Battling Infertility in Nepal

In Nepalese society children are considered a gift from god –a blessing that every couple looks forward to. As soon as a couple gets married, they immediately encounter questions from well-meaning family and friends about when they plan on having a baby. In Nepali society, often the answer is, within the first couple of years of marriage. However, a growing number of couples these days are finding out that getting this blessing is not as easy as they had imagined, and that they might need some medical help before they can conceive.

“In this day and age, any couple can have a baby, no matter their medical issues,” says Dr. Padam Raj Pant from Grande International Hospital. “So, we prefer to use the term sub-fertility rather than infertility. Infertility implies that the couple is barren and cannot have children, which is wrong.”

“A couple is advised to seek medical help if they are unable to conceive naturally after trying continuously for an entire year,” says Dr. Akriti Bharati from Vatsalaya Natural IVF Center. However, there are some clauses. For couples who are above the age of 35, medical intervention is advised after six months, rather than a year, because of declining egg reserve in the woman due to age. Similarly, if either man or woman has a known condition that affects their ability to conceive naturally, again, medical intervention is sought/advised immediately.

“Globally, 12-15% of couples suffer from sub-fertility,” says Dr. Pant. However, sub-fertility is on an increasing trend around the world, and even the WHO has changed its standards in recent years owing to this trend. “Earlier, in order to have children, having 50 million sperm per milliliter was considered the minimum standard. Then, the number was decreased to 30 million and 20 million. Finally, in 2010, the cutoff point for sub-fertility in men was revised to 15 million,” he adds.

Causes of Infertility
Infertility itself can be classified into two categories. “If a man or a woman has never had a child and is unable to conceive, it is termed as primary infertility, and if they have successfully conceived before, but are now having trouble conceiving another child, it is called secondary infertility,” says Dr. Bharati.

Infertility is caused by various factors. “Both men and women are equally involved. Research has shown that 40% of the time, infertility is caused by male , and 40% of the time it is female infertility we’re dealing with. Besides that, there are times when everything is normal and the cause is unknown,” Dr. Bharati explains.

The most common reason for female infertility leading to IVF treatment these days is tubal blockage, according to Dr. Bharati. The fallopian tubes are where the sperm and egg meet and conception takes place. However, if the tubes are blocked, conception cannot happen, and pregnancy does not take place.

Age is an important factor in female fertility, since women are born with a fixed number of eggs. “Throughout her reproductive period, from menarche to menopause, a woman’s egg reserve is only 300-400,” says Dr. Sabina Simkhada from Vardhan Fertility Center. And, each month, starting from menarche, one egg gets released during ovulation. “So, as the woman ages, even when she is unmarried, or has not planned for a baby, from a fertility point of view her eggs are getting wasted and her egg reserve is declining with time.”
On day 2 or 3 of the menstrual cycle, the egg reserve can be examined through ultrasound. Normally, the egg count during this time should be 8-10 in each ovary. However, if the egg count is less than 5-6 in each ovary, it is diagnosed as low ovarian reserve.

Another cause of female infertility is endometriotic cyst, also called chocolate cyst, which is a cyst that forms in the ovary when the endometrial lining enters the ovary. “This cyst is an egg-eater and rapidly reduces the egg reserve in a woman,” explains Dr. Simkhada. One of the reasons for the formation of chocolate cyst is delayed marriage, she further adds.

Other causes for female infertility include diseases like tuberculosis, harsh curettage of the uterus, birth conditions that lead to lack of uterus in a woman, etc. However, the most growing cause of female infertility is PCOD, or Polycystic Ovarian Disease. This is a condition where egg count in the ovary is too high, leading to high competition among the eggs, resulting in difficulty for any one egg to reach maturity and ovulate. PCOD is also related to sedentary lifestyle, stress, and obesity.

Among men, low sperm count and low sperm motility are the most common factors. Beside low sperm production, tubal blockages can cause lack of sperm in the semen (even though the man produces sperm in his testes) which causes infertility.

Lifestyle, occupational, and environmental factors play a huge role increasing male infertility. “Due to causes like smoking, pollution, and industrial exposure, the DNA of the sperm is becoming fragmented, and it affects the sperm’s ability to fertilize the egg,” says Dr. Bharati. A study done by Dr. Pant in several districts of Nepal has also shown that use of chemical fertilizers is also reducing the sperm count in men in villages.

Temperature plays an important role in male infertility. In order to produce viable sperm, the testes need an optimal temperature that is slightly lower than the normal body temperature; hence, the reason why the testes are located a bit outside of the male body. But, higher environmental temperature in the genital area caused by various environmental causes, such as sitting in hot vehicles for a long time, prolonged use of laptop (while placing the laptop in the lap), working in hot climates, etc. can also affect the sperm count in men. Dr. Pant reports that occupational drivers often suffer from male infertility due to long time spent sitting in a hot vehicle seat. Similarly, Shristi Khadka, Executive Director of Vatsalaya, has also reported seeing an increasing trend of male infertility in her clinic in recent years, especially among men who return from working in foreign countries, especially the Gulf countries.

Besides sperm count, previous surgery, such as hernia surgery, hydrocele, pelvic trauma, history of sexually transmitted diseases, and lifestyle factors like smoking, stress, etc. also can lead to male infertility.

Treatment Options for Infertility
Depending on the cause of infertility, there are several options for its treatment. Generally, the first step is to determine the cause of infertility itself, and based on the cause of infertility, the treatment is recommended.

The diagnosis options for infertility start from the least invasive and move toward the most invasive. Dr. Pant at Grande International Hospital usually starts with the history of the patient, including their lifestyle and previous history of diseases like tuberculosis, mumps, etc. If the medical history is fine, the first step is semen analysis. After semen analysis, on day 2-3 of the menstrual cycle, serology of the patient is done to check the level of different components in the blood, then hysterosalpingogram (HSG) is done between 6-10 days of the menstrual cycle, followed by transvaginal ultrasound and endometrial sampling.

Based on the diagnosis of these tests, further treatment is advised.

In case of male infertility, if the sperm count is between 5 to 10 million per ml, the patient can go for IUI (intra uterine insemination) where the semen is put through a special centrifuge to weed out weak or non-motile sperm cells, and the healthy sperm is then injected into the uterus of the female. If the sperm count if less than 5 million and/or if the sperm motility is too low, IVF treatment is recommended.

If the male is suffering from obstructive azoospermia, where the testes produce sperm but the sperm is not found in the semen due to tubal blockage, the sperm is extracted from the testes through a process known as testicular sperm aspiration, and IVF is recommended.

In case of female infertility, depending on the condition, the treatment may vary. For PCOS patients, medicine is given to induce ovulation. “For my PCOS patients, I first encourage them to try naturally after inducing ovulation, and more than 50% of patients conceive this way. Only if the patient is unable to conceive even after 5-6 months of starting ovulation treatment, then I recommend going for IVF”, says Dr. Bharati.

Similarly, for uterine abnormalities, for example, if the uterine walls are stuck together, surgery may be necessary. In some women, they are born without a uterus, so in such cases, surrogacy is their only option.

Another less highlighted cause of infertility is cancer treatment. “I’ve met many cancer patients who go through chemotherapy or radiotherapy and the cancer gets cured. After this, when the patient wants to start their family, they have no eggs or sperm left, because chemotherapy and radiotherapy are toxic so the eggs and sperm get destroyed,” says Dr. Bharati. “So, in such cases, what can be done is that, once the cancer is diagnosed, the patient can come and get their eggs or sperm frozen before going for treatment. And, once their treatment is completed, they can have their own biological child. ”

In Vitro Fertilization (IVF)
Generally, during natural conception, the sperm and the egg meet inside the female body, which is known as in-vivo fertilization. However, when natural conception does not take place for any number of reasons, the sperm cells and the egg cell are retrieved from the respective male and female bodies and the sperm is made to fertilize the egg in a petri dish. This process is known as in vitro fertilization, or IVF treatment.
The standard IVF treatment consists of sperm and egg being put together in a petri dish and being allowed to fertilize on their own. However, if the number of eggs or sperm is too low, a procedure known as intracytoplasmic sperm injection (ICSI) is carried out, where one sperm is selected and injected inside the egg, thus fertilizing the egg.

Suresh Yadav, embryologist at Vatsalaya, explains the entire procedure in detail. “What the doctor does is stimulate the patient and monitor the growth of the follicle. Once the follicle reaches the optimal size, they collect the eggs and bring it to the lab to us. We select the mature eggs out of the eggs retrieved and clean the egg with fresh reagent (called denudation) and nourish the egg so that it does not die. The egg is kept in an incubator that maintains uterus-like temperature, oxygen levels, etc. to ensure that the egg is kept alive and well,” he explains.
After retrieving and denuding the egg, an equal number of sperm cells are selected from the husband’s sample, and the embryologist injects the sperms one by one into the respective eggs. This process is called ICSI. After the fertilization, the fertilized eggs are kept in an incubator. On day 3, the embryologist checks the number of zygotes formed. Sometimes, all the eggs form zygotes, while sometimes only a few eggs form zygotes. “It all depends on the quality of the eggs, the quality of the sperm, and how we perform the procedure,” says Mr. Yadav.

The zygotes that are formed are then transferred into the patient’s body on day 3 itself, and the remaining embryos get frozen in liquid nitrogen at -20 0C for future use. Those frozen embryos can be used at any time in the future.
Mr. Yadav usually transfers two embryos at a time to increase the chances of implantation in the womb. If both embryos implant, twins are born, and if only one embryo implants inside the body, one child is conceived.
In order to ensure that the wrong embryos from another patient are not transferred into the patient’s womb, care is taken to properly label everything. “In recent years, REI system has been introduced, which is a software system that codes the gametes and ensures that the correct embryo is implanted into the correct patient,” says Dr. Swosti Sharma from Hope fertility Center. “Furthermore, new technology, such as Real Time Incubators, allow the doctors and embryologists to monitor the embryo growth without removing it from the incubator,” she adds. The Real Time Incubators even helps select the best embryos for implantation.

IVF treatment in Nepal was only introduced to Nepal 16 years ago. The first baby born through IVF in Nepal was Om Mani Tamang, who was born at Om Hospital on March 3, 2005, under the supervision of Dr. Bhola Rijal. Even today, there are only 11 IVF centers in Nepal, out of which nine are located inside Kathmandu Valley. One is located in Pokhara, and another in Biratnagar.

Although IVF treatment is expensive, with one IVF treatment starting from around three lakh rupees, IVF is not guaranteed to give you a baby. “People come to us expecting 100% results, which we cannot guarantee,” says Dr. Sharma. Worldwide, the success rate of IVF is only 40 percent.

Myths about IVF Treatment
There are a few myths floating around IVF, which Dr. Bharati was kind enough to address for us. A common myth is that IVF patients need bed rest. “A large study was done where half the patients were given complete bed rest, and the other half went about their day as normal, and the results showed no difference between the two groups. Furthermore, we have seen that when patients take bed rest, their minds are not occupied and they end up getting stressed, which has a negative effect on implantation, so we do not recommend getting bed rest during IVF treatment,” she explains.

Similarly, there are myths floating around about the food that IVF patients can and cannot have, but IVF patients can eat the same food as patients with normal pregnancy and do not have to follow any additional restrictions.
There are also rumors that there are higher chances of abnormalities from IVF babies, which Dr. Bharati denies. There are chances of abnormalities even in normal pregnancy, and overall, the chances of fetal abnormalities in IVF is similar to normal pregnancy.
Another myth is that IVF results in a male child, which is highly preferred in our Nepalese society, which is completely false. “We cannot know the gender of the baby by looking at the embryo. In order to know the gender of the embryo, we must use a test called pre-gestational diagnosis (PGD). But, sex selection is illegal in Nepal and we do not do that.”

Another rumor is that IVF often leads to twins and triplets, which is somewhat true. During normal conception, usually one egg is released per month, and if it gets fertilized, a baby is conceived. But, in case of IVF, at least two zygotes, if not more, are transferred into the mother’s womb in order to increase the stakes that at least one embryo is gets implanted and results in a baby. But sometimes, all the embryos get implanted, which leads to birth of twins or triplets.

Social Cost of Infertility
Although both men and women can be the cause of infertility in a couple, unfortunately, there is still a prevalent belief among Nepalese society that sub-fertility is a woman’s issue. “It is my policy to have both the husband and the wife present during consultation, because I have found that often men are not aware that they could also have an issue that is impacting their ability to have a child.” says Dr. Pant.

An interesting incident he recalls is of a woman in her 20s, who sought his help after being unable to conceive after two years of marriage. After some questioning, he finds out that she is her husband’s fourth wife, who he had married after being unable to have a child with his three previous wives. After being asked to bring her husband, who was in his 60s, to the hospital with her, the man insisted that there were no medical problems from his side, and that he was strong and healthy despite his age. However, after medical examination, they found out that the man did not have any sperm, and that was the reason why he was unable to have kids with any of his wives. “We really need more awareness around this subject,” emphasizes Dr. Pant.

Infertility has led to many social evils in our society, as well. “In parts of Terai, if a woman is unable to conceive, she is forced to leave the house. Many women have suffered, become homeless, or even lost their lives because of infertility. So, this is not just a medical issue, it is also a social one,” says Dr. Pant.

Even in well-educated, elite circles on Kathmandu, infertility is a topic of shame. Dr. Sharma recalls, when giving an interview for a television program, she was asked to bring in a patient of hers as well. Her embryologist Pratigya personally called 45 couples who had successfully given birth through IVF at their center, and not a single couple agreed to come on camera and talk about it.

People are still insecure that other people will find out that they needed IVF to conceive a child, says Dr. Sharma. “For many women, due to our societal structure, conceiving a child is a validation that she is a member of her husband’s family. And, no one questions the man. They only question the woman—at every family gathering she faces questions from friends and family. And, when she has to go through IVF she feels like she a failure, because she needed to spend so much money just in order to conceive a child. Even when the couple is battling with male-factor infertility, I have found women questioning their self-worth for being unable to conceive naturally.”
She also recalls an incident where a relative of a staff member whose husband was suffering from azoospermia refused to get treated at her center for fear that her relative would know all about their infertility issues. “People do not want even their closest relative to know about their medical condition and their treatment,” she adds.
When faced with male-factor infertility, Dr. Sharma says that she has often found her male patients questioning their manliness. However, in such cases, their response is often to ask the doctor to get their wives pregnant by any means possible, including using donor sperm if necessary, so that no one finds out that they were unable to impregnate their wife.

Future of Infertility Treatment
In recent years, there have been many improvements in technologies for infertility treatment around the world that have taken this field by storm.

When Dr. Pant started working in this sector in 2050 B.S., he had very few options for treating his patients. Necessary medicines were hard to come by. Even doing an IUI was difficult, because he often could not find the medicines needed to give to his patients in order to perform the procedure. In the 27 years that he has been working, he has seen massive changes in the sector. In 2005, Dr. Bhola Rijal delivered Nepal’s first “test-tube baby”. And now, with technologies such as ICSI and PGD available in Nepal, almost any couple can have a child.
Even more interesting developments are taking place around the world. Dr. Sharma reports of successful uterus transplants that have taken place which will allow women born without a uterus to finally be able to give birth to a child naturally. There have been 10 reported cases where uterus transplant has been successful.
Similarly, through a process called mitochondrial transplant, three-parent babies have also been born around the world. In this procedure, the mitochondria in the mother’s egg is replaced with mitochondria from another person. This leads to the baby getting its nuclear DNA from its mother and father and its mitochondrial DNA from the donor, thus getting DNA from three people, rather than two. This procedure is done in order to prevent certain genetic disorders.

This rapid technological development in fertility treatments around the world is very encouraging, and soon we might see a day when people no longer have to worry about not being able to conceive a child.

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