• Say couples must not have children at all cost
By Azoma Chikwe
Studies in Nigeria havesuggested that there is a high prevalence of infertility with about 1 in 4 women of thechild bearing age experiencingdelay in conception. With a population in excessof 180 million, of which about 22 per cent are women in theproductive age group, it is evident that Nigeria suffersa high rate of infertility.
In response to these sobering statistics and due to the high premium placed on child bearing in Nigeria and indeed Africa at large, “In vitro fertilization andembryo transfer (IVF) clinics” are proliferating across thecountry in efforts to address the problem. Although IVF has been practiced in Nigeria for over 20 years with the first baby being born in 1986, there is yet to be any regulation around the practice.
So, recently,the Association of Fertility and Reproductive Health Practitioners of Nigeria(AFRH) Ethics Committee held a public and focus group discussion on the Practice of Assisted Reproductive Technology (ART) in Nigeria with the aim of drafting ethical guidelines for the practitioners within the bounds of Nigerian’s Medical, legal,religious and socio-cultural realities. Participants were drawn from the catholic, protestant and pentecostal clergy, Islamic clerics, legal practitioners, medical professionals and the general public.
The AFRH as a body of practitioners of ART is making concerted efforts to address these gaps in order to protect patients’ rights and assure quality and standards.
Assisted reproduction by its very nature raises ethical issues that is open to individual interpretation and needs to be addressed such that regulations to guide the practice are codified and adopted across board by all practitioners.
Some of the ethical issues addressed at the event were is the treatment of single women ethical? All discussants agreed that within medical and legal provisions, it was ethical but under the religious searchlight, it was unanimously agreed as unethical.Is the treatment of couples with human immunodeficiency virus HIV ethical? It was agreed that by the human right charter, everyone has the right to procreation. It was also agreed that it is medically ethical. Strict protocols and safety measures are to be put in place to protect the clients and even the medical professionals. The couple should also be properly counseled on the possibility that the child(ren) to be born may be HIV positive.Should market forces influence ART practice in Nigeria? Respondents agreed that allowing market forces of demand and supply will lead to substandard treatments.
It was asked if Pre-Genetic Diagnosis(PGD) use in the treatment for the purposes of sex selection or other similar uses ethical? The panelists agreed that PGD could be used in the screening of genetic or sex linked diseases like sickle cell anemia, haemophilia, cystic fibrosis etc. but if the intention is for sex selection, then a line should be drawn.
Is gamete donation ethical? The panelists agreed that it was medically ethical as there is usually a medical indication for it. Religious clerics, however, disagreed and viewed it as inappropriate especially as there is some form of pecuniary compensation for their time and expense, the possibility of incestuous relationships from intergeneration and inheritance issues can arise in the future.
Should donors be paid? It was unanimously agreed that they should be compensated for their time and effort. How can the interest of the donors be protected? Adequate counseling and information should be provided to the donors, informing them of the side effects of these medications and treatment so that they can make an informed decision. Practitioners also must ensure that there must be non-maleficence and that the Hippocratic codes are strictly adhered to. Is the use of donor gamete without the spouse/partner’s consent ethical? It was unanimously agreed that following the common law principle of ‘Volenti non fit injuria’(which means,’’to the consenting, no harm is done’’), the consent of a partner in the use of donor gamete is mandatory and must be sought before treatment is given.
It was also asked if surrogacy is ethical? The religious clerics strongly disagreed with having another woman help carry a baby to term. Other people were of the opinion that the act was being carried out by financial challenged for pecuniary benefits without due consideration of the emotional pain they would eventually go through when they are separated from the baby at birth. Apart from the emotional trauma, they are also open to exploitation. In Nigeria, there is no enforceable law on surrogacy and so the parties are not protected. Medical professionals, however, have the duty to evaluate case by case and make judgment based on the HippocraticOath.
On if research in ART is ethical? All the speakers agreed that research is very necessary in making advancement in medicine, however, boundaries must be set and every research must be ethical. Research should only be carried out on spare embryos which would have otherwise been discarded and only after consent has been granted by the couple. Embryos must never be created strictly for the purpose of research. The research must be in ART and for the furtherance of the good of mankind.
In conclusion, it was agreed ethical considerations should be made on a case by case basis with the Hippocratic Oath in mind.
However, Dr Ahmad Sa’eid, Department of surgery, Lagos State University Teaching Hospital(LASUTH), Ikeja, who is a muslim cleric, said, “We are hopeful that whenever these policy is developed, whatever laws are developed, it is going to take to cognizance the fact that more than 90 per cent of the citizens of this country are either Christians or Muslims. You cannot make a law that will disregard these faiths, it is extremely important.
“ Number two, we are hopeful that when such policies or laws are developed, it will also take care of the concern that our culture is very important to the people, who are born and are citizens of this country. The fact that it is happening in other part of the world, does not mean everything happening there should be imported into Nigeria. Yes, it is recognised that there are so many things in life that we want but there are laws that guide what we get within the legal framework. If I don’t have a job, that will buy me a plot of land, no matter how much I want to be happy, it doesn’t mean I have to go outside of the law to be happy. theSe are the concerns of religious bodies.
“Child bearing brings joy but the fact that I want to feel the joy of child bearing doesn’t mean that I must get it at all cost. I don’t have to become a pagan simply because am looking for a child ,if I truly believe in the God that I worship, faith will teach me patience, perseverance and trust in God,like in the scripture, men have lived to their 90s before having their first child, women lived to their 80s before having children. So, if I say am a Christian or a Muslim and am looking for a child and technology offers itself, I do not have to close my eyes like a man who wants to be rich but does not have a job and then he gets human parts simply because he wants to be rich .These are the concerns religious bodies are expressing.”
Drop in sperm count globally
Meanwhile, speaking on the surge in infertility problem in Nigeria, Consultant Obstetrician and Gynaecologist and President, AFRH, Dr Fate Iketubosin, said, “ there are number of factors responsible , male infertility problem has been on the increase for the last 20years, the average sperm count of men have dropped as World Health Organisation(WHO) had to revise what is now a normal sperm count downwards from 20 million to now 3million and that is because of the global trend. And why is that so ,because of the food chain. People eat a lot of processed food, foods that they use chemicals to produce ,these chemicals have now gotten to the food chain and affecting us in a negative way and that’s on the male side.
“On the female side, a number of factors affect infertility, one of them is that more and more women have embarked on successful careers,,they have delayed having children and women have life span in which they can have children naturally. So, many times, the time they begin that quest for a child ,they are already too old and that is also consciously unethical. The discussion of egg donation is born out of the fact that there a lot of women over the age of 38 years who are now trying to have a child for the first time.
“This is a global problem, that’s why you find out in some countries they have gone back to organic products and organic farming which is a bit more expensive than processed goods.This is a fact of life and its going to need like a bigger government policy to look into it, agricultural policy. We should monitor what we put in our food chain,what we use in agriculture because we are seeing the effect,and its going to take another generation for us to be able to reverse it.”
On a bill to regulate IVF practice, Iketubosin said there is a difference between what should be legislation and what is regulatory. “Legislation should deal with law enforcement, for example, what is the status of surrogacy in law? It doesn’t exist even though it is practiced. A child born through surrogacy ,whose child is it? These are aspects that the bill should addresses,these questions exsist.”
Practitioners seek position
Medical Director, The Bridge Clinic and Chairman, AFRH Ethics Committee, Dr Richardson Ajayi, speaking on religious groups and their position on natural procreation as against assisted reproduction or IVF, said, “ I think the whole concept of ethics is the expression of different positions, so if there are certain religious groups that have certain positions and certain non-religious groups that have certain positions, what we are trying to do is to reflect the framework of our group by getting a position, that is, what we believe is wrong or right according to our own group.
“The law is slow in Nigeria, once our association takes a position on any issue, the next phase is to try and put it into law. That could define what the legal position on IVF in Nigeria should be.
I think the issue of stigma in IVF has been defeated a long time ago, we had Mrs Amekwe on the stage,we have two other people who have openly said they have IVF children including Mrs Amekwe talking about her 17year old child,so, am not sure if the stigma is still real but stigma is what you believe in. If you think there is a stigma then there is a stigma but if you think there is no stigma, then there isn’t but I think more people are being more open to IVF. it is a treatment of a medical condition which is the inability to have children and provided you see it to such objective term, there is no reason to feel stigmatised about having a baby. Everything is God ,its God that gives life, so you should be happy.
“I think it is the right of everybody to be able to have a child , we need to see how we can make IVF more affordable to all Nigerians because its not a preserve of the rich. Its a universal human right . I believe we can make IVF available to everyone.
Poorly regulated industry
“The industry is poorly regulated, not just the IVF industry but the whole of the medical industry in Nigeria needs a lot of deeper framework for regulation. The current law we have is a Nigerian health act which gives broad use about a lot of specialities in medicine. I think each focus area such as IVF need to deepen their pespective and if we can deepen our perspective, we can turn everything into a deeper regulatory framework which currently does not exist,” he said.