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When IVF Fails, Other Therapies Can Help

Tuesday, December 28, 2010

Many Nigerians Wrongly Believe IVF Babies Are Not Normal

Dr. Abayomi Ajayi is the Managing Director of Nordica Fertility Centre in Lagos. The fertility expert tells ADEOLA BALOGUN why it is necessary to take the campaign against infertility to the grass roots as it is being done in the case of the Human Immunodeficiency Virus scourge After about 17 years of marriage, a lady of about 43 years just had a baby. How did this happen? It is possible for even older people to have babies with the new technology around. She probably must have gone through assisted reproduction.

Many of us are familiar with IVF, but I can read something up here called ICSI. What is it about?

When we talk about IVF, from the name, In vitro fertilisation means fertilisation takes place outside the body. What IVF is all about is bringing the sperm and the egg together outside the body. Of course, the first baby was delivered in 1978 for which Robert Edwards was awarded the Nobel Prize (in medicine) this year. But we also discovered after IVF that a particular group of people, even if we bring together their sperm and egg, the sperm just cannot fertilise the egg. This went on for quite a while until 1992 when a gentleman in Belgium discovered a technique called Intracytopalsmic Sperm Injection, whereby we can pick one single sperm and actually inject it into one egg and after that, fertilisation takes place. it is just like IVF as well. So, it is just the laboratory procedure that is different from IVF because every other thing is the same.

But is it more expensive than IVF?

Well, in our own clinic, it is not more expensive because we want it to be a clinical decision, not a monetary decision. Money does not come into whether you need ICSI or not. it is the sperm that you give us on the day of treatment that determines whether you need ICSI or you need just IVF.

But in Nigeria, people who seek the fruit of the womb often throng houses of worship instead of the hospital. What is your opinion on this?

I believe there is nothing you can do without God. So, I am not against people going to church or mosque or wherever. But what I am also after is that they should do the thing that God also has made us to know about because without God, there is no inspiration. And all these discoveries are highly inspirational; it is just like saying you still want to be using typewriters today when you know that things would be faster using computers. IVF is another invention. I guess that people should continue to believe in facilities of the 21st century and pray to God to make it successful. Just as people don‘t take appendicitis to the church, I want them to take infertility to the hospital, but keep praying in the church for the success.

Is it true that women are the only ones affected in infertility cases?

It is not true; that is the cultural backlog that we still have. People used to think that men could not be infertile, but we know that men contribute the same percentage, if not more, to infertility than women. For whatever reason, the sperm count continues to be decreasing worldwide and Nigeria is not an exception. I don‘t want to sound like an alarmist, but the human race might seem to be going into extinction because it is becoming more difficult to reproduce. It is not only a women affair; it is fairly shared between the sexes.

What are the possible reasons for that?

There are many factors. Environmental factors are involved; some things that we are born with called congenital factors, and other reasons. But definitely, the more we get away from nature, the more we encounter some problems.

There are cases of childless couples who, after 10 years of marriage, a woman outside is said to be pregnant for the man. Is it always true that the man is actually the father of the child outside?

Well, we know that very often, people play on the need of other people. When a man is successful and people see that the only thing he needs in his life is a baby, it is so easy to conjure things up. I have seen where friends organise what you just said: one of them impregnates the woman, gives it to this other guy and everybody is happy and they get money from this woman who lives in affluence. But all this is short-lived because technology is also catching up with that. DNA is there; so even now you don‘t need to take blood samples to do it. But the bad thing about it is that most men don‘t even want to do DNA because everyone is happy as I said. The man knows that this child might not be his, but they really don‘t want to find out. But all those heartaches should not be because now it is possible with technology for almost everybody to have children. Technology has taken care of the large chunk of the male factor; in fact things are even getting better with ICSI. There is even a new one which we are bringing up very soon called Intracytopalsmic Morphologically Sperm Injection. It is the newest in the world and it is more sophisticated than ICSI, which addresses male infertility especially. Technology is actually catching up with male factor infertility and it may get to a point that almost every man will be able to father a child.

Why are men running away from taking the blame, leaving the woman to face the stress?

Culturally, the man is egocentric and he is not supposed to fail. Again, the fact that another woman can have a baby for the man is another reason; and since it is the woman that carries a pregnancy, he can afford not to bother. That way, men have not been exposed to the ridicule and the stress. so, it makes them to not to want to admit, but the picture is changing now because awareness is catching up and people are beginning to see the light.

Would you say we have enough awareness?

No, we can never have enough awareness yet, but today is different from yesterday.

Maybe some people are aware, but do not have the wherewithal to fight it.

Maybe that is the reason for the limited access, but the biggest I think is awareness. The second one is the wherewithal, but this is where I think the government needs to come in because there is a limit to which private organisations can cater for those suffering from the scourge of infertility.

In terms of infertility, who is more vulnerable to environmental hazards and infections, the man or woman?

As for the environment, I think the man is more vulnerable. But to infection, the woman is more vulnerable. Don‘t forget that the sperm making machine in man is hanging out; it is exposed to the vagaries of the environment, it is not protected at all, unlike the woman‘s, which is inside. But of course, there is an opening that leads to everything and if there is any infection there, it gets inside.

When can we say a couple is suffering from infertility?

Well, the World Health Organisation says when they have been trying to conceive for one year but there is more clarification based on the age of the woman. We now say that one year if she is less than 35 and six months when she is over 35.

What would you want to advise prospective couples to do medically before getting married?

Of course, you would want them to undergo screening for communicable diseases, infectious diseases like HIV and the rest. But when it comes to fertility, you discover you cannot begin to tell them to do semen analysis before they get married. Even now with technology, it is just for you to find out what the problem is and it can be treated. So, I don‘t think that should disturb marriage relationships.

There are still some infertile couples that have been cleared of any medical defects or problems. What happens here?

There is a problem called unexplained infertility and it is recognised all over the world. This happens when you have done your common investigations and you cannot still identify why this couple are not able to conceive and the incident rate from one environment to another varies. In Nigeria, it is about 10 per cent. But the wonderful thing is that it can be treated. There are ways to treat unexplained infertility.

We recently had a 56-year old woman who was delivered of triplets after IVF. It is like multiple births are very common with IVF. how can that be reduced to just one baby at a time?

Nigeria has the highest twinning rate, even without IVF, in the world. We share it with the Republic of Ireland and our women tend to do well with multiple pregnancies more than Caucasians for reasons nobody knows. There is a place called Igbo-Ora, where we have a lot of triplets and their mothers are never admitted in any hospital.

Where would you advise a couple, who have remained childless for three or four years to go for counselling; church or hospital?

The truth is that both medical and religious counselling are okay. But while one is based on facts, the other one is based on emotion. The two are okay, but the man of God can never be wrong. I will tell you a story. There was a woman who wanted to get married and she said, ‘Pastor, I saw you in my dream, you told me to marry Dayo.’ The man of God said, “Okay, if I said so, then it must be right.’ Then three years down the line, they started fighting, the woman came and reported and said, ‘Pastor, you are the one that told me to marry him’ and the pastor said, ‘When did I tell you?’ The lady said, ‘But I told you I saw you in my dream telling me to marry him.’ Then the pastor said, ‘Well, maybe some witches must have worn my image to tell you that.’

Apart from funds, how would you convince someone who had failed to have a baby after two failed attempts at IVF to try more?

It is important for people to prepare their minds when they want to go for IVF. It is not that we put a baby somewhere for picking. Some people would need to do it two times. Some would need to do it three times, while some people will do it once. The most important thing is that if you don‘t give IVF enough chance to work, you call a good technology a bad name. If at the beginning you have a mindset that you might need to do it more than once, the chances of success are very high. Even in countries where the government is responsible for the bills, so many people do it once and then run away, but we know why this is so. The psychological toll that the treatment of infertility takes on couples is enormous and that is why some centres have trained counsellors, who can meet the emotional needs of these couples when the treatment is going on because we know that the treatment of infertility is emotive. But we also know that infertility itself is also a terrible thing, so one needs to be mentally prepared for the worst but if you do it once and it works, fine.

It is understood that someone with a low sperm count can be helped out. But what of someone who does not even have any count at all?

No-sperm count can also be helped. We know that there are two types of no-sperm counts. It is either the testes have failed or they are working, but the conveyor belt has been blocked. If the testes are working, we can go to the testes to bring out sperm cells and we can use that to do ICSI. And we have achieved so many pregnancies through that here.

I thought you would have studied in the US, Britain that we all know; why did you choose Denmark?

Well, when we wanted to start, I tried to look at successes all over the world because we wanted to bring in something fantastic to Nigeria. That is why our name is Nordica. It is not a Nigerian name; we are a franchise. The Nordic countries generally have the highest success rates in IVF. Apart from that, IVF there is just like a routine. For instance, about six per cent of babies born in Denmark are from IVF, so it is like it is part of their culture. And that was what I was looking for and that was why I went there.

After your training in Nigeria, a medical doctor would want to set up a hospital and practise. Why going for extra training in assisted reproduction?

I think the plight of infertile couples pushed me into that. When I was doing my residency in UCH to become a gynaecologist, that was when I saw that there was a special need for people with infertility. I saw that after attending to them, it was like we were telling them to go home and pray. When the two tubes are blocked, the gynaecologist would try to do tubal surgery; the success of tubal surgery is about five, 10 per cent. So, essentially, what you are doing is telling them I leave you in the hand of God. When I got to urology, the success rate was worse. And I said to myself, there must be a way out and I started to find out why IVF was not happening much in Nigeria. I discovered that it was lack of infrastructural support. That was what made me to finally go into it. Even one of my friends, a doctor, had a problem with his marriage and ended up with another lady who had had three children for different men. Of course, it didn‘t last a year because the lady said she had a baby for him. Meanwhile, his wife, who got separated from him, got pregnant instantly after meeting a new man and we all knew that the other lady‘s baby was not for him. So we knew that it was a male factor.

But the impression we have is that all these facilities are not here and that is why people go abroad to have IVF.

I don‘t think it is so. Some are worried about their identities; they want to protect their confidentialities. There is nothing wrong since they can afford it. Even in the US, there is what we call cross-border fertility treatment. But the thing I tell people is that IVF is best done in your own environment. For instance, we have seen people who go to the UK in their late 40s and they need donor eggs. The waiting period for donor eggs in Britain is about three to five years. Even those that go there are referred back to us. Inasmuch as we cannot stop that, we want people to know that the facilities are here and their confidentialities are assured. But people need to go to good centres and people also need to get information; they should go on the Internet and read. I keep telling my patients that if they read about IVF and the doctor is telling them something else, they should speak out. Because we know of some doctors even in Lagos who don‘t do IVF, but they claim to be doing IVF. They give patients all kinds of stupid prescriptions, telling them that they import bottles to keep babies, which is ridiculous and they collect a lot of money from patients.

Why is it that some people, after achieving success with IVF, feel reluctant to share it with people?

I have had many experiences in that regard. It is because of this stigmatisation: some people believe that IVF babies are not normal babies, so they don‘t want people to know that they have IVF babies and that is not right. There are about four million babies from IVF worldwide and they are all normal babies; even some doctors think IVF babies are not normal. One doctor called me one day and said, ‘Oh, my wife has just been delivered’ and I said where? He said UCH, and I said I am actually on my way to Ibadan, I will see your wife shortly. Later, he called back and said, ‘Doctor don‘t come oh, everybody will know that he is IVF baby.’ It is that bad.

Why is infertility still being discussed in hushed tones?

It shouldn‘t be, but it is because in fertility discussion has not been taken to the community yet. Now people can discuss freely about HIV to a large extent because it has been taken to the community. That is what we tell all the support groups that IVF and fertility should be discussed at the community level; so that it is no longer hidden. You know you can be working with someone with infertility challenge in the office for years and you would not know. You ask her how the children are and she says they are fine, and she even gives you a smile. And the day you don‘t ask her about the children, she takes offence. This pretence that we put on is not helpful, but again you need to understand why people put on the pretence because the people who are supposed to help them do not know how to.

Tuesday, October 26, 2010

IVF: Nordica reduces cost through egg sharing

The Medical Director of Nordica Fertility Centre, Dr Abayomi Ajayi, has advised couples seeking solution for fertility through In-vitro-fertilization (IVF) to be mindful of where they go to for treatment. Speaking during Nordica Open Day recently at Nordica Fertility Centre, Ikoyi, Lagos, Ajayi noted that it has become necessary to warn patients because many quack and sub-standard IVF centres are springing up everywhere in the country.

He spoke on this and other issues. Exerpts:
Open Day programme
We have seen from our experience that the main problem with assisted conception is still awareness. Not only awareness in the sense that people don’t know that it exists, but also awareness because we want the consumer to be intelligent, to be learned, so that you can ask questions wherever you go.

We are not saying that everybody should come to Nordica, wherever you are going, just be sure you are going to the proper place. You are asking the right type of questions, you can only do that when you have enough knowledge of how things work. Because we hear all sorts of stories of how people say they are doing assisted conception in Nigeria, which is not true.

So, unless you know how it is done everywhere in the world, we know that some people will not go to the internet to go and goggle In-vitro Fertilization (IVF) procedures, but we can show them how it is done, then, you take it from there and ask wherever you are going, what is the difference between what I saw here and what you are doing? So that you can be able to say whether anybody you are seeing is making sense. So what we are doing is to enlighten the patients and also to raise awareness.

Results
Well, I can only talk about people who come to me, I know they are getting results. And that’s what we are saying, go to places where you can get results. And you can never get results if the proper thing is not done.
Acceptance
If you ask me, I think IVF is being accepted, of course, but I think it can get better. There are different groups of people when you talk of awareness. Some do not know it exists at all. Some know that it exists but they don’t believe it can be done, either because of their previous experience or whatever. And probably, another group are people who probably think they cannot afford it.
So, every group has different needs, and we need to meet those needs. If you ask whether it is being accepted, I think yes, it is being accepted actually.

Awareness
Because we have a limited budget, we can only do the best that we can . And that’s one of the things we are doing, we are raising awareness. Also, we are improving not only with the patients, we are also doing a lot of things with the doctors. Improving their skills, we teach ultra-sound to the doctors because we have seen there are very few places where ultra-sound is taught in Nigeria. I think they are up to ten. They can learn ultra-sound, learn it properly. We also teach endoscopy.
As we are trying to increase awareness to the patient, we are also improving the quality of healthcare. Because we cannot claim to be an island. Though we have an island of services, where other people also know a few things that you know about and that’s the only way we think we can contribute to improving the level of healthcare in the country. That’s just the bits and pieces of what we can do,
Indigent patients
We have a scheme for people who cannot afford IVF. We do eggs sharing for the younger ones. Through the egg-sharing scheme, if you are below 34 and everything is alright, it is possible for you to do IVF paying only N100, 000, but you share your eggs with other people. That way, we can bring it down for people who are younger.

But for other people who are not as young as that, the only thing we do is to rely on the programme that we have which has to do with a non-governmental organisation, which we call Fertility Treatment Support Foundation (FSS). They have a website.
Of course, we also think it is also proper to make IVF more accessible in the sense of going to the people rather than having them all come to Lagos. We have a branch now in Asaba.

Grassroot
When you talk about grassroot, I know another question that is being asked all the time is cost. That’s for government to go to the grassroot, because they probably might be able to provide the treatment either subsidized or completely free. But if you are looking for people to be able to pay, then, you need to get your target audience right. I think the first group of people that we need to appeal to are people who can read and write. Before we take it to the rest of the people.

Infertility
Infertility is not peculiar to this generation alone. If you look back, there are some people you can remember, maybe our own category of grannies who didn’t have children. They might not have been many, but they were definitely there. You can remember one granny or one aunt who didn’t have children, so infertility has been with us from time past.

However, the treatment of infertility depends on your civilization. In some parts of Nigeria before, I think it happened in all parts of Nigeria, when a man is infertile, it can be arranged for the brother to be sleeping with the wife, and it is a guided secret, they swear so that was how they were solving those issues then. But now science has come, and nobody want anybody to sleep with his wife if he can afford the treatment.
So I think one of the things we are seeing is that there is more report, people are coming forward with more cases of infertility because they knows it is possible for it to be treated now.

Fertility nurses speak on IVF
Tina Igbokwe: “IVF is a solution to many infertility problem or challenges. For the fact that the success rate is not 100 per cent does not mean it does not work. It works. The percentage is between 25 and 30 per cent. And I think that’s a good one because what does nature even offer us? Nature gives us about 18-20 per cent. So if nature gives you 18-20 percent and IVF gives you 25-30 per cent that means it is a good one. And it has put smiles on the faces of so many couples, it has brought joy to many homes.
“IVF has come a long way in Nigeria. And it is getting better by the day. We are getting more results. Last year we had wonderful results, this year we will even do better.”

Gbemisola Babalola
“IVF has provided succour for couples who have lost hope of conception. It is solution for a lot of couples that have lost hope of having children. Some go home with twins and triplets.”

Saturday, June 19, 2010

IVF BABIES ARE NORMAL CHILDREN

Oladapo Ashiru is a professor of Anatomy and Reproductive Endocrinology and a specialist in Assisted Reproductive Technology (ART), of which Invitro Fertilisation (IVF) is a part. Ashiru who is
also the medical director, Medical Arts Center, Ikeja is an Adjunct professor at the University of Illinois, Chicago in the United States (U.S.) In this interview with APPOLONIA ADEYEMI, he highlights how scientific procedures used to tackle infertility in advanced world is now being embraced by Nigerians who need the services. Excerpts:
REcently, A 56 year old Nigerian woman gave birth in Lagos. Whether the reproductive process is through normal delivery or invitro fertilisation (IVF), which is the assisted method, is it appropriate for women in those age range to get pregnant and go through deliveries process ?
When Adam and Eve were in the Garden of Eden, everything was easy for them. They had children with ease. Conception was with ease. So, was pregnancy and delivery.
From the work I have done in comparative anatomy, the other animals have children so easily because they have no sin. Look at the rat, the rabbit, the pig, their reproductive system is so efficient, but when Eve went to the tree of knowledge and ate the apple, God told them that it is with difficulty that they will feed their family. So, man has to struggle to feed his family.
And then, it is said, ‘Even to conceive, it will be with difficulty. And beyond that, to even deliver, it will be with pain in labour.
However, because God always loves, due to his divine intervention, we are brought closer to him. That divine intervention and divine love has made it such that people are now able to have babies with ease. And some are able to have it with assistance.
However you may look at it, there is nothing that is happening in this world in the field of science that is not with the permission of the Almighty God.
Do doctors, have such beliefs?
I believe and you have to believe that even in this field (science) because when we go through this field, you will know that there is still the Almighty in his infinite mercy and power.
Why do I say that? When you look at this 56-year-old woman, irrespective of the age, if God wants to help, he will give the entire wherewithal to do it.
What I am telling you is that when we have 10 patients who go through IVF, and you give them the same type of treatment, and the uterus is very prepared, and you have embryos that are grade A embryos, and you put the embryo in each of them, the law of nature will just show.
In one particular person, there will be 10 eggs, and nine of them will fertilise and become good embryos.
In another, one, there may be 10 eggs and only two will fertilise. You have done the same treatment and in the same condition.
Beyond that, when you now put three embryos each in them, in one, all the three will grow into triplets. In another one, just two will grow into twin. In one, only one will grow and in another, there will be nothing.
Beyond that, you may have one embryo that grows and later it will split into two. That one is no longer science. That is nature. That is God in his infinite power.
Specifically, in science, is there age limit for women seeking IVF treatment?
There are some things you have to recognise. The age limit is the physical condition of the woman. If the woman is physically able to carry the pregnancy, she can carry it.
Some will go through using their own eggs and some will use donor eggs. There are things we can do to restore some egg reserve in a woman, that is to help to reactivate them before you can get some eggs from them.
You will worry when a woman at that age is getting into pregnancy. There is the possibility of abnormalities and pre-implantation genetics diagnosis helps to eliminate that.
If advancing age is a factor in IVF treatment, would it not be a risk for a woman in that age to go ahead and carry pregnancy?
In terms of carriage, what you need to do is to look at the physical condition of the woman. You look at the cardiovascular and the renal conditions and see whether they are fit. Somebody may be 42 years and may not be fit to carry pregnancy. Such a person can be advised to have a gestational host. This is what is called surrogacy.
Similarly, somebody may be 52 years and will be fit to carry pregnancy. So, it is for the doctor to look at it.
What are the risks elderly women who are not fit to carry pregnancy face?
They may end up with renal problems, high blood pressure or cardiac problems. All my patients, both the obstetricians in my facility and I monitor the pregnancies for them until the babies are delivered because high risk problem could be water and salt retention.
Pregnancy in elderly people has its own limitation, but with good medical care, most of our patients have been able to have babies in their late 40s and early 50s.
The risk involved has to do with aging. Usually, for those people who are coming this far, they have the financial resources to go through it. And then, because they have been going through this kind of process before, they are already accustomed to medical help. So, such people would have prevented any possible risk because already, they are people who care about their health.
Any risk in pregnancy will not show overnight. They could go into premature (early) delivery. So, you have to give them bed rest.
I have some patients in their late age and they are having twins and triplets. So, they are admitted into the hospital. Once we see the signs, we get them admitted as early as may be, 20 weeks. So, they are observed in that process. They are people that are very careful. The whole process may cause them money but if that is what they want, it is fine.
Most people who go for IVF treatment in our environment do so at an advanced age. Is it advisable to seek this service at earlier age?
Yes, you can come for IVF even at late 20’s. IVF is meant for a purpose, the original reason that IVF came into operation is for women who have blocked tubes. If the tubes are blocked, there’s no way the sperm can reach the egg to cause pregnancy. In the early days, they go and operate and repair that tube. That is almost being left aside, to just go in, get the eggs, fertilise them and put back the embryo into the tube.
The second reason IVF has come into play are for men that have low sperm and thereafter, other reasons come along the line.
The more IVF is into operation, the more perfect we are in it and the more efficient it is becoming in terms of predicting pregnancy. So, it is coming to a point were a woman may even chose IVF and get out of it.
In our center here, when we see young couples, we encourage them to try and have their pregnancy in the least invasive way like through the natural way. We counsel them to use some low tech procedures like giving them medication to ensure that they ovulate and the sperm increases, monitoring the time of ovulation and telling them to go and meet in their private time to have intercourse or getting the sperm and injecting it into the uterus or the tubes. Those are the low tech procedures. However, if the tubes are actually blocked, then, they go for high tech.
If they are approaching 40, we advise them to go straight for IVF.
Will you say IVF has come to stay in our environment?
It is. Those who need it, know they have no other option. The other option to IVF is to do nothing because if the sperm is low or the tubes are blocked, there is no way there is going to be pregnancy. If somebody is in her late 30’s or early 40’s and has tried all these things and it’s not working, she needs to go fast to IVF and the beauty of this is that at an early age the success of this is higher.
Many people in our environment who have children through IVF are secretive about it and some also belief children from this process are not normal. Are IVF babies normal children?
They are normal as any other kid. The first IVF baby, Luis brown has had her own baby and she had it naturally. There is nothing wrong with IVF.
It is only in Nigeria that we have this type of problem. In America, people let you know when they are sick. They tell you, ‘I have glaucoma. I have cancer of the colon. They tell you the type of medical condition they have. The only ailment Nigerians are able to say they have is headache, but beyond that, Nigerians are not willing to communicate and it is not helping.
Some religious and pro-life groups do not agree that God has a hand in IVF. What is your take on this?
I don’t want to get into any religious argument, but if you look at the Catholic Church, they do not believe in contraceptives. If you look at the aspect of going to the moon, did they believe God has a hand in it? Those trips that were made to space have enabled us to use cell phones that every body is using including religious groups.
Any science advance is meant to help mankind. For example, this IVF technology is now going to be used for people who have some serious diseases. It’s all part of divine love and divine help.
What are the challenges professionals in the field of IVF face?
I think the major challenge we have is that we need the support of government.
The other day, I brought in a media equipment for IVF, which is used to wash sperm. It is not for human consumption and somebody from the National Agency for Food and Drug Administration and Control (NAFDAC) seized it. The patients were going to go into the procedure the next day. It had already been delayed due to the delay in air travel because of the volcanic ash. Somebody there asked us to bring N40,000 for something we bought for $600, which is about N40,000. I could not go to iron it out with them because the patients were already waiting to use the material and I was in the cycle of (an operation).
These are the kind of assistance we need. We need more co-operation and more understanding from the government.
What is number of IVF babies globally to date?
I think it should be approaching three million worlds wide, as at 2006. I am sure we should be approaching four million by now. IVF started in 1978 and we had our first IVF baby in Nigeria in 1989.

Friday, January 15, 2010

TUBAL BLOCKAGE: IVF BETTER THAN SURGERY

The primary benefit of tubal surgery to repair tubal blockage is that it is done once. However, according to Consultant Gynecologist and Invitro-fertilization (IVF) expert, Dr Abayomi Ajayi, the success rate is very poor in the range of between 10-15 per cent. There is also the risk of tubal or ectopic pregnancy following tubal surgery.

He disclosed that in IVF, you can avoid surgery and pregnancy rates are in the range of 25-30 per cent.Dr Ajayi spoke on this and other issues.Tubal surgery vs lVF The primary benefit of tubal surgery to repair tubal blockage is that it is done once. However, its success rate is poor in the range of between 10-15 per cent. There is also the risk of tubal pregnancy (Ectopic) following tubal surgery and this may be life-threatening if rupture occurs. In-Vitro-Fertilization (IVF) has the advantages; you can avoid major surgery and pregnancy rates are in the range of 25-30 per cent. Complications following IVF are also minor. IVF however is more expensive than tubal surgery as it involves the use of hormonal preparations, there is also an increased risk of multiple gestation following IVF.

Various factors affect the success of IVF and the single most important is the age of the woman, the younger in age, the better the outcome. Older women however can benefit from IVF by using donor oocytes from younger women. IVF also has the advantage of overcoming male infertility through a process called Intra-cytoplasmic sperm injection for men with low sperm count (oligospermia). It is therefore imperative that tubal fertility problems be promptly referred to assisted conception units for care. Undertaking tubal surgery may not be the best option and it involves a lot of risks.

In-Vitro Fertilization and Embryo Transfer remains the most acceptable means of passing tubal factor infertility.Ectopic pregnancy The tubes may develop adhesions and thickened walls and close off completely. In that case, a woman’s hormones can be fine, her eggs can mature and she can even release healthy eggs every month, but the sperm may not be able to reach them. If the tubes are opened enough to allow the sperm through, fertilization may occur in the fallopian tubes. Then, when the growing zygote is traveling through the tube to reach its destination in the uterus, it may get stuck and implant in the partially-obstructed tube, resulting in an ectopic pregnancy, which may cause further tubal damage and even loss. There is a risk of recurrence of ectopic pregnancy and when both tubes are affected, the woman is unable to conceive by natural means.

Treatment
There are two basic approaches to treat infertility due to tubal blockage viz: Tubal Surgery and In Vitro Fertilization (IVF).

Tubal surgery involves techniques aimed at re- opening blocked tubes, while IVF replaces the functions of the fallopian tube with laboratory and minor surgical procedures that result in fertilization and transfer of fertilized eggs or embryos into the uterine cavity.

Since the advent of In Vitro Fertilization (IVF), reconstructive tubal surgery is becoming a lost skill. IVF is more popular than tubal surgery due to the better pregnancy outcome using assisted conception procedures. Sometimes, a woman’s inability to conceive is because the pathway from her ovaries to her uterus is compromised. The ovaries could be covered with adhesions that obstruct entry of eggs into the pelvic cavity. The fallopian tubes could be narrowed or even completely obstructed or perhaps the uterus is bound up with scar tissue that keeps it from holding the fertilized egg successfully. Blockages such as these may be caused by congenital defects, by scarring from past infections, by surgical procedures like tubal ligation. A blocked tube prevents sperm from being able to reach an egg and also prevents embryos from being able to reach the uterus. Tubal block can be intentional (such as in tubal sterilization) or unintentional (due to disease conditions that result in involuntary infertility).

Whether intentional or resulting from disease, tubal blockage may be corrected with reconstructive tubal surgery. Prevalence and causes An estimated five million women in Nigeria have had a tubal sterilization for one reason or the other. Approximately one-sixth of the cases of infertility in the country are due to tubal disease. Most of these cases are caused by pelvic inflammatory disease (PID) - an inflamatory condition of the fallopian tubes (salpingitis) and may also involve the ovaries (oophoritis), and pelvic peritoneum (peritonitis). In many, perhaps the majority of cases, PID is unrecognized or ‘silent’ and/or misdiagnosed. Endometriosis is another condition that can cause tubal blockage and is sometimes confused clinically with PID. Congenital abnormalities or malformations of the uterus and fallopian tubes may also result in tubal blockage. In these cases, the blockage is usually at the uterine, or proximal, end of the tube rather than at the fimbrial end as occurs with PID. Symptoms Most fallopian tube obstructions produce no overt symptoms other than infertility. Adhesions and scar tissue may cause pain and limit mobility.

Many women discover blocked fallopian tubes only after experiencing infertility and as a result of one or more diagnostic procedures, including a hysterosalpingogram (where dye is injected into the uterus and examined via x-rays to see if it spills into the pelvic cavity), laparoscopy or laparotomy. Mechanical Infertility Perhaps the most heartbreaking causes of mechanical infertility known to mankind is Pelvic Inflammatory Disease (PID). This infection is being singled out because it can destroy a woman’s fertility without warning, long before the woman even considers getting pregnant. PID is usually the result of bacterial infection that can involve the ovaries, fallopian tubes, uterus and cervix. The bacteria commonly enters the body through the vagina and cervix and spread from there throughout the pelvic cavity. Many women in their teens and 20s are routinely diagnosed with acute pelvic inflammatory disease (PID). The most common cause of PID is sexually transmitted diseases, especially Chlamydia and Gonorrhea. PID can also result from using an intrauterine device (IUD), complication from earlier pregnancy or infection following surgery of the reproductive tract. Depending on the infectious organism and the severity of infection, the acute phase of the disease may be characterized by lower abdominal pain, fever, painful sexual intercourse, irregular bleeding and profuse vaginal discharge. As with any bacterial infection, signs such as these should be treated as quickly as possible with antibiotics. On the other hand, some pelvic infections involving Chlamydia species, may not have symptoms of any kind, yet can cause extensive damage to the reproductive organs, especially the fallopian tubes. Most fertility problems associated with PID are not caused by active infection, but instead by scarring from past infections. Untreated, chronic PID creates a condition of long-standing inflammation within the pelvic cavity, and this sets up a reactionary environment within the reproductive organs, especially the fallopian tubes. One of the most common outcomes of PID is fallopian tube obstruction. The fallopian tube is the ‘golden path’ that the embryo must travel to reach the uterus. It is also the location for fertilization of the egg (oocyte). The tubes contain two specialized kinds of cells viz: those that produce mucus, glucose and other substances needed to nourish the egg (both before and after fertilization) and tiny hair-like structures that move the embryo through the tube and into the uterus. Unfortunately, the fallopian tubes are often the first locations attacked by the opportunistic bacteria. And because they have such narrow structures, it doesn’t take much to obstruct them. The tubes can become inflamed within (salpingitis), become filled with fluid (hydrosalpinx) or pus (pyosalpinx), creating a bulge and/or possibly destroying the lining and musculature needed to nurture the egg and move it along. Fluid from a hydrosalpinx can drain into the uterus and have an adverse effect on implantation.
SOURCE: SUNNEWSONLINE

Tuesday, January 12, 2010

Nigeria: IVF Treatment Has Come of Age in Country, Says Wada

THRICE his life was at stake while propagating the concept of Invitro Fertilisation (IVF) in Nigeria, but today, he is rest assured Nigerians need not seek IVF treatment abroad.

This statement sums up the travails of Dr. Ibrahim Wada from the Gwagwalada General Hospital, Federal Capital Territory to NISSA Premier Hospital, Jabi, Abuja, from where he now oversees the Garki General Hospital, Wada, Abuja. He opens up to Abayomi Adeshida. Excerpts:
Motivation into medicine
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From early childhood, I had bias towards any medical stories in the press. That was the earliest inkling I had towards my future, anytime I read the papers and anything I read about doctors, I just cut it and paste it on my little wall. Then of course, my performance in school made people to start calling me doctor, it was more or less expected. I found myself in medical school almost as a predestined situation, and then I became a gynaecologist ultimately as a choice.
I chose the option of fertility in terms of IVF because as I was training, i realised there was a group of women desperate to have children and IVF was the only way out.
That inspired me. If I was not a doctor, I would have been a cleric, Imam or something like that because of the extent to which I fear God, and the extent to which I see the balance of nature beyond human comprehension and the awesomeness of God and I have continued to learn it and to teach it, so I have continued to thank God for choosing my path for me along these two professions.
Challenges as a doctor
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Well, I like to look at myself as somebody who came from the very basic level of life in Nigeria in the early sixties. I remember as a child in primary school, I used to farm for my food, not just to sell, but I used to go to the farm with another more senior boy, and as it came out, I virtually toiled for everything that we ate. Apart from that after school I used to hawk, I used to sell things for my mother, so how more basic can you get? I was used to the life of hardship and that saw me through virtually the whole of my education to the medical school.
Introduction of fertility treatment into Gwagwalada Teaching Hospital
I look back at how everything was against me and against this new idea that I had brough in this part of the country. I faced challenges from every side, even from the people themselves. I paid a heavy price, but I thank God it was not with my life; although three times, I remember, my life was on the line.
But I knew if I had taken one more step forward I'd be gone, Almighty God brought me back to life and success is now the story.
I never knew I'd live to see the first test-tube baby. The storm around me was so much I thought maybe just before that day like the biblical Moses, I may not see the promised land. But God preserved me to even see her grow.
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There were serious challenges. I joined the National Hospital in 1999, the first test-tube baby in that hospital was born in 2007; about eight year's journey! I fought that and I didn't give up. So, the success of my actual return to Nigeria was the birth of the first test-tube baby at the National Hospital, a public institution because that's what I came for!
In all honesty, I didn't board the plane from England to come and open a hospital in Nigeria; my background does not allow that. I am the last business man in the whole country because if I can treat everybody free, I'll do it. Ask any staff I am the non-business man amongst them, I am the one who'll say let them go, or give discount, I don't use business sense to run this place. Mine is success.
Technology transfer
Technology has many facets; one man does not make it alone. Everybody has a portion to fill; so, when I came back, I knew I still needed complementary assistance. It took me the best part of three, four years to break all the difficulties that our system posses against high-tech medicine. Now I have learnt enough of how to conquer the problems of bringing high-tech medicines into the country that I started to teach other Nigerians what I knew even though, it wasn't easy.
Success of IVF in Nigeria
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Today's IVF treatment is high tech. I think we've broken it down to its simple state that Nigeria is at world class level, other entrants have confidence to come in.
I mean yes, there were a few units in Lagos then, but now its spreading like wild fire. I think its not just what I have done, but what the knock-on effect of my life and achievements have brought on the entire country.
So, in our own Centre here, I cannot recall the exact count, but I stopped counting when 1,000 families were affected, because it was my mission after the first child was born to let her life touch 1,000 lives. Everyday we record successes, I am not doing daily count, but I am aware we are well above 1,000 successful births.
Cost and access
Relevant Links
West Africa
Nigeria
Health
One nagging problem that may not just be wished away by those of us who are engaged in this business is the run away exchange rates and the fact that we are producing nothing among the high-tech medicine we use in this country and we are going to live with this problem for so many more decades. No group is working on it now! The materials are here but nobody is developing the market, thereby, the major things we need, scanners, incubators, medications, are all imported. That means we are subject to variations in value of naira to foreign currencies.
I think that's a key issue; the other key issue of course is that we have to pay heavy import duties to bring these things in. Most countries have exempted Medicare items from import duties, but it is not so in Nigeria.
Regulation of the practice
We are working on an Association and basically, it is concerned about the ethics in this kind of medical practice. We are trying to get a charity funded IVF project for the poor to come up at Garki; We've started on a small scale but I can see a future for it too because there may be good-hearted Nigerians who would say okay, I want to donate this huge amount towards what you are doing so that poor people could enjoy IVF services. So, we are hoping that far, so people could get to access this technology.