Imagine longing for exhausting, sleepless nights with cranky babies, milk bottles and soiled diapers. Picture yourself praying to be blessed with a child of your own, despite hearing your peers complain about the trials of motherhood regularly. Worst still, imagine waiting to be blessed with the good news, only to be told that you can never conceive due to inexplicable reasons.
This was precisely how British homemaker Lesley Brown had felt for a long time before she met Professor Robert Edwards and Dr Patrick Steptoe in 1976. They combined their research and pioneered what is now a go-to treatment for infertility in women, commonly known as In-Vitro Fertilisation (IVF). Lesley became the first woman to undergo a successful pregnancy initiated by the process, giving birth to a beautiful baby girl on July 25th, 1978. Together, the trio revolutionised human reproduction forever and made not just Lesley’s but countless other women’s dreams of motherhood a reality. Since then, nearly four million babies have been born through IVF and considering the on-going medical advancements, the number is only expected to rise.
According to the American National Institute of Child Health and Developement, IVF is just one of the various infertility treatments in the Assisted Reproductive Technologies (ART) category. Treatment options include various medical, surgical and hormonal treatments to enable pregnancy in infertile couples who have been trying to conceive for over a year or more. Any one of the ART treatments may be considered — depending on each couple’s specific problems — but IVF remains most commonly sought-after, often administered alongside male fertility treatments.
In a nutshell, the process involves withdrawing sperms and eggs from the man and woman and incubating them in a Petri dish with hopes to produce an embryo. The fertilised egg will then be inserted back into the woman’s uterus for pregnancy. The entire treatment can be summarised into four broad stages:
1. The patient is given hormone injections (fertility drugs) which mimic hormones that occur naturally in the female body, such as follicle-stimulating hormones (FSH) and the luteinizing hormone (LH). She is also monitored regularly via ultrasounds to gauge the best time for egg retrieval. This is generally when the egg releases from the follicle and travels to the ovaries.
2. Once the timing is determined, the eggs are given a hormonal drug called Human chorionic gonadotropin (HCG) to help ripen the egg for fertilisation. The egg is then located and retrieved using a hollow needle.
3. If the male sperm count is low, doctors may inject the sperm directly into the egg as opposed to allowing it to find its own way.
4. The fertilised embryo is then set aside to incubate in a Petri dish for about five days, until it becomes ready for implantation. It is then inserted back into the uterus using a catheter. Some medical facilities also offer the option of freezing unused embryos and storing them for later implantation.
The single, biggest risk of any fertility treatment — IVF included — is that of multiple births. According to the Human Fertilisation and Embryology Authority (HFEA) in the UK, IVF often causes Ovarian Hyperstimulation Syndrome wherein the patient produces more than one egg, resulting in twins, triplets and so on. According to Dr Sethna, Consultant of Obstetrics and Gynaecology at Concept Fertility Clinic and Lady Dufferin Hospital in Karachi, “Some countries like the UK restrict the number of eggs replanted using controlled drug dosage and monitoring.” Others like the US and Pakistan have incorporated no such practice yet.
For most patients, however, the actual procedure of egg retrieval, impregnation and implantation is less debilitating that the emotional roller coaster of being unable to conceive and trying to make it happen. “People taunted me about how many doctors I would see and how long I would keep trying,” shares Zoya Mehmood* who underwent several failed IVF treatments before finally conceiving a baby boy. “People at work, home and other social gatherings would ask questions and offer unwanted advice, albeit in the kindest possible way,” she adds. “I felt humiliated, exhausted and depressed each time but I persevered.” On the other hand, lawyer Alya Karim* found it extremely difficult to organise her hospital visits around a nine-to-five job. “Since the eggs must be retrieved before ovulation, doctors must track the eggs regularly,” explains Alya. “This means trekking back and forth for ultrasounds. Your work colleagues will understand but only for so long.” Now a mother of a beautiful boy, Alya adds that it was most difficult to keep her hopes high and not let successive futile IVF experiences affect her work. Nonetheless, Zoya, Alya and their fellow IVF patients made it through, finding support from doctors, nurses, and of course, compassionate family members.
It would be incorrect, however, to assume that every woman who undergoes the treatment gets the desired results. “It is a painstaking process, that gives no guarantees,” says homemaker Bina Shahid*, who eventually decided to adopt a baby girl after an unsuccessful attempt at IVF. “They planted three embryos into me but it just didn’t work. Another patient next to me, however, went on to have a baby.” Age, unfortunately, is the main factor which affects the outcome of IVF treatments. “The older a woman is, the less likely it is that she will get pregnant or complete the pregnancy successfully,” explains Dr Sethna. As women are born with a set number of eggs which decline and deteriorate in quality as we grow older, many doctors believe the chances of an IVF pregnancy are higher in younger patients. In fact, studies reveal that the chances of a successful treatment falls from about 40% for women under 35 to just 10% for those over 40. According to research conducted by Dr Howard Jones, who ‘created’ the first American IVF baby Elizabeth Carr in 1981, IVF treatments generally result in childbirth for just one in five couples, closely mirroring nature. “The take-home baby rate at Concept Clinic is about 32%,” Dr Sethna points out.
As the human population ages and social dynamics change, more and more women are delaying motherhood in favour of thriving careers. As a result, infertility appears to be becoming increasingly common in women these days, thereby increasing the demand for IVF and other fertility measures. “It is a problem faced by the old, young, rich and poor across cultures and races,” says Alya. “The only difference is that the more affluent couples can afford a medical treatment.” In Pakistan, the cost of each IVF session generally falls between Rs200,000 to Rs400,000, depending on the hospital and doctors involved. This, coupled with the toll hormone injections take on the patient can make their experience quite traumatic. “Intense mood swings, anxiety, weight gain, bloating and excessive hair growth are just some of the side effects of IVF,” says Alya. “And they are all very unpleasant!”
Unfortunately, the greater half of the Pakistani population remains largely unaware or wary of treatments like IVF and infertility in general, believing it to be a result of contraception, God’s will and even attribute it to superstitous beliefs. Dr Sethna cites internal infections and endometriosis — a hormonal disease wherein cells similar to those that line the uterus grow outside the uterine cavity — as some of the main causes of infertility in Pakistan. Many infertile couples, however, resort to homeopathy or faith-healers to cure themselves, often aggravating their situation further. According to Zoya’s experiences at the hospital, “Some people reject IVF assuming it involves the use of sperm donated by third parties, especially those in the rural communities. Other worry artificial treatment will lead to genetic abnormalities, miscarriages and even difficult babies!” But in a country where over 22% of all married couples find it difficult to conceive naturally but aren’t brave enough to speak about it, Zoya often wonders if the social pressure to start a family was greater than her own desire for a child. “Our social system does nothing for working women,” she says. And Alya agrees with her, saying that, “Infertility is always the woman’s fault. Our culture says that a man can take another wife and if he doesn’t, he must be good. But male infertility is never considered. God forbid a woman leave her husband to pursue her dreams of motherhood!” According to Dr Sethna, “Male infertility accounts for 30% of total infertility problems.” He advises both couples to get tested for infertility to detect any problems they might have — the man and woman, alike.
“Infertility is a hidden disease,” says Dr Sethna. “It is virtually impossible to know just how many couples are affected by it.” Keeping this in mind, one can safely conclude that raising awareness regarding infertility and how it can be countered is imperative in Pakistan. In fact, the need for awareness is even greater considering everyday practices like smoking, stress, lack of hygiene and poor dietary habits are some of the main causes of infertility.
*Names have been changed to protect privacy.
Different types of Assisted Reproductive Technologies (ART)
• Intra-Uterine Insemination (IUI): This treatment is administered in the case of unexplained infertility where both the male and female have no obvious medical conditions.
• In-Vitro Fertilisation (IVF): The most commonly used fertility treatment, IVF can treat different types of infertility.
• Intra-Cytoplasmic Sperm Injection (ICSI): Usually offered in cases of severe male infertility, ICSI is considered after IVF has been unsuccessful.
• Intra-Cytoplasmic Morphological Sperm Injection (IMSI): This form of ART is offered to males with very low sperm count.
• Low Stimulation IVF: A common side-effect of IVF is Ovarian Hyperstimulation Syndrome wherein the ovaries produce more than two eggs due to the hormone supplements. Low Stimulation IVF allows patients at risk of Hyperstimulation to reduce the chances of multiple births, beginning with the lowest drug doses possible.
• Natural Cycle IVF: In cases where egg stimulation is impossible for medical or personal reasons but the patient is ovulating normally, her natural cycle is monitored regularly. The egg is extracted prior to ovulation, fertilised and then replanted into the womb.
SOURCE: NATIONAL HEALTH SERVICES (NHS); LISTER FERTILITY CLINIC
Published in The Express Tribune, Ms T, November 23rd, 2014.