Poor sperm quality, low sperm count major IVF challenge at Muhimbili – Part 1

Muhimbili officially launched IVF services in September 2024 and began receiving patients in December of the same year, following the establishment of the centre.

Consultant obstetrician-gynaecologist and fertility specialist at the centre, Dr Matilda Ngarina, says that since the programme started, 26 women have undergone egg retrieval procedures for IVF treatment.

“We have already carried out embryo transfer procedures for eight women after fertilisation in the laboratory, and frozen embryo transfer for 10 others,” she says.

According to her, the first eight women underwent fresh embryo transfer within the same treatment cycle, while embryos for the other 10 were frozen under specialised conditions before later transfer into the uterus.

However, behind the progress, Dr Ngarina says the programme has exposed the scale of fertility challenges affecting many couples, particularly men.

“When we analyse the patients we receive, nearly two-thirds of the problems originate from men. Sometimes there is no sperm at all, or the sperm count is very low, immobile, or the sperm have abnormal heads or tails,” she says.

She explains that some men appear physically healthy, yet laboratory tests reveal no sperm in their semen.

“You may analyse sperm today and shortly afterwards find most of them have died. Male sperm quality is declining significantly, and globally, the exact causes are still not fully understood,” she says, adding that lifestyle factors play a major role in the problem.

“Alcohol consumption, smoking, drug abuse, stress, lack of sleep, and even tight clothing around the reproductive organs can affect sperm quality,” she says.

She notes that some men require surgery or specialised treatment from male reproductive health experts, while others must first change their lifestyle before qualifying for IVF treatment.

Women facing delayed fertility challenges

For women, Dr Ngarina says delayed childbearing has become one of the biggest fertility challenges currently observed at the hospital.

“A large proportion of women we receive are over 40 years old or approaching that age. Many delayed childbirth because of education, careers, or personal circumstances,” she says.

She explains that some women arrive at the hospital already showing early signs of menopause.

“We are seeing women aged 34, 35, or 36 whose egg reserves have already declined significantly or become depleted. This is becoming increasingly common,” she says.

According to her, many women delay seeking medical assistance because they believe they still have enough time to conceive.

“Many believe they can give birth at any age, but the reality is that egg quality declines with age,” she says.

Apart from age, Dr Ngarina identifies polycystic ovary syndrome (PCOS), endometriosis, and premature ovarian failure as the three major conditions contributing to infertility among women.

She explains that in some women, eggs fail to mature properly and rupture, preventing them from leaving the ovaries to meet sperm.

“The eggs are produced, but they fail to rupture and move out to meet the sperm. Instead, they remain trapped inside the ovaries,” she says.

She notes that although some women appear to have many eggs during ultrasound scans, many may still be unsuitable for fertilisation.

“You may feel excited seeing many eggs, but once retrieval is done, they turn out empty,” she says.

Dr Ngarina adds that endometriosis has also become a serious challenge for fertility specialists in Tanzania.

“It is a very complicated disease. The inner lining of the uterus grows outside the womb and spreads to other parts of the abdomen. Every time a woman menstruates, those areas also bleed,” she says.

According to her, the condition causes internal organs to stick together and affects both egg quality and the ability to conceive.

“We have had patients with endometriosis from whom we retrieved eggs, but none were suitable for fertilisation,” she says.

Despite the challenges, Muhimbili National Hospital has already recorded the birth of three babies through IVF since the programme started.

Dr Ngarina says one successful patient conceived during her first IVF attempt after spending more than eight years in marriage without a child.

“Her problem was blocked fallopian tubes, but her eggs were healthy, and her husband had no sperm complications. Once we fertilised the eggs and transferred them, pregnancy occurred immediately,” she says.

Stigma and secrecy

However, Dr Ngarina says social stigma surrounding infertility remains another major obstacle, with many patients unwilling to disclose that they conceived through IVF.

“Many patients do not even want relatives to know they underwent IVF. We have kept some information confidential until delivery,” she says.

According to her, some patients demand extremely private treatment arrangements to avoid social judgement: “Infertility carries enormous stigma in our society.”

A long and uncertain journey

Dr Ngarina says IVF treatment is lengthy, costly, and does not guarantee success for every patient.

She explains that, contrary to common assumptions, IVF is not a one-day procedure but a process requiring weeks of preparation before embryo transfer.

“We prepare the woman for nearly a full month using special medicines, and once menstruation begins, we start 14 days of hormone injections to stimulate egg growth and maturation,” she says.

During this stage, doctors closely monitor egg development using ultrasound scans before retrieval through specialised procedures performed under sedation.

However, treatment outcomes differ significantly among women.

“One woman may produce four eggs, another 30, while another may produce none at all,” she says.

After retrieval, the eggs are taken to the laboratory for fertilisation using sperm from the male partner.

The resulting embryos are monitored inside specialised incubators for three days before transfer.

“On the third day, we assess how many eggs have developed into embryos and classify them according to quality,” she says.

Dr Ngarina explains that not all women qualify for immediate embryo transfer. Those producing many eggs may face ovarian hyperstimulation syndrome caused by excessive hormonal response.

“In such cases, we first freeze the embryos until the body stabilises,” she says.

She says some women begin treatment only for their eggs to turn out empty, fail to fertilise, or develop into weak embryos unsuitable for transfer.

“There is no guarantee that once eggs are retrieved, you will automatically get a baby,” she says.

Another challenge, she explains, is that many couples arrive at Muhimbili National Hospital after unsuccessful treatment elsewhere and are already beyond their peak reproductive years.

“We receive many women above 40 years old. Some are even 60 and still seeking their first child,” she says.

According to her, only about 20 percent of patients seek treatment while still within the ideal reproductive age.

She says some infertile couples are advised to use donor eggs, which further increases treatment costs.

So far, Muhimbili National Hospital has successfully conducted both fresh and frozen embryo transfers, with two women achieving successful pregnancies.

One was delivered through fresh embryo transfer, while another delivered twins through frozen embryos, although the babies later died. Two other pregnant women are progressing well.

Dr Ngarina says the global IVF success rate averages about 40 percent and depends largely on the cause of infertility and the patient’s age.

Regarding costs, she says one IVF cycle at Muhimbili costs approximately Sh14 million, covering ovarian stimulation, egg retrieval, fertilisation, embryo transfer, and embryo storage for one year.

“It is still expensive for ordinary Tanzanians because most medicines are imported and costly,” she says.

She explains that preparations for establishing the IVF service began in 2018 but were delayed by several challenges, including the Covid-19 pandemic.

“Now the major task is ensuring these services become accessible to more Tanzanians at affordable costs,” she says.

To be continued...