Govind Sharma
Infertility in young men and women is a global reproductive issue but it is rarely discussed in public and is often overlooked. It has been neglected in the context of a health issue though the World Health Organization (WHO) has recognized infertility as a public health issue.
Earlier, the infertility was limited to metro cities only but now this health issue is prevalent even in small cities like Jammu and Srinagar which is evident with the mushrooming of a number of infertility centres in these twin cities of the union territory of Jammu and Kashmir in last few years.
Some experts link infertility to biological factors but several others are of the opinion that social, health and lifestyle factors such as excessive consumption of fast food, smoking, drinking and drug addiction may also contribute to infertility in young men and women.
The issue is grave as it causes financial and emotional stress for couples and also social stigma but there is a little open discussion about it and widespread ignorance regarding it in young males and females. In this scenario, it is very much important to educate our young population regarding infertility, its causes, diagnosis and treatment options so that this public health issue may not go unnoticed and young couples may enjoy the parenthood.
So, this correspondent talked to various experts including leading gynaecologists and sociologists of Jammu to know causes, symptoms and treatments of infertility as it is a major health as well as socio-economic psychological problem having a great social stigma upon the couple. As per Dr B R Bhagat- a leading gynaecologist of Jammu, having baby is the legitimate right of every couple and failure to achieve pregnancy within 12 months of unprotected intercourse is called as infertility.
Dr Bhagat said infertility can be primary where in the couple has never conceived and secondary if the couple had at least conceived once. Presently, 10 to 15% couples are infertile and the incidence is on rise because of advanced age at marriage, job/financial insecurity and global warming. For infertility, it is not only the female which is responsible as males are equally responsible. In 40 to 55% of cases female factor and in 30 to 40%, male factors are responsible for infertility. In about 10% of cases, both male and female are responsible for infertility whereas in 10 to 13% cases, the cause is not known and such infertility is called as unexplained infertility.
According to him, age perse is the independent and high risk factor for infertility. The fertility starts declining after the age of 35 years in females and 50 years in male. So ideally the couple should be subjected to investigations and examination by 1 year and those who are 35 years should receive infertility care by 6 months and in older women beyond 40 years immediate evaluation and treatment is warranted.
“Ideally the couple who is planning to conceive should contact the doctor for pre conceptional counseling. During pre-conceptional counseling, the detailed history regarding her life style, age, duration of marriage, presence of associated diseases like obesity, hypertension, thyroid disorders, diabetes, drug intake, smoking, alcohol intake is taken. The couples who are obese are advised to lose weight stop smoking and alcohol, optimize diabetes, thyroid and hypertension and should take folic acid 5mg daily for 3 months per conceptionally,” he added.
Dr Bhagat said that in females the problem can be with the tubes which may be blocked or distorted because of PID, genital tuberculosis, chlamydial infection and endometriosis. There may be uterine anomalies most common being uterine septum, bicornuate/unicornuate uterus and cervicovaginal causes including vaginismus, dysmenorrhea, vaginal septum and abnormal mucus production.
The other problem, he said, can be with the ovulation in which the eggs are not formed or there may be decreased ovarian reserve. The work up of female includes detailed history regarding her age, duration of marriage, menstrual history, contraceptive history and sexual history besides the medical and surgical history. Personal history in terms of sexual history, duration of continuous stay with regular coitus is taken. It is pertinent to mention here that couples visiting weekly are more prone to infertility as they miss the fertile period which is usually day 12 to 16 of menstrual cycle.
To diagnose causes of infertility in female, Dr Bhagat said investigations such as complete blood counts, ESR, blood group, thyroid profile, prolactin, and AMH are conducted. The tubal patency can be tested by an X-ray of pelvis after injecting radio opaque dye into the uterus called as hysterosalpingography preferably done within 10 days of cycle. Other methods are saline sonosalpingography, sono hysterography and salpingoscopy. These tests are done as first line and if any abnormality is detected patient is advised to undergo laparoscopy and chromo perturbation.
“Ovulation usually occurs on day 14 of cycle and can be confirmed by menstrual pattern, basal body temperature, ovulation predicting kits, serum progesterone and rarely by endometrial biopsy. Now-a-days ovulation can be monitored and detected by TVS or TAS by serial monitoring from day 10 of the cycle,” he further stated.
He said the male partner is equally responsible for the infertility. Various causes includes congenital malformation of the genetalia like congenital absence of vas and hypospadiasis beside various syndromes like Kartagener syndrome and young syndrome, erectile dysfunction, retrograde ejaculation and pre mature ejaculation. Varicocele also contributes to the male factor. History of viral disease in childhood like mumps is a major cause for testicular atrophy and absence of sperms. The investigations in the male primarily include semen analysis, thyroid profile, diabetes etc,” he explained.
Regarding treatment, he said the treatment of infertility is the treatment of the couple. Reassurance, faith and confidence in the treating doctor is the key. The females with regular menstrual cycles with normal patent fallopian tubes and no other obvious cause detected should be offered super ovulation by various drugs like clomiphene citrate, letrozole, injections and intrauterine insemination for at least 3 to 6 cycles. Of course a female with blocked fallopian tubes is offered IVF/ICSI (test tube baby).
“In the males with normal semenogram and partner with patent fallopian tubes with no other obvious cause are advised IUI. The men with absence of sperms with a normal female partner are advised donor insemination/donor IVF/donor ICSI. In selected cases of oligospermia varicose surgery may play a role. The male partner with obstructive azoospermia, the sperms are retrieved from the testis and are offered IVF/ICSI. In rare cases blocked tubes may be corrected by surgery (tuboplasty) and in males surgery on vas (vasoplasty) may help. For the couples with absent uterus surrogacy/gestational carrier are offered. Donor eggs and donor sperms are another modality for the elderly couples. Assisted hatching is another modality in which by using laser the outer shell of the embryo zona pellucida is punctured to enhance chances of implantation,” he shared.
Dr Bhagat said that despite the lot of modalities available infertile couples still do exist. Treatment of infertility involves life style modification a lot of time with fullness and money. He said there can be various complications of infertility treatment which include ovarian hyperstimulation syndrome, multiple pregnancy, pre term labor, pre maturity, gestational diabetes, gestational hypertension etc. and at last there can be a failure of the treatment.
As per renowned sociologist of Jammu, Prof Vishav Raksha (HoD Sociology, University of Jammu), there are several social factors which impact the infertility in young couples and these social factors later give rise to many medical conditions. “Worldwide, increasing maternal age can be seen as a common cause as women delay their marriage and childbearing age to get higher education and make their career,” she added.
Another social factor, she said, is nuclearization of families. With increasing urbanization, nuclear families are on the rise where both the partners go to job and they have no time to take care of children. Therefore, they deliberately delay pregnancy and when they make up their mind to have a child, they fail to do so due to age related complications.
“Due to rapid urbanization, elevated standard of living, rise in education status, women are becoming more independent and are following the trends of modern lifestyle. This appraisal of socioeconomic status of women has contributed to modified dietary habits and physical inactivity, which is considered to be the risk factors of developing primary infertility,” she asserted.
Ayurveda expert, Dr Twinkle Gupta, said that one of the causes of Infertility according to Ayurveda is overindulging in sex as this will lower “Shukrakshya” and cause impotence. Insufficient amounts of “Artava dhatu” (female reproductive tissues) also impact the likelihood of conception. Other issues include mental disturbances and improper food consumption.
“Depression, insomnia and worry can affect one’s ability to conceive while according to certain studies, eating more spicy food causes ‘Pitta’ to grow and ‘Shukra dhatu’ to produce less. The genetic aspects of infertility may also be important. Further, controlling one’s sexual impulses for an extended period of time may result in ‘Veerya-Avrodha’ (trouble in producing sperm) when it lowers libido,” she added.
Explaining Ayurvedic treatment for male infertility, Dr Twinkle says the intake of Ashwagandha helps to improve sperm health. The sperm’s motility, quality, and quantity are boosted. Additionally, Ashwagandha is known to reduce stress. She says the consumption of Shilajit helps the sperm to maintain its mobility and intake of Maca root enhance male fertility and libido. The root of the plant is dried and consumed in the powdered form.
Regarding Ayurvedic treatment for female infertility, she says consumption of Shatavari increases fertility and vitality by acting as a reproductive tonic. It helps to reduce stress and balance the imbalanced hormones while Agnus castus helps in the proper regulation of the menstrual cycle. All those hormones that are imbalanced come in the optimal range after the intake of Agnus castus. Further, Cinnamon helps to curb the cysts in the ovary and at the same time it also helps in boosting fertility.
According to her, other factors that will help the couple to conceive are common. A healthy diet, lifestyle modifications, and Yoga/Meditation will do the rest of the work. Apart from medical reasons, there are also various social reasons which directly or indirectly contribute to infertility in young population.
Dr Twinkle says that one can reduce the risk of infertility by taking certain precautions which are:
* Maintain a healthy body weight: If you want to become a parent, maintaining a healthy weight is beneficial. By calculating your Body Mass Index, which takes into account both your height and weight, you may determine whether your weight is within a healthy range.
* Exercise: Regular physical activities might not only help you lose the extra weight that might hinder fertility but can also help balance hormones, improve insulin and lower stress, all of which can enhance fertility.
* Avoid smoking: Fertility immediately increases after quitting smoking. While the decline in egg production cannot be reversed, quitting smoking can increase fertility. The longer a person has not smoked, the lower the rate of smoking-related problems during pregnancy becomes.
* Don’t postpone having kids when you’re ready to: The primary factor affecting a couple’s ability to successfully use fertility treatment is the age of the female spouse. The second most crucial issue is how long infertility has existed.
* Be knowledgeable: Always comprehend the instructions given to you by your doctor and lead by example. To take an active role in your health, ask questions, comprehend the process, and be informed.
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