Children are a way of leaving a part of us into the next generation and in turn the eternity. However, many couples face problems in conceiving children even after many years of marriage. Infertility is the failure to conceive after one year of unprotected intercourse. However, women above 35 years should seek treatment after four-six months. In addition, I would like to include social and family factors, wherein there is non-consummation of marriage and absence of sexual intercourse due to lack of privacy, lack of information of sexual activity, performance anxiety, vaginismus, premature ejaculation, past history of sexual abuse, religious rules and customs especially with regards to first sexual intercourse, etc. Prevalence of unconsummated marriages is reported from seven per cent to 64 per cent in various studies.
Infertility affects about 10-15 per cent of couples in the reproductive age groups. Infertility can be caused due to male and or female factors, each of which account for 35 per cent of the cases. Further, 20 per cent cases occur due to both factors and in 10 per cent of the couples the cause remains unknown. Female factors are mostly related to cervix, uterus, fallopian tubes, ovaries, hormonal conditions, advanced age, pelvic inflammatory disease, endometritis, peritoneal problems, and other factors. Male factors can be due to problems related to sperm formation, concentration or transportation, mainly due to hormonal imbalances, genetic factors, drugs, radiations, infections, trauma, varicocele, age, ductal obstruction, etc. Factors that can affect both sexes include environmental and occupation factors, toxic effects of drugs, tobacco, etc, excessive exercise, chronic alcoholism, inadequate diet and advanced age. All these can make it difficult to conceive or result in miscarriages.
Infertility can be primary or secondary. Primary infertility is wherein there has never been any pregnancy. Secondary infertility is wherein at least one prior child birth has been achieved.
Treatment modalities include:
? medical treatment like, use of antibiotics, hormonal therapy, stimulation of ovarian follicles, etc.
? surgical procedures that include repair and correction of any defects that could hinder conception.
? Artificial insemination: This is the process in which sperms are deposited directly into the cervix or uterus of the woman without sexual intercourse, with an aim of achieving a pregnancy. Intra Uterine Insemination (IUI) is more commonly used and has a comparatively higher success rate.
? Invitro fertilisation (IVF): This is a process of fertilisation of the egg with the sperm in a laboratory setting. It involves monitoring and stimulation of the women's ovaries, removing the ovum or ova from her body and combining it with the sperms in a laboratory setting. The embryo thus obtained is then deposited back into the womb of the mother with the intention of achieving a successful pregnancy. The baby thus produced is popularly known as a test tube baby. During this process it is not uncommon to have multiple embryos and around 31 per cent of IVFs in 2006 in US resulted in multiple births. Further, the pregnancy rate per cycle was 35 per cent and live birth per cycle was 29 per cent. Around 85 per cent successful pregnancies are seen in the first four cycles of IVF. However, if no pregnancy occurs in four cycles, other methods of Assisted Reproductive Technologies (ART) need to be considered.
? Assisted Reproductive Technology (ART): This includes all fertility treatments that handle either the eggs or embryos. Cryopreservation is the process in which cells are frozen to sub-zero temperatures for future use. It can be used to preserve semen, oocytes, and embryos. In case of unsuccessful attempts in IVF, fresh or preserved donor cells can be used. These include:
1. Use of donor oocyte: This is done in case of women with poor ovarian reserve, wherein the oocytes of a donor female are used for IVF.
2. Use of donor sperms: This procedure is done in case the male partner cannot produce enough sperms.
3. Donor embryo: Embryos can be donated to other couples or for research. Embryo cryopreservation is helpful in prevention of multiple pregnancies, prevents maternal and foetal complications in IVF, and decreases cost of IVF treatment as it provides an opportunity to achieve pregnancy from the same IVF cycle.
4. Gestational carrier/ surrogate: A gestational carrier is a woman who carries the pregnancy for the couple after the IVF.
However, all the above alternatives are governed by strict protocols and rules due to its medico legal implications.
The first successful invitro fertilisation (IVF) was done in 1978 in UK and the first IVF baby in India was born just 67 days after. Evolution of IVF and its progress has given hope to many childless couples. Success rate of IVF globally is 40 per cent and 30-35 per cent in India. When the mother's age is less than 35 years, it increases the chances of a successful IVF.
ART has been available for more than three decades and more than five million children were born from interventions like IVF. However, these technologies are still widely unavailable, inaccessible and unaffordable in many parts of the world. Inequitable access and high cost of fertility care services can adversely affect the poor, unemployed, and uneducated population. The average cost of IVF treatment in Goa is believed to be around `90, 000 to `1.4 lakh. The Government of Goa has recently inaugurated the Intrauterine Insemination (IUI) centre at North Goa District Hospital, which is a step in the right direction. However, much still needs to be achieved in terms of making the treatment easily available and affordable to all sections of
the community.
Choosing adoption
Extending the love of parenthood by way of adoption of orphaned, surrendered or destitute children is a great service to humanity. It gives an orphaned child a home and provides him/ her with love, care and nurture which his own parents could not provide. It gives the child an opportunity to experience and share the joy of a family and gives the unfortunate couples an opportunity to
experience parenthood.
Of late, many couples from abroad too want to adopt orphans and special need kids from India. It is heartening to note that many couples are coming forward for adoption within India too. However, a long waiting period, legal issues, rigid adoption rules and social stigma can lead to malpractices and illegal adoption. In a recently published article in the Hindu, it is stated that the there are around 28,000 parents currently registered to adopt. However only 2,200 are legally free for adoption, although there are around 2,27,518 (UNICEF 2020) children living in Child Care Institutions (CCI). Also, older children, siblings, and children with disabilities often do not find a home in India.
Major reforms are needed to bring in more children from the CCI's into the adoption pool. Further, the administrative and systemic delays in the adoption process needs to be looked into for an efficient and
speedy procedure.
Legal, timely and hassle-free execution of the adoption process with reduction in waiting period is the need of the hour, so as to provide a meaningful, satisfactory and enjoyable life to both the concerned parents and children.
?(Dr Saroj Salelkar, MBBS, DPH, MPH,
PDCR is a public health specialist
and general physician)