From Hatching: Experiments in Motherhood and Technology by Jenni Quilter published on Dec. 6, 2022, by Riverhead, an imprint of Penguin Publishing Group, a division of Penguin Random House LLC. Copyright © 2022 Jenni Quilter.
Most people understand in-vitro fertilization to be privilege for the wealthy, the well-insured, or those living in a country with a generous social safety net. In 2014, IVF clinics across Europe reported 508,433 cycles. In 2015, the United States reported 231,936 cycles. In 2013, across Africa—the entire continent—there were only 25,550 cycles.
Yet the effects of infertility are outsized precisely where there is little support. In 2001, at a World Health Organization meeting, two researchers proposed a continuum of social suffering to measure the effects of infertility. The language is banal, but the extraordinary pathos remains. In the developed world, couples tend to experience social suffering in level 1 (fear, guilt, self-blame) through level 2 (marital stress, depression, helplessness) and level 3 (mild marital or social violence and abuse, social alienation). Spend any time on the thousands of internet chatboards devoted to infertility, and you’ll see comments that align rather well with these levels. But the consequences of infertility extend to level 4 (severe economic deprivation, moderate to severe violence, total loss of social status), level 5 (violence-induced suicide, starvation/disease), and level 6 (lost dignity in death)—and these levels are seen much more commonly in the developing world, where a 2004 WHO study estimated that 186 million women suffer from infertility.
In Africa, the percentage of women who identify with the statement that “the ideal number of children is zero” has always been less than 2 percent. In Nigeria, a woman loses her right to inherit her husband’s property if she has no children with him. In areas of Egypt, a woman’s name changes if she gives birth, and if she does not, she becomes known as “Um Ghayeb,” literally “Mother of the Absent.” Women like me, in America, mostly have the privilege of keeping their grief about infertility private. It is a humbling readjustment to realize just how much further your grief and pain could extend.
Though there has always been some variation in the price of IVF, in the U.S., the average cost is around $12,000 per cycle, in the Czech Republic, $3,000—which has created a burgeoning industry in IVF tourism, as the middle class in one country take advantage of another’s. But this sliding scale is still out of reach for all but the singularly rich in Africa.
For the past 15 years, Willem Ombelet, originally from Pretoria, South Africa, and long based in Genk, Belgium, has led the charge to lower the cost of IVF in Africa. He has organized conferences, published journals, and brought together medical professionals and embryologists and researchers to tackle infertility in Africa. It was Ombelet’s query about hand-me-down IVF equipment in 2008 that led professor Jonathan Van Blerkom, months later, to idly recall—on a drive home one day—how when he was a graduate student, driving rabbit and pig embryos from Arizona to Colorado, he kept the embryos alive in a very simple combination of sodium bicarbonate, water, and citric acid. It was relatively easy to monitor the pH balance; if it got too high, he just needed to inject some CO2. You could, he reasoned, do the same with human embryos. He also had a thought about how you might generate that CO2. As a child, one of his favorite toys was a plastic scuba diver he’d purchased with box tops from Kellogg’s Corn Flakes. One chamber of the tank was filled with vinegar and the other with baking soda. As the contents reacted with each other, they gave off CO2, causing the diver to dip and resurface, releasing bubbles. Van Blerkom wondered if you could keep an embryo alive using the same technique.
The result of Van Blerkom’s thinking was an embryology kit that fits inside a shoebox and that looked, with its modest metal casing, glass tubing, and basic cork stoppers, a lot like a high school science experiment. The materials barely cost more than $10. In a conventional IVF clinic, approximately 35 percent of running costs are spent in the laboratory. Some of this is diagnostic blood and semen work, but then there are the considerable operating costs of an embryo lab, which include staffing, equipment, and maintenance. Incubators are extremely costly, as are air purifiers and ventilation hoods. But Ombelet and Van Blerkom rethought a few basic assumptions. What would happen if you reduced the number of times an embryo was moved from one receptacle to another, or removed from the incubator for observation? You wouldn’t need quite the same emphasis on air quality control, and you wouldn’t need as many trained embryologists. They reasoned that it was quite possible to combine sperm and egg in the test tube and leave the ensuing embryo to grow rather than removing excess sperm. They also thought it quite possible to find a microscope that would work well enough through glass. If this was true, then the only remaining requirement was a consistent temperature, and this was relatively easy to achieve with a minimum of equipment.
They then had to establish whether such a low-cost method would work as well as conventional IVF. Ombelet designed a study to submit to the Belgian Ethics Committee wherein a number of couples younger than 36 and with a sperm count of more than 1 million received ovarian stimulation. If the oocytes harvested numbered more than eight, half were fertilized and cultured the usual way, and the other half using the new method. An independent embryologist, blinded as to which were which, would then select the best embryos to implant, and the others would be frozen. The results were remarkable. Using conventional IVF resulted in a 29 percent live birth rate. Using this new method, it was 30.4 percent. Sixteen live births resulted from embryos that had been cultured using this low-cost method. The implications for the developing world were clear. If you could find a clinician to prescribe a hormone stimulation protocol, who was also able to carry out laparoscopic surgery, you could conduct IVF anywhere. At the very least, Ombelet told me in 2016, IVF could cost less than 920 euros in a country like Belgium, which was little more than $1,100 at the time.
When Ombelet’s team published their results in 2012, they rightly assumed a flurry of media interest, and with it, the prospect of increased funding and the chance to roll out low-cost IVF centers throughout the development world. Yet though the trials were widely reported on in the press, the money never came. Then came additional bureaucratic hurdles that were almost laughable in their banality. The test tubes, stoppers, and medium that they had used in the first experiment were not CE accredited in the EU (which is equivalent to being FDA approved). They had to redo their trial with new materials. It took years to replicate the results.
During this time, Ombelet began a partnership with the Pentecostal Church in Ghana to build an IVF clinic. Ghanian doctors and technicians were recruited and flown to Genk for training. There had been two “missions,” when Ombelet and his team had flown to Ghana and worked alongside their Ghanian counterparts trying to create the success of the Belgian trials. But there had been minimal success. In the first trial, they underestimated the number of women who were suffering from uterine polyps and myoma (fibroids) that blocked the implantation of an embryo. They also used limited air filtration. In the second mission, they realized too late that the women had started their stimulation protocol a week later than they should have, so that their uterine lining wasn’t thick enough when it came time for the embryos to implant. The complications were depressingly simple: Ghana needed clinicians who were more experienced in prescribing hormone protocols, and to do more diagnostic work on patients. Ombelet revised his understanding of what was necessary; some air quality and microscope controls were necessary, as was a baseline standard of patient care. The set-up cost of their IVF clinic wasn’t $1.6 to $3.3 million, as it would be in the developed world, but it was $350,000 to $550,000 USD—a sizeable drop, but hardly a small cost. The overall issue became one of replicable infrastructure rather than design. In interview, Ombelet told me that he had received expressions of interest from China, India, and Colombia—but that everyone was waiting to see what might happen in Ghana.
The day I visited him in 2016, he had received bad news: An IVF pregnancy in Ghana had ended in miscarriage. At lunchtime, I watched him give a presentation to his colleagues. Ten or so nurses and doctors sat around the table in the staff room, unwrapping their sandwiches, watching Ombelet as he ran through his PowerPoint, listing key statistics, describing his treatment protocol and study results, insisting on the importance of funding. His audience seemed detached. They listened politely and ate their food, checking their phones discreetly. There were no questions at the end. I asked a nurse afterward how she felt about it. “Dr. Ombelet has been giving the same presentation for years now. And it is always ‘Next year, next year,’ ” she said. “He has been waiting for a birth, for it all to happen. And it hasn’t.” Ombelet had the air of a man waiting for a train that should have come a long time ago. Still he waited, peering anxiously into the distance, reluctant to leave his spot, quietly furious that the universe had not yet provided. He spoke of plans to roll out low-cost IVF in London and Portugal by the end of 2016, essentially offering it as a cheaper option at already-established IVF clinics: Maybe the road to addressing IVF in Africa would be paved by the working class in the developed world. But he knew that this would also meet resistance: Why would the IVF industry want their patients to opt for a $2,000 treatment when they would pay $12,000? I asked Ombelet how much money he needed to establish a few working clinics in the developing world, with trained clinicians and appropriate equipment. His answer was laughably low for the systemic change it offered: less than $10 million. He had approached several different organizations for funding, and though there was polite interest, no funding had materialized.
The knee-jerk reaction of many people in the developed world to the prospect of infertility care in the developing world seems to be mild outrage; the world is already overburdened as it is, and we hardly need more children we cannot feed. On a list of health priorities in these countries (HIV prevention, malaria, clean water), infertility seems less consequential. Yet if you conceive of infertility care as part of a broader program of reproductive health, you can start to sense its importance. If you want women to make mindful decisions about how many children to have (and when to have them), they need to know they can be medically supported should they choose to delay pregnancy. They need to be able to diagnose the cause of their infertility, to understand if it is the result of a treatable infection, or male-factor infertility. It should not have to remain a mystery. To assume that women in the developing world cannot be trusted with this kind of information—that they will simply use IVF to unthinkingly give birth to more and more children—is to resort to a caricature of female passivity and stoicism that has more to do with a neocolonial condescension than anything else.
A year later, in 2017, a baby born was born in Ghana. It was the third attempt for the couple, who had been infertile for eight years. Ombelet had done it: He and his team had prevailed, dealing, with accreditation complications, import duties on equipment, and resistance from the larger IVF industry. The photos of the birth—the baby, surrounded by the all-African medical team, dressed in scrubs—are quietly remarkable, but the press coverage outside of Belgium and Africa has been minimal. Other births have followed since. The door has been opened to reimagining the cost structure of IVF, basic treatment protocols, and who might benefit, and Ombelet continues: commuting to his clinic in Genk, collaborating with his peers in Ghana, presenting his case to anyone who will listen. He has proof of concept now, but remarkably, it seems, people are still waiting.
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