Cost of bearing

As fertility technology advances in leaps and bounds, society lags behind in grappling with issues of morality and ethics. Fatemah Farag delves into the world of assisted reproduction
Cost of bearing
"I will do anything to have a baby," Soha, a professional woman in her late thirties, tells me as she prepares her bloated body for her second injection of hormones that day. From the look of it, she really will do anything to her body to get pregnant. A full course of fertility treatment, or "cycle", can take up to five weeks. "This is my fourth cycle," says Soha. "The last time I took 90 injections and this time I will have taken 130. It just became easier to learn how to give myself the shots," she adds with a tired giggle as she puts the needle away.
Soha, like many women using hormones, has suffered all sorts of physical pain in quest of fertility: a body bloated to the point of being unrecognisable, nausea and persistent abdominal pain. In addition, the psychological stress of the treatment -- particularly when it fails -- can be devastating.
The process Soha is undergoing is in-vitro fertilisation (IVF), a technique hailed by Cairo University gynaecology and obstetrics Professor Mohamed Abul-Ghar as "revolutionary." Abul-Ghar, an internationally renowned fertility expert and head of the Egyptian IVF Centre, is a pioneer of assisted fertility in Egypt. "Not only can we redress many the infertility problems faced by women," explains Abul-Ghar, "but with the technological and procedural developments made in 1992, we can also redress many cases of male infertility." This is quite a breakthrough, suggests Abul-Ghar, given that 40 per cent of infertile couples have "weak sperm" to blame. The condition could not previously be effectively treated through drugs.
For many, the IVF advancements has been life giving. Somaya is now the proud mother of a four-year-old girl. "She is the light of my life. Every day I pray to God to bless the doctor that made it possible for me to have my daughter," she says, watching her little girl play on the swings. It seems almost redundant to ask her if it was worth the effort, but I ask anyway. Without reservation, Somaya insists she is willing to go through the process again. "My life would have been a fraction of what it is today. I want to give [my daughter] a brother or sister, and I will have to go through IVF again. I will do it gladly. Even if I do not succeed, I know that the gift of a child is worth making the effort."
Experiences of women like Soha and Somaya are fraught with complex issues: the pressure they are under to have their own children (as opposed to adoption); the difficulty of what they go through, both emotionally and physically; and, finally, the quality of the services they are receiving -- and at what cost. For the past month, the public has been bombarded with a plethora of stories in papers and on television and radio shows taking issue with the concept of surrogate mothers (See related article). Though it's a hot topic of debate, the procedure is not yet practised in Egypt. Meanwhile, no one seems to show the least interest in difficulties experienced by the likes of Soha and Somaya. The practice of in-vitro fertilisation in Egypt has mushroomed in the past 15 years. There are 30 IVF clinics functioning in the country, but the practice of IVF is never called into question.
For a medical take on what Soha was going through, I went to meet Dr Ragaa Mansour at the Egyptian IVF Centre, the first centre to introduce IVF to Egypt. Pensive men loiter outside the four-storey modern building, smoking cigarettes, while inside, equally pensive women fill the waiting room. At the heart of the complex sits Mansour, decked in green doctor's scrubs and looking a little tired after a busy morning. She explained that the most commonly used procedure -- "protocol" in medical lingo -- is called the Golden Standard.
"The first two weeks begin with one injection per day, given under the skin," explains Mansour. This shuts down the pituitary gland, which normally controls ovarian functions. "When it has shut down, we start administering another injection." By now, the woman is taking two injections a day. The second injection is comprised of follicle-stimulating hormones, are supposed to "kick the ovaries into overdrive", continues Mansour. This can take another 10 days. The result? "The ovaries double in size, and instead of one follicle on one ovary that month, there should be five follicles on each." So far, so good, but this also means that the woman has 10 times the normal estrogen levels within her. "It is, of course, an uncomfortable state," Mansour admits. Hence, Soha's condition when I met her.
The next step is to "harvest" the eggs, a procedure that requires a short period of sedation. To retrieve the eggs, an ultrasound probe is inserted into the woman's vagina and threaded up through the uterus. A needle is then inserted into each of the ovaries which sucks the eggs out. Though this sounds remarkably complex and even horrific to the layman, Mansour describes it as "very simple" and insists that it is a great improvement from the technology used in the 1980s, when a laparascope had to be introduced through the stomach.
I watched the procedure on a television screen outside of the operating room and the ovaries flinched every time the needle attempted to prick them. "Well, ovaries have feelings too," a technician assured me. Fair enough.
Having donned some green scrubs of my own, removed my high heels in favour for green slippers, and completed my new look with a hair net and face mask, I was finally shown into the lab where the fertilisation takes place. Here, an egg is being fertilised and we watch as the technician deftly guides a reluctant sperm towards the awaiting egg. "We have to guide it very carefully, or the sperm runs away," explains Mansour. I was fascinated. The whole of male-female intimacy seemed to be summed up in this short on-screen exchange, with male behaviour captured succinctly by the sperm's elusive antics. The mature female (the egg) waits patiently until the male is finally manipulated towards his destiny. The sperm is finally deposited inside the egg, where it sits limply, looking somewhat resigned and baffled. Commitment-phobic.
The petri dish is then moved into an incubator, where it will take three days to reach the eight-cell stage. "When this happens, we implant the embryo into the mother's womb in another one-day procedure," says Mansour. The chances of success in a very good clinic is still only 35 per cent; in exceptionally good clinics success rates can go up to 50 per cent.
"In Egypt, we literally started from scratch in 1984," recounts the centre's Abul-Ghar. "I got in contact with Mansour and Dr Gamal Sorour, who is currently the head of the Faculty of Medicine at Al-Azhar University. We started training people for both the clinical and laboratory aspects of the procedure. We purchased all the equipment directly from abroad and we bought a flat. Finally, in March 1986, we [the Egyptian IVF Centre] became operational."
Mansour recounts: "In 1979, I went to Ohio State University Hospital. In 1980, the US was lagging five years behind Europe in introducing IVF. There were ethical debates regarding the welfare of the child and the concept of assisted vs natural reproduction, but eventually the procedure was approved and Ohio State was the third medical institution in the US to introduce IVF." Getting in on the first stages in the US gave Mansour insight into what she would soon be implementing back home. "I remember in the first year, we worked on lab animals and I fertilised some 2,000 mouse eggs," she giggles. On a more serious note, she told me, "I would see Egyptian couples coming to the US seeking this treatment. They were lonely and isolated, and of course it was very expensive. So, I thought, why not provide this treatment back home?"
The first thing these doctors sought when initiating IVF in Egypt was religious acceptance. "In our society, ethics and religion are inseparable," notes Mansour. The doctors were pleased to find that in 1981, a fatwa (religious ruling) had been issued condoning IVF. "According to the fatwa, IVF is acceptable under Islam if it takes place using the husband's sperm and the wife's egg and the resultant embryo is implanted in the wife's womb," says Mansour. "The Coptic church also released a very nice booklet that condones the use of IVF for married couples."
Though the religious establishment had issued clear and binding guidelines for IVF practice, the medical profession still lagged behind. "There is no law that governs the practice, but we are sure that because the religious aspects are so sensitive, that all the current centres abide by their guidelines," Abul-Ghar explained. "But as to what quality of service these centres are offering, or what their success rate is, that is a difficult question to answer in Egypt."
Specialists indicate that in the US and Britain, for example, there is a registry which records all the data collected by IVF centres: how many cases have been admitted and how many have achieved pregnancy. "There is always a wide range of success rates within the same country," says Abu Ghar. "In the US, many centres had to shut down because their success rate was less than 20 per cent. There is also an International Registry, which we at the Egyptian IVF Centre voluntarily give in our data. We are the only centre in Egypt which does this, though. There is no Egyptian Registry."
Over the past 15 years the Ministry of Health and the Doctors Syndicate have formulated their own regulations regarding the practice of IVF. But Mansour laments that these regulations, while very good, are only useful if a centre decides to abide by them of its own volition. "There is a committee within the Ministry of Health which is responsible for investigating centres, which is all well and good, but it does not include specialists in the field, which affects its ability to deal with IVF centres," says Mansour. "Only specialists would know what to look for when visiting a centre, let's say, in Mansoura, and what questions need to be asked. Such an investigative committee is a top priority for the development and improvement of IVF in Egypt."
As far as specialists are concerned, weeding the good from the bad is an effort worth making, not only to protect patients, but also because good centres claim to provide state-of-the-art technology and international-standard care. With almost maternal pride, Mansour shows off the Egyptian IVF Centre's latest microscope equipment. Abul-Ghar highlights the achievements of the past years, "We have contributed invaluable and original research and published our work in the most prestigious international medical journals. Our research has modified techniques used in certain areas. We are recommended by the American Fertility Society and we have been approved as a centre where new drugs can be tested. This is very difficult and we are the only centre in the Middle East, after Israel, where this takes place."
Abul-Ghar notes that testing in centres outside the country where the drug was developed is the last step before it is dispensed in the West. Almost bursting with pride, he adds, "So what we say works will be given to European patients. For international pharmaceutical companies to allow an Arab centre to be the final word on such a subject was not easy. It meant we had to prove we were among the best internationally."
The bottom line is that if you are lucky enough to fall on a good Egyptian centre, you will not only get state-of-the-art treatment, but you'll get it at a fraction of Western prices. The Egyptian IVF Centre charges around LE6,000, including medication for the standard procedure. "Our prices are half that of the Arab world [there are centres in the Gulf] and a fraction of both European and American prices, says Abul-Ghar. "In fact we lure a lot of business from the Arab world, although we have yet to become a centre for European business."
This all seems like a good deal, but what if you are one of the many low-income couples who also seek IVF. "We can solve the problems of a huge majority of infertile couples," notes Abul-Ghar. "The biggest problem is the economic factor, because treatment is expensive, when compared to the average income in Egypt. It is heart-breaking to see low- to middle-income couples struggling to put the money together," he said. For those who cannot afford assisted reproduction, but suffer the same emotional pressures as their wealthier counterparts, Al-Galaa Hospital has recently established a subsidised facility offering comparable services at half price. Still expensive; but then everything in this day and age comes at a price -- even having a baby.
Recommend this page
Related stories:
Legislating morality
© Copyright Al-Ahram Weekly. All rights reserved
Send a letter to the Editor