SUDHA UMASHANKAR

Infertility no longer means childlessness. Many couples are resorting to Assisted Reproductive Technology (ART) to fulfil their dreams of parenthood. Our writers talk to doctors to find out the reasons for the high incidence of infertility and the advances in the field; and offer suggestions on how to cope with the emotional trauma.

Cutting edge technology has pushed the frontiers of science in the field of infertility.

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.

Emotional hurricane

L ast night a woman told her story for the first time before someone. It had taken her years to gather courage to share it. But the look of relief as she spoke, her sense of comfort as her feelings were understood was palpable to me.

Shalini, 29, has been battling infertility for five years. She began planning a family at 24. Thinking age was on her side, she did not contact a doctor when she failed to conceive after two years of unprotected sex. She went in for fertility treatments but, during the counselling session, confessed that she feels infertility is the will of god and she has lost her will to battle god. Exhaustion, defeat and anger alternate, punctuated by resolve, hope and grief.

When the world stops reeling after a diagnosis of infertility, what you are left with is a constant need to think clearly and resolutely. The excessive demands of infertility and the prolonged amount of time that could be involved in resolution require not only clear thinking but emotional strength and stability, internal and external resources, colossal resiliency to recover from each month’s potential disappointment and the capacity to identify feelings to communicate it effectively to the people you rely on. So, how do you cope through this journey to parenthood?

Accept and acknowledge

You will experience negative and painful emotions. Acknowledge the validity of your emotional state and don’t try to change or suppress it. Realise the impact that infertility has had. Contact a counsellor if you need help with coping. Research shows that people who seek counselling have greater success in conception because chronic emotional stress is reduced.

Healthy lifestyle

According to Dr. Rohit Gutgutia, Genome: The Fertility Clinic, Kolkata, obesity and polycystic ovaries contribute to infertility. “These are exacerbated by an unhealthy lifestyle, junk food and chronic stress.” Eat well and exercise. For those already undergoing treatment, fitness coach Sanjib Das suggests light cardio and core workouts to strengthen abdominal muscles and yoga to increase circulation, flexibility and decrease stress. He advises his clients against weight training or high impact workouts during this time.

Boost self esteem

Infertility can impact your self-esteem and body image leading to depression and hopelessness. Identify unrealistic, distorted messages of low self-worth, shame, guilt and responsibility related to infertility. Reframe and restructure these messages into realistic, constructive thoughts. Learn to focus on factors that are within your control - stop smoking - rather than on factors beyond your control like age. For the infertile partner in a couple, feelings of guilt and responsibility can arise. Recognise that men and women react differently to infertility, so talk to your partner about their feelings. Question internalised cultural values around motherhood and gender roles, and release unnecessary social pressure. Find your own truth.

Coping with the fertile world

Explain your situation firmly and clearly to those who pass insensitive statements like, “When are you starting a family? You are old enough” or “Where’s the good news?” Many people do not understand infertility and, remember, others do not know what you are going through. After sharing, recognise those who are downers and draw strong boundaries. Be clear on what hurts you or makes you feel disillusioned. De-clutter personal relationships and reduce stress associated with them. If being involved in baby-focused activities bother you, avoid them. Reach out to supportive individuals who can provide empathy and concern.

Find silence within

It’s easy to get swallowed by the demands of infertility, but find a space for yourself through art, meditation, hypnosis, therapy, prayer, reading, spirituality, or connecting with people, animals and your inner creativity. Identify physical signs of stress and work on them through yoga, tai chi, Pranayam etc.

If you do decide to stop treatment, don't believe it is giving up. There is a lot of courage in setting limits and knowing when to re-think your life. But, at the same time, don't be afraid to explore alternatives.

As a former client said, “My delight in my child comes from having her and not by a biological connection to her. The rewards are so great, if you are able to work and get through the hard stuff.”

I hope all of you can reach an ending that makes you happy.

Emotional rollercoaster

Rage at the betrayal of your body

Shame/embarrassment for not functioning"normally"

Guilt and self-blame

Resentment or sadness at the joy of others whohave children

Emotional turmoil, hopeful one minute, anxietyand disillusionment the next

Tension in relationship with your partner

Isolation from family, feeling you don't fit in withyour friends who have kids

Feeling stigmatised, you are not a real woman ifyou can't have a child

Profound sadness thinking about a childlessfuture

MANSI PODDAR

The writer is a Psychological Counsellor. Website: www.mansitherapy.com