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Dr. Uma Shrivastava M.D, M.Sc, is a Consultant Reproductive Endocrinologist and Infertility and IVF Specialist. In her 28 years of practice, she has treated over 20,000 couples and been involved in about 6000 live births. She was conferred with “His Royal Highness Crown Prince Dipendra Youth Science and Technology Award” for the successful treatment of male infertility in Nepal in 1999 by the Royal Nepal Academy of Science & Technology (RONAST), and she is also the recipient of the First IVF Success in Nepal by Her Royal Highness Princess Himani Devi Shah and other civic societies.
Nisantan Kendra is one of the oldest infertility clinics in Nepal. Can you tell us about the state of reproductive health care and how infertility treatment was one done when you first started?
I opened the clinic with two other doctors, Dr. Bimala Malla and Dr. Peden Pradhan, in Putalisadak in 1992. It was called Reproductive Health Care Center. But, in 1993, my two partners had to leave after they had their postings somewhere else. I was all by myself, and since I am not a gynecologist—being a reproductive endocrinologist—I had to continue the clinic as an infertility center.
I have been running Nisantan Clinic from 1993 onwards. At that time, we would barely receive 2-4 patients a week, and most of the women who came to us had no idea about infertility treatment. Then, we started counseling them, which is a major part of infertility treatment.
My aim was, however, not fulfilled by just running an infertility center, and as a hormone specialist I couldn’t start the diagnosis without finding out what problems the couple had. Soon, I brought a hormone-testing machine, ELISA Reader, from India. I was acquainted with Professor Steig Larson while I started my career at TU Teaching Hospital, Gynae Department. He used to encourage me a lot, and finally we received American-designed ELISA Reader by Dr. Menon from Bombay. With the help of Indian doctors, I started hormone testing in Nepal for the first time in 1993.
The trend in Nepal back then was to do an endometrial biopsy. We used to take out a small endometrial tissue from the inside of the uterus by curettage, and based on its patterns, we would determine if the eggs were being developed. It was a very indirect process, when we could directly measure the hormones and determine whether they were high, low, or normal through hormone testing.
Then, slowly, I got in touch with my professors from Delhi, Calcutta, and Bombay, and started attending conferences. There was zero knowledge about infertility in Nepal back then. There was no one I could turn to, and even till this day, there is no one. When I reached out to my professors in the UK, they suggested me to go to India to enhance my skill and knowledge. I went to Calcutta for IVF training, and when I came back, I brought an ultrasound machine. With the addition of ultrasound machine, finally, our infertility diagnostics testing was 75 percent complete. We still haven’t been able to do genetic testing, and we refer those tests to India.
The development was very gradual. I was desperate to get the diagnostic machines, as it was important to find out the causes of infertility. But, since I started from a private clinic, I was on my own, and I didn’t have any support from anyone. I tried to operate from TU Teaching Hospital, too, but neither the dean nor the director took me seriously. When they told me if there was really any need for an infertility center for a handful of cases, I felt discouraged and left my job to completely focus on my clinic.
Back then, I would think, was infertility problem only related to women, because only women would visit the clinic. Some came with their friends and some came by themselves. Some of the women would cry a lot and some were depressed. Gradually, men also started to come for counseling in late evenings. These days, most of the time, couples come together for their treatment. So, while we listen to their problems, it is quite challenging for the doctors, as we can’t assure them that the treatment would be a 100% success.
The success rate is different for different causes. For example, we are using IVF as a last resort now. This is the not the first line of treatment for Nepali women, because many can’t afford it. Also, without running a full diagnostics, if we were to give them high doses of hormones and if she failed to get pregnant, it’s a disaster for her body. Some women might even lose their periods and go into menopause.
The first time I saw IVF procedure at the Royal Free Hospital in the UK back in 1989, I thought this technology would never come to Nepal. So, when I started the procedure in 2002, it was like my dream come true. I started it with my junior team of doctors and it took us about a year to get fully established. For the last three years, though, I’m outsourced only for IVF procedure, because all the machines in my clinic are old. My clinic caters to the low-socio economic women, and we are charging lower than that of Paropakar Maternity Hospital, and in fact, we are under pressure by the government to increase the fee.
What are the different types of infertility you have seen in a couple, and what are their causes?
Both men and women equally contribute to fertility problems. The role of male in infertility is his sperm production. If a person produces less than 15 million sperm per milliliter of semen, it is considered poor sperm count, and it could make him infertile.
While some men don’t produce sperms at all, some men produce low number of sperms due to genetic as well as developmental factors, or abnormalities in the hormonal system, such as endocrine or even neuro-endocrine system. But, sometimes, even when the sperm count is good, the ejaculatory duct or the tubes through which the sperm travels is blocked due to procedures like vasectomy or infections which prevent the delivery of sperm and makes him infertile. Male factors contribute to almost 50 percent of all infertility cases.
In women’s case, too, developmental, genetic, and hormonal factors are the main causes of infertility. Some women are born without a uterus or a womb, and in some women, ovaries are not fully developed, so they don’t ovulate and don’t produce any eggs. Every year we receive around 6-7 women who don’t have a uterus, which means she has never menstruated. There is another group of women whose hormones are either too high or too low, due to which her ovaries fail to produce eggs, or she is already at a menopausal level.
In some cases, the eggs and uterus are good, but both the fallopian tubes are blocked, preventing the eggs to be fertilized by sperm. This is called tubal infertility. And sometimes there could be tumors in the outer, middle, and inner layers of the uterus obstructing a fetus from growing fully in the womb.
Endometriosis is another cause of infertility, where the menstrual blood, instead of being expelled through the body, flows back into the fallopian tubes and attaches onto the pelvic cavity and abdominal organs in the form of a growth from previous menstrual blood that we also refer to as chocolate cysts.
So, male and female factors contribute to infertility equally at 40 percent, while about 20 percent couples are diagnosed with idiopathic infertility, or we don’t know the cause of their infertility.
Do we have any statistics on how many Nepali women undergo infertility treatment, and at what age?
I am not aware if such data exist. We don’t even have one standard protocol on infertility treatment in Nepal. In 2012, the government asked me to make a protocol for the management of infertility in Nepal for all primary, secondary, and tertiary levels in the capacity of a consultant, and I made one. But, they are still working on it. In my 28 years’ long practice, I have conduced about 20 research works. Some of them are published, and some I have only presented in conferences. Based on my studies, I assume that about 13-15 percent of Nepalis have infertility problems.
If the couples are 35 years and older, how should they get tested for fertility problems?
Infertility doctors refer to people aged 35 and older as advanced age, and new treatments like assisted reproductive technologies (ART) were innovated targeting people of this age group. In the past, such technologies were not used.
After 35, the hormone level starts to drop and there is a rapid decline in the number and quality of eggs in the ovaries. If somebody comes for treatment at 35, first we will run an ovarian reserve test. If her menstrual cycle is regular, we will conduct an FSH test to see the brain’s hormone. Then, we move on to ultrasound to count the follicles in her ovary and also measure the production of anti-mullerian hormone (AMH). If she is missing about 5-7 follicles, her FSH level is high, and her AMH levels are under 0.5 ng/mL, she is diagnosed as a poor case for fertility. When we refer such cases for IVF and unfortunately if the treatment fails, many times patients get angry and feel cheated, and the doctors, too, are hurt and disappointed. So, after many researches, we have come to the conclusion that after 35, the eggs are of poor quality, so there is least chance of success for fertility.
But if they still want to conceive at the advanced age, we have hormone measures and we follow standard protocols to use those measures. If necessary, we will refer her to IVF. But, if her tubes are not blocked and she needs longer time, we will place her on regular hormone therapy, and whenever her follicles or eggs are matured enough, or are of good quality for fertilization then, we will refer her for IUI, or we can even refer her to IVF according to her affordability. Most of the times, if they fail to have good quality of eggs, we also suggest them to take donor eggs.
Every now and then, we get to hear about women giving birth in their 50s and 60s, what are the dangers of giving birth at such age? Do we have any legislation setting the age cap for fertility treatments?
I had this case where a 53-year-old postmenopausal woman wanted a baby. She was on hormone treatment for around 6 months and we did her IVF, but unfortunately she miscarried at three months, before the placenta was developed. When one goes through such treatments in the advanced age, eggs are of poor quality and fertilization is difficult. And, even if the egg fertilizes, there could be implantation failure, because the uterine cavity is very dry. If one manages to get through this phase, too, and her hormone reserves support the embryo after the placenta is developed, after sometime, the hormones could be in short supply leading to miscarriage. And, let’s say one does pass this stage, too, but there are risks of genetic aneuploidies in some percentage of women. About 6-7 percent of women above 35 are likely to have a baby with a chromosomal disorder, such as Down syndrome, and the risk increases to 10-15 percent in women above 40. So, we caution the women in this age group about these risks, so they have a realistic idea of what they can expect.
Do we have a maximum legal age for women to go for IVF treatment in Nepal?
We don’t have any such guidelines in Nepal. We try to look at the Indian guidelines, where the upper age limit for conception using assisted conception/IVF is 50 years for female and 55 years for male. But, even in India we hear about women going for IVF treatments in their 60s and 70s. So, it is basically a research for the doctors who want to find out if they can be successful.
What is the success rate of IVF in our country?
We don’t have that data, either. It’s difficult to conduct such study in a poor country like ours. But we often hear people say that they have 70 percent or 80 percent success rate. Without reading international papers and never attending international conferences, I think we are just deceiving ourselves by making such claims, because the normal fertilization rate or conceptual rate of normal couple is about 25-30 percent. While doing IVF, however, we make multiple follicles that do increase the success rate of IVF. Internationally, the maximum success rate in IVF is 40 percent, but in the context of Nepal, we don’t have any data.
A lot of women are having twins and triplets from IVF treatment, why is this happening?
The IVF procedure itself doesn’t necessarily lead to multiple pregnancies. But the doctor could transfer multiple embryos during the IVF cycle to increase the chances of pregnancy with the hope that at least one egg would successfully implant.
The international guidelines allow the transfer of maximum 2-3 embryos, but I don’t think people are strictly following the instructions, as we hear stories of sextuplets and quadruplets every now and then. The doctor, however, needs to explain all the possibilities to the couple that there could be single birth, multiple births, or no implantation at all.
Is there anything you think you would want the government to do in the field of reproductive health?
We don’t have a proper guideline on fertility and reproductive health in Nepal. At present, some of us are making 20 eggs, some are making two eggs, and some are using single egg for IVF treatment. There is a need for a standard protocol that we should all follow for such treatment. Also, if the government could buy the hormones required for IVF the same way it is providing free hormonal injections for family planning, even the women from Baitadi and Bajura could afford these treatments. While some places in India are offering IVF treatment at 40,000 to 50,000 Indian rupees, the treatment cost is very high in Nepal due to expensive hormone injections, hi-tech machines, and maintenance cost of clinics. If the government could provide at least hormone injections for free, the price of IVF treatment would be a lot cheaper here, too.
