When she got married at the age of 35, Angelique Zaninka, a resident of Kanombe, had hopes of starting a family with her partner. Among their priorities was having children, however, this was never the case, even after five years of trying to conceive.

Due to pressure from society and family members, she felt ashamed to discuss the issue with her husband, and like many women facing infertility issues, she decided to secretly seek help from a gynaecologist. After being examined many times by different doctors, the results kept coming out fine, indicating that there was nothing wrong with her reproductive health.

"I had to sit back and endure the suffering from society, as everyone believed I was the problem, given that my age was also at risk of having infertility issues,” says.

Early last year Zaninka’s husband suggested that they go for a check-up together; this is when it was discovered that the husband had chromosomal abnormalities, a condition that was hindering the couple from conceiving. After treatment, the couple finally conceived, and now have a five-month-old baby.

In the society we live in, Dr Theodomir Sebazungu, a gynaecologist at University Teaching Hospital of Kigali (CHUK), says, there are many women suffering silently with infertility stigma, bearing the most suffering as compared to their male counterparts, yet at times the fault could be the husband and not the other way around.

He says it’s ideal for society, mostly women who are forced to believe they are the reason behind infertility, to shun any kind of embarrassment and instead, talk about the issue as well as seek medical help as a couple.

He points out that there is a big issue when it comes to men willingly accepting to be examined since in Rwanda, just like any other African country, it’s believed that being sexually potent as a man is proof of fertility already.

In many cultures, he says there is still a strong but false stigma attached to infertility.  "This stigma is attached to fertility, making women alone bear the suffering as most men will not see the need to be examined,” he says.

Status of infertility

A recent study carried out by University of Rwanda’s School of Medicine and Health Sciences and other affiliations has revealed that the overall prevalence of primary infertility caused by chromosomal abnormalities was 25.4 per cent among the patients who consulted the genetic department.

Dubbed "Prevalence of primary infertility caused by chromosomal abnormalities and assessment of clinical manifestations in Rwandan patients”, the study showed that females were more affected than males — with 32 and 20.58 per cent of females and males being primarily infertile due to chromosomal abnormalities, respectively.

The study carried out research on 59 patients, male and female, with primary infertility who consulted the genetic department between June 2009 and June 2019.

The study whose findings were conducted in three referral hospitals — University Teaching Hospital of Kigali (CHUK), Rwanda Military Hospital (RMH), and University Teaching Hospital of Butare (CHUB) — which work with the Genetic Lab located in Huye.

Symptoms considered for females were the inability to conceive for one year despite unprotected and regular sexual intercourse and abnormal menstrual cycles. Symptoms considered for males were the inability to induce pregnancy regardless of multiple unprotected sexual intercourse. The majority of patients (57.6 per cent) were males whilst 42.4 per cent of patients were females.

Impact of stigma

Emmanuel Mahoro, a psychologist working with young people in Rwanda, says it has been identified that infertility in women is always associated with high depression rates and other mental health issues, which all come from social stigma. She says, for instance, the bad attitude and treatment from family members and discrimination from society can cause even mental and emotional trauma to the victim.

"This can lead to permanent psychological issues on the victim, as they will be subjected to live in isolation for the rest of their lives,” she says. Mahoro says the stigma can have a negative impact, as there are high possibilities of a woman feeling ashamed and blaming herself for letting her man down for not giving him a child.

Breaking the stigma

Dr Kenneth Ruzindana, a consultant obstetrician and gynaecologist at CHUK, says society needs to know that when people get married, some couples don’t choose to not have children, and it becomes a problem if you don’t have children yet you want to have them.

He says the pressure is more pronounced on women than men, all the causes of infertility are related to female, and there could be male-related factors as well or both, adding that it’s not an inclusively women problem—unfortunately, women are the only ones who bear the brand and the stigma from the society.

Dr Ruzindana strongly believes that there is need to understand that sometimes it takes time, and it’s important for any couple trying to conceive to spend at least one year trying and then go for a diagnostic check-up to find out where the problem is.

Meanwhile, Rwanda is currently developing a guideline for health care workers for preconception care visits, which is being done by the Ministry of Health through Rwanda Biomedical Center (RBC). The policy includes all the interventions done by medics to optimise the health of the couple before conception.

Ideally, he says, every couple that is planning or trying to conceive is encouraged to come for a preconception care visit. Any reproductive-age woman or man should have at least one preconception care visit in their lifetime before they try to conceive.

Dr Iba Mayale, a gynaecologist and obstetrician at Galien Clinic in Kigali, says in African setting, it was and still is taboo to not be able to give birth, and this still hits hard on a woman as compared to a man. He notes that this is due to lack of knowledge and awareness about infertility in general.

In normal circumstances, from a medical point of view, Dr Mayale says it’s just ideal for the couple facing any challenges when it comes to conceiving to seek medical attention.

"The first step when it comes to breaking the stigma, should start with the couple themselves, as infertility can either be caused by a man or a woman, when you understand this, it’s easier to start seeking medical attention as a couple, unlike cases where men will send their partners for a check-up,” he says.

When this is done, he says it’s easier to get any support needed as far as treatment is concerned thus avoiding stigma. To minimise infertility stigma, he says, they invite all patients with any infertility issue, and provide a conducive environment that allows the couple to open up and discuss what they are going through.

Fertility treatment options available

Currently, in Rwanda, there is a wide variety of treating fertility including Vitro fertilisation for couples that cannot be able to conceive naturally.

For such a couple, Dr Ruzindana says they have assisted reproductive technology which is available across the country. "When a couple visits medical care for infertility issues, he says the first step is to find out if they really have the issue, then identify the underlying issues which could be from female or male, then the treatment starts from there,” he says.

Other fertility treatment options include; minimally invasive surgical techniques, intrauterine insemination, in vitro fertilisation, and egg freezing among others.

Some facilities that have the capacity of treating infertility include Rwanda Military Hospital which opened a fertility clinic offering highly specialised services such as in vitro fertilisation or uterine insemination.

There are also other specialised private fertility clinics including Mediheal Diagnostic and Fertility Center, Kigali IVF and Fertility Clinic, and Asha Infertility Treatment, among others.