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We Received Treatment …. and Then the Surprise – Infertility (pt. 3/3)

The Many Facets of Infertility Treatment in Nigeria

By Dr. Nwamaka Osakwe

“Are you going to do the test this week?” Nnenna asked her husband. It had been three months since the first semen analysis revealed he had a low sperm count. Against her wishes, he had begun taking herbal drugs, and he just completed a regimen.

“I just finished the medicine yesterday. Next week I’ll go.”

Nnenna was tired of waiting. But she didn’t say anything more. Her husband’s recent mood swings made her feel as if she was standing on a precipice.

Like her husband, many people battling infertility combine orthodox and unorthodox treatment. For example, in a study in Ogbomoso, Nigeria, a woman said, “My husband does not believe in orthodox medicine. He sees hospital treatment as a waste of money”. Another one said, “I was given a concoction …. I carried a sacrifice to one of the junctions in our neighbourhood naked in the middle of the night two years ago”. Other women faced similar harrowing experiences.

The length couples go to have a baby is the subject of many Nigerian movies. Ayobami Adebayo captures this narrative well in her award-winning book Stay with me.

Medical treatment for infertility, including assisted reproductive technology (ART), is available in Nigeria. Indeed, many couples have experienced success with orthodox care. Nnenna had heard some of the women share their stories in the hospital and hoped for a positive outcome.

Medical treatment for men

Treatment for male factor infertility depends on the underlying cause.

  • Men who have varicocele may be offered surgery.
  • Antibiotics can be used for men who have infections.
  • Testosterone is helpful in men with hormonal imbalances.
  • Men with low sperm count or abnormal sperms not amenable to treatment may be offered ART.

Medical treatment for women

Treatment of female factor infertility also depends on the underlying cause. The options include:

  • Ovulation induction for women with ovulation problems
  • Surgery for women with tubal or uterine factors like blockage, adhesions, fibroids
  • ART.

Although Nnenna had fibroids, she was not offered surgery. “The doctor told me the fibroid was on the outside of the womb. He said it was not the cause of the problem.”

Not all fibroids cause infertility; it depends on where they are located, which can be in the inner layer of the womb, the middle layer, or the outer layer. Fibroids on the outer layer do not bulge into the uterine cavity, so they don’t cause fertility problems.

In general, treatment is individualized. “Sometimes, by the time the women come to us, they’ve been taking different things. Some of them take Clomid on their own before they come to the hospital,” said Dr. Okwuosa, a consultant gynecologist at the Nnamdi Azikiwe University Teaching Hospital.

Doctors use Clomid to stimulate ovulation in women with ovulatory problems. Women with polycystic ovarian syndrome often benefit from it.

A procedure inappropriately used is dilatation and curettage (D&C). Gerrits and Shaw, in their review, found there was unnecessary overuse of D&C as a treatment for infertility in sub- Saharan Africa. Some people regard D&C as a way of cleansing the womb. Although diagnostic D&C has been used in investigating infertility, there is no evidence for D&C as a fertility treatment.

Although most of the listed therapeutic options are available in public and private hospitals in Nigeria, ART is mainly available in the private sector.

Assisted reproductive technology

“Many people refer to it as artificial reproductive technology. But it’s not. It’s assisted reproductive technology.” Dr. Onwudiwe of Pink Petals Fertility clinic said during our chat.

Several steps are involved in achieving successful ART through in-vitro fertilization (IVF):

  • The woman’s body is stimulated with medication to produce multiple eggs, and the eggs are retrieved
  • Sperms are retrieved from the man’s semen.
  • The egg is fertilized with the sperm outside the woman’s body. Sometimes an intracytoplasmic sperm injection is done, particularly for men with very low sperm count or poor-quality sperm.
  • The embryo is transferred into the prepared uterine lining.

If necessary, donor eggs and/or donor sperms may be used. Doctors may recommend donor eggs for women with ovarian failure, poor quality eggs, or genetically transmitted diseases. Donor sperm is used when the man has no sperm, poor quality sperm, or genetically transmitted diseases.

Since the first successful Nigerian IVF in 1989, ART has increased, now performed in several centers. However, despite this growth, finance remains a problem. In many studies, participants report that cost is a barrier to accessing IVF.

“Compared to other countries, ART is relatively cheap in Nigeria,” Dr. Onwudiwe said. “We even have people flying in from the US and UK to have it done here. On average, IVF costs about 1 million to 2.5million naira. But this depends on the couple. The more the interventions required, the more the cost goes up. The cost is certainly pricier in some centers.”

Dr. Onwudiwe explains that drugs, the media required, the need to use generators to maintain constant electricity add to the cost of the procedure. “You may think IVF is expensive, but sometimes when you sum what some couples spend overtime running around for a solution, it adds up. Sometimes they end up even spending more than [the] amount [for IVF].”

In his practice, finance is not the only barrier Dr. Onwudiwe encounters. “Some people worry about it being an artificial procedure. I tell them it’s not artificial but assisted. We are not manufacturing any other thing but what the body has already produced. It takes some people a period to adjust and agree. We give them time. Some of them go back and discuss with their family, pastors, or religious leaders.”

Sociocultural and religious beliefs play a significant role in the acceptance of ART. However, with more people being open, IVF acceptance has increased. “A lot of people now know children born from IVF. I also tell people about Hannatu Kupchi,” said Dr. Onwudiwe.

When Hannatu Kupchi got into medical school, it was widely publicized. Although she was identified as Nigeria’s first IVF baby, this fact has since been corrected.

In a focused group discussion convened by the Association for Fertility and Reproductive Health in Nigeria, religious clerics accepted people’s right to access IVF but opposed gamete donation and surrogacy. Surrogacy is when a woman carries a child for another person.

A form of surrogacy is the gestational carrier. A gestational carrier is a woman who carries a genetically unrelated baby for another person or couple. This is usually used when a woman cannot carry a baby for some reason, such as the absence of a uterus. Surrogacy adds to the cost of ART where it is used.

When Nnenna’s husband’s sperm count remained persistently low, the couple raised the money for IVF. Nnenna was unprepared for the discomfort that came from the injections. “It was not easy. I just kept praying. Let it not fail.”

A comprehensive ranking of different fertility centers in Nigeria is publicly available; however, the IVF success rate is unavailable. Nnenna knew a woman who had been unsuccessful twice. Made Adeboye had eight IVF treatments. Luckily, Nnenna was successful the first time. “We didn’t tell anyone. We wanted to be sure the babies would stay.”

The babies did stay—twin boys.

Bottom line

Several infertility treatment options are available in Nigeria. However, treatment is individualized and depends on the underlying condition. Therefore, it is essential to systematically review and appropriately refer couples to receive the most appropriate treatment if necessary.

To learn more about evaluating infertility, click here. If you’re a health practitioner looking to improve the care of your patients with fertility problems, a CPD course on Reproductive Health is coming soon.

Nwamaka Osakwe, MBBS, is a physician who loves writing about health and wellness. You can reach her here.

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