CONCEPTIONS Thirty-five years later, the first assisted reproductive technology program opens in Cambodia In the fall of 2014, the first assisted reproductive technology (ART) program opened in Cambodia. This event took place in Phnom Penh 35 years after Cambodia emerged—in the early days of 1979—from the worst geopolitical nightmare and genocide that the world has known since the Holocaust. In nearly 4 years of abuse, the Khmer Rouge regime through active killing and starvation had exterminated a third of the country's population, who perished in the Killing Fields. In January 1979—the nightmare suddenly over—the country stood in rags and tears, with all needing to be rebuilt from scratch while wounds healed. Nearly concomitantly, in 1978, the birth of the first baby conceived in vitro paved the way for the hallmark of today's infertility treatments worldwide, assisted reproductive technology, or ART. In an extraordinary expression of human resilience, Cambodia has regained all the fundamentals of life and now strives as one of the emerging countries of Southeast Asia. In the wake of this return to normal of public and private life—‘‘business as usual’’—Cambodia opened its first ART program. Today, therefore, Cambodian couples, as others elsewhere, can be told that state-of-the-art infertility services are available at ‘‘a clinic near you.’’ This rare event—the opening of a first ART program in the country—is an occasion for pausing and musing over the needs of ART programs in emerging countries. Specifically, we will attempt to pinpoint how these needs differ from either those of the industrialized world or certain options proposed in developing countries. For clarity's sake, we will center our discussion on the following three questions: In today's rapidly evolving ART environment, what should be the cornerstone fundamentals—protocols, tools, investments, and so on—for a new ART program? How do these choices differ in an emerging country—such as Cambodia— compared with those that exist in either industrialized or developing countries? Could there be a specially designed controlled ovarian stimulation (COS) adapted to the demographics of infertility in the emerging countries? What is the net value of nearby infertility care compared with—as was the case earlier in Cambodiae—cross border reproductive care (CBRC)? How can fertility care at a ‘‘clinic near you’’ enhance both the efficacy and safety of ART? Finally, which are the medical and social obligations befalling the leading ART centers of emerging countries?

STRATEGIC CHOICES FOR ART IN EMERGING COUNTRIES A New Entity: the Emerging Countries Historically, countries were sorted in two distinct categories based on their economic status (after the collapse of socialism rendered the 3-world system obsolete), the industrialized and developing countries. Today, this dichotomy may be too narrow for properly reflecting the realities of our rapidly changing world. Along with these two extremes, there is indeed a mounting new third entity, the emerging countries. The latter 1146

share certain features with either their industrialized or developing counterparts but differ from both. Notably, emerging countries are distinctive by the existence of a new and rapidly expanding middle class. Cambodia—left for dead 35 years ago at the end of the Khmer Rouge nightmare—today bustles and thrives alongside its larger neighbors, Thailand and Vietnam, as one of the emerging countries of Southeast Asia.

Infertility in the Emerging Countries The emerging countries—in the wake of the four major players of the BRIC group (Brazil, Russia, India, and China)—have specific needs for infertility management. These stem from some outstanding differences in the prevailing causes, demographics, and social impact of infertility, as well as from the distribution of resources. Characteristically, emerging countries have a higher incidence of infertility owing to potentially preventable sexually transmitted and postpartum/abortion-related infections than is seen in industrialized countries. This in turn has an impact on the demographics of infertility, generating a larger fringe of younger infertile women—a characteristic also found in the developing countries. These younger women are prone to respond more strongly to COS. This host of younger infertile women found in emerging—and developing—countries justifies custom designing some COS protocols for tending to women with high-responding characteristics. Along with the young infertile women, the emerging countries also have their fair share of age-associated infertility. As in industrialized countries, these cases of infertility—most often unexplained—are primarily associated with a postponement of the family project. Logically, therefore, these women—generally older—need to rapidly access ART, just like their age-matched counterparts in industrialized countries. Therefore, it would be an error to design fertility care centers in the emerging countries that solely offered simplified COS treatments tailored for the younger age groups. This kind of approach, a single-simplified treatment, is indeed often found in the developing world but only because of a lack of resources (for patients and the health care system alike). The social consequences of infertility can be devastating in emerging and developing countries alike. In these communities, families often make up for the lack or insufficiency of social and/or retirement protection systems. Childlessness is therefore bound to bear harsher consequences with financial implications not known in the industrialized world. These particularities should not be dismissed or ignored. It would be indeed wrong to suggest that fertility care in nonindustrialized countries is nonurgent and just a frivolous perk, which can wait for other public health needs to be fulfilled. The rapidly expanding middle classes of the emerging countries expect a level of fertility care that is defined by their financial resources and ability to enquire and compare. Large fractions of these middle classes are indeed bound to seek abroad—through CBRC—the treatments that are lacking at home. Hence, the offerings made through CBRC—amply advertised online—illustrate the scope of fertility care that is expected locally in the emerging countries. These perceptions are substantially different from VOL. 103 NO. 5 / MAY 2015

Fertility and Sterility® what exists in the developing world owing to the lack of a significant middle class. The demographics of infertility in the emerging counties—more young infertile women—call for broadening the treatment possibilities beyond the classical proposals made in the industrialized countries. Custom-designed treatments—notably, COS protocols—must be tailored to the needs of the large numbers of young infertile women who may be hyper-responsive to ovarian stimulation. Indeed, properly screened women of

Thirty-five years later, the first assisted reproductive technology program opens in Cambodia.

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