Infertility affects up to 15% of reproductive-aged couples worldwide. Studies have shown that about 10 % of women in reproductive age group suffer from infertility. Subfertility is becoming more common worldwide, particularly in ageing populations and urban settings specially where women are having their first babies at older ages.
Many infertility problems in women are related to poorly treated or untreated reproductive tract infections. These can be easily prevented by early detection.Although male infertility accounts for approximately 30% and combined cause account for another 30% of the world’s infertility cases , the social burden falls disproportionately on women.
Infertility is a condition where childlessness can be seen as a social stigma ,especially for women — and stigma is a sign of social unacceptability.
Years back , the stigma of infertility involved three beliefs that:
1) infertility was due to psychological and not physical factors; 2) infertility was associated with sexual incompetence; and 3) infertility is a woman’s problem.
Now, years later, though these attitudes are less prevalent, but the stigma still lingers in people’s minds.
Also earlier, it was not considered publically acceptable to talk about sexuality or sexual body parts and because of the very fact that fertility issues are related to these it became a social stigma. Infertility was typically seen as something to hide and never talk about but in recent decades people have begun to speak about it though there is still a certain level of discomfort in doing so.
The reason people don’t understand infertility is because one doesnt talk about it. One is embarrassed, ashamed, angry, or depressed. To overcome this stigma , we need to start opening up – because sharing the problem can improve ones emotional, mental, and physical health.
In many developing nations the greatest social burden of infertility rests on married women, who are expected to become pregnant and they infact often carry the burden of their husband’s infertility, even when they themselves are healthy and fertile.
The social suffering seems to be worse when women are expected to have many children. This leads to depression, despair, and threats of divorce. When a couple is unable to reproduce, the man may divorce his wife or take another wife if they live in a culture that permits polygamy.
In few cases where the factor is male infertility ,men’s responses are similar to women’s. They also experience guilt, shame, low self-esteem, anger, isolation, loss and personal failure. The inability to father a child leads him to question his masculinity.
Infertile people are viewed as a burden on the socioeconomic well-being of a community. Stigma may extend to siblings, parents and in-laws, who become disappointed for the loss of continuity of their family .
Women face both emotional and financial constraints because of lack of support to seek modern technical treatments. It often means a lonely path for women wishing to conceive.
For many infertile women, in vitro fertilization (IVF) can help. IVF is a procedure in which sperm and eggs are combined in a petri dish and incubated in an environment favorable to reproduction. This technology enables eggs to be fertilized directly by sperm outside the woman’s body .Healthy embryos are then implanted into the woman’s uterus where, if all goes well, they will attach and grow.
Though IVF has grown globally but almost since its inception, in vitro fertilization (IVF) has been a subject of moral and ethical controversies . Today some arguments once made against the process have fallen by the wayside, while others have remain unchanged.
The chief argument in favor of IVF is the potential of giving a chance to infertile couples to have children of their own.
Another important scientific advantage of IVF was that by studying fertilization and early embryonic development outside the womb, scientists might learn more about how to prevent certain birth defects.
But for IVF opponents , there were a number of reasons not to proceed specially , when no one knew if the science would actually work. They considered IVF inherently wrong because it was unnatural and was seen as going against nature.Fecundation must be carried out according to nature and through reciprocal love between a man and a woman. It would lead to the end of the nuclear family and creation of all sorts of non-traditional families, with marriage replaced by laboratory breeding . Mental bonding arises from intimate physical and emotional contact between parents and children. IVF was thought to weaken family bonds and dilute parenthood. Several questions arose. Would birth of in vitro children weaken family bonding? Will in vitro children be looked upon as possessions rather than individuals with their own rights? Will they be as secure as natural children?
Also it was thought that as the new technology enabled more women to have children, the pressure to do so would increase and another emerging fear was the birth of deformed babies with terminal illnesses.
IVF can have tremendous impact on women: it is a very demanding process – physically and psychologically . It has a far reaching effect on her relationship with her partner and her social environment. Emotions and expectations are high and the whole process leaves the women exhausted and disheartened.For other women, the experience of IVF can be more mixed, since they gain positive experiences like adopting a healthier lifestyle and getting closer to their partner.
Infact how one experiences the process can depend on one’s circumstances and personal situation.
Going through IVF can be a very private and delicate issue. Some of the couples prefer to keep the fact to themselves while others decide to share the news their family and friends. Similarly the attitude of the people around can vary greatly. When some close people show disinterest and lack of understanding it causes great disappointment.
To avoid all this many women participate in IVF forums and make use of it in order to reveal their innermost thoughts and feelings. These women share their experience and coupled with the anonymity , express themselves freely without any fear. The internet and social media are extremely important ways of expression for such people. It is important to analyze emotional concerns expressed in such media. The anonymity and privacy of the forums should be honoured.
Understanding the pain and disappointment of women or couples where IVF-treatment is unsuccessful or ends in a miscarriage is very important. Women going through IVF are in a very vulnerable state, emotionally and physically. This requires a great deal of understanding between the IVF health care providers and their patients.
Another cause of concern is uncertainty and frustration when there is lack of full explanation of test results and diagnostic procedures. There should be complete transparency throughout the procedure. Sometimes too optimistic attitude of doctors regarding the positive outcome of an IVF treatment can lead to great disappointment and distress to the IVF users after a cycle failure, specially when the doctors are not able to offer a satisfying explanation after the failure.
Apart from physical and emotional repercussions, there are significant practical problems for women specially if they are working. They may need considerable time off and some choose to put their work, educational or recreational plans on hold. Few studies have shown that this treatment has negatively affected their careers.
Couples pregnant after ART feel different from their fertile peers and are reluctant to share their excitement or worries.They experience higher anxiety levels. It may be because a pregnancy following ART is thought to have a higher risk of complications than one following natural conception . Many also often worry about the possibility of negative health consequences on the children born after IVF. Some birth defects, especially digestive tract abnormalities, cleft palate and heart problems, occur more often among infants conceived by ART than in those conceived naturally .But on the whole there is no evidence to suggest that children conceived by ART are at risk of impaired cognitive or socio-emotional development.
Many parents feel under pressure to try for a second pregnancy after the first successful one , to achieve the ‘complete’ family, shortly after the birth of their first child .. This situation increases levels of anxiety and has an effect on the couple’s ability to enjoy their firstborn.
Multiple embryos are created during IVF . Many viable embryos are created by fertilizing a great number of eggs simultaneously. The most healthy are chosen for implantation while the others are discarded or donated to research , or stored indefinitely for future use or donated to other couples .
Many couples undergoing IVF desire to have a twin pregnancy to complete their family instantly. Thus it can be difficult for couples to make a decision about the number of embryos to be transferred because of their emotional stress in quest for a baby . Though it might seem desirable from a social point of view, multiple pregnancies are linked to a significant increase in mortality and morbidity for both the mother and babies and there are financial and emotional problems atthached to it. Also the ethical and moral issues as to how to deal with the extra embryos have been the source of much speculation. The use of embryos for the purpose of research, specifically has also been a point of strong debate since embryo is seen as a form of human life .
The use of donor gametes, either in the form of donor sperm or donor oocytes, is common place in ART. In recent years, the use of donor gametes have increased considerably. Oocyte donor has to undergo IVF and it is considered an ethical prerequisite that oocyte donors participate voluntarily without undue influence.
There are concerns that financial compensation of oocyte donors may lead to exploitation as women .The concept of any buying or selling of human gametes is immoral and this is a strong argument used against fertile women serving as oocyte donors .
Another ethical and legal issue surrounding the use of donated gametes is to what extent the anonymity of the donor should be preserved. The issue is emotional. Indeed, the right of human beings to know their genetic roots is universally important, for their self identity.
Recently, there is an increasing consideration towards the rights of offspring to know their biological parents.
So the two major issues in relation to gamete donation are the donor’s right to anonymity and the child’s right to know his/her genetic origin. Many countries have now passed laws to reduce the donor’s right to anonymity and provide access to information about the donor to the offspring upon reaching a certain age.
It has been shown that adopted children benefit from knowledge about their biological parents, and that when they are not given such information they may become confused about their identity and at risk of emotional problems .And the same has been extrapolated to the children born from the donor gametes .
Despite this evidence, actual disclosure is about 10%.The main reasons couples give for not wishing to disclose are fear of stigma for the child, the inability to access genetic information on the donor, and insecurities about how to disclose to the child . Many couples also decide not to disclose because of fear of criticism and discrimination towards them but especially towards their child . But there is an inherent fear of the possibility of discovery of reality through medical tests and procedures and improved genetic technology. Both donors and offspring have an inherent right to meet and develop a relationship .
IVF allows doctors to do genetic testing prior to implantation. Preimplantation genetic screening (PGS) and diagnosis (PGD) offer the unique ability to characterize the genetic composition of embryos prior to embryo transfer.
Sex selection is possible and might become an option and if practiced, alter the gender proportions in certain nations where one gender is culturally preferred.
Of more concern is the possibility that in the future, technology will permit the manipulation of genetic material within an embryo. So does that mean that parents someday have the ability to select genes for intelligence, talent or for beauty? And will such a parent lose affection for her child if she turns out to be just average, ordinary underachiever?
These risks to society and human dignity posed by IVF and other such fertility technologies is enormous.
Another important social consideration is the fact that gamete donation also technically allows gay and lesbian couples and single men and women, to achieve parenthood. Social and cultural expectations place a heavy burden on those who cannot achieve a genetic link with their child.
Another topic of ethical, social, and legal debate surrounds the use of surrogacy. It involves a couple who undergoes IVF with their genetic gametes and then places the resultant embryo in another woman’s uterus, the surrogate , who will carry the pregnancy and relinquish the child to this couple upon delivery.
As with donor gametes, surrogates are subject to significant medical and emotional risks from carrying a pregnancy and undergoing a delivery .
Some opine that the use of surrogates is like selling a child or a parental right. Another concern is the possibility that financial pressures could lead to exploitation of this service.Today international surrogacy is an emerging industry, especially in developing nations.
Another pertinent question is whether older women be offered in vitro fertilization?
Can older women cope with motherhood? What will be the potential health of the child? Why are we taking a risk when in vitro fertilization is rarely successful in older women? Many such questions need to be answered yet.
Whatever the social concerns may be but the fact remains that the birth of the world’s first test tube babies probably did silence the critics of in vitro fertilization.Many social concerns failed to materialize and test tube babies are not shunned. IVF facilitates a very traditional outcome, which is a mother , a father and children . Far from destroying the traditional family, the effects of IVF are often conservative.
As thousands more test tube babies have been born, opposition to the procedure is nearly vanishing and people are getting used to all sorts of new technology.
by Dr. Sonia Malik
(DGO, MD, FICOG, FAMS)
PROGRAMME DIRECTOR OF SOUTHEND FERTILITY & IVF