‘Does the clinic have a more private entrance?’
This was the question Dr Pankaj Shrivastav would be asked most frequently by potential patients when he first established the Dubai Gynaecology and Fertility Centre – the UAE’s first fertility unit – at Rashid Hospital in July 1991.
‘Seeking medical intervention for fertility-related issues was seen in a negative light in those days,’ he recalls.
Twenty-five years on, thanks to greater awareness on the issue, the stigma of going in for fertility treatment has become a thing of the past. ‘Today in the UAE, infertility is viewed as a medical condition; not something to be shied away from,’ says Dr Shrivastav, who is now Director of Conceive Fertility Hospital in Sharjah and Dubai.
It is estimated that infertility affects 15 per cent of the global population of reproductive age, and the World Health Organization (WHO) has called it ‘a global public health issue’.
According to a recent study conducted by Aster DM Healthcare, one in five couples in the UAE face fertility issues – a figure that is higher than the world average. The same study also revealed statistics that projected the incidence of infertile women in Dubai seeking treatment every year to almost double from 5,975 in 2015 to 9,139 in 2030.
Not surprisingly, this increased demand for fertility services has seen a spurt in the rise of specialist clinics opening up across the UAE. Last year, NMC Health invested Dh696 million in Fakih IVF Group to tap into the booming fertility market, and Aster opened its new IVF clinic in Mankhool in May this year.
While there are multiple causes for infertility, social factors such as late marriages play a pivotal role in difficulties of conception, says Dr Gautam Allahbadia, IVF Consultant & Head at Aster IVF & Women Clinic. ‘Across the region and globally, more women are working than ever before and a large percentage of them delay starting a family until well established in their careers. But the ticking biological clock in women cannot be overlooked, for a woman’s fertility peaks between the age of 26 to 28, after which there’s a steady decline.’
However, certain causes are specific to the Middle East region and particularly the UAE, adds Dr Allahbadia. ‘The high rate of obesity in the country brought on chiefly by a sedentary lifestyle is taking its toll as a prime influencer for infertility occurrence. Our research shows that 47.5 per cent of UAE residents are overweight, which WHO estimates is double the world average.’
In women, obesity can cause hormonal imbalances that affect ovulation, while it impacts males by reducing sperm quality. Infertility rates can also be twice as high in smokers, both male and female, compared to non-smokers, he adds. ‘Surveys show that 18.1 per cent of the UAE population are smokers, and this is taking a toll on fertility rates as it not only lowers sperm counts in men but also reduces the success rates of fertility treatments.’
The Middle East and South Asia are known for high incidence of diabetes, but diabetes is very closely related to a hormonal problem called PCOS – polycystic ovary syndrome, says Dr Shrivastav. ‘PCOS is [characterised by] insulin resistance and often appears with weight gain. With high obesity rates in the UAE, PCOS is a contributing factor to female infertility.’
Lifestyle choices play a paramount role in fertility, he continues. ‘Apart from cigarette smoking, a disturbing trend is the rise of shisha smoking among young males and females. Today, 18- to 24-year-olds have picked up the habit as a social event to bond with friends. While the health impact of shisha smoking on the respiratory and cardiovascular systems are well documented, very few are aware that in females, shisha has a direct toxic effect on eggs, while in males, sperm production is highly compromised leading to significantly lowered semen volume, semen count and decreased sperm motility.’
Dr Shrivastav is equally concerned about the increasing number of young women showing a premature decrease in the number of eggs in their ovaries. ‘What is striking about the phenomenon of diminished ovarian reserve is that the ovaries of a 30- to 32-year-old behave like that of a 40- to 42-year-old. While no studies have established a link, my suspicion is that the environmental toxins we are exposed to on a daily basis – bisphenols, pesticides, vehicle fumes, commercial cleaning products, plastic containers, hormones in meat, etc. – are finally catching up to us. These contain endocrine disruptors, which prevent both male and female hormones from functioning normally.’
Men who pump their bodies with anabolic steroids to build up muscle mass are also essentially killing off sperms, he warns, as such drugs interfere with the hormone signals needed to produce sperm.
Sociocultural factors have led to a long tradition of consanguineous marriages across the Arab world and the UAE is no exception, says Dr Ghina Shami, Specialist OB/GYN-IVF at Fakih IVF fertility centre in Dubai. ‘Research indicates that this could also have an effect on the reproductive health of the progeny of such marriages.’
However, the chief redeeming factor in the spiralling cases of infertility in the region is the fact that it is no longer seen as a women-centric issue, she adds. ‘The promise of fatherhood means that men are showing the same commitment to tests and treatments as women. Additionally, couples have become more aware of the risks of delay and are seeking help earlier. This helps us in diagnosing problems at a nascent stage and administering effective treatment.’
Citing his personal experience, Michael*, 32, recommends couples not delay seeking treatment. It was when his wife showed no signs of conceiving even after several months of their decision to start a family that he consulted an endocrinologist. ‘I was devastated when I learnt that I had an obstruction in the epididymis, a duct located at the back of the testicles that stores and carries sperm. This blockage meant that there was zero sperm count in the semen.’
It was hard to get over the initial shock, he admits. ‘I was completely shattered thinking we’d never have a family of our own.’
However, a consultation with Dr Allahbadia in Dubai not only gave him the much-needed emotional support but also showed him the way forward. ‘I was advised to go in for a testicular sperm aspiration (TESA) procedure to retrieve sperms surgically. The sperms thus drawn out were fertilised with my wife’s egg in vitro [outside the body in a laboratory], and fortunately for us, the very first attempt was a success. My wife is two months pregnant now and we hope to have a healthy baby early next year.’
For Aarti*, another UAE resident, after more than eight years of popping pills, taking injections and submitting to every form of treatment prescribed by several gynaecologists in Dubai and abroad, it was eventually IVF that helped her conceive a healthy baby boy recently.
‘Awareness of infertility issues and treatments available were almost negligible when I got married in 1996,’ says Aarti.
In her fifth year of marriage a gynaecologist recommended IUI, intrauterine insemination, a procedure that increases the number of sperms reaching the fallopian tubes to further the chances of fertilisation. But the continuous intake of ovulation stimulation medicines played havoc with her mood, says Aarti. ‘I was constantly angry, frustrated and irritable.’
Despite the wholehearted support of her husband, in-laws and friends, she began to get woefully depressed. ‘The pressures that were building up came from within; I was fighting many battles within.’
After five years of IUI, she decided to put a stop to any further treatments. ‘This was when a friend – much against my will – dragged me to Dr Pankaj Shrivastav in Sharjah. He looked at my X-ray and said the left fallopian tube was blocked.
‘To know that I had been misdiagnosed and that all the treatments I had undergone had been in vain was shocking, to say the least,’ she says. Fortunately for Aarti and her husband, their very first attempt at IVF was successful and they became proud parents, 10 years after marriage. A second son was born last year, again through IVF.
With the population of the UAE having risen from around two million in the early Nineties, when the first fertility clinic was established, to more than nine million in 2016, this surge alone has led to the need for more fertility clinics here. Meeting this demand are a host of big and small clinics and hospitals offering a range of assisted reproductive technologies in various price ranges. With such an abundance of choice, what should be the defining criteria when choosing a clinic or specialist? Or when should a couple decide to go in for treatment?
Dr Shrivastav minces no words: ‘People have exaggerated ideas about their own fertility. Some very young couples attempt to conceive right away and if they’re not successful, they get tensed and impatient.’
Humans are a low fertility species, he says. ‘We should give up this unrealistic expectation of getting pregnant immediately. My advice for very young couples is to first look at your lifestyle habits, your weight, BMI. Take stock of these and rectify if need be.’
Fertility in females declines from age 28, accelerating in the late 30s to a precipitous decline after 40. ‘If you’re below 35 and have no obvious problem, I’d advise couples to try for at least six to nine months, but if you’re above 35, wait no more than six months before consulting a fertility specialist.’
Dr Allahbadia cautions that going the route of a GP followed by a gynaecologist could cost a couple 18 to 24 months. ‘Remember, you are running a race against time before the eggs run out. Just like you would go to a cardiologist for cardiac problems, I recommend going directly to a fertility physician for conception issues.’
‘We must concede that medical technology may not always come to our aid if we delay starting a family,’ he adds. ‘Give pregnancy a priority if you are above 28 or 30. Or opt to freeze eggs when you are 25 to 30 to take the pressure off for those who marry late.’
When it comes to choosing a fertility clinic or specialist of your choice, Dr Shrivastav believes adequate research is vital. ‘Infertility treatments require intense care and expert guidance. You need to look for qualified doctors and clinics with proven successful outcomes. Personally, I believe, reputation does count and the traditional word-of-mouth is the best recommendation.’ There’s no denying that fertility treatments are expensive, but clinics that offer reduced prices may also be cutting corners, he cautions.
Treatment options include fertility drugs for men and women, intrauterine insemination, and a range of injections and surgeries. IVF (in-vitro fertilisation) and IntraCytoplasmic Sperm Injection (ICSI) are currently among the most expensive assisted reproductive technologies in the UAE.
The advent of PGS (preimplantation genetic screening) in the UAE, which tests for overall chromosomal normalcy in embryos, is a boon for couples with diseases running in the family. ‘The UAE also allows for couples to opt for the gender of their choice as part of Family Balancing to achieve a balanced representation of both genders in the family,’ says Dr Allahbadia. ‘Gender is selected by Preimplantation Genetic Diagnosis (PGD), a technology that involves testing the chromosomal make-up of an embryo, and is done in conjunction with IVF.’ The US and the UAE are the only two countries where this is legal, and is one of the prime reasons attracting medical tourists to Dubai, he adds.
Fertility treatments, especially IVF, are one of the most sought-after procedures among medical tourists in Dubai. Childless couples topped the list of people who visit the emirate for healthcare, according to a 2014 study by Dubai Healthcare City. Medical tourists pour in from across the GCC, East and North Africa, the Indian subcontinent, and Asia.
‘The reputation of integrity that fertility clinics and hospitals here have, with good success rates, excellent lab facilities, and qualified specialists, is bringing larger numbers of medical tourists every year,’ says Dr Shami. ‘Overcoming the heartbreak of childlessness with the help of medical intervention is today a reality among couples not just in the UAE, and is seen as an accepted form of achieving parenthood.’
Additional inputs by Hina Navin