Infertility is a silent struggle in India. One out of every six couples faces some issues when trying to conceive. Often they are unable to discuss it with anyone or get proper guidance due to the stigma associated with it. Here is a compilation of the most commonly asked questions, along with their answers by Dr Sulbha Arora, Clinical Director, Nova IVF Mumbai
We keep hearing about infertility and IVF and surrogacy all around us now, in the news and there are even movies being made on these themes. Is it true that infertility is on the rise?
There are two reasons we hear about it more now. Firstly yes, its incidence is on the rise. According to the International Institute of Population Sciences, infertility is growing at an alarming pace, especially in the cities. Their data showed that in India it has increased by 50% in the last three decades. Approximately one out of six couples of reproductive age will face difficulty conceiving, and there are an estimated 30 million infertile couples in India now. Secondly, and this is a good thing, we hear about it more now because people are finally starting to break the taboo and talk about it. Also, it is now known that it is not just a female problem. Men suffer from it too, in fact in 50% of cases there is either a male or a combined male&female factor involved. So the stigma associated with the word baanjh – people are overcoming that and opening up about their struggles, which is a great first step towards finding a solution. So couples walking into fertility clinics and asking about assisted methods of reproduction is common these days.
What are the reasons for the rise in infertility?
For reproduction to take place successfully, many factors need to be functioning optimally. You need healthy eggs, healthy sperms, functioning fallopian tubes, the ability of the sperms to fertilize the egg to form a healthy embryo, and successful implantation of the embryo into the uterus. There are many reasons causing this rise, and some are related to changes in our society, in the world that we live in. A few decades ago, most women had their first child at about 21. Today, the average age is closer to 26 or 27. And many couples start planning a baby even later than that. In today’s day and age, it is as important for a woman to be well educated and excel in her career as it is for a man. This has led to a trend of delayed marriages and childbearing. For many women, today, having a child before they reach their mid-30s is very low on the priority list. By the time they start to plan a pregnancy, the biological clock has already slowed down. You must have heard of the term biological clock and that as age progresses, the chances of conceiving reduce. Now, why is this? Fortunately, as age progresses, the uterus remains a string organ, so your capacity to carry the baby would not be majorly affected. However, what slows down with age is the capacity to produce eggs. Women are born with a fixed number of eggs, as opposed to sperms that are produced lifelong. We can never make new eggs. To give you’re a perspective, a girl is born with about 20 lakh eggs. By the time she gets her first period, this number is already reduced to 4 lakhs, as it starts to decline right from birth and then continues throughout life, till you reach a point where you have run out of eggs. Now, as the aging process affects every woman’s body differently, some may reach this stage in the 20s itself, and some may still have good quality eggs left into their late 30s. Also, this decline is seen in the quantity as well as the quality of eggs produced. The best eggs are given out in the 20s. With advancing age, the eggs get weaker and there is a higher percentage of abnormal eggs as well. Also, Indian women have an ovarian reserve 6 years less than the reserve of Caucasian women. So the chances that a European woman would have at the age of 40, and an Indian woman would have the same chances at 34. So the single most important determinant of a couple’s fertility is the age of the female partner. The more you delay your plans of conceiving, the more exposure you have also had to other factors that cause infertility, such as lifestyle factors, environmental toxins, and sexually transmitted diseases. Environmental factors have also caused a drastic decline in the average sperm count across the world from what it was 40 years back to what it is today.
What are the lifestyle factors that can affect fertility?
There has been an increase in the incidence of lifestyle disorders such as obesity, sedentary lifestyle, mental and emotional stress, hectic routines, disrupted sleep patterns, unhealthy food habits, smoking and alcohol consumption, and an earlier onset of metabolic disorders such as diabetes or hypertension. All of these have a direct or an indirect effect on fertility as well. For example, we are well aware that smoking causes cancer, but not many people are aware that it can also cause poor sperm quality and motility in men; or a faster depletion of ovarian reserve, poor quality eggs, and miscarriages in women, thus leading to infertility in both genders.
When should a couple consult a fertility specialist?
Infertility is defined as failure to achieve pregnancy after one year of unprotected intercourse. This is because it is normal to take up to a year of trying naturally to conceive. If at the end of a year you are still not pregnant, it is time to get yourself evaluated. This duration is six months if you are over the age of 35, and immediately if you are over the age of 37. If you have associated problems such as irregular periods, or painful periods, you should seek help right at the start, as they may be signs of underlying problems that may make it impossible for you to conceive naturally.
What would their basic evaluation involve?
The initial evaluation must always include an assessment of the woman’s ovarian reserve, an ultrasound of her uterus and ovaries, and a semen analysis for the man. In addition, there are some preliminary hormonal tests for the woman. If the ovarian reserve and semen parameters are both good, a tubal patency test may be advised to rule out a blockage in your fallopian tubes.
Does consulting a fertility clinic necessarily mean they would have to undergo an IVF, because that is a common fear that couples have?
No, certainly not. We provide an entire range of fertility solutions right from the most basic to the most advanced ones. Based on the results of your fertility assessment, we will guide you regarding your different options, whether you can try naturally or with simple methods like IUI and what would be your chances with those; or whether you would need more advanced treatments like IVF or ICSI.
What is the ideal time to try at home for couples trying to conceive naturally?
Ovulation occurs roughly 14 days before the next period. So if your cycles are 28 days, this would be around the 14th day. If your cycles are 30 days, this would be around the 16th day. Your fertile period starts 3-4 days before ovulation because the sperms can remain active in your genital tract for up to 4-5 days. After ovulation, the egg can be fertilized for only one day more. So the fertile period starts 3-4 days before ovulation and ends one day after ovulation. For someone with a 28-day cycle, this would be from the 10th/11th day onwards till the 15th/16th day.
What can they do to improve their chances of conceiving?
Focus on your overall health. If you are overweight, then losing even just 5-10% of your body weight can increase your chances of conceiving and reduce the risks of complications during pregnancy. If you have any hormonal disorders, especially, thyroid or prolactin, then those need to be corrected. Women who are planning a pregnancy should ideally take Folic Acid supplements. This is a vitamin that is vital for the baby’s neurological development and should be started even before conception. If you are trying naturally, then you need to have relations during the fertile period. It’s alright if you can manage it daily or on alternate days or even once or twice in that entire period. The main thing is, don’t let it become a schedule that you have to stick to even if you are exhausted or not in the mood, as it can create serious stress on your marital relations.
You mentioned earlier that the female age plays the most important role in determining her chances of conceiving. What are the options for women who don’t want to plan a pregnancy just yet?
Egg freezing is an excellent option for women who have reached or crossed 30 and are not planning on getting married and starting a family any time soon. It is like an investment for your future. So if you freeze your eggs at say the age of 32, and then by the time you actually want to start a family you are 40 or 42, you can have your frozen eggs thawed at that time and fertilized with your husband’s sperms. The resulting embryos will then be transferred into your uterus – at a time when you would have likely run out of good-quality eggs naturally. So as far as your fertility is concerned, at the age of 42, you will still be 32. For married women wanting to postpone childbearing, embryo freezing rather than egg freezing is a better option.
Does freezing her eggs or embryos by taking out multiple eggs in one cycle mean that her ovarian reserve would get depleted faster?
No, it does not. The way our bodies have been programmed, each month a few eggs are selected by the ovaries from the underlying pool or reserve of eggs, out of which one will go ahead and grow, the rest will die anyway. By these procedures we are only ensuring all the selected eggs can be retrieved instead of them dying and getting wasted. We are not pulling out more eggs from the pool, so that remains untouched, and hence it does not lead to a faster depletion or earlier menopause.
What are the treatment options for older women? Would surrogacy help?
A common misconception is that older women can benefit from surrogacy. Surrogacy is meant for women who are physically unable to carry a child, such as women who have had a hysterectomy, those with a scarred uterus, or medical problems such as heart disease that can make pregnancy life-threatening for them. Fortunately, as age advances, the uterus remains a strong organ. What gets affected is the ovaries. The quantity and quality of eggs. Therefore when the ovarian reserve has severely depleted, an IVF would give you a much better chance of conceiving as opposed to simpler methods like planned relations or IUI. Some women may need to opt for IVF using donor eggs.
What is the difference between an IUI and an IVF?
An IUI is a simpler treatment method. Here we track the growth of your follicles (or eggs) by ultrasound, and at mid-cycle, when the follicle is ready, we give you a trigger injection that helps you ovulate. At the time of ovulation, we ask your husband to provide his sperm sample. The sample is then processed to remove the excess liquid, the dead sperms, the weak sperms, and the healthiest sperms are concentrated into a tiny quantity of liquid. These sperms are then transferred directly into your uterus with the help of a very fine straw called a catheter. The sperm wash takes about 45 mins to an hour. The IUI takes just a couple of minutes. In a natural cycle, the sperms are deposited in your vagina, from where a large number leak out and get wasted. Some will not survive the acidic vaginal environment and some will not be able to cross the cervical barrier to reach your egg. With an IUI, we increase your chances of conceiving by taking the sperms all the way inside your uterus, overcoming the barrier, and leaving them as close to the ovulated egg as possible to make their job of finding and fertilizing them much easier. Therefore this increases your chances of conceiving from about 5-7% with natural relations to about 15-20% with each IUI. However, the success rates with this process are limited. It still needs healthy tubes to pick up and bring the egg into the uterus. Tubes may be open but still not functioning properly, and though we can check if your tubes are open or not, there is no test to determine that an open tube is indeed able to transport the egg successfully. An IUI also depends on a successful sperm-egg interaction. When we do an IVF, we go a few steps further. WE aspirate the eggs and take them out of the vagina. We fertilize the eggs with the sperms in the lab, and the resulting embryo/embryos are then transferred directly into the uterus where now the only thing left for nature to do is to implant them. Therefore an IVF further increases your chances of success to 60-70% with each attempt. The resulting pregnancy is no different from a natural pregnancy, whether conceived naturally or by IUI, or by IVF.
What are the complications of IVF? Is IVF painful?
It is another common misconception that IVF is painful. IVF is a simple and straightforward process, there is nothing painful or complicated about it. We are just simply trying to make you pregnant, which is a normal function of every female’s body in all species. Yes, there is a daily injection you need to take for about 10 days, but these are not heavy or oily injections or even the needle is not thick. So it’s just one prick that you have to tolerate for just 10 days. The egg pick-up is a 5-min procedure that is done under complete anesthesia, so you don’t feel a thing. It is not a surgery, there are no cuts or stitches involved. The embryo transfer is done 5 days later and is a completely painless procedure that requires no anesthesia. What makes the process painful in our minds is the huge amount of mental stress we go through, which reduces our pain threshold and makes us feel pain when it’s not. So the best thing you can do is relax, learn more about the process, ask questions. The fear of the unknown is always worse than the fear of the known. So educate yourself about it. Over the years, IVF has become much more simplified and patient-friendly, and there are really only two main complications we worry about – ovarian hyperstimulation and multiple pregnancies. The first occurs when you have made over 20 eggs in one cycle, and your rapidly increasing hormone levels can put your health at risk. However, this risk has been almost completely eliminated with the use of softer stimulation protocols, freezing all your embryos in case we get more than 20 eggs, and transferring them later when your body has cooled down. Also, we never transfer more than 2 embryos. With that, the majority of women end up with a single baby and about 1/3rd of women may have twins.
What are the precautions required after undergoing fertility treatments?
You need to continue all your routine activities and routine diet. Remember that pregnancy is as natural a part of our body’s functioning as eating is. And our body will function best when we keep it as close to normal as we can. Contrary to popular belief, you don’t need bed rest after an IVF, in fact, bed rest can reduce your chances of conceiving. Bed rest is meant for people recovering from an illness. Not for people trying to have a baby. Putting yourself in an unnatural state of low activity will slow down all our body’s processes and reduce its chances of working well. So continue all your routine activities. Diet-wise the only restrictions required are restricting tea/coffee to not more than 2 or 3 cups a day, no smoking, and no drinking. The most important thing that you can do to increase your chances is to focus on things that make you happy. The wait between the embryo transfer and the pregnancy test can be excruciating. Keep yourself busy, whether with work, or with watching a good TV series, with your pets, your family, go for a walk with your music, or spend time with hobbies you enjoy such a painting or cooking. A positive mindset has much better chances of leading to a positive result.
Is it true that IVF always leads to twins or triplets?
The chances of multiple pregnancies were much higher some years back when embryo transfers were done at the Day 2 or Day 3 stage of embryo development. Human embryos are designed in such a way by nature that many will have chromosomal abnormalities, and will not lead to a successful pregnancy later. Most of these embryos stop growing between Day 2 and Day 5. Now that we transfer embryos only at Day 5, we are able to select the one or two best embryos for transfer, thereby minimizing your risk of multiple pregnancies. When embryo transfers were done on Day 2 or 3, as doctors did not know which one or two would succeed, they used to transfer many embryos in one go with the hope that at least one would click. If many clicked it gave rise to triplets and higher-order pregnancies. Now that we don’t transfer more than 2 embryos, this risk has been eliminated. After transferring two embryos, the majority of couples will still have a single baby as both may not click, and in about one-third of patients, there will be twins. If the couple does not want twins at any cost, we are more than happy to even transfer one single embryo. Any surplus embryos can be frozen and kept stored for you.