Infertility

Trends in India
Infertility in India
India hosts a population of 1.3 Billion. Two-Thirds of
Indian population is below 35 years of age (Census 2011)

Infertility is growing at an alarming pace in India,

especially in the cities. Census reports from 1981, 1991,
2001 and 2011 show that infertility has increased by
50% in India in past 3 decades.

Out of around 125 million couples estimated to be

attempting parenthood at any given time in India, 13 to
19 million couples are likely to be infertile.

(Continued..)
 Currently it is estimated that nearly 30 million couples in the
Country suffer from infertility, making the incidence rate 10
percent.

Male infertility is almost as high as female infertility. In every

100 couples, 40 percent of the males suffer from infertility
compared to 50 percent women. In the remaining 10 percent,
the causes are common to both men and women or are
unknown.

(Findings from the Indian Institute of Population

Sciences, Population Study 2012)
 Causes of Male Infertility in
India
Irregular or abnormal sperm production. It is estimated that one

in every five healthy young men between the age from 18 to

25 suffers from abnormal sperm count. Causes are not well

explored scientifically.

Hampered sperm delivery due to either erectile dysfunction or

early ejaculation. Guilt associated with sexual desire and

performance anxiety- not well explored.

(Continued..)
 Presence of medical conditions such as obesity that

may hamper sperm production

Infections (Sexually Transmitted Diseases),

Lifestyle conditions such as diet, addiction to smoking

or alcohol, sedentary existence, mental and emotional

stress
Causes of Female Infertility in
India
Genital tuberculosis (a chief factor in rural India)

Delayed marriage and deferred childbirth among couples-

especially women (>30 years)

Polycystic ovary disease (PCOD)

Hectic lifestyle and job stress (Chief contributor)

(Continued...)
 Fallopian tube defects

Endometriosis

Sexually Transmitted Diseases

Obesity

Use of medication

Smoking and alcohol consumption.

 Common Causes for Infertility among both men
and women:
Declining libido among couples living in cities

High stress levels

Poor eating habits

Increase in medical conditions such as diabetes

 First line of Treatment
Methods used for monitoring fertile periods:
Monitoring basal body temperature is widely used across the

Country

Calculating most fertile period ( self-monitoring of the cycle for 6

months: adding 9 to the date of starting shortest cycle and

reducing 9 from the date of starting the longest cycle gives a

wide window when couple can try for the baby)

Monitorng vaginal mucous changes

Usually a combination of all these methods are used.

Investigations that the Couples
undergo to diagnose infertility
For women:

Detailed reproductive history: Age of menarche, menstrual cycle, type

of bleeding, family history, operative procedures in past etc.

Ultrasonography- both abdominal and transvaginal- is used to monitor

the uterine endometrium and fallopian tubes for irregularity.

Hormonal charting (women): FSH-LH, Thyroxin, serum testosteron,

blood sugar levels and others if clinically implied

Pap smear to rule out oncological implications

Ovarian follicular response: to monitor growth and release of follicles in

ovaries

(Contd.)
Note: Radiological Assessment of Fallopian tubes is
advised only if all of the reports mentioned are
normal
Follicular monitoring and triggering ovulation (if
necessary) are common procedures
Postcoital transvaginal smear and USG: within 4-6
hours of intercourse- to monitor deposition of
sperm and their mobility and response to vaginal
mucous

For Men:
Semen Analysis
 Treating Infertility:
Artifical Egg Stimulation: Using HCG/Clomid/Decapeptyl (or
similar drugs depending on womans general health and
hormonal essay)

Intra Uterine Insemnisation (IUI)

Advanced fertility treatments include:

IVF or in vitro fertilization

ICSI or intracytoplasmic sperm injection, -- more often used in case of

male infertility.

Surrogacy (A booming industry right now)

Adoption
IVF in India
Indias first IVF baby was born in October 1978 (three
months after the worlds first IVF baby in Britain)
IVF only recently taking off as hotspot of medical
tourism
India will become the country performing highest
numbers of IVF cycles in world before 2020
IVF in India from medias eyes:
Lethal business of IVF clinics (tehelka May 2012)
Booming IVF Market of India (RNCOS 2010)
Indias Baby Making Business (eHealth website)
Egg donors cash in on IVF baby boom (Times of India)
The Rent-A-Womb Boom Business Is Indias surrogacy....
(The daily beast e newspaper)
 Policies for addressing Infertility in
India:
None implemented.

India is struggling to control its population, and

contraception perhaps, is the most talked about topic after
Maternal Mortality Ratio and Infant Mortality Rates.
Infertility is not yet the major focus of discussions at
national forums.

Government of India is currently formulating its National

Health Policy (version 2015): Infertility does not appear
anywhere in this document (neither does midwifery/
midwives for that matter).
Some government medical college hospitals do
offer services for infertile couples:

Armed Forces Medical College- Pune (Maharashtra);

All India Institute of Medical Sciences (AIIMS)

Governed directly by Central Government (not under

jurisdiction of State Governments)
Long waiting line
Time consuming visit
Over-worked doctors inadequate numbers of other
care providers
Limited information and counselling for couples
 Treating Infertility:
Infertility remains the open domain for private practitioners in India.

Private hospitals offer free initial consultations, customized packages for

infertile couples, with choices like:

Women having problem with age less than 32 years,

Men having problem (with women aged less than 32 years),

Couple saver-offers when both men and women have problems.

Packages are higher priced in case woman is older than 32 years.

No insurance policy covers infertility investigations and treatments.

 Social Consequences of
Women bear
Infertility:
the stigma of being childless. Divorcing or leaving a
childless woman and marrying another one has been a common practice,
but reducing among learned families gradually.

Childless women are often not allowed to participate in rituals for any new
bride coming to the family as it may affect the new bride adversely.

Indian social norms dictate that a woman is complete only with giving birth
to a child. Couple in general and women in particular bear strong social
burden of producing a child soon after the marriage.

Apart from social stress; Infertility also places significant financial burden
on the family.
Artificial Reproductive Treatment in
India
Many Benefits for stakeholders:

Every couple has a chance to have their baby.

Women who donate eggs have financial encentive.

Government gets additional foriegn currency

transactions.
ART related malpractices/ dilemma:
for clients
People move to superspeciality clinics which may be in a

different region of India: Language barriers.

Planning stay and sustenance over-and-above the cost of

treatment.

Though regulations for ART clinics have been formed, the

transparency and information sharing is questionable.

ART related malpractices/ dilemma: for
donors
No law to protect these womens rights.

Agreement with gamete bank often made through

mediators: Husband/ family members

How many times is enough?

Impact of frequent and prolonged hormonal

supplements over normal hormonal balance: not well

 Ethical dilemma
Embryos being formed outside human body, and often
tested to avoid aneuploid/ polyploid conditions

Sex selection

Embryo freezing

What should be done with frozen embryos?

Donation
Assisted Reproductive Technology
Act (2008)
Proposed by Indian Medical and Research Council

(ICMR) in 2008

Drafted as ART rules and regulations guidelines 2010

Not passed by Government of India parliament till date.

 93 page directive on functionalizing
and regulating ART centres
Proposes three levels of ART
specialization.
Chapters on:
Minimum staff requirements
Minimum physical requirements
Procedures
Artificial Insemnisation- Husband
Artificial Insemnisation- Donor
Intra Uterine Insemnization-Husband
Intra Uterine Insemnization-Donor
InVitro Fertilization &Embryo Transfer
Intra Cytoplasmic Sperm Infiltration
Cryopreservation
Embryo donation
Culture media and lab procedures
Other chapters:
Selection of clients: no discrimination, right method for right couple

Selection guidelines for appropriate treatment: Evidence-based

guidelines

Counselling process

However: loosely framed, practical enforcement will require

ammendments and specific guidelines

Additional Rules:
Accreditation and registration of ART clinic
Quality control regulation
Research: with consent of clients, forwarded by director
of ART clinic and passed by Indian Medical Research
Council
Embryo handling: with respect and utmost care. Strict
prohibition on transferring human embryo to non-
human animal and vice versa
No hybridization
Directive to established process for client feedback and
complaints addressal
Legal contract
Third party donor of egg /sperm / both must waive off
their right to be known to the offspring. They will never
contact the offspring.
However, the child born- under conditions- can initiate a
search for his biological parent after obtaining legal
adulthood or anytime based on crisis.
Single mother/ father can apply for ART in India and will
not be refused treatment on this basis. Childbirn will
have full birth rights on single parent.
ART Regulations:
ART for an HIV positive parent will be taken on a case-
to-case basis after the ruling by Supreme Court of India.
Gemetes from under 21 year old male will not be
accepted. Upper age limit for males is 48 years.
Women can donate their gamete between 18- 35 years
of age.
Sex selection and destruction of foetus based on sex is
srtictly prohibited and punishable by law.
No more than 3 embryos can be placed at a time inside
the womb barring special conditions which should be
documented.
 Surrogacy:
Surrogacy refers to a contract in which a woman carries a

pregnancy for another couple.Surrogacy comes as an

alternative when the infertile couple is not able to carry the

fetus till full gestation period.

Pikee Saxena, Archana Mishra and Sonia Malik. Surrogacy: Ethical and Social Issues.
Indian Journal of Community Medicine. 2012. Oct-Dec; 37(4): 211213.
 Types of surrogacy:
Surrogacy can be of two types:
Gestational Surrogacy: Infertile couple produces egg
and sperm, which in fertilized in vitro. The resulting
embryo is implanted into the surrogate mother.
Biological surrogacy: Male from the infertile couple
provides the sperm, which is artificially deposited into
the surrogate mother (IUI). In this case, the egg is from
the surrogate mother, making her also the biological
mother of the baby.
 Surrogacy in India
Commercial surrogacy is legally allowed. Rather, no law
governs commercial surrogacy.

Many American and European countries, including

Sweden, do not recognise surrogacy agreements.

As a result, India has become the hotspot of surrogacy

medical tourism. Cost is 1/3 from developed countries
allowing surrogacy.
Pertinent to Surrogacy
The surrogate mother will be admitted and registered on her own
name, not on the name of clients seeking surrogacy.

Birth certificate will carry surrogacy-seeking-parents name.

However, the parents will also receive another certificate bearing
the name of surrogate mother.

Surrogacy-seeking-clients will bear the full cost of treatment and

sustenance for surrogate mother

Surrogate mother and the clients can together decide the

surrogacy fee.

Continued..
ART and surrogacy regulations:
Couples cannot choose a sperm or oocyte donor from
their friends or relatives.
Neither the clinic nor the couple will know the gamete
donor. The identity will be safe-guarded by gamete-
banks. However, full disclosure of physical
characteristics, and when possible, DNA fingerprints will
be made available without disclosing actual identity.
Gamete donor must be free of HIV and hepatitis B and C
infections, hypertension, diabetes, sexually transmitted
diseases, and identifiable and common genetic
disorders such as thalassemia.
Oocyte sharing is encouraged.
Protecting the child:
Surrogacy-Seeking-Parent/s must leagally adopt the
child before leaving India, in case the child is not
biologically theirs.
Surrogacy can be offered only to couple who have
clinically failed to carry a pregnancy to term due to non-
treatable disorders.
ART centre cannot act as middle-man for surrogacy fee
Women over 45 years of age cannot be surrogate
mothers
No woman may act as a surrogate mother more than
 References:
1. Adamson PC, Krupp K, Freeman AH, Klausner JD, Reingold AL, Madhivanan P.
Prevalence & correlates of primary infertility among young women in
Mysore, India. Indian J Med Res. 2011;134(10):4406.

2. Ganguly S, Unisa S. Trends of Infertility and Childlessness in India: Findings

from NFHS Data. Facts, views Vis ObGyn [Internet]. 2010;2(2):1318.
Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=
4188020&tool=pmcentrez&rendertype=abstract

3. Manna N, Pandit D, Bhattacharya R, Biswas S. A community based study

on Infertility and associated socio- demographic factors in West Bengal,
India . IOSR J Dent Med Sci Ver II [Internet]. 2014;13(2):137. Available
from: www.iosrjournals.org