Assisted Reproductive Technologies (Art) Equity, Justice and Autonomy in Ghana

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However, these services are available only in the burgeoning capital cities of only four out of the sixteen regions of the country, patronised mainly by the middle or upper class of the society. There is a dearth of evidence on the factors that limit access to ART services to most Ghanaians. This study aims to document these barriers to ART in Ghana. Materials and methods: A cross-sectional survey was conducted across all twenty-two fertility centres in Ghana in July 2022 using two structured questionnaires administered separately via Google App to sensor ART personnel in these centres and treatment defaulters at Hallmark Medicals, Kumasi. Results: Sixty-one ART professionals and 104 ART clinic defaulters responded to the questionnaires. Mentorship/observership from more experienced senior colleagues locally (65.57%) was the most common mode of acquiring knowledge and clinical skills in ART. Almost all (91.80%) ART professionals offered all ART procedures available globally, but 86.89% yearned for a regulated practice. They identified high treatment costs (70.49%) and lack of awareness (16.39%) as the main barriers to ART services in Ghana. Most women who defaulted to ART clinic attendance or treatment (88.47%) had visited the fertility centre based on word-of-mouth recommendations, compared to 4.8% who did so following traditional and social media information. More than half (50.96%) were in their thirties, and only 30.77% were in their forties. Almost half (48.08%) of them required IVF. A good number (58.65%) sought treatment within five years of Infertility, but 70.2% defaulted because of prohibitive treatment costs and 35.57% for partner non-availability. Conclusion: Even though there is complete autonomy to all ART services in Ghana, access is limited by prohibitive treatment costs, partner non-availability and lack of awareness. Meanwhile, the ART professionals advocated a regulated practice. Assisted Reproductive Technology Access Equity Ghana Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Ghanaian families have a pro-natalist attitude and expect children to maintain family lineage, happiness, and harmony. Childbirth, therefore, guarantees marital stability and economic or social security in a society that lacks formal social security systems for older people. Infertility, thus, exerts devastating biomedical, psychological and sociocultural consequences on affected couples [ 1 , 2 ]. The exact burden of infertility in Ghana is not known, but it is estimated to affect about 11.8% of women and 15.8% of men [ 3 ]. Tubal and severe male factors are the commonest causes of Infertility in Ghana, for which assisted reproductive technology (ART) treatment is the most effective. Many Ghanaians are turning to ART treatment for assistance to achieve their dream of parenthood. ART refers to medical procedures that involve the manipulation of eggs, sperm or embryos outside the body to facilitate conception. The typical approaches are in-vitro fertilisation and intra-cytoplasmic sperm injection. Ghana requires about 1500 ART cycles per 1 million people a year (i.e., 45,000 IVF cycles each year for her 30 million population) for adequate fertility treatment [ 4 , 5 ]. Even though statistics on IVF cycles are lacking, it is unlikely that the few ART centres in Ghana can provide the required number of IVF cycles. For instance, in 2020, four out of the fifteen ART centres in Ghana reported 677 cycles [ 6 ]. This suggests a high unmet need for IVF services. While restrictive legislation and regulation appear to be the main barriers to infertility treatment in developed countries [ 7 ], the factors limiting access to ART services in Ghana are poorly documented. Some studies found that the high cost of setting up and associated scarcity of ART centres, the high cost of ART treatments, socioeconomic deprivation, and the lack of skilled infertility personnel make ART largely inaccessible in Africa [ 8 – 11 ]. Understanding the landscape of ART access in Ghana is crucial for policymakers, healthcare providers, and researchers to address existing barriers and improve the availability and affordability of fertility treatments for all individuals and couples in need. Thus, this study seeks to document the barriers to ART services in Ghana. Materials and Methods This cross-sectional study was conducted across twenty-two fertility centres in Ghana. A structured questionnaire (supplementary file 1) was administered via a Google app to 61 ART personnel from all fertility centres in Ghana through the Fertility Society of Ghana (FERSOG) WhatsApp group to obtain information on fertility professionals' sociodemographic characteristics, training, work experience and the type of services they offered. Another structured questionnaire was administered to patients who defaulted treatment at Hallmark Medicals, a private fertility centre in Kumasi, through telephone conversations. The patients were conveniently identified through the hospital's records and contacted to obtain information on their knowledge of ART services and reasons for dropping out of the recommended treatment. Ethical approval CHRPE/AP/205/24 was obtained from the Committee for Human Research Publication and Ethics, Kwame Nkrumah University of Science and Technology (KNUST). Informed consent was obtained from each before enrolling in the study. Data were analysed using STATA version 14.0. Results Demographics Characteristics of ART Healthcare Professionals in Ghana Table 1 shows the demographic characteristics of ART professionals in Ghana. Most of the personnel, 39(63.93%) were males. Thus, the gender distribution of the personnel was almost two males to one female. The majority of the personnel, 43(70.49%), were aged between 30 and 49. Embryologists constituted nearly a third of the health professionals' group, with 18 members making up 29.51% of all healthcare personnel, followed by fertility nurses 17(27.87%). There was only one clinical psychologist among the ART personnel. Clinical Fellowship and membership were the most common and highest educational levels attained by ART professionals, followed equally by postgraduate masters and degrees in midwifery. Five per cent of the personnel had a PhD. Table 1 Demographic Characteristics of ART Healthcare Professionals in Ghana Variables Frequency (n = 61) Percentage Sex Female 22 36.07 Male 39 63.93 Age (Years) 60 1 1.64 Clinical Role Reproductive Endocrinology Sub-specialist 8 13.11 Obstetrician and Gynaecologist 14 22.95 Embryologist 18 29.51 Fertility Nurse 17 27.87 Clinical psychologist 1 1.64 Other (Counselor, Urologist, and Fellow in training) 3 4.92 Level of Education Clinical Fellowship 12 19.67 PhD 3 4.92 Membership 11 18.03 Postgraduate Masters 9 14.75 Postgraduate Diploma 1 1.64 MBChB 2 3.28 Degree in Biomedical Sciences, Laboratory Technology 4 6.56 Degree in Nursing/Midwifery 9 14.75 Degree in Psychology 1 1.64 Diploma in Nursing/Midwifery 4 6.56 Diploma in Perioperative Nursing 1 1.64 Nurse Assistant- Clinical (NAC) 3 4.92 Other (Degree Chemistry) 1 1.64 Training and Experience in ART Table 2 shows the survey results on training ART professionals and their constraints. Training on the Job (Mentorship) emerged as the most frequent approach used by 20(32.79%) ART professionals to acquire knowledge and skills, followed by Clinical Fellowship Training 12(19.67%). Notably, 3(4.92%) of ART professionals had a PhD. Interestingly, two out of three 40(65.57%) respondents received ART training in Ghana. Aside from Ghana, India and Europe were featured as favourite destinations for ART training. Most professionals, 41(67.22%), reported having less than five years of experience in ART. Table 2 Training and Experience in ART Variables Frequency (n = 61) Percentage Level of Professional Training in ART Fellowship 12 19.67 PhD 3 4.92 Post Graduate Masters 7 11.48 Post Graduate Diploma 5 8.20 Six Months Observership 3 4.91 Training on the Job (Mentorship) 20 32.79 Other (Senior Resident, Fellow in Training) 11 18.03 Country of Training in ART Europe 5 8.20 South Africa 2 3.28 Australia 1 1.64 India 12 19.67 Ghana 40 65.57 Other (Nigeria) 1 1.64 Challenges in ART training Difficulty financing training; Difficulty finding mentors 19 31.15 Difficulty with traveling abroad for training; Difficulty financing training; Few opportunities available for training; Difficult finding a mentor 41 67.21 Difficulty with traveling abroad for training; Difficulty finding mentors 1 1.64 Duration of ART Experience (years) 10 6 9.83 Restrictive and Regulated ART Environment Yes 53 86.89 No 8 13.11 ART services offered and their barriers An overwhelming majority of ART professionals had been involved in or offered almost all ART services available globally, including IVF for single women, commercial surrogacy, multifetal pregnancy reduction, intrafamilial donor sperm insemination and sex determination. Only 2(3.28%) of ART personnel had never been involved or offered IVF for single women, multifetal pregnancy reduction and sex determination (Table 3 ). Table 3 Types of ART services offered by ART professionals Variable Frequency Percentage Services involved in or offered. IVF for single women; Use of donor gametes; Commercial surrogacy; Embryo adoption; Multifetal pregnancy reduction; Cryopreservation and transfer of frozen-thawed embryo (FET); intra-familial donor insemination; Sex selection; pre-implantation genetic diagnosis (PGD) 56 91.80 Use of donor gametes; Commercial surrogacy; Embryo adoption; Pre-implantation genetic diagnosis (PGD); Cryopreservation and transfer of frozen-thawed embryo, (FET) and Intra familial donor insemination 2 3.28 Sex selection 3 4.92 Over 70% of ART personnel mentioned the high cost of services as the main barrier to ART in Ghana, followed by poor knowledge of the availability of ART services by the patients 10 (16.39%). Only an insignificant 6.56% of ART professionals considered religion as a barrier to ART (Fig. 1 ). Demographic Characteristics of Women Who Defaulted in Infertility Treatment. Figures 2-4 show the demographic characteristics of 104 fertility clinic attendants who defaulted in treatment. More than half 53(50.90%) of these women were in their thirties (30-39 years), and about a third, 32(30.77%), were in their forties. The overwhelming majority of the defaulters, 91(87.50%), were married and 90(86.54%). Christians). Only a very small proportion, 5(4.81%) of these women who desired a pregnancy did not have a partner. Living experiences of women with infertility and their sources of referral for ART Table 4 shows the living experiences of the women with infertility and their sources of referral for ART. Forty-five per cent (45.19%) of these defaulters sought treatment after 2–5 years of Infertility. About a quarter of them did so after 6–10 years. Almost two-thirds, 74 (71.15%) of the couples, live together. Nearly a third of the couples were in distant relationships, and among these, 13(43.34%) had their partners abroad, while more than a third lived in different cities in Ghana. Word-of-mouth recommendations from people who had a personal experience with ART or knew someone with the experience was the source of referral to the ART clinic in an overwhelming 88.47% of instances. Radio and social media, combined, constituted an insignificant 4.88% of sources of information on the ART clinic. Health professionals were the sources of information in another 6.73% of instances. Table 4 Living experiences of the women with infertility Variables Frequency (n = 104) Percentage (%) Duration of Infertility (Years) 20 5 4.81 Couples living together? Yes 74 71.15 No 30 28.85 Residence of partner if couples don't live together Abroad 13 43.34 In Ghana, but in different cities or town 11 36.66 In the same city but in different locations 6 20.00 Source of information about the ART clinic Recommendation from a friend, family or colleague who has patronised the services 36 34.62 Recommendation from a friend or family who has heard about the hospital but has not patronised it themselves 56 53.85 Radio 2 1.92 Hospital social media handle 3 2.88 Others (Nurse, Doctor, and Sign board) 7 6.73 Causes of Infertility and Fertility Treatments Offered and Received Fibroids was the commonest diagnosis made in one out of four 27(25.95%) of these women with Infertility who defaulted treatment, followed by unexplained Infertility in one out of five (20.19%) and tubal blockage 15(14.44%). Male Infertility and anovulation contributed almost equally, 9(8.65%) vs 10(9.62%) to the Infertility in these women. In nearly one out of five cases (17.30%), the cause of Infertility was any combination of advanced age, anovulation, tubal factor, male factor and fibroids. In-vitro fertilisation (IVF) was the most common treatment offered to almost half (48.08%) of these women with Infertility, followed by ovulation induction with timed intercourse in about a third, 35(33.65%), and ovulation induction with intra-uterine insemination (IUI) in 14(13.46%) of the cases. Intra-cytoplasmic sperm injection was only infrequently offered in 3(2.88%) of cases. Very few of these women, only 14.42%, had had any form of infertility treatment, ovulation induction and timed intercourse being the commonest treatment received by about half of these women, while just more than a quarter each had received either ovulation induction with IUI or IVF treatment (Table 5 ). Table 5 Causes of infertility and treatments offered and received Variables Frequency (n = 104) Percentage (%) Cause of the Infertility Abnormal semen parameters 9 8.65 Advanced age 4 3.85 Anovulation 10 9.62 Fibroids 27 25.95 Tubal blockage 15 14.44 Unexplained 21 20.19 Advanced age; Anovulation; Tubal blockage; Fibroid 9 8.65 Tubal blockage; Abnormal semen parameters; Unexplained 9 8.65 Treatment Offered In-vitro fertilisation (IVF) 50 48.08 Intra-Cytoplasmic Sperm Injection (ICSI) 3 2.88 Ovulation induction and intrauterine insemination 14 13.46 Ovulation induction and timed intercourse 35 33.65 Ovulation induction and timed intercourse; In-Vitro Fertilization (IVF) 2 1.93 ART Treatments received before Yes 15 14.42 No 89 85.58 ART Treatments Received if "Yes" Ovulation induction and timed intercourse 7 46.66 Ovulation induction and intrauterine insemination (IUI) 4 26.67 In-Vitro Fertilization (IVF) 4 26.67 Follow Up and Reasons for Defaulting Treatment Two out of five defaulting patients mentioned the high cost of treatment, while one out of five cited partner non-availability as the reason for default. The high cost of treatment and partner non-availability were the reasons for default among 14.42% of the patients. Thus, the high cost of treatment stood out as the commonest reason for defaulting to ART treatment (Table 6 ). Table 6 Follow-up and reasons for not returning Variables Frequency (n = 104) Percentage (%) Last visit to the Clinic (Months) 24 10 9.62 Reason for not returning for the treatment recommended My partner is not available for the treatment 19 18.27 We can afford the treatment, but we do not like the care at the clinic 1 0.96 The clinic is too far from where we live 5 4.81 The cost of treatment is too high 44 42.31 We already have a child or children and are no longer keen on the treatment 3 2.88 The cost of treatment is too high; My partner is not available for the treatment 15 14.42 The cost of treatment is too high; We already have a child or children and are no longer keen on the treatment 5 4.82 The cost of treatment is too high. We have found another place where we prefer to have the treatment 9 8.65 My partner is not available for the treatment.; The clinic is too far from where we live 3 2.88 Discussion We interviewed 61 health professionals; more than half (52.46%) were less than 40 years old, just a little more than a third (36.06%) were clinicians (Obstetricians and Gynaecologists/Reproductive Endocrinologists and Infertility experts), about a third (29.51%) were embryologists and the remaining third (34.43%) were fertility nurses and other supporting staff such as counsellors or clinical psychologists. In a similar study by Whittaker et al. on access to ART in sub-Saharan Africa, a smaller sample size of 31 participants was involved [ 12 ]. While their research primarily included only fertility specialists and embryologists, ours covered a broader participant base to include the complete complement of healthcare professionals involved in ART. About two-thirds of the health professionals acquired their ART subspecialty skills through Fellowship and various postgraduate studies (PhD, postgraduate masters and diplomas), while a significant third (37.7%) did so through mentorship or observership with more experienced senior colleagues. Very importantly, a majority (65.57%) of professionals acquired their skills locally in Ghana. Among the 34.43% who had their training abroad, India was the most common destination visited by 19.67%, followed by Europe (8.20%). These findings were similar to observations in Southeastern Nigeria, where all ART practitioners, primarily obstetricians/gynaecologists, received their training from India [ 13 ] [ 14 ]. Most ART professionals interviewed were inexperienced because a majority (57.38%) of respondents had less than five years in ART practice. Even though this may appear less assuring of the quality of ART services in Ghana, the young age of most professionals offers the opportunity for a more extended and vibrant ART service. Advocacy by the majority (86.89%0 of ART professionals for a restrictive environment for the practice speaks of members of a fraternity who are intent on curbing the excesses of the practice. The ease of access to all services, including IVF for single women, commercial surrogacy, multifetal pregnancy reduction, intrafamilial donor insemination, and sex selection, suggests that couples with Infertility in Ghana have high patient autonomy. Only 3.28% of professionals had not offered or been involved in IVF for single women, multifetal pregnancy reduction and sex selection. Future studies must establish why some ART experts have never provided or been engaged in offering these services. [ 15 ] [ 16 ]. For more than two-thirds (67.21) of ART professionals, a combination of difficulties associated with travelling abroad, financing the ART training, finding training opportunities, and finding a mentor were the main challenges to training. These findings were consistent with reports on ART in Africa, which identified the lack of structured training and financial constraints as factors militating against ART training [ 12 ]. The African network and registry for ART report for 2020 further underscores the need for accessible and affordable training to address these gaps [ 15 ]. Mentorship was significant for transferring ART knowledge and skills, contributing to training a third (32.79%) of all professionals in this study. [ 17 ]. At the time of collecting this data, the Reproductive Endocrinology and Infertility (REI) unit of the Ghana College of Physicians and Surgeons had just admitted its first-year Fellows. The Ghana College of Nurses and Midwives also took their first year of Membership students in Fertility Nursing this year (2024). The Ghana Association of Embryologists (GACE) was in talks with stakeholders about starting formal professional training for embryologists. This formal training of ART professionals is expected to improve the number of professionals with ART subspecialty skills. The opportunities these colleges offer will obviate the need to travel abroad for studies and the attendant financing burdens. Almost three-quarters (70.49%) of ART professionals identified high ART treatment costs, while 16.39% identified the lack of awareness for ART services as the central berries for treatment. These findings are in consonance with Whittaker et al.'s study on access to ART in sub-Saharan Africa, where high treatment costs, lack of public funding, poor policy awareness, and a shortage of skilled professionals were major obstacles [ 12 ]. The high cost and uneven distribution of ART services in Ghana's burgeoning cities create inequities concerning who can afford or access the services. Appropriate government interventions, such as tax exemptions and regulations on the cost of ART drugs and consumables, can significantly mitigate the high cost associated with both access for clients and the setup of new clinics. A majority of the women who defaulted treatment at the centre were married (87.50%), Christian (86.54%), young women, 65.38% being below 40 years of age. These findings align with other observations in which most women utilising ART services were in their thirties [ 18 – 20 ], identified as Christians [ 19 , 21 ] and were mostly married [ 19 – 21 ]. We postulate that the default rate was higher among the younger women either because of an exaggerated confidence in fertility or because they were more dependent on their partners for the final decision and finances for the treatment. Over half (58.65%) of the treatment defaulters sought treatment early, within five years. These observations were similar to those of a study in which the majority (40%) of women utilising ART services in some selected facilities in Accra had experienced Infertility in less than five years, followed by 35.33% in 5–9 years [ 22 ]. In another study which explored the experiences of women accessing ART services in Ghana, it was found that most women had been married for years, had tried natural conception and eventually resorted to ART services because they were either worried about their age or desired to satisfy their spouses and avoid the displeasure of in-laws [ 20 ]. Word-of-mouth recommendation was a more important referral source to the clinic than traditional and social media. This is because an overwhelming 88.47% of these treatment defaulters visited the clinic based on word-of-mouth recommendations compared to only 4.8% who did so based on traditional and social media adverts. This means that satisfied clients were more prone to return with another patient. Word-of-mouth was also the primary source of information about ART for women with infertility seeking ART services in Northern Nigeria [ 18 ], with family relations giving the most information (46.0%), followed by friends (28.7%) and health facilities (18.0%). Distant relationships featured as a possible contributor to infertility among these treatment defaulters because a significant three out of ten couples do not live together. Among these, 43.34% had their partners abroad. One out of four women in this study had fibroids identified as the cause of Infertility. Fibroids are prevalent among women with infertility [ 23 , 24 ], and their prevalence as a cause of Infertility among ART treatment defaulters in this study corroborates existing literature on the high prevalence of fibroids among African women [ 25 ]. Fibroids cause Infertility through impaired uterine contractility, altered endometrial receptiveness [ 26 ], blockage of fallopian tubes and prevention of gamete passage [ 27 ]. Unexplained Infertility was the second most common cause of Infertility identified, responsible for infertility among 20.19% of these women. This compares with the findings in a study in Zimbabwe, which reports unexplained infertility as the most common cause of Infertility, affecting 22% of the women seeking treatment at gynaecological clinics [ 28 ]. Unexplained infertility is a diagnosis of exclusion for couples who are unable to conceive despite regular unprotected sex and do not fit the criteria for diagnosis of male or female factor infertility [ 29 ]. In various reviews regarding infertility, unexplained infertility has been reported to account for varying numbers of cases, ranging between 10.4% − 30% [ 30 – 32 ]. Tubal blockage may be caused by sexually transmitted infections, pelvic infections, fibroids, pelvic adhesions after fibroid surgery and other factors. It is reported to account for 30–40% of female infertility. Where resources and skills are available, it may be managed by tubal microsurgery. However, the majority of case management requires IVF [ 33 ]. In the present study, it was the third most common cause of infertility, accounting for 14.44% of infertility among women defaulting to fertility treatments at the centre. This finding is consistent with data from other regions where tubal factors are a common cause of infertility. For instance, in Zimbabwe, tubal blockage was responsible for 20% of infertility among women seeking fertility treatment [ 28 ]. Similarly, it represented 22.3% and 25.5% of the causes of infertility cases among Omani women [ 34 ] and women in Austria [ 35 ], respectively. It was also observed that male infertility contributed to 8.65% of infertility cases in this study. This proportion of male factor contribution is low compared with that in Zimbabwe (19%) and reports across Africa (22.26%). The observed discrepancy could be because many patients presented semen analysis from non-standardised laboratories, where the WHO strict criteria were not applied. In-vitro fertilisation (IVF) was the most common treatment offered (48.08%) to these women who defaulted, followed by ovulation induction with timed intercourse (33.65%). In-vitro fertilisation, ovulation induction with timed intercourse or intrauterine insemination (IUI) are common treatment options offered to couples requiring fertility treatment, even though the latter two are not assisted reproductive technologies [ 31 ]. IVF offers the best success results [ 36 , 37 ]. Ovulation induction involves using drugs to trigger the release of mature oocytes. [ 31 ]. For fertilisation to occur after the induction, it can be coupled with timed intercourse or intra-uterine insemination in which washed partner spermatozoa are placed in the uterine cavity near the tubal ostia. Ovulation induction with timed intercourse is frequently used for women with less severe infertility issues, such as ovulatory disorders [ 36 ]. Furthermore, it is less invasive and costly compared with IVF, making it a first-line treatment option. In this study, only a small number, 14.42%, had some form of treatment before presenting to the fertility centre. Almost half (46.66%) of them had had ovulation induction with timed intercourse, suggesting that their diagnosed cause of Infertility could not have been severe. The reasons for ART treatment defaults provided by these women in this study were the high treatment cost (70.20%) and partner non-availability (35.57%). These findings agree with those of a study in Northern Nigeria, where women receiving ART services cited high financial costs as a barrier to continued use of the services [ 18 ]. Other studies exploring the experiences and challenges of Ghanaian women using ART services reported high costs as a significant challenge for their continued fertility treatment [ 20 , 21 ]. The financial burden associated with ART service utilisation is a recognised barrier to ART access in low and middle-income countries, particularly the African subregion [ 12 , 15 , 38 ]. The high cost of ART services in Africa has been attributed to the capital-intensive nature of setting up ART facilities, the highly privatised services, the limited number of clinics relative to demand, the high operational cost and a lack of government support [ 12 , 15 , 24 ]. Even though couples with infertility in Ghana enjoy autonomy in their choices of ART treatment options, this may be compromised when financial constraints limit their choices. Addressing these challenges with strategies such as introducing supportive regulatory frameworks and policies to reduce operational costs and promote public investments in ART services can make these services more accessible and affordable. Without government support or subsidised programmes, the economic burden on patients impedes equitable access. Partner non-availability was the second most common reason for the discontinuation of ART services by 18.27% of respondents in this study. Similarly, Arhin et al. reported a lack of support from male partners, seeking alternative treatment and relocation as major reasons for discontinued ART service utilisation [ 39 ]. The non-involvement or unavailability of male partners in seeking fertility treatment is problematic because males contribute equally to Infertility and must be evaluated to arrive at a conclusive diagnosis of the cause of Infertility. Furthermore, ART treatment can be an emotionally challenging journey, making emotional support from a partner essential for the overall outcome. Conclusion The findings of this study highlight significant barriers to accessing ART services in Ghana despite the absence of restrictive legislation that allows for greater patient autonomy. The primary obstacles identified were prohibitive treatment costs, lack of partner availability, and insufficient awareness of ART services. These barriers contribute to high levels of inequity and injustice in the accessibility of ART for Ghanaians facing infertility challenges. Moreover, while ART professionals in Ghana are generally well-educated and capable of providing a broad range of services, the majority desire a more regulated practice environment. To improve equity and justice for ART services in Ghana, it is essential to address these financial, informational and regulatory challenges, ensuring that all individuals in need can benefit from the available reproductive technologies. Recommendations The Government of Ghana must introduce policies and regulatory frameworks to support the existing private-public collaborations in training ART professionals, establish more ART clinics, equitably distribute trained ART experts, and reduce ART operational costs to make ART services more accessible and affordable. At a minimum, the Government of Ghana's budgetary allocation for health must absorb the cost of fertility assessment and some essential treatments through the National Health Insurance scheme. The Fertility Society of Ghana (FERSOG), the health regulatory authorities, and parliament must take the necessary steps to enact the laws and guidelines required to regulate and curb excesses in ART practice in Ghana as desired by the practitioners. ART practitioners must formulate innovative policies and strategies for targeted information dissemination through means outside the traditional and social media platforms to improve public awareness of the causes of infertility, the role of male partners and the availability of effective treatment options, including ART. Abbreviations ART: Assisted Reproductive Technology IVF: In-Vitro Fertilization E.T.: Embryo Transfer FERSOG: Fertility Society of Ghana CHRPE: Committee on Human Research, publications and Ethics KNUST: Kwame Nkrumah University of Science and Technology ICSI: Intracytoplasmic Sperm Injection NAC: Nurse Assistant- Clinical IUI: Intra-Uterine Insemination FET: Transfer of Frozen Thawed Embryo PGD: Pre-Implantation Genetic Diagnosis Declarations Ethics approval and consent to participate We conducted this survey according to the guidelines and regulations outlined in the Declaration of Helsinki. Ethical approval for the survey, CHRPE/AP/205/24, was obtained from the Committee on Human Research, Publications, and Ethics (CHRPE) at Kwame Nkrumah University of Science and Technology (KNUST), School of Medical Sciences - Kumasi. Consent from all eligible participants was sought formally before being recruited to participate. The study was carried out in accordance with the declaration of Helsinki. Consent for publication Not applicable. Availability of data and materials The datasets used or analysed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare no competing interests. Funding No external funding was either sought or obtained for this study Authors' contributions Conception of the Research Proposal: Francis Jojo Moses Kodzo Damalie, Charles Mawunyo Senaya, Elikplim Adzo Damalie, Herbert Ekoe Dankluvi, Millicent Osaah, Beatrice Yeboah, John Jude Annan, Ellis Fleischer Djoleto, Rudolf Kantum Adageba, Alexander Tawiah Odoi Project Development, Data Collection and Analysis and Interpretation: Francis Jojo Moses Kodzo Damalie, Elikplim Adzo Damalie, Herbert Ekoe Dankluvi, Millicent Osaah, Beatrice Yeboah, Ellis Fleischer Djoleto Manuscript Writing: Francis Jojo Moses Kodzo Damalie, Charles Mawunyo Senaya, Beatrice Yeboah, John Jude Annan, Ellis Fleischer Djoleto, Rudolf Kantum Adageba, Alexander Tawiah Odoi All authors read and approved the final manuscript. Acknowledgements The authors wish to acknowledge the participants who consented and contributed to the success of this study. References Hazlina NHN, et al. 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Transnational connections of health professionals: medicoscapes and assisted reproduction in Ghana and Uganda. Ethn Health. 2016;21(4):357–74. Archary P et al. Assisted reproductive technologies in Africa: The African Network and Registry for ART, 2020. Reproductive BioMedicine Online, 2024: p. 104353. Banker M, et al. International Committee for Monitoring Assisted Reproductive Technologies (ICMART): world report on assisted reproductive technologies, 2013. Fertil Steril. 2021;116(3):741–56. de Ziegler D, et al. Training in reproductive endocrinology and infertility and assisted reproductive technologies: options and worldwide needs. Fertil Steril. 2015;104(1):16–23. Adesiyun AG, Ameh N, Avidime S. Awareness and Perception of assisted reproductive technology practice amongst women with infertility in Northern. Open J Obstet Gynecol. 2011;1:144–8. Hiadzi RA, Boafo IM, Tetteh PM. God helps those who help themselves'… religion and Assisted Reproductive Technology usage amongst urban Ghanaians. PLoS ONE. 2021;16(12):e0260346. Anaman-Torgbor JA, et al. Experiences of women undergoing assisted reproductive technology in Ghana: a qualitative analysis of their experiences. PLoS ONE. 2021;16(8):e0255957. Kyei JM, et al. Challenges experienced by clients undergoing assisted reproductive technology in Ghana: An exploratory descriptive study. Int J Gynecol Obstet. 2020;149(3):326–32. Kyei JM et al. Ways of coping among women with infertility undergoing assisted reproductive technologies in Ghana. Pan Afr Med J, 2022. 41(1). Donnez J, et al. Uterine fibroid-related infertility: mechanisms and management. Fertility and sterility; 2024. Freytag D, et al. Uterine fibroids and infertility. Diagnostics. 2021;11(8):1455. Morhason-Bello IO, Adebamowo CA. Epidemiology of uterine fibroid in black African women: a systematic scoping review. BMJ Open. 2022;12(8):e052053. Rizk BR, Khalaf Y, Borahay MA. Fibroids and Reproduction. CRC; 2020. Sefah N, et al. Uterine fibroids—Causes, impact, treatment, and lens to the African perspective. Front Pharmacol. 2023;13:1045783. Madziyire MG, et al. The causes of infertility in women presenting to gynaecology clinics in Harare, Zimbabwe; a cross-sectional study. Fertility Res Pract. 2021;7:1–8. Raperport C, et al. The definition of unexplained infertility: a systematic review. BJOG: Int J Obstet Gynecol. 2024;131(7):880–97. Abebe MS, Afework M, Abaynew Y. Primary and secondary infertility in Africa: systematic review with meta-analysis. Fertility Res Pract. 2020;6:1–11. Carson SA, Kallen AN. Diagnosis and management of infertility: a review. JAMA. 2021;326(1):65–76. Abdallah KS, et al. How and why to define unexplained infertility? Seminars in reproductive medicine. Thieme Medical Publishers, Inc.; 2020. Ambildhuke K et al. A review of tubal factors affecting fertility and its management. Cureus, 2022. 14(11). Albalushi H, et al. Prevalence of congenital uterine anomalies and tubal blockage in infertile Omani women: A retrospective study. Oman Med J. 2023;38(1):e463. Mayrhofer D, et al. Incidence and Causes of Tubal Occlusion in Infertility: A Retrospective Cohort Study. J Clin Med. 2024;13(13):3961. Coccia ME, Rizzello F, Orlandi G. Assisted Reproductive Technologies , in Female Reproductive Dysfunction , F. Petraglia and B.C. Fauser, Editors. 2020, Springer International Publishing: Cham. pp. 263–284. Prevention CfDCa. 2021 Assisted Reproductive Technology Fertility Clinic and National Summary Report —2023 US Dept of Health and Human Services. Fiebai PO, Ikimalo JI. Challenges with assisted reproductive technology (ART) in sub-Saharan Africa. Afr J Reprod Gynaecol Endoscopy. 2019;4(1):3–8. Arhin SM, et al. Pharmacotherapy of infertility in Ghana: Why do infertile patients discontinue their fertility treatment? PLoS ONE. 2022;17(10):e0274635. Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile1.docx Cite Share Download PDF Status: Published Journal Publication published 30 Sep, 2025 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 15 Apr, 2025 Reviews received at journal 13 Apr, 2025 Reviews received at journal 13 Apr, 2025 Reviews received at journal 11 Apr, 2025 Reviews received at journal 09 Apr, 2025 Reviews received at journal 04 Apr, 2025 Reviews received at journal 25 Mar, 2025 Reviewers agreed at journal 24 Mar, 2025 Reviewers agreed at journal 23 Mar, 2025 Reviewers agreed at journal 23 Mar, 2025 Reviewers agreed at journal 22 Mar, 2025 Reviewers agreed at journal 21 Mar, 2025 Reviewers agreed at journal 21 Mar, 2025 Reviews received at journal 21 Mar, 2025 Reviewers agreed at journal 21 Mar, 2025 Reviewers agreed at journal 20 Mar, 2025 Reviewers agreed at journal 20 Mar, 2025 Reviewers agreed at journal 19 Mar, 2025 Reviewers agreed at journal 19 Mar, 2025 Reviewers agreed at journal 19 Mar, 2025 Reviewers invited by journal 19 Mar, 2025 Editor assigned by journal 19 Mar, 2025 Editor invited by journal 18 Mar, 2025 Submission checks completed at journal 17 Mar, 2025 First submitted to journal 17 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6180416","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":432779938,"identity":"48b9550c-d0e9-4ab5-a0e9-26f6e8784df6","order_by":0,"name":"Francis Jojo Moses Kodzo Damalie","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCklEQVRIiWNgGAWjYBACxgaGBAYeIIOPmYHxMViImbkBTEsQ0sLGzMBszMBgANTCiF8LGIC1AJE0WAsDAS3M7Q0PH7yp2SbPxs58rLqg4k80fztQy48KhsSZDTgc1nMg2XDOsduGbcxsabdnnDHInXGYsYGx5wxD4mxcfpmRkCbNw3absY2Zx+w2b5tBbgNQCzNjG0PiPLxa/t22b2Pm/1YM0jKfKC28bbcTgbawMYO0bIBpwekwkF/m9t1OBvrFWJrnjHHuRqCWgz1nJIxxed+wvSfxwZtvt237+Q8//MxTIZc77/zhgw9+VNjIzjiAQ0sDTwKm6AF8ESnPwI7DsFEwCkbBKBgFMAAAaDtZVzrkFagAAAAASUVORK5CYII=","orcid":"","institution":"Kwame Nkrumah University of Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"Francis","middleName":"Jojo Moses Kodzo","lastName":"Damalie","suffix":""},{"id":432779940,"identity":"116f787c-b308-47e3-93f1-6e34e0dd7d5b","order_by":1,"name":"Charles Mawunyo Senaya","email":"","orcid":"","institution":"Kwame Nkrumah University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Charles","middleName":"Mawunyo","lastName":"Senaya","suffix":""},{"id":432779941,"identity":"38a3884b-9275-4247-844e-b68465f0481b","order_by":2,"name":"Elikplim Adzo Damalie","email":"","orcid":"","institution":"Hallmark Medicals","correspondingAuthor":false,"prefix":"","firstName":"Elikplim","middleName":"Adzo","lastName":"Damalie","suffix":""},{"id":432779942,"identity":"506cf711-9481-4711-9bc5-f46886a45f3f","order_by":3,"name":"Herbert Ekoe Dankluvi","email":"","orcid":"","institution":"Hallmark Medicals","correspondingAuthor":false,"prefix":"","firstName":"Herbert","middleName":"Ekoe","lastName":"Dankluvi","suffix":""},{"id":432779943,"identity":"743ce32c-f5ea-40e2-9f73-2fe72a7522a3","order_by":4,"name":"Millicent Osaah","email":"","orcid":"","institution":"Hallmark Medicals","correspondingAuthor":false,"prefix":"","firstName":"Millicent","middleName":"","lastName":"Osaah","suffix":""},{"id":432779944,"identity":"10d51ecd-92db-428a-9c57-09a28b3f546e","order_by":5,"name":"Beatrice Yeboah","email":"","orcid":"","institution":"Komfo Anokye Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Beatrice","middleName":"","lastName":"Yeboah","suffix":""},{"id":432779945,"identity":"859c66b1-dd22-43f9-bef7-05954f492bf3","order_by":6,"name":"John Jude Annan","email":"","orcid":"","institution":"Kwame Nkrumah University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"John","middleName":"Jude","lastName":"Annan","suffix":""},{"id":432779946,"identity":"0fe43bcb-92f9-462f-8d05-9ca19bbd4b60","order_by":7,"name":"Ellis Fleischer Djoleto","email":"","orcid":"","institution":"Hallmark Medicals","correspondingAuthor":false,"prefix":"","firstName":"Ellis","middleName":"Fleischer","lastName":"Djoleto","suffix":""},{"id":432779947,"identity":"1289206b-f9a5-4d7a-acb4-2c6c93c5796d","order_by":8,"name":"Rudolf Kantum Adageba","email":"","orcid":"","institution":"RUMA Fertility and Specialist Hospital, YB 254 Asuoyeboah I.P.T","correspondingAuthor":false,"prefix":"","firstName":"Rudolf","middleName":"Kantum","lastName":"Adageba","suffix":""},{"id":432779948,"identity":"85c66222-176f-4a68-ad23-3411727beac1","order_by":9,"name":"Alexander Tawiah Odoi","email":"","orcid":"","institution":"Kwame Nkrumah University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Alexander","middleName":"Tawiah","lastName":"Odoi","suffix":""}],"badges":[],"createdAt":"2025-03-07 18:53:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6180416/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6180416/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-025-13457-3","type":"published","date":"2025-09-30T15:56:58+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":79172415,"identity":"a2dcfb46-c172-4f9e-86f9-6470bd4a75a3","added_by":"auto","created_at":"2025-03-25 09:40:32","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":161618,"visible":true,"origin":"","legend":"\u003cp\u003eBarriers to ART services identified by ART professionals\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6180416/v1/398ef2a10dae4a51b7a0809b.jpg"},{"id":79175991,"identity":"8097b6bf-430e-4c3b-922e-cb891975485b","added_by":"auto","created_at":"2025-03-25 09:56:32","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":127820,"visible":true,"origin":"","legend":"\u003cp\u003eAge distributions of ART clinic attendants who defaulted treatment\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6180416/v1/b95c7dc8100c950770c1e1a9.jpg"},{"id":79173820,"identity":"ee837199-f46b-431c-8ffa-e65e9ed7685a","added_by":"auto","created_at":"2025-03-25 09:48:32","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":81275,"visible":true,"origin":"","legend":"\u003cp\u003eThe distribution of ART clinic defaulters according to religion\u003c/p\u003e","description":"","filename":"Picture3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6180416/v1/3d9d320fc409f6e5d40ddc6e.jpg"},{"id":79173822,"identity":"67d49f10-78bc-4890-9c6b-451964320f77","added_by":"auto","created_at":"2025-03-25 09:48:32","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":142372,"visible":true,"origin":"","legend":"\u003cp\u003eThe distribution of ART clinic defaulters according to marital status\u003c/p\u003e","description":"","filename":"Picture4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6180416/v1/ed3a3e8d97e776c7198e1312.jpg"},{"id":92883929,"identity":"38e85a36-651b-432a-b5af-dc53b63c7d6f","added_by":"auto","created_at":"2025-10-06 16:11:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1882072,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6180416/v1/1b1f6799-75b9-4440-ba0e-d76dd213da2c.pdf"},{"id":79172423,"identity":"fbc533ee-1d25-4677-acbf-87d04567cf4e","added_by":"auto","created_at":"2025-03-25 09:40:32","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":23512,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6180416/v1/b714ff8fb2d0fd5800d7eb51.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eAssisted Reproductive Technologies (Art) Equity, Justice and Autonomy in Ghana\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eGhanaian families have a pro-natalist attitude and expect children to maintain family lineage, happiness, and harmony. Childbirth, therefore, guarantees marital stability and economic or social security in a society that lacks formal social security systems for older people. Infertility, thus, exerts devastating biomedical, psychological and sociocultural consequences on affected couples [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The exact burden of infertility in Ghana is not known, but it is estimated to affect about 11.8% of women and 15.8% of men [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTubal and severe male factors are the commonest causes of Infertility in Ghana, for which assisted reproductive technology (ART) treatment is the most effective. Many Ghanaians are turning to ART treatment for assistance to achieve their dream of parenthood. ART refers to medical procedures that involve the manipulation of eggs, sperm or embryos outside the body to facilitate conception. The typical approaches are in-vitro fertilisation and intra-cytoplasmic sperm injection. Ghana requires about 1500 ART cycles per 1\u0026nbsp;million people a year (i.e., 45,000 IVF cycles each year for her 30\u0026nbsp;million population) for adequate fertility treatment [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Even though statistics on IVF cycles are lacking, it is unlikely that the few ART centres in Ghana can provide the required number of IVF cycles. For instance, in 2020, four out of the fifteen ART centres in Ghana reported 677 cycles [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This suggests a high unmet need for IVF services.\u003c/p\u003e \u003cp\u003eWhile restrictive legislation and regulation appear to be the main barriers to infertility treatment in developed countries [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], the factors limiting access to ART services in Ghana are poorly documented. Some studies found that the high cost of setting up and associated scarcity of ART centres, the high cost of ART treatments, socioeconomic deprivation, and the lack of skilled infertility personnel make ART largely inaccessible in Africa [\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Understanding the landscape of ART access in Ghana is crucial for policymakers, healthcare providers, and researchers to address existing barriers and improve the availability and affordability of fertility treatments for all individuals and couples in need. Thus, this study seeks to document the barriers to ART services in Ghana.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis cross-sectional study was conducted across twenty-two fertility centres in Ghana. A structured questionnaire (supplementary file 1) was administered via a Google app to 61 ART personnel from all fertility centres in Ghana through the Fertility Society of Ghana (FERSOG) WhatsApp group to obtain information on fertility professionals' sociodemographic characteristics, training, work experience and the type of services they offered. Another structured questionnaire was administered to patients who defaulted treatment at Hallmark Medicals, a private fertility centre in Kumasi, through telephone conversations. The patients were conveniently identified through the hospital's records and contacted to obtain information on their knowledge of ART services and reasons for dropping out of the recommended treatment. Ethical approval CHRPE/AP/205/24 was obtained from the Committee for Human Research Publication and Ethics, Kwame Nkrumah University of Science and Technology (KNUST). Informed consent was obtained from each before enrolling in the study. Data were analysed using STATA version 14.0.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003eDemographics Characteristics of ART Healthcare Professionals in Ghana\u003c/h2\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e shows the demographic characteristics of ART professionals in Ghana. Most of the personnel, 39(63.93%) were males. Thus, the gender distribution of the personnel was almost two males to one female. The majority of the personnel, 43(70.49%), were aged between 30 and 49. Embryologists constituted nearly a third of the health professionals\u0026apos; group, with 18 members making up 29.51% of all healthcare personnel, followed by fertility nurses 17(27.87%). There was only one clinical psychologist among the ART personnel.\u003c/p\u003e\n \u003cp\u003eClinical Fellowship and membership were the most common and highest educational levels attained by ART professionals, followed equally by postgraduate masters and degrees in midwifery. Five per cent of the personnel had a PhD.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDemographic Characteristics of ART Healthcare Professionals in Ghana\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency (n\u0026thinsp;=\u0026thinsp;61)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e36.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e63.93\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (Years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u0026ndash;39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e39.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40\u0026ndash;49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e31.15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50\u0026ndash;59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14.75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.64\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eClinical Role\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReproductive Endocrinology Sub-specialist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eObstetrician and Gynaecologist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22.95\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmbryologist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29.51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFertility Nurse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e27.87\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eClinical psychologist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.64\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther (Counselor, Urologist, and Fellow in training)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.92\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLevel of Education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eClinical Fellowship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.92\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMembership\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostgraduate Masters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14.75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostgraduate Diploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.64\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMBChB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDegree in Biomedical Sciences, Laboratory Technology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDegree in Nursing/Midwifery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14.75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDegree in Psychology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.64\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiploma in Nursing/Midwifery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiploma in Perioperative Nursing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.64\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNurse Assistant- Clinical (NAC)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.92\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther (Degree Chemistry)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.64\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003ch3\u003eTraining and Experience in ART\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e shows the survey results on training ART professionals and their constraints. Training on the Job (Mentorship) emerged as the most frequent approach used by 20(32.79%) ART professionals to acquire knowledge and skills, followed by Clinical Fellowship Training 12(19.67%). Notably, 3(4.92%) of ART professionals had a PhD. Interestingly, two out of three 40(65.57%) respondents received ART training in Ghana. Aside from Ghana, India and Europe were featured as favourite destinations for ART training. Most professionals, 41(67.22%), reported having less than five years of experience in ART.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eTraining and Experience in ART\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency (n\u0026thinsp;=\u0026thinsp;61)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eLevel of Professional Training in ART\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFellowship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.92\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePost Graduate Masters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePost Graduate Diploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSix Months Observership\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.91\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTraining on the Job (Mentorship)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32.79\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther (Senior Resident, Fellow in Training)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry of Training in ART\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEurope\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSouth Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAustralia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.64\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGhana\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65.57\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther (Nigeria)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.64\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eChallenges in ART training\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDifficulty financing training; Difficulty finding mentors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31.15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDifficulty with traveling abroad for training; Difficulty financing training; Few opportunities available for training; Difficult finding a mentor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDifficulty with traveling abroad for training; Difficulty finding mentors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.64\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of ART Experience (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.84\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u0026ndash;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57.38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u0026ndash;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.95\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRestrictive and Regulated ART Environment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e86.89\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003ch3\u003eART services offered and their barriers\u003c/h3\u003e\n\u003cp\u003eAn overwhelming majority of ART professionals had been involved in or offered almost all ART services available globally, including IVF for single women, commercial surrogacy, multifetal pregnancy reduction, intrafamilial donor sperm insemination and sex determination. Only 2(3.28%) of ART personnel had never been involved or offered IVF for single women, multifetal pregnancy reduction and sex determination (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eTypes of ART services offered by ART professionals\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eServices involved in or offered.\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIVF for single women; Use of donor gametes; Commercial surrogacy; Embryo adoption; Multifetal pregnancy reduction; Cryopreservation and transfer of frozen-thawed embryo (FET); intra-familial donor insemination; Sex selection; pre-implantation genetic diagnosis (PGD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e91.80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUse of donor gametes; Commercial surrogacy; Embryo adoption; Pre-implantation genetic diagnosis (PGD); Cryopreservation and transfer of frozen-thawed embryo, (FET) and Intra familial donor insemination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSex selection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.92\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eOver 70% of ART personnel mentioned the high cost of services as the main barrier to ART in Ghana, followed by poor knowledge of the availability of ART services by the patients 10 (16.39%). Only an insignificant 6.56% of ART professionals considered religion as a barrier to ART (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographic Characteristics of Women Who Defaulted in Infertility Treatment.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFigures 2-4 show the demographic characteristics of 104 \u0026nbsp;fertility clinic attendants who defaulted in treatment. More than half 53(50.90%) of these women were in their thirties (30-39 years), and about a third, 32(30.77%), were in their forties. The overwhelming majority of the defaulters, 91(87.50%), were married and 90(86.54%). Christians). Only a very small proportion, 5(4.81%) of these women who desired a pregnancy did not have a partner.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eLiving experiences of women with infertility and their sources of referral for ART\u003c/h3\u003e\n\u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e shows the living experiences of the women with infertility and their sources of referral for ART. Forty-five per cent (45.19%) of these defaulters sought treatment after 2\u0026ndash;5 years of Infertility. About a quarter of them did so after 6\u0026ndash;10 years. Almost two-thirds, 74 (71.15%) of the couples, live together. Nearly a third of the couples were in distant relationships, and among these, 13(43.34%) had their partners abroad, while more than a third lived in different cities in Ghana.\u003c/p\u003e\n\u003cp\u003eWord-of-mouth recommendations from people who had a personal experience with ART or knew someone with the experience was the source of referral to the ART clinic in an overwhelming 88.47% of instances. Radio and social media, combined, constituted an insignificant 4.88% of sources of information on the ART clinic. Health professionals were the sources of information in another 6.73% of instances.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eLiving experiences of the women with infertility\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency (n\u0026thinsp;=\u0026thinsp;104)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDuration of Infertility (Years)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u0026ndash;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e45.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u0026ndash;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e25.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u0026ndash;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11.54\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.81\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCouples living together?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e71.15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e28.85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eResidence of partner if couples don\u0026apos;t live together\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbroad\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e43.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIn Ghana, but in different cities or town\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e36.66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIn the same city but in different locations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSource of information about the ART clinic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRecommendation from a friend, family or colleague who has patronised the services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e34.62\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRecommendation from a friend or family who has heard about the hospital but has not patronised it themselves\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e53.85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRadio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.92\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHospital social media handle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers (Nurse, Doctor, and Sign board)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.73\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eCauses of Infertility and Fertility Treatments Offered and Received\u003c/h2\u003e\n \u003cp\u003eFibroids was the commonest diagnosis made in one out of four 27(25.95%) of these women with Infertility who defaulted treatment, followed by unexplained Infertility in one out of five (20.19%) and tubal blockage 15(14.44%). Male Infertility and anovulation contributed almost equally, 9(8.65%) vs 10(9.62%) to the Infertility in these women. In nearly one out of five cases (17.30%), the cause of Infertility was any combination of advanced age, anovulation, tubal factor, male factor and fibroids.\u003c/p\u003e\n \u003cp\u003eIn-vitro fertilisation (IVF) was the most common treatment offered to almost half (48.08%) of these women with Infertility, followed by ovulation induction with timed intercourse in about a third, 35(33.65%), and ovulation induction with intra-uterine insemination (IUI) in 14(13.46%) of the cases. Intra-cytoplasmic sperm injection was only infrequently offered in 3(2.88%) of cases.\u003c/p\u003e\n \u003cp\u003eVery few of these women, only 14.42%, had had any form of infertility treatment, ovulation induction and timed intercourse being the commonest treatment received by about half of these women, while just more than a quarter each had received either ovulation induction with IUI or IVF treatment (Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCauses of infertility and treatments offered and received\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency (n\u0026thinsp;=\u0026thinsp;104)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCause of the Infertility\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbnormal semen parameters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdvanced age\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnovulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9.62\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFibroids\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e25.95\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTubal blockage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14.44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnexplained\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdvanced age; Anovulation; Tubal blockage; Fibroid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTubal blockage; Abnormal semen parameters; Unexplained\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment Offered\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIn-vitro fertilisation (IVF)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e48.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntra-Cytoplasmic Sperm Injection (ICSI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOvulation induction and intrauterine insemination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOvulation induction and timed intercourse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e33.65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOvulation induction and timed intercourse; In-Vitro Fertilization (IVF)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.93\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eART Treatments received before\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14.42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e85.58\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eART Treatments Received if \u0026quot;Yes\u0026quot;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOvulation induction and timed intercourse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e46.66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOvulation induction and intrauterine insemination (IUI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIn-Vitro Fertilization (IVF)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003ch3\u003eFollow Up and Reasons for Defaulting Treatment\u003c/h3\u003e\n\u003cp\u003eTwo out of five defaulting patients mentioned the high cost of treatment, while one out of five cited partner non-availability as the reason for default. The high cost of treatment and partner non-availability were the reasons for default among 14.42% of the patients. Thus, the high cost of treatment stood out as the commonest reason for defaulting to ART treatment (Table \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab6\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eFollow-up and reasons for not returning\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency (n\u0026thinsp;=\u0026thinsp;104)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLast visit to the Clinic (Months)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e37.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u0026ndash;12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e40.38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13\u0026ndash;24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9.62\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eReason for not returning for the treatment recommended\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMy partner is not available for the treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWe can afford the treatment, but we do not like the care at the clinic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe clinic is too far from where we live\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.81\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe cost of treatment is too high\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e42.31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWe already have a child or children and are no longer keen on the treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe cost of treatment is too high; My partner is not available for the treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14.42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe cost of treatment is too high; We already have a child or children and are no longer keen on the treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.82\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe cost of treatment is too high. We have found another place where we prefer to have the treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMy partner is not available for the treatment.; The clinic is too far from where we live\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe interviewed 61 health professionals; more than half (52.46%) were less than 40 years old, just a little more than a third (36.06%) were clinicians (Obstetricians and Gynaecologists/Reproductive Endocrinologists and Infertility experts), about a third (29.51%) were embryologists and the remaining third (34.43%) were fertility nurses and other supporting staff such as counsellors or clinical psychologists. In a similar study by Whittaker et al. on access to ART in sub-Saharan Africa, a smaller sample size of 31 participants was involved [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. While their research primarily included only fertility specialists and embryologists, ours covered a broader participant base to include the complete complement of healthcare professionals involved in ART. About two-thirds of the health professionals acquired their ART subspecialty skills through Fellowship and various postgraduate studies (PhD, postgraduate masters and diplomas), while a significant third (37.7%) did so through mentorship or observership with more experienced senior colleagues. Very importantly, a majority (65.57%) of professionals acquired their skills locally in Ghana. Among the 34.43% who had their training abroad, India was the most common destination visited by 19.67%, followed by Europe (8.20%). These findings were similar to observations in Southeastern Nigeria, where all ART practitioners, primarily obstetricians/gynaecologists, received their training from India [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Most ART professionals interviewed were inexperienced because a majority (57.38%) of respondents had less than five years in ART practice. Even though this may appear less assuring of the quality of ART services in Ghana, the young age of most professionals offers the opportunity for a more extended and vibrant ART service.\u003c/p\u003e \u003cp\u003eAdvocacy by the majority (86.89%0 of ART professionals for a restrictive environment for the practice speaks of members of a fraternity who are intent on curbing the excesses of the practice. The ease of access to all services, including IVF for single women, commercial surrogacy, multifetal pregnancy reduction, intrafamilial donor insemination, and sex selection, suggests that couples with Infertility in Ghana have high patient autonomy. Only 3.28% of professionals had not offered or been involved in IVF for single women, multifetal pregnancy reduction and sex selection. Future studies must establish why some ART experts have never provided or been engaged in offering these services. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor more than two-thirds (67.21) of ART professionals, a combination of difficulties associated with travelling abroad, financing the ART training, finding training opportunities, and finding a mentor were the main challenges to training. These findings were consistent with reports on ART in Africa, which identified the lack of structured training and financial constraints as factors militating against ART training [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The African network and registry for ART report for 2020 further underscores the need for accessible and affordable training to address these gaps [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Mentorship was significant for transferring ART knowledge and skills, contributing to training a third (32.79%) of all professionals in this study. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. At the time of collecting this data, the Reproductive Endocrinology and Infertility (REI) unit of the Ghana College of Physicians and Surgeons had just admitted its first-year Fellows. The Ghana College of Nurses and Midwives also took their first year of Membership students in Fertility Nursing this year (2024). The Ghana Association of Embryologists (GACE) was in talks with stakeholders about starting formal professional training for embryologists. This formal training of ART professionals is expected to improve the number of professionals with ART subspecialty skills. The opportunities these colleges offer will obviate the need to travel abroad for studies and the attendant financing burdens.\u003c/p\u003e \u003cp\u003eAlmost three-quarters (70.49%) of ART professionals identified high ART treatment costs, while 16.39% identified the lack of awareness for ART services as the central berries for treatment. These findings are in consonance with Whittaker et al.'s study on access to ART in sub-Saharan Africa, where high treatment costs, lack of public funding, poor policy awareness, and a shortage of skilled professionals were major obstacles [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The high cost and uneven distribution of ART services in Ghana's burgeoning cities create inequities concerning who can afford or access the services. Appropriate government interventions, such as tax exemptions and regulations on the cost of ART drugs and consumables, can significantly mitigate the high cost associated with both access for clients and the setup of new clinics.\u003c/p\u003e \u003cp\u003eA majority of the women who defaulted treatment at the centre were married (87.50%), Christian (86.54%), young women, 65.38% being below 40 years of age. These findings align with other observations in which most women utilising ART services were in their thirties [\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], identified as Christians [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] and were mostly married [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. We postulate that the default rate was higher among the younger women either because of an exaggerated confidence in fertility or because they were more dependent on their partners for the final decision and finances for the treatment.\u003c/p\u003e \u003cp\u003eOver half (58.65%) of the treatment defaulters sought treatment early, within five years. These observations were similar to those of a study in which the majority (40%) of women utilising ART services in some selected facilities in Accra had experienced Infertility in less than five years, followed by 35.33% in 5\u0026ndash;9 years [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In another study which explored the experiences of women accessing ART services in Ghana, it was found that most women had been married for years, had tried natural conception and eventually resorted to ART services because they were either worried about their age or desired to satisfy their spouses and avoid the displeasure of in-laws [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWord-of-mouth recommendation was a more important referral source to the clinic than traditional and social media. This is because an overwhelming 88.47% of these treatment defaulters visited the clinic based on word-of-mouth recommendations compared to only 4.8% who did so based on traditional and social media adverts. This means that satisfied clients were more prone to return with another patient. Word-of-mouth was also the primary source of information about ART for women with infertility seeking ART services in Northern Nigeria [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], with family relations giving the most information (46.0%), followed by friends (28.7%) and health facilities (18.0%).\u003c/p\u003e \u003cp\u003eDistant relationships featured as a possible contributor to infertility among these treatment defaulters because a significant three out of ten couples do not live together. Among these, 43.34% had their partners abroad.\u003c/p\u003e \u003cp\u003eOne out of four women in this study had fibroids identified as the cause of Infertility. Fibroids are prevalent among women with infertility [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], and their prevalence as a cause of Infertility among ART treatment defaulters in this study corroborates existing literature on the high prevalence of fibroids among African women [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Fibroids cause Infertility through impaired uterine contractility, altered endometrial receptiveness [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], blockage of fallopian tubes and prevention of gamete passage [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Unexplained Infertility was the second most common cause of Infertility identified, responsible for infertility among 20.19% of these women. This compares with the findings in a study in Zimbabwe, which reports unexplained infertility as the most common cause of Infertility, affecting 22% of the women seeking treatment at gynaecological clinics [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Unexplained infertility is a diagnosis of exclusion for couples who are unable to conceive despite regular unprotected sex and do not fit the criteria for diagnosis of male or female factor infertility [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In various reviews regarding infertility, unexplained infertility has been reported to account for varying numbers of cases, ranging between 10.4% \u0026minus;\u0026thinsp;30% [\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Tubal blockage may be caused by sexually transmitted infections, pelvic infections, fibroids, pelvic adhesions after fibroid surgery and other factors. It is reported to account for 30\u0026ndash;40% of female infertility. Where resources and skills are available, it may be managed by tubal microsurgery. However, the majority of case management requires IVF [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In the present study, it was the third most common cause of infertility, accounting for 14.44% of infertility among women defaulting to fertility treatments at the centre. This finding is consistent with data from other regions where tubal factors are a common cause of infertility. For instance, in Zimbabwe, tubal blockage was responsible for 20% of infertility among women seeking fertility treatment [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Similarly, it represented 22.3% and 25.5% of the causes of infertility cases among Omani women [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] and women in Austria [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], respectively. It was also observed that male infertility contributed to 8.65% of infertility cases in this study. This proportion of male factor contribution is low compared with that in Zimbabwe (19%) and reports across Africa (22.26%). The observed discrepancy could be because many patients presented semen analysis from non-standardised laboratories, where the WHO strict criteria were not applied.\u003c/p\u003e \u003cp\u003eIn-vitro fertilisation (IVF) was the most common treatment offered (48.08%) to these women who defaulted, followed by ovulation induction with timed intercourse (33.65%). In-vitro fertilisation, ovulation induction with timed intercourse or intrauterine insemination (IUI) are common treatment options offered to couples requiring fertility treatment, even though the latter two are not assisted reproductive technologies [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. IVF offers the best success results [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Ovulation induction involves using drugs to trigger the release of mature oocytes. [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. For fertilisation to occur after the induction, it can be coupled with timed intercourse or intra-uterine insemination in which washed partner spermatozoa are placed in the uterine cavity near the tubal ostia. Ovulation induction with timed intercourse is frequently used for women with less severe infertility issues, such as ovulatory disorders [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Furthermore, it is less invasive and costly compared with IVF, making it a first-line treatment option. In this study, only a small number, 14.42%, had some form of treatment before presenting to the fertility centre. Almost half (46.66%) of them had had ovulation induction with timed intercourse, suggesting that their diagnosed cause of Infertility could not have been severe.\u003c/p\u003e \u003cp\u003eThe reasons for ART treatment defaults provided by these women in this study were the high treatment cost (70.20%) and partner non-availability (35.57%). These findings agree with those of a study in Northern Nigeria, where women receiving ART services cited high financial costs as a barrier to continued use of the services [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Other studies exploring the experiences and challenges of Ghanaian women using ART services reported high costs as a significant challenge for their continued fertility treatment [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The financial burden associated with ART service utilisation is a recognised barrier to ART access in low and middle-income countries, particularly the African subregion [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. The high cost of ART services in Africa has been attributed to the capital-intensive nature of setting up ART facilities, the highly privatised services, the limited number of clinics relative to demand, the high operational cost and a lack of government support [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Even though couples with infertility in Ghana enjoy autonomy in their choices of ART treatment options, this may be compromised when financial constraints limit their choices. Addressing these challenges with strategies such as introducing supportive regulatory frameworks and policies to reduce operational costs and promote public investments in ART services can make these services more accessible and affordable. Without government support or subsidised programmes, the economic burden on patients impedes equitable access.\u003c/p\u003e \u003cp\u003ePartner non-availability was the second most common reason for the discontinuation of ART services by 18.27% of respondents in this study. Similarly, Arhin et al. reported a lack of support from male partners, seeking alternative treatment and relocation as major reasons for discontinued ART service utilisation [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. The non-involvement or unavailability of male partners in seeking fertility treatment is problematic because males contribute equally to Infertility and must be evaluated to arrive at a conclusive diagnosis of the cause of Infertility. Furthermore, ART treatment can be an emotionally challenging journey, making emotional support from a partner essential for the overall outcome.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings of this study highlight significant barriers to accessing ART services in Ghana despite the absence of restrictive legislation that allows for greater patient autonomy. The primary obstacles identified were prohibitive treatment costs, lack of partner availability, and insufficient awareness of ART services. These barriers contribute to high levels of inequity and injustice in the accessibility of ART for Ghanaians facing infertility challenges. Moreover, while ART professionals in Ghana are generally well-educated and capable of providing a broad range of services, the majority desire a more regulated practice environment. To improve equity and justice for ART services in Ghana, it is essential to address these financial, informational and regulatory challenges, ensuring that all individuals in need can benefit from the available reproductive technologies.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations\u003c/h2\u003e \u003cp\u003eThe Government of Ghana must introduce policies and regulatory frameworks to support the existing private-public collaborations in training ART professionals, establish more ART clinics, equitably distribute trained ART experts, and reduce ART operational costs to make ART services more accessible and affordable. At a minimum, the Government of Ghana's budgetary allocation for health must absorb the cost of fertility assessment and some essential treatments through the National Health Insurance scheme.\u003c/p\u003e \u003cp\u003e The Fertility Society of Ghana (FERSOG), the health regulatory authorities, and parliament must take the necessary steps to enact the laws and guidelines required to regulate and curb excesses in ART practice in Ghana as desired by the practitioners.\u003c/p\u003e \u003cp\u003eART practitioners must formulate innovative policies and strategies for targeted information dissemination through means outside the traditional and social media platforms to improve public awareness of the causes of infertility, the role of male partners and the availability of effective treatment options, including ART.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eART: Assisted Reproductive Technology\u003c/p\u003e\n\u003cp\u003eIVF: \u0026nbsp;In-Vitro Fertilization \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eE.T.: \u0026nbsp;Embryo Transfer\u003c/p\u003e\n\u003cp\u003eFERSOG:\u0026nbsp;Fertility Society of Ghana\u003c/p\u003e\n\u003cp\u003eCHRPE: Committee on Human Research, publications and Ethics\u003c/p\u003e\n\u003cp\u003eKNUST:\u0026nbsp;Kwame Nkrumah University of Science and Technology\u003c/p\u003e\n\u003cp\u003eICSI: Intracytoplasmic Sperm Injection\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNAC:\u0026nbsp;Nurse Assistant- Clinical\u003c/p\u003e\n\u003cp\u003eIUI:\u0026nbsp;Intra-Uterine Insemination\u003c/p\u003e\n\u003cp\u003eFET:\u0026nbsp;Transfer of Frozen Thawed Embryo\u003c/p\u003e\n\u003cp\u003ePGD: Pre-Implantation Genetic Diagnosis\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted this survey according to the guidelines and regulations outlined in the Declaration of Helsinki. Ethical approval for the survey, CHRPE/AP/205/24, was obtained from the Committee on Human Research, Publications, and Ethics (CHRPE) at Kwame Nkrumah University of Science and Technology (KNUST), School of Medical Sciences - Kumasi. Consent from all eligible participants was sought formally before being recruited to participate. The study was carried out in accordance with the declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used or analysed during the current study are available from the corresponding author upon reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo external funding was either sought or obtained for this study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConception of the Research Proposal:\u003c/strong\u003e Francis Jojo Moses Kodzo Damalie, Charles Mawunyo Senaya, Elikplim Adzo Damalie, Herbert Ekoe Dankluvi, Millicent Osaah, Beatrice Yeboah, John Jude Annan, Ellis Fleischer \u0026nbsp;Djoleto, Rudolf Kantum Adageba, Alexander Tawiah Odoi\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProject Development, Data Collection and Analysis and Interpretation:\u003c/strong\u003e Francis Jojo Moses Kodzo Damalie, Elikplim Adzo Damalie, Herbert Ekoe Dankluvi, Millicent Osaah, Beatrice Yeboah, Ellis Fleischer \u0026nbsp;Djoleto\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eManuscript Writing:\u003c/strong\u003e Francis Jojo Moses Kodzo Damalie, Charles Mawunyo Senaya, Beatrice Yeboah, John Jude Annan, Ellis Fleischer \u0026nbsp; Djoleto, Rudolf Kantum Adageba, Alexander Tawiah Odoi\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to acknowledge the participants who consented and contributed to the success of this study.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHazlina NHN, et al. 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Hum Reprod. 2021;36(11):2921\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArchary P et al. Assisted reproductive technologies in Africa: The African Network and Registry for ART, 2020. Reprod Biomed Online, 2024. 49(5).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSauer MV. Italian Law 40/2004: a view from the 'Wild 'West'. Reprod Biomed Online. 2006;12(1):8\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkoye IB, Nwabachili CO. Rethinking a Legal Framework for Assisted Reproductive Technology. IJOLACLE. 2023;4:30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEkechi-Agwu CA, Nwafor AO. Regulating assisted reproductive technologies (ART) in Nigeria: lessons from Australia and the United Kingdom. Afr J Reprod Health. 2020;24(4):82\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOliveira BL, et al. 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Transnational connections of health professionals: medicoscapes and assisted reproduction in Ghana and Uganda. Ethn Health. 2016;21(4):357\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArchary P et al. \u003cem\u003eAssisted reproductive technologies in Africa: The African Network and Registry for ART, 2020.\u003c/em\u003e Reproductive BioMedicine Online, 2024: p. 104353.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBanker M, et al. International Committee for Monitoring Assisted Reproductive Technologies (ICMART): world report on assisted reproductive technologies, 2013. Fertil Steril. 2021;116(3):741\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ede Ziegler D, et al. Training in reproductive endocrinology and infertility and assisted reproductive technologies: options and worldwide needs. Fertil Steril. 2015;104(1):16\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdesiyun AG, Ameh N, Avidime S. Awareness and Perception of assisted reproductive technology practice amongst women with infertility in Northern. Open J Obstet Gynecol. 2011;1:144\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHiadzi RA, Boafo IM, Tetteh PM. God helps those who help themselves'\u0026hellip; religion and Assisted Reproductive Technology usage amongst urban Ghanaians. PLoS ONE. 2021;16(12):e0260346.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnaman-Torgbor JA, et al. Experiences of women undergoing assisted reproductive technology in Ghana: a qualitative analysis of their experiences. PLoS ONE. 2021;16(8):e0255957.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKyei JM, et al. Challenges experienced by clients undergoing assisted reproductive technology in Ghana: An exploratory descriptive study. Int J Gynecol Obstet. 2020;149(3):326\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKyei JM et al. Ways of coping among women with infertility undergoing assisted reproductive technologies in Ghana. Pan Afr Med J, 2022. 41(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDonnez J, et al. Uterine fibroid-related infertility: mechanisms and management. Fertility and sterility; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFreytag D, et al. Uterine fibroids and infertility. Diagnostics. 2021;11(8):1455.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorhason-Bello IO, Adebamowo CA. Epidemiology of uterine fibroid in black African women: a systematic scoping review. BMJ Open. 2022;12(8):e052053.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRizk BR, Khalaf Y, Borahay MA. Fibroids and Reproduction. CRC; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSefah N, et al. Uterine fibroids\u0026mdash;Causes, impact, treatment, and lens to the African perspective. Front Pharmacol. 2023;13:1045783.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMadziyire MG, et al. The causes of infertility in women presenting to gynaecology clinics in Harare, Zimbabwe; a cross-sectional study. Fertility Res Pract. 2021;7:1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRaperport C, et al. The definition of unexplained infertility: a systematic review. BJOG: Int J Obstet Gynecol. 2024;131(7):880\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbebe MS, Afework M, Abaynew Y. Primary and secondary infertility in Africa: systematic review with meta-analysis. Fertility Res Pract. 2020;6:1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarson SA, Kallen AN. Diagnosis and management of infertility: a review. JAMA. 2021;326(1):65\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbdallah KS, et al. How and why to define unexplained infertility? Seminars in reproductive medicine. Thieme Medical Publishers, Inc.; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmbildhuke K et al. A review of tubal factors affecting fertility and its management. Cureus, 2022. 14(11).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlbalushi H, et al. Prevalence of congenital uterine anomalies and tubal blockage in infertile Omani women: A retrospective study. Oman Med J. 2023;38(1):e463.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMayrhofer D, et al. Incidence and Causes of Tubal Occlusion in Infertility: A Retrospective Cohort Study. J Clin Med. 2024;13(13):3961.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoccia ME, Rizzello F, Orlandi G. \u003cem\u003eAssisted Reproductive Technologies\u003c/em\u003e, in \u003cem\u003eFemale Reproductive Dysfunction\u003c/em\u003e, F. Petraglia and B.C. Fauser, Editors. 2020, Springer International Publishing: Cham. pp. 263\u0026ndash;284.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrevention CfDCa. \u003cem\u003e2021 Assisted Reproductive Technology Fertility Clinic and National Summary Report\u003c/em\u003e\u0026mdash;2023 US Dept of Health and Human Services.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFiebai PO, Ikimalo JI. Challenges with assisted reproductive technology (ART) in sub-Saharan Africa. Afr J Reprod Gynaecol Endoscopy. 2019;4(1):3\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArhin SM, et al. Pharmacotherapy of infertility in Ghana: Why do infertile patients discontinue their fertility treatment? PLoS ONE. 2022;17(10):e0274635.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Assisted Reproductive Technology, Access, Equity, Ghana","lastPublishedDoi":"10.21203/rs.3.rs-6180416/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6180416/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRestrictive legislation, which is the main barrier to some assisted reproductive technology services in many countries, is non-existent in Ghana. However, these services are available only in the burgeoning capital cities of only four out of the sixteen regions of the country, patronised mainly by the middle or upper class of the society. There is a dearth of evidence on the factors that limit access to ART services to most Ghanaians. This study aims to document these barriers to ART in Ghana.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and methods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA cross-sectional survey was conducted across all twenty-two fertility centres in Ghana in July 2022 using two structured questionnaires administered separately via Google App to sensor ART personnel in these centres and treatment defaulters at Hallmark Medicals, Kumasi.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSixty-one ART professionals and 104 ART clinic defaulters responded to the questionnaires. Mentorship/observership from more experienced senior colleagues locally (65.57%) was the most common mode of acquiring knowledge and clinical skills in ART. Almost all (91.80%) ART professionals offered all ART procedures available globally, but 86.89% yearned for a regulated practice. They identified high treatment costs (70.49%) and lack of awareness (16.39%) as the main barriers to ART services in Ghana.\u003c/p\u003e\n\u003cp\u003eMost women who defaulted to ART clinic attendance or treatment (88.47%) had visited the fertility centre based on word-of-mouth recommendations, compared to 4.8% who did so following traditional and social media information. More than half (50.96%) were in their thirties, and only 30.77% were in their forties. Almost half (48.08%) of them required IVF. A good number (58.65%) sought treatment within five years of Infertility, but 70.2% defaulted because of prohibitive treatment costs and 35.57% for partner non-availability.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEven though there is complete autonomy to all ART services in Ghana, access is limited by prohibitive treatment costs, partner non-availability and lack of awareness. Meanwhile, the ART professionals advocated a regulated practice.\u003c/p\u003e","manuscriptTitle":"Assisted Reproductive Technologies (Art) Equity, Justice and Autonomy in Ghana","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-25 09:40:27","doi":"10.21203/rs.3.rs-6180416/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision 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