Q: How prevalent is infertility in the Maasai community ? A: When I started working at Endulen Hospital (in 2008) not one patient reported infertility problems to me. Since then, the number of cases has been increasing slowly, as a result of increased trust and willingness to report the problem. By May 2010, 25% of the female patients at my outpatient consultations were reporting an inability to conceive. All can be epidemiologically defined as infertility cases, as these women had had unprotected sexual intercourse for more than two years. However, no study on the prevalence of infertility has been conducted in this area. Q: Why is infertility so high in this community? A: Many of the women that I have counselled on infertility had a history of a sexually transmitted infection (STI). Factors that are known to increase the risk of STIs include having had the first sexual contact at an early age and multiple sexual partners, combined with a polygamous marriage structure. Condom use--to prevent STIs--is low, as many Maasai people believe it is a waste of semen. But STIs are not the only cause of infertility. Tuberculosis and unsafe delivery practices can also cause infertility. Q: Is infertility a new problem for the Maasai people? A: No. Traditionally, Maasai society has developed creative solutions to infertility. If a woman did not conceive, her husband often permitted her to have sexual relationships with other men. Sometimes she went on a special journey for this purpose. If the woman conceived, the children were regarded as her bus band's children. But people are realizing more and more that this traditional solution can lead to health problems, such as HIV. Couples are therefore looking for safer solutions to overcome infertility. Q: What is the attitude to infertile women ? A: Women have limited say over money and goods. It is very important for a woman to have a husband or male relative to take care of her. Having children affirms her blessed relation to Engai [God], strengthens the relationship with the children's father and can secure inheritance of cattle via her sons. Traditionally, men hold decision-making power in Maasai society. They own the cattle, which are the main source of both food and income. If women do not have a husband or are not well taken care of, which is often true of infertile women, they may feel forced to ask for support from another man in return for transactional sex, and this creates new risks. Q: Do safer infertility treatment options exist for this community ? A: Risky sexual behaviour has been used to solve fertility problems for a long time in this community. Changing this will be difficult and can only be achieved in time, with education about prevention, diagnostic options and treatment so that people have an alternative to traditional solutions to infertility. Otherwise, infertile couples put themselves at risk of STIs, including HIV infection. At Endulen Hospital ultrasound services, semen evaluation and counselling are available. More advanced infertility treatment options are available in Arusha, about a one-day journey away. Q: What sort of programmes are in place? A: Endulen Hospital runs health education programmes, which include reproductive health, in secondary schools. Adolescents that do not go to school are hard to reach as they are mostly away with the cattle during the day. The hospital deploys extensive outreach clinics in child and maternal health by car and plane. On top of this, hospital staff sets up special campsites in remote corners of our catchment area. The staff then travels around in the area to offer voluntary counselling, testing and care for HIV, as well as education on STI prevention. Currently, these programmes do not educate people on the link with prevention of infertility. Q: You talk about Maasai women and infertility, what about the men ? …