In recent times, there have been some misconceptions about Assisted Reproductive Technique (ART), especially In Vitro Fertilisation (IVF).
A school of thought says it is fraught with risks due to multiple births and caesarean births. Another is worried about the high cost, lack of regulation and guidelines; and indiscriminate springing up of fertility clinics. There are also fears that IVF babies cannot compete favourably with those born through natural means.
Director, Nordica Fertility Center, Victoria Island, Lagos, Dr. Abayomi Ajayi, in this interview with CHUKWUMA MUANYA throws more light on these misgivings on IVF, why Nordica is offering free IVF treatment to Nigerians, plans by the clinic to offer free treatment and screening services to more Nigerians; among other things.
There are heightened fears on the perceived risks associated with Assisted Reproductive Technique (ART), especially In Vitro Fertilisation (IVF). A school of taught says that it's association with multiple pregnancies and Caesarean section increases the chances of mother and child mortality. How true is this?
Yes! Multiple pregnancies, we know that about 25 or 30 per cent of babies born from assisted conception, especially IVF will be more than one. Therefore the more the number of babies the higher the risk of operative deliveries to start with. That is one way of looking at it. Of course we know the procedure that assisted conception involves. It involves multiple ovulation sometimes even multiple transfer of embryos and therefore sensible success rate. And one of the problems of this is multiple pregnancies and multiple births. They are the attendant risk of this multiple transfer. You remember the one that happened recently in the United States which was overblown. But in this environment we tend to tolerate multiple pregnancies better than Caucasians for whatever reasons. Naturally, Nigeria and the Republic of Ireland have the highest twinning rates in the world. So, there is something in us that carries at least two better than the Caucasians. But when it gets beyond three now it becomes something.
But unfortunately the procedure of IVF also involves transferring more than one except now in Europe where they are doing what is called single embryo transfer.
We have not started doing that here in Nigeria and I am not sure whether we are looking forward to doing single embryo transfer, except in very selected patients. Because like I said we tend to accept multiple births.
It is has also been said that IVF is bedevilled with multiple births because the practitioners are trying to increase the chances of conception?
Yes! That is the thing, because here everybody pays out of pocket. Government does not pay for anybody and therefore you want to maximise the chances without causing any harm to the patient and that is why we do not transfer more than three. The worse case scenario we have triplets, which even without IVF in this environment almost every obstetrician would have had to deliver one or two triplets in his career.
So triplet is still not being frowned at but higher order of multiples above triplets is what people are not comfortable with.
Considering what happened in the United States where assisted conception led to sextuplets, what are the chances on the procedure we practise in Nigeria on your patients having such?
in Nigeria it is better we confine it to not more than three because there is no support system here, unlike in the United States. You remember when the woman even had the babies there was a Nigerian that had sextuplets before who came to visit, and all the children survived. That is of course because services are well advanced, if they have to take over the ventilation of the babies, they have the facilities. But here it is not readily available.
Another issue is that of cost. It has been suggested that it costs between N600 and N1.5 million to procure one cycle of treatment, making it out of reach of the ordinary Nigerian. And in that cycle, the chances of the woman getting pregnant is not more than 30 per cent. How true is this?
That is true! The success rate of IVF is about 25 to 30 percent and that is any where in the world. What IVF tries to do is what happens in a woman in a natural cycle. And the success rate of nature is about 18 to 20 per cent every month. So if IVF can give you 25 per cent, it is a little bit more than what nature can do. And therefore the success rate is like that and people are still working to see how we can improve the success rate. But as of now that is it. One thing we cannot afford to do is compromise standards. IVF babies are normal babies and that is because the quality control system in the body are not tempered with in IVF.
So, that is why we have normal babies. So people want to increase success rate without decreasing the quality of the baby. So that is usually the balancing act that is being carried out in researches.
On the issue of cost I can only talk about my own centre, I do not know how much other people charge. I know that there is no treatment that is up to N1.2 million for a cycle in my centre.
But people are crying that they cannot afford this. How much do you charge for an average cycle here?
We charge between N600 to N800, very maximum N900. You always take things out of context not comparing it what happens in other parts of the world. For instance in the United Kingdom, a cycle costs about $4000, that is without the air fares and other logistics. We have to bring in all the materials we are using even our consumables from there. And they do not have the problem of electricity supply. I have three electricity generating sets here now, and if I tell you how much I spend on diesel every month.
There are costs for us that we need to meet, but we are also mindful of the environment in which we practise that it might get to a point and people will not be able to afford it. But is not as bad as it sounds most of the time.
Do you have plans for the ordinary Nigerian to be able to access this assisted fertility technique considering the cost and the economic realities. Practically a couple that earns an average of N100,000 month cannot afford it. How can it happen?
The bad thing about our environment is that you have to pay for everything out of pocket. There is nobody helping you, no government to help, whatever. Whether it is possible for government to help, I am not very sure. You know that the government is saddled with so many responsibilities now. But the good thing here is that we have the extended family network. Infertility is always a challenge not only to the couple but to the whole family. So even if you are earning a N100,000 you will see the rate that family members are ready to help because they know that if you do not have this, you will continue to look for it and it is unsettling.
Even the World Health Organisation (WHO) defines health as not only physical but also emotional. Therefore if someone has something troubling him or her, is not likely to be at his or her best and people are aware of that. So, it is like people rally round. I am sure that is not everyone that comes around here is paying out of their own pocket; this like most of the time a joint effort. We are mindful of that in this environment, and that is why we want to give the patient the best value for their money.
Do you have a program to help those who cannot afford it?
Yes! We did this EART (Expanding Access to Reproductive Treatment), which has crystalised now to Fertility Treatment Support Group (FTSG). There is now a support group that is incharge of that program. We are still running it this year.
The programme is offering free IVF treatment to patients. It was so rewarding to us that really encourage us. We tried to get sponsors last year but we did not succeed. Well, we got some sponsors; some of the media houses came to our rescue. But we did not really get anybody to bring out the money, so it was like we sponsored almost the whole thing and that limited the number of women we could give access to. But we are still working on it, to see how we can increase the number.
How many women or families have benefited from this programme?
What we have in mind is that we are going to give free treatment to 16 women; we are going to be giving two women every quarter. But we are going to be giving free screening to 10 women every quarter.
And out of these ten women, we choose two people. The first set that we gave was so revealing. There were some things that we found out, that out of these 10 people- some that were not even part of the two that finally had IVF- there was a life saving situation in one of the women. I am not sure whether the woman would not have dropped dead one day if the condition was not diagnosed. She had what was called a polyp in the uterus and she was bleeding every month, and they were not doing anything about it. It was during our screening that we saw that, and what we now did was to use what we call hysteroscope to bring out the polyp. She is alright now, she does not have a child yet but she is alive and well. And that made us to see that it is beyond even having children, that this programme can also help in sustaining health in this environment.
Another issue is the fear that people born through IVF cannot compare favourably with people born through natural means. Some suggest that IVF babies are not normal or not perfectly normal. Can you compare children born through IVF with those born through natural means?
The answer is yes! As I told you earlier on, all the quality control system in the body are reclaimed in IVF and so babies born through IVF are normal babies. We have had over three million babies born all over the world by IVF and they are perfectly normal babies from what statistics have shown us. You can talk to even some of our own babies. One just came on Saturday.
How many babies have been born in this facility through IVF?
We presented our figures a few weeks ago, over 268. We still have about 60 women on the waiting list, and two of them have delivered.
What is the age of the first IVF baby?
The first will be five in September
Boy or Girl?
A boy, Julian.
What is the next thing for Nordica? What are your plans for the future?
Well! Two things we did. We had a dinner where we invited all stakeholders, including the press to see what we have done so far in our last six years of establishment of Nordica. We also wanted to work with the media in raising the awareness on endometriosis. So these were two things we wanted to do together. It is very important for the public to be aware of things concerning assisted reproduction, for it to always be in their consciousness that it is necessary for some people to have assisted conception and they should not leave it as the last resort; that when you need it, you need it and you should go for it soon enough because we know that success decreases with age especially of the woman. Also for us to raise the awareness of this condition called endometriosis, which is not given its proper place in media practise in Nigeria.
What is endometriosis? And what is its impact on fertility rate in Nigeria?
Well endometriosis is the occurrence of endometrial tissue in any other place apart from in the endometrium (the inner lining of the uterus). And what happens is that this endometrial tissue reacts to the hormone that the woman secrets every month, just like the endometrium does. You see what happens it that the women sheds her endometrium when she sees her menstrual cycle. The same thing she now sheds the endometrium in order places apart from inside the uterus. So you can imagine if it is on top of the ovary, she is now shedding her endmetrium inside the abdomen. So with time there is a collection of blood, which contains some unwanted substances and it starts to form what we call additions or scarring inside the woman. So, definitely because of this, it disturbs the anatomy of the reproductive organ leading to infertility.
The other way is that because of these chemicals that are contained, which is not normally in the abdomen, these chemicals are released which kill eggs and ill sperms. So two ways that endometriosis can affect fertility is either chemical or mechanical.
What the percentage of the infertility caused by endometriosis?
It would be around 20 to 40 per cent.
You said its being neglected?
When we were in medical school we were told 15 years ago that endometriosis was not common in this environment. Now, whether it was not common then or we were just simply missing it, I do not know. But I know now that it is common. Maybe because we now have better facilities to diagnose and we are better skilled at doing some of things. But it is not a peculiar thing to Nigeria, because in the United Kingdom, between the unset of symptoms and diagnosis takes about eight years in which she must have seen about five doctors who will not have made the diagnosis. And that is where records are kept. So in Nigeria, where records are not kept, many women go through out their life time without a diagnosis.
At what stage will a couple need assisted reproduction and how should they go about?
I think the question to ask is at what stage will they need intervention, evaluation of a doctor. This depends on the age of the woman to start with because there is no particular age at which women get married.
It is when the man comes along. So if the woman is above 35, then after six months of trying she should see the doctor who should do some investigation. But if she is less than 35 years she can wait for one year and then see the doctor. But if there are obvious things in the offing then she does not need to wait this long. For example if her menses are irregular; if the man has some history of trauma to the testes while he was younger, undescended testes. Those are things that are obvious and they are pointer to the fact that you do not need to wait, you need to quickly see the doctor. When these things are not present, we allow six months for women who are above 35 and above, and we allow one year for a woman who is less than 35 to be properly evaluated
Are you concerned about late marriage especially by women, and its impact on childlessness?
I think that is a fact all over the world. Women are going to school more than they used to do before and that also is taking a toll on fertility, because we know that a woman is most fertile in those years that they go to school. And by the time they finished school they want a career and may be Mr. Right might not come on time. All these are things that might hinder reproduction when they finally decide to do that. So what we try to let people know is that no matter what you do, nobody is against a woman having a career or whatever, do not forget to have children at the right age.
Another issue is that of quackery. Some clinics are making audacious claims on IVF. Do you have an association? How is the regulation of the practice in Nigeria?
Regulation. None for now and that is one of the things that we are clamouring to have in our industry.
So for now what the IVF clinics do is just to register with the Medical and Dental Council of Nigeria (MDCN) and the Nigeria Medical Association (NMA)?
You are just a doctor and that is it. If you are a gynaecologist, you belong to the society of Gynaecologists of Nigeria (SOGON).
Do you not think this is a dangerous trend, and you are allowing cracks in the practice?
Obviously, it is not a very healthy development. If you trace the history of IVF all over the world, it is just the same thing that happened even in UK that is happening here. We need to form a strong body that will see to it. But of course we cannot do anything without the government, because no matter how we need policing and the only person that provides policing in Nigeria is still the government. So it is for us to have a body and then align with the government in order to give teeth to whatever regulation that we want to be in place.
More studies are implicating petrochemical products and paints as major causes of infertility. How strong is this link?
Well! The environment has always played a factor in fertility especially with industrialisation. We know there are so many hydrocarbons in the atmosphere that can be converted into oestrogen (female sex hormone) and when a male is exposed to a particular level of oestrogen it affects spermatozoa formation. Everywhere in the world the environment's an issue. In Denmark, it has been shown that in mothers who smoke their boys usually have lower sperm counts.
What is your advice to Nigerians to things they should do to ensure that they stay fertile? Or have maximal fertility rate?
I think the most important thing is that you live a healthy life. And living a healthy life involves what you do, what you eat and what you drink. And probably even what you wear. It is better to maintain a healthy Body Mass Index (BMI) and that might involve exercises. BMI is a measure of weight in kilograms over height in metres square (kg/m2). BMI between 20 and 25 is normal/healthy, 25 to 30 is overweight, and above 30 is obesity. And then you must watch what you eat also to ensure that you are eating balance diet. Not too much alcohol, if possible none at all. Sometimes we talk about this cotton underwear. Some people who are on the borderline, this might be helpful for them. Limit the exposure of the testes to hot temperature. Avoid hard drugs, avoid if possible smoking, it has been known to affect both the man and woman. No obesity, and if you can be in control, choose the job you do.
What is your parting remark?
Infertility will always be with us and therefore it is important for people to know what to do when they face the challenge of infertility. It is important for us to give the right knowledge to people, so that they will do the important thing when they are faced with the challenge of infertility. I am not saying that you should not go to any religious setting, but they should do the right thing go to the proper places where they can be helped. The most important thing is for you to know where you can be helped; you need knowledge. The Internet is there. I keep saying that to my patients.