Cradling her two-month-old twin girls in a quiet apartment in Dubai, Zenub is the perfect picture of the radiant mother she struggled so hard to become. Yet, the path to attaining this joy was not an easy one.

Married in 2016, she and her husband waited until five years later to attempt to become parents, only to be met with heartache and physical trauma. Two ectopic pregnancies — a life-threatening condition when a fertilised egg grows outside the main cavity of the uterus — left the young woman shattered in both body and spirit.

“The treatment was harsh,” she remembers during our Zoom interview, explaining how the effects of the chemotherapy medication to treat the condition kept her alive but ravaged her body.

Nonetheless, Zenub’s desire to become a mother never wavered.

But a further ectopic, the doctors cautioned, could prove deadly. IVF (in vitro fertilisation), sometimes called the ‘test tube baby’ procedure, was now the only option for her. A friend, who had also conceived via IVF guided Zenub to award-winning specialist gynaecologist DrZeryab Setna in Karachi.

While IVF treatment offers hope to couples struggling with infertility in Pakistan, that hope comes at a high cost and with no guarantees. Expensive procedures, societal stigma and unethical practices can often add to the emotional and financial burden borne by couples opting for assisted reproduction

With her medical reports from the Middle East and an uncertain sense of hope, she flew to Karachi to initiate the gruelling procedure, spending more than Rs1 million on tests, scans, drugs, egg retrieval, transfer and an anaesthesia procedure.

“You are taking your body to hell, and your beliefs to the test,” says Zenub, who chose to be identified by her first name only. And yet, with one baby snuggled into each of her arms, she acknowledges that the journey was worth every tear, every rupee.

Not all stories, though, end in such triumph.

In Lahore, Saima*, 36, has a darker tale to tell. She sold her wedding jewellery while her husband, a low-ranked government employee, borrowed hefty amounts to pay for an Rs800,000 IVF attempt, only to discover that there were no healthy embryos and therefore no pregnancy. “I feel incomplete because of the taunts I receive from my in-laws,” she says, her pain also fuelled by rising debt.

Beyond financial loss, some couples face deception, as Saif* and his wife learned in Karachi. Lured by a Facebook advert promising 100 percent success through IVF — a scientifically ludicrous claim — they found themselves confused and dismissed. Saif says, “The doctor at this DHA clinic didn’t want to listen to us. We were clueless about what was happening during our consultation. I think it was a scam.”

Their stories are not isolated, each one portraying a larger, more complicated picture of assisted reproduction in the country. From hope to heartbreak, IVF in Pakistan is a journey of extremes.

Across the country, the coveted procedure — which combines male and female reproductive cells in a laboratory to create a baby — promises miracles and sometimes makes them happen. But for many, it delivers confusion, heartbreak and debt. Costs range from Rs600,000 at private clinics to Rs200,000–350,000 in public centres. But beyond money, couples face cultural stigma, misinformation and, sometimes, unethical practices, where poor communication and questionable staff qualifications leave patients vulnerable.

THE STIGMA SURROUNDING FERTILITY TREATMENT

Infertility is not just a medical condition — it’s a deeply emotional experience, made even harder by the societal pressures that come with it. “Society sees children as the ultimate purpose of matrimony,” says Dr Nighat Ali Shah, Professor and Head of the Department at the Sindh Reproductive & Genetic Health Centre (SRGHC), part of the Jinnah Sindh Medical University, where the Sindh government has set up the first IVF centre in the province. She points out that couples struggling with infertility can feel isolated and judged.

The emotional toll of infertility is something many couples face in silence, but Dr Gul Rana Ahmed, Infertility and IVF Expert at the OVA IVF Clinic, Pakistan, believes that it’s vital to offer support, not just medically, but emotionally, too. “We offer counselling and help, especially after failed cycles,” she shares.

The road to parenthood can be long and full of heartache, but compassionate care can make a world of difference, easing the heavy burden that stigma places on couples. Transparency, open conversations, and accessible mental health support are essential to help couples go through this challenging journey, she says.

This stigma also fuels misconceptions, particularly about who bears the burden of infertility, explains Dr Tabaan Khan, a gynaecologist and Senior Medical Officer at Sindh Integrated Emergency and Health Services. Shedding light on the situation in Pakistan, she says that normally, people who go for fertility treatments fall in the age group of 32 to 38.

“This is typically the age when couples in Pakistan seek fertility treatment. What I’ve observed is that men often hesitate to undergo testing due to stigma. There’s a widespread belief, not just among men but within entire families, that infertility is solely a woman’s issue. But that’s not true,” she explains.

Dr Tabaan adds that male factor infertility accounts for nearly 45 to 50 percent of cases in the country. “The problem is that many men go undiagnosed due to hesitation, denial, or disbelief that they could be the cause. That’s why, at fertility centres now, we make it a point to test both partners when they come in.”

For Humaira*, this reluctance delayed her journey to parenthood. After 10 years of marriage, she travelled from Birmingham to Lahore for fertility treatment. The cause of their infertility was male-related, but her husband’s hesitation delayed their decision to start treatment. “He resisted for years and would have emotional outbursts before agreeing to treatment,” she says.

Initially, the couple tried IUI (intrauterine insemination) in the UK but, after three failed cycles, they turned to IVF in Lahore to save on costs. “The UK treatment was too expensive, and our insurance wouldn’t cover more.”

At a well-known Lahore clinic, Humaira and her husband were advised to combine IVF with ICSI (intracytoplasmic sperm injection), where a single sperm is injected into an egg. The first cycle showed promise with a healthy embryo, but it didn’t implant. “The treatment was costly by Pakistani standards, but, in the end, it is God’s will,” she reflects.

Though the couple has paused treatment, Humaira says she still dreams of having a child. “My husband is open to adoption, but it’s hard to let go. I regret the time lost because of his initial hesitation to treatment.”

THE HIGH COST OF IVF

Stories such as Humaira’s show the emotional toll, but the financial burden of IVF weighs just as heavily, as seen by the experiences of Zenub and Saima. While Zenub’s Rs1 million IVF treatment resulted in her twin daughters, Saima had to endure a financial crisis that left her dreams unfulfilled.

Married for eight years now, Saima was 28 when she tied the knot, while her husband was 33. They soon started trying for a baby after their wedding but failed. Several doctor appointments and tests later, no underlying cause could be established: they were diagnosed as having unexplained infertility. With the years going by with no pregnancy, family pressure intensified and gossip gave way to advice for her husband to remarry for the sake of having an heir.

Saima recalls, “One of my cousins was also having a similar problem with conceiving. Her husband worked in Saudi Arabia, so they could afford the IVF treatment. They had a child after 10 years of marriage, which gave me hope.”

“So, I began insisting we also go for IVF, and my husband was on board. I sold all my wedding jewellery, and my husband, who barely earns enough to feed the whole household, including his siblings, parents, and me, took loans from people. We paid a total of Rs800,000 to a very well-known clinic in Lahore and they were quite transparent with us, telling us that success wasn’t guaranteed but they’d try their best.”

As she underwent the procedure at the age of 34 , the doctors could only retrieve 12 eggs from her first cycle, but none of them could give a euploid (an embryo with the normal number of chromosomes).

“We are shattered,” she says. “We can’t afford another round immediately but I’m saving up money again to try a second time. My husband has yet to pay off the loans we initially took, so I have joined a rotating credit fund.”

Infertility treatments, in particular IVF, can be very costly, which is of great concern for couples. The costs can pile up fast, from consultation fees to medication and treatment costs, and additional cycles. For couples from relatively low- or medium-income families, the financial burden can render treatment almost inaccessible.

Nonetheless, couples go to great lengths to make the treatment possible, even if they have to exhaust all their savings, as in the case of Saima.

According to Dr Setna, who runs the renowned The Fertility Clinic By Setna in Karachi, while costs do cause some constraints, most couples — irrespective of their socio-economic status — seek help and consider IVF.

“Unfortunately,” Dr Setna explains, “IVF is an expensive treatment with almost all inputs, including medication, being imported. We are unable to offer discounts generally, but we have partnered with Oraan, a financial services provider to facilitate instalment plans for our patients.

“Our patients are welcome to contact the Oraan platform, which will help develop an instalment plan that works for them.”

Dr Gul Rana also says that due to the high costs, many low-income couples find it difficult to opt for a second attempt. “However, those who are highly motivated to have a child often save up or seek financial help to try again,” she says. “Many clinics, including ours, offer discounts, or low-cost cycles for financially constrained couples, to make treatment more accessible.”

PUBLIC AND NON-PROFIT IVF CENTRES — A RAY OF HOPE?

To ease these financial burdens, public and non-profit IVF centres offer a lifeline for low-income couples. While there is an acute dearth of public-funded IVF centres in the country, the SRGHC, a project of the Sindh government, provides hope despite its challenges. Limited resources, the high prices of imported medication, and the need to outsource certain tests mean the treatment isn’t entirely free, though costs are significantly subsidised.

The IVF centre at SRGHC, developed under the guidance of Dr Shah, functions in collaboration with various laboratories. “While we don’t have a full embryology lab yet, we do offer andrology services such as semen analysis, hormonal work-ups, and IUI procedures,” she explains. “The unit operates seven days a week, regardless of emergencies. It doesn’t stop.”

Dr Shah adds that in discussions with the government — which has shown strong interest in supporting fertility services — she proposed a three-pronged financing model: one-third of the cost covered by the patient, one-third subsidised by the government, and one-third provided as a loan.

“At our clinic, we once had a woman whose husband sold his rickshaw, their only source of income, to pay for the IVF treatment,” recalls Dr Shah. “Despite their sacrifice, the cycle failed. We managed to raise internal funds to cover some costs and refunded what we could for another cycle. But that kind of support is rare and not something private clinics can typically offer, as they must cover all expenses themselves. We, on the other hand, were able to manage it only because of government funding and other support.”

Dr Shah notes that, while SRGHC covers doctor and lab fees, patients must still bear the cost of medicines, which typically falls between Rs100,000 and Rs150,000, depending on their age and hormonal response.

“Younger women often need fewer injections, keeping costs down, but older or less responsive patients may require up to six shots a day, which quickly adds up,” she explains, adding that price gouging by pharmaceutical companies makes matters worse.

“On day six of a patient’s cycle, for example, a supplier refused to release medicines unless we paid double,” she recalls. SRGHC covered the difference, leaning on cooperative pharmacies and clinics such as The Fertility Clinic by Setna to help source supplies.

THE DECLINE IN FERTILITY

Efforts to improve access come as infertility rates rise, creating a growing need for such services. World Health Organisation (WHO) data from 2024 shows that globally, one in six people face infertility, defined as the inability to conceive after 12 months of trying. Pakistan, the world’s fifth-most populous country, presents a complicated demographic profile, with both high rates of fertility and infertility.

According to the non-profit organisation Population Council’s ‘Pakistan@2050’ report, the country’s fertility rate is higher than both South Asian and global averages, second only to Afghanistan. The Pakistan Demographic and Health Survey (2020) shows a total fertility rate of 3.7, with 3.0 being wanted fertility, meaning many women have more children than desired. The country also faces high infertility rates, with a prevalence of 21.9 percent, including 3.5 percent primary and 18.4 percent secondary infertility, according to the Pakistan Journal of Medical and Health Sciences. Primary infertility is the condition where a woman has never conceived, while secondary infertility is when a woman has conceived before but is unable to do so again.

As explained by the Mayo Clinic, infertility, affecting both men and women, can result from hormonal imbalances, genetic disorders, lifestyle choices, and reproductive system issues. For women, causes include irregular ovulation, Polycystic Ovary Syndrome (PCOS), blocked or damaged fallopian tubes, or endometriosis. In men, low sperm count, hormonal imbalances, and reproductive system issues can contribute to infertility. Sometimes, the cause remains unexplained.

Presenting her observations over the last 10 years, Dr Shah says that rising pollution, consumption of processed foods, as well as climate change, have been key drivers in contributing towards poor quality eggs as well as sperm.

According to Dr Shah, “I have noticed an extremely prominent decrease in the quality of mature follicles over the past 10 years. When earlier, we used to take and put them under the microscope, we used to have a good feeling that these were healthy follicles. Now, even with young females, what we find is that they degenerate very rapidly.”

She notes that one of the most common conditions seen in women visiting fertility clinics is PCOS, which is highly prevalent in the population. “Among men, contributing factors include the use of substances such as paan [betel], gutka, chhalia, cigarette, and naswar, all of which affect sperm quality.” Over time, she observes, these factors appear to be contributing to a steady decline in reproductive health.

With infertility on the rise, waiting to start a family can stack the odds against couples. Career dreams, money troubles, or life’s twists often lead couples to delay having kids, only to hit the wall of age-related fertility decline. For women past 35, becoming pregnant gets harder, and IVF, though a lifeline, grows tougher with time, dimming the spark of hope.

Asma*, now a 40-year-old banker, underwent three unsuccessful intrauterine insemination (IUI) cycles, beginning at the age of 36, in Lahore before turning to IVF in Karachi. Her age, along with diabetes and hypertension, complicated the process. “I do regret waiting so long and not trying in my early 30s,” she says.

After exhausting her savings and taking on loans, she developed ovarian hyper-stimulation syndrome (OHSS), a painful side effect of IVF. Even so, she was able to freeze three viable embryos. In an unexpected turn, she conceived naturally at 38 and gave birth at 39. “Our daughter is nothing short of a miracle,” she says. She has opted to still keep the embryos for the future.

According to Asma, IVF can offer hope, but it also brings risk, uncertainty, and financial strain. Her advice to others is simple: “If you’re over 35 and trying, don’t put it off. Look into your options early if you can.”

Doctors agree that while IVF can still work later in life, age has a clear impact on fertility. “IVF is generally most effective before 35,” says Dr Setna. “But we do see promising outcomes with customised protocols, even in women in their early 40s.”

Dr Gul Rana shares a similar view, saying many women in their late 30s and 40s have conceived at her clinic with the help of individualised treatments.

Still, biology has its limits. “Women are born with a fixed number of eggs,” explains Dr Shah. “And men’s sperm quality starts to drop after 44, especially with stress, poor diet, or smoking.” She advises couples not to delay seeking help and to keep options such as adoption in mind if treatment doesn’t succeed.

As for IVF success rates, they vary globally and are influenced by factors such as patient age, health and clinic protocols. The American Society for Reproductive Medicine (ASRM) reports IVF success rates of 30-35 percent for women under 35, dropping to 25-30 percent for ages 35-37, and lower still for women over 40. In Europe, the European Society of Human Reproduction and Embryology (ESHRE) cites a 20-40 percent success range, with similar age-related declines.

In Pakistan, IVF success rates align with global trends but vary by clinic, technology and patient demographics. The Fertility Clinic by Setna reports 35-40 percent success across age groups. OVA IVF & Reproductive Health Clinic notes 25-35 percent success per cycle, though cumulative cycles can lead to higher take-home baby rates. The SRGHC reports lower success rates of 17-18 percent, likely due to limited resources and broader patient access.

NEED FOR STRICTER REGULATION

While age and access shape IVF outcomes, unethical practices in Pakistan can add another layer of pain for couples, as discovered by Saif and others. Following three unsuccessful attempts at conception, Saif, 31, and his wife, 27, decided to go for IVF on the advice of friends and family.

“I found one such clinic located in Karachi’s DHA through an ad on Facebook that promised 100 percent success with a foreign-qualified doctor,” says Saif. “The beginning of the consultation was promising, as the doctor assured us that a 27-year-old woman couldn’t develop complications. He even told us that we would be able to choose a boy through the procedure, and quoted us the price of Rs800,000 for the first round of egg retrieval.”

But as the conversation went on, Saif said he began to feel increasingly uncomfortable. “When I asked questions about his lab, he said he outsourced everything but never provided any clear responses. My questions were making him upset.

“We consulted with everyone and decided not to proceed with it. The clinic seemed dubious. I did try to Google whether it had branches in the countries it listed but couldn’t find anything. I’m grateful I didn’t pay, as my instincts worked. But when couples are desperate and they are assured of the results, I can understand how difficult it is to resist. My wife was very upset with me. She still is. We are saving a bit more and are going to go to a clinic that is the most reliable one in Karachi.”

Sidra*, 35, who has been married for eight years but never actively tried conceiving a baby, had a similarly unpleasant experience at the same DHA clinic Saif and his wife had gone to. “My friend and I went to check out IVF because of its upscale DHA location,” she remembers. “The consultation was unprofessional. The doctor, seated at a laptop, dismissed our questions regarding age and number of eggs, said the AMH [Anti-Müllerian Hormone] test was unnecessary, made derogatory remarks about other doctors, and said my friend’s eggs were ‘unused’ because she wasn’t having intercourse. His business card had misspellings, and his lack of knowledge felt like deceit.”

Sidra is worried about unsuspecting patients getting duped in such an upmarket area. “I am a layperson but know the AMH test is necessary before IVF. I wonder how such a clinic is running. Where are the authorities? Is there an error-check mechanism to verify the credentials of the doctor or can anyone set up a clinic and play with people’s lives?”

Like Sidra, Ayesha*, a 38-year-old educator, says she felt she was deceived at an upscale Lahore clinic that promised her an 80 percent IVF success rate for Rs600,000. Her hopes crumbled when four embryos failed.

In 2023, she underwent IVF with ICSI at a well-known IVF clinic in Lahore due to her husband’s low sperm motility, costing Rs550,000 plus Rs70,000 in tests. The process, with frequent visits and costly injections, was gruelling. “The clinic’s rush, with too few doctors, felt like a scam,” she says, cursing long waits and broken promises.

Ayesha endured steroid side effects, which were initially dismissed as “normal” but were later blamed on her body. Only two weak embryos survived from six eggs, contradicting the 80 percent claim. “They pinned it on us,” she says, heartbroken and in debt.

Dr Tabaan warns of the dangers of unregulated clinics. “They falsely claim 100 percent IVF success, ignoring factors like age, and some offer illegal gender selection, risking patient health. Seven or eight out of 10 patients at these clinics seek gender selection, which is unethical and unsafe. With no effective reporting channels, these practices persist, as patients rarely disclose their experiences due to stigma.”

She notes that many small clinics popping up in different cities lack the expertise for complex IVF, leading to high failure rates and potential health risks from improper medications or procedures.

A DREAM WORTH FIGHTING FOR

IVF in Pakistan tests hearts and wallets, with couples facing stigma, debt and deceit for a shot at parenthood. The journey is fraught with financial and emotional stress, accompanied by public judgment and unethical activities in a poorly regulated sector. Unfortunately, there is often also a cultural stigma attached to and not enough awareness regarding alternatives to expensive medical intervention, such as adoption.

However, amid demands for more transparency and reform are tales of hope and victory. Zenub’s journey is one such story, a testament to the strength and hope many cling to despite all odds.

“After my miscarriages, I thought I’d never even have one baby, but God has blessed me with two,” she says with a smile, her eyes brimming with tears of joy. “When someone says, ‘You spent one million on IVF?’, I tell them: ‘I’d spend all the money in my life to hold my daughters in my arms.’ There is nothing in life like the feeling of being a mother. I couldn’t ask for more.”

*Names changed upon request to maintain privacy

The writer is News Editor at Dawn.com. She can
be reached at [email protected]

Published in Dawn, EOS, May 11th, 2025