Struggling to Reproduce

Infertility is slowly making inroads into urban India. Consequently, the number of Indian couples turning to artificial methods to conceive has gone up considerably.

By Amresh Kumar Tiwary

As per a study conducted in nine Indian cities in which 2,562 people participated, nearly 46 percent were found to be infertile. Results from another parallel survey conducted among 100 infertility specialists showed that nearly 63 percent of the infertile couples belonged to the child-bearing age group (31-40). As life runs on the fast lane, a phenomenon called infertility slowly makes inroads into the lives of urban India, giving more and younger couples sleepless nights and problems in having a child. It is rather ironic that from a time when family planning drives launched in the 1970s were the government’s prime focus, the country has come to a point where suddenly the young and modern India seems to be caught in the ever-increasing problem of infertility. A trip through the infertility roller-coaster seems inevitable for many such hard-hit couples who, soon after marriage, realise how uphill a task getting pregnant can be nowadays! With the crisis brewing at a rapid rate, almost 30 million couples in the country suffer from infertility, making the incidence rate of infertile couples 10 percent. Today, the number of Indian couples turning to artificial methods to conceive has gone up considerably. However, keeping infertility at bay is not impossible at all, and all that is required is tenacity, consistency, and willpower in our day-to-day activities. But before we delve deeper into the problem, it is important to understand what exactly infertility is and how one defines it. Every human being wishes to procreate, and historically, infertility has been like a curse for any individual affected by it. Couples may find it difficult to conceive naturally due to different reasons. Assisted Reproductive Technology (ART) consists of a comprehensive programme that is offered to such couples. Infertility centres these days provide comprehensive infertility management and ART programmes to patients. The various forms of treatments like Intrauterine Insemination (IUI), In Vitro Fertilisation (IVF), Third Party Reproduction , and Intracytoplasmic Sperm Injection (ICSI) are in vogue these days. ICSI, pronounced “eeksee” or “icksy”, is an in vitro fertilisation procedure in which a single sperm is injected directly into an egg. The technique was developed by Gianpiero Palermo around 1991 in Brussels. Today it has become the treatment of choice for men with weak sperm that cannot travel themselves into the egg.

When can ICSI be performed?

Men with obstruction in their passages can father a child by using their own sperm that have been extracted by a surgeon. ICSI can also be offered to patients with previous IVF failures due to failed fertilisation   and patients with unexplained infertility. ICSI is different from conventional insemination because we clean away the follicle cells from around the eggs and an embryologist chooses the sperm to be injected. A small number of eggs do not tolerate the injection procedure, and you can expect that about 5 per cent of eggs die as a direct result of ICSI. However, fertilisation rates, embryo quality , and pregnancy rates are the same as for couples who do not undergo ICSI.

How is ICSI performed?

The process involves the injection of a single sperm into the ooplasm of the oocyte. Following the first ICSI birth in 1992, thousands of babies have been born around the world. Sperm for ICSI can be obtained from ejaculation, even when only a few are present, or through surgical retrieval from the epididymis or testis. Microinjection is normally performed under a specialised microscope with the aid of a micromanipulator, which allows small movements under high magnification. The scientist or embryologist sits at the ICSI station, looks either directly into the microscope or at a monitor that magnifies the image, and then injects the egg by moving two manipulators that look and function like joysticks. He holds the oocyte with one hand and injects it with the other.

IVF

Reproduction is the process in which there is fusion of the male and female gametes resulting in the exchange of genetic material, thus forming a new individual with an entirely different genotype. Mammals reproduce through sexual reproduction, but technology now allows mammals to reproduce “asexually” through the process of in vitro fertilisation. In this technique, the entire process of fertilisation takes place outside a woman’s body. This involves extracting a woman’s eggs, fertilising the eggs in the laboratory with sperm, and then transferring the resulting embryo(s) into the woman’s uterus through the cervix (embryo transfer), where they can develop. Most couples transfer two embryos; however, more may be transferred in certain cases. IVF is the most common form of ART, and it is often the treatment of choice for a woman with blocked, severely damaged, or absent fallopian tubes.

Evaluation and Preparation of a Couple

Proper evaluation of an infertile couple before IVF is very important for the success of IVF and prevention of complications. Any ART procedure should be preceded by a traditional fertility workup, and at this stage it should be decided whether ART should be instituted, postponed for other treatment modalities, or refused to the couple. Once the patient has been selected to undergo ART treatment, thorough testing should be undertaken to correct any problems which may lead to IVF failure. At this stage, it should also be decided whether a specific procedure such as egg, sperm, or embryo donation is required.

Third Party Reproduction

Third party reproduction refers to the use of oocytes, sperm, embryos, or a uterus that have been provided to a couple or single individual (called intended parents) by a third person (donor) in order to help them become parents.

 

According to the current Indian guidelines on ART drafted by the ICMR, all donors except the surrogate must be anonymous to the commissioning couples.

According to the current Indian guidelines on ART drafted by the ICMR, all donors except the surrogate must be anonymous to the commissioning couples. The ICMR guidelines also state that the activity of supplying various gametes and surrogates will not be carried out by the IVF centre, but by separate entities called ART Banks. All legal issues are also the responsibility of these banks. Once the requirement is identified, the medical fitness of the donor is assessed. After fulfilling the various formalities, the couple and their donor or surrogate are taken into the third-party programme. 

Recurrent Pregnancy Loss Programme

There is nothing more painful than losing a pregnancy repeatedly! It is not only devastating for the patient but also the treating doctor! Recurrent Pregnancy Loss (RPL) is defined as a situation where a woman has lost three or more than three pregnancies. In fact, RPL may be caused by chronic infections like genital tuberculosis! Research has also shown that the majority of recurrent failures, whether at implantation or later in pregnancy, are due to impaired blood circulation within the pelvis, especially the uterus. The cause for this may vary.Doctors carry out tests to rule out the cause of RPL and accordingly treat the patient. If the patient has a genetic cause, the patient and her husband are informed about the defect and counselled regarding future implications. Endocrinal causes like PCOS can also be a reason and need to be tackled by taking insulin-lowering medication. There is no need to go through extensive testing after a single pregnancy loss. This could have happened by chance, and one should not worry about it.

Male Infertility Programme

Ever since the human race evolved on Earth, it was the female who had been seen as responsible for procreation. So, if anything was amiss, the woman was supposed to be at fault. All research focused around the development of medication and technology for female infertility. While such innovations improved success in female infertility, no attention was being given to the male counterpart. This was also because infertility was the realm of the gynaecologist! There were no special doctors for men with problems. In developing countries like India, another reason was a complete denial by men in accepting themselves to be the cause of infertility in the couple! However, the last century saw rapid advances in the management of the infertile male, both in diagnostics and treatment. The WHO gave guidelines for a proper semen examination, and based on these, treatment protocols were developed. Today, a male infertility programme involves not only standard testing procedures like semen analysis but also special tests to determine the fertilising potential and quality of the sperm. This is called the DNA Fragmentation Test. In patients who are azoospermic on testing, testicular fine – needle aspiration is undertaken. If this too does not show sperm in the sample, doctors proceed to a testicular biopsy. The sample is checked for sperm and, if positive, it is frozen or cryopreserved until the wife is ready for ICSI. Men who have mild male factor infertility can be offered IUI, but those with weak sperm are treated by either IVF or ICSI , and recently, by IMSI.

 

Infertility in Couples
By Dr Sudha Prasad

 

 

Infertility is defined as difficulty in conceiving or becoming pregnant, despite having regular sex without contraception for two years in a row. The time a couple takes to conceive could vary from days to months. In the past, infertility was largely seen as only ‘a female problem’, with women easily becoming the target of social stigma.

Approximately 40 per cent of infertility in couples can be attributed to male subfertility. ICSI has raised hopes for these couples. This method of treating predominantly male-factor infertility has been a breakthrough, and it has established itself as the preferred method of treatment in the field of assisted reproduction.

According to experts, assistance can be given to both men and women depending on the cause of infertility. Infertility management involves detailed investigations to reach a logical diagnosis and then specific treatment. However, such a theory no longer exists, and the time when women were solely battling the blame for being barren has become a part of a bygone era! There have been enough research revelations that have attributed the male to the cause of infertility, and there is a general realisation that implicating a woman with prejudice would only result in ignoring the root cause of the issue. Now, one in every five men between the age group 18 to 25 is found to suffer from abnormal sperm count — one of the main causes of infertility. With the problem having become widespread, what are the reasons, one may ask? Irregular and low sperm count, hampered sperm delivery, and poor motility of sperm are prominent causes of infertility in men. Some other medical reasons such as obesity and lifestyle disorders — including diet imbalance, addiction to smoking or alcoholism, sedentary lifestyle, or mental and emotional stress — contribute to poor sperm count.

Polycystic Ovary Disease (PCOD), a condition characterised by excess production of hormones and lack of ovulation, coupled with hectic lifestyle and job stress, lead to conception problems amongst women. Primary Ovarian Insufficiency (POI) is another cause of ovulation problems. POI occurs when a woman’s ovaries stop working normally before she is 40. Other than the above, changing lifestyle patterns, strenuous work schedules , and stressful surroundings are some major reasons responsible for tilting the scale towards the inability to conceive. With an increase in stress and fatigue, men and women often suffer from a steady decrease in libido , which has lately become an issue of concern for many. surroundings are some major reasons responsible for tilting the scale towards the inability to conceive. With an increase in stress and fatigue, men and women often suffer from a steady decrease in libido , which has lately become an issue of concern for many. High testicular temperature is increasingly cited as a cause for male infertility. Scientific studies have indicated that prolonged use of mobile phones can significantly affect male infertility. Exposure to any type of intense and prolonged radiation is known to harm sperm production. 

Thus, it would be wiser for men to wear loose underwear and pants and to take frequent breaks when they work in a sitting position for

periods. Resting laptop computers on the lap raises the scrotum’s temperature, say researchers , and hence it is better to avoid using them on laps literally. Though physical exercise is imperative, great caution is required especially when it comes to specific sports where the testis is not properly protected in men. Testicular injuries must always be treated without any delay, lest they result in long-term consequences on fertility. Another issue of concern is the declining libido among urban couples, which has emerged as one of the main factors affecting couples living in the cities. Hectic schedules, poor work-life balance, constant tension , and increase in travel time leading to low levels of libido and less sexual activity among couples, are the biggest hindrance to conceiving nowadays. As stress levels are usually high among urban couples, poor eating habits and an increase in medical conditions such as diabetes lead to lack of quality and quantity of sperm and eggs. Thus, habits such as smoking, tobacco consumption, frequent drinking, unhealthy food habits, and lack of exercise have to be immediately done away with. It could also be shocking to know that products like furniture polish, all-purpose cleaners, bug sprays, bathroom cleaners, and room deodorisers may contain chemicals that could diminish conception by 33 per cent. Organic, non-toxic alternatives are always a better option. Paint thinners, household glues, and oil paints can be toxic and negatively affect fertility, increasing the risk of miscarriage when pregnant. If the ‘sniff test’ indicates a strong and offensive smell, it is better to avoid them. Women should be wary of paraben, a preservative found in most cosmetics, from shampoo to moisturisers to lipsticks. Parabens 

A male infertility programme involves not only standard testing procedures like semen analysis but also special tests to determine the fertilising potential and quality of the sperm. This is called the DNA Fragmentation Test.

-belong to a group called xenoestrogens, or false oestrogens , that could induce infertility.

Consuming full – fat dairy products daily could help fertility. Cow’s milk, especially that which is milked when the animal is pregnant, is rich in fertility-enhancing hormones. Microwaved food could be quick, but plastic containers need to be avoided. Hormones leach more when certain plastics are hot and wet. And finally, a good sleep is ideal, as 80 per cent of ovulation occurs between midnight and 4 a.m. Interrupted sleep could weaken immunity, disrupt reproductive hormone levels, and hinder ovulation.

The author is Director of Matritava Advanced IVF & Training Centre in Vasant Vihar, New Delhi.