1. What is infertility?
Infertility is a term that is used to describe the inability of an individual to successfully contribute to the process of conception. In females, it refers to their lack of ability to conceive post having regular, unprotected intercourse. In some cases, it also refers to their inability to carry a pregnancy to its full term. A normal fertility helps conception in the first 12 months of trying for almost 86% of couples, with around 7-8% couples conceiving in their second year, depending on their age. Hence, many practitioners also treat an inability to conceive within the first 12 months as infertility.

2. Is infertility a global problem?
Sub-fertility as well as infertility are a global public health issue affecting approx. 8-12% couples, worldwide. It is prevalent in both males and females. While over 10% of women world-wide, who have been in stable relationships for over 5 years yet been unsuccessful in conceiving, have been estimated to be inflicted with this problem; the count is much smaller in the case of men, primarily because of non-acknowledgement, even though it contributes to almost 50% of reported cases.

3. Do infertility problems occur only among women?
No, infertility problems are as common in men as they are in women. Almost 50% of cases of infertility are attributable to male infertility related issues. However, due to the social structure prevalent, most of such male infertility related issues go unacknowledged.

4. What could be the probable symptoms that suggest a possibility of infertility related problems?
Though the process of conception and the possibility of infertility related problems could be time-driven factors, some symptoms could indicate a bent towards infertility and could be medically examined and addressed in time to curb the problem at the very onset. Some of these indications include:

Indications in Females:
Infertility symptoms in females can be related to either one of multiple of these problems:
• Changes in menstrual cycle: Irregular or infrequent periods mean that the number of days between two cycles varies each month. This is a common indication of infertility as it reflects that the ovulation cycle is not stable, i.e. the body is not producing ovules (egg) regularly or at times not at all.
• Abnormalities in periods: Sudden changes in the bleeding pattern – heavier periods, no period or cramping and pelvic pain associated with periods – could also be indicative of an underlying fertility related problem.
• Hormonal Disturbances: Sudden changes in skin like more than usual acne, changes in sexual drive, unexplained and sudden growth of facial hair, excessive weight gain/loss, etc.
• Other Symptoms: Other symptoms such as pain during sex, milky-white discharge from breast/nipples (unrelated to lactation) can also be indicative of infertility and one should seek medical advice at the earliest.
• Age-related: As one advances in age, the egg count decreases rapidly along with a related deterioration in the egg quality. Hence, if a woman is in her early 30s and is failing to conceive, it could be related to a fertility problem.

Indications in Males:
Infertility symptoms in men can be quite elusive as they are very closely related to the cause of infertility. These often go unnoticed until the point that the couple start trying for a baby. Some of these are:
• Sudden changes in sexual drive.
• Pain, inflammation or lump in the testicles or if the testicles are small and firm.
• Problems related to ejaculation and erection
• Sudden, unexplained changes in hair growth patterns.
• Known semen abnormalities

5. Who are at risk of infertility problems?
Age is one of the most crucial risk involved in fertility related matters. For couples who start trying for a baby later in age, the chances of infertility increases manifolds. Couples where either partner is in their mid-30s or into 40s are at higher risk of infertility problems. While a man’s overall lifestyle, health and other factors can affect his chances of contributing to a successful conception, in a woman age and chronic health conditions play a major role.

6. What increases infertility risk in men?
While health and lifestyle are the most important factors that contribute to their fertility levels, including their sperm quality and count, there are many other factors that affect fertility and push towards higher infertility risk among men. Some of these include:
• Age
• Alcohol and tobacco consumption
• Excessive physical exercise, especially excessive cycling
• Weight related issues
• Exposure to toxins at workplace or as part of a medical treatment like chemotherapy/radiation
• Surgical procedures like vasectomy or its reversal
• Family history of infertility or fertility related disorders or other genetic medical conditions like cystic fibrosis
• Medical history of sexually transmitted infections (STIs)
• Certain chronic problems like high blood pressure, diabetes, renal or hormonal problems

7. What can increase the risk of infertility among women?
Ovulation related issues contribute to over 25% of female infertility cases, with tubal blockage and uterine problems coming in as the other infertility causes in women. However, some other factors like the ones enlisted below also put females at risk of infertility:
• Advanced age
• Frequent or heavy alcohol or caffeine consumption
• Cigarette smoking
• Weight-related issues
• Eating disorders and lack of balanced healthy diet
• Intense and extended athletics or no exercise at all
• History of STIs, endometriosis, polycystic ovarian syndrome (PCOS) or fibroids
• Chronic health issues like high blood pressure or diabetes.
• Hormonal problems like thyroid etc.
• Mental stress and fatigue

8. How is age related to a woman’s ability to conceive or infertility aspects?
A woman’s fertility rate begins to recede with her age. As a woman nears her mid-30s, her natural fertility starts to fall and many experience difficulties in conception as well as multiple pregnancy failures. The reason for this is that the ovarian reserve in women is fixed since birth and as they age it starts to fall drastically as the follicles keep leaving the reserve in a continuous flow (menstrual cycle). This follicular depletion accelerated as she approaches 40s and decreases not just her egg count but its quality too, as she ages. For men, this progressive drop in fertility rate hits after the age of 40.

9. What are common causes of infertility in men?
One of the most common causes of infertility in men are semen disorders. The semen comprises a milky white fluid and sperms that are ejaculated during orgasm. Abnormal semen contributes to over 75% cases of male infertility. The common semen related disorders include:
i. No sperm presence in semen
ii. Low sperm mobility
iii. Abnormal sperm shape/size
iv. Low sperm concentration (under 10 million/milliliter) in the semen (Ideal: 20 million/milliliter of semen)
The major causes of these abnormalities and a consequent infertility in men are:
1. Ejaculation Disorders
2. Frequent use of saunas, hot baths etc. that lead to overheating of testicles.
3. Testicular infections
4. Testosterone deficiency
5. Deformed or undescended testicles that usually happens as a birth defect or abnormal fetal development.
6. Genetic disorders like Klinefelter's syndrome that lead to abnormally developed testicles.
7. Very frequent intake of medications like Sulfasalazine, Anabolic steroids (frequently taken by athletes), etc. or exposure to chemotherapy/radiation.
8. Conditions like hypospadias (a condition where the urethral opening is not at the tip of the penis but at its underside) or cystic fibrosis.

10. What are common causes infertility in women?
There are a number of conditions that lead to fertility among women, such as:
1. Ovarian Disorders: The most commonly reported reason for infertility among women is a disorder in the ovulation process.
Ovulation involves the production and release of egg. This cycle happens on a monthly basis. However, certain situations lead to a malfunctioned ovulation. These causes include:
i. Polycystic ovary syndrome (PCOS) which lead to mal function of ovaries
ii. Very high prolactin levels in non-lactating females
iii. Damaged or abnormal eggs – Poor egg quality is common in older women
iv. Thyroid disorders
v. Medical conditions like cancer, diabetes, AIDS, etc.
vi. Premature (before the age of 40) ovarian failure
2. Uterine Disorders: Once fertilized, the egg travels from the ovary to the uterus and it is important that the uterus be healthy to receive and nurture the fertilized egg. However, at times, disorders of the uterus lead to infertility problems in women. Uterine disorders can be attributed to one or more of these reasons:
i. Pelvic or cervical surgery that may cause scarring or damage of the uterus or fallopian tubes or at times shortening of the cervix which serves as the mouth of the uterus.
ii. Endometriosis – a condition where the cells that line the uterus start growing outside the uterus.
iii. Sterilization treatments like tying of tubes, etc.
iv. Uterine fibroids or endometrial polyps
3. Medications: Certain medications like those used in chemotherapy or certain NSAIDS like aspirin and ibuprofen lower fertility rates in females.
11. How long should one wait before approaching a doctor for infertility related consultation?
If you or your partner are under 35 and have been unsuccessfully trying to conceive for a year or more, it is time you plan a visit to your doctor. However, for couples over 35, a visit to the doctor to rule out the possibilities of infertility becomes due if you have been trying for a baby without any success for about six months.

12. Who should one visit for infertility related problems?
You can start with preliminary consultation with a general practitioner or a gynecologist. Frequently in the event that the doctor suspects of or determines through preliminary investigations an infertility related problem, he/she may refer you to a reproductive endocrinologist or who is commonly referred to as a fertility specialist for a more in-depth analysis of your problem and further line of treatment. This serves as a good second opinion for your infertility treatment too.

13. How do doctors diagnose fertility problems in couples?
It takes two to make a baby and thus all preliminary investigations are done for both the partners to ascertain as well as rule out fertility-related problems. The doctor, as part of this assessment, may probe the partners to understand more about their sexual habits and ask for some tests to be performed to diagnose the real cause of the problem. Through these preliminary investigations, the doctor arrives at a conclusive diagnosis of fertility related issues in either of the partners.

14. What are the common tests that the fertility specialist performs?
Some of the common tests advised as part of the diagnosis process for infertility treatment in India include:
Infertility Tests for Male Partner
• General physical examination
• Semen analysis
• Blood Test for Testosterone Level
• Ultrasound Test of urogenital area
• Chlamydia Test

Infertility Tests for Female Partner
• General Physical Examination
• Blood Test for Progesterone and other hormone levels
• Hysterosalpingography to check for any blockages in the path that the egg takes from the fallopian tubes
• Laparoscopy
• Ovarian reserve testing
• Genetic Testing
• Pelvic ultrasound
• Chlamydia Test
• Thyroid function Test

15. What is the clomiphene citrate challenge test (CCCT)?
Clomiphene Citrate Challenge test (CCCT), or what is also known as the Clomid Challenge Test, is one of the diagnostic tests used for the diagnoses of egg quality and the overall health of the ovaries. This comprehensive test is the most commonly recommended non-hormonal test to check the progressive deterioration in fertility or the egg reserve in the ovary (ovarian reserves) in females who are aged 38 years or more. This test rests on the premise that as women grow old, the ability of their ovary to bear eggs diminishes and so does the egg quality. This often leads to low rates of fertility and high rates of miscarriage. Besides age, other considerations that weigh your doctor’s decision to prescribe CCCT to you could include any one of these conditions, as well:
- Unexplained infertility or poor response to prior fertility drugs
- Prior history of an ovarian surgical procedure - Very short menstrual cycle

- Other symptoms that suggest a diminished ovarian reserve

Test Procedure
The test comprises 3 parts:
1) On Day 2 or 3 of menstrual cycle, a blood test is done for Follicle Stimulating Hormone (FSH) and Estradiol
2) On Day 5-9, 2 pills per day of Clomiphene Citrate is prescribed
3) On Day 10 of cycle, a repeat blood test for FSH is done

What This Test Measures?
The CCCT measure the level of follicle stimulating hormone (FSH). A healthy ovary requires this essential hormone to produce eggs, but in very small quantities. However, a malfunctioning ovary would use up substantially high levels of this hormone to produce egg.

16. What are the treatments available for infertility?
There are a number of options available for the treatment of infertility. However, which option would best suit a particular couple depends largely on a number of factors like the cause of infertility, the age of the patient and the partner, how long the infertility symptoms been present and of course personal preferences.

Treatments for Men
Depending upon the above factors, treatments in men could include one or more of the following:
• Antibiotic treatment to address any infections of the reproductive tract, as a start.
• Medication, recommendations and counselling on aspects related to treatment of sexual intercourse problems like erectile dysfunction, premature ejaculation, etc.
• Hormone Replacement Therapy for hormone related problems that are being cited as a probable reason of the infertility.
• Surgical Procedure for the treatment of obstructions or to retrieve sperms directly from the testicles, in cases where no sperm is present in the semen.
• Assisted Reproductive Technology (ART) that involves artificial or assisted insemination of the egg. Some commonly known ART methods include IVF.

Treatments for Women
In females, the doctor may have to resort to one or more therapies to restore fertility and enable the woman patient to conceive. Some of these treatments may include:
• Using fertility drugs to induce ovulation.
• Intrauterine insemination (IUI) wherein healthy sperms are injected into the uterus around ovulation to assist in fertilization.
• Surgical Procedures like hysteroscopic surgery in cases of uterine related problems like endometrial polyps, intrauterine scarring or uterine septum to restore fertility.

17. What are the commonly used medicines to treat infertility in women?
Fertility drugs are one of the first line of treatment that most doctors resort to for the treatment of infertility among women. These medicines that are taken to treat ovulation disorders can be given for oral consumption or as injectables. In fact, these infertility drugs find use in infertility treatments even if the couple have opted for assisted reproductive technology methods like IVF. The most commonly used medications to treat infertility in women and help stimulate ovulation are:

Clomiphene or Clomiphene Citrate: An oral fertility drug that increases the production of hormones that help in maturing the eggs in the ovaries. It is usually the first line of treatment and only once the patient does not respond successfully (does not conceive) even after being on this medication for continuous 6 six menstrual cycles, the doctor advises other fertility treatments.

Gonadotropins and Human Chorionic Gonadotropin (hCG): Injectable hormone medication that help stimulate the growth of the egg in the ovaries, thus bettering the chances of ovulation. This drug is recommended usually once the female patient has failed to respond successfully to clomiphene. Use of gonadotropins is accompanied with transvaginal ultrasound to closely monitor the size of the developing eggs and regular blood tests to keep a tab on the production of estrogen by the ovary. Once the eggs grow in the follicle, hCG hormone is injected to trigger the release of the developed egg.
Bromocriptine or Cabergoline: Oral pills that are usually given to treat abnormal levels of the prolactin hormone that is found to stop ovulation.

18. What are the common ways of improving fertility?
Fertility is a direct offshoot of how you live. Your lifestyle that includes your eating habits, health & hygiene, exercise, sleep patterns and other sexual habits has a direct bearing on the fertility among men and women alike. Some common ways of improving fertility include:
1. Eat right
2. Moderate Exercise
3. Understand your body and your fertility cycle including basal body temperature, ovulation etc.
4. Manage weight
5. Experiment with different sexual positions during intercourse

19. What does Assisted reproductive technology entail?
When the above mentioned treatments of infertility fail, a couple may choose to opt for the more complex fertility treatment options like Assisted Reproductive Technology. Assisted reproductive technology (ART) entails an assisted manipulation of the egg and the sperms. This fertility treatment involves the use of fertility medications, artificial insemination, in-vitro fertilization and or surrogacy to help infertile couples to achieve pregnancy.

20. What is the success rate of Assisted reproductive technology?
In general, the success rate of ART is quite good, being on the higher side. However, it has been seen that several factors go into the success or failure of an ART procedure. While some factors relate to the experience level of the clinics offering this service; other factors depend on the patients themselves like their age or the cause of their infertility etc. It has also been noticed that the success rate of ART starts declining after age 35.

21. What are the different methods used as part of assisted reproductive technology?
Several techniques are used as part of the Assisted Reproductive Technology (ART). These include:
• Intrauterine Insemination (IUI) or Artificial Insemination
• In Vitro Fertilization (IVF)
• Intracytoplasmic Sperm Injection (ICSI)
• Zygote Intrafallopian Transfer (ZIFT)
• Assisted Hatching
• Gamete Intrafallopian transfer (GIFT)
• 3rd Party Assisted ART
• Sperm Donation
• Egg Donation
• Surrogacy

22. What are the chances of conceiving multiple pregnancies with Assisted reproductive technology methods?
The chances of multiple gestations increase multifold in the case of Assisted Reproductive Technology methods. This is primarily because the follicles where the eggs grow are stimulated in excess along with excess embryo transfers to ensure success of the method and achieve reasonable pregnancy rate. However, it is seen that the percentage of multiple-infant births is particularly high for women who are less than 35.

23. What is artificial or intrauterine insemination?
Intrauterine insemination (IUI) or what is also called Artificial Insemination involves the placement of sperm into a woman's uterus or cervix through the use of artificial means like a long, narrow tube rather than by natural process of a sexual intercourse. This process can thus be either intrauterine when the sperm is places in the uterus or it can be intracervical if the sperm is placed in the cervix. This technique finds good and more effective use in the following conditions or cases where:
o The female partner has intrauterine scarring or cervical defects.
o The male partner has either low sperm count or low mobility of sperms
o The male partner has erectile problems
o The male partner has retrograde ejaculation
The doctor may recommend IUI in combination with fertility drugs to increase the chances of getting pregnant, in certain cases. The overall success of this ART method depends on the cause of the infertility and it increases significantly by almost 20% per cycle, if the insemination process is performed regularly. IUI depends on the cause of the couple's infertility.

24. What does In vitro fertilization (IVF) mean?
In-vitro fertilization (IVF) is one of the most commonly employed ART technique. It involves stimulating the production of eggs and their retrieval from a woman for fertilization with a male sperm in a lab setting. This is usually followed by implanting the embryo in the woman’s uterus after 3-5 days’ of incubation, to see the pregnancy to its full term. It involves the following phases:
1) Stimulation of egg for growth & maturation
2) Egg retrieval from the ovary
3) Lab incubation of the egg with the sperm
4) Embryo transfer

25. What is the success rate of IVF method?
Just like any of the ART techniques, IVF too has a very good success rate. However, it is too dependent on factors like the couples age group, sexual and lifestyle patterns, reasons and age of their fertility problem etc. Also, choosing a high quality IVF treatment becomes important.

26. Is the IVF procedure painful?
Minimal physical pain is associated with the IVF process. Potential phases where you may hurt a little during an IVF process include:
1) Mild vaginal pain during ultrasounds for monitoring follicles
2) Some bloating and discomfort associated with the egg maturing
3) Egg retrieval, which is done under local anesthesia
4) Progesterone injections

27. What are the risks of IVF?
Potential risks associated with IVF include:
- Birth defects
- Multiple births
- Premature deliveries
- Ectopic pregnancy
- Ovarian Cancer
- IVF Failure

28. How expensive is the treatment for infertility?
Treatments for infertility in India can be quite affordable, when compared to western countries. But still they vary considerable based on the experience and service quality of the infertility clinic and typically the overall treatment and procedure cost may be a little on the higher side for an average Indian household. Make your choice of an affordable IVF treatment but keep in sight the best IVF centre in India to avoid failed IVF costs.

29. Is infertility treatment covered under medical insurance plans?
Most treatments and procedures used for infertility treatments do not stand covered under standard medical insurance plans. However, recently Bharathiya Mahila Bank, India (BMB) has come forth with a medical insurance plan that provides cover for infertility treatment for women holding an account with their bank.

30. What is Preimplantation genetic testing (PGT)?
Preimplantation Genetic Testing (PGT) comprises tests to check the embryo produced through IVF for genetic defects or abnormalities before they are transferred to the uterus for a successful pregnancy. PGT comprises two types of test:
A) Preimplantation Genetic Diagnosis (PGD): This is done for couples where either one or both partners carry some genetic condition to test and determine that the same has not been transmitted to the egg/embryo. Thus, PGD involves genetic testing before (diagnostic) the embryo implants.
B) Preimplantation Genetic Screening (PGS): This is performed when the intended parents have no known chromosomal defects to rule out chromosomal or genetic abnormalities before the embryo is transferred to attach in the uterus.
31. What happens if one does not respond to the drugs for ovarian stimulation?

A bad level of response to drugs for ovarian stimulation is generally associated with a poor ovarian reserve and in such cases usually an alternate stimulation technique may be used. In several cases, egg donation is resorted to.

32. What to look for when searching for a place to treat infertility?
A couple should look for the experience of the medical professionals and success rate of the clinic when making a choice of a place to treat fertility. Good quality service and being equipped with not just a well-trained staff but an equally well-equipped clinic and lab become important considerations in making the choice.

33. How do you and your doctor decide on which method would best address your infertility treatment?
Which treatment would best suit your case depends largely on the cause of you or your partners’ infertility besides other factors like cost, accessibility to fertility clinic and the like. Based on these and in consultation with your doctor, a couple may decide on which option to go with.

34. What is the psychological implications of infertility?<br> Cases of infertility are closely related to a sense of low self-worth, depression and anxiety. The social implications of this disorder are also very glaring and often lead to the couple going through great emotional rigors. Proper psychological counselling hence becomes an important part of the treatment for infertility.

35. What is surrogacy?
Surrogacy is one of the ART techniques wherein another woman carries the baby in her womb and gives it birth for the infertile couple. This technique is usually employed when a woman is unable to carry pregnancy to full-term because any number of reasons.
In such cases, the couple can choose a surrogate or a gestational carrier, who will be artificially inseminated by the male partner’s sperm. This is done when the female of the couple is unable to produce healthy eggs. In some cases of surrogacy, where the female of the couple is unable to carry the pregnancy to term but produced healthy eggs, the egg is incubated with the sperm through IVF and then the embryo is planted in the surrogate’s uterus.

36. What are the cost implications involved with Surrogacy?
Surrogacy can be an expensive option as it involves costs like travel costs, medical costs, costs associated with multiple tries, legal costs and the like, that go beyond the usual package costs that just cover the clinic costs.

37. What are the legal arrangements that govern surrogacy in India?
Surrogacy is fast establishing itself as a viable infertility treatment option in India and legal arrangements are available for the same as well. The couple needs to make a legal agreement with the surrogate mother in which a practicing lawyer and the fertility specialist bear witnesses. This agreement details the financial and other arrangements binding on the surrogate and the intended parents, including the fee that the surrogate gets during the term of the pregnancy.

38. What does a typical surrogacy package include? What are the exclusions?
A typical surrogacy package usually includes more or less all of these (depending on the clinic):
- Recruitment of 1-2 Surrogate/Donor Egg
- Background check of Surrogate(s)
- Psychological screening, medical investigation for Surrogate
- Medications
- Egg retrieval, delivery and post -delivery charges
- C-Section Fee
- Embryo freezing and storage
- Compensation for Surrogate including invasive procedure fee, monthly allowance, maternal clothing allowances
- All birth related documentation including birth certificate
- Legal contracts

However, it does not include costs of transfers, flights and hotels charges, visa/passport fees, blastocyst, etc.

39. What is a typical profile of surrogate mothers available in India?
A typical profile that suits best for a surrogate mother, especially in Delhi, is one in which the surrogate mother is aged between 25 and 35 years and has a previous live birth or is a mother herself. Usually, such a female is required to clear some primary medical tests and investigations along with a baseline psychological assessment to be deemed as fit for the role of a surrogate.

40. What is the average success rate of surrogacy method?
Surrogacy is a relatively stable method with high rates of success.

41. How are surrogate babies breastfed post-delivery?
There are multiple ways in which your baby can get breast milk and its unparalleled health benefits, even if born through surrogacy! Several milk banks exist from where milk can be sourced. You may also avail a milk donor. In some cases, lactation is induced in the intended mother through nipple manipulation, massage and mechanical methods, so that she may herself breastfeed the new born.

42. Can the intended parents meet the surrogate mother? How often?
Yes, the intended parents can meet the surrogate mother. The frequency of such visits is however a personal preference. Intended parents can decide on the level of contact that they feel comfortable in with the surrogate mother.

43. How is egg donation different from surrogacy?
While in egg donation, the donor just shares her eggs for the couple where the female partner is unable to produce eggs; in case of surrogacy, the donor lends her womb for the plantation of either the embryo within her uterus or lets the male sperm be artificially inseminated into her for fertilizing the egg.

44. Can the intended parents choose the egg donor?
Yes, of course, intended parents can make a choice of their sperm and/or egg donors’ profiles.

45. What is ovulation induction?
Ovulation induction is the method of stimulating the ovaries to produce more eggs so as to maximize the chances of conception, whether through a sexual intercourse or through artificial insemination.

46. What are the different methods used for ovulation induction?
Ovulation induction is achieved through fertility drugs like Clomiphene or Clomiphene Citrate, or Gonadotropins and Human Chorionic Gonadotropin (hCG) or Bromocriptine or Cabergoline. The treatment also involves administration of FSH and LH, especially for patients who have a hormone malfunction. For patients who fail to respond to the drugs, surgical interventions like Laparoscopic ovarian drilling may be resorted to for ovulation induction. For obese patients, weight management and exercise become the first line of therapy. Some newer methods like aromatase inhibitors and insulin sensitizers are also being used widespread.

47. What is Intra-Cytoplasmic Sperm Injection (ICSI)?
Intra-cytoplasmic Sperm Injection (ICSI) is one of the most commonly used infertility treatments used in cases of male infertility resulting from abnormalities in the sperm count, quality or motility. It is an in-vitro fertilization method that entails direct injection of just one, healthy sperm into the egg for fertilization, using a pipette. This method is found to be very successful and increases the likelihood of fertilization manifolds. However, ICSI is more expensive than IVF.