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Treating infertility and handling trauma

Rasheeda Bhagat

WORLD over, there is a lot of wrong perceptions on infertility and the various lines of treatment available for it. In India, the tendency is to first blame the woman if a couple is unable to have a child. But times are changing and male infertility too is being recognised as a fact of life. In fact, according to certain infertility centres, nearly half their patients are men, says Dr Jayant Mehta, Scientific Director, Institute of Reproductive Medicine (IRM) at the Madras Medical Mission in Chennai.

``Initially, it used to be more women patients but in recent years that has changed and we find more male patients at IRM. Men have realised that they are not the superior sex.''

Last week, IRM organised a workshop in Chennai to spread awareness on gynaecological problems that lead to infertility and the line of treatment available. According to Dr Mehta, one in five couples has a fertility problem, and almost all of them face tr emendous pressure from their family and society to get a child.

Refuting the perception that many successful career women in Europe, including the UK, are opting not to have children at all, as it would hamper their career, Prof Stephen Smith, Head of the Department of Obstetrics and Gynaecology at the University of Cambridge, says that younger couples tended to put off having children. ``But it is not true they do not want to have children. They just put it off till the woman is 35 to 40. But those women eventually always want to have a child. But sometimes they le ave it till it is too late.''

Defining ``too late'', Dr Thangam Ram Varma, Director, IRM, said this tended to differ in India from the West. ``In England, if a woman gets into the 40s, her ovarian reserves and hormones deplete, reducing her fertility. But in India, the sad part is th at this probably starts earlier _ between 30 and 35. What a woman in England goes through between 40 and 45, Indian women experience between 30 and 35. At a much younger age, there are changes in her hormone profile and she might get gynaecological disea ses.''

Dr Alison Murdoch, Medical Director of the International Centre for Life, Newcastle, UK, says that even in the UK, infertility has ``still got stigma attached to it and treatment for infertility is not totally covered by the NHS (National Health Service) and a lot of people have to pay for this treatment, though the investigations are free.''

Each IVF (invitro fertilisation which is also referred to as test-tube bay) procedure costs 2,000-3,000 pound sterling. As for the strike rate, she says: ``We are looking at one in five who will have a baby the first time. Some couples will try five or s ix times, but there are people who will say after the first attempt: Do not do it again. If you are older and you do not get many eggs, you will probably say do not do it again.''

Dr Mehta says that at the IRM, the success rate is 28 per cent with IVF procedures and 35 per cent with intra-cytoplasmic sperm injection (ICSI). In the ICSI procedure, a single sperm is picked up and injected inside the egg (which is the cytoplasm). ``F or the very first time a man with a very low sperm count or none at all, can be the biological and legal father of the child. For those who have no sperms, we take a testicular biopsy and prepare the sperm from the sample for fertilisation.''

The overall success rate in engineering a pregnancy is about 25 per cent, but between pregnancy and delivery of baby, the rate comes down to around 18 per cent, he added.

Breaking the news to a couple that the treatment is not working is a difficult job. As Dr Murdoch says: ``We have to be psychiatrists too. In my clinic, you will find about 30-40 per cent of couples who will be crying at any given time. That is normal. O f course, patients have to be counselled, but it all depends on how they have been handled in the first place. If they have been told, `Oh yes, I will make you pregnant', it is difficult for them to accept it.''

So, should doctors have to be honest, giving them unnecessary hope?

Dr Thangam's response to this is two-fold. She agrees that many doctors in India, some of them without adequate training, sometimes waste years in repeating the treatment for years.

``In infertility, if one sort of treatment does not work, you have to find out why it has not worked and what do we do next. If you hold on to somebody who is 35, doing the same treatment for two years, she will become 37 and it might be too late, becaus e in this country, the body clock is slightly earlier than in the western woman. But I do know that there are couples who are taken for a ride with the same treatment being done for five or six years.''

But she would not agree that doctors are guilty of keeping hope alive unnecessarily. ``You cannot really tell a woman as long as she has the ovary and the egg, and the man has a sperm, that she cannot get pregnant. I have actually bitten my finger for te lling a woman I never thought would get pregnant. I did everything possible and told her so, but she shocked me. I delivered her third child before I left England (in 1998).

``And I would not have given her any chance. She had an almost frozen pelvis; I did not know where her tube was; she had a large fibroid which I had to remove. In short, it was a mess. I have come to the conclusion that in difficult cases you can tell th em their chances are less or remote, but not that they will never get a child. Not unless the woman loses her ovary or the man his testes.''

Dr Thangam adds that technologically the science has advanced to the extent of giving a couple some hope of getting a child. ``We have not excelled nature in its job, but we can do something for some people. But we do have to treat our patients with all the love, and kindness and compassion. And if their chances are low, advice them against selling their land or some other property for undergoing the treatment which is expensive.''

Adds Prof Smith, ``Many of the patients for whom the treatment does not work, do get very upset. Our job is all about handling grief and can be very stressful for us too. The

treatment is very expensive and only one out of 10 will take the entire treatment; and only one out of 10 is happy at the end. Either they can't afford the treatment or it does not work.''

Does the realisation that two people cannot have a child change them as human beings in any way?

``I do not think it changes you as a person but it changes the direction your life can take. Most people when they get married think they will have children and plan their lives accordingly. But once they realise they cannot have a child, and with that o ption blocked, their life can take another direction,'' says Dr Murdoch.

She adds that marriages can break over the issue of childlessness, and ``part of our job is to help them with the grieving and to put them back on another track''.

To the query whether infertility experts like her counsel patients on pursuing an interesting hobby or goal, her response is simple. ``Counselling is not about telling people what to do. It is about listening to them and letting them talk to each other a nd letting them cry. When they first find out... they have not sat down together and talked about it. So they blame each other, they are hurting and they are embarrassed. The important thing is to get them talking; then they understand.''

Adds Prof Smith, ``It is very, very fundamental emotion; outside your own birth and death there is no other emotion similar to having a child. What we find is that there are many people who are busy with their careers and put off having a child till it i s too late. But the number who would say that we absolutely do not want to have a child is very, very small.''

Dr Franco Lisi, Director of Infertility Service at the Clinica Vilda Europa in Rome, says that many couples in his country, like elsewhere in Europe, would delay a pregnancy ``for social reasons such as a job or sometimes even for domestic reasons such a s not wanting to take responsibility too soon in life. But what is very painful is that you build up a life with the goal of getting pregnant and getting a child and then realise that you can't have a baby.''

Next comes the economical factor in treating infertility. He believes no country, however prosperous, can afford to provide such treatment totally free for the entire population. ``So at the end of the day it means the therapy has to be paid for, and onl y some can pay for it.''

But he is more worried about the wrong message being conveyed by a section of the media in Italy that IVF is the therapy for the old. With egg donation, IVF has made pregnancy possible in very old women who are 60-65.

With this being widely publicised by the media which, however, fail to highlight that this is possible only with another woman donating her egg, ``a 48-year-old woman will say: She was 65 years old and could get pregnant so why not I wait till I am 65''.

As for the future, Dr Mehta says that it holds a lot of hope, especially in the area of stem cell exploration, which makes it possible to generate healthy organs. ``Maybe in 10 years this technology will be ready for clinical application''.

In this technique, which is still being researched, the stem cells are taken from a human embryo and cultured in the lab. ``These stem cells are yet uncommitted. They do not have the signal which determines whether they will become a limb, an eye or any other organ. You can programme these uncommitted cells to become a particular organ. It means a person with a heart problem can have another heart generated by programming these cells to become compatible with his system.''

Picture: (From left) Prof Stephen Smith, Head of the Department of Obstetrics and Gynaecology, University of Cambridge; Dr Alison Murdoch, Medical Director of the International Centre for Life, Newcastle, UK and Dr Franco Lisi, Director of Infertility Se rvice at the Clinica Vilda Europa, Rome... Working towards engineering a pregnancy.