Every month two test tube babies are conceived in Kashmir after infertile couples undergo in-vitro fertility (IVF) treatment at Rotunda Hygeia, state’s first and Kashmir’s lone infertility treatment centre. Shazia Yousuf reports.
Every 45 days, experts – Dr Bala Krishan and Yatnale Srikanth (embryologist) – are hired by Kashmir’s only infertility treatment centre, Rotunda Hygeia, to conduct a special workshop. A batch of eight couples are selected to undergo the in-vitro fertility (IVF) procedure in this workshop. At a success rate of 40 percent, three women in every batch conceive a child. If all the pregnancies resulted in live births, Kashmir valley would receive six test tube babies every three months, two in a month and thus a test tube baby every fortnight.
Rozeena is one among those aspirants that hopes to bear a live baby after conceiving one in this month’s workshop. It is 4:00 pm and 29-year-old Rozeena eagerly waits for her turn in the waiting room. She holds a bunch of papers – test reports she was asked to submit by 4:30 pm. She has been waiting for some time and is growing eager. “You insisted on coming early, now wait,” says her brother.
Rozeena waits. She has been waiting to be a mother since she got married to Bilal four years ago. “After one year of my marriage, I consulted the first doctor. Since then I have been roaming around the state. No doctor, no shrine is left now. I am confused, one doctor says one thing another says something else,” she explains.
Conceiving a baby through IVF treatment was Rozeena’s choice. A month ago, when she first heard about this treatment, she was very hopeful. “But when I told my husband, he refused to spend money on a treatment that has no guarantee. He said it will annoy his parents if the treatment does not bear any results,” she recalls.
The following day Rozeena went to her father’s place. “We arranged some money. She collected the rest by selling some gold ornaments. She is hopeful, so are we,” says her brother.
It was with the birth of Louise Brown, the world’s first test tube baby in 1978 that introduced IVF treatment to the world of infertility, bringing hope to millions of couples around the world. An assisted reproduction technique, in IVF, fertilization of the egg occurs outside the womb in a Petri-dish. The man’s sperm and woman’s egg are fertilized in a vitro (glass) dish and after fertilization the resulting embryo is transferred into the uterus of woman.
In the span of 30 years, IVF treatment has become the cornerstone of reproductive medicine and infertility treatment. The treatment, experts say, doesn’t interfere with nature, but only provides a helping hand to it.
The IVF treatment cycle involves five main steps. The first stage is referred to as “super ovulation” and during this the female is given a Decapeptyl injection which stimulates the ovaries to produce multiple eggs (usually 20 – 30) in a single cycle, and from this a healthy egg can be selected. Following this, the egg is retrieved from the ovary in the ‘egg retrieval’ stage, a procedure which usually takes thirty minutes. The third and fourth step – ‘fertilization’ and ‘embryo culture’- involves the fertilization of ova in an incubator and the formation of embryo. The sperm and ova are incubated together for about 18 hours. The fertilized egg is left to grow for about 48 hours after which the egg consists of 7-8 cells.
The final step is the ‘embryo transfer’ in which the resulting embryo is transferred into the uterus of the female. More than one embryo is passed into the uterus to improve the chances of pregnancy. Two weeks after the embryo transfer, a blood test is carried out to see if the woman is pregnant.
Although Rozeena’s husband has agreed on participating in all the medical procedures, she knows that her decision to undergo IVF has strained their relationship. “He is not happy with me but I know once our child comes, everything will be like before. Him and his family will treat me the same way they used to, I will get that respect back,” she says while attempting to conceal her joy. “I know there is only a 40 percent chance, but 40 percent is enough to pin hopes on,” she adds.
Infertility does not mean sterility. Here conceiving is a challenge but never an impossibility.
IVF treatment was initially used on women who had tubal factor infertility, a condition in which the fallopian tubes are blocked, damaged or absent. Today the treatment is applicable on almost all infertility treatments like endometriosis, immunological problems, unexplained infertility and male factor infertility.
The tests which are carried out prior to the IVF treatment include sperm survival test and a blood FSH level test. The FSH level gives an indication of whether or not the woman will produce enough eggs after super-ovulation. If the FSH level is high (greater than 10 mIu/mL) it suggests early ovarian failure.
According to a study carried out in 2008 by the Department of Endocrinology at Sher-i-Kashmir, Institute of Medical Sciences, around 15.7 percent of women in Kashmir who are currently of child bearing age will never have a child without clinical intervention.
With Islamic sanction behind it, the IVF intervention is gaining popularity in Kashmir. IVF treatment is not considered un-Islamic as long as the procedure on a woman is carried out by a female doctor and the egg and sperm for the embryo are produced by the couple itself and not a donor.
“For IVF treatment we need an egg, sperm and uterus and they should essentially come from the couple undergoing treatment. We do not give IVF treatment if the husband suffers from Azoospermia even if he is willing. Because that is prohibited in Islam though legal in India,” says the Administrative Director of Rotunda Hygeia, Shabir Ahmad Rather.
Azoospermia is a condition in which no sperm is found in the semen sample of the husband. Although, in this situation, there is the option of a sperm donor, however this is considered to be un- Islamic.
However, the clinic gives IVF treatment to other male factor infertilities through ICSI (Intracytoplasmic Sperm Injection). ICSI is a more recent development associated with IVF that allows the sperm to be injected directly into the egg. This procedure is used when sperm have difficulty in penetrating the egg and also when sperm numbers are very low. “We do ICSI when the husband is oligospermic because in that case we do not need any donor,” Shabir says.
Although the female egg donation is also considered to be impermissible in Islam, the institute conducts the procedure. “Different scholars give different versions about its permissibility. We do it here,” Shabir says.
Stress disorders have reduced the reproductive age of Kashmiri women by a decade. A finding by Dr Abdul Hameed Zargar, Director SKIMS, showed that 11 percent women out of the 2,000 women examined between 2004 and 2006 in J&K suffered from premature menopause — a rise of 2 per cent from the late 90’s.
There is an abnormally high rate of POF (premature ovarian failure) among Kashmiri women than elsewhere in the country. The psychological trauma due to turmoil is believed to be the main cause. “Stress leads to hormonal imbalance that can result in some abnormalities like galactoria that can cause infertility among females,” Says Dr Raheel Nisa, a gynecologist at Rotunda hygeia.
Other reasons believed are late marriages and haphazard prescription of ovary stimulating drugs that lead many women to suffer from POF.
More than 50 percent of patients in the clinic records are in their early 40’s. Doctors say that the quality of the oocyte degrades with the age of the female.
Many years are already wasted by the time a couple drops in to the IVF treatment center. “A simple FSH test can tell whether a couple needs IVF assistance or not, but the doctors keep them hanging on medicines for their own interests,” says Shabir, while counselling Shahzada and Mohammad Ashraf, a couple who have come from Kupwara for the IVF treatment.
Ashraf, aged 45, an employee in the Health Department and Shahzada, aged 44 have been married for 25 years. “They have taken a loan from the bank but it is not about money alone, so much time has already been wasted. And their age has already lessened the chances of conceiving, courtesy our doctors,” adds Shabir.
However, private practicing doctors do not give any solid reasons about their treatment procedure. “If someone has raised a finger on my work, let him. I don’t feel the need of giving clarifications. I have my own reasons of what I do as they have theirs,” says Dr Farhat Jabeen, a senior gynecologist.
Older woman stand very poor chances of conceiving from IVF treatment, however there is no age limit on women undergoing IVF treatment. Although the success rate is 40 percent all over the world, the percentage varies with the age group. It is the highest when the patient is between 25-30 years of age while for patients below 21 and above 40 it can be less than 20 percent.
In 2005, 55-year-old Raja from downtown Srinagar delivered a healthy female baby after she was given IVF treatment at Rotunda Hygeia.
Although IVF treatment centres have now been established in many Muslim countries including Saudi Arabia, social conservatism and myths about its unacceptability in Islam hampers its expansion in Kashmir. The lone fertility clinic has not been able to document reliable statistics.
“Our patient flow has doubled since the institute was established. However, we do not know how many pregnancies at this clinic have resulted in live births. Because of social taboo, the couple do not show us their faces after they are successfully treated here. They forget us like a nightmare. There is no way of maintaining any statistics,” Shabir says.
Furthermore, the social taboo often leads aspiring parents to go outside the state for IVF treatment, in which case, the already high cost of the treatment increases manifold. “When we started IVF treatment in this state, we received so many threats to close down the clinic after we formally inaugurated it on July 13, 2003. It was believed that we will provide some immoral and unethical treatment here which is not true,” recalls the Director. “Many people still consider infertility as ill luck rather than a disease. Most wives want a child to ward-off the curses they hear from their husband’s family,” adds Dr Raheel.
The cost of IVF treatment ranges from 1.2 to 1.6 lac rupees including medicines. Achieving parenthood through IVF is a dream that can be realized only by affluent couples while the poor still wait for the government to come up with IVF treatment facility in government hospitals. “Most couples take a step back when they hear about its cost,” says the Director.
IVF treatment is an alternative for couples who otherwise are left with options like adoption or in some cases, a second marriage. “Test tube baby will come from my own womb. He will be my own child, my own part. I can give him more love than an adopted baby,” says a patient Fareeda, when asked why she didn’t opt for an adoption.
The risk involved in IVF treatment is failed pregnancy. This is due to multiple pregnancies; this is when the mother carries more then one foetus in her womb. Rehmaan sold a part of his property so that he could afford IVF treatment. After 20 days of treatment, his wife, Sakeena conceived a child but after three months, she suffered a miscarriage.
Another risk associated with IVF treatment is multiple births. Two women so far have delivered healthy triplets after IVF treatment at the infertility centre while there are many cases of twin deliveries.
“IVF treatment cannot be held responsible for pregnancy loss as complications can occur in normal multiple pregnancies also. Even many infertile women after miscarriage come to us for repetition of the procedure. It is also a myth that test tube babies have birth defects,” says Dr Raheel.
Treatment of infertility is associated with huge costs, however, it can be avoided to a large extend by some small precautions. “Childhood disease like mumps in male children and tuberculosis in female children can lead to infertility if not treated properly. Further there are some minor deformities in gonads of children that can result in infertility if not given proper attention. Parents can play a role,” says Dr Raheel.
Due to its high cost, IVF treatment is recommended to couples who can not conceive with simpler treatment options. Although the fertility centre receives patients from remote corners like Uri, Banihaal and Kargil, but the treatment is still in its infancy in Kashmir.
(Note: Names of patients in the story have been changed)