Dr. Rajesh Chaudhary: What I have learnt as a lead IVF specialist at Nairobi's fertility clinic
In Nairobi’s Upper Hill, a number of patients are lost in thoughts inside a fertility clinic run by a Nepalese couple.
Women are the majority of those inside when we visit. They patiently await their turn to be served. The pin-drop silence in the waiting area is perhaps too loud. Among the patients is Wairimu, a businesswoman from Eldoret.
“My friend at work told me about this place,” she says.
This is her second visit.
“I arrived last evening from Eldoret, slept at a cousin’s place in Imara Daima and prepared myself for today because during my last visit, doctors presented a number of solutions for my situation and then advised that I take time to soul-search and make a decision before coming back. I am desperate to be a mother and will do it at any cost,” she said.
And she knows why it is so quiet in the waiting room.
“When you are in this waiting area, all you can think about is babies; what it will feel like to hold your own in your hands, the pressures your man, family and friends have put on you to deliver. You want to hold a baby in your arms so bad,” a tearful Wairimu explains.
She is here to be served by Dr Rajesh Chaudhary, the lead in vitro fertilisation (IVF) specialist at Fertility Point Kenya. He works alongside his wife, Dr Manju, an embryologist. The couple has been in Kenya for the past three years.
Rajesh says: “It was my dream to include and work with her ever since I met her.”
“We have been working together since 2014 after I graduated from Manipal University in India. We have one child together,” Manju notes, and the couple goes on to clarify that they didn’t make theirs in a lab.
Their clinic is one of the 12 branches of Fertility Point, an Abu Dhabi-based global IVF clinic for reproduction and embryology. The two services they are most known for are IVF and artificial insemination, also called intrauterine insemination (IUI).
IVF involves fertilising an egg outside the body then implanting the resultant embryo in the body, while IUI entails inserting purified sperm inside a woman’s uterus.
As the medics continue to learn more and more about Kenyans through the clinic, they have noted a pattern that makes them to urge women to consider having babies when they are younger. Some focus on being “career women” and by the time they are considering childbirth, biology might have turned against them.
“Eight out of 10 eggs we get from many women who come here – who are usually in their late 30s going to 40 — are usually genetically abnormal. Women in their 50s are coming over and they want a baby. Family has to be started at 30. It should be understood that in 15 years, there are only 180 months during which a woman will have the ‘golden moment’ to get pregnant,” discloses Rajesh.
“We are concerned because low eggs in the reserve is the most common problem Kenyan women come here with,” he adds.
He advises that the late 20s, if not early 30s, is the right age to have a baby.
According to Rajesh, most women get pregnant after three or four attempts and when all fails, he advises them to go for IVF. In IVF, eggs meet sperm in a petri dish in a laboratory. The resulting embryo, which has high implantation potential, is transferred back into a woman’s uterus for a successful pregnancy.
There are four main IVF treatment options available, depending on a patient’s situation. They include IVF using own eggs and partner’s sperm, IVF using own eggs and donor sperm, IVF with donor eggs and partner’s sperm and IVF with donor eggs and donor sperm.
The procedure, says Rajesh, is the most effective fertility treatment available and has high chances of success.
“At the moment, in terms of fertility, our success rate in Kenya is at 70 per cent, though the chances of getting a baby through IVF are usually 60 per cent. But according to studies, the success rate of IVF in African women is 20 per cent,” the expert explains.
IVF is recommended for women suffering from blocked fallopian tubes, endometriosis, ovulation disorders, premature ovarian failure, fibroids, male infertility factors, same-sex couples, single women and other unexplained infertility factors.
The main factors contributing to infertility in many women are age, blockage of the fallopian tubes or infection in the fallopian tubes and infections in the uterus.
“Most of the infections as per what I have observed are due to sexually transmitted diseases, with 10-15 per cent out of 15 million dealing with infertility – which means 15 per cent need IVF, according to data,” Rajesh says.
An embryologist, like Manju, specialises in the care of embryos from the time of egg retrieval to the time when the embryo is implanted into the woman’s uterus.
Manju is responsible for insemination of eggs to create embryos, freezing sperm, eggs and embryos as well as grading and observing them.
The first step in the IVF process is meeting a specialist to work out the best treatment approach.
A fertility investigation is then conducted during the initial consultation and you may be asked to undergo blood tests, an ultrasound to check hormonal levels and to assess your uterus and ovarian function.
The experts require the patient to provide relevant medical records and laboratory results if they have already undergone similar tests and treatment previously. If the infertility is due to a male factor, a semen analysis is conducted based on medical history, physical exams and test results.
The Nepalese couple then prepares a personalised treatment plan for the patient.
Rajesh explains that in the lab, they embark on ovarian stimulation, which is the first step to IVF treatment.
They stimulate the growth of follicles in a woman’s ovaries to produce more eggs than usual.
“This is because if there are more eggs, then there is a greater chance of obtaining embryos to increase your chances of pregnancy,” he says.
The injections are administered using follicle-stimulating hormone FSH (in some cases, luteinising hormone, LH) to stimulate the maturation of a larger number of follicles containing eggs.
The FSH stimulation is done over 10-12 days and during this time, they monitor the follicular growth through ultrasound and blood tests until it reaches the correct number and size.
Once the patient has the optimum number of follicles ready, a human chorionic gonadotropin (HCG) shot is triggered for final maturation of eggs.
HCG is a hormone for the maternal recognition of pregnancy produced by trophoblast cells that surround a growing embryo – which eventually forms the placenta after implantation.
“This is usually done 36-40 hours before the scheduled egg retrieval,” the specialist explains.
The next step is egg retrieval and sperm collection. Egg retrieval is a procedure done under sedation. The eggs are retrieved by inserting an ultrasound-guided thin needle into the ovary and aspirating the follicular liquid which contains the eggs from the ovarian follicle.
Once the follicular liquid is removed, it is immediately passed on to the laboratory to ascertain whether it contains eggs. The retrieved eggs will be stored in a culture dish while the sperm is being prepared for fertilisation.
On the day of egg retrieval, the patient’s partner can provide the semen sample to the lab. The best motile sperm is selected to fertilise the eggs.
This is where Manju comes in and according to the embryologist, it requires her full focus and undivided attention.
“Embryo transfer is a minor procedure and in most cases sedation is not required,” she says. “Between day three and five after fertilisation, the best embryo with the highest implantation potential is selected for transfer.”
She goes on: “During this stage, couples with higher chances of passing on any genetic diseases can consider genetic screening of the embryo pre-implantation genetic diagnosis (PGD). The highest quality embryo is inserted into a thin catheter and transferred into the uterus through the cervix.”
“Most women are able to continue with their routine activities the next day after the embryo transfer. Two weeks after the procedure, blood tests are conducted to confirm pregnancy,” adds Manju.
Payment for the IVF process with the couple is Sh450,000.
According to Rajesh, the injection goes for Sh100,000 to Sh150,000, depending on the ovary in reserve while pre-IVF assessment scans and blood tests cost Sh100,000.
And while fertility clinics like this one may seem like a woman-only domain, men are also a target as they are equally susceptible to infertility.
“We have observed that women are 50 per cent responsible for infertility, and that men are equally 50 per cent responsible. And this concerns me because Kenyan men are a bit reluctant to come for check-ups,” says Rajesh.
“We understand that it is important to provide male fertility investigation and treatment in order to be sure that we deliver comprehensive care to our patients that leads to successful treatment outcomes. We offer the best diagnosis and treatment in all areas of male factor-related infertility and our andrology lab is well-equipped with most advanced technologies for semen analysis and other sperm functional tests to give you the most accurate results,” Rajesh points out.
There are many causes of male fertility, according to the facility’s official website.
“As a first step in your fertility investigation, you will be asked to undergo a physical examination and we will evaluate your medical history, taking into account your personal and family background, social and environmental factors that can influence your fertility. A semen analysis may be ordered to measure any abnormalities in the morphology and motility of the sperm. Our infertility specialist will help you diagnose the issue and recommend treatments or procedures that will result in conception,” it highlights.
The insemination (IUI) procedure follows the more natural cycles of a woman. It also involves stimulating ovaries with hormones.
Ovulation is then monitored to know the best time to carry out the procedure.
“IUI treatment can be considered when there is a prolonged infertility when the sperm has difficulty reaching the uterus, ovulatory dysfunction, minor tubal defects among others,” the expert said.
The steps in this treatment include ovarian stimulation, whereby on day three of the menstrual cycle, hormones are injected to stimulate the ovaries.
There is also semen preparation, where on the day of the insemination, a fresh semen sample is collected and then prepared, washed and sufficient concentration of motile sperm is obtained from it. Finally, insemination happens, wherein on the day of ovulation, the highly motile semen sample is placed in a fine catheter and then inserted into the uterus.
The IUI procedure is painless and takes about 20 minutes.
Rajesh further tells Lifestyle that he is currently studying the impact of Covid-19 on both male and female fertility.
“The latest research confirms that Covid-19 may negatively affect sperm quality and reduce fertility in men. The magnitude depends on severity of the disease as there is a connection between changes in multiple seminal biomarkers and the reproductive function in male patients recovering from Covid-19,” he says.
A peer-reviewed study that appeared in Hormones, a global scientific research journal, discusses the effects of Covid-19 on the male and female gonads.
“There is lower Covid-19-related morbidity and mortality infection among females compared to males. Not only do men die at twice the rate that women do, but over 80 per cent of severe Covid-19 cases occur in men. This effect seems to be largely mediated by the ability of sex hormones to regulate the immune response differentially,” the study states.