By Ujeena Rana
Some call it an attempt to play god. Some call it defying the odds. Science has always made enemies with naysayers who carry placards that read “If God does not will, let it be.”
Factors behind Subfertility
Dr. Sabina Shrestha, fertility specialist who has been with Om Hospital and Research Centre for 14 years, remarks, “these days, doctors prefer to use the term ‘subfertility’ instead of ‘infertility’”—the new political correctness vis-à-vis medical science. Subfertility is treatable and benign compared to infertility. So, the difference in nomenclature is not just limited to form but in substance as well.
“What I have observed in my career so far is that 13-14 years back, female conditions (blockage of fallopian tube, infection due to TB) were identified as the dominating factors for subfertility. Then the trend changed and male factor (low count of sperm, low motility, morphological abnormalities) proved to be the deciding factor. However, lately, hormonal changes (polycystic ovary, irregular menstruation, thyroid, and diabetes) have been identified as prime factors,” informs Dr. Shrestha. Another fertility specialist, Dr. Mira Thapa from Nepal Int’l Fertility and Laparoscopic Centre, elucidates, “it is caused by the hormones inbuilt by the body as well as those induced courtesy our lifestyle—smoking, drinking, lack of exercise, food habits, obesity and unguided intake of contraceptive pills.” Moreover age is directly proportional to the ovulation factor. “Many women marry late and/or plan to have a baby late and after they hit their late thirties, their chances of conceiving falls dramatically,” illustrates Dr. Shrestha.
Available Treatment Methods
Married couples become exceedingly upset when after the first year of marriage and after meticulous planning and multiple attempts to conceive, they fail. Most often than not, counselling and investigation by experts can provide impetus to the standstill encountered by couples. Other times, fertility experts make avail the discoveries in science and find an alternative way to assist the couple to their way to parenthood. The alternative way simply could be intake of medication, or IUI (Intra-uterine-insemination), IVF (in-vitro fertilization), ICSI (intra-cytoplasmic sperm injection), and Assisted Laser Hatching. “All these treatment methods are at Om Hospital,” informs Dr. Shrestha. Another application she wants to introduce in Nepal is PGD (pre-implantation genetic diagnosis) to examine if the embryo (ready to be implanted in the uterus following the IVF process) has the entire chromosomal normalcy. The centre Dr. Thapa is affiliated with does IUI, IVF, ICSI, and laparoscopic surgery along with semen freezing, embryo freezing, and egg freezing. “Nepal has not yet made ovarian tissue freezing process available,” reveals Dr. Thapa.
“Thailand, Nepal, and India are now off the chart. In Nepal, the new law was put into practice on 18 September 2015 arguing that the earlier provision exploited impoverished Nepali women who were outsourced as surrogate mothers.”
Manhood and Infertility
A constant inquiry is “do men think themselves less of a man when they learn that they are the cause for the failure to conceive naturally? Are not raised eyebrows directed at men thereby putting their manhood under question?” Inarguably, men are also victims of hegemonic masculinity. Dr. Shrestha answers, “Earlier, men never indulged the possibility that they could be the cause. They invariably thought that their wife might be the one with the medical abnormality. But lately, men readily accept the reality since they know that help is available to deal with the condition.” But doomed are those women whose husbands, in-laws, relatives are unsupportive and therefore dump all the blame on the woman and make her life hell. It could also be because ours is a society where parenthood determines a happy conjugal relationship. Furthermore, we are privy of others’ matters—however personal that may be. “20% of such women take anti-depressant drugs since they cannot cope with the stress,” states Dr. Shrestha underlining societal behavior towards those who cannot conceive. It should be noted that if men get suspicious about any anomaly in them, they visit fertility clinics alone and get the tests done for confirmation. “Otherwise, in 70-80% cases, the husband and wife pay us a visit together,” informs Dr. Thapa.
Advanced Polyclinic in Pokhara, New Road provides IUI services to couples who are undergoing difficulties conceiving naturally. “Compared to IVF, it is less painful, easy and affordable. The maximum one has to pay for the service is Rs. 20,000 whereas for IVF the least cost is Rs. 3 lakhs,” informs Sudeep Gurung, Branch Manager. At Nepal Int’l Fertility & Laparoscopic Centre, conventional IVF package costs around Rs. 2.75 lakhs and if the IVF is assisted with ICSI, then the treatment package costs around 3 lakhs.
If IUI fails, IVF is suggested as the go-to-next treatment. “We started IUI service in mid-2013 and we have only 10% success rate,” states Gurung. On a sad note, he states that during follow-ups by the clinic, clients do not want to reveal if the IUI treatment had been successful since they want to maintain privacy about the method of conception. Additionally, couples do not want to end up becoming a case study. “We are the first one to facilitate IUI services in Pokhara,” claims Gurung. It could be that infertility cases are on the rise, therefore, Sahara International Fertility Centre was founded in Pokhara which handles all conditions pertaining to infertility. Visit to Kathmandu or Delhi for infertility related cases demands time and money. “There are too many centers providing IUI services in Pokhara; but, ours is the first in Pokhara to provide IVF and ICSI services,” stresses Dr. Gir Dhari Sharma, IVF specialist and Chairperson of Sahara Hospital.
Heat and Migrant Workers
Pokhara is not the solitary case when it comes to facing a rise in subfertility cases. “It is on the rise everywhere,” asserts Dr. Shrestha. Mirroring the phenomenon is the number of fertility clinics mushrooming across the country. Another trend that many fertility experts like Dr. Shrestha and Dr. Thapa have noted lately is with migrant workers. “After multiple years of stay in Gulf countries or Malaysia, the husbands come home on a 2-3-month holiday. The couple gets engaged in intercourse. After their brief stay, the husbands go back leaving their wives bewildered over their inability to conceive.” Most husbands are employed as chefs or construction workers who have to work in continuous excessive heat throughout the day. Exposure to prolonged heat can impair sperm production. Extreme heat kills sperm. The sperm needs to go through a complete cycle to come to its active form. By the time the husbands leave, the sperms have not yet fully matured. “Only fully matured sperms can fertilise an egg. Additionally, new sperm takes roughly two and a half to three months to fully mature. Not to forget, when sperms are initially formed, they lack the ability to swim forward or fertilise an egg,” comments Dr. Thapa.
Science has accomplished great things. There have been cases where couples who could not conceive for 15 years have had babies after undergoing medical treatments. There are answers but one needs to seek. However, “even the best labs in the world have only 50% success rate. With time science will achieve what is today still considered unattainable,” remarks Dr. Shrestha on a positive note.
Surrogacy- Should it be made legal?
Nepal was considered the ideal breeding ground by agents and foreign nationals for surrogacy especially after India in 2013, in an attempt to protect Indian surrogate mothers’ rights, imposed restrictions over single people, same-sex couples, and foreign nationals, those trying to have a baby through surrogacy procedure in India. Activists lobbying to end commercial surrogacy in India advocated that the reproductive rights of the surrogate mothers were being disregarded.
News ran wild and infertile foreign couples in hope of a child through surrogacy bought tickets to Nepal. The Cabinet decision in 2014 passed the provision befitting the interests of foreign nationals who belonged to the “infertile and desperately in need of a baby” category. The singular condition put across agents and foreigners was that the surrogate mothers offering wombs for rent cannot be Nepali nationals. Resultantly, Indian surrogate women were brought to Nepal to get the job completed. Critics cried foul play and termed the provision—medical tourism—against the health of the country.
Against the directive of the government of Nepal, commercial surrogacy was being conducted in a hush-hush manner where Nepali women were also hired to carry surrogate pregnancies “commercial surrogacy” (that paid them whatever little money that trickled down from the top), and/or when forcibly made to do so by the men in their life. Not playing the “women victim card” here since the women picked to do the job grappled with poverty and instead of manual work that paid them scanty daily allowance, some of them, in fact, preferred the deal since along with money they could get rest and food courtesy the baby implanted in their uterus. “The influx of the surrogate mothers was so high that they had to change into gowns in the same room where doctors used to change. There, simply, was no space left. And most women belonged to poor rural areas,” reports Dr. Uma Shrivastava, senior IVF Specialist whose service was outsourced by Grande City Clinic. The clinic was the first in Nepal to practice surrogacy. Later on Venus Hospital, Baneshwor and Grande International Hospital, Dhapasi also took in surrogacy cases. Dr. Shrivastava runs Infertility Centre, Bijulibazar and has to her credit in 2003 the first IVF success case in Nepal. She was also commissioned to work as a Consultant by the Ministry of Health in 2012 to make protocols for the management of infertility in Nepal. Therein, she had emphasised the need of “medical surrogacy” and the conditions clearly underlined in the protocol were:
- If the women had too many surgeries for tumor/cancer
- If the couple had too many IVF failures
- In the miscarriage is recurrent
Every country has its own laws pertaining to surrogacy. Countries like Belgium and Netherlands allow altruistic surrogacy but not commercial surrogacy. Sweden’s stance on surrogacy is very clear—no commercial or altruistic surrogacy; even to the extent of disallowing its citizens from reaching out to clinics abroad. The United States has rules varying from state to state. In most of the countries, the rules vis-à-vis surrogacy are too strict and hence the system is impermeable to any hanky-panky business. Besides, surrogacy in these countries is exorbitantly high; therefore in search of countries that practice leniency and where work can be done cheap, foreigners used to pick countries like Nepal, India, Thailand, and Cambodia.
But Thailand, Nepal, and India are now off the chart. In Nepal, the new law was put into practice on 18 September 2015 arguing that the earlier provision exploited impoverished Nepali women who were outsourced as surrogate mothers. Sources have confirmed, off record, that surrogacy is still practiced at certain hospitals in Kathmandu—unrecorded and unreported.
Almost all the experts that I talked to stress on the fact that the provision of surrogacy should be allowed for married infertile Nepali couples who genuinely need the medical service. Proponents of surrogacy claim that the concept of surrogacy has been tainted because of commercial surrogacy “the baby factories”; nevertheless, surrogacy needs to be taken as a positive practice wherein the beneficiaries are the childless couples who cannot conceive for various medical complications. However, everyone reiterates the need of proper management on part of the government. “Clear rules, policy and guidelines should be laid out. Furthermore, the provision should be routinely regulated”—these voices echo from every quarter.
“After studying the indications, surrogacy for such couples should be permitted,” emphasise Dr. Shrivastava and Dr. Shrestha. The same sentiment is shared by Dr. Sharma, “If the egg and sperm belong to the biological parents and genetically the baby is theirs, I see no problem in seeking help from a second party to carry the child in their womb for nine months.”
Experts seem to think alike; but, what does the law say? “Supreme Court had ordered the Parliament to come up with laws germane to surrogacy. But surrogacy laws vis-à-vis India and Thailand have undergone massive amendment and the impact of the laws abroad automatically reverberate in Nepal as well,” comments Binita Karki, an advocate. Therefore, lobbying for surrogacy has been on hold. “And because Parliament did not include any such law concerning surrogacy in the new Constitution, therefore no act has been introduced so far. Hence, unless law is proposed, surrogacy in Nepal is an illegal act,” remarks Karki.
Surrogacy case, however, is not as benign as it appears. What if the child born through surrogacy has medical complications? Will the biological parents take it? Who has to keep the baby then? If the biological parents want to abort the child during mid-pregnancy, will the surrogate mother have any say on it? Everyone is for the surrogacy provision in relation to heterosexual infertile married couples, what about same-sex couples, single men and women? Can donors be other than the commissioning parents? What about issues other than medical anomaly—what if a woman brings to the fore “reproductive right” and “my body, my right” but wants to have a baby nevertheless through surrogate pregnancy because it is her right to enjoy motherhood? Is altruistic surrogacy the answer to all? There is a plethora of matters to be taken into account by lawmakers.