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On birth: Dr. H and the women

Making a living working around the biological clock

By Iva Skochová
Staff Writer, The Prague Post
May 9th, 2007 issue

VLADIMÍR WEISS/THE PRAGUE POST

One of the reasons Dr. Hrehorčák cites for his great fertility success rate is the lack of Czech regulation in this highly controversial field. enlarge

At the age of 35, he has managed to make hundreds of women pregnant. All of them were ecstatic about it, too. “It is great to see how much pregnancy changes women, how happy it makes them when it happens,” says Martin Hrehorčák, lead doctor at the Clinic of Reproductive Medicine at Motol University Hospital in Prague 5.

His staggering record of impregnations aside, he actually has no children of his own. “No, my work has not changed how I feel about having children,” he says smiling, in the glow of a picture of his new dog, an English setter, on his computer screen. But, he concedes, “I would like to have kids one day.”

Techniques at Motol University Hospital, barred elsewhere, help hundreds conceive. enlarge

For the time being, he is fully focused on his work. He realizes he is lucky he can do that without having to choose between his career and the ticking biological clock, unlike most of the 500 female patients who visit him annually with fertility problems. And he knows a thing or two about biological clocks.

“A lot of what we do here has to do with women waiting longer to have kids,” he says. Unlike men, who produce sperm continuously throughout their lives, traditional fertility doctrine holds that women are born with a fixed number of eggs, roughly 1 million, which they keep losing with age. And, although recent studies on mice, such as one by Jonathan Tilly at Massachusetts General Hospital, have shown there may be a way for them to replenish eggs, this has not yet had much impact. “Men have a clear advantage,” Hrehorčák says. “Their fertility does not decrease as rapidly as women’s.”

During the interview, Hrehorčák excuses himself a few times to perform an ultrasound on a patient. Wearing scrubs, he moves quickly through the halls, looking young enough to blend in with the crowds of medical students he instructs on a regular basis.

No judgment
In the past five years, he has seen a whole spectrum of women come through the door: Some come a few times, get pregnant quickly and are never seen again, while others come back for years. “The ones who keep coming are the ones you get to know and feel bad for,” he says. “The women who really want to conceive are the ones who have the hardest time with it.”

In the Czech Republic, he says, women can undergo in vitro fertilization (IVF), a technique by which egg cells are fertilized by sperm outside the womb and then transferred back into the uterus, until the age of 48. Health insurance fully covers three cycles of IVF. If more is needed, it’s up to the patient to cover.

Because older women are at higher risk for pregnancy complications and birth defects, some say the maximum age at which IVF is practiced should be lowered. Hrehorčák disagrees. “I don’t judge people,” he says. “When I see a 50-year-old woman who wants to have a child and feels up for it, why not?”

Hrehorčák says the Czech Republic’s lack of legal regulation on limiting some kinds of fertility practices makes it something of a haven for women or couples who are struggling.

“In the Czech Republic, we can do almost any method of IVF,” he says. This is not the case in countries such as Germany or Italy, where religious groups have won bans on methods that involve the destruction of unused fertilized eggs. Such laws make it impossible to donate eggs to infertile women or ban fertilizing more than one egg outside the womb in order to improve the odds.

On the other hand, he says, the lack of regulation makes it impossible for fertility doctors to perform practices common elsewhere, such as the use of a surrogate mother. Because there are no statutes laying out the rights of all parties involved, many consider it too risky that a woman who agrees to bear the child of another woman could change her mind and sue for custody. That’s a real loss, Hrehorčák says: “For women unable to gestate their own baby, this is a real option.”

Another thing Hrehorčák would like to see changed is for single women and lesbians to be clearly authorized to use sperm banks to become pregnant. “There are currently no laws to allow that, so it is not done,” he says. “Of course, they can ask a friend to donate sperm, but that’s a whole different issue.”

Part medicine, part science fiction
Arguably, no other field of medicine raises as many ethical questions as fertility. Practices that might have seemed like sci-fi episodes years ago are now performed routinely. Since 1978, when the first test-tube baby was born in the United Kingdom after an exhaustive moral debate, the IVF procedure has become the norm, accounting for about 100,000 pregnancies worldwide each year.

These days reproductive genetics is almost as hotly debated as stem-cell research and cloning.

“New technologies bring new possibilities,” Hrehorčák says. “I am open to it. We can’t stop it from happening anyway.”

As liberal as the good doctor is, he still believes the line needs to be drawn somewhere, even if the technology makes something possible. “I wouldn’t allow gender selection,” he says, referring to the process in which sperm or embryos get tested for X or Y chromosomes and only those of the desired sex are implanted. “That is discrimination.”

He speaks with the conviction of someone who has spent a great deal of time thinking and arguing his points. He has.

The one thing he sometimes finds difficult — ironically enough — is reasoning with people who have doubts but are not religious. Because of the high level of atheism in the Czech Republic, he says, “People won’t say ‘my religion does not allow this.’ Instead, they will say reproductive genetics is ‘against nature.’ What does that even mean? Driving cars is against nature. Everything people do is against nature.”

Hrehorčák finds it easier to work with people who have religious boundaries. “We can talk about the specific issues their religion prohibits and work around them,” he says. “For example, we don’t have to fertilize all eggs. The couple makes the calls.”

Hrehorčák, who speaks Hebrew, in addition to Czech and English, studied in Israel, the world’s most progressive country in fertility treatment. “In Israel, having kids is priority No. 1. At the same time, Judaism does not consider the embryo a child. That’s why they are on top in this field,” he says. “They say: ‘God gave us the tools to procreate.’ And they are using those tools as much as they can.”

Although reproductive medicine is a field many doctors choose because “there is a future in it,” Hrehorčák ended up in it partly by accident. The field of fertility is nice, he says, because you don’t deal much with ill people.

“Initially, I wanted to be a biologist,” he says. “But my mom, also a gynecologist, convinced me that medicine is more practical for life.”

The one thing she never quite prepared him for was the need to get up early. Most hospitals require doctors to be in at 7 a.m. at the latest. “At medical school, they told us that after three months of getting up early, we would get used to it,” he says. “I never got used to it.”

Still, the benefits of working for a hospital, rather than the stereotype of working for a private fertility clinic, are too huge to give up, Hrehorčák says. His work covers a fascinating range: fertility consultations; surgical oocyte, or egg, retrieval; working at the hospital’s neonatal clinic; and performing surgery needed for problems unrelated to fertility in such a way as to preserve the chances of future fertility.

His clinic also helps young cancer patients retain their fertility. Before chemotherapy, doctors can preserve the eggs, sperm or embryos of patients — including child patients — because chemo would otherwise damage them forever.

“The main goal of cancer patients used to be survival,” he says. “Now, with better treatment, more people survive. They might also want to have children one day.”

Being part of something that helps people achieve something they really want is the aspect of his work Hrehorčák finds most rewarding.

“I still find it nice. Some women get tears in their eyes when we tell them they are pregnant,” he says. “That still gets me.”

Iva Skochová can be reached at iskochova@praguepost.com

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