Farida Akhter || Thursday 25 March 2010
Unregulated Trade Over Infertility of Women
In Bangladesh population is seen as the cause of all problems including socio-economic, political, environmental and security in the conventional or mainstream discourses. In recent years it is being related to risks associated with climate change. often with bizarre arguments to control number of peoples in Bangladesh. Consequently it is argued that fertility of women must be controlled as a “solution” through use of temporary and permanent contraceptive methods.
While fertility of women is being controlled by the Bangladesh government, bilateral and mulilatral development partners, the infertility has become a matter of trade and business in the last decade. It has also become a big show of the few doctors who “help” the couples to get the treatment for infertility and to get a baby or babies. The huge media coverage on the so-called success of the Assisted Reproductive Technologies particularly of In Vitro-Fertilization and Frozen Embryo babies focus on the success of the doctors involved in the trade. The success is always of the doctor of the doctor’s solving ‘problems’ of the couple who are ‘infertile and must remain in the back for social reasons.
According to the doctors involved in the business of infertility treatment, there are over 3 million identified infertile couples and 10 to 15% of the couples are suffering from infertility. This statistics is given primarily to justify the need for introduction of the technologies for Infertility Treatment, known as “Assisted Reproductive Technologies (ART)”. There is no official statistics on infertility. Infertility involves both members of the couple, but it is not often diagnosed properly. Apparently it is taken for granted that infertility means female infertility. But when it comes to the issue of treatment, it is found that the infertility of a couple is caused by men (33%), women (33%) and husband and wife both (33%). The problem is acute among men in terms of deficiency of sperm counts but they do not often go for testing of infertility. It is the woman, who is seen as the “infertile” or “Bondha” or “Baja”, which is the one who cannot conceive a baby. For men the term is “Nopungshok” meaning one who cannot produce enough sperms for impregnating a woman. Male infertility is also linked with women, because ultimately it is the women’s womb that will produce the baby. The issues of infertility become an issue in the married couple after 5 years of marriage when they find that they are not able to have babies. However, couples can wait longer and try many other ways including treatments to have babies. Going for a “technological help” to have babies is a very recent phenomenon.
Since early 2000, the technologies already used and abused in the developed countries such as IVF, (commonly known as “Test Tube baby”), Embryo transfer, Frozen Embryo, “Intra-cytoplasmic sperm injection” or “ICSI”, intra uterine insemination (IUI) etc. have found their ways into Bangladesh with clinics run by private practicing doctors, having been trained abroad on these technologies. They provide high “hopes” to infertile couples although the success rate is still very low. There are advertisements of the clinics and promotion in newspaper reports with photos of babies carried in the arms of the doctors (both male and female) as the “producer of the babies”. The parents of the ART babies are hardly shown. This is also because they think that privacy of the couples should be maintained. There is a huge cost involved without any real assessment of the cost needed in the treatment. There is no regulation on the safety or suitability of the techniques and if it fails it is seen as “bad luck”. More than 479 babies are already born but over 20,000 couples have sought treatment in different clinics so far.
The practice of providing Infertility Treatment is done mainly through the private clinics, although there are limited services available in the government hospitals such as Dhaka Medical College Hospital and Post Graduate Medical University and Hospital ( Bangabondhu Sheikh Mujib Medical University Hospital (BSMMU). Dr. Parveen Fatema, who is known to be the first doctor to “help” the birth of Triplets Hira, Moni and Mukta in 2001 was actually employed as an Associate Professor of department of Gynecology and Obstetrics in the government hospital (BSMMU), but soon she opened her own private clinic “Centre for Assisted Reproduction (CARe) in 2000. In an Interview with the Daily Star (October 19, 2003), Dr. Parveen Fatima clearly mentioned that she started the service without any equipment, did not have the required trained manpower and even she herself did not have the “technical know how”. She said, “Though I trained many people including nurses and technicians but it was extremely difficult to find young doctors assisting me…… Then I needed an embryologist to complete the fertilization process. Realizing the problem my husband Dr. Moazzem who is a pediatrician offered to help me. After training, my husband now looks after the embryology section in the centre.”
INFERTILITY: THE ENTRY POINT OF TRADE
In the year 2000, just the year before the first Test Tube babies (Hira Moni and Mukta) were born, the Bangladesh Fertility Society held a three-day long International Congress during 12 – 14 January, 2001. In a Press Conference held on 14 October, 2000 announcing the Congress as well as the formation of the Bangladesh Fertility Society registered under Social Welfare Department as an NGO, they said, there are over 3 million infertile couples in the country, and this infertility is found both among men (40%) and among women (60%). During last 50 years the fertility of men has been severely affected, reduced by 50%. The spokesperson of the organization stated that they already gave treatment to 1133 persons, out of which only 233 women could get pregnant. Among those who got pregnant 50% experienced miscarriage.
In 2003, an infertility care centre, Dr. Fatima Parveen of CARe revealed that there are 2 million infertile couples in the country. Whatever the statistics is, the real issue is that there is growing infertility and therefore the technologies of infertility have a bright scope for business.
CAUSES OF INFERTILITY
According to Bangladesh Fertility Society, the causes of such a situation of infertility, were drug addiction, environmental pollution, Menstrual Regulation and delayed marriage. Another Infertility care centre Harvest Infertility Care Ltd. revealed that the causes are use of detergent powder, chemical fertilizer, pesticides, use of preservatives in food, excessive use of plastic materials etc.
According to the doctors involved in infertility treatment, 10 – 15% of the couples are suffering from infertility and 50% of these cases are due to infertility among men. Although the causes of infertility are identified mostly outside the bodies of the infertile couples, no efforts have been made to reduce the causes, rather the use of technologies has been justified.
CLINICS INVOLVED IN ASSISTED REPRODUCTIVE TECHNOLOGIES (ART)
A number of clinics have grown in last decade to provide Assisted Reproductive Technologies as Infertility care. These are either independent specialized private clinics with doctors from the government hospitals or part of the large private hospitals. The following list shows the different clinics that are providing ART services
Square Fertility Centre at SQUARE Hospitals
Ovulation Induction and Cycle Monitoring
Intra-Uterine Insemination (IUI) including Donor Insemination
In Vitro-Fertilization (IVF)
Gamete Intra-Fallopian Transfer (GIFT)
Zygote Intra-Fallopian Transfer (ZIFT) and Tubal Embryo Transfer
(TET) – Treatment of Male Infertility / Assisted Fertilization (ICSI)
Surgical Sperm Retrieval
Assisted Hatching (On Process)
Gametes and Embryo Donation
Embryo Freezing and Replacement of Frozen Embryos
Sperm and Embryo Banking
The centre is specially designed by specialists from Singapore, Mount Elizabeth Hospital.
Bangladesh Assisted Conception Centre and women’s Hospital (BACC & WH)
Semen Analysis
Hormone Test
Transvaginal USG
Laparoscopic Surgery
Ovulation Induction
Intra-Uterine Insemination (IUI)
In Vitro-Fertilization (IVF)
Intracytoplasmic Sperm Injection (ICSI)
TESA/MESA/PESA
Cryopreservation
Infertility Care and Research Centre (ICRC)
Controlled Ovarian stimulation with timed intercourse
Laparoscopic adhesiolysis and Laparoscopic “drilling” of the ovarian capsule
Tubal Reconstructive surgery
Intra-Uterine Insemination (IUI)
In Vitro-Fertilization (IVF)
Intracytoplasmic Sperm Injection (ICSI)
Frozen Embryo
United Harvest Infertility Care
Intra-Uterine Insemination (IUI)
Intracytoplasmic Sperm Injection (ICSI)
In Vitro-Fertilization (IVF)
Anwar Khan Modern Hospital
Frozen Embryo
Apollo Hospital
In Vitro-Fertilization (IVF)
Samrita Hospita
Intracytoplasmic Sperm Injection (ICSI)
In Vitro-Fertilization (IVF)
Centre for Assisted Reproduction (CARe)
In Vitro-Fertilization (IVF)
Besides, these clinics there are number of private doctors practicing infertility treatment. There is no record for these clinics and there is no control over their activities. The clinics maintain secrecy in sharing information about their services. They have printed brochures which explain the technologies, but the clinic management is very careful in sharing information and to respond to any researchers. They are reluctant to discuss with any one who is not their “client”.
INFERTILITY TECHNOLOGIES USED IN BANGLADESH
The two most ‘famous’ technologies seen as successful so far are the IVF or commonly known as Test Tube and the other is Frozen Embryo. The Country’s first Test Tube babies were born in 2001 and first frozen embryo baby was born in 2008. Dr. Fatima Parveen became famous for the Test Tube baby named Hira, Moni and Mukta while Dr. Rashida Begum of Infertility Care and Research Centre was in media carrying the baby Aupshora. The difference in the cost of Test-Tube baby is quite significant. While the Test-Tube babies cost over 200,000 Taka, the frozen embryo babies cost 65,000 taka. In an interview with NewAge Xtra (October 10, 2008) Dr. Rashida Begum makes a distinction between Test-Tube technology and Embryo transfer as follows:
“Frozen embryo technology is an extension of In Vitro Fertilization (IVF) or the Test-Tube technology. In Test-Tube Technology the sperms and the eggs are fertilized outside human body in a glass dish. After fertilization when embryos are created they are put inside the mother’s uterus and the baby then grows up inside its mother. In case of embryo transfer, instead of putting the whole of embryos – prepared in the IVF process – inside the mother’s uterus, a standard quantity is provided. The surplus embryos formed using test tube technology are dehydrated and preserved in liquid nitrogen at minus 196 degree Celsius with a special medium and later skipping other medical stages of test-tube technology, adequate embryos are implanted into the uterus of a mother. The surplus frozen embryos can be preserved for infinity. Once the initial supply of embryos fails to grow a baby inside the mother’s womb, frozen embryos are used inside the mother’s uterus for a continuing effort to grow a baby.”
THE STORY OF HIRA, MONI and MUKTA
The first triplets of test tube babies are named “Hira, Moni and Mukta” meaning Diamond, Gem and Pearl. They were born on 30th May, 2001 at 12 hours and 17 minutes at midnight. The couple, Abu Hanif and Firoza Begum, was delighted to have them after their 16 years of married life. They are still celebrated as the first triplets of Test Tube baby. So far, the success of the Test Tube babies in Bangladesh has been in triplets or quadruplets. Is it the baby boom again with ART? Abu Hanif and Firoza sought help from Dr. Fatima Parveen in 1994 to have one baby and after 6 years, they could have the three babies through the use of In vitro Fertilization (IVF).
Abu Hanif is a low-paid government officer. He did not have the capacity to bear the cost of Test Tube baby which costs about Tk. 2 to Tk 3 lakh. With the help of the two sisters of Firoza, Abu Hanif spent over Tk. 100,000 in the first few days of the treatment. In order to promote the technology, the Dr. Fatima Parveen took the payments in installments. After birth, the couple could not see the babies as they were kept in an incubator machine for 30 days. Every day cost was about Tk.7000, Abu Hanif could pay only Tk. 3000 per day. They saw the pictures of the babies in the lap of the doctor. The doctor said the babies are fine, showing movements of hands and legs. They were not breast fed by Firoza, the mother of the babies, but the doctors said, they were fed “breast milk” (Manab Jamin and Jugantar, 2 January, 2001).
TRIPLETS, QUARDRUPLETS ARE NOTHING BUT SIDE EFFECTS
In the brochure of ART, very few clinics are talking about “Patient Safety” and effects on the baby. There is however no mention of “Side effect” as such. About Patient safety, the clinic Infertility Care and Research Centre (ICRC) mentioned that ” Ensuring that treatment is performed safely is of paramount importance to the centre. All drugs have side effects and all procedures have risks, although we try very hard to make sure that these kept to minimum. In some cases gonadotropins might cause ovarian hyper stimulation syndrome (production of too many eggs). Those cases are risky. In those cases further treatment for fertility is stopped and treatment for side effects is started according to symptom.”
It further says, “The number of abnormalities found in IVF babies is exactly the same as in babies conceived naturally. The only major difference between IVF and natural conception is the tendency for more IVF pregnancies to be multiple, in other words chances of twins or triplets are high.”
From this point of view the first so-called successful IVF case of Hira, Moni and Mukta and the other quadruplets and triplets born were actually side effects and cannot be considered normal.
While having more than one child is seen as the “side effect”, the other effects on women having the procedure are not mentioned. As only 25% of the procedure is “successful” according to the clinics, what are the health impacts on the women who have not succeeded in conceiving?
The trauma of failure of conception after ART use, is very high. This is added with the high cost involved in the entire procedure.
TAKE HOME BABY
All those who seek infertility treatment are not lucky to have babies. According to Dr. Rashida Begum, the doctor who is famous for using Frozen Embryo technology, the success rate is 20 to 25%. So, the number of couples having “Take Home babies” is only 20 – 25% and they spend about 80 thousand takas for the Frozen Embryo technology. In other words, the price of each Take Home baby is 80 thousand taka or over 1200 US dollars. The IVF babies are called “Dish babies” as they are believed to be born in ‘dish’ at a cost of over 200,000 to 250,000 taka i.e. i.e. about 3000 US dollars.
SOME CASES OF UNSUCCESSFUL CLIENTS
The couples who go for infertility treatment, they are not told about the causes of infertility. But they are given treatment and asked to go for tests one after the other. The cause of infertility in individual cases may vary, but the treatment is done according to doctor’s skill and access to the technology. Here are few cases to show how the couples are treated for infertility.
A couple, Akher Banu and Nuruzzaman, married for 18 years sought help to have baby in the Muhammedpur Fertility Services and Training Centre. Nuruzzaman actually is a migrant worker in Libya. This centre has been involved in service delivery of contraceptives research on Norplant and Depo-Provera. The most important service of the centre is providing Menstrual Regulation Services. In other words, this centre was involved in “fertility control” technologies. The couple was asked to go to Dr. Parveen Fatima but another acquaintance of the couple suggested them to go to Dr. Baset. Dr. Baset gave them a lot of test including Ultra sonogram, urine, blood test etc. The husband was asked to test sperm counts. Sperm were collected and kept in refrigerator. After ovulation of egg of the wife, they test the sperm. After 7 days of Menstruation, the wife is given an injection (name not known) this costs Tk. 2,200 each dose. Akher Banu was given this test twice, but she could not conceive. Dr. Baset gave her treatment with 14 hormone injections . While Akhter Banu went to Dr. Baset to have IVF, after failure of two times, he admitted that actually he performed IUI not IVF. The couple already spent Tk. 70,000 (over 1000 US dollars). Later on she went to Dr. Parvin Fatema and visited her and spent Tk. 6,000 as fee and few tests. But by the time the tests were done, the vacation time for Nuruzzaman was over, so he had to leave. Akher Banu (42) did not get pregnant, but she was left with all the hormones and other drugs in her body.
Nahid Hasan and Murshid Hasan were married for 13 years. They wanted a baby, so they went to renowned Gynecologist Dr. T. A. Chowdhury. He gave many tests costing them about Tk. 80,000 to 90,000 (1100 US dollars). Then they saw the advertisement in the newspaper about Dr. Parvin Fatima for IVF. They spent about Tk. 1 lakh and 16 thousand (about 2000 US dollars) but did not succeed in having the IVF baby. A lot of tests were done on Nahid’s body including blood test, hormone test, ovulation development test etc. She was given 10 to 12 injections. Each time she got fever after the injection and there was severe pain in the injection site. The cost of each injection was between Tk. 1500 to 1600. Nahid was not successful after all these efforts. She has seen about 38 women receiving treatment, only 9 of them could get pregnant.
There are many stories of the couples with unsuccessful treatments. No one bothers about them afterwards. There is no follow up on the side effects of the medicine. They have to live the rest of their life with the brand of being “infertile”.
TRIPLETS and QUADRUPLETS: TEST TUBE BOOM!!
Bangladesh is known for baby boom, and therefore the government has taken up extensive programmes for controlling birth as part of the population control policy. Mass sterilization programmes are carried out with monetary incentives and disincentives. Coercion is exercised over poor people to reduce child birth. In such a situation, the private clinics are spreading with technologies for infertility care. The problem is that while the couples are trying to get one baby, usually the successful cases are showing three to four babies at a time. An editorial of a newspaper Manab Jamin has urged the doctors to use the technology in a way that they can reduce the number to one baby per procedure (June 2, 2001).
The assisted reproduction is resulting in the birth of girls, while there is wide use of technologies such as sex determination and also ultra sonogram in the pregnant women to find out whether the baby is a boy or girl. Out of 26 cases of Test Tube babies in Bangladesh 17 were girls and 9 were boys. In the quadruplets out of four babies only 1 is a boy and three are girls. In another case, among the twins one was a girl and another was a boy etc. For an infertile couple, having a baby is important, so the sex of the child is of secondary importance, while the general trend is to have an offspring to inherit property. That means the couples basically try to get boys but they get more girls than boys. So they take chances for getting boys and accept the girls which help them to overcome the infertility problem or the stigma of being infertile. The cost for the IVF treatment is about Tk. 1 lakh 20 thousand (about UD$2000) on an average plus other additional costs for medicines. Most of the women have tried more than once to be successful, and have to go under different medicinal treatment and therefore suffer from side-effects. The overall success rate is only 30%. That is one in three women have the chance of being successful in getting babies.
The health or drug policies have no provision of regulating the activities of private clinics using the ART for infertility treatment. In the Draft National Health Policy, 2009 it is mentioned that “Each healthcare centre will maintain the guideline and service protocol for providing standard quality services to the patient. A guidebook highlighting standard and quality health services, monitoring and evaluation will be supplied to every centre”(No. 8 under Strategies). Regulatory bodies i.e. Bangladesh Medical and Dental Council BMDC), State Medical Facility (SMF) etc. will be made more effective and functional through revising their mandate and capacity building for enforcement of standard. However, it is not clear, whether ART is seen as a health service or something else? Who is going to monitor? The clinics UBINIG has investigated none have any particular registration for providing ART.
ADVERTISEMENTS and BILL BOARDS ON ART
Even though the secrecy is maintained at the level of recipients, the Advertisements in newspapers and the Bill Boards on the roadsides are quite big and open. It addresses both men and women’s infertility, shows the picture of an attractive “white baby with blue eyes” The Advertisements talk about “Good News” for infertile couples wanting children. The message is “Bandhatto mochon” which does not mean the desire for a child but to get over the stigma of being infertile. The technologies such as IVF and ICSI are presented as if they are guaranteeing 100% success, and then the offer “Sujog apnar hater mothai” the chances are in your hand (if you can spend money, of course!). There are ads on electronic media too.
SUCCESS OR FAILURE IS LIKE A LOTTERY
The doctors often explain the cause of failure as the higher age of the clients. Clients who are over 35 years of age, having complication in uterus, particularly if there is uterine tumor are unlikely to be successful. But a couple will only know they are infertile after trying to have babies in natural way. Why would a couple go to seek infertility treatment before they have tried the natural way. By the time they would know that they have complications for having babies, it is very much likely that they would become older i.e. over 35 years. Dr. Rashida Begum has compared the infertility treatment with Lottery – you can try with equal chances of winning or losing. Therefore, according to her, only those who can afford and also have strong mental condition to accept the failure should take the treatment.
TREATMENT AVAILABLE IN DHAKA AND IN DISTRICTS
The clinics have opened their business in Dhaka and also in few other districts such as Comilla, Sylhet and Chittagong – mostly by the doctors going from Dhaka and also from doctors at the District level Medical Colleges but practicing in private clinics. The doctors have very high media projection after birth of the babies.
INFERTILITY TREATMENT IS A BIG BUSINESS
Let’s see the income earned by Dr. Perveen Fatema, the gynecologist who is considered to be most successful in this business. Weekly Magazine Saptahik 2000, 96 (July, 2007, year 10, #8) carried out an investigative research on the Test Tube babies in Bangladesh. According to their estimated calculation (as real income is not shown by the clinic) out of 1000 patients seeking treatment only 300 were successful in getting babies. The earning from these couples were Tk. 3 crore 60 lakh. For those 700 couples who were not successful yet paid Tk. 1 lakh 20 each, the earning was Tk. 8 crore 40 lakh.
It is also found that those who seek treatment for infertility only 5% finally decide to go for IVF. The number of total patients coming for infertility treatment during last 7 years was 20,000. It is also found that those who seek treatment for infertility only 5% finally decide to go for IVF. The number of total patients coming for infertility treatment is over 20,000.
CONCLUSION
It is undoubtedly true that infertility is becoming a growing problem in the country. However we need to address the causes of infertility more than start business over the problems couples are facing to get over the stigma of being infertile. A woman having contraceptives may also get infertile at some point, but the government does not take responsibility for them. The food production with chemicals particularly pesticides have serious impact on the reproductive organs, functions and fertility of all life forms; human fertility of male and female is obviously affected.
Few doctors have seized the opportunity of growing infertility. In the name of secrecy the doctors have used the success stories of IVF babies and Frozen egg babies in their publicity. We only see the babies in the doctors’ arms, not in the mothers lap or fathers’ arms. They are only doctor’s babies.
ANNEX
A list of Reproductive technologies used in Bangladesh
In Bangladesh following Reproductive technologies are being used. Information is collected both from public hospitals and private clinic sources. The technologies are listed as follows:
1. Gravindex test – Known as Pregnancy test for pregnancy confirmation.
2. Ultra sonogram – Usually used for diagnostic purpose. Also an indicator for sex determination of the fetus. Ultrasound is used for detecting Gynecological diseases.
3. CT Scan – Used for diagnosis of the Gynecological/Obstetrics diseases.
4. MRI (Magnetic Resonance Imaging) – Used for a confirm diagnosis for General diseases and also for Gynecological diseases.
5. Hystero Salpingogram – A special x-ray for detecting any abnormality in Fallopian tube and also Salpings. For Infertility detecting case it is done.
6. Pap smear – Test for detecting any cancer cell of the Reproductive organ.
7. FNAC (Fine needle aspiration cytology) guided by CT SCAN – Test for detecting any malignancy and also confirmatory test. Plain FNAC is also done and costly too.
8. Biopsy – For confirmation of pathology of any disease in the body. This is related with any system of the body.
9. Semen Analysis – Test for fertility.
10. VDRL – This test is usually done for STD and it is related with Infertility. Used to detect the causes of Infertility.
11. T.S.H & L.H – Thyroid hormone & sex hormone test to assess hormonal influence which is related to Ch. an ovulation & Infertility.
12. Hormone test (Estrogen/ Progesterone/Androgen/Testosterone) – For detecting any hormonal imbalance in the body which is related to Infertility for both female and male.
13. Prolactin test (Pituitary Hormone) – Usually done for Infertility cases as well as Endocrine disorders which is also related to Pregnancy & as well as Infertility. It is used for detecting ovarian function & cycles, & other gynecologic diseases.
14. Cervical Biopsy & Endometrial Curettage – Test to diagnose the causes of Gynecological diseases.
15. Cytology and Culture – This lab. test is done for clinical evaluation of the reproductive organs.
16. Laparoscopy – Approximately 25-30% of women whose basic evaluation is normal will have findings on laparoscopy explaining their infertility (e.g., peritubal adhesions, eudiometric implants). This is usually performed in clinic or hospital by gynecologist.
17. Induction of Ovulation – This is done by giving Clomiphen citrate, Bromocriptine and Human menopausal gonadotrophins (hMG) By gynecologist or Embryologist. Medication is costly and for one session 4000-5000 taka is required.
18. IVF (In-vitro fertilization) – This technique for test tube baby is applied in our country by ICSI (Intra Cytoplasmic Sperm Injection) method.
Cost of Different Technologies
| Service | Price in Taka |
| Pregnancy test | 150-200 |
| Semen Analysis | 200-300 |
| VDRL | 150-200 |
| TSH & LH | 200-300 |
| Prolactin test | 200-250 |
| Sex hormones | 300-400 |
| Biopsy | 350-500 |
| FNAC (Plain) | 1500-2000 |
| FNAC Guided CT SCAN | 5000-6000 |
| Pap’s smear | 300-400 |
| Culture | 250-350 |
| Hystrosalpingography | 1500-1635 |
| Ultrasonogram | 500-700 |
| CT Scan | 3000-3500 |
| MRI (single) | 5000-6135 |
| MRI (Double) | 10,000-12,270 |
| Curettage | 3000-5000 |
| Laparoscopy | 5000-8000 |
| Ovulation medication (Conservative treatment) | 4000-5000 |
| IVF | 150,000-200,000 |