Why I am putting all my eggs in one basket

Last Thursday, a young woman and her husband walked back into a fertility clinic in Nairobi. The beginning of yet another emotionally-draining and torturous cycle.

At the clinic were excited couples who were taking the very first step, full of hope and expectation. There were also others like Emily* and her husband, who had been on the roller-coaster, and spiralled down the path of dashed hopes. They had grown accustomed to pain and disappointment, but they were not giving up yet. Maybe this time the procedure would work, sounding the death knell for prolonged infertility.

Emily and her husband of 10 years are desperate to become parents, but only a handful of people — her parents-in-law, a close friend and their doctor — know of their decade-long struggle with infertility.

 “I dread family and social gatherings. I will be asked when I am bringing them a baby. Those asking don’t know that I also want to have a baby, but I can’t ... not yet,” she says.

Emily didn’t always face this struggle. She conceived naturally in 2010, two years into marriage.

“But the amniotic fluid leaked suddenly. I experienced premature contractions and despite efforts by doctors to save the pregnancy, my baby died. I delivered him at 18 weeks.

“I held his little lifeless body and said goodbye. I had no idea how difficult it would become to get pregnant after that,” she whispers.

UPHILL TASK

When conceiving proved to be an uphill task, Emily and her husband sought assistance in the form of assisted reproductive techniques (ART), and specifically in vitro fertilisation (IVF).

With IVF, ova are fertilised with sperms outside the body, then implanted into the woman’s womb. An IVF cycle usually starts at the beginning of the woman’s period. During this time, the woman is counselled and tests for sexualy transmitted infections  including HIV are done.

IVF may be used for women whose fallopian tubes are damaged or blocked, a condition that affects seven out of ten women with infertility. It may also be used if the woman has a problem producing an egg or if the male partner has a very low sperm count or sperm with very low speeds. IVF can also be used when there are genetic problems in either partner or in cases of unexplained infertility.

Emily started the journey in 2014. After tests and counselling, she was given fertility drugs that came in form of daily hormonal jabs that she injected on the stomach for two weeks, tablets and suppositories (inserted in the rectum or vagina to dissolve). These were supposed to induce multiple egg production, thus increase the chances of successful fertilisation, because some eggs won’t fertilise or develop normally after fertilisation.

As she took in the hormones, scans and lab tests were done to evaluate the maturity of the eggs and once ready for harvesting, a slightly bigger and heavier (because of the hormonal treatment) Emily returned to the fertility clinic for the next step.

This happened 36 hours before the eggs were harvested, because Emily needed to get a human chorionic gonadotropin (HCG) injection to induce ovulation (release of the eggs from the ovary). Emily produced 40 eggs that first time, the equivalent of 40 months of menstruation or three years. She was also put on antibiotics to keep infections at bay.

The egg retrieval process was done under local anaesthesia. A thin aspiration needle fetched the eggs from the now swollen ovaries, under the guidance of an ultrasound scan.

The collected eggs and sperm  were then manually combined in a laboratory—in a test-tube— resulting in an embryo or embryos, hence the term “test-tube baby” a colloquial term for babies conceived through this method. The first baby born through this technology was Louise Brown in 1978 in England.

Of the 40 eggs retrieved from Emily, only 36 were good and from these 21 developed into embryos and were used.

 Embryo transfer is done by inserting a long, thin, flexible tube called a catheter into the vagina, through the cervix and into the uterus. This takes place two to six days after egg retrieval.

A syringe containing one or more embryos suspended in a small amount of fluid is attached to the end of the catheter and is then placed into the uterus. If successful, an embryo will implant in the lining of the uterus about six to 10 days after egg retrieval.

 “The embryologist said that I had very good embryos and they were very optimistic that it would go well. They implanted three embryos. We were on our way to becoming parents of triplets,” Emily recalls.

FROZEN

The other 18 embryos were frozen using liquid nitrogen, also called cryopreservation, and would be thawed for future use. This makes future cycles of IVF less expensive and less invasive. However, the live birth rate from frozen embryos is slightly lower than the live birth rate from fresh embryos. Emily used these frozen embryos in consecutive six cycles but unfortunately, none yielded a pregnancy.

“After two weeks, I took a pregnancy test and it turned positive. A scan later showed we were expecting triplets. I had even began looking for baby names and where I would get a baby stroller for triplets. Finally, we would become parents,” she says.

Unknown to her though, the surge of hormones meant that her ovaries were more responsive than usual and producing too many eggs as a result. This is known as ovarian hyperstimulation syndrome (OHSS). Her body was also retaining fluid. As a result, Emily experienced weight gain, severe stomach discomfort, intense pain and sweating which came alongside the early signs of pregnancy. The fluid build-up was unbearable and she went for five draining sessions where over 10 litres of fluid was collected.

However, she was not out of the woods yet. Everything changed one Sunday as they were having lunch at a restaurant in Lavington, Nairobi County.

“I went to the bathroom and as I stood up to flush the toilet, I saw blood stains on the tissue. I was not in pain at the time, but I did not want to imagine that something was happening to our seven-week pregnancy. By the time I got outside, blood was gushing down my trousers.”

She was rushed to Nairobi Hospital.

“The moment I got out of the car at the casualty, something heavy in my womb gushed down. I knew there and then, I had lost my babies. I had lost the pregnancy.”

TOOK A TOLL

The loss took a toll on her body as well as her psychological and emotional stability.

“I did not understand why it had happened. I blamed myself. I would cringe when I saw pregnant women or mothers with babies. I asked why I was not like them. I am glad my parents-in-law and husband were there to support me.”

A battery of costly tests later, Emily and her husband were found to be clinically fit to get pregnant. The infertility was unexplained and in spite of countless drugs and a Sh500,000 surgery to unblock her fallopian tubes, all six IVF cycles failed.

Infertility affects 10 to 15 per cent of Kenyans. Globally, the figure stands at 11.9 per cent according to the World Health Organisation. The causes aretraced to the male partner in 20 per cent of the cases, the female in 38 per cent of cases, while another 27 per cent in both the man and woman, while in 15 per cent others, no cause of infertility is attributed to either partner.

According to Dr Jane Machira, an obstetrician and gynaecologist, the consequences of infertility hit women hard, especially in African countries like Kenya, where having children is of much importance.

“Infertility in the African setup has been feminised and the woman is thought to be the reason behind childlessness in the household. This is despite studies showing that the male partner contributes significantly to the causes of infertility.

“Consequently, women in a childless marriage suffer emotional and physical abuse, financial neglect, divorce and sometimes death,” she adds.

Therefore, infertility treatment using IVF and other assisted reproductive techniques seem like the silver bullet for such families; the financial, mental and physical costs notwithstanding.

In most cases IVF centres offer a package which ranges between Sh400,000 and Sh500,000 per cycle. This covers the cost of IVF medication, scans, egg collection and embryo transfer. However, charges such as nutritional supplements, antibiotics and others that are not included in these costs.

IVF treatments and fertility treatments in general are not covered by insurance. This means that a couple has to raise the funds required for the initial investigations and for the procedures. However, the National Hospital Insurance Fund pays for such treatments for civil servants.

For a majority of patients these IVF treatments are out of reach and this leads to further despair with many forced to take out loans and sell their property such as land to raise the money required.

Many don’t opt for fundraisers, a common way of raising funds for other medical costs, because infertility, though stigmatised, is not considered as critical as illnesses such as cancer.

Emily does not have a permanent job. But her husband and her in-laws have been picking up the tab in the quest for a child.

“We have spent nearly Sh2 million and counting, and the procedure we started last week will cost us about Sh700,000,” she told HealthyNation.

DIFFERENT APPROACH

Because genetic abnormalities have been known to cause miscarriages, this time time around the couple would like their embryos to undergo a test called the Preimplantation genetic diagnosis (PGD), a genetic test on embryonic cells to help select the best embryo(s) for pregnancy that are free from genetic disease. The test costs Sh200,000.

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Thirty-eight-year-old Catherine*, and James, her husband of eight years have a sunnier story to tell.

IVF allowed them to be parents to their three-year-old daughter.

Catherine had a botched fibroid surgery at age 23, that left her right fallopian tube damaged, and her chances of getting pregnant at 50-50.

Fortunately, a hospital visit to address constant abdominal pains led her into a fertility expert’s office, where the couple’s IVF journey began.

“It was not an easy journey. It was an emotional roller-coaster. We were expecting multiple babies as three embryos were transferred, but only one, our daughter made it. We faced anxiety and spent Sh400, 000 from our pockets, but we are glad we went through it for our daughter. Now, we are expecting our second child through IVF.”

The science behind IVF is mind bogging to many and Catherine and her husband agree that it has made them question a lot of long-held patriarchal traditions and beliefs.

“Men need to be the strongest support for their wives during this journey. Infertility can also be from the man, not just the woman. More importantly, you married the love of your life whether she will get children or not,” says James.

For Catherine, the IVF procedure made her “question whether I was challenging God.”

“I am a staunch Christian and going for IVF in the beginning was unsettling. However, when I spoke to my mother, she asked me if I would sit in pain if I broke a leg or got malaria? I would do something about it and that is what we did about our infertility.”

Catherine and James were faced with the dicey dilemma of whether to use a frozen embryo from the first IVF or get fresh ones for their second child.

In the first cycle, they had five embryos. They implanted three (but only one survived and led to their daughter). Two embryos were frozen for future use.

“But when we wanted to try for the second child, we debated whether the quality of the frozen embryo would guarantee us a child. So we asked the fertility clinic to discard them and we took fresh embryos. It was a tough call.”

Such ethical concerns, myths and misconceptions exist around the complex series of procedures used to treat fertility or genetic problems and assist with the conception of a child.

“While not loudly voiced, patients have told me that they think that IVF babies are abnormal and have developmental problems.

“This is not true. Only a slightly higher incidence of abnormalities are noted in IVF-ICSI babies than in the normal population,” Dr Machira told HealthyNation.

The fertility expert based at Gynacare Centre in Nairobi adds that some people also think that they are emotionless and less human since they have been conceived in a laboratory tube which is also not true.

In addition, because of the term “test tube babies” many people think that grown babies are transferred into the uterus. The process involves very early embryonic cells—only seen under the microscope—being transferred soon after fertilisation and no longer than within five days.

Furthermore, the success rates of  IVF depend on the age of the female partner. There are better prospects for those under 35 and this diminishes as the women grow older.

A woman’s weight, and lifestyle habits such as smoking and diet also affect the likelihood of successful pregnancy with IVF.

Dr Machira emphasizes that while IVF is a relatively safe procedure, women over age 35 are at higher risk of OHSS.

Other risks include the risk of injury to the surrounding organs during egg retrieval, the risk of multiple pregnancies, premature delivery and low birth weight, and ectopic pregnancies among others.

IVF may be an option if you or your partner has:

• Fallopian tube damage or blockage.

• Ovulation disorders. If ovulation is infrequent or absent, and fewer eggs are available for fertilisation.

• Premature ovarian failure. This is the loss of normal ovarian function before age 40, meaning the woman doesn’t produce normal amounts of the hormone oestrogen or doesn’t have eggs to release regularly.

• Endometriosis. This occurs when the uterine tissue implants and grows outside of the uterus — often affecting the function of the ovaries, uterus and fallopian tubes.

• Uterine fibroids. These are benign tumours in the wall of the uterus and are common in women in their 30s and 40s. Fibroids can interfere with implantation of the fertilised egg.

• Previous tubal sterilisation or removal. If you’ve had tubal ligation — a type of sterilisation in which your fallopian tubes are cut or blocked to permanently prevent pregnancy — and want to conceive, IVF may be an alternative to tubal ligation reversal.

• Impaired sperm production or function. Below-average sperm concentration, weak movement of sperm (poor mobility), or abnormalities in sperm size and shape.

• Unexplained infertility, meaning that no cause of infertility has been found despite evaluation for common causes.

• A genetic disorder.

• Fertility preservation for cancer or other health conditions. If you’re about to start cancer treatment — such as radiation or chemotherapy — as these could harm your fertility.