BARREN HEALTH CARE

The birth of a child… this event could, perhaps, be considered the greatest happiness for parents. For the overwhelming majority of mums and dads, life takes on a specific meaning with the appearance of the long-awaited baby, but unfortunately, far from all potential parents are given an opportunity to savour the joys of motherhood or fatherhood. A diagnosis of infertility can instantly shatter the happiness of a marriage.

According to the World Health Organization, there are currently 60-80m people in the world who suffer from infertility. For our country, with an average infertility rate of 15 per cent, that means thousands of couples of child-bearing age who dream of having a child. Even though modern medical science has made a substantial breakthrough, for a certain percentage of couples this news still remains a damnation. The reason for this is not at all that the aim cannot be achieved, but rather that the necessary funds are lacking to achieve the joy of knowing motherhood and fatherhood.

Extracorporal fertilization as the last hope

Elnur and Leyla met at university. They got on very well, and within a year of meeting they  were married. It appeared there was nothing that could spoil the young couple's happiness. But a year went by, two, three, and still the family had no child. Relatives and neighbours were baffled - why don't the young couple have a family? After four years their friends started to whisper behind their backs… Leyla is infertile. And on one occasion the mother-in-law said this openly to the young woman. Leyla was very upset that she just could not give her beloved husband a child. She had already been seeing all sorts of doctors for a long time, the leading lights of Azeri medicine, ordinary gynaecologists at her local women's clinic, but the treatment had no effect. The cause of the infertility, as was shown by medical tests, lay with Leyla, she was found to have a pathological condition that prevented her from becoming pregnant.

At one clinic which Leyla visited, the doctor immediately recommended extracorporal fertilization to the young woman, which the doctors at the clinic said was her only hope of knowing the joy of motherhood. Leyla was already desperate, but when they told her the cost of the procedure in question she realized that she and her husband would not be able to afford it. It turned out that the extracorporal fertilization itself costs 2,900 AZN, and that was without the cost of the numerous tests that would have to be made and the cost of the medicines which she would have to obtain independently. Doctors said that the overall cost of extracorporal fertilization, with all of its ramifications, would cost Leyla about 4,000 US dollars. Moreover, none of the doctors could give her any guarantee that the procedure would be successful.

A depressed Leyla returned home and told her husband everything. Elnur said he would get hold of the money at any cost, as long as he could have a child, and anyway he was sick to death of all the gossip. So they borrowed the money and the couple set off for the clinic. Unfortunately, the first attempt at extracorporal fertilization was not successful for the couple, because the embryos implanted in Leyla did not take. As a result, this considerable sum of money turned out to be thrown to the wind. The clinic recommended that Leyla try her luck again, but this was simply impossible because she and her husband had barely paid off the previous debt. Incidentally, the second and all subsequent attempts at the clinic cost exactly the same as the first one and not a penny less. There are no concessions for any category of citizens either in this clinic or in any others, not even at state clinics. In spite of their initial decision not to repeat the extracorporal fertilization, Leyla and Elnur nevertheless decided to try their luck a second time, and so they are now saving up for another go.

Infertility epidemic?

Surprising as it may seem, in spite of the widespread view that Azerbaijan has no demographic problems, married couples are coming up against the problem of infertility more and more often. The permanent parliamentary commission on social policy recently discussed reproductive health and national legislation in this field. According to the head of the Baku health authority, Leyla Seyidbayova, in Europe these illnesses are encountered among people below the age of 25, but in Azerbaijan they are much "younger". "Divorces have become much more frequent, one of the causes of which is precisely health disorders. Young people don't know anything about each other's physical condition before they marry, and when they find out the problems begin," she said. She believes the spread of such disorders could be prevented by education on reproductive health among young people. MP Malahat Gasanova underlined the importance of reflecting reproductive health issues in the country's legislation. In the opinion of gynaecologist Lala Samedova, infertility as such is not an illness (a highly contentious statement in our view - author's note), but rather a condition of a married couple that is unable to have children. And the man and the woman are "guilty" in equal measure. She said that young parents have recently been given this diagnosis more and more often in Azerbaijan.

"It is time to seek medical help if a couple have been trying unsuccessfully to have a child for a year. But this is a timescale that is set for women who have not yet reached the age of 30, for those who are older than 30 this timescale is considerably reduced. First of all the couple should undergo an examination. It is possible that there will be no need for hi-tech intervention, just a correct medical approach to conception. Medical experience has shown that the cause of infertility often lies in a negligent attitude to one's own health: starting sexual activity at an early age, frequent change of partners, sexually-transmitted diseases, excessive drinking and smoking. Among women, inflammation can lead to blockage of the fallopian tubes, and infertility among women can also be caused by hormonal disorders, when the egg cell fails to mature etc. But if a man has only to provide semen for analysis in order to reveal infertility, a woman has to undergo numerous examinations: blood hormone tests have to be carried out, ultrasonic examination, laparoscopy might be required, etc. This is the reason we advise that both partners begin examinations at the same time, rather than laying all the blame on the woman from the outset, as often happens in our country."

If the infertility is of a serious nature, hi-tech procedures come into play. Doctors effectively take on the role of nature. Extracorporal fertilization consists of several stages: stimulation of the ovaries to allow several egg cells to mature, extraction of the egg cells and fertilization in laboratory conditions. The embryos obtained develop in an incubator for 3-5 days. "The most viable ones (no more than 2-3) are transferred to the womb cavity. Further development of the embryos and pregnancy proceed as in normal conditions. In the tenth week of pregnancy, if need be, superfluous embryos are removed. The success rate of extracorporal fertilization hovers around the level of 30-45 per cent," she said. She added that, unfortunately, it happens that doctors immediately refer the patient to extracorporal fertilization without testing for all possible methods of curing the infertility, but such an approach to solving the problem is nothing but a lack of medical professionalism.

No free extracorporal fertilization for now

The director of the scientific research institute for midwifery and gynaecology, Faiza Aliyeva, said the first extracorporal centre was set up in Azerbaijan in 2004 by decision of the Health Ministry, on the basis of the family planning centre, and a few months later another similar centre was opened at the Central Clinical Hospital. She said that the demographic situation in Azerbaijan was not as yet any cause for concern (we will comment on this contentious assertion below - author's note), and so there could be no question of free extracorporal fertilization for the time being. She stressed that if there were a serious demographic problem in the country the state could take on some of the cost of providing extracorporal fertilization. "There is such experience in certain countries. For example, in Turkey the government pays half of the cost of the medical provision needed for extracorporal fertilization. In Azerbaijan extracorporal fertilization costs much less than in other countries, and the cost of the procedure is calculated with due account of the cost of the equipment, the purchase of medicines and various reagents. In line with world practice, extracorporal fertilization is used if pregnancy does not ensue following six years of unsuccessful treatment of infertility," she said. She believes that extracorporal fertilization can be seen as the most humane and cheap method of treating infertility, and if you compare it with the amounts women spend on essentially useless treatment over the course of several years, then that is indeed the case. Also, she said, a woman can inflict irreparable damage on her own health by incorrect treatment.

We were told at the permanent parliamentary commission for social policy that there is currently no need to allocate funds from the state budget for extracorporal fertilization. This is because the country has no problems with its birth rate. Such an issue could only be put on the agenda if a demographic problem were to arise in Azerbaijan.

We would like to dwell on two points in this regard. The example of Turkey cited above shows that in a civilized society the attitude to the problem of treating infertility does not have to be linked to the presence or absence of demographic problems. In Turkey the demographic situation is better than in Azerbaijan, but the government there still partially finances the extracorporal fertilization project. But as concerns the main issue - whether we in Azerbaijan have a crisis situation in the field of demography - we will cite a few figures. According to the official figures of the Azerbaijani State Statistics Committee, the mortality index (the number of deaths per 1,000 inhabitants) in our country has been rising, albeit slowly, since 2001. In 2001 it was 5.7, in 2006 it was 6.2. This means that the number of deaths has been rising steadily - from 45,284 in 2001 to 52,248 last year. According to one of the key indices defining the health care system's level of development - infant mortality (the number of children dying at an age of up to one year per 1,000 born), we are at the level of African countries. In 2006 this index in our country was 10.1 (in 2004 it was 9.8, and in 2005 it was 9.3), and the overall number of deaths up to the age of one last year was 1,508 (in 2004 it was 1,287, and in 2005 it was 1,321). Another important indicator of the health of the nation is maternal mortality (the number of women who die during pregnancy or childbirth to every 100,000 children born alive). If in 2003 this figure was 18.5, then in 2004 it was 25.8, in 2005 it was 28.9, and last year it was 34.2. And alongside all this, the belief of UNICEF experts that the real figures for child mortality are much higher. But even the official indices show a serious crisis in the national health care system. So the problem of extracorporal fertilization, and indeed the radical reform of the entire health care system, are of real relevance to us.

Incidentally, in neighbouring Russia increased attention to these issues has brought about the necessary result - the birth rate there this year has been the highest in the past 15 years, while mortality is the lowest since 1999. Infant mortality has also fallen, from 15.3 to 11. In the same country they have already raised the question of free extracorporal fertilization for low-income couples. According to RIA-Novosti news agency, the state is to allocate funds for the development of assisted reproduction techniques which make it possible to treat infertility. This is the view of Professor Vladislav Korsak, president of the Russian Association of Human Reproduction and member of the council of the European Society of Human Reproduction and Embryology. "Given the objectives which the government is setting itself (stabilizing the demographic situation), the fight against infertility is one of the key factors that can produce a result," he said. He said that there are currently only about 60 clinics in Russia which deal with extracorporal fertilization and other techniques for the treatment of infertility. However, until this year only state centres received state orders for carrying out extracorporal fertilization, of which there are only four in the country. "We have to announce a tender for the conclusion of a state contract for the treatment of infertility with the use of assisted reproduction technology. And moreover, the cost of the issue should not be the determining factor in the tender. The main thing is the work experience, how many extracorporal fertilization cycles have been conducted, how many pregnancies and births have been produced," said Korsak, who heads the international centre for reproductive medicine, which received the state order for the first time this year. The expert noted that, besides bureaucratic barriers to the development of reproductive technology, there is an acute shortage of personnel since no-one receives specialist training as "clinical embryologist".

In Ukraine they have gone further still - a free artificial insemination centre will shortly be opened in Kiev where extracorporal fertilization will be carried out completely free of charge. This decision was taken by deputies at a plenary session of the Kiev city council. Unfortunately, there are currently no such programmes in our country, the state is clearly satisfied with the current demographic situation, and so the problems of infertile couples are of no interest to anyone apart from themselves. However hard it may be to recognize this, it is precisely for this reason that thousands of potential parents will never hear from the mouths of their as yet unborn children the cherished words "mum" and "dad"…