Wednesday, February 9, 2011

A pregnancy from IVF is a miracle - Dr. Richardson Ajayi

As a young doctor working in the United Kingdom, Dr. Richardson Ajayi regularly witnessed difficulties experienced by Nigerian couples who were traveling abroad for fertility treatment. He became convinced of the need to set up such a clinic in Nigeria. He acknowledged the importance of ensuring the clinic was of the same standard as available in the United Kingdom.

So in collaboration with consultants from Kings College Hospital, London, he conceptualized The Bridge Clinic to provide the same quality of services in compliance with the strict code of conduct of the Human Fertilisation and Embryology Authority (HFEA) of the United Kingdom. The ISO certified Clinic which marked its 10th anniversary recently has had a consistent pregnancy rate that has led to the birth of over 1,000 babies. In this interview with Sola Ogundipe, Ajayi gives a rundown of the contributions of The Bridge Clinic to successes of IVF in the country . He also talks about issues related to healthcare delivery. Excerpts.

What’s your assessment of the standard of care in Nigeria?
I think it is wrong to assume that in Nigeria as a resource-poor setting, we cannot have the same standard of care available abroad. There is only one standard of care enforced by licensing and regulation abroad and we have to be at the same level here in Nigeria.
The Bridge Clinic clocked 10 recently. What has it been like doing IVF for one decade?
It’s been like swimming against the tide. The first thing we had to deal with in the early days was creating the infrastructure. We also had to create the staff because IVF was not taught in the schools so we had to focus on training. After that, we had to convince the patients because IVF was still relatively new. People had to be convinced that IVF was not by choice. It was the way to go. The question of the cost was also there. But the key thing was to convince the people that they needed IVF which had become the cornerstone of infertility treatment.

I make bold to say it is wrong for anyone to attempt to treat infertility of more than three years standing without resorting to IVF. IVF makes the coming together of the sperm and egg possible to attain pregnancy. It is able to generate embryos for the couple. The union that is not taking place in the body of the woman makes pregnancy unattainable. We can make that happen.

The Bridge did not pioneer IVF in Nigeria. What innovation did you introduce?
Before we started IVF in Nigeria, everybody was doing it as part of their general medical services, but it was The Bridge Clinic that made a bold decision about IVF. We can reproduce it, we can sustain it, and we can make it into an ongoing concern. We are not experimenting and we are ready to stick our neck out.

We are confident because we have done it and shown how it is done, others have come. There needs to be focus on quality. Healthcare is all about intervention. Evidence-based medicine says anything you do must have a scientifically verifiable outcome. This must be so from the patient’s point of view. There is no point going to see a doctor who is saying I’m just trying my best. The service must be guaranteed.

How would you describe IVF to a lay person?
A pregnancy from IVF is a miracle. It gives access to an opportunity for a blessing. IVF is not a guarantee. A month in your bedroom gives 20-25 per cent of getting pregnant. IVF does the same. The fact that IVF is not a guarantee is not a failing of the IVF process, but a reflection of human reproduction. IVF does not improve on the natural human fertility, but it improves chances for couples who are not getting pregnant naturally. If you are not getting pregnant naturally, then you are operating on a zero per cent chance every month. IVF takes you to 25 per cent chance which is what the natural process is.

There have been issues about declining male fertility, could you shed light on these?
A Finnish study shows a declining sperm count over the generations. Our grandfathers had higher sperm count than our fathers who had higher sperm counts than our generation. There are many theories, but a common theory is that the male of our species is getting exposed to a lot more female hormones than ever, basically due to a lot of xerophenes in the atmosphere. This comes from plastics used for packaging; plastics used for computers etc. These xerophenes have female hormone oestrogen-like effects and exposure of males to them could be deleterious.

There are reservations about the regulation of fertility treatment in Nigeria. Please comment.
Regulation is one of the biggest problems we have in Nigeria. It is absolutely essential that we have adequate regulation of the profession, but the shame of it is that we are never going to have regulation here in Nigeria for a long time to come. For whatever reason, there is no political will to go in that direction. The reason is that those who can make the changes are not interested. There are different standards. We at The Bridge Clinic decided to play at the highest level from the very beginning. We decided to work as if we are regulated by the Human Fertilisation and Embryology Authority (HFEA) in the UK. One of the stipulations of the HFEA is that any clinic that runs IVF must have a quality management system, so we implemented such a system and actually had our recertification audit recently. There were recommendations about what we needed to do. For instance, we were told we have to use only disposable equipment because of the infection risk associated with sterilisation. It is one of the standards that are being pushed in Europe.

For instance, sterilisation procedures must be of such a high standard to be acceptable that it is better to just use disposables and this is what we are moving towards. By the end of April this year, we at The Bridge Clinic would have converted to using disposables. These recommendations are going to cost us about N25 million, but they are necessary improvements, even if they are not going to be seen on the outside. They are internal, like writing a patient’s name on a dish with a pen. Some of these pens have special constituent called volatile organic compounds which may have detrimental effect on the embryos. So now we have to go and buy a special pen that is only available in Europe at more than 30 times the cost of a normal pen. These are the standards we are setting for ourselves and they are the highest. As a result, we turn out to be more expensive than every other person doing IVF.

Are you saying high standards are the way to go?
The point here is that if we have chosen these are our standards, it would be difficult for others who have not decided to go down this road to say let us go and regulate together. As I said earlier, I believe there is only one standard of healthcare. Because of my heritage, I worked in the UK for a number of years and I came back to Nigeria with a vision of reproducing what I’ve learnt. When I go back to see my colleagues in the UK I need to be able to tell them this is what I am doing. Not that I am compromising to manage in Nigeria.

The standards we set for ourselves are very high, but I believe that should be the reference. That is the standard the rest of the world utilises and we shouldn’t have a Nigerian version. We should have the same as the rest of the world. For example, the laboratories that we use are standard. We were part of the group that set up PathCare which is the only ISO 1009 certified laboratory in the country so that we can assure the quality of care we give our patients. In the UK, America or South Africa, you cannot run a lab unless you have this certification, so it is the same standard.

What is the Vision of The Bridge Clinic?
Our Vision is to be the reference point in healthcare delivery because of our philosophy of benchmarking with international standards and I believe that with time there will be the realisation from the customers and service providers that there needs to be some kind of assurance level in healthcare delivery. And that assurance level is quality. Once that realisation is there, the change will occur. I actually think it has started to occur because there is now an association for quality in healthcare. With that kind of change, we can move in the right direction.

You have a Foundation called Aspire, what does it do?
We have a Foundation called Aspire. It has two objectives. One is to provide information about our LIHN initiative (Let It Happen Naturally). It is an intervention for infertility. There are posters circulating around. The second initiative showcases the free packages The Bridge Clinic offers yearly. It goes through a process of helping people and if it shows that someone is eligible, they obtain assistance. We get their tests done at PathCare which is supporting for free, and we have a pharmacy that supplies their drugs for free. When you put all these together, we can provide access. We can do a few cycles every month through this programme. The potential beneficiaries present themselves at our Centre in Oduduwa Crescent, GRA, Ikeja. They complete a questionnaire and show evidence of payment. We are also talking to the universities to provide them with IVF support. This is called the low cost IVF initiative where we manage an IVF Centre but provide services at a heavily subsidised cost. That subsidy is enjoyed by the patient. So the University can provide the service at an affordable cost to those who need fertility treatment.

What is the public perception of infertility?
The nation’s maternal mortality rates remain high and are a priority for government. This may affect the perception about infertility. But the World Health Organisation (WHO) defines health as the complete state of physical and mental well being, so infertility is a cause of a lot of mental instability, ostracisation and is an important issue that requires attention. Unfortunately we are not getting the right kind of support we need here.

The National Health Insurance Scheme (NHIS) is a form of legislation and if it is changed that it should provide some form of support for management of infertility, then it would be done. There are two sides. You can look at the employer perspective whose concern is to protect itself from recurrent expenditure, and women having children is a recurrent expenditure, because not only are you going to pay for them to have the children, you are also going to pay for someone to cover their position when they are on maternity leave. So from this point of view, most companies do not look after reproductive treatment. But it is something we should look at because it is important. Infertility is a cause of social problems.

What are the common causes of infertility in this environment?
There are many peculiarities of infertility. The most common is the prevalence of tubal infertility. There are many incidences whereby infertility is caused by blockage of the fallopian tubes. Many reasons account for this. First there is a high rate of unsafe abortions leading to a high rate of infection as a complication of the abortion because abortion is illegal in Nigeria and people tend to do it illegally hence all the risks. If we look at it in the loosest term, abortion is illegal in Nigeria.

Second it the high rate of sexually transmitted infections which are associated with pelvic inflammatory disease and tubal blockage there is also high prevalence of fibroids and many have operations to remove them many of which are complicated with adhesions formation and tubal insufficiency. Because it is difficult to regulate hygiene standards and all that, there is a high rate of infection after child birth, sepsis, and sometimes even in the process of testing if the hygiene standards are not as good as they should be this can lead to tubal infertility. So there are so many compounding factors leading to this and this has to do with the peculiar nature of our healthcare delivery system in Nigeria.

Then there is male factor infertility. This is more difficult to elucidate because we are experts on women, the so-called experts on men are urologists, but the urologist is not really interested in reproduction, rather he is interested in the urinary system. Beyond saying there is a high prevalence of infertility, I would be speculating without any evidence that these are the reasons. But there is a high prevalence in Nigeria anyway. People often say it has to do with the level of pollution and contamination of the environment. There is also high incidence of infection which can cause obstruction of the tubes in the man.

In your view, which is the way forward for healthcare delivery in Nigeria?
There needs to be uniformity within the healthcare profession. We need to put our house in order before we can go out to talk with a single voice. It is a gynaecologist who has had experience in this field is qualified to set up a fertility centre. In more developed countries that is how it is. In Nigeria, everybody is setting up an IVF Centre, so when you set up a society of IVF practitioners, everybody will turn up.

How then will you expect uniformity about recommendations to the governing body and to the government?
I think the Nigerian Medical and Dental Council needs to set up a health professionals Council, which must be an independent body that regulates doctors. The Council must set standards and the consumers must be part of the council and there must be representatives of each specialty. It must be independent and must be objective. Once this can be done, it will be easier to regulate the system, but currently we cannot do that. We cannot ask the practitioners to regulate themselves. There needs to be an independent body to do that only then can we move forward and legislate.

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