As some Nigerians continue to fall prey to substandard and fake fertility treatments across the country, a renowned fertility expert and the Managing Director of Nordica Fertility Centre, Dr. Abayomi Ajayi in an interview with journalists recently, called on patients to learn about invitro fertilisation, intra uterine insemination, who should use IVF, and when assisted reproductive techniques must be considered. Martins Ifijeh brings excerpts
Most Nigerian couples have issues differentiating IUI from IVF. Could you elaborate on the differences?
Let’s put it this way, IUI, which is Intra Uterine Insemination and IVF, which is Invitro Fertilisation are cousins but they are not interchangeable; they both belong to the group that we call Assisted Reproductive Techniques (ART) but the most basic form of that family or the least developed is IUI which any doctor can do. You seriously don’t need any particular equipment to do that except to prepare sperm because we know that when the semen comes, there is sperm, there is seminal fluid so all you just need to do is to separate them from each other, concentrate the sperm, and then you are able to introduce it back into the woman. And for a woman to be able to do IUI, her tubes must be opened, while the sperm must be good.
But when you look at our environment, the commonest problems are blocked tubes on the part of the woman and bad sperm on the man’s part. This makes the IUI of limited use in this environment.
You look at it in this environment where the commonest problems we have are those two things, blocked tubes and bad sperm quality, it has very limited use in this environment.
But there are some people who will still benefit from it but you need to be sure that those two things- the sperm parameters are good, and tubes are open so it is useless for anybody who has blocked tubes to be doing IUI, if you do one million, you can’t get pregnant.
But the common happening now is that people are mixing up the two and the patients are not any wiser. Someone who is ideally supposed to be doing IVF, is rather recommended for IUI which is not the ideal solution. For IVF, you need to bring out the sperm, egg, then combine them to form an embryo before you can transfer back into the patient. And for this to happen, you have to start with the use of drugs, which makes the woman to produce eggs, and that is why it is called IVF and Embryo transfer.
It is important, especially now that it is hard to get money for patients not to waste their resources and even their productive life in the hands of charlatans who give IUI in place of IVF just because they want to exploit the patient.
I was talking to a 50 years old woman who said she went to store her eggs in one clinic. This made me wonder, how can she store her eggs when she wont be needing it, because she can’t use her eggs, what she needs are donor eggs. So what is she storing? And she will continue to pay money for this kind of thing. It is so important the media educate the public on IVF, so they can make informed choices and also know from knowledge which doctor is telling them the right thing.
Have there been any regulation recently to tackle quackery and monitor fertility clinics in the country?
Regulation is slow even though we are making efforts at it. If you are waiting for legislation or regulation, a lot of people will still continue to be misinformed and misled. The fastest thing is for the citizens to be equipped with information. Once a buyer of a treatment plan knows what he or she is buying, the person will most likely not waste any money on quacks.
Though our associations is working on regulation, but I tell you, how many clinics can you police a day. In a year how many? If they know you are coming, they will put up their best behaviour, when you leave, they continue with what they are doing. So the easiest thing to do is educate the people who are investing their time and money in these clinics so that they know and can ask their doctors questions. They can tell their doctor what you are giving me is IUI and not IVF. Imagine a doctor in a teaching hospital doing IUI for a 43-year-old, that is criminal, you don’t do IUI for a 43-year-old, because you wouldn’t achieve the needed result.
Don’t you think these lapses are from the professionals themselves?
The problem is that most of them don’t know, you just assume that they know because this is a different branch of medicine. The fact that you are a gynaecologist just doesn’t make you a fertility specialist.
So who are the right people to practise it?
Someone who has been trained as a fertility expert is qualified to practise, because you need to know the indications. The fact that you can do surgery or you are a gynaecologist doesn’t mean you can practise as a fertility specialist.
Like I told you, IUI is the most basic form of assisted conception, once you are trained, you can do it because you don’t need big equipment to do that, all you need is a functioning lab, but the fact that you can do it doesn’t mean the patient needs it. Your job is to be able to identify the patient who really need it. Unfortunately in this country, not many patients will benefit from IUI because our biggest problems are tube blockage and sperm quality issues. These two are contraindications when it comes to age (above 38). Once the person is above 38, it is relative contraindication to IUI because the success rate goes down dramatically not to talk of when the person is 43 years old. At that age if you do one million IUI, it wouldn’t work even when the tubes are open.
Why I think all we need is patient education is because that’s how endometriosis started, but when people started getting education on it, they started asking doctors questions, and this makes doctors uncomfortable and sit up. At that point the doctors will be forced to learn more about the health issue so they don’t get embarrassed. So the same step I think we need to take here, educate our patients correctly.
Also one of the problems that patients are having now is comparing oranges with apples. They are comparing IUI with IVF because they don’t know the difference between the two. So when somebody says, I am going to do it for N10, they run there but what is the person doing, is it IUI or IVF? But if you know what it is, you will ask questions. I keep telling patients that it is their body. You shouldn’t let any body insert anything into you without you knowing what they are doing.
But most times when patients become inquisitive, doctors become defensive and harsh. What should the patient do?
The patient should walk away from such a doctor. Don’t forget that infertility treatment in Nigeria is paid out-of-pocket. That’s the more reason you should ask questions because you sweated for the treatment money.
Who should use IVF?
Patients whose tubes are blocked, patients who we don’t even know why they should not have children (this category is called unexplained infertility because they have done the entire test and they are normal). For those people, if they are less than 38, they could first start with IUI. But for those who can afford IVF straight away, they can take IVF, but the expert must lay everything on the table so they can make their choices themselves. If sperm count is just likely not very good, just likely, not that it is severely bad, they can try IVF. Someone suffering from endometriosis can also try IVF.
But one thing we can also know now is that IVF can be used for some people who don’t have infertility like in cases of sex selection, if you want to prevent diseases, because now, we are able to do the gene analysis of the embryo we can use that to prevent genetic diseases, so now the scope of IVF is expanding beyond just infertility treatment and it is ethical.
There have been accusation lately that many doctors coax their patients to do caesarean sections, now again it seems we are also going the same root with IVF?
That is why I said IVF can be used for unexplained infertility. Let’s look at a couple that have been married for eight to 10 years and they have not had children and let’s say theoretically that the woman is about 36, or say 34 and they come in front of you and you know the pressure that family will be going through, and they have the means and as a responsible doctor, you present the two options to them, say; you can do IUI or IVF, the success rate of IUI is 10 – 15 per cent.
The success rate of IVF is 25 – 30 per cent and they have the money, tell me which one they are likely to choose. Of course, it is IVF so that is not doctor now. I told you that a responsible doctor must give them all the options because some of them might say, why don’t I try IUI once or twice and if it doesn’t work I will do IVF. There are controversies over success rate of IVF. Some experts are saying one per cent, some say 46 per cent, while some even claim 100 per cent.
What is the success rate?
Don’t let us quote things out of context. Is this person talking about a particular age range because there are some age range you can have forty something per cent, those are the cream of IVF, less than 35 years old and you can have very lower percentage when talking about over 40 years of age.
So what is the average success rate of IVF?
That is why we always say 25-30 per cent when taking everybody together.
With your experience, what has been the success rate for you?
For women below 35, it is 40 to 50 per cent. For 35 years upward upwards it is 25 to 35 per cent.
What are the factors you will see in a woman that will make you recommend IUI for her?
The woman’s tubes must be open, at least one, but if the two are open, the chances are better but at least one must be open, if the two are blocked, it is criminal to do IUI for such a person. Another thing is that the sperm count must be good as well as sperm mortality. If the sperm count is good but motility is bad, you are not going to get anything. But for some people, you explain to them that we are not going to get anything here because of this sperm and if she says why don’t you try, I don’t have any money for any other thing, you try but you have told her that this is not your preferred form of treatment.
In terms of cost, is IUI cheaper than IVF?
Of course, it is like buying Volkswagen and Mercedes Benz. But some doctors are not telling their patients the truth, they say I am doing IVF for you but actually what they are doing is IUI. And so they don’t collect the money for Volks but actually collect money for Mercedes.
At what point would you advise couples to go for treatment?
When there is no problem at all, what we define as infertility is when you have tried for one year. For example, if the man knows that even before he got married that one of his testicles is missing, he knows that there is a problem, such a person should seek help faster. He doesn’t need to wait for one year. If the woman is less than 35 years, you can wait for one year, if she is over 35, after six months, you should be going to do your test. If for example the woman also has irregular cycles, then she doesn’t need to wait for one year before seeking help, she will be advised to start almost immediately. Another category will be women who do not menstruate regularly.
If she is not ovulating, she cannot conceive. There are some women who only menstruate four to six times a year, such a patient should see the doctor early so that she can be able to get pregnant but if everything is okay, we say wait for one year before you start your investigations. Again, it also depends on the woman’s age. If she is less than 32, she can stay one more year with her gynaecologist. But for the man, if there is a problem of low sperm count or tubes are blocked, he is required to start treatment immediately because the earlier you start your treatment, the better the success rate. And that is why we say that once you need IVF, you better start on time.