Unproductive Humans

As people lead stressful lives, the natural process of reproduction has become an uphill task. But there are options galore for assisted pregnancy these days
By Dr Swapnil Shikha

As per a study, in nine Indian cities out of the 2,562 people who participated in it, nearly 46 percent were found 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 (31-40).
As life runs on the fast lane, a monster called infertility slowly makes inroads into the lives of urban India giving more & younger couples sleepless nights & problems in having a child. It is rather ironic that from a time when family planning drives launched in the 70s were the government’s prime focus, the country has come to a point where suddenly 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 realize 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 to be 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 will in our day-to-day activities. But before we go any further to delve deep into the problem, it is important to understand what exactly is infertility and how does one define 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. The ART (Assisted Reproductive Technology) consists of a comprehensive programme that is offered to such couples.
Infertility centres these days provide comprehensive infertility management/ART Programme to patients. The various forms of treatments like Intrauterine Insemination, (IUI) In Vitro Fertilization (IVF), Third Party Reproduction and Intracytoplasmic sperm injection (ICSI) are in vogue these days.
ICSI, pronounced “eeksee” or “icksy”, is an in vitro fertilization 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 sperms 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 sperms that have been extracted by a surgeon. ICSI can also be offered to patients of previous IVF failures due to failed fertilization and patients with unexplained infertility. ICSI is different from conventional insemination since 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% of eggs die as a direct result of ICSI. However, fertilization rates, embryo quality and pregnancy rates are the same as for couples who do not have ICSI.

How is ICSI performed?
The process involves the injection of a single sperm within the ooplasm of the oocyte. Following the first ICSI birth in 1992, thousands of babies have been born around the world. Sperms for ICSI can be obtained from ejaculation, even when only few are present, or through surgical retrieval from epididymis or testis.
Microinjection is normally performed under a specialized microscope with the aid of a micromanipulator which allows small movements under high magnification. The scientist/embryologist sits on 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 through the other.

IVF
Reproduction is the process wherein 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 fertilization. In this technique, the entire process of fertilization takes place outside a woman’s body. This involves extracting a woman’s eggs, fertilizing 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 it 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 infertile couple before IVF is very important for success of IVF and prevention of complications. Any ART procedure should be preceded by traditional fertility workup & 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 of patient should be undertaken to correct any problems which may lead to IVF failure. At this stage, it should also be decided whether 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 uterus that have been provided to a couple/single individual (called intended parents) by a third person (donor) in order to help them/him or her to become a parent.
According to the present Indian guidelines on ART drafted by the ICMR, all donors except the surrogate need to be anonymous to the commissioning couples. The ICMR guidelines also state that this activity of supplying various gametes and surrogates will not be carried out by the IVF centre but separate entities called ART Banks. All the legal issues are also the responsibility of these banks. Once the requirement is fulfilled, the medical fitness of the donor is assessed. After fulfilling the various formalities, the couple and their donor/surrogate is 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! 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! We also discovered that majority of recurrent failures whether at implantation or later pregnancy is due to an 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. In case the patient has a genetic cause, the patient and her husband are informed regarding the defect and counseled regarding future implications. Endocrinal causes like PCOS can also be the 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.

Experts advise on ways to conceive

Approximately 40% of fertility in couples can be attributed to male sub fertility. ICSI has raised hopes of 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 Dr Sonia Malik, Programme Director, Southend Fertility and IVF, New Delhi and President, Indian Fertility Society, “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.”
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. Also earlier infertility was largely seen as only ‘a female problem’ with women easily becoming the target of social scorn. Dr Gauri Aggarwal, Fertility Specialist, Yashoda Superspeciality Hospital, Ghaziabad, observes: “However, such a theory no more exists and the time when women were solely battling the blame for being barren has become a part of the bygone era! There have been enough research revelations that have attributed the male for the cause of infertility and there is a general realization that implicating a woman with prejudice would only result in robbing the root cause of the issue. Now, one in every 5 men between the age group 18 to 25 is found to suffer from abnormal sperm count – one of the main cause of infertility.”
With the problem having become widespread what are the reasons one may ask? Irregular and low sperm count, hampered sperm delivery and motility of sperm are prominent causes of infertility in men. Some other medical reasons such as obesity and lifestyle disorders that includes diet imbalance, addiction to smoking or alcoholism, sedentary existence, or mental and emotional stress contribute to poor sperm count.
On the other hand, Dr Sonia Malik points out: “Polycystic ovary disease (PCOD), a condition characterized by excess production of hormones and lack of ovulation coupled with hectic lifestyle and job stress lead to conception problem 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 & women often suffer from a steady decrease in the libido which has lately become an issue of concern for many.”
Having said that all is not grim. It is prudent to adhere to certain precautionary measures on a day-to-day basis. The general preventive measures like — maintaining weight, avoiding cigarettes, alcohol, reducing stress, increasing intake of nutritious diet — though very vital, may sound clichéd, but, certain factors that impact fertility in both men and women are being ignorantly dismissed.
High testicular temperature is increasingly attributed 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.
Although ovaries in women are protected in the interior of their body, testisis located outside, not for aesthetic reasons, but for functional ones. Testicular temperature should be lower than the body temperature and anything distorting this may harm male fertility.
Thus, it would be wiser for men to wear loose underwear and pants and have frequent breaks when working in the sitting position continuously. Resting laptop computers on lap raises the scrotum’s temperature, say researchers and hence it is better to avoid using mini computers on laps literally!
Though physical exercises are imperative, great caution is required especially when it comes to specific sports where testis is not properly protected in men. Testicular injuries must always be treated without any delay lest it may result in long-term consequences on fertility.
According to Dr. Sowjanya Aggarwal, Infertility & IVF Specialist, Max Super Specialist Hospital, Vaishali, another issue of concern is the declining libido among urban couples which has emerged as one of the main causes that has come to engulf 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 comes across as the biggest hindrance in conceiving nowadays. As stress levels are usually high among urban couples, poor eating habits and increase in medical conditions such as diabetes lead to lack of quality and quantity of sperms and eggs. Thus habits such as smoking, tobacco consumption, drinking frequently, unhealthy food habits and no 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 deodorizers may contain chemicals that could diminish conception by 33%. Organic, non-toxic alternatives are anytime a better option.
Dr. Sowjanya Aggarwal, said, “Paint thinners, household glues and oil paints can be toxic and negatively affect fertility increasing risk for miscarriage when pregnant. If a ‘sniff test’ indicates strong and offensive smell its only better to avoid them. Women should be wary of paraben, a preservative found in most of the cosmetics, from shampoo to moisturizers to, lipsticks. Parabens belong to a group called xenoestrogens, or false estrogens that could induce infertility”.
Serving full fat dairy products a day 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 needs to be avoided. Hormones leach more when unhealthy plastics are hot and wet. And finally, a good sleep is most 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.

Male Infertility Programme

Ever since the human race evolved on the earth, it was the female who had been seen as responsible for procreation. So, if anything was amiss, the woman supposed to be at fault. All research focused around the development of medication and technology in 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 males with problems. In developing countries like India, another reason was a complete denial by the males 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 that treatment were issued.
Today, male infertility programme involves not only the standard testing procedures like semen analysis but also special tests to determine the fertilizing 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 sperms in the sample, doctors proceed to a testicular biopsy. The sample is checked for sperms and if positive, it is frozen or cryopreserved till the wife is readied for ICSI. Men who have mild male factor infertility, can be offered IUI but those that have weak sperms are treated by either IVF or ICSI and recently IMSI.

(The author is Director, Amrapali Healthcare Ltd, Noida)