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Fertility specialist and founder of Montgomery Fertility Center Oluyemisi (Yemi) Famuyiwa discusses her article “Infertility public health: the WHO’s new global guideline.” Oluyemisi examines the historic release of global guidelines that reframe infertility as a matter of social justice rather than a luxury concern. The conversation highlights the practical strengths of these recommendations for low-resource settings while acknowledging critical gaps regarding environmental toxins and cultural nuance. Oluyemisi argues that addressing the emotional toll of fertility struggles requires a shift in how health care systems prioritize reproductive rights. Listen to discover why this scientific milestone must become a moral mandate for equitable access worldwide.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Oluyemisi Famuyiwa, fertility specialist. Today’s KevinMD article is “Infertility public health: the World Health Organization’s new global guideline.” Yemi, Happy New Year and welcome back to the show.

Oluyemisi Famuyiwa: Thank you. Thank you for having me. Happy New Year.

Kevin Pho: All right. What is your latest article about?

Oluyemisi Famuyiwa: It is really impressive. We have been talking about infertility for a long time, and we all know that they recently assessed it as affecting one in six people. I think the WHO, or the World Health Organization, took this one step further. This is their first time ever creating a white paper about it. They made standard recommendations for it, and they want to elevate it to a global stage.

What this document did was say that fertility treatment should be available worldwide. They make specific recommendations, but they also took into account that not every place has the right resources. So they are taking it down to what we can do even in a low-resource setting. They want to create some standard guidelines that can be used in these settings in a systematic fashion that may help. If resources are available like in a high-technology place like the U.S. or the U.K., then there are other guidelines.

They also acknowledge that for some of the guidelines, they try to use what is called the best available science. We all know the best available science may not be available to everybody. So they said: “In that case, can we extrapolate to a low-resource setting so we can still get care for people who need it?” They came up with 40 guidelines and six specific best practices guidelines. They based these on the strength of the evidence available. Out of all of those, there is only really one that they make a really strong recommendation about. The other ones are sort of low-hanging fruit where they say you can do these other ones if you can.

Kevin Pho: Just for some context around the paper, what led the WHO to write this paper? And is this the first time that they addressed infertility in this fashion?

Oluyemisi Famuyiwa: This is absolutely the very first time. We all know fertility is declining worldwide. What they did was come up with a multidisciplinary team to acknowledge this as a health issue. The thing with infertility is that when you hear the WHO saying this is a problem and we are going to try and give you guidelines, in some countries that may be extrapolated to the government now saying: “Well, maybe we can allocate some resources and try to address this.”

The WHO does not jump right into high tech. They try to say that you can even see it as a public health issue. People encounter their initial care at the primary care level, so primary care doctors can start talking to them about it. We can promote health education that can be low-cost and taught in schools because a lot of people have no idea that some of the things that they are doing with their bodies have an impact on fertility.

They are saying that if we can disseminate this information all the way down to the primary care level and make it almost like a PSA statement, then we can make it gradual so that there can be a progressive workup. I think the reason they wrote it is because it is so prevalent. They are saying that if we can even start talking about it early enough, we can avoid some of the more complicated issues down the road. That may actually translate into cost savings down the road if you get things before they get worse.

Kevin Pho: Now in low-resource countries, just give us a picture. What are infertility treatment or options like in low-resource countries?

Oluyemisi Famuyiwa: They helped to say: “OK, how can we first diagnose it?” Let’s make sure that we agree on what to call ovulation. In the low-resource setting, instead of going straight to an ultrasound, let’s do a mid-luteal phase progesterone level. If it is abnormal, repeat it with the next level. In a low-resource setting, let’s do a semen analysis. If the semen analysis is normal, then you are good. But if one parameter out of the semen analysis is abnormal, then repeat it in 11 weeks. New sperm regenerate every 72 days or so. So they say count 11 weeks and repeat it. If it is still abnormal, then it is a big issue.

Then you can look at other factors. Does a person have a varicocele that needs surgery? For the women, do they have a hydrosalpinx that needs to be removed? Can you diagnose either unexplained infertility or PCOS, which is very prevalent? If you do, here is a systematic approach for unexplained infertility. Go through this low-resource algorithm first. Let’s see if Letrozole will do the trick. That is the treatment of choice. I know a lot of people think that Clomid is, but I think the literature has settled that equation out. Letrozole is the treatment of choice to begin with. If it does not work, go systematic. Use gonadotropins with IUI. If that does not work, then go to IVF. It does not abolish IVF, but it says to be systematic about it.

For PCOS, it is the same thing. Let’s cut out a systematic manner. In another low-resource setting, if you are really good at it and have been doing it a long time, you can use an ultrasound to evaluate if the tube is open and if the cavity is OK. Yes, you are going to have false negatives. Yes, it is not as good as having an HSG or being able to do the high-tech stuff. But if you are good at it and have been doing it a long time, you can do a hysterosonogram and see if there is a polyp. If you are really good at it, you can actually even see fluid tracking out the tube or air bubbles going out the tube. You have to be comfortable and good at it. That is a low-resource setting that you can use. A 3D ultrasound would be wonderful, but you may not have that available. In other words, you use what you have and see if we can get the biggest bang for your buck with what you have. If a patient needs IVF, then they need to be guided towards that without wasting additional time.

Kevin Pho: So it sounds like these new WHO guidelines or paper give a more systematic, algorithmic approach to people in low-resource settings to best utilize what is around them.

Oluyemisi Famuyiwa: Yes. The way I read this document, it is meant to be a living document. They realize that there are gaps in the literature. They realize we do not have as much scientific data for some countries all over the world like we may have in the Scandinavian countries or in the U.S. They comment that, yes, we know that there are gaps, and this is only a beginning.

It is so interesting that these are all the things that I try to do and talk about, especially in my upcoming book. In my book, I extrapolate it. I am not sure how often they are going to renew this document, but the next step they talk about is looking at exposure, lifestyle, and toxins. I already do that in my book that is coming out. Hopefully, those will be addressed in the upcoming guidelines that are coming forth.

Kevin Pho: Without these guidelines, I think I read in your article that in low-resource countries people resort to unsafe treatments. They use things that may not be medically legitimate and actually put women at harm.

Oluyemisi Famuyiwa: Yes, absolutely. I will give you an example. I had a patient who had fibroids who came to see me from one country. She said she went to an herbalist to get this treated because maybe she did not have access to the clinic or did not trust the clinic. I have no idea why. She had something inserted in her vaginal cavity. She stated that it burned at the time, but she was told to lie down and bear the pain and it would dissolve her fibroids. So she did that in excruciating agony.

When I examined her, it was like somebody had literally melted her vaginal cavity. It was all scarred up. There was a very tiny passage where maybe she got menstrual effluent. Beyond the scarred vaginal area that was all sealed off was still the fibroid uterus that is still there. I showed her on the ultrasound and said: “I don’t know what they did, but it’s still there. But I tell you what, now you have severe scarring.” She is going to need plastic surgery to undo that and additionally will need surgery on the fibroid that was never taken care of. If there are guidelines, women won’t resort to some of this. I call it “desperation medicine,” but they do not know better. There are no resources, and it is a mental agony for these women.

Kevin Pho: We have talked about how that paper addressed infertility in low-resource settings. Tell us some other takeaways that you got from the paper.

Oluyemisi Famuyiwa: I think the biggest takeaway is that they do come down really very hard and say tobacco use is bad. That one is unequivocal. They give the “Five A’s” of how to approach it. Ask at the time wherever you encounter the person: “Do they smoke?” Then you want to find out if they need access or help getting over it. Are they ready for it? Are they mentally ready to change? Also, assist them with coming up with a plan and then advocate for follow-up. That is the only thing that they come about strongly.

In essence, what it does is it gives women who are struggling in some of these countries words for what they are going through. They realize, “Oh yeah, this applies to me.” It gives language to care providers that they can use to connect to patients. It also may spur government initiatives. Now if the World Health Organization is talking about it, governments may move because they make policy that affects the health ministries. That may help initiate government support that may help these women down the road.

Kevin Pho: Are there any areas in this document that fell short or something that you would like to see more of addressed?

Oluyemisi Famuyiwa: I think that they did talk about it, but they didn’t really address it fully. The gaps will be in the next step. They need to address exposures, low-hanging fruits, and how they affect you. What can you do with your lifestyle and weight management? It is not just tobacco use again, but alcohol. What are the other things that people can do that are low-hanging?

More importantly, one of the things that I felt excited about was that this document says that IVF is an important part of fertility. It is not the initial go-to part of fertility, but it is crucial. There has been some talk in the general media where some people are saying that regenerative medical care can replace IVF. They are saying you can do all the preventative stuff and you can do all the initial workup, but IVF is still a crucial part of your armamentarium to treat fertility.

Kevin Pho: How about here in the United States? How does this document affect what you do as a fertility specialist and the patients that you see here in the United States?

Oluyemisi Famuyiwa: It does not affect what I do because I already do all these things. But I think it helps because I am trying to encourage my colleagues in the primary care field, in the family medicine field, and in the OB/GYN field to help with the initial workup. I recently signed a contract with Kaiser to be seeing their patients, and I am so excited about that. One of the things I do is go to my Kaiser colleagues and say: “Hey guys, you can really help me out before you send me this patient. You can do this, this, and this.” I give them the initial workup so that when they come to see me and they have all these done, I can speed up my treatment plan because all that initial stuff has been done.

Kevin Pho: As you know, I am a primary care doctor. Tell us about some of the workup that we can do before sending patients to you.

Oluyemisi Famuyiwa: OK. You can assess their day three hormones, for instance, by checking their blood work on the second or third day of their period for FSH, LH, estradiol, and progesterone. Checking the anti-Müllerian hormone is just blood work. Have them get an HSG or something similar to see if their tubes are open and the cavity is normal. Have their partners get a semen analysis if they have a male partner. If you have done that alone, you have done 90 or 95 percent of the workup. When they come to see me, it just expedites access to treatment with that basic one alone.

Kevin Pho: So what about next steps? What do you see from a policy standpoint as it relates to infertility in the coming year or so?

Oluyemisi Famuyiwa: Next steps will be for some governments in these lower-resource settings to step in and start allocating funds to it. Next steps in the U.S. are going to be tough because medication is so expensive. I am begging Mark Cuban with Cost Plus. Please, please, please invest in fertility medications. It is just killing everybody. If you can get to a point where medication is more affordable, a lot of this drama will be removed.

Kevin Pho: We are talking to Yemi Famuyiwa, fertility specialist. Today’s KevinMD article is “Infertility public health: the World Health Organization’s new global guideline.” Yemi, as always, let’s end with take-home messages that you want to leave with the KevinMD audience.

Oluyemisi Famuyiwa: The take-home message is that infertility is a real struggle. There is help out there, and there is systematic help. There are things you can do to even prevent some, not all, causes of fertility issues. Stay tuned, follow, and read more.

Kevin Pho: Yemi, as always, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.

Oluyemisi Famuyiwa: Thank you so much for having me.