Thirty-three-year-old Shruti and her 37-year-old husband Arun had ticked off all the boxes on their checklist — a rising career graph, a swanky apartment on Palm Beach Road in Navi Mumbai, a Beagle and the latest SUV, which Arun made sure was child-friendly. While they crafted their future years lovingly and were finally ready to be parents, they failed at what they thought would have been an easy task for two healthy and consenting adults — natural conception. When they failed after almost two years of trying, they consulted Mumbai’s leading infertility specialist Dr Anjali Malpani, who had set up one of India’s first and trusted in-vitro fertilisation (IVF) clinics. Their self-confidence was beaten, their hope was shaky but they drew solace from the fact that there were many worried couples like them in the waiting room.
Their desperation is not new to Malpani, now Professor Emeritus at Mumbai’s King Edward Memorial (KEM) Hospital, where Dr Indira Hinduja had delivered India’s first test-tube baby in August 1986. “I remember my roommate was tasked with the job of administering injections to the would-be mother at midnight. It was a novel and secret project. Today, there are so many more Assisted Reproductive Technology (ART) procedures than just IVF that have spelled hope for childless couples. But sadly, the problem has now become bigger than the solution. India has a high prevalence of infertility, with an estimated 28 million couples affected and approximately one in six couples struggling to conceive. However, what is alarming is that less than one per cent of these couples seek medical help, nor do they prep for an intended pregnancy though they may be mindful about all other aspects of life,” she says.
The World Population Prospects 2022, by the United Nations, estimated that the fertility rate of Indians (the number of children born to a woman) had plunged by more than 50 per cent. The number of births per 1,000 had gone down to 18.9 during 2015-20, with a predicted drop to 18 by 2025-30 and a further drop to 12.1 by 2045-50 and 9.3 by 2095-2100. According to the recent Sample Registration System (SRS) data by the government of India, India’s fertility rate has declined by about 28.5 per cent. “There’s a larger problem of infertility among young people,” adds Malpani. Contrary to perception, infertility is no longer a “woman thing.” About 35 to 40 per cent of infertility cases are because men do not have a healthy sperm.
Malpani had a solution for Shruti and Arun. While Shruti’s egg reserves were not too high, Arun says it was the poor quality of his sperm which prevented conception. So, Malpani chose the intracytoplasmic sperm injection (ICSI), which involves injecting a live sperm into a woman’s ovum or egg in a laboratory. It’s unlike IVF, where the sperms are left to fertilise the egg, in a petri dish, on their own. With the embryo holding steady in Shruti’s womb now, the couple are expecting their first baby.
Shruti and Arun’s story gets repeated across India. Dr Aviva Pinto Rodrigues, infertility specialist at Nova IVF Fertility, Bengaluru, sees the 28-35 age group getting affected the most. “Yes, there are techies in the urban set-up, but I have had couples from the hinterland around Chennai who have tried for a decade and failed despite living in a stress-free environment,” she says.
Dr Surveen Ghumman Sindhu, senior director and head of department, Infertility and IVF, Max Multi Speciality Centre, Panchsheel Park, New Delhi, has seen infertility issues among young Indians rise sharply over the last five years. “I have had a 28-year-old school teacher from Darbhanga (Bihar) reporting low sperm counts and take action at the right time. So people are aware. I have patients from Tier II and Tier III cities in north India. So it can safely be assumed that infertility is a pan-Indian problem,” she says.
Some triggers for early-age infertility are easy to flag. Poor lifestyles, long working hours, less relaxation and me time, job pressure, stress, obesity and diabetes are a common refrain. “In women, fat cells release estrogen in addition to what the ovaries produce. Too much natural estrogen can cause your body to react, prevent you from ovulating and having a regular menstrual cycle. Being overweight impacts basic sperm parameters in men such as sperm count, concentration and motility (movement), reducing the couple’s overall chances of conception. In women, diabetes can cause irregular menstrual cycles and even stop them, while in men it can lower levels of testosterone,” says Sindhu.
Late marriage and postponing parenting decisions for career growth and settling down in life mean that most young Indians are diminishing their chances of natural conception. “You can’t blame them. A work-life balance may be easy to recommend but can anybody follow it realistically? At work, an early pregnancy still means that a woman will be overlooked for a promotion or a plum posting. Besides, the real growth thrust happens mid-career, between 30 and 38 years, for both men and women. So, they choose to wait rather than getting offloaded. Then there’s the unsaid social pressure of motherhood which builds up stress and anxiety in women that delays pregnancy further. I have seen many women patients stress themselves out during an IVF cycle, under pressure to fulfil the only womanly duty that matters to society,” says Malpani. Some studies, like the one in the 2018 American Journal of Reproductive Immunology, found that women who had higher levels of a stress-related molecule were less likely to get pregnant after one IVF cycle. Stress lowers immunity in women, not ideal for embryo implantation. In men, stress lowers sperm concentration.
Unfortunately, women alone carry the baby to term and even when there are options like egg freezing available, many come in late for the procedure. “Unlike sperms, which can be banked anytime, the ideal time to harvest eggs is between 20 and 30 years of age. Women’s fertility starts dipping from age 35, which means you have fewer eggs left in your ovaries to work with. An Anti-Müllerian Hormone test measures ovarian reserve. Any reading between four and five is healthy, less than two is trouble. Today, most 30-year-old women register a score of 0.8 or 1, which means they are done with their eggs. In such a scenario, there can be no babies conceived in the bedroom,” says Malpani.
One of her patients, Shama, 31, admits that she is so exhausted by the end of a busy workday that she doesn’t have it in her to be intimate with her partner. “By the time we have settled in for some me time, we just want to curl up and sleep. I have fallen asleep while watching television or reading a book. Even weekends are stressful in a different way because you are taking care of what you couldn’t during the weekday and are setting a calendar for drives, binge-watching, eating out and so on. There’s no discovering each other, just going with the expected flow,” she says. Malpani has another explanation for this disinterest, “Most young people in urban India are sexually active by 16 and so the passion ebbs by the time they are 30. This loss of libido is a major concern in cities.”
Of course, the lack of sex education in our country, feels Dr Rupali Goel, senior consultant, obstetrician and gynaecologist, Indraprastha Apollo Hospitals, Delhi, means that youngsters are not guided on sexual hygiene. “They need to be educated about the right age to harvest their eggs. Doing so after 35 makes you more prone to having babies with congenital defects,” she says. She also feels that young women and men, who take up smoking rather early in life, need to make informed choices at the first puff. “Studies have shown that women who smoke more than six cigarettes a day have a higher chance of damaging their eggs and blocking their fallopian tubes. Men report lower sperm motility or erectile dysfunctions. But are we telling these to our kids?” she says.
While these are known troubles, Sindhu is closely following the latest threat to fertility among Indians, endocrine disruptors or environmental toxins. “Be it plasticisers, pesticides, herbicides, heavy metals, toxic gases and traffic fumes, endocrine disrupting chemicals have been increasing everywhere in the world resulting in declining sperm counts in men, and early puberty, menopause and hormone dysfunction in women. Cocktails of chemicals such as bisphenols and dioxins, which interfere with hormones and affect sperm quality, are sometimes present at levels up to 100 times higher than safe levels. This could emerge to be the biggest reason for the rising infertility among the current generation,” she says.
However, the problem with statistical analysis is that numbers just quantify the problem, they rarely probe deeper complexities. What the numbers do not tell you is that some of the couples seeking treatments use technology as an easy option for securing their parenthood even though biologically they may be capable enough. This social surrogacy means they do not choose to get pregnant naturally, opt for an IVF and implant the embryo in another woman, usually a family member, to gestate and birth their babies. Like 33-year-old Avisha, who walked into Malpani’s office three years ago, saying she wanted surrogacy since she couldn’t afford nine months of pregnancy at a crucial juncture in her life. She had just become vice-president, marketing, in an MNC she worked at and was a step away from being director. “But if I take a maternity break, I won’t be able to become one. And it’s unfair that a junior associate will get a promotion,” she told the doctor. Many couples with difficult job postings seek solace in technology to freeze their eggs and sperm, which are good enough to last a decade. They have a back-up plan in place. “One of my patients said she didn’t want to take so much pain on herself considering the RoI (return on investment) on children was low as they would never value her the same way she would value them,” says Sindhu.
Many would argue that this goes against the altruistic grain of motherhood but in a societal construct still balanced against women, technology is both a tool of convenience and empowerment. Preying on this legacy-hunting desire among couples are commercial IVF centres and clinics, many of whom lead young people to believe that they are infertile, when all they need is a little assistance. “With venture capitalists looking at bottomlines, these centres convince every mid-30s woman into accepting donor eggs at a higher cost when the fact is, their eggs can be harvested with a little ovarian stimulation. Similarly, men are told they need a donor sperm because they have poor sperm morphology. But the truth is, sperm counts fluctuate all the time in even healthy men and can vary all the way from 10 million per ml to 80 million per ml. A semen analysis is a high-complexity test but because it costs very little, many laboratories do it very casually and provide erroneous results. Many times, we have repeated tests after six weeks with varying results. Sometimes, men may need a little nudge with medication and lifestyle correction,” says Malpani. So, misdiagnosis also adds up the infertility numbers.
But there is a solution to every problem. “These are the best of times when ART has opened many doors, where frozen eggs and sperm can stay as good as when you bank them, where men with zero sperm count can father their children and a woman can become pregnant with just 20 eggs,” says Malpani. Although no procedure can guarantee a 100 per cent success rate, the IVF success rate in India is typically between 45 and 60 per cent and in under-35 women, who have no other health complication, it goes up to 65 per cent. ICSI usually fertilises 50-70 per cent of the eggs. Hope is just about floating to the top.
Outside Sindhu’s clinic, Shampa, 36, is awaiting her embryo transfer. “I froze my eggs at 28, knowing I had a stressful travelling job. Priyanka Chopra isn’t the only one fighting the fertility battle,” she says, before changing into her hospital gown.
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