|Year : 2018 | Volume
| Issue : 1 | Page : 2-5
Assisted reproduction technology in Nigeria: Challenges and the way forward
Lukman Omotayo Omokanye1, Abdulwaheed Olajide Olatinwo1, Ganiyu Adekunle Salaudeen2, Kabir Adekunle Durowade3, Abubakar A Panti4, Rabiu Olayinka Balogun1
1 Department of Obstetrics and Gynaecology, College of Health Science, University of Ilorin, Ilorin, Nigeria
2 Department of Epidemiology and Community Health, College of Health Science, University of Ilorin, Ilorin, Nigeria
3 Department of Community Medicine, Federal Teaching Hospital, Ido Ekiti, Ekiti, Nigeria
4 Department of Obstetrics and Gynaecology, College of Health Sciences, Usmanu Danfodiyo University, Sokoto, Nigeria
|Date of Web Publication||28-Aug-2019|
Dr. Lukman Omotayo Omokanye
Department of Obstetrics and Gynaecology, College of Health Sciences, University of Ilorin, Ilorin
Source of Support: None, Conflict of Interest: None
The challenges associated with infertility have necessitated different healthcare-seeking behaviors ranging from spiritual, traditional/alternative health care to orthodox medical types including biotechnological devices such as assisted reproductive technology (ART). ART is the highest breakthrough in the medical treatment of infertility in the whole world. Its evolution has presented multitudinous ethical, legal, and social challenges resulting in a tectonic shift in the way clinicians and the general population perceive infertility and ethics. Hence, there is a urgent need for stakeholders (fertility specialists, clients, professional organizations, religious bodies, bioethicists, and government) to formulate cultural and context-specific guidelines to help address some of these ethical dilemmas.
Keywords: Assisted reproduction technology, challenges, Nigeria
|How to cite this article:|
Omokanye LO, Olatinwo AO, Salaudeen GA, Durowade KA, Panti AA, Balogun RO. Assisted reproduction technology in Nigeria: Challenges and the way forward. Afr J Infertil Assist Concept 2018;3:2-5
|How to cite this URL:|
Omokanye LO, Olatinwo AO, Salaudeen GA, Durowade KA, Panti AA, Balogun RO. Assisted reproduction technology in Nigeria: Challenges and the way forward. Afr J Infertil Assist Concept [serial online] 2018 [cited 2019 Sep 23];3:2-5. Available from: http://www.afrijiac.org/text.asp?2018/3/1/2/265669
| Introduction|| |
Infertility is a prevalent condition in many countries with its impact more prominent in the developing countries of Africa and Asia. The burden of infertility as shown by its prevalence varies across the world; studies from Nigeria, Ghana recorded the prevalence of 30.3% and 11.8%, respectively, while a study involving 27 African countries found a range of between 10% and 20%. These values are higher when compared with results from studies carried out in more developed nations of the North; studies conducted in Scotland and the USA found the prevalence of 9.1% and 10%, respectively.,
The birth of Louise Brown on July 25, 1978 was the culmination of decades of scientific research in reproductive medicine. Since then, abundance of breakthrough in both clinical medicine and basic science have all allowed increasing numbers of infertile couples the chance to have a baby. To date, more than 5 million babies have been born worldwide through assisted reproduction technologies.
In Nigeria, Oladapo Ashiru pioneered thein vitro fertilization (IVF) program in 1984 and his team successfully delivered the first IVF baby in 1989. This was subsequently followed by reported birth of IVF babies in private and public-funded facilities within the country. This includes Orhue at University of Benin Teaching Hospital; 2007, Joseph Ikechebelu at Life Specialist Hospital, Nnewi, 2011 and Omokanye and his team at University of Ilorin Teaching hospital, Ilorin; Nigeria.
While assisted reproductive technology (ART) including IVF has given hope to millions of couples suffering from infertility, it has also introduced countless ethical, legal, and social challenges. ART has resulted in a tectonic shift in the way clinicians and the general population perceive infertility and ethics. ART is directly challenging society to reevaluate the way in which human life, social justice and equality, and claims to genetic offspring are viewed. Furthermore, these issues will force legal systems to modify existing laws to accommodate the unique challenges created by ART. Society has a responsibility to ensure that the advances achieved through ART are implemented in a socially responsible manner.
| Emerging Issues in Assisted Reproduction Technology|| |
Financial aspect for in vitro fertilization treatment
One of the most obvious ethical challenges surrounding ART is the inequitable distribution of access to care. The fact that significant economic barriers to IVF exist in many countries results in the preferential availability of these technologies to couples in a position of financial strength. The cost of performing ART per live birth varies among countries. The average cost per IVF cycle in the United States is USD 9266, whereas it ranges between 2800 and 3000 USD in Nigeria in private and public sectors, respectively, in a country, where the national monthly minimum wage is approximately 50 USD. According to studies from other emerging nations such as Brazil and South Africa, ART is also mainly private sector driven, expensive, and may be unaffordable for those in need. This is in contrast to the practice in many European countries where a specific number of cycles of IVF treatment are reimbursed by their governments.
Another topic of ethical, social, and legal debate surrounds the aspect of reproduction without coitus in religious circles. Human response to new developments regarding birth, death, marriage, and divorce is largely shaped by religious beliefs. When assisted reproduction was introduced into medical practice in the last quarter of the 20th century, it was fiercely attacked by some religious groups and highly welcomed by others. Today, assisted reproduction is accepted in nearly all its forms by Judaism, Hinduism, and Buddhism, although most Orthodox Jews refuse third party involvement.
On the contrary, assisted reproduction is totally unacceptable to Roman Catholicism, while Protestants, Anglicans, Coptic Christians, and Sunni Muslims accept most of its forms, which do not involve gamete or embryo donation.,, Orthodox Christians are less strict than Catholic Christians but still refuse third party involvement. Interestingly, in contrast to Sunni Islam, Shi'a Islam accepts gamete donation and has made provisions to institutionalize it. Chinese culture is strongly influenced by Confucianism, which accepts all forms of assisted reproduction that do not involve third parties. Other communities follow the law of the land, which is usually dictated by the religious group(s) that make(s) the majority of that specific community. The debate will certainly continue as long as new developments arise in the ever-evolving field of assisted reproduction.
Multiple gestation pregnancies versus number of embryo transfer
Increasingly, nations have enacted legislation that defines the parameters for acceptable practice of ART. The transfer of multiple embryos in a single cycle increases the rates of multiple births. Because of the increased social costs and health risks associated with multiple births, legislation or guidelines from professional societies have been introduced in many countries restricting the number of embryos that may be transferred per IVF cycle in an effort to limit the incidence of multiple gestations. Indeed, a study in the United Kingdom found that the total health care system costs following a singleton birth were ≤ £3313, ≤ £9122 following a twin birth and ≤ £32,354 following a triplet birth. Additionally, the health risks, both to the mother and the infant, increase dramatically with increasing number of infants.
Pregnancy rates associated with IVF are high compared to those seen in the early days of the procedure. Single embryo transfer would inherently decrease maternal and infant health risks associated with multiple gestation pregnancies., Therefore, a trend toward single embryo transfer is likely to increase in the future.
Variability of legislation regulating IVF exists in different countries and even states/provinces within a single nation. For example, in an effort to minimize multiple gestation pregnancies resulting from ART, some laws place limits on the number of embryos that may be transferred, cryopreserved, or fertilized per IVF cycle., In some cases, these regulations or fiscal pressures result in couples traveling across international border to obtain treatments that are unavailable in their native country. This practice, known as cross-border reproductive care, is thought to account for as much as 10% of the total IVF cycles performed worldwide., There exists no legislation on ART in Nigeria as at this moment.
Fate of leftover embryos
The fate of extra embryos in resource-limited settings like ours is another problem; for how long do the fertility clinics store them and at what conditions; keeping in mind that power supply is a problem in Nigeria. Studies from developed countries have shown that the viability of the frozen embryos reduces with longer storage time. The fate of surplus embryos is another topical issue: Do they get donated to someone else or are they destroyed? The earlier stated views of the Catholic Church regarding the embryo and personhood present a strong argument against their destruction.,, The acceptability of third-party gamete is controversial, especially in the African setting. Bello et al. in a study conducted in Ibadan, Nigeria, found only 35.2% and 24.7% of women open to accepting donated eggs and sperm, respectively. Furthermore, the issue about parenthood (in the case of a sperm donor/egg donor) comes to bear what right does the donor have regarding the child? From the point of view of the child, is there a right to know about the means of his/her conception and biological parent? Comodification of gametes is not considered a major ethical challenge presently, but stakeholders have been aware of this possibility in the future.
Surrogacy and gestational carriers
In the African culture, every woman wants to be a “mother,” by delivering her baby through the natural means (per vaginam). This feeling has led to nonacceptance of cesarean section by some women as it makes them “less than a mother.” From this perspective, the practice of surrogacy may not be widely acceptable to many in developing countries such as Nigeria. Surrogates and gestational carriers are subject to significant medical and emotional risks from carrying a pregnancy and undergoing a delivery. Some also are concerned that the use of surrogates and gestational carriers is a form of “child selling” or the “sale of parental rights.”
Another central concern surrounding the use of surrogates and gestational carriers is the possibility that financial pressures could lead to exploitation and comodification of the service. The mean compensation for a gestational carrier in the United State in 2008 was estimated at approximately $20,000. In contrast, a gestational carrier in India receives an average of $4,000 for the same service. Regulation of surrogates and gestational carriers varies widely from nation to nation and even within regions of individual countries. Due to these financial and legal considerations, international surrogacy has emerged as an emerging industry, especially in developing nations. This practice has exacerbated the already difficult ethical and legal issues surrounding gestational carriers. At the present time, issues surrounding issues of individual rights, commodification, exploitation, citizenship of the offspring of international gestational carriers, and even fair trade are largely unresolved internationally.,
Preimplantation genetic testing and fertility preservation
Preimplantation genetic screening and preimplantation genetic diagnosis (PGD) offer the unique ability to characterize the genetic composition of embryos before embryo transfer. Given the recent successes of these technologies, the broader implementation of this technology in the future is likely. Although controversial, using PGD to choose embryos solely on the basis of gender is currently being practiced. This is one of the leading indications for IVF in Nigeria and many developing nations where higher premium is placed on having male child. Sex selection in the proper setting may offer a substantial health benefit. For example, choosing to transfer only embryos of a certain sex may confer a therapeutic benefit if used to avoid a known sex-linked disorder and single gene mutation as in sickle cell anemia in Nigeria., However, sex selection PGD purely for the preference of the parents could conceivably, if practiced on a large scale, skew the gender proportions in certain nations where one gender is culturally preferred.
Recently, several laboratories have demonstrated the ability to successfully cryopreserve oocytes following an IVF cycle. These developments have profound implications. As the birth control pill gave women the ability to prevent pregnancy, oocyte cryopreservation may give women the flexibility to preserve their fertility potential, starting at a young age, while postponing childbearing. However, as this technology at the present time in many countries is generally only available to those with financial means. This poses ethical and social issues that will certainly see more attention in the future.
Side effects of assisted reproductive technology and quality assurance
The safety of the various procedures during IVF has always been a topic for discussion. The adverse effects of Ovarian Hyperstimulation Syndrome (OHSS) are well-documented. The introduction of newer drugs and modification of the procedure to mitigate these effects had led to some improvement in this aspect. Multiple pregnancy and its attendant complications during pregnancy or childbirth is one major issue with IVF. This is due to the transfer of multiple embryos to the uterus to ensure that at least one or two survive and develop until birth. With increasing sophistication and fine-tuning of the procedure, fertility specialists around the world are now able to transfer 1–2 embryos with very good outcomes.,
Studies from Nigeria have shown the average number of transferred embryos is between 2 and 5, and this is mainly due to economic reasons and the fear of failure., On the contrary, between 1 and 2 embryos were transferred in a report from the South African Register of ART. The fewer numbers of transferred embryos reported here is likely due to the longer experience with ART and better technical expertise.
Quality assurance of the procedure remains an important factor that must be addressed in emerging economies of the world. Because of lack of national regulatory agencies in most developing countries, most IVF clinics make their own rules and follow different standards. This does not augur well for the practice of assisted reproduction in these climes.
Status of babies delivered through in vitro fertilization
Multiple studies have failed to find a clinically relevant association between IVF or embryo cryopreservation and adverse maternal or fetal effects.,, Other studies have suggested that infants of IVF pregnancies may be at a small but statistically significant increased risk for rare epigenetic and other abnormalities. Despite this controversy, there is a general consensus that IVF confers a small but measurable increased risk for a variety of congenital abnormalities including anatomic abnormalities and imprinting errors as compared to the general population. Some maintain, however, that this is secondary to an increased baseline risk for these problems in the population of infertile patients. Regardless of the cause, this small increased risk, while statistically significant with extremely large sample sizes, will likely not be a powerful enough factor to dissuade infertile couples from pursuing parenthood through IVF.
The need for regulation guidelines
The need for strict regulation of the practice of ART has led to the setting up of bodies such as the Human Fertilization and Embryology Authority (HFEA), which oversees and makes policy regarding ART in the UK, for example, centralized mandatory IVF reporting registries. At present, there is no law governing the practice of ART in Nigeria despite the relatively long duration of practice. Most ART centers in Nigeria and other developing countries operate based on HFEA guidelines; this practice, however, is not optimal as there are several contextual differences among the different countries. A bill for the establishment of the “Nigerian Assisted Reproduction Authority” has been presented by the Association for Fertility and Reproductive (AFRH) to the Nigerian parliament for consideration and if passed will be a good starting point for regulation of ART practice in Nigeria.
Assisted reproductive technology in people living with human immunodeficiency virus
The high prevalence of human immunodeficiency virus (HIV) infection among people in the reproductive age group in Africa has brought a new dimension to this discussion on ethics of ART. The older arguments against ART in people living with HIV include the nondesirability of bringing HIV-infected babies into the world, the risk of children being orphaned early in life, and associated psychological consequences. With the introduction of highly active antiretroviral treatment (HAART), people living with HIV now have a longer lifespan. Furthermore, the availability of better procedures such as sperm washing during ICSI and the prevention of mother-to-child transmission using HAART have made the risk of transmission of infection insignificant., Results from these studies carried out among people living with HIV who had ART showed very good outcomes., These positive developments have made the case for access to ART for people living with HIV with a caveat that all necessary protocols need to be followed to prevent transmission of the infection to the newborn.
| Conclusion and Recommendations|| |
ART has emerged as one of the most widely adopted and successful medical technologies in the last century. While giving hope to millions of couples suffering from infertility, ART also has presented new ethical, legal, and social questions that society must address. Many countries have taken steps to regulate certain aspects of ART. However, such is in evolution in Nigeria. There is an urgent need for stakeholders (fertility specialists, clients, professional organizations, religious bodies, bioethicists, and government) in developing countries to formulate cultural and context-specific guidelines to help address some of these ethical dilemmas.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Fadare JO, Adeniyi AA. Ethical issues in newer assisted reproductive technologies: A view from Nigeria. Niger J Clin Pract 2015;18 Suppl S1:57-61.
Bhattacharya S, Porter M, Amalraj E, Templeton A, Hamilton M, Lee AJ, et al.
The epidemiology of infertility in the North East of Scotland. Hum Reprod 2009;24:3096-107.
Chandra A, Stephen EH. Impaired fecundity in the United States: 1982-1995. Fam Plann Perspect 1998;30:34-42.
Omokanye LO, Olatinwo AO, Durowade KA, Raji ST, Biliaminu SA, Salaudeen GA. Assisted reproduction technology: Perceptions among infertile couples in Ilorin, Nigeria. Saudi J Health Sci 2017;6:14-8. [Full text]
Okwelogu IS, Azuike EC, Ikechebelu JI, Nnebue CK.In vitro
fertilization practice: Awareness and perceptions among women attending fertility clinics in Okija, Anambra state, Nigeria. Afr Med J 2012;3:5-10.
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.
Omokanye LO, Olatinwo AW, Biliaminu SA, Durowade KA. Successful pregnancy outcome afterin vitro
fertilization at a public health facility in Nigeria. Niger J Med Investig Pract 2014;9:157-9.
Brezina PR, Zhao Y. The ethical, legal, and social issues impacted by modern assisted reproductive technologies. Obstet Gynecol Int 2012;2012:686253.
Omurtag KR, Styer AK, Session D, Toth TL. Economic implications of insurance coverage forin vitro
fertilization in the United States. A review. J Reprod Med 2009;54:661-8.
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.
Sallam HN, Sallam NH. Religious aspects of assisted reproduction. Facts Views Vis Obgyn 2016;8:33-48.
Inhorn MC. Making Muslim babies: IVF and gamete donation in Sunni versus Shi'a Islam. Cult Med Psychiatry 2006;30:427-50.
Ledger WL, Anumba D, Marlow N, Thomas CM, Wilson EC. The costs to the NHS of multiple births after IVF treatment in the UK. J Obstet Gynaecol 2006;113:21-5.
Collins J, Cook J. Cross-border reproductive care: Now and into the future. Fertil Steril 2010;94:e25-6.
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.
James S, Chilvers R, Havemann D, Phelps JY. Avoiding legal pitfalls in surrogacy arrangements. Reprod Biomed Online 2010;21:862-7.
Humbyrd C. Fair trade international surrogacy. Dev World Bioeth 2009;9:111-8.
Okohue JE, Onuh SO, Ikimalo JI, Wada I. Patients' preference for number of embryos transferred during IVF/ICSI: A Nigerian experience. Niger J Clin Pract 2010;13:294-7.
] [Full text]
Olukoya OY, Okeke CC, Kemi AI, Ogbeche RO, Adewusi AJ, Ashiru OA. Multiple gestations/pregnancies from IVF process in a fertility center in Nigeria, 2009-2011: Implementing policy towards fewer (double and single) embryo transfer. Nig Q J Hosp Med 2012;22:80-4.
Dyer SJ, Kruger TF. Assisted reproductive technology in South Africa:First results generated from the South African register of assisted reproductive techniques. S Afr Med J 2012;102:167-70.
Wennerholm UB, Söderström-Anttila V, Bergh C, Aittomäki K, Hazekamp J, Nygren KG, et al
. Children born after cryopreservation of embryos or oocytes: A systematic review of outcome data. Hum Reprod 2009;24:2158-72.
Logerot-Lebrun H, De Mouzon J, Hachelot A, Spira A. Pregnancies and births resulting fromin vitro
fertilization: French national registry, analysis of data 1986 to 1990, FIVNAT (FrenchIn Vitro
National). Fertil Steril 1995;64:746-56.
Petersen K, Hornnes PJ, Ellingsen S, Jensen F, Brocks V, Starup J, et al
. Perinatal outcome afterin vitro
fertilisation. Acta Obstet Gynecol Scand 1995;74:129-31.
Nicopoullos JD, Almeida P, Vourliotis M, Gilling-Smith C. A decade of the United Kingdom sperm-washing program: Untangling the transatlantic divide. Fertil Steril 2010;94:2458-61.
du Plessis E, Shaw SY, Gichuhi M, Gelmon L, Estambale BB, Lester R, et al.
Prevention of mother-to-child transmission of HIV in Kenya: Challenges to implementation. BMC Health Serv Res 2014;14 Suppl 1:S10.
Sauer MV, Chang PL. Establishing a clinical program for human immunodeficiency virus 1-seropositive men to father seronegative children by means ofin vitro
fertilization with intracytoplasmic sperm injection. Am J Obstet Gynecol 2002;186:627-33.
Savasi V, Ferrazzi E, Lanzani C, Oneta M, Parrilla B, Persico T. Safety of sperm washing and ART outcome in 741 HIV-1-serodiscordant couples. Hum Reprod 2007;22:772-7.