue invading the uterine muscle, enlarging the uterus, and disrupting the blood supply to the uterine lining, which reduces the chances of implantation. Fibroids, especially those inside the uterine cavity, can block embryo implantation. Congenital anomalies such as Mayer–Rokitansky–Küster–Hauser syndrome (absence of uterus) prevent pregnancy, even if the ovaries are normal. Other abnormalities like a septate uterus, a closed cervix (atresia), or vaginal septa can physically prevent sperm from reaching the egg. How do untreated sexually transmitted infections affect female fertility, particularly the fallopian tubes? Untreated sexually transmitted infections (STIs) such as chlamydia and gonorrhoea can scar and block fallopian tubes. Blocked tubes prevent sperm from meeting the egg and are a main cause of infertility in women here. If the blockage is near the uterus (proximal), it’s nearly impossible to fix surgically. If it’s further away (distal), surgery may help, but scar tissue often reforms. For blocked tubes, IVF bypasses the problem by fertilizing the egg outside the body. Are lifestyle factors contributors to infertility? Very much so. Obesity can interfere with hormone balance and ovulation. Excessive physical activity can also suppress reproductive hormones. Smoking, alcohol, and recreational drugs introduce toxins that damage eggs, sperm, embryos, and hormonal function. Healthy lifestyles are essential for protecting and supporting fertility. What are the most common male infertility issues? Male infertility involves three primary parameters: sperm count, motility (movement), and morphology (shape). A normal sperm count is at least 15 million sperm per millilitre of semen. Oligospermia means lower than normal count. Motility should be at least 50% actively moving sperm; astheno-oligospermia describes sperm that are both few and poorly motile. Morphology refers to the normal shape of the sperm head and tail; abnormal morphology impairs fertilization. Azoospermia means no sperm in the semen, often due to blockages in the reproductive ducts or testicular failure. If a man has azoospermia, are there treatment options? Yes. If ducts are blocked, surgery can sometimes restore sperm flow. If surgery isn’t possible, we perform testicular sperm extraction (TESE), retrieving sperm directly from the testicles to use in IVF. Can you explain how IVF and IUI treatments work? IVF involves stimulating the woman’s ovaries to produce multiple eggs, retrieving these eggs, fertilizing them with sperm in a lab, and then transferring the resulting embryos into the uterus. We can evaluate embryo quality microscopically and time the uterine lining preparation for optimal implantation. IUI is simpler. We prepare the sperm and inject them directly into the woman’s uterus near ovulation, hoping the sperm swim naturally to fertilize the egg in the fallopian tube. Which method has a higher success rate? IVF is much more effective. At Mediheal, our IVF success rate is currently about 80%. IUI is less reliable, with success rates of only 1-5%, and is mainly useful for mild male factor infertility. IVF is often described as costly. How do Rwanda’s costs compare internationally? IVF in the USA can cost $15,000 to $35,000 per cycle. In Rwanda, it costs roughly $4,500 to $6,000 per cycle. While still expensive for many, it is more affordable than in a foreign country option. Are there efforts underway to make IVF more affordable or covered by insurance? Yes, we are currently in talks with the Ministry of Health, Rwanda Social Security Board (RSSB), and private insurers to explore insurance coverage for IVF, including potential inclusion under Mutuelle de Santé for poorer families. At present, IVF is not covered by any insurance and is accessible mainly to middle-income couples. How prevalent is infertility in Rwanda? About 17.5% of couples experience primary infertility, meaning they have never conceived. Secondary infertility, when couples who had a previous pregnancy struggle to conceive again, affects about 34.5%. Are there enough fertility specialists and IVF clinics in Rwanda? Unfortunately, there are very few specialists. Besides myself and Col Dr Eugene Ngoga, who works at Rwanda Military Referral and Teaching Hospital in Kanombe, only a handful of others exist. We need more trained fertility experts to meet rising demand. Currently, there are only two IVF clinics: Mediheal Diagnostic and Fertility Centre in Kimihurura, established in 2014 as Rwanda’s first IVF center, and an IVF unit at King Faisal Hospital. Before 2014, how did Rwandans access IVF services and what has been the progress in this clinic? Most couples travelled abroad; to Nairobi, India, or South Africa for IVF, which was costly and emotionally difficult. The government supported establishing Mediheal to provide local treatment and reduce the need for abroad travel. In 2014, our IVF pregnancy success rate was around 10%. Today, it has risen to about 80%. We see roughly 200 new patients each month. How have awareness campaigns affected men’s willingness to seek infertility evaluation? Awareness campaigns on radio, TV, and social media have encouraged men, even from rural areas, to seek evaluation. This has helped reduce stigma and blame on women. Is it true that IVF babies are less healthy than naturally conceived babies? It is a misconception that babies conceived by IVF are unhealthy. IVF uses the couple’s own eggs and sperm, therefore, the babies born are as healthy and normal as those conceived naturally. Why isn’t IVF provided for free since most couples can’t afford it? IVF requires specialized labs, expensive medications, highly skilled staff, and constant technological upgrades. Even with lower fees than abroad, the charges cover these costs and help sustain the service. The fees support the continuation and expansion of services for everyone. Offering free IVF is not currently feasible. What’s your message for couples struggling with infertility? Don’t give up. Infertility is not the end of your journey. Come see us for evaluation and treatment. Sometimes medication or IUI can help; other times, IVF is necessary. Many couples who once thought they would never have children now have healthy babies.
