What happened next: infertility

Posted on 11 April 2019

Becoming pregnant should be a joyful time for any couple. But after 18 months of trying with no success, Kyle and Philippa Nipper were confused and frustrated – until a chance meeting changed their lives

Kyle and Philippa Nipper were married in April 2015, and right away, their thoughts turned to starting a family. “we always knew we wanted to have kids together,” says Philippa. “we gave it six months before we started trying – so yes, you could say we were pretty keen.

With several nieces and nephews around, children aren’t exactly a foreign concept to either of them. Kyle, a former professional cricketer, is now Director of Cricket at Maritzburg College in Pietermaritzburg, one of South Africa’s oldest and most prestigious boys’ schools, while Philippa teaches Grade 4 at St Charles College nearby.

Conventional wisdom holds that becoming pregnant can take as long as a year. So when Kyle and Philippa were still trying to fall pregnant 12 months later, they didn’t think much of it. “It wasn’t a big issue in our lives at the time,” she says, “and we didn’t want it to control us. But gradually we started to become disappointed.” That disappointment would grow into frustration as time went on. Philippa resorted to trying an at-home ovulation test, which is designed to show the days in your menstruation cycle when you are most likely to conceive.

“It never showed an ovulation window. That’s when something in the back of my mind went, wait, maybe there is more to this. I said to Kyle, I think something’s wrong.”

Having had successful surgery to treat her endometriosis a few years earlier, Philippa worried that the disorder may have recurred. This condition develops when some of the tissue that lines the uterus begins to grow on other organs in the pelvis, including the ovaries or fallopian tubes. While many women with endometriosis do fall pregnant, in general it can make falling pregnant difficult, and lead to a few risks during pregnancy too.

Although her doctor reassured her that nothing was wrong, Philippa says she knew deep down that something was amiss. “We didn’t realise it would be so difficult to get pregnant,” she says. “We were trying to work it out, we were overthinking everything. It became emotionally exhausting.”

Eighteen months after they had first started trying to fall pregnant, a chance meeting would put much of the Nippers’ worrying in a whole new light. “One day, I went to Pilates,” Philippa remembers, “and I met Dr Kasturi Moodley. She was talking to someone about a specialised clinic that she was opening. And it was as if a spark went off in my head. I just thought, maybe this is worth investigating.”

In 2015, Dr Kasturi Moodley was working as an obstetrician at Mediclinic Pietermaritzburg with some distinction. “We have been helping our patients for many years, and they present with a wide variety of issues,” she says. “So they were well-served in a gynaecological sense. But one issue emerged as a stumbling block.” As many as 15% of South African couples experience fertility issues, according to 2011 data from Statistics SA, and that number is growing across all population groups. In the Pietermaritzburg area, these patients were not getting the care they needed, says Dr Moodley. “We were able to help them up to a point. But because we lacked the proper equipment and personnel, we would have to refer many of them to practices in Johannesburg and Cape Town.”

She had the idea to bring together a range of expertise into one place, and this is how the Pietermaritzburg Fertility Clinic was created. This world-class fertility clinic is staffed with a team of gynaecologists and embryologists and equipped with its own specialised laboratory and theatre.

In 2017, Philippa walked through the doors of this new facility armed with little more than an idea at the back of her mind. She walked out with a diagnosis, and a whole lot of hope. “Dr Moodley ran some tests, and we found that I had a blocked fallopian tube, together with a malfunctioning ovary,” she says.

 

STEP ONE: DIAGNOSIS

“It sounds strange, but I didn’t feel like this was bad news,” says Philippa. “It was a relief. I had a name for what was wrong, and we had a course of treatment to fix it, a plan A, B and C. But most importantly was the way Dr Moodley handled it: she said, this is the issue, don’t worry about it, we’ve got this.”

Dr Moodley says in her experience, most young couples start trying to become pregnant without imagining that it may become difficult. “A lot of people, like Kyle and Philippa – in their late 20s or 30s, and in relatively good health – automatically assume that they will conceive naturally,” she says.

“When they start trying, but nothing happens, they’ll speak to their gynaecologist about it. But many of the issues that lead to infertility won’t be picked up even then. You can be perfectly gynaecologically healthy, without ever picking up that something will affect your fertility. These issues need specialised testing, and without it, you could keep trying for months or years with no success.”

Fertility specialists will generally take a three-step approach to understanding a patient’s condition: they will look to address any hormonal imbalances, examine the fallopian tubes for obstructions and analyse the quality of the male partner’s sperm. Common fertility tests involve a blood test, as a way to check the body’s levels of follicle-stimulating hormone (FSH), which triggers the ovaries to prepare an egg for release each month. A hysterosalpingogram (HSG), or “tubogram”, will take a closer look, with a series of X-rays of the fallopian tubes and uterus, taken after a liquid dye is injected into the cervix.

“There are many hormonal and biomechanical factors to take into account when testing for fertility,” says Dr Moodley, “and most of these will not be detected in the course of an ordinary examination. For example, I would estimate that perhaps as many as 40% of my patients have obstructions in the fallopian tube, and this cannot be examined by a standard ultrasound.”

Early diagnosis is key. “The earlier we are able to identify an issue, the more treatment options we have,” she says. “Hormonal variances, blockages, sperm quality – these can be corrected fairly quickly and with a minimally invasive approach, if we pick it up early enough.”

Ovulation from an ovary is random, explains Dr Moodley. “Month by month, a woman may produce an egg in the left fallopian tube, and then in the right, then the left again, and so on. If there is a blockage, you could be ovulating, yet not fall pregnant for months or years.” Dr Moodley says her role as a fertility specialist is to create optimal conditions for what remains a natural process. “We can address hormone imbalances through medication and diet. If there is a blockage in one fallopian tube, we can ensure the sperm is positioned to meet the egg on the other side. And if there are issues with the quality of the sperm sample, we can fix that too.”

Philippa says she felt as if she was toeing the line of a race, and had an expert at her side. “Look, when I walked in the first time I didn’t know what to expect – so to have that open communication, that confidence … I felt she was in my corner. We just knew we were in the right hands, right from the beginning.”

STEP TWO: TREATMENT

Having been diagnosed with a blocked fallopian tube and a problematic ovary, and having had her treatment options laid out, Philippa was prescribed rounds of intrauterine insemination (IUI) treatment. In the typical female reproductive cycle, the ovaries will develop follicles, or fluid-filled sacs, that each contain an immature egg. While several follicles begin to develop each cycle, normally only one will ovulate an egg, and during ovulation, these follicles will release a mature egg. Follicles can disintegrate, in a process known as atresia, at any stage and for no discernible reason. IUI is designed to help these follicles along as they grow their eggs. “We use a variety of medications to encourage the follicles to grow – we usually aim for at least two follicles per ovary – and we monitor their growth using ultrasound scans,” says Dr Moodley. “At around days 10-12 of a patient’s cycle, when we know the follicles have grown at least 2 to 5 mm, or up to 18 to 20 mm, we know the egg is most likely to be ready, and we use more medication to stimulate the follicles to release their eggs.”

Thirty-six hours later, once the egg has travelled from the ovary into the fallopian tube, Dr Moodley and her team will turn their attention to the sperm sample. Here, the clinic’s embryologist is responsible for washing the semen. Using a technique known as density gradient centrifugation, she is able to filter out sperm that are unviable, as well as debris and other cells that are detrimental from the semen sample. This process is designed to increase the number of viable sperm and activate the cells, increasing a couple’s chance of a successful pregnancy.

The washed sperm is then placed directly inside the uterus, as close as possible to the mature egg. “IUI is a great way to bypass the flaws your body may have,” explains Dr Moodley. “We can synchronise the natural process and make it that much easier for your body to do what it wants to do.”

As optimal as IUI might be for the body, it can take a toll on the patient. Philippa had injections twice a day, and went for scans every two or three days – for a total of six months. Then there is the mental side. “I did get my hopes up, yes, but there was more disappointment,” she says. “I had three rounds of IUI, and there were many times when I had to change courses of medication, because I wasn’t responding as we hoped. I was in the clinic almost every day after work. It was an exhausting process: you think to yourself, I have this issue, here is the treatment, why isn’t it working?” The mental side of this treatment is crucial, says Dr Moodley. The medication, the needles, the scans, almost-daily doctor visits, the time o work – “fertility treatment can be a psychologically stressful and emotionally draining experience. Patients can end up feeling like a wound-up clock. This stress is the enemy of pregnancy.” Philippa says this is where Dr Moodley really stepped up. “She seemed to know when we would get stressed, and why, before it happened. She would spell things out for us. She would even draw pictures. We never left her rooms feeling anxious or uncertain.”

 

STEP THREE: SUCCESS

In December 2017, Philippa has just finished her third round of IUI treatment. She had also developed a cyst on her ovary, and had had treatment to reduce its size. She remembers feeling despondent, believing there was no way this round would be successful. “The clinic called and said it was time to come in for a blood test. I really didn’t want to. I was feeling down in the dumps about the whole thing. Later that day, I got a call from Dr Moodley. “‘You won’t believe it,’ she said, ‘but I’ve got some good news.’”

Hearing that she was pregnant took Philippa’s breath away, but she was determined to keep it a secret as long as possible. After two years of trying, you can’t blame her. “Kyle has this cricket ball that he has kept as a memento from a game where he was named Man of the Match. So I found it, and wrote on it, ‘Making a debut, Sept. 2018.’ When he got home, I threw it to him. Once he realised what it meant, things got pretty emotional.”

Philippa and Kyle kept the news between them for the next 12 weeks, and Dr Moodley moved the couple’s consultations over to her practice at Mediclinic Pietermaritzburg. “Once you’ve had successful fertility treatment, and once you’ve passed that first trimester, we take an ‘All is well’ approach,” she says. “So we treat it as any other normal, spontaneous pregnancy. We do find that some of our patients are on the older side, and in those cases we may recommend delivery by elective Caesarean section as it may be a slightly higher-risk case, but in general terms, all the usual rules apply.” Philippa gave birth to Tenley Joy Nipper in August 2018 – the first baby to be born with help from the Pietermaritzburg Fertility Clinic – and for her part, she is a dream baby. “She sleeps well, she gurgles away happily all day. She loves, loves, loves her food. She is just so at home.”

Dr Moodley would encourage more couples to see a fertility specialist sooner rather than later. “People are worried that fertility issues are bad news, or that it’s costly and invasive. My advice: don’t wait. The older you are, unfortunately, the harder it is to fall pregnant naturally. Philippa came to us at 29, and that helped us to help her.” Two years of trying to have a baby has taught Philippa a lot, and succeeding has solidified a few home truths. “We knew what is required to make a baby, of course,” she laughs. “But I’ve learnt so much about our bodies, and how they work. I’ve also learnt how important it is to have a support system, and the value of knowing when to trust my gut.”

This journey began when she and Kyle were open-minded enough to approach Dr Moodley’s clinic, and ended with the Nippers finding a new identity as a young family. “We put all our trust in Dr Moodley. We knew they were going to be able to help Kyle and I realise this dream. I still visit her clinic, I still take Tenley to see them, and they call me to update me on other success stories they’ve had. Every time, it feels like home. They’re like family.”

 

 

PHOTOGRAPHS: GEOFF REDMAN