Dr Babatunde Okewale, an Obstetrician and Gynaecologist (O&G) and a fertility expert is the Chairman and Chief Medical Director of St Ives Specialist Hospital with branches in Lagos and Abeokuta, Ogun State. In this interview by TAYO GESINDE, he speaks on the reason for the increase in infertility in the world today, why Invitro Fertilisation (IVF) is expensive and how to prevent infertility.
What are the causes of infertility in men and women?
I think one of the best ways to understand the cause of infertility is first to know how conception occurs. There are basically five criteria for anyone who is trying to conceive. The first thing is that the husband’s sperm must be of good quality and quantity. The second requirement is that the woman herself must know her fertile period; when she is ovulating because it is only when they make love at that time that pregnancy can occur. The third one is that the inside of the womb of the woman must be able to accept and keep a pregnancy. So, there shouldn’t be anything in the womb that can disrupt pregnancy whether it is fibroid, adhesions or polyps. The fourth requirement is that the fallopian tube of the woman must be opened so that the eggs that are formed in the ovary can enter the tube and mix with the sperm that are coming so that fertilisation can occur. Finally, the woman must be producing quality eggs. If you see anybody that got pregnant naturally, what it meant was that those five requirements were fulfilled. Conversely, if there is a problem with any of those five things, it could cause infertility; if there is problem with the sperm, a woman has problem with her menstrual period, if the inside of the womb cannot accept pregnancy, if her fallopian tubes are blocked or she doesn’t produce quality eggs every month.
It seems cases of infertility are on the increase these days. What is responsible for that?
That is very true and it is not only in Nigeria, it is a worldwide phenomenon. And part of the reasons are these; as industrialisation increases worldwide, pollution increases, especially in the third world countries and there are quite a lot of pollutants that affect men’s sperm and sometimes affect women’s fertility. Some of the industries that have been implicated are industries such as plastic industry, industry that produce paints because you have heavy metals in paint production. Pollution generally affects the sperm count of men unknowingly because of the industrial pollution that goes into the water system of the populace, water gets contaminated. People are digging borehole and don’t know where the water they are getting is coming from. The second thing is that women are not getting married early again unlike in the past. The older a woman gets the more difficult it is to achieve a pregnancy. In fact, the best time, for any woman to achieve a pregnancy is between age 20 and 30. Once you are hitting 35, the ability to achieve a pregnancy starts decreasing at a very fast rate such that by 40, for most women, they find it extremely difficult to achieve a pregnancy. The other things are infections. The kind of infection that affect fertility has changed over the years. In the 70s, we were talking about Gonorrhoea which could be easily detected but the kind of s3xually transmitted disease that causes blocked tubes and affect sperms now are different. These ones are in the group of Chlamydia, they don’t show any sign and would have done their damage before you know it. So, indiscriminate unprotected s3x too can cause infertility. Also, excessive smoking and alcohol intake affect sperm but they are minor. Pollution, industrialisation and infections are playing a big role in infertility.
Is IVF the only solution to infertility?
No. In fact, IVF is just one of the solutions in infertility. It is not all the infertility causes that you need IVF for. If you have menstrual disorder, all you just need is an ovulation drug that would correct the problem, or if the problem is fibroid that is blocking some passage ways that will allow sperm to meet with eggs; if you remove the fibroid that should sort out the problem. IVF is however the first treatment option in women that have blocked tube. What it does is that it bypasses the tube and makes fertilisation occur outside of the womb.
Some women have done IVF four, five times without it resulting in pregnancy and some of them later conceive naturally. What is responsible for that?
The truth of the matter is; before you embark on IVF you must be sure that that is what is needed. It is not a situation of let me try IVF then try other things. There are some indications for IVF that lent themselves into the fact that after having an IVF, you can still conceive naturally. For example in cases of unexplained infertility (when all examination had been done and there is no reason for why pregnancy has not occurred), we advice IVF because what it does is to ensure that both the egg and the sperm meet. In such couples, they had IVF, got pregnant and have a baby. Subsequent conception does not have to be IVF. The drugs used in the IVF have made some correction in their reproductive hormones. It does happen but it is very rare. So, the reason IVF fails is that people don’t go for test to find out whether that is what they really need. Another reason IVF fails is either because the quality of the woman’s egg is low or the quality of the womb is not fertile or okay. But if the womb is very fertile, if you put an embryo there, it will grow. The problem in women is that as a woman grows older, the quality of the egg and the quality of the womb start deteriorating. IVF is usually very successful in women below the age of thirty. As a woman grows older, the failure rate of IVF starts increasing. In fact, let me give you some statistics; if a woman is below 30, her chances of getting pregnant in a cycle of IVF is 60 per cent, while in a woman who is 40 years old, her chances of getting pregnant in more than one cycle is not more than 25 per cent. What have made the differences are the age and the quality of the egg and the inside of the womb. The best time for pregnancy in women either naturally or IVF is below the age of 35. Most failures in IVF are in women who are using their own eggs above 35 years old. The converse again is if a woman is 60 and wants to get pregnant by IVF and decides to use the egg of a younger person, the chance that she will get pregnant with the egg of a 3o-year-old is high.
Talking about pregnancies, why do women have miscarriages?
Generally speaking, the incidence of miscarriages in natural conception is about one in four. Most people might not know that. In fact, most people have miscarriages even before they missed their periods. What causes miscarriage in the early stage of pregnancy mostly is abnormality in the formation of the embryo. Again, if people get married late, the incidence of abnormality increases. Any woman who gets pregnant above the age of 35 should ideally be screened for Down syndrome. For most abnormal pregnancies, the way the body deals with them is to let them go (miscarriage) before 12 weeks.
IVF is on the high side for many Nigerians, especially in the rural areas. What are you doing to ensure that they too can benefit from this procedure?
What we have been doing for the past 10 years is that we work closely with a Non-Governmental Organisation (NGO) that twice in a year our patients pay only 50 per cent while it pays us the balance. So, we do a promo twice a year courtesy the NGO. Ideally, the government should step in, in such situation. In UK and some other socially responsible societies, the government steps in. In UK for instance, the government ensures that you have free IVF for the first three cycles it is only if nothing happens after three cycles, that you start paying. And people that can’t afford it, it is highly subsidised because infertility is a social problem. Although our governments don’t see it that way, they are more interested in population control so more money is being put into contraception. But for a couple trying to conceive, infertility is a social problem and government should be able to help. Having said that, IVF is an expensive procedure all over the world not only in Nigeria. Part of the reason is that an IVF laboratory is a high tech lab. There must be light 24 hours and there is a level of sanitation that must be present in the lab. Though it is not as expensive as heart or kidney transplant. The only problem is that people don’t see infertility as a diseased process, they only see it as a lifestyle issue.