Infertility no longer means childlessness. Many couples are resorting to Assisted Reproductive Technology (ART) to fulfil their dreams of parenthood. Why has the incidence of infertility increased? What are the advances in the field? Read on to find out.

Mrs. A was becoming desperate. She wanted to have a baby but had not conceived. Even worse, she had undergone IVF twice without success. Almost at the end of her tether, she approached Dr. Nandita Palshetkar, Infertility Specialist and Medical Director Lilavati Hospital's Bloom IVF Centre Mumbai and La Femme Fortis Bloom IVF, New Delhi. After studying her history and examining her, Dr. Palshetkar put her on the ICSI-IMSI plan. The treatment was successful and the patient deliriously happy.

Another couple from the U.S. also faced a similar dilemma. The man had an undescended testis on one side and a blocked sperm passage on the other. Earlier attempts to correct the block elsewhere were unsuccessful. Finally they consulted Dr N. Pandiyan, Chief Consultant in Andrology and Reproductive Medicine and Head of the Department of Reproductive Medicine, Chettinad Hospital and Research Institute, Chennai. Here, the man underwent micro epididymal sperm retrieval and his wife ICSI. The treatment worked and the woman went back to the U.S. to deliver her baby. A few months later the couple came to India to show the baby to the doctors who helped them to realise their dream.

Causes

Given the growing number of people in India, one wouldn't think infertility is a big problem among our population. But infertility is indeed on the rise and it has a lot to do with changing social mores and lifestyles.

Dr. Priya Selvaraj, Assistant Director, GG Hospital, Chennai, (which is credited with commissioning India's first frozen oocyte baby) points to two factors: one, the average age of marriage and childbirth among women has gone up and second, a rise in the number of male infertility cases. Apart from genetic factors, she lists the causes for these as “career demands, long working hours and possibly the need to put career and financial security before starting a family; lifestyle disorders like diabetes and hypertension occurring earlier due to eating at odd hours, junk foods and low physical activity; lower libido and erectile dysfunction owing to medical disorders and habits such as smoking and alcohol consumption, which is directly proportionate to stress.” Another important factor is obesity, which sometimes leads to polycystic ovarian syndrome in women.

Dr. Kamala Selvaraj, Associate Director, GG Hospital, Chennai, and Dr. Pandiyan add to the list: Induced abortion, atmospheric pollution, pesticides, use of gadgets like cell phones and laptops, radiation, promiscuity and sexually transmitted diseases…

Why does late marriage matter so much? Dr. Pandiyan explains that a woman reaches maximum fertility in her mid-20s. The decline in fertility begins in the 30s and is significant after 35. Pregnancy after 40 years is rare and cannot happen after menopause unless through egg donation. In men, fertility declines rapidly after 40 years. He also warns: “Promiscuity and sexually transmitted diseases increase chances of damage to the reproductive organs thereby increasing the risk of infertility.”

Many wonder when the diagnosis of infertility is made. According to Dr. Palshetkar, “If one year of unprotected intercourse fails to result in pregnancy.” Dr. Kamla Selvaraj suggests that, in the case of a late marriage or if the woman is over 35, an evaluation after six months may be necessary, especially if the woman has problems like irregular menstrual cycles or the man has low sperm count or erectile dysfunction. Dr. Palshetkar also points out that, in India, tuberculosis also contributes to the increased incidence of infertility.

Options

But the doctors all agree that there are solutions to the problem. The first step, says Dr. Priya Selvaraj, is awareness. This involves dissemination information about nutrition and health, screening for genetic conditions and treating existing problems. Dr. Kamala Selvaraj suggests marriage at the right age (21-25 for women and 26-28 for men), avoiding smoking and drinking for 3-6 months before attempting to get pregnant.

Dr. Pandiyan takes this a step further: “Avoid maternal exposure to persistent organic pollutants. If possible diagnose and treat undescended testis early. Encourage abstinence before marriage, one spouse relationship, safe sexual practices, early and appropriate treatment of sexually transmitted diseases, exercise and lifestyle modifications.”

And for those who need it, there are Assisted Reproductive Technologies. Dr. Palshetkar points out, “The specialist usually checks for sperm count and motility in the man and tubal patency in the woman. If both are normal, Intra Uterine Insemination (IUI) is done for couples with blocked tubes, failed ovulation or very poor sperm quality and quantity and those who have not conceived with IUI, we have the option of IVF or ICSI . It is especially useful in male factor infertility.

Agrees Dr. Rishma Dhillon Pai, Senior VP, Federation of Obstetric and Gynaecological Societies of India and Consultant Gynaecologist Lilavati and Jaslok Hospitals, Mumbai, “Almost all cases of infertility and most cases so far considered untreatable can be treated in some way or other. Besides technologies like IVF and ICSI, PESA and TESA have given hope to men with absent vas or men with testicular failure. The one new thing is IMSI or intra cytoplasmic morphologically selected sperm injection (which involves examining sperm under a high magnification microscope to select the best ones). Unmarried women at the peak of their career with no partner in sight and cancer patients about to undergo radiation can now have their eggs frozen. Even if you are 50 today, you can still find a egg donor and/or surrogate mother. Every woman has the right to have a child.”

Cutting edge technology has pushed the frontiers of science in the field of infertility. Dr. Priya Selvaraj exults, “In cryo preservation, extra embryos (fertilized eggs) can be stored at sub-zero temperatures for future use, reducing the repetition of stimulated cycles. Prolonged cultures to the final stages of embryo development called the blastocyst, when used in indicated cases, has shown better results and avoids multiple pregnancies .Those keen on having their biological child despite a transmittable or sex-linked genetic disorder also have the option of prenatal genetic diagnosis through embryo biopsy.”

What about possible birth defects, one might wonder? According to Dr. Palshetkar, the risk is as low as 1-3 per cent. It increases a little in the case of multiple pregnancies.

Side-effects

Women undergoing ART are administered with many hormones as part of the treatment. Side-effects are a major concern. Dr. Priya Selvaraj, however, counters this. “It is not harmful to undergo repeated stimulation cycles when the prescribed gap is followed,” she says. “A few women develop ovarian hyper-stimulation syndrome, which is completely treatable and poses little risk.”

Dr. Palshetkar agrees, “These hormones are already being produced in the body in minimal doses. So they do not have major side effects. Some women may complain of breast tenderness and bloating, which are self limiting and resolve once the injections are stopped.” For those who want a baby at any cost these are minor issues.

If the woman is unable to carry the baby, surrogacy is always an option. Dr. Kamala Selvaraj cites the case of Shanthi, who was born without a womb. Knowing that surrogacy was the only option, Shanti and her husband approached GG Hospital. After a mock stimulation cycle, Shanthi was put on hormones, her eggs retrieved and fertilised by her husband's sperms. Earlier a surrogate mother had been chosen; a woman who undertook surrogacy to provide for her own children. After an uneventful pregnancy, Shanti's twins were born through a C-section. Today Shanthi says she is ready to give up anything for her biological twins.

Technological help

In vitro fertilization (IVF) involves removal of mature eggs or oocytes from the woman's ovary and allowing fertilization to take place with sperms in a petri dish in a culture medium. The fertilized eggs are then transferred to the woman's uterus. A boon for couples with unexplained fertility and women with blocked or damaged fallopian tubes and male partners with sperm disorders. Success rate depends on the couple's age and the duration of infertility.

Intra cytoplasmic sperm injection (ICSI) is an advanced technique in which a single healthy sperm is injected into the retrieved egg under absolutely sterile conditions. The fertilized eggs are then placed back in the woman's uterus. Ideal for men with very few normal or motile sperms or no sperms at all in their sample.

Intra uterine insemination (IUI) is a simple procedure in which a catheter is used to inject a small quantity of washed sperm into the woman's uterus. This increases the number of motile sperms reaching the fallopian tubes around the time of egg release, thus improving the chances of fertilization.

In almost all these procedures, the woman's ovaries are stimulated to achieve improved egg production (the eggs' quality diminishes with age). The growth of follicles are closely monitored and the eggs are either collected surgically or allowed to release in a specific time frame by administering appropriate hormones.

Laser Assisted Hatching (LAH) Before implantation the embryo has to come out of its protective shell – zona pellucida - through a process known as hatching. Otherwise pregnancy will not happen. Culture techniques in the lab too contribute to the hardening of the embryo wall. In LAH a laser is used to make an opening in the zona to help the embryo hatch and implant correctly. Patients older than 35 years with previous IVF failures and with frozen embryos benefit from LAH.

Vitrification is ultra-rapid freezing of the embryo to ensure better survival and pregnancy rates. IT has also indirectly reduced multiple pregnancy rates.