Infertility: New approaches for old scourge

InfertilityA WOMAN of reproductive age who has not conceived after one year of regular unprotected vaginal sexual intercourse is considered to be infertile.

Infertility is a common clinical condition worldwide, with 10% to 15% of couples affected, that is, it affects more than 80 million couples worldwide.

This estimate is probably distributed equally among the male and female population. It is advisable to start infertility investigations after a year of regular unprotected sexual intercourse.

This should be sooner in couples with confounding causes like ovulation failures, fibroids, obesity, women over 35 years of age and where there are abnormal sperm parameters. In the female, the predisposing factors for infertility, include an ovulation, menstrual irregularities, woman’s age > 35 years and endometriosis.

Other notable causes in women include post-abortal and puerperal sepsis, uterine fibroids and chronic medical illnesses like diabetes, tuberculosis. In the developing world like Nigeria, blockage of the fallopian tube is attributed to sexually transmitted infections (STDs)/pelvic infections, particularly those associated with chlamydia infections have undoubtedly contributed significantly to the spike in the recent increase in the proportion of female infertility.

Factors causing male infertility include sperm abnormalities shown by abnormalities in semen parameters, spermatic duct blockage, impotence, retrograde ejaculation and un-descended testes.

The IVF process involves the following integrated processes: • Ovarian stimulation to produce multiple eggs using sex hormones FSH with or without LH • Trans-vaginal egg retrieval to get the eggs from the ovary • Fertilizing the eggs with sperm derived from husband or male donor in the laboratory. The resulting embryos are incubated for 3 to 5 days in a CO2 incubator. • The embryos are transferred to the uterus of a woman undergoing IVF or a fully counselled/ consented gestational host.

Over five million live births have been reported so far throughout the world, using the IVF process. World-wide, pregnancy and live birth rates per treatment cycle have significantly increased from 10-15% in the mid to late 1970s to 50-60% or more presently. This is steadily increasing.

This increase in IVF treatment outcomes and live births rates has mostly been attributed to recent technology advancements, notably in fertility drug modifications to improve efficacy and safety, advent of new artificial reproductive technologies/techniques, improvements in IVF equipment and of course the much needed expertise.

Main complications of IVF and ART are ovarian hyperstimulation syndrome (OHSS), ectopic pregnancies and complications arising from multiple/higher order pregnancies (and its associated maternal and fetal morbidities/mortalities, like abortions, maternal diabetes, hypertension, premature deliveries and socioeconomic difficulties).

These complications occur more commonly after IVF and ART treatments compared to natural conception. Suggestions for risk prevention in IVF include close adherence to safety and quality processes in IVF treatments and giving customised patient-specific treatment protocols.

Interests in the techniques of mildly or minimally hyperstimulating the ovaries for IVF are being explored with zeal in some centres around the world. This could be the harbinger of ‘very low cost IVF treatments’ been touted across the world.

This becomes especially important, if it guarantees better successes and reductions in complications of treatment when compared to the very expensive conventional IVF processes. Infertility carries a significant social stigma in a society like ours. Therefore, infertile couples sacrifice a lot of their investments in money, time and energy to have children.

Failure of treatments bring to the fore a lot of often persistent and unpalatable socioeconomic and psychological consequences that can result in family disharmony, turbulence and separation.

Interestingly, a number of treatment modalities that are hitherto social taboos are becoming socially acceptable by the society at large, for example egg-donation, surrogacy, in vitro maturation of immature eggs, and ovarian tissue or womb transplant. All these have further expanded the benefits and the reach of fertility treatments to affected couples or individuals seeking treatments.

It is noteworthy, that the advent of Assisted Reproductive Technology (ART) has created a plethora of new expensive drugs, sophisticated/complex equipment and treatment modalities for infertility patients.

This makes infertility treatment very expensive, and largely unaffordable by many patients especially in low-resourced areas of the world.

Failure to explain the details involved in the expensive IVF processes, its successes and failures to prospecting patients before undergoing fertility treatment can lead to a lot of misunderstandings and acrimonies between patients and fertility experts following failed treatments.

Therefore, the need for proper counseling of patients wishing to undergo fertility treatments cannot be overemphasized. To avoid exploitation of desperate patients seeking treatments and provide value for the money so spent, it is imperative that provision of fertility treatments in Nigeria should not be an all-comers’ market.

There is therefore a great need to regulate and provide guidance and a strictly applied code of ethics for all fertility experts and physicians in Nigeria. However, the good news is that success rates and live births following IVF treatments are continually on the increase in well-established fertility clinics manned by qualified specialists.

To reap the full benefits of recent advancement in IVF treatment strategies, bring succour and family fulfillment to infertile couples and to prevent patients’ exploitation, a lot more needs to be done to standardise and regulate fertility practices in Nigeria, like in most developed world for example EU and USA. This will no doubt prevent abuse and exploitations of the ART processes to the detriment of the individuals, families and the society at large.

In this vein, the recent effort by the Association for Fertility and Reproductive Health (AFRH) in Nigeria to address the many issues that affect the management of infertility and reproductive health in Nigeria, West Africa and Africa as a whole is highly commendable.

The other goals of AFRH are to create fertility awareness in Nigeria, give education and support to patients; bring together fertility physicians in Nigeria, Africa and abroad for the purpose of promoting research in reproductive health and to organize yearly conferences, provide timely/purposeful educational materials.

The AFRH also provides a robust and acceptable standard/code of practice policy documents, periodic public/stakeholders’ consultations, and periodic revision of the practice code in line with cutting-edge researches, societal norms and aspirations largely to meet patients and societal expectations. • Dr. Lateef Akinola is a member of the Scientific Committee of Association for Fertility and Reproductive Health (AFRH).

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