WHY MOST NIGERIAN MEN HAVE LOW SPERM COUNT

Professor of Anatomy and Reproductive Endocrinology, Medical Art Centre, Ikeja, Lagos, Oladapo Asiru, traces the history of in vitro fertilisation in Nigeria and gives reasons for increasing infertility in the country, in this interview with NIYI ODEBODE.

There has been controversy over the history of in vitro fertilisation in Nigeria. Can you give a brief history of the practice?

The experimental work on in vitro fertilisation was started in Nigeria in 1983 by Dr. Akin Abisogun and me. When we succeeded in performing IVF in experimental animals, we started it in humans in the latter part of 1983. For the first time, in 1984, it led to a pregnancy. The first pregnancy ended up as a miscarriage. Following that, it became a big household event. Our success generated a visit of the then Minister of Health, Dr. Emmanuel Nsan, to our centre as well as a visit by his successor, Prof. Olikoye Ransome-Kuti, who established a ministerial panel to look into our work.

Prof. Osita Giwa-Osagie and I were successful in achieving the feat, which was among the few in the world. By 1986, we had delivery from gamete intra fallopian transfer. In 1989, we succeeded in having a baby girl born from IVF. The mother was a woman whose two fallopian tubes had been removed in England as a result of an ectopic pregnancy. She came to Nigeria, we were able to do IVF for her and she got pregnant on the first attempt. The Lagos University Teaching Hospital's magazine published it. Mr. Onajomo Orere of The Guardian reported it when Mr. Lade Bonuola was the editor. It was also reported by Ms. Luisa Agunyi-Ironsi of Tell magazine.

By 1998 and 2001, two other doctors joined the IVF programme in Nigeria. Today, we have about 15 IVF centres.

With your explanation, what would you say about a claim that the first IVF baby in Nigeria was delivered in Abuja in 1998?

It is totally incorrect. The first IVF baby was delivered in 1989. She is still alive. It was well publicised as I had said. The woman was interviewed. When the publicity became too much, her lawyer wrote to us that we should stop it.

What are the recent developments in assisted reproduction?

We are moving to another level in assisted reproduction, which is pre-implantation genetic diagnosis. Before we can take a woman through IVF, we will have a biopsy to know the genetic composition of the embryos. We can know the male and female embryos. We can decipher an embryo as a sickle cell embryo or whether an embryo will have leukemia in future or whether it will have diabetes. We can know the abnormalities that occur in foetus by looking at the embryo. For example, if an AS person marries an AS person, we can select the embryo that is not SS and transfer it to the mother.

We can do this at the embryo level, which is about four days in the laboratory. We have set up the technology in collaboration with my colleague, Dr. Satishkumar Sharma of Craaft Clinic, Mumbia, India. We have about 25 patients going through it. At the end of the day, the pregnancy and the baby will be normal because we would have selected the embryo. We are doing it for those that are very old, those who have had failed IVF and those who have had repeated miscarriages. Many people, who are pregnant, lose the pregnancies because the embryos are not normal.

If you go through IVF, if you have three embryos, if one of them is not good, it will affect the other two. If you remove the bad one, and use the two good ones, the pregnancy will survive. What we do simply is to discard bad embryo and take those that are good and transfer them into the woman.

What is the financial implication? It is expensive, but it is better to go through it than to spend money on IVF and not get pregnant. The technology was developed in Chicago. My colleauges from America, who were supposed to come, were afraid of coming to Nigeria because they felt they would be detained and kidnapped.

When you are transferring technology, your partners must come here and use your system. I went to India and Chicago. I felt that it could be done in Nigeria. We have people who need it, especially the sickle cell people. Instead of asking them to go to America, which is very expensive, we can do it here. Even in America, there are about four centres that are main centres. We plan to make this place a centre of pre-implantation genetic diagnosis in Nigeria.

We can then have satellite centres coming to use the facilities here. You have not talked bout the cost implication. You know IVF is between N800,000 and N1m. With this technology, you will need another $3000. Government can assist by removing taxes and cutting duties on the drugs, which are very expensive.

You mentioned miscarriages. What causes miscarriages?

The commonest cause of miscarriage is abnormality in embryo. Nature will not allow abnormality to occur. If the child is going to be abnormal, there may be a miscarriage. We have found out that a high percentage of miscarriages are due to abnormality of the embryo which are equally environmentally induced, such as exposure to X-ray, chemical and toxins.

There are many centres that claim to do infertility treatment, particularly assisted conception and reproduction. Can you differentiate between the two?

Some people think that if you take the sperm and introduce it to the woman, that is assisted reproduction technology. No, that is assisted conception. In assisted reproduction technology, you must take the sperm and take the egg and manipulate them outside the body, in the laboratory, and take it to the woman. Some people do not need IVF; they only need artificial insemination. If I have a woman that is 22 years and trying to conceive and there is cervical hostility, artificial insemination is sufficient. But by the time women are getting old, there is no time for trial and error. IVF is the answer.

I must add that there are some people who are not medical doctors but claim that they are doing infertility treatment and IVF. They are all over Lagos deceiving couples who need treatment. People are being deceived because of the prevalence of infertility in Nigeria. What are the causes of infertility? We have male factors.

Most of our men in this country have low sperm, particularly those ones I see in my clinics. And what are the reasons? They include infections, alcohol, cigarette smoking, occupational hazards, pesticide, toxic pollution in the environment, use of artificial sweeteners like saccharine and wearing of tight pants.

For women, the causes include infections, blockage of tubes and occupational hazards which affect ovaries.

Are more people coming for IVF in Nigeria?

There is more awareness of IVF in Nigeria. More people are coming for it because they know there is a solution. More men are now coming out. They know there is a solution. However, many people are not ready to come out to say that they have done it.

Through donor sperm, we’ve produced 2000 babies – Prof Giwa-Osagie

When Prof Osato F. Giwa-Osagie (OON) and a few of his colleagues at the Lagos University Teaching Hospital (LUTH) disclosed, in the early 1980s, that they could assist couples having infertility problems to achieve pregnancies through other means, not many believed them. In fact, their claims were subjected to close scrutiny by two panels set up by the Federal Government before being given a clean bill of health.

However, these In-Vitro Fertilisation pioneers were forced to go it alone due to government’s unwillingness to offer adequate support and assistance to them at the time.Subsequently, Giwa-Osagie, who is the president of the Nigerian Fertility Society (NFS), went solo because as he put it, "I was not prepared to be intellectually dead."

In 1987, he set up the Advanced Fertility Clinic (AFC) in Lagos and the decision paid off.

In this exclusive interview, the renowned gynaecologist and obstetrician speaks on the evolution of his specialised practice in the last 21 years among other issues.

Advanced fertility centre at 21

It has been quite challenging. When I came back to Nigeria in 1978, 30 years ago, I found that virtually every gynaecologist considered himself to be a specialist in treating infertility. But I soon realised that most of them were treating infertility as generalists would do, not as sub specialists or super specialists. So, I took it up at that level. I applied modern techniques. Indeed, we kept adding more modernisations to improve the efficiency of the processes we were doing to increase the convenience both for the practitioners and the patient, and, therefore, to cover more and more causes of infertility. These included ultra-sonography and sperm banking, among others. That’s how it has evolved.

Twenty one years down the line, we remain committed to making a difference in the lives of our patients. With our pioneering role in assisted reproduction, we are committed to bringing the benefits of modern science to the healthcare of men and women of all ages. We practise medicine with empathy and regard our patients as our ambassadors at large. Through the use of advanced technology and motivated staff, we are producing results of international standard in a patient friendly atmosphere.

It was a humble start but we are moving ahead. But as I said earlier, it has been a challenging experience at 21.

Sperm bankingInitially, all we did was just check the tubes, check for ovulation and give the patient some drugs to stimulate ovulation. Most people were not doing artificial insemination. In fact, the first papers on artificial insemination were published in the 1970s by people like Prof Akingba, Prof Chukwudebelu, Prof Ladipo. But when we set up Advanced Fertility Centre in 1987, we set up a human sperm bank, which was the first in the whole of West Africa, East Africa and Central Africa. Nobody else at that time had a human sperm bank.

Now, why did we need a sperm bank? We needed a sperm bank because it allows you to store the sperm so that it can be used for the patient, if, for instance, her husband is not around. It allows you to use sperms that had been screened for people who cannot produce sperm just the way you use blood bank to serve people who need blood.

Of course, when assisted conception became more advanced, sperm banking became imperative. For instance, in the age of HIV/AIDS, you are no longer allowed to do insemination using fresh semen. So, what is done is that you freeze the semen, you test the donor twice to make sure that they are negative for HIV, hepatitis before you can now use it to inseminate of for In-Vitro Fertilisation (IVF). You cannot do that unless you have a sperm bank. It means now, in effect, that any place that is doing something like IVF must have a sperm bank whereas it was a novelty when we started.Advent of IVF in NigeriaSecondly, with Prof Ashiru at the Lagos University Teaching Hospital (LUTH) and Prof Abisogun, we again, had started IVF in the whole of West, East and Central Africa. I know this because I keep records of what is going on in my special area so I know who is doing what, where and when.

After we succeeded in IVF in 1984, we had the first baby in 1989, almost 20 years ago. We were not able to continue in the public hospital because the Federal Government, at the time, was not prepared to fund the process. You have to have equipment, you have to have drugs and you have to have a means of getting money that you will use to maintain the equipment and pay for the drugs for the patient. That mechanical was not available as in early or mid 1980s at Nigerian teaching hospitals. So, we had to make a choice. Prof Ashiru decided to go to USA. He was there for some years but has since come back and started his own practice. I stayed. I decided that if I was to stay in Nigeria, I must be able to do what I am interested, in otherwise I would go intellectually dead. And I was not prepared to be intellectually dead. With the assistance of some family members, friend and old school mates, we were able to purchase and instal sperm bank, utrasonagraphy as well as pay for our embryologist, Mrs B.O. Kayode to go abroad and train in sperm preservation and the embryology of IVF so that she became the first female IVF embryologist in the whole of West Africa.

Once we had that in place, we started offering it to patients. This was how the IVF was set up at Advanced Fertility Centre then at Surulere, Lagos. We moved to Onikan in 2001 and of course, we updated our equipment. We now do ICSI. It allows you to inject one egg one sperm, which for those who have very low sperm count.

Achievements

We’ve had over 2000 pregnancies of donor sperms. We’ve been having successful IVF pregnancies and deliveries since around 1988. We had our first set in our new location at Onikan, Lagos, in 2001. It was a set of twins. We have also been successful in getting pregnancies using donor eggs for people who don’t have ovaries and don’t menstruate at all. We have success there, including menopausal women, women who are no longer menstruating. These are all techniques available in assisted conception world-wide. They are now available in Nigeria.

At 21, Advanced fertility centre is a thing of obvious satisfaction to me.But even more satisfying to me and my colleague, Prof Ashiru, is that we started IVF in West Africa when people thought it was not possible. Many of our colleagues criticised us and said we were making false claims. There were two panels set up by the Federal Government to look at our work and confirmed that we were doing the correct thing.

Today, there are 14 IVF centres in Nigeria and that for me is a thing of great joy. You start something and many people join in, you should be happy about that. Out of the 14, seven are in Lagos, three in Abuja, one in Benin City, one in Aba, two in Port Harcourt and I understand one will be starting soon in Enugu. The one at the National Hospital Abuja, which AFC assisted to start, was the first government-funded IVF centre in Nigeria, followed by the one at UBTH, Benin City. So, that is satisfying to the pioneers and it made my staying in Nigeria and not going abroad worthwhile.

If you go abroad, everything is ready for you, between three and six months you are already doing the procedure. We started it from scratch here and we had no support from the government at all at that time. Now the climate is more civilized, better informed and people know that these things are available and can make informed choices.

Turning point

From the pint of view of my practice, the turning point was when I was able to give sufficient confidence in some people to make them prepared to assist me to fund what I wanted to do. You can have very bright ideas but if you cannot get the money from the bank, friends or relations, you cannot get anywhere. That is a constant truth. But I was lucky I had that breakthrough in the mid’80s, which was why I was able to start in 1987. The next thing was when we were able to obtain a loan from the United Bank’s for Africa (UBA) to reequip our hospital and modern machines which is the situation we are in now.

It is not easy to repay loans but we thank God that we were able to handle that in AFC.

Assessment of healthcare under democracy

In the field of healthcare, the major positive thing I have seen is that the whole issue of maternal and child health is being taken more seriously than ever before. And the health system is being geared towards attempting to achieve the Millennium Development Goals as they apply to mother and child health.

Secondly, under the democratic dispensation, HIV/AIDS started to be tackled very seriously. I remember when even enlightened people, in place like Lagos were saying it didn’t concern them. This was because they were still suffering from the believe that HIV/AIDS only affected homosexuals or those that had blood transfusion. But now everybody knows that in Africa the major route of spreading HIV/AIDS is through sex, heterosexual sex.

CondomsThe level of advocacy and, indeed, the enlightenment campaign by journalists is amazing in the last eight years or so. So, we’ve made much impact in terms of HIV/AIDS. And as my own support to the fight against HIV/AIDS, I have been distributing condoms free at various places I go. I travel much in this country and I know what men can do when they are out of their homes. I see them surrounded by young ladies in hotels all over Nigeria and I say to them when we meet socially, if you must have sex with the these ladies that you hardly know or even ladies that you know but obviously you cannot vouch for you might as well use condom.

Initially, people would think that maybe you are encouraging promiscuity, but the truth is that if people could abstain from sex there would be no unwanted pregnancies, there would be no sexually transmitted diseases and HIV/AIDS would go down tremendously. The fact, however, is that people cannot abstain from sex and many of them cannot help but have sex with more than one partner. Now, when you have sex with more than one partner, you can never be sure where that partner has been or would be. Therefore, if you are going to do that, you must protect yourself. Far from encouraging promiscuity. That strategy is to assist those who cannot obtain but we still believe that abstinence is the cheapest and the surest way of not catching HIV/AIDS in Africa.