Joshua Sur­tees

The as­sump­tion that the Caribbean is a hotbed of fer­til­i­ty is a fal­la­cy, lo­cal ex­perts say.

Ris­ing teenage preg­nan­cies and large fam­i­lies with up to ten chil­dren can give a false pic­ture of a high­ly re­pro­duc­tive pop­u­la­tion but, with a falling T&T birth rate (cur­rent­ly 15.2 births per year per 1,000 peo­ple), the med­ical di­rec­tor of T&T's on­ly IVF fer­til­i­ty clin­ic, Dr Cather­ine Minto-Bain, says we are just about re­plac­ing our pop­u­la­tion.

In re­al­i­ty, she says, T&T and the rest of the re­gion has ma­jor prob­lems that need to be ad­dressed.

April 21-26 is Na­tion­al In­fer­til­i­ty Aware­ness Week, a move­ment cel­e­brat­ing its 25th an­niver­sary this year with events where peo­ple can find out about the is­sues in­volved.

Male in­fer­til­i­ty is the biggest prob­lem. Last year, Health Min­is­ter Fuad Khan re­vealed that 34 per cent of T&T's men have a low sperm count, based on tests over a two-year pe­ri­od.

At the T&T IVF Fer­til­i­ty Cen­tre (TTIFC), Minto-Bain says, 90 per cent of the women who want to do­nate eggs are re­ject­ed be­cause they don't have enough of suf­fi­cient qual­i­ty to be ac­cept­ed.

Male and fe­male fer­til­i­ty rates are the sub­ject of on­go­ing re­search but, so far, an­swers are elu­sive. There ap­pear to be no pat­terns ac­cord­ing to eth­nic­i­ty, ge­og­ra­phy or age in terms of male re­pro­duc­tive health.

In 2011, TTIFC pub­lished a re­port and held a sym­po­sium ex­plor­ing male fer­til­i­ty lev­els based on a sam­ple of its 3,000 pa­tients.

They were in­ter­est­ed in whether en­vi­ron­men­tal pol­lu­tion might be af­fect­ing fer­til­i­ty, but, the MD says, in­fer­til­i­ty did not clus­ter around any in­dus­tries in par­tic­u­lar, nei­ther petro­chem­i­cal nor farm­ing.

TTIFC is now part way through a UWI-fund­ed re­search study in­to T&T's women, par­tic­u­lar­ly the rise in the num­ber of women with poly­cys­tic ovaries.

It is known that African-Caribbean women are more like­ly to have high num­bers of fi­broids (mus­cu­lar tu­mours) in their ovaries than oth­er eth­nic groups–mak­ing it more dif­fi­cult to get preg­nant–and that they pro­duce few­er eggs, with an ear­li­er menopause. But the low num­ber of healthy eggs in women in their late 20s and 30s was across all eth­nic groups.

"Trinidad has big prob­lems," Minto-Bain said. "Obe­si­ty and di­a­betes are con­tribut­ing fac­tors. We cur­rent­ly have 4,000 on our books and we haven't done any ad­ver­tis­ing cam­paign for eight months as we are in­un­dat­ed. It's all word-of-mouth."

Fi­nanc­ing fer­til­i­ty treat­ment is a ma­jor is­sue for many in T&T. It's cer­tain­ly not cheap–full IVF costs $31,000.

But the TTIFC has adopt­ed the UK-pi­o­neered sys­tem of egg-shar­ing.

Un­der the sys­tem, if a cou­ple is ex­pe­ri­enc­ing prob­lems due to male fac­tor (low sperm count), the woman in the cou­ple can vol­un­teer to do­nate eggs to the clin­ic, for the ben­e­fit of oth­er women to use for IVF, and in ex­change can re­ceive IVF treat­ment them­selves for $5,000.

This would have made a huge dif­fer­ence to women like Sher­ma Dy­er (name changed)

Now aged 43, she and her hus­band be­gan try­ing for a ba­by be­fore they turned 25. They could not con­ceive and even­tu­al­ly went to a gy­nae­col­o­gist (there were no fer­til­i­ty clin­ics back then, TTIFC was es­tab­lished 17 years ago) who pre­scribed Clo­mid–the most com­mon­ly used fer­til­i­ty-aid drug.

When that didn't work she had an op­er­a­tion to clear her blocked ovaries but, she says, "Af­ter a while I guess we kind of gave up. It was very cost­ly to keep re­turn­ing."

At her age egg-shar­ing is no longer an op­tion. In the end the cou­ple adopt­ed and now have a six-year-old child.

Adop­tion is an op­tion Minto-Bain rec­om­mends to many of her pa­tients.

"We have a good adop­tion board here in T&T," she says. "We spend a lot of time talk­ing to peo­ple about their op­tions. These peo­ple are re­al. To go ahead with IVF they might have to re-mort­gage a house, sell a car... Some­times I tell them hon­est­ly IVF won't work for them, so go for sperm donors or adop­tion."

The TTIFC, un­like some clin­ics in the re­gion, does not mar­ket it­self heav­i­ly. "It's a fine line be­tween sell­ing a prod­uct and sell­ing dreams that are un­ob­tain­able. Many women won't get preg­nant through IVF," she says.

At the oth­er end of the scale, the more re­cent clin­ic in the Caribbean, the Bar­ba­dos Fer­til­i­ty Cen­tre (BFC) has been pub­li­cis­ing its ser­vices more ag­gres­sive­ly.

Last month the BFC held a free con­fer­ence in Port-of-Spain for peo­ple in­ter­est­ed in IVF.

Es­tab­lished in 2002 by Dr Juli­et Skin­ner it prides it­self on be­ing JCI ac­cred­it­ed, the on­ly fer­til­i­ty clin­ic with such ac­cred­i­ta­tion in the Caribbean. Its mar­ket­ing lit­er­a­ture boasts that women trav­el from across the Caribbean and the world for treat­ment.

IVF treat­ments at the BFC are ex­pen­sive. At US$5,500-6,500 it is an op­tion that nor­mal Trinida­di­ans and To­bag­o­ni­ans might strug­gle to af­ford.

Sim­pler treat­ments such as in­tra-uter­ine in­sem­i­na­tion–the in­tro­duc­tion of pre­pared sperm in­to the uterus–cost $375.

Speak­ing to the two women, one gets a sense of the com­pet­i­tive­ness of the in­dus­try.

Minto-Bain de­scribes the JCI as "a mar­ket­ing tool for the US med­ical pop­u­la­tion, not IVF ac­cred­i­ta­tion."

In the Ba­jan cor­ner, Dr Juli­et Skin­ner, con­sul­tant gy­nae­col­o­gist at the clin­ic, says that "oth­er clin­ics in the Caribbean do not work to a recog­nised ac­cred­it­ed stan­dard." A claim Minto-Bain re­jects, say­ing her clin­ics and ser­vices in Mar­aval and St Joseph are reg­u­lar­ly in­spect­ed by ac­cred­i­tors work­ing to the UK's HFEA stan­dards.

Minto-Bain says her mul­ti­ple-preg­nan­cy rates are very low: 3.8 per cent of con­cep­tions are mul­ti­ple.

"You need a low mul­ti­ple-preg­nan­cy rate in Trinidad be­cause the pub­lic health sys­tem can't cope with too many births and there is no pri­vate care. It's not fair to over­load the sys­tem with twins and triplets."

Skin­ner, mean­while, fo­cus­es on the suc­cess rates of her clin­ic, say­ing 80 per cent of women un­der the age of 35 achieve preg­nan­cy af­ter treat­ment.

Read part two of our fea­ture on fer­til­i­ty in to­mor­row's Life sec­tion with an ex­clu­sive in­ter­view with Dr Juli­et Skin­ner of Bar­ba­dos Fer­til­i­ty Cen­tre.

FACT­BOX

- Women are born with sev­en mil­lion eggs. Mi­cro­scop­ic in size, they are re­leased through­out the woman's life in month­ly ovu­la­tions, un­til she reach­es menopausal age.

- Men are not born pro­duc­ing sperm but be­gin to at pu­ber­ty and con­tin­ue to pro­duce sperm, typ­i­cal­ly be­yond the age of the fe­male menopause

- The first ever test-tube ba­by, Louise Brown, was born in Old­ham, Eng­land, on Ju­ly 25, 1978, af­ter her moth­er was treat­ed with the first IVF pro­ce­dure by Patrick Step­toe and Robert Ed­wards. Ed­wards was lat­er award­ed the 2010 No­bel prize for med­i­cine. It took 175 IVF treat­ments be­fore Brown was con­ceived.

- Low sperm count in men is usu­al­ly ge­net­ic but can al­so be due to lifestyle, in­jury, in­fec­tion.

- In­for­ma­tion on Na­tion­al In­fer­til­i­ty Aware­ness Week can be found at the web­site www.re­solve.org