TheNigerianVoice Online Radio Center

How we pioneered IVF in Nigeria

By NBF News
Click for Full Image Size
Listen to article

Ajayi
Fertility problems are common in Nigeria, up to 1 in 4 couples will experience delay in achieving pregnancy. Although some patients will fall pregnant by themselves with standard gynaecological treatment, up to 60 per cent will require assisted conception techniques like in In-vitro fertilization (IVF) or Intra-Cytoplasmic Sperm Injection (ICSI) to achieve pregnancy. This is particularly true for couples that have been trying to conceive in excess of 3 years.

According to Dr Richardson Ajayi, Managing Director, The Bridge Clinic, the clinic was set up in collaboration with Dr. John Parsons, the Director of the Assisted Conception Unit of Kings College Hospital London and Dr. Virginia Bolton, who was then the Chief Embryologist. They both have well over 21 years experience in assisted conception treatment and the additional experience of successfully transferring the technology of assisted conception to many developing countries such as Pakistan, Kuwait and Saudi Arabia.

They have successfully transferred the technology of assisted conception treatment to The Bridge Clinic and couples can now expect the same pregnancy rates here in Nigeria without the burden of traveling abroad and at a fraction of the cost.

The clinic started operations in 1999 by batching clients for a team from the United Kingdom to come to Nigeria to treat. 'We were able to transfer the technology of IVF to a Nigerian team by 2001 and although the collaboration is maintained with intermittent visits by our technical partners, the day to day client management is carried out by our well trained Nigerian staff,' he stated.

In this piece, he provide information about the Bridge Clinic, educate couples about the causes of infertility and their management and provide instructions to patients currently undergoing a treatment programme.

The Bridge Clinic
The clinic has the largest number of pregnancies from assisted conception in Nigeria and the first conception and birth from surgically collected sperm in the country. Among other firsts are first conception and birth of babies through IVF surrogacy, first conception and birth of babies with Micro Sort sex selection and the first clinic in West Africa to be awarded an ISO Certification (the quality management certification) from TUV Austria in 2004.

There was also successful recertification of the clinic quality management system in accordance with ISO 9001:2000 from the certifying body TUV Austria in 2005 and 2006.

In Vitro Fertilisation (IVF)
IVF literally means fertilization in glass. This treatment effectively bypasses the fallopian tubes and is the most effective treatment for patients with absent, blocked or damaged tubes.

The woman is given fertility drugs to stimulate her ovaries to produce many follicles. Each follicle should contain one egg. The chances of pregnancy are increased if more than one egg can be obtained and fertilized. The number and size of the developing follicles in the ovaries is measured by ultrasound scans.

The final preparation for egg collection involves a hormonal injection (hCG) given to the woman 36 – 40 hours pre-operatively. This mimics the natural process which normally triggers ovulation.

The eggs are collected vaginally using ultrasound guidance, under local anaesthesia. The ultrasound probe is introduced into the vagina, the ovaries are visualised and then an aspiration needle (attached to the probe) is passed through the top of the vagina into the follicles. The fluid within the follicles is aspirated and then examined in our IVF laboratory for the eggs to be identified. In rare situations, the eggs may be collected abdominally if the ovaries prove to be inaccessible using the transvaginal ultrasound scan.

After egg collection, the eggs are incubated for a short time and the sperm is then added to the eggs and incubated in the laboratory for a further 24 – 48 hours. If the semen is normal, fertilization usually takes place. The fertilized eggs (now called embryos) are returned to the uterus 48 – 72 hours after egg collection. We refer to this as an embryo transfer.

A maximum of three embryos are transferred into the uterus through the cervix. It is generally a painless procedure, similar to a cervical smear and on average takes up to 15 minutes. On rare occasions this procedure may take longer.

Occasionally the woman will experience period-like pain during the procedure, but this is generally short-lived. We encourage the male partners to be present during this special time, if they wish to do so. After the procedure, women are encouraged to carryon with their normal routine as there is no evidence to suggest that bed rest increases the chances of pregnancy.

Natural conception
Natural conception depends on several factors and processes. Firstly, the woman needs to produce an egg from one of her ovaries, which must be able to travel freely down into the fallopian tube. The man has to produce a high number of good quality sperm, which are capable of making the journey from the vagina, through the cervix, uterus, and into a fallopian tube where fertilization takes place. The timing of sexual intercourse is also crucial, as conception can only occur following ovulation (release of an egg). Once fertilization has occurred, a normal uterus is required in order for the embryo to implant and develop. If any of these requirements are not met, the probability of conception occurring naturally is reduced or impossible, in which case the couple will need help to achieve pregnancy.

Infertility
A couple aged 25 have a 25 per cent chance of conceiving each month and most such couples would have achieved a pregnancy within one year. Infertility is defined as the inability to achieve a pregnancy after one year of regular unprotected intercourse.

The cause of infertility can be in the man (abnormality of sperms) or in the woman (blocked fallopian tubes or ovulation problems). It is our policy to consider infertility as a couple's problem, so both partners are investigated early.

Reasons for Infertility
Approximately 15 per cent of couples have difficulty achieving a pregnancy. It has been found that female factors are responsible in 40 per cent of cases, male factors account for a further 40 per cent and the remaining 20 per cent there are a combination of female and male factors.

There is a diagnostic category called unexplained infertility, but the proportion in this group depends on the sophistication of the tests carried out.

Female infertility problems
A woman usually produces a single follicle each month as a result of various hormonal changes. The egg which develops within the follicle, once matured, is released. The fallopian tube subsequently picks the egg up, and moves it towards the uterus. The quality of cervical mucus at the time of ovulation must be such that it allows free passage of the sperm into the uterus.

Common female infertility problems are due to the following, ovulatory problems such as polycystic ovarian syndrome, tubal blockage and endometriosis.

Ovulatory problems
Ovulatory problems are the most common cause of female infertility and occur as a result of hormonal imbalance. Common causes of this include stress, weight loss or weight gain, excessive prolactin production (the hormone that stimulates milk production in the breasts) and polycystic ovarian disease. It is highly unlikely that there is an ovulation problem if the periods are monthly.

About 20 per cent of women have polycystic ovaries (PCO) but it is likely that the incidence is higher in Nigeria. This term describes the appearance, as seen on an ultrasound scan of an increased number of small cysts on the surface of the ovary. Many women with PCO have normal regular cycles and have no problems conceiving. However, some women with these ultrasound findings have a condition known as polycystic ovarian syndrome (PCOS). These women have a hormone imbalance with irregular or absent periods and they may have difficulty conceiving.

Treatment in the first instance usually involves the use of drugs to correct the hormonal imbalance and to stimulate ovulation. If the woman is obese, weight loss may also improve the hormonal imbalance. Alternatively, a laparoscopic ovarian drilling (making tiny holes on the surface of the ovaries using diathermy or laser) may be performed. In cases of PCOD these two modes of treatment may precede an IVF treatment cycle.

Tubal Blockage
In normal circumstances, the fallopian tubes act like fishing rods, picking up the released egg and helping to move it towards the uterus. Damage to the tubes may impede the pick-up or transport of the egg, thereby preventing fertilization. Greater damage may result in complete tubal blockage.

Tubal blockage can occur as a result of an infection which ascends into the tubes, or which descends to the tubes from other sites in the peritoneal cavity, such as the appendix, or from previous surgery. If fluid collects in the fallopian tube (hydrosalpinx), it may be a potential source of chronic infection. This fluid may also be detrimental to the development of the embryo. It is important to note that although tubes may be opened at hysterosalpingography (HSG) or laparoscopy, they may not be functioning and may be the cause of infertility. The tubes are lined by hair-like processes called cilia, which assist in transportation of the egg. These may be damaged and disturb tubal function in the absence of blockage.

Some blockages can be treated by micro-surgicaltechniques, but the results are poor and most cases will require IVF.

Endometriosis
Endometriosis occurs when tissue, which normally lines the womb, is found at other sites in the pelvis. At the time of menstruation, bleeding occurs from this tissue and this may give rise to abdominal pain and painful intercourse. Blood filled cysts may also develop within the ovaries. These cysts are known as chocolate cysts because of their dark brown appearance. The association between mild to moderate endometriosis and infertility is weak.

Laser treatment through the laparoscope is a possible method for improving the fertility of the patient. Drug therapy is not helpful, however, it is effective in reducing the pain.

on IVF treatment.
IVF is an appropriate treatment for infertility associated with endometriosis where other methods have failed. Any resulting pregnancy is usually an excellent temporary cure for endometriosis.

Male infertility problems
Sperm are produced in the seminiferous tubules of the testes, from where they move to be matured and stored in the epididymis. This process takes approximately three months to complete. During sexual intercourse the sperm leaves the epididymis and travels through the vas deferens where they are mixed with fluid secreted from various glands. This mixture of sperm and seminal fluid (semen) is then deposited in the vagina of the female partner following ejaculation.

Causes of male infertility can be divided into two categories, firstly, physical abnormalities such as blocked epididymis or impaired sperm production and secondly, abnormalities of the sperm themselves. However in most cases of male infertility the cause is unknown.

To determine male fertility we carry out a semen analysis where we test the number, activity and shape of the sperm. A normal assessment should show a sperm count of more than 20 million sperm per milliliter with at least 40 per cent of the sperm actively moving and more than 30 per cent of the sperm of normal shape. They must be capable of moving through the female genital tract to reach the fallopian tube where the egg is fertilized, and so must survive for a period of 24 – 48 hours.

Common male infertility problems are due to the following, abnormal sperm parameters in ejaculate, azoospermia (no sperm cells in ejaculate).

Abnormal sperm parameters
Abnormalities in the semen are primarily due to a defect in sperm production by the testicles. The cause of this is usually unknown but occasionally may be associated with previous infections, surgery or excessive drinking. Certain drugs, radiation and radiotherapy may have a detrimental effect on the production of sperm. The presence of a varicocele may lead to a rise in the temperature around the testicles, which may adversely affect sperm production and motility. However, recent evidence suggests that there is no benefit in the removal of varicocoeles.

Azoospermia
The absence of sperm in the ejaculate (azoospermia) may be due to an obstruction at the level of the vas deferens, epididymis, or even at the level of the testes. It may also be due to a bilateral congenital absence of the vas. Some men might have testicular failure i.e failure of production of sperm. This may be the result of a chromosomal disorder or previous infections such as mumps. It may also be associated with the history of undescended testes.

Antisperm antibodies
There may be anti-sperm antibodies in the semen which attach onto the sperm and impair their motility and their ability to penetrate and fertilize an egg. These may occur following reversal of a vasectomy or other surgery on the male genitals and may also be related to previous infections or injury.

Until recently there has been no effective treatment for the male infertility problems discussed above. Drugs rarely improve sperm counts. However since the introduction of micromanipulative techniques, Intra Cytoplasmic Sperm Injection (ICSI) in particular, the success rates for couples with male infertility problems have markedly improved. Another option available to the couple is to use sperm from a donor (AID).

Ovulation induction and cycle monitoring
If a woman has an irregular menstrual cycle, monitoring with ultrasound scans and hormone assessments may help to identify the fertile time of the month and so improve the chances of natural conception. If ovulation is not occurring, then drugs may be administered after the onset of menstruation to stimulate egg production.

Fertility tablets, are not always effective and more powerful fertility injections may be necessary to stimulate egg production in the ovaries. With these more potent drugs, there is a greater risk of increased egg production and therefore, the risks of multiple pregnancy are greater. Women receiving fertility injections are monitored by ultrasound scans.

Intra Uterine Insemination (lUI)
Intra Uterine Insemination (IUI) involves the injection of treated sperm from the husband, partner or donor into the woman's uterine cavity via the cervix. It is generally a painless procedure which takes only a few minutes and is performed on an outpatient basis. The chances of success are increased if the insemination is combined with ovulation induction using small doses of fertility drugs (10 - 15 per cent per cycle).

The development of the ovarian follicles is monitored with ultrasound and the insemination is timed to take place 36 – 40 hours after administration of the hormone (hCG) injection, which triggers ovulation. When ovulation has occurred, the male partner is asked to produce a semen sample. This sample is prepared in the laboratory, and is then placed in the uterine cavity by means of a fine catheter.

lUI should be performed in cases where the woman has healthy fallopian tubes confirmed by laparoscopy and the sperm preparation is satisfactory.

Donor Insemination (D1)
Donor insemination is the treatment used for women whose partners have no sperm in the ejaculate, or for couples who do not wish to undergo the ICSI procedure. It is carried out with frozen thawed HIV, free sperm with a pregnancy rate of about 11 per cent per treatment cycle.

In Vitro Fertilisation (IVF)
IVF literally means fertilization in glass. This treatment effectively bypasses the fallopian tubes and is the most effective treatment for patients with absent, blocked or damaged tubes.

The woman is given fertility drugs to stimulate her ovaries to produce many follicles. Each follicle should contain one egg. The chances of pregnancy are increased if more than one egg can be obtained and fertilized. The number and size of the developing follicles in the ovaries is measured by ultrasound scans.

The final preparation for egg collection involves a hormonal injection (hCG) given to the woman 36 – 40 hours pre-operatively. This mimics the natural process which normally triggers ovulation.

The eggs are collected vaginally using ultrasound guidance, under local anaesthesia. The ultrasound probe is introduced into the vagina, the ovaries are visualised and then an aspiration needle (attached to the probe) is passed through the top of the vagina into the follicles. The fluid within the follicles is aspirated and then examined in our IVF laboratory for the eggs to be identified. In rare situations, the eggs may be collected abdominally if the ovaries prove to be inaccessible using the transvaginal ultrasound scan.

After egg collection, the eggs are incubated for a short time and the sperm is then added to the eggs and incubated in the laboratory for a further 24 – 48 hours. If the semen is normal, fertilization usually takes place. The fertilized eggs (now called embryos) are returned to the uterus 48 – 72 hours after egg collection. We refer to this as an embryo transfer.

A maximum of three embryos are transferred into the uterus through the cervix. It is generally a painless procedure, similar to a cervical smear and on average takes up to 15 minutes. On rare occasions this procedure may take longer.

Occasionally the woman will experience period-like pain during the procedure, but this is generally short-lived. We encourage the male partners to be present during this special time, if they wish to do so. After the procedure, women are encouraged to carryon with their normal routine as there is no evidence to suggest that bed rest increases the chances of pregnancy.