Dr. Faye Iketubosin is one of the most renown names in fertility, and one of the pioneers of IVF, in the country. The Medical Director of Georges Memorial Medical Center, we were opportune to spend some time with him, to ask him some questions about fertility, IVF, and the man behind the stethoscope.
Kemi and I arrived at the Clinic for the chat, and though I knew what to expect (as he as been my Doctor for almost a decade), I knew Kemi was quite curious, and maybe a little nervous. But when he arrived, with his disarming charisma and sense of humour, she quickly relaxed, and it soon became like chatting with an old friend.
Doctor Faye, was there a defining moment when you just knew you wanted to be a Physician?
For me, I think that was easy. From when I was 4 or 5 years old, I always said I wanted to be a doctor. Partly because my Uncle, my Mom’s younger brother, was a doctor, and through secondary school, holidays, I spent time with him, and I never changed my mind.
The only time I contemplated doing something else was after my A levels, but really nothing else appealed to me, and since then, I have never looked back.
Why did you choose to specialise, first in Obstetrics and Gynaecology, and then Fertility?
In medical school, Obstetrics and Gynaecology was my best subject, and I won a number of prizes. I was given an exemption from doing the primaries, to being able to start my residency. I was the only one given that privilege, because I won the department’s prize. That was at the University of Ibadan, by the way.
After that, I started my training for two years. It was the prerequisite for doing the Royal College Examination; two years in a recognized teaching hospital in Nigeria, which I did. After which, I moved to the UK. Fertility has always been something I have been interested in. While in the UK, I worked with lots of fertility experts, and eventually, when I left the rotations, I went to work with Professor Ian Craft, at the London Fertility Center. Ian Craft was one of the biggest names in IVF, and that was where I really developed my interest in the treatment.
However, I do have a passion for other aspects of Ob/Gyn, and also made sure I trained in them, as I knew that, to practice in Nigeria, you needed to be a broad-based gynaecologist, instead of just narrowing on infertility.
Infertility seems to be on the rise, especially here in Nigeria. What are some of the most common factors that cause this?
I think 50% of the causes of infertility are the male factor related. I see that a lot, and it is not just in Nigeria…it is every where. The sperm count for a lot of men is getting lower generally. A lot of things have contributed to this; our diet has changed, we are eating more processed food, and of course, toxins, pesticides and environmental factors are some of the things that have worked their way into the food chain, and are having long term effect on men’s sperm count. We see a lot of that.
On the female side, we see blocked tubes, mainly because of infections, or previous surgeries, which often can lead to adhesions, which causes tubal blockage. The other area, when you’re talking in terms of assisted reproduction is an older population, because in Nigeria, people don’t seek help early, and by the time they access specialised help, they are depleted of their eggs, by virtue of age.
Polycystic Ovarian Syndrome (PCOS) seems to be more common now. Why is this so?
Not really. I remember I returned in 1994, and was doing a lot of ultrasounds and laparoscopies, and we were picking up a lot of polycystic ovaries. We often opted to conduct an ovarian diathermy, which was quite successful in resolving ovulation issues with PCOS women.
If you don’t look for something, you would not know it’s there. We used to think endometriosis was very rare, but it was because we were not looking for it. Now that the technology is available, we have been doing a lot of laparoscopies, and we see a lot more of these conditions, which are visually diagnosed. In the olden days, if a woman came with pain, you would think of everything else but endometriosis. Now, as part of your work up, a laparoscopy is performed, and it is picked up.
So, it’s not as if there are a lot more people with the condition, it’s just that we are looking more. PCOS is not an acquired condition, it’s something you are born with. It has always been with us. You will notice that there are some of our mothers and aunties, who are very hairy. We just thought, that was the way they were made, but really, most of them had polycystic ovaries, and the hair was the outward manifestation of having male hormones in their body.
How can some of these infertility triggers be avoided?
Well, male factor infertility is very difficult to treat, because we don’t have all the answers. If a man’s comes with borderline low sperm count, say ten million, you look at his lifestyle; smoking, alcohol intake and the kind of under wear he wears, the type of job he does, the environment in which he works. All these contribute to that situation, so if he makes needed changes, he might be able to improve his sperm count naturally. Its not as straightforward as a woman having difficulty ovulating, where you give her appropriate medication and, 9 times out of 10, she is going to ovulate. The lower the sperm count, the harder, it is to treat.
Even nowadays, men with healthy sperm count have fertility issues, because of motility and morphology issues. Why is this the case?
Well, we are looking at sperm in greater detail, and one of the problems apart from number is the quality. You find that every semen sample ought to have a percentage of abnormal sperm, and up to 20% is okay, but now, you see men who have up to 100% abnormal. So the count maybe 40 million (a normal count can be anywhere from 15 million) but all of them are abnormal. That’s a very tough situation.
What would you advise a patient to do first, when dealing with a fertility issue?
The general rule is this, we know that in nature, it takes up to one year before you can think something might be wrong. We generally don’t encourage investigation until you have been trying for one year. The exception to that is if a woman is 35 years old. In that case, we say try for six months, and if nothing happens, seek help. And trying for six months means you have regular cycles, you are aware of when you are ovulating, and your intercourse is timed for that period.
The exception to that is if you have a woman, who has had abdominal surgery before, or treated an infection. You would want to see a doctor earlier. On the other hand, there are some men who go check themselves out privately, and already might know they have low sperm count. When there is an established situation, you don’t need to wait.
One of the problems we have is people trying and trying, and waiting too long to see a doctor. It is reassuring to go to a doctor and they tell you nothing is wrong, because if you go to a doctor after six months, and you do all the tests and nothing is wrong, and you are young, he can say you should try for another six months. It may take only medication, which would enhance your conception chances, and if you do have issues, then you can begin to deal with it early.
The problem is, a majority of people don’t access health care or fertility treatment on time, to be able to ascertain if they need help or not. By the time they do, the odds are stacked against them, age wise.
One message I need women to understand is, regardless of our environment, there is a huge misconception among women that , as long as they are having periods, they are able to have children. It’s a huge misconception. You meet some women, who are in their 40s, but who feel they can have the same chances of getting pregnant as a 25 year old. And it comes as a rude shock when they see a gynaecologist and they hear, “Ma’am, it’s going to be difficult.” It’s a very difficult message for them to accept.
We see it a lot here; women at 45 thinking they have the same chances as a woman in her 20s, and when you run the tests and they see the results, they are wondering “Why did I wait for this long?”
So one message, that women need to understand is that the fact that you have a period doesn’t mean you are fertile.
What kinds of fertility treatments are available to couples?
We usually start from very simple treatments, however, the treatment will depend on the cause of infertility. If its a problem with ovulation, you might just need a medication to get things moving. If it’s an issue where the fallopian tubes are blocked, you have no choice but to go straight to IVF. If it’s that the sperm count is low, then you have to go to IVF and ICSI. The treatment depends on the cause.
What advice do you have for couples going through the IVF process?
To be honest, men are often a stumbling block. The perception is that IVF is a last resort treatment…which is not right. In many cases, it is the first resort treatment, or maybe even an only-resort treatment, like if a man has a sperm count of only one million. There is nothing else you can do. The perception that if you are doing IVF, your case is very serious, or that “it is not my portion”, and so on, is often a mind set we should disabuse ourselves of .
IVF is an emotionally stressful treatment, because the process of involves injections, screening, scans, and the longer you are undergoing the treatment, the higher your expectations are, and in real sense, there is no where in the world where IVF offers 100% success rate.
To fail in IVF is part of the process; some people will fail, some people will succeed, but every one expects to succeed…but that’s not the case. We often say when you are starting on the journey of IVF, you should factor, as part of your projections, that you might have to cycle up to three times. You may be lucky and succeed the first time. If this does not happen, it’s not the end of the world. It may be for a variety of reasons, or just bad luck. It is advisable that, at the onset, look at it as a three-step treatment.
Secondly, IVF is very expensive and it does put a lot of strain on couples. Couples do a lot of thing to try to afford the treatment, and that in itself adds to the strain, because they are thinking, “If it doesn’t work, what am I going to do? What would happen to this money? I have borrowed?”, etc. As much as possible, from a financial point of view, try as much as possible to save towards it before you start, so you have less financial pressure on you.
I know there are a couple of banks that now offer facilities specifically for fertility treatment. That may be a way out, especially if you are older, as most people tend to be, and you haven’t gotten the time to save.
It is also important for the couple to be committed to the treatment together. You sometimes find that it is seen as a woman’s problem, and the man is not supportive, particularly when it is not a male factor issue. When it’s male factor issue, men behave differently. When its not a male factor issue, some men think of it as “Its your problem, fix it.” It’s a struggle to get them to come for tests, to submit samples, and so on.
Couple commitment is important, because you don’t want to discuss your business with a third party, especially something as sensitive as this. Even with your parents and siblings, you may not want to do that, so you as a couple, you have to be each other’s support system, and when it succeeds, you rejoice together, and when it doesn’t succeed, you comfort each other.
Also, you may need to make some lifestyle changes. For instance, if you are a smoker (men and women smoke). Smoking has been shown to affect fertility of both men and women, so you would do yourself a favour to stop smoking. Women who are overweight, it is best for them to get on a diet and lose weight. There are some adjustments you can make before you start.
What are some of the complications that may arise from fertility treatments?
Well, one of the things that cause ovarian cancer is incessant ovulation. And that’s why ovarian cancer is more common with woman that ovulate, than those that don’t. So if you find a woman who has been on the pill for a number of years, her ovarian cancer risks is less, but that’s just the theory. There are other causes of ovarian cancer, and not just rapid ovulation.
The most significant complication of IVF is Ovarian Hyperstimulation Syndrome (OHSS), which can be life threatening, especially, when it is severe. It is important that women are told about this complication, and if they do have this complication, they should go back to the clinic where they were treated, rather than going to a Generalist. Many a woman have come to great harm, because they have gone to a doctor who does not know about OHSS, and have thus received the wrong treatment.
There are complications that can occur during the treatment, like bleeding during egg collection, which is uncommon…but it can happen.
Overall, the long term effect of IVF would be in the aspect where it involves using egg donors. We set a limit because a woman is born with a finite number of eggs…she doesn’t make new eggs. Now if a woman donates her eggs, and they donate continuously, without being given any cap or limit, it is possible for them to exhaust their eggs before they are ready to use them themselves. We make these donors understand this risk. The main incentive for egg donation in Nigeria is cash, so you need to impress upon these donors the risks. “Once you have done this 6 times, don’t do it ever again…no matter the pressure. Or you get to the age of 32, and find out your eggs reserves are depleted.”
These are some complications of IVF, but these are things that can be prevented.
In the event of a failed cycle, what kind of post-treatment support do you think is best?
Ideally, there should be facility for counselling. The first time, you get the news you haven’t succeeded, it comes as a shock. A shock because the treatment has failed. “What am I going to do, I’m not going to have a baby.“ Shock because, all this money you have spent, has gone down the drain, and you wonder how you are going to get money to do this again? So all kinds of thoughts come and there is need to be able to express such thoughts and emotions. There has to be someone you can talk to at this point. It need not be your husband, as he is also involved and, though men may not show their emotions, it does not mean they are not going through same as you. There must be someone in the treatment facility that you can call up, whom you can see, and sit down and express yourself, who will support you until you feel able to put it behind you and look into the future.
How soon after a failed cycle should a couple cycle again?
Ideally, you should wait for one natural cycle, before trying again.
We all know how expensive IVF is. How can it be made more accessible, and affordable, to the man on the streets?
The only way this can happen is if the Government gets involved. The United Kingdom’s NHS has this provision, but it also has very strict criteria, very strict! To qualify, neither party can already have any children, you must not be more than 25 years old, etc. Its a public service, so they want to offer it to only those who have a greater chance of succeeding.
But in Scandinavian countries, the government pays for three cycles of IVF, and in some cases, four. It does not matter who you are, and your financial status does not matter at all…all that matters is that you are having challenge with fertility, and there is fund available for you to access, whatever fertility treatment you need.
Support comes through several means. It can come in form of support for drugs, which are expensive. and dependent on age and consumption. Then there is laboratory work. Those are two components, and if one can get help for either, it would go a long way. If the cost of the entire treatment is NGN 1 million, and the Government says, looking at the component of these treatment, they would support to the tune of NGN 500,000 or NGN 750,000, that would be of great help to a struggling couple.
The ideal would be for the Government to have in place IVF in public institutions, which it can support.
Don’t we have such Government-owned IVF centres already?
There are a few Teaching Hospitals that have IVF centres, like University of Benin Teaching Hospital (UBTH) and Lagos State University Teaching Hospital, LASUTH, which is run by the Bridge Clinic as a public service
The major challenge with this is, you know what Government is like…there is never enough. They can never meet up with the needs of these hospitals, and you know IVF is not something that you can manage, or have to recycle drugs and accessories.
What are the challenges that Fertility Practitioners face the most?
Maintaining infrastructure, because IVF is a very expensive treatment to offer. Almost everything that you use is imported. First of all, setting up is capital intensive; your incubators, your centrifuges, etc, are a huge capital cost, at the onset. And they have a maintenance component…you just have to maintain them. And then there is the cost of getting your consumables. There is no company in Nigeria, which makes things,we need for even a single cycle.
All your consumables are imported, from one country or another, and when they come in, they could be seized by Customs, or even delayed. The costs just keep escalating.
What are your thoughts on the Stress-Infertility connection?
I think there is no doubt that stress has an effect on fertility. And in practice, we have seen couples who have been married and trying to conceive, and nothing is happening, and they go on a vacation and come back pregnant. What has changed? They have removed themselves from that environment, and they were living a natural life, enjoying themselves, and it is only when they come back and maybe after two months, the lady realises she hasn’t had a period for some time, and she finds out she is pregnant. Stress is definitely a component.
Even when couples are going through IVF, we tell them they should reduce their stress level. Don’t stop work because you are going through IVF. Still go to work, and do whatever you normally do…don’t come for injections and just go back home. That’s not good, because you will just focus on the treatment, and that increases your stress level.
How much influence do Genes have on Fertility?
Well, there are some sperm disorders that are genetic. You will find that there are some families where all the brothers have low sperm count. Now, this is a very sensitive area, and that is where you can even fault fertility practitioners.
In nature, in the animal kingdom, weaker genes are weeded out. If a lion can’t hunt, it will starve. The same way if a man has sperm issue. Not those ones who had testicular trauma when they were younger, but those who have a genetically caused low sperm count situation. You will find out that, in nature, that gene will be weeded out, because they will not be able to reproduce, but with IVF, we are able to take the few good sperm they can produce, fertilize an egg, and perpetuate these same genes, so the condition is replicated in the next generation. So we can be criticized for doing that.
But you see, how do you tell a couple not to bother? That’s one of the controversies IVF practitioners can be criticised for.
What do you think about Alternative Fertility Treatment?
There are a number of treatments that are classified as alternative treatment. I’m not an alternative practitioner, but I think that there are a lot things that are not harmful. A lot of these things are plant based and some of are complementary. But in some situations, it is dicey.
Do you have a specific memory of an outcome with a patient that you are exceptionally proud of, or happy with?
One memory that stands out for me was not as much as what I did, but more of what I didn’t do. I had a patient, about 20 years ago. After performing a laparoscopy, I saw her pelvis, and it was a mess. I told her that, from what I saw, it would be very difficult for her to conceive naturally. She worked in our hospital, but she was not a medical person, but to my surprise and joy, she conceived naturally. That just confirmed my belief that doctors only treat, but it is God that does all the work.
And what has your been your lowest point?
Well, every time a cycle fails, I’m unhappy. Because, during the cause of treatment, you get to know these women and you find that each one is going through one challenge or the other, particularly in our own society, where there is so much importance attached to childbirth. It’s shocking the kinds of horror stories women go through, from being called a man by their mothers-in-law, and all sorts of nasty things, so when any of these women don’t succeed, you know their lives are going to get worse. You can just feel their pain, because their family situations are really helpless. So those are really low moments.
What is the most challenging part of your job?
The most challenging part is keeping the place running. You are doing everything yourself; generating power, water, fixing burst, buying diesel, facing FOREX fluctuations, which could move against you. It can be extremely challenging in Nigeria, but at the end of the day,it is fulfilling. You see, a lot of my colleagues refuse to come back to Nigeria, because they can cite a million reasons for them not to…but I always tell them that I have no regrets coming back. It is the most challenging, but fulfilling place to practice, as long as you are a very content person. Nigeria is a very materialistic society, but if you are not after money and get fulfilment from adding value to people, you will be fine here, and whatever the challenges, you don’t see them as such, but as opportunities to be better.
What is the most rewarding part of your job?
Seeing the babies, especially, when they come premature, like weighing 800 grams when they are born, and they leave the hospital weighing about 2.2kg, and you see them two years later, running around the place. It is a truly wonderful feeling!
What is something people might not know about you?
I’m a very private person. I love sports, and I’m a very keen golfer. I like music, and I sing. From the age of 11, I joined the choir, and then left for many years, but I’m back in the choir again.
If Dr. Faye wasn’t a Doctor, what would he be?
A Doctor (laughter)! It was the only thing I ever wanted to be. If I were to come back into this world again, I would only want to be a doctor.
© The Fertile Chick
Dr. Faye Iketubosin is the Medical Director of Georges Memorial Medical Center, located at 6, Rasheed Alaba Williams Street, Off Admiralty Way, Lekki, Lagos (T: +234-1-271 8727)