Naomi Gunasekara
Baby Sivarajah, Sri Lanka's first test-tube baby, was delivered under caesarian-section three years ago spelling hope for thousands of childless couples. With test-tube technology no longer alien to Sri Lanka, there are also many other options available here.
Architect Ramani has not given up hope of holding that little bundle of joy in her arms. Ramani has everything she wanted from life; a steady job, a loving husband and an understanding family, all except a baby. Now time seems to be running out for her.
"I wanted to start a family once I finished my education because I thought getting married would be a hindrance to my studies. I've been married for 1 1/2 years now and feel miserable without a child," said Ramani who first started treatment for her irregular periods and now undergoes fertility treatment. "I want a baby, test-tube or not, because being without one makes me feel very empty."
A number of professional couples including Ramani and Ruwan (not their real names), who had married late and face fertility problems, attended a seminar on Recent Advances in Fertility Treatment conducted by the Lions Club of Battaramulla in association with Region 1 of District 306C at Hotel Hilton last Sunday. The aim was to enlighten the public on the various modes of treatment available for those suffering from fertility problems.
According to Sri Lankan-born Singaporean Prof. Ariff Bongso, Research Professor and Scientific Director of the ART (Assisted Reproductive Techniques/Test-tube technology) Programme at the Department of Obstetrics and Gynaecology at the National University Hospital of Singapore, a woman's fertility decreases with maturity and a number of professional women face fertility problems because they marry late.
"The best age to have children is between 19-23 when a woman's fertility is high," he says. "As women grow older, they encounter many fertility problems and it becomes difficult to put them under simple treatment because they don't have time to go through all that. So it is always easy to correct fertility problems and determine if there are special problems to be looked into when treating young women because we have time on our hands to put them through simple treatment," he said.
While women between 19-23 have a 25-30% chance of conceiving, women between 35-40 have only a 5% chance. This decreases further as they grow older and a woman over 45 has only a 1% chance of having a child, says Prof. Bongso who has been treating fertility problems for many years. "If you marry late and do not conceive within eight months, it is best to consult a doctor because the chances of a perfectly healthy couple conceiving within a month is only 25-30%," he advised the couples attending the seminar.
Prof. Bongso is a world-renowned personality in the field of fertility treatment, having produced the first test-tube baby in Asia in 1983, followed by the first GIFT baby in Asia in 1985. He also delivered the first babies in the world through micromanipulation in 1989, followed by the first co-culture baby in 1991 and blastocyst culture baby in 1993. He will be the chief consultant and advisor to the proposed Ninewells Care Mother and Baby Hospital to be set up in Colombo soon.
According to Dr. Rohana Haththotuwa, Consultant Obstetrician and Gynaecologist and Director of the proposed Ninewells Care Mother and Baby Hospital, 10% of married couples in Sri Lanka suffer due to sub-fertility problems. "Male sub-fertility ranges between 8-22% while female sub-fertility ranges between 25-37%," he said.
"Those days the whole blame was placed on the female because she did not conceive. But studies reveal that the male contribution is much more," he said, pointing out that 60% of the sub-fertile couples suffer due to sperm problems. "A lot of men face sperm problems today due to stress, environmental issues and pollution."
Male sperm must be good in quality, quantity, vitality and morphology for a pregnancy to take place. Accordingly, the sperm concentration in 1ml of sperm should be over 20 million and if this reduces, a couple will face problems in having a child. However, there is hope for the childless because science has advanced to the extent of locating the sperm in the testicles to help egg fertilisation in test-tubes/petri dishes.
According to both Prof. Bongso and Dr. Haththotuwa it is not every couple that is required to resort to test-tube technology in order to have their own child. "The test-tube is the last option available for a sub-fertile couple who first receives simple treatment to overcome fertility problems. Most of these problems can be overcome with consistent treatment. But the couple must work as a team. There must be patience, perseverance and a plan," said Dr. Haththotuwa, who advised patients to come with their spouses for treatment. "If you fail to conceive while you are under treatment, it becomes very stressful. So it is always better to keep your hopes low and work towards your dream as a team," he said.
Every couple who faces fertility problems will first undergo simple treatment methods like artificial insemination (AI-where the doctor deposits the husband's washed sperm into the vagina), or intrauterine insemination (IUI-where the washed sperm of the husband is deposited in the uterine cavity). These methods are carried out by monitoring of ovulation (MOO) or induction of ovulation (IOO) by doctors who recommend the method for about 4-6 cycles. The success of such treatment is 20-25% and it is a simpler and cheaper process that is constantly monitored by the doctors by way of ultra sound scans/blood tests and administering hormones to help the ovary to produce eggs.
Patients who fail to conceive after receiving either AI or IUI treatment for 4-6 cycles, and those who have other complications (please see box) are generally advised to opt for a test-tube baby. The test-tube procedure is known as ART/Assisted Reproductive Technique and helps patients through the five options of GIFT, IVF, ICSI, TESA and Blastocyst or Extended Culture. The success rate of ART is 40-45% if done in a reputable, hygienic clinic under the guidance of a trained embryologist.
ICSI, IVF and TESA are the common ART procedures. In ICSI, fertilisation is brought about by the direct injection of a single sperm from the husband into each egg of the woman using a machine called the micromanipulator. This helps men with very poor sperm to father their own children. TESA on the other hand, is designed for men who have no sperm. Sperm is extracted directly from the testes using a simple surgical procedure when TESA is followed and then fertilised in a petri dish. In IVF, the wife's eggs are mixed with the husband's motile sperm in a petri dish in a medium containing special nutrients to allow a single sperm to get inside the egg on its own and help women with blocked tubes.
Once eggs are fertilised using one or more of the above processes, up to three fertilised eggs/embryos are placed in the womb. These eggs can be frozen and kept for future use too because the success rate increases with every ART treatment. Miscarriages may occur during pregnancy unless the patient takes adequate care, says Prof. Bongso. "Once the embryo is placed in the womb the patient must take extra care for six weeks by avoiding things like carrying heavy items, climbing steps, long walks, swimming, horse-racing, physical and emotional stress because they may cause miscarriages."
Since up to three embryos are transferred to the womb to get the optimum chance of pregnancy, a couple has a 20% chance of having twins and a 1% chance of having triplets.
There are no major complications in going for ART, says Dr. Haththotuwa who feels that while swelling in the abdomen may take place due to an over-dose of hormones, this too can be prevented by seeking the help of an experienced doctor. The success of ART is 45% for all age groups while those under 35 show a success rate of 50% and those under 40 show a rate of 10%.
The ART procedure, if followed in Sri Lanka costs about Rs. 400,000, whereas in Singapore it costs S$7,000-9,000. The cost is high because the hormone tablets prescribed for treatment are expensive.
Prof. Bongso pointed out that while there was hope for the childless in Sri Lanka, if a test-tube baby unit with state-of-the-art technology is to be set up here, then all quality standards met by his Singapore clinic will have to be met by the Sri Lankan unit too.
By Esther Williams
When Viswajith developed symptoms of vomiting, fever and paleness, his mother, Baby Nona panicked and rushed him to the Kurunegala Hospital. He had the same symptoms that her five year-old child had had before he died. She was told that little Viswajith had thalassaemia. Little did she know that she herself was a carrier.
Now 14, Viswajith who has the physique of a seven-year-old, goes into hospital for blood transfusions on a regular basis. The excessive iron in his body has affected his pancreas that has resulted in diabetes. In addition, he is given Desferal (Desferrioxamine), an iron chelator to remove excess iron in the body. The process takes 8-12 hours and is done at night while the child sleeps. "It does not hurt me," laughs Viswajith, a 9th grade student of Malagane School who has accepted the painful treatment as part of his life.
Malini Dissanaike from Malsiripura has had to deal with this deadly disease of the blood affecting her third child, Nimishika (10) who was diagnosed with thalassaemia five years ago. Because of the ailment, the child has many restrictions to her normal activities and diet.
What is thalassaemia? Thalassaemia is an inherited blood disorder/disease by which a person cannot make enough haemoglobin /red blood cells that carry oxygen from the lungs to different parts of the body.
It takes two forms - Thalassaemia Major or Cooley's Anaemia which is a serious inherited childhood anaemia that needs regular blood transfusions for a patient to survive. Thalassaemia Minor, occurs among patients / carriers who although having slight anaemia, can have normal healthy lives. Most of them do not know they have it. It is only discovered if they have a special blood test and if they have a child with Thalassaemia Major. Healthy children already born cannot catch thalassaemia from anyone else.
Origin: Thalassaemia is derived from a Greek word meaning sea. Researchers think that it may have originated over 50,000 years ago in a valley south of Italy and Greece, now covered by the Mediterranean Sea. There are 100,000 children born in the world with thalassaemia Major. Incredible as it may seem, people who are likely to carry the gene of thalassaemia are people of Mediterranean descent - from Cyprus, Egypt, Greece, India, Italy, Lebanon, Sri Lanka, Malta, Middle East and Turkey.
Sri Lankan situation: There are over 1000 patients of thalassaemia in Sri Lanka, concentrated mainly in the North West, North Central, Central and Uva Provinces.
Symptoms: Thalassaemia patients are normal at birth but become anaemic between the ages of three to 18 months. They become pale, do not sleep well, do not want to eat, may vomit their feeds, do not gain weight, have fever of an unknown origin and usually die between ages 1 and 8 if not treated.
Under treatment, like normal children, they can play, school and grow up in a healthy environment. Several of them have a normal IQ and therefore cannot be considered mentally retarded in any way. Their treatment however requires much discipline and patience.
Quality of life: With the advancements made in the treatment, most thalassaemics (major), grow up to adulthood, earn a living, get married and even have children. However they live with more risks because of the amount of medication and treatment they receive and are highly susceptible to infections.
Thalassaemia major patients can also carry other illnesses such as Sickle cells, diabetes, liver dysfunction, etc. This is because the excessive amounts of iron accumulated through frequent blood transfusions act as a toxic element, causing damage to important organs. Other effects of thalassaemia are facial deformity, skin pigmentation, bone and joint pain, enlarged spleen and pathological fractures due to bone marrow expansion. People with Thalassaemia Major can have babies only if their partner does not carry any sort of thalassaemia. But all Thalassaemia Major patients' children will carry Thalassaemia Minor. If a Thalassaemia Major partner does not carry any thalassaemia gene, none of the children would have Thalassaemia Major.
Treatment: Regular blood transfusions are required on an average of every 4-8 weeks, depending on individual requirements to maintain haemoglobin levels. Desferal is injected under the skin using a portable battery operated pump. Desferal picks up the iron and carries it out in the urine. However, scientists also believe that a cure for thalassaemia is possible through gene therapy, a process still in the experimental stages and bone marrow transplantation, a risky process that may result in death.
Medical facilities: The Kurunegala National Hospital maintains a special ward for thalassaemia that currently has 415 registered patients. It has also formed an association that aims to increase awareness and understanding of the disease. Explaining the problem, Dr. Manoja Samarasinghe, who is in charge of the Thalassaemic Unit at Kurunegala says that the worst cases of thalassaemia result in enlarged heart with an irregular rhythm, leading to heart failure, diabetes and renal failure. Paediatrician Dr. Shantimala de Silva, who contributed towards starting the Kurunegala Unit talked about pre-natal diagnosis, done in the west to see if you are a carrier. For this to be done in Sri Lanka, legal complications have to be dealt with first.
Having worked with thalassaemics, Dr. de Silva appeals to the public to screen themselves to make sure they are not carriers of the gene. Also if they do have a gene to ensure that they marry non-carriers. "Until the time we have prenatal diagnosis, this should be done, besides helping through blood donations," she added.
The Shi-en Ikebana and Floral Art Society's ninth Festival of Flowers at the Lanka Oberoi last month helped raise funds for the cause. The proceeds of the flower exhibition were given to the Kurunegala National Hospital for an infusion pump costing Rs. 30,000 for thalassaemic victims.
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