|Year : 2016 | Volume
| Issue : 2 | Page : 23-26
Assisted reproductive technology: Experience from a public tertiary institution in north central Nigeria
Lukman Omotayo Omokanye1, Abdulwaheed Olajide Olatinwo1, Lateefat Olayinka Saadu2, Sikiru Abayomi Biliaminu3, Kabir Adekunle Durowade4, Abubakar A Panti5
1 Department of Obstetrics and Gynaecology, College of Health Sciences, University of Ilorin, Ilorin, Nigeria
2 Assisted Reproductive Technology Unit, University of Ilorin Teaching Hospital, Ilorin, Nigeria
3 Department of Chemical Pathology and Immunology, College of Health Sciences, University of Ilorin, Ilorin, Nigeria
4 Department of Community Medicine, Federal Teaching Hospital, Ekiti State, Nigeria
5 Department of Obstetrics and Gynaecology, College of Health Sciences, Usmanu Danfodiyo University, Sokoto, Nigeria
|Date of Web Publication||20-Sep-2017|
Lukman Omotayo Omokanye
Department of Obstetrics and Gynaecology, College of Health Sciences, University of Ilorin, Ilorin
Source of Support: None, Conflict of Interest: None
Background: According to the World Health Organization, more than 180 million couples globally suffer from infertility, the majority being residents of developing countries. Assisted reproductive technologies (ARTs) offer a chance at parenthood to couples, who until recently would have had no hope of having a “biologically related” child. Objectives: This study aimed to determine pregnancy outcomes following assisted conception. Materials and Methods: This is a prospective study of 104 clients who underwent the procedure of ART between January 1, 2012 and December 31, 2016 at the ART unit of University of Ilorin Teaching Hospital, Ilorin, Nigeria. Results: Of the 510 clients who had infertility consultation at the ART clinic, 104 (20.4%) underwent ART procedures. The patients aged 27–46 years with a mean age of 33 ± 4.0 years. More than half (58.7%) had primary infertility. Their duration of infertility ranged from 1 to 20 years (4.6 ± 2.9 years). Majority (81.7%) had conventional in vitro fertilization while 19 (18.3%) had intracytoplasmic sperm injection. Thirteen (12.5%) cases of cycle cancellation and 11 (11.7%) cases of mild-to-moderate ovarian hyperstimulation syndrome were recorded. The clinical pregnancy rate per cycle started was 39.4%. However, 9/41 (22%) resulted in spontaneous miscarriages and 32 (6 sets of twin, 25 singleton, and 1 high-order multiple births) were successfully delivered, giving a live birth rate per cycle started of 30.8%. Pregnancy outcomes were not significantly affected by age of the women, types of infertility, and duration of infertility (P > 0.05). Conclusion: The outcomes of ART procedures in a resource-limited country like ours are encouraging. This underscores the need to encourage ART in public tertiary institutions in Nigeria through the support of government and nongovernmental organizations for the benefit of infertile couples who were hitherto hopeless.
Keywords: Assisted reproductive technology, experience, Nigeria, public tertiary institution
|How to cite this article:|
Omokanye LO, Olatinwo AO, Saadu LO, Biliaminu SA, Durowade KA, Panti AA. Assisted reproductive technology: Experience from a public tertiary institution in north central Nigeria. Afr J Infertil Assist Concept 2016;1:23-6
|How to cite this URL:|
Omokanye LO, Olatinwo AO, Saadu LO, Biliaminu SA, Durowade KA, Panti AA. Assisted reproductive technology: Experience from a public tertiary institution in north central Nigeria. Afr J Infertil Assist Concept [serial online] 2016 [cited 2018 Feb 21];1:23-6. Available from: http://www.afrijiac.org/text.asp?2016/1/2/23/215111
| Introduction|| |
According to the World Health Organization, infertility affects up to 10.5% of couples of reproductive age group globally and 20% of couples of reproductive age group in Nigeria. Its impact is particularly prominent in cultures where a high premium is placed on childbirth (as it is in Nigeria and many other African countries), leading to social, psychological, and economic challenges.,
The first pregnancy after in vitro fertilization (IVF) of a human egg and the first birth of an IVF child were reported in 1976 and 1978, respectively., Since then, over five million births have been achieved worldwide by IVF and its modifications inclusive of contributions from developing countries like Nigeria. Although advances in laboratory technology and clinical practice have permitted IVF to progress in low-resource setting like ours, it still remains out of reach of many infertile couples as the service is largely in private sectors,, not until recently that few public tertiary institutions, joined that offer relatively affordable IVF program. Therefore, this study is conducted to determine the pregnancy outcomes of assisted reproductive technology (ART) procedures in a tertiary public institution in a low-resource setting.
| Materials and Methods|| |
This is a prospective study of 104 eligible clients who underwent assisted conception program, i.e., IVF/intracytoplasmic sperm injection (IVF/ICSI) treatment cycles in batches of 5–10 couples at the ART unit of University of Ilorin Teaching Hospital (UITH), Ilorin, between January 1, 2012 and December 31, 2016. Patients were recruited using purposive nonprobability sampling method. The case records of the patients were retrieved from ART unit/gynecological case notes and theater records. Data extracted from the case notes included bio-social variables, types of stimulation protocols, cycle cancellations, risk of ovarian hyperstimulation syndrome (OHSS), and pregnancy outcomes.
Informed consent was obtained from each patient, and protection of personal data and confidentiality were prioritized. Institutional Review Board approval was obtained, and the study has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.
A total of 104 clients were included in the study. All patients had a body mass index (calculated as weight in kilograms divided by the square of height in meters) ranging between 18 and 30 with a mean of 24 ± 4 kg/m2. Their infertility evaluation results were normal. Seminal fluid analysis was conducted for male partners. The criteria for men were a sperm count of at least 20 million cells per milliliter of semen and progressive sperm motility (grades a + b) of 50% or greater. Male partners with semen count and/or motility less than the cutoff values were offered ICSI unless the sperm count was zero after centrifugation; therefore, donor sperm was used for IVF.
All clients consented to treatment before its commencement. In addition, all female partners had oral contraceptive pills for menstrual cycle synchronization and precervical assessment (trial/dummy transfer) on day 2/3 of menses prior to the commencement of stimulation.
Two stimulation protocols were used for the study depending on the clinician's/patient's choice: The long agonist protocol with 60 clients and the antagonist protocol with 44 clients.
In long agonist protocol, patients received 0.5 mg daily buserelin (Suprecur®; Aventis Pharm, West Malling, UK) subcutaneously from day 21 of the cycle proceeding the synchronized cycle for 12–14 days. With the onset of menstrual cycle, the dose of Suprecur® was reduced to 0.25 mg daily till the day of trigger, and 150 IU (2 vials) of recombinant follicle-stimulating hormone (FSH) (Gonal F®; Merck Serono, Modugno (Bari), Italy) and 75 IU (1 vial) of highly purified FSH (Folliculin®; Barrat Pharmaceutical, Ambernath (E) India) were commenced on day 3 of menstrual cycle for 11–14 days.
Serial transvaginal ultrasonographic scan was done at interval from day 5/6 of stimulation to determine the number of follicles and endometrial thickness. Two hundred and fifty microgram (6000 IU) of recombinant human chorionic gonadotropin (hCG: Ovitrelle®; Merck Serono, Germany) trigger was administered subcutaneously whenever two or more follicles have grown to 18 mm or more, and oocyte retrieval was carried out at 35.5 h thereafter.
While in antagonist protocol, patients were commenced on 150 IU (2 vials) of recombinant FSH Gonal F (Gonal F®; Merck Serono, Germany) and 75 IU (1 vial) highly purified FSH (Folliculin®; Barrat Pharmaceutical, India) on day 3 of menstrual cycle for 11–14 days. Transvaginal ultrasonographic scan was also done at interval from day 5/6 of stimulation to determine the numbers, size of follicles, and endometrial thickness. Subcutaneous 2.5 mg daily gonadotropin-releasing hormone (GnRH) antagonist (Cetrotide®; Merck Serono, Germany) was administered whenever the follicles have grown to 14 mm size usually around day 6/7 of stimulation and was continued till the day of trigger to prevent premature luteinizing hormone surge. Eighty-three microgram (2000 IU) of recombinant hCG (Ovitrelle®; Merck Serono, Germany) and 0.25 mg of buserelin (Suprecur®; Aventis Pharm, West Malling, UK) were administered subcutaneously for trigger whenever two or more follicles have grown to 18 mm or more and oocyte retrieval was carried out at 35.5 h thereafter.
An excessive ovarian response (OHSS) risk was defined as 15 or more follicles 11–14 mm in diameter by days 10, 11, and 12 of controlled ovarian stimulation (COS), while a failed response was defined as no follicles after 10 days of COS, as the need to continue COS beyond 20 days. Similarly, clients with failed response to stimulation, no oocyte at retrieval, failed fertilization, and no available embryos for transfer had their cycle cancelled.
Oocyte retrieval, insemination, embryo transfer, and luteal-phase support
Oocyte retrieval was done at about 35.5 h of hCG injection by the transvaginal needle aspiration under ultrasound guidance and was transferred immediately to the laboratory for oocyte screening and pickup. Mature oocytes were inseminated with prepared sperm after 6 h of oocyte pickup and were incubated. ICSI was done in cases of severe male factor infertility. Best cleavage embryos were transferred on day 5 of oocyte retrieval usually at the blastocyst stage using transabdominal ultrasound guidance, and the transfer catheters were checked to ensure that all the embryos were transferred. The number of embryos transferred (ET) was individualized using patients' age and experience from previous failed ART cycles, two or three in most cases. The luteal-phase support was conducted with progesterone (800 mg twice daily [Cyclogest pessaries®; Cox, Barnstaple, UK] and intramuscular 100 mg twice weekly [Gestone®; Ferring Pharmaceuticals, Mumbai, India]). Serum pregnancy test was carried out 2 weeks after ET and subsequently transvaginal ultrasound at 6th week for detection of gestational sac and/or viability of the fetus.
Statistical analysis was done using Epi Info version 126.96.36.199 (Centers for Disease Control and Prevention, Atlanta, USA). Categorical data were expressed as numbers and percentages while numerical data were expressed as mean and standard deviation. Associations of categorical variables were tested using Chi square test, while statistical significance was set at P ≤ 0.05. Results were presented in tables.
| Results|| |
A total of 104 clients were recruited for the study. The patients aged 27–46 years with a mean age of 33 ± 4.0 years while their spouses aged 31–50 years with a mean age of 39 ± 4.7 years. More than half (58.7%) had primary infertility. Their duration of infertility ranged from 1 to 20 years (4.6 ± 2.9 years), with majority (96.2%) experienced 1–10 years of infertility [Table 1].
The cycle cancellation was 12.5%, incident of OHSS was 11%, and the mean number of oocytes retrieved and fertilized was 10.4 ± 6.0 and 6.9 ± 3.9, respectively. Also, the number of embryos transferred ranged from 1 to 3 [Table 2].
[Table 3] shows the pregnancy outcomes. Forty-one pregnancies were recorded from 104 clients giving a pregnancy rate of 39.4% per cycle started, out of which 9/41 (22%) resulted in early first-trimester miscarriage and 32 were successfully delivered, giving a live birth rate of 30.8% per cycle started. Pregnancy outcomes were not significantly affected by age of the women, types of infertility, and duration of infertility (P < 0.05) [Table 4].
|Table 4: Relationship between sociodemographic variables and in vitro fertilization outcome|
Click here to view
| Discussion|| |
The clinical pregnancy rate in this study was 41/104 (39.4%), this is however slightly higher than 180/600 (30%) and 31/115 (27%) reported in Benin and Nnewi in southwestern and eastern Nigeria, respectively. This may be attributed to the smaller sample size of our study population as against previous studies., Furthermore, achieving competence and capacity on ICSI for insemination in severe oligospermic male partner and the use of donor sperm in azoospermic male partner could be contributory.
In addition, the live birth rate of 30.8% in our series is higher than 16.2% and 18.3% reported in similar studies in Nigeria while the miscarriage rate of 22% (of those who became pregnant) is comparable with 21.9% reported in Philadelphia, USA, but far higher than findings of 6.6% and 8.7% obtained in Benin and Nnewi, Nigeria, respectively. In the absence of national legislation as regards the number of ET, the maximum number of embryos transferred in this study was three as against elective single ET policy in most European countries due to paucity of facilities to conduct advanced screening of embryos prior to transfer with resultant prevalence of multiple births of 6/104 (5.8%) which is comparable to 36/600 (6%) reported by Orhue et al.
In this study, the prevalence of OHSS was 11.7%, all were mild OHSS that did not warrant cycle cancellation and majority (9 out of 11) resulted from GnRH agonist stimulation protocol. This is, however, lower than OHSS episode of 15% reported in a previous study in Benin, Nigeria. The findings of lower OHSS episode in GnRH antagonist stimulation protocol as against GnRH agonist stimulation protocol are in keeping with findings from previous studies.,, Furthermore, the cycle cancellation rate of 12.5% resulted from poor ovarian response and failed fertilization involving five and eight clients, respectively, with the majority, i.e., three and seven, respectively, resulted from GnRH agonist stimulation protocol. This is inconsonance with the findings of Craft et al. where a significantly higher cycle cancellation rate was observed in GnRH agonist stimulation protocol compared with GnRH antagonist stimulation protocol. Our cycle cancellation rate of 12.5% is higher than 8.1% reported in an earlier study within the same facility but slightly lower than 16% reported in Benin, Nigeria.
The age-related decline in female fecundity and fecund ability has been well documented in both natural and artificial reproduction and probably results from a combination of progressive follicular depletion, decline in granulose function, poor oocyte quality, and reduced endometrial receptivity. On the contrary, we obtained an insignificant association between pregnancy outcomes, age of the women, types of infertility, and duration of infertility. This may be related to the limited sample size in this study. This finding is in keeping with the results of an earlier report in the same institution.
| Conclusion|| |
The clinical pregnancy and live birth rates of ART in UITH Ilorin are 39.4% and 30.8%, respectively. This has enabled couples to fulfill their parental desires who previously do not have the hope of becoming parents. Thus, there is a need to encourage ART in public tertiary institutions in Nigeria for the benefit of teeming population of affected citizenry who were hitherto hopeless.
We appreciate the UITH and University of Ilorin on the provision of ART equipment and enabling environment to conduct this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
WHO. National, Regional, and Global Trends in Infertility Prevalence since 1990: A Systematic Analysis of 277 Health Surveys. December 2012. p. 12.
Bello FA, Akinajo OR, Olayemi O. In-vitro
fertilization, gamete donation and surrogacy: Perceptions of women attending an infertility clinic in Ibadan, Nigeria. Afr J Reprod Health 2014;18:127-33.
Steptoe PC, Edwards RG. Reimplantation of a human embryo with subsequent tubal pregnancy. Lancet 1976;1:880-2.
Steptoe PC, Edwards RG. Birth after the reimplantation of a human embryo. Lancet 1978;2:366.
Ikechebelu JI, Eleje GU, Ibadin K, Joe-Ikecheelu NN. Outcome of in vitro
fertilization procedure at a private fertility center in Nnewi, South-East Nigeria. Afr J Infertil Assist Concepts 2016;1:2-5.
Omokanye LO, Olatinwo AW, Durowade KA, Biliaminu SA, Salaudeen AG, Panti AA. Pregnancy outcomes following assisted reproduction technologies for infertile women at a public health institution in Nigeria. Trop J Health Sci 2015;22:25-7.
Orhue AA, Aziken ME, Osemwenkha AP, Ibadin KO, Odoma G.In vitro
fertilization at a public hospital in Nigeria. Int J Gynaecol Obstet 2012;118:56-60.
European and Israeli Study Group on Highly Purified Menotropin versus Recombinant Follicle-Stimulating Hormone. Efficacy and safety of highly purified menotropin versus recombinant follicle-stimulating hormone in in vitro
fertilization/intracytoplasmic sperm injection cycles: A randomized, comparative trial. Fertil Steril 2002;78:520-8.
Ben-Rafael Z, Fateh M, Flickinger GL, Tureck R, Blasco L, Mastroianni L Jr., et al.
Incidence of abortion in pregnancies after in vitro
fertilization and embryo transfer. Obstet Gynecol 1988;71:297-300.
Klemetti R, Gissler M, Hemminki E. Comparison of perinatal health of children born from IVF in Finland in the early and late 1990s. Hum Reprod 2002;17:2192-8.
Ombelet W, De Sutter P, Van der Elst J, Martens G. Multiple gestation and infertility treatment: Registration, reflection and reaction – The Belgian project. Hum Reprod Update 2005;11:3-14.
Takahashi K, Mukaida T, Tomiyama T, Goto T, Oka C. GnRH antagonist improved blastocyst quality and pregnancy outcome after multiple failures of IVF/ICSI-ET with a GnRH agonist protocol. J Assist Reprod Genet 2004;21:317-22.
Kolibianakis EM, Collins J, Tarlatzis BC, Devroey P, Diedrich K, Griesinger G, et al.
Among patients treated for IVF with gonadotropins and GnRH analogues, is the probability of live birth dependent on the type of analogue used? A systematic review and meta-analysis. Hum Reprod Update 2006;12:651-71.
Al-Inany HG, Youssef MA, Ayeleke RO, Brown J, Lam WS, Broekmans FJ, et al.
Gonadotropin-releasing hormone antagonists for assisted reproductive technology. Cochrane Database Syst Rev 2016;4:CD001750.
Craft I, Gorgy A, Hill J, Menon D, Podsiadly B. Will GnRH antagonists provide new hope for patients considered 'difficult responders' to GnRH agonist protocols? Hum Reprod 1999;14:2959-62.
Baird DD, Strassmann BI. Women's fecundability and factors affecting it. In: Goldman MB, editor. Women and Health. New York: Academic Press; 2000. p. 126-37.
Zadehmodarres S, Oladi B, Saeedi S, Jahed F, Ashraf H. Intrauterine insemination with husband semen: An evaluation of pregnancy rate and factors affecting outcome. J Assist Reprod Genet 2009;26:7-11.
[Table 1], [Table 2], [Table 3], [Table 4]