Like every newlyweds, the Johnsons looked forward to having, not just kids, but healthy ones at that. However, parenthood eluded them for the first three years of their marriage. When they eventually became parents, it was double whammy: the child not only had Down syndrome, she also had hole in the heart, dying three months later. After trying for children for another two years unsuccessfully, they turned to fertility clinics. SOLAADE AYO-ADERELE examines causes of infertility among couples, and what couples who seem unable to have normal children could do.

Anyone looking at the way Ben and Clara Johnson doted on their triplets (pictured) can hardly guess the quantity of tears that attended their quest for babies. “Our intention was to start raising a family immediately after marriage in 2003, but that wasn’t to be, as we tried for babies for three years without success. When I eventually conceived and had a baby the fourth year, it turned out that she had Down syndrome and a hole in the heart!” Clara, now 35, recalls. Then, she was 32.

Just as the new parents prepared to take their baby overseas for surgery to correct the abnormality in her heart, she died at three months. Thus began a fresh quest for babies. However, for a couple that had experienced the birth of abnormal baby once, the Johnsons opted for in-vitro fertilisation this time around, because, as Ben, 40, puts it, “we waited another two years without conception. Besides, it’s the only way we can guard against the unpalatable experience of having abnormal baby again.”

If the Johnsons thought that conception via the IVF was for the asking, they soon discovered that though they had the financial wherewithal to secure the services of any doctor of their choice, IVF also has its downturn: decreasing egg quality with increasing female age. Indeed, endocrinologists say, “as women age, we need more eggs to be able to make IVF work because of the lower quality of the eggs.”

As at her first IVF trial, Clara says, “I first had a free IUI (intrauterine insemination) at a popular fertility clinic in Lagos, but it didn’t work for me. Then, I was introduced to another one, where the doctors spoke more grammar than anything else. In fact, my conclusion at the second fertility clinic was that the owners were just after patients’ pockets. Nothing more. In all, I had three IVF treatments which cost us so much in terms of emotional stress and financial strain,” Clara notes.

“It was at the Medical Art Centre, a fertility clinic in Maryland, Lagos, that I was diagnosed with polycystic ovary syndrome” — one of the most common female endocrine disorders affecting approximately 5-10 per cent of women of reproductive age (12-45 years old) and is thought to be one of the leading causes of female sub fertility.

“I underwent fertility treatments that resulted in a set of triplets, but I had the babies at six months due to my ignorance. The referral centre where I took the premature babies to couldn’t help, because there were no sufficient incubators to go round the babies that needed them. So, I lost all the babies and we were back to square one.

“I underwent another round of treatments in February 2010; this time, it’s called Preimplantation Genetic Diagnosis, PGD. Through it, we were able to choose the sexes and I was also able to carry the babies — two boys and a girl — to term. And here they are.”

Fertility expert and consultant reproductive endocrinologist, Prof. Oladapo Ashiru, who successfully treated the Johnsons, attended to many issues contained in their stories, providing useful insights into causes of infertility among men and women, steps to preventing abnormal babies, and the options available to couples who may be trying for babies.

Ashiru, whose practice as fertility expert spans three decades concurrently in Nigeria and the United States of America, explains, “There are several causes of male infertility and they can be categorised into four levels, all of which refer to the different anatomical parts of a man — the brain, the endocrine organs below the brain, the testes where the sperm is produced and the ducts that carry the sperm during ejaculation. In summary, the first level prone to major attack are the testes, and it can be in form of infection, prominent of which is mumps, which can lead to permanent testicular damage in a male child.

“The male infertility can also be from embryological abnormalities during development; one of such is undescended testes. Since sperm production has to be at a temperature slightly below body temperature, when the testes are left in the abdomen, it will affect sperm production and cause male infertility.

“There is also a situation where the duct that carries the sperm is abnormally located and openinto the urinary bladder instead of coming out to the penile gland to open. Infertility can also result from non development of the testes, called testicular agenesis.

“Another major area of focus in male infertility in this part of the world, which really requires a lot of attention, is occupational and environmental hazards. We now know that the following can be extremely toxic to sperm or prevent sperm production: pesticides, paint fumes, petrochemical and polyethylene products, crude oil fumes or its injections, plastic fumes, X-ray radiations, lead fumes from bullets, welders and battery chargers fumes. Workers in this type of occupation need to wear appropriate protection masks.”

And for the health freaks who believe that sugar is bad, Ashiru says that the use of artificial sweeteners can decrease sperm count, leading to infertility.

Again, the use of tight pants and sitting on the hot driver seat of a trailer vehicle can be toxic to the sperm by increasing the temperature beyond the ideal for sperm production.

Stress can also lead to infertility in men; same goes for smoking and alcohol, the Adjunct Professor at the University of Illinois at Chicago COMMAND ART said.

In women, Ashiru says, causes of infertility can also be explained from the four levels. According to him, many of the causes arise from abnormalities in the endocrine organs. “Virtually all the endocrine glands in the body have direct or indirect effect on the process of ovulation,” he says. “These endocrine glands act like an orchestra in symphony; consequently, an abnormal function in any of the glands can lead to abnormality in ovulation or the process of placenta formation for the support of pregnancy. These abnormalities present initially in various forms like irregular bleeding, prolonged period between menstrual cycles, very painful menstrual period and other symptoms.

“The next cause can be found in the uterus. Here, there can be tubal blockage — the fallopian tubes that carry the eggs and allow the sperm to fertilise the eggs in the space may be blocked by infection. The infection can be from sexually transmitted diseases or from prior surgery like appendectomy or from previous delivery by cesarean section or a very high fever from unknown origin.

“This infection can compromise the integrity to the fallopian tubes that carry eggs and therefore make pregnancy impossible naturally. Also, in the uterus, fibroid formation can be a cause of infertility. They are more of a problem if they are large or if they are sitting or protruding into the cavity of the uterus where the baby is supposed to grow and develop.

“Environmental hazards such as pesticides, petroleum products, radiation, X-ray and polyvinyl products can also play major roles in female infertility. The last level is the brain. Stress plays a very important part here. Sometimes, stress can prevent ovulation or lead to termination of early pregnancy.”

On the treatment options available to couples who may have tried for years to achieve pregnancy, Ashiru has this to say, “If a couple has been trying to achieve pregnancy for over one year without success, they need to see a doctor. The options will be to start from the low technology type of treatment. This may include basic investigations such as sperm analysis, blood analysis of the fertility panel, and ultrasound scan.

“The next level of investigation will be the X-ray of the woman’s fallopian tubes. The next level may involve the use of medications to ensure that the hormones are functioning correctly and followed by artificial insemination of the husband’s sperm. When no pregnancy is achieved with these steps, then it is time to proceed to the use of higher or more advanced technology such as IVF and Intracytoplasmic sperm injection, ICSI.

“There is more complex technology now available to help virtually any woman to have a baby, regardless of her age, as long as she is in good physical and medical condition.

“Treatment starts with investigation of both husband and wife. Usually, they end up using medications to improve the sperm as well as the ovarian functions. Some can get pregnant at this stage.

“The next stage will be to ensure the integrity of tube and the endometrial cavity, especially its readiness to facilitate a successful embryo implantation. Here, some may require additional surgical intervention by gynaecological endoscopic surgeons to remove adhesions, polyps or submucous fibroid we may find in the cavity before they can proceed with further conception treatment.

“Once all is clear at this point, a woman may be successful in getting pregnant. Others may require sperm to be processed and inseminated before they can be pregnant. What we do is called Fallopian Tube Sperm Perfusion. This is especially for men with reasonably low sperm. The next stage that follows this if there is still no conception is IVF.

“At what point does a specialist decide that a woman should undergo IVF treatment?” SUNDAY PUNCH probes.

“Once the above stages have been tried for about three to six cycles depending, and there is no conception, especially if the woman is over 30 years of age, we advise they proceed to IVF. Some patients will have to go straight to IVF, based on medical findings. For instance, if the X-ray shows that the two fallopian tubes are blocked, we do not waste any time trying any form of conception but IVF. The same applies if the sperm is very low or if the couple is over 35 years old, with partially blocked tubes, low sperm and have been married for over three years.”

Ashiru, who set up the first IVF laboratory in the Lagos University Teaching Hospital, Idi-Araba, explains what PGD is and the processes involved. He says, “Preimplantation Genetic Diagnosis can only be done through IVF. What it entails in a nutshell is that a woman is given a series of medication to ensure that she produces several eggs, may be eight or as much as 20 eggs, instead of the usual one egg.

“The eggs are removed from the ovary through a very simple procedure called egg aspiration under conscious sedation. The eggs are then fertilised manually with the husband’s sperm through the use of a technique under the powered microscope called ICSI. This is termed Day One of the egg outside the body, and now under our care in the laboratory.

“In normal IVF, the embryo is returned into the woman’s womb on Day Three. In PGD cases on Day Three, we take out the eight or 20 fertilised embryos one by one and remove one cell out of the six-eight cells in each of them by a technique using laser biopsy. The embryos are returned to continue development in the incubator in the lab, while the biopsied cells are now processed through a series of laboratory chromosomal analysis that enables us to know whether the cell is normal or having abnormalities like Down syndrome or sickle cell gene; or whether it is male or female.

“In short, we have the full characterisation of the cells. This analysis takes between six and 20 hours. On Day Five, the woman returns to the clinic to have transferred to her womb the normal embryos. We usually return not more than four embryos.”

The Johnsons said they were able to choose the sexes of their babies through the PGD, making one wonder if this would not lead to ‘cultivating’ the so-called ‘designer’ babies or skew the gender ratio, with the possible socio-economic consequences on the larger society if it becomes the norm.

In response, Ashiru, who became a professor of medicine at 32 says, “In the Johnsons’ PGD treatment, they had biopsied 12 embryos, three were normal male and three were normal female, while the remaining six were abnormal (Down syndrome and more).

“We transferred four embryos — two male and two female. Mrs. Johnson ended up with a triplet gestation with two boys and one girl. The final selection was not done by us but by God. There were cases where we transferred two male and two female and they had twin girls, or one boy and one girl. So far, we’ve not had twin boys.

“What we try to do is family balancing. Indeed, sex selection is not our aim. Our main focus is to reduce and prevent abnormalities such as sickle cell or Down syndrome in high risk couples, as well as increase the chances for pregnancy in couples with failed IVF.

“It is well known that PGD increases the chances of pregnancy in patients with advanced maternal age and repeated failed IVF. I believe this is the only way. Same goes for sickle cell carriers. The only other way is to counsel them to seek new partners. Once two people who are sickle cell carriers are married, taking the chance of having a baby with sickle cell is not good. With the advancement in technology, one should make use of such technology,” says the physician who was conferred with the Order of the Federal Republic , OFR, by the Federal Government.