Introduction
Infertility is commonly defined as the inability of an individual or a couple to conceive despite two years of cohabitation and exposure to pregnancy (1). Clinically, infertility is a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse (2). Infertility may be primary or secondary. Primary infertility refers to infertility of a couple who have never been able to conceive whereas secondary infertility is the failure to conceive following a previous pregnancy. Infertility among couples may occur either due to a combination of factors. The factors that may lead to infertility may be genetic, environmental, infectious or parasitic diseases (3-7). Furthermore, the incidence of infertility among couples is associated with the life style, stress, postponing parenthood and obesity (8-11). The problem of infertility may also arise as a result of high level of sexual mobility, premarital sex, extramarital sex and prostitution (8, 12).
Alhtough all around the world, 8-12 percent of couples suffer from infertility, infertility rates vary dramactically between countries and regions (1). Estimates suggest that in the developing world, the overall burden of infertility is over three times higher than developed countries. According to the WHO study, more than 187 million ever-married women of reproductive age suffered from primary or secondary infertility in the developing world in 2002 (13). In Sub-saharan Africa, the prevalence of infertility ranged from 9 percent in Gambia to around 10 percent in Togo and Rawanda and to about 32 percent in Nigeria (14, 15). In India, the burden of primary infertility among couples ranged between 4 to 17 percent (13, 16). As per the estimates from Indian census data 2001, 1991 and 1981, researchers showed that childlessness in India has risen up. In 1981, approximately 13 percent of ever-married women of reproductive age were childless, which increased to nearly 16 percent in 2001 (17).
Infertility is an important public health issue with serious social consequences. Parenthood is highly emphasized in each and every society. Most societies around the world are structured in a way in which children are required for care and maintenance of older parents. Even in societies with social support systems, children and family are expected to provide much of the care for the elderly (13). With the view of the importance attached to parenthood in societies, childless coupels experience negative consequences in terms of their status, respect and authority. Regradless of the medical cause of infertility, couples experience a sense of failure, loss, and exclusion (13, 18). They are treated as outcast and also they lack equal opportunities in family functions and religious events. Couples themselves view infertility as a tragedy, which carries social, economic and physiological consequences. It is also not surprising that childlessness affects women to a greater degree when compared with men (19, 20).
Due to physiological, familial and community pressure in producing a biological child, most of the couples seek various traditional methods and religious practices, including visits to temples, observing tantric rites, wearing charms, participating in rituals and visiting astrologers (16, 21, 22). Studies suggest that women first seek treatment from traditional healers and afterward take help from medical science (23, 24). Few studies also identified allopathic as the first treatment sought. Couples also follow religious practices with allopathic treatment, either simultaneously or subsequently (25).
Infertility is an emergent issue in India. Untill recently, not much attention has been given on this issue and very few studies have understood the level, trends, and consequences of infertility in India. Family planning programs in India also viewed exclusively the patterns and determinants of overfertility rather than infertility. Furthermore, there is a lack of information about modern treatment facility regarding infertility among currently married infertile couples. An understanding of the levels of infertility among couples is crucial in order to improve the clinical management of infertility and maintain policies for the betterment of society. Therefore, this paper aimed to fill the knowledge gap in treatment of infertility and treatment seeking behavior among currently married women in India. An attempt has also been made to access net effects of socioeconomic and demographic factors on infertility and the treatment seeking behavior.
Methods
The study used the data from the third round of District Level Household and Facility Survey (DLHS-3) carried out in India during 2007-08 (26). The DLHS-3 is one of the largest ever demographic and health surveys carried out in all the states and union territories of India with a sample size of 720,320 households. The survey was funded by different national and international organizations such as Ministry of Health and Family Welfare (MoHFW), United Nations Population Fund (UNFPA) and United Nations Children’s Fund (UNICEF) and International Institute for Population Sciences (IIPS), Mumbai was the nodal agency for the development of survey design, instruments, data entry and tabulation software, training and supervision of the field work. In total, 643,944 ever married women aged 15-49 years and 166,260 unmarried women aged 15-24 years were successfully interviewed. The principal objective of the survey was to provide district level estimates on reproductive and child health (RCH), family planning, immunization and other reproductive health indicators. The survey also includes the information related to accessibility of health facilities; assess the effectiveness of Accredited Social Health Activist (ASHA) and Janani Suraksha Yojna (JSY) in promoting RCH care.
The data regarding infertility and childlessness was also collected in the survey from married women of 15-49 years for the first time ever. Married women were asked direct questions regarding infertility and treatment seeking behavior. In order to get a clear picture regarding the type of infertility i.e. primary and secondary infertility, women were asked about the reasons and timing since the time they faced problems in conceiving. Regarding treatment seeking behavior, women were enquired about the type of treatment sought and the result of the treatment.
Fundamental problem of infertility studies lies in the conceptualization and definition of infertility. There have been variations observed in the definitions adopted by medical scientists, social scientists, and other researchers. The variation occurs largely (a) in the reference period used to establish the infertility and (b) in the categorization of women who have experienced pregnancy but not a live birth. Inability to conceive within two years of exposure to pregnancy is the epidemiological definition of infertility recommended by the World Health Organization. Clinical studies often use a one-year period of exposure. One community based study in Egypt considered one year of unsuccessful efforts to conceive as the criterion for infertility. But in demographic studies, it is common to use a period of five years as a exposure time (13). In this study, primary infertility is defined in women of age 15-49 years who have been married for last five years and had regular sexual intercourse without contraceptives and did not conceive at all, though they have the desire for a child. Secondary infertility is defined in currently married women for more than five years who are not able to conceive in the last five years but who have had at least a pregnancy in their reproductive life.
The present study also considered a number of potential socio-demographic covariates in the analysis to understand the differentials and determinants of infertility and treatment seeking behavior. The variables used were age of the respondents (<25 years, 25-35 years,>35 years), age at marriage (<18 years, 18-30 years,>30 years), children ever born (no children, one, two, three or more than three), religion (Hindu, Muslims and others), caste (scheduled castes, scheduled tribes, other backward classes and others), place of residence (rural, urban), years of schooling (no schooling, <10 years and>=10 years of schooling), work status (working, not working). Economic status of the households was also included in the analysis and measured as wealth index. Wealth index is a composite measure of a household’s cumulative living standard. As this survey does not collect the direct information on income and expenditure of households, wealth index was calculated using a set of the proxy indicators, such as household ownership of selected assets, housing conditions, consumer durables, water and sanitation facilities. Wealth index score of the household was computed using Principal Component Analysis (PCA), then households were categorized into five quintiles. In this study, first two quintiles of households were categorized as "poor", third quintile of households categorized as "middle" and last two quintiles of households were categorized as "rich". It is recommended that using the wealth index as a proxy of income is particularly valuable when there is a lack of reliable data on income and expenditure because it represents long-term economic status and also is much easier to implement.
In this study, bi-variate and multi-variate statistical techniques were applied to understand the extent of infertility and treatment seeking behavior among women from different socioeconomic backgrounds in India. Cross tabulations were used to understand the prevalence of infertility and treatment seeking behavior. To understand the socio-demographic association with primary infertility, Cox proportional hazard model was applied at the national level.
Further, binary logistic regression model was also used to understand the adjusted effects of socio-demographic predictors on treatment seeking behavior among infertile currently married women. To see the level of significance, p-values were presented in both the models. All analyses were performed using STATA version 12.0 (27).
Results
Table 1 presents the percentage of currently married women aged 15-49 years who ever faced infertility problem by demographic and socioeconomic characteristics. Results show that about 8 percent of currently married women in India ever experienced infertility during their reproductive life period. Among them, majority (6 percent) suffered from secondary infertility which means that they faced problems in conceiving following a previous pregnancy, while the remaining 2 percent experienced primary infertility. It should also be noted that infertility rate among women increased with the age of women. Results indicate that primary infertility was higher (3 percent) among younger women (<25 years) and lower among older women (>35 years) whereas reverse is true in case of secondary infertility i.e. higher among older women and lower among younger women.
Approximately, 25 percent of currently married women who had never given a birth reported the problems of infertility. The rate of infertility was found higher among women belonging to Hindu religion, scheduled castes and those residing in rural areas. Similar pattern was observed for primary and secondary infertility among women in the country. Higher level of infertility was estimated among women who had never attended school (9 percent), whereas it was lower for women with more than 10 years of schooling (7 percent). It was concluded that uneducated or less educated women are not aware of their reproductive health consequences as they are getting into marriage and reproduction at early ages that may increase the possibility of secondary infertility. Further, infertility rate was higher among women who were engaged in employment sector (9 percent).
Women marrying after 30 years of age had the highest rate of infertility (19.7 percent). Nearly 6 percent of women who married after 30 years of age also reported to have primary infertility and 13 percent of them had secondary infertility. It can be reasoned that women who married after 30 years of age already crossed the peak reproductive period i.e. 22-29 years and after this age, women’s reproductive capacity or fecundability decreases and hence they had difficulties in getting pregnant. However, it also depended on age and biological capability of their husband at the time of marriage.
Table 2 depicts the state level prevalence of infertility among currently married women in India. Results show that women’s infertility was observed to be high in West Bengal (13.9 percent) followed by Goa (13.1 percent), Bihar (12.3 percent), Haryana (11.4 percent), Chhattisgarh (11.3 percent) and low in Meghalaya (2.5 percent) followed by Arunachal Pradesh (3 percent), Himachal Pradesh (5 percent) and Assam (5 percent).
Causes of incidence of infertility among women are also presented in table 2. 76 percent of currently married women who ever experienced infertility reported that they faced the problem at their first conception. Approximately, 12 percent of them faced the problem after a live or still birth and 7 percent after spontaneous abortion. The study also showed the state level variations in causes of infertility among women. More than 80 percent of infertile women in West Bengal, Bihar, Goa, and Kerala reported they faced problems at the time of first conception. Infertility among women caused after a live or still birth was found to be high in Manipur (34 percent) and Mizoram (27 percent). On the other hand, infertility among women caused after spontaneous abortion was found highest in Manipur (13 percent) followed by Tamil Nadu (12 percent).
Table 3 represents the treatment seeking behavior among infertile women in India by demographic and socioeconomic characteristics. Results indicate that about 80 percent of infertile women received treatment services in the country. However, nearly half of them received allopathic treatment. Treatment received by infertile women was found to be higher among women aged more than 35 years, belonging to the religion other than Hindu or Muslims, residing in urban area, having more than 10 years of schooling and belonged to rich wealth quintiles. By caste status, more infertile women from castes other than scheduled castes or scheduled tribes went for treatment.
Variation was also noticed in types of treatment received by infertile women. About half of the infertile women (50 percent) preferred allopathic treatment. More women who attained more than 10 years of schooling (73 percent) opted allopathic treatment compared to those who never attended school or received less education. Similarly, uptake of allopathic treatment was higher among women residing in urban areas (62 percent). On the other hand, non-allopathic treatment was popular among scheduled tribes (35 percent), poor wealth quintiles (37 percent) of infertile women.
Hazard risk of primary infertility among women in India: In table 4, results of Cox regression model has been depicted for India to understand the hazards of facing infertility problem by different socioeconomic characteristics. Findings show that hazards of primary infertility decrease with the age of women. For example, risk of primary infertility was higher among women aged less than 25 years compared to older women. High risk of primary infertility was estimated among Hindu women in comparison to those from Muslim and other religions. Hazard risks of primary infertility were 19 percent and 6 percent higher for women who belonged to other backward classes (OBCs) and scheduled tribes, respectively compared to scheduled castes women. Women education was found to be significantly associated with the hazard risks of primary infertility. Women with less than 10 years of schooling were 41 percent and women with more than 10 years of schooling were 70 percent less likely to be primary infertile than women with no schooling. Non-working women showed 11 percent lower risks of primary infertility compared to working women. Women belonging to rich wealth quintiles showed 43 percent lower risks of primary infertility compared to women from poor wealth quintiles. Hazard risks of primary infertility was 30 percent and 8 percent higher among women residing in the central and the eastern regions of India compared to women form northern India. On the other hand, south Indian women showed 4 percent lower risk of primary infertility than that of women residing in the northern region.
Determinants of treatment seeking behavior among infertile women in India: Table 5 depicts the results from logistic regression analysis to examine the determinants of treatment seeking behavior among infertile currently married women. Women more than 35 years were 43 percent more likely to receive any kind of treatment services for infertility compared to women of age less than 25 years. Likelihood to receive treatment was 18 percent higher among women who had one child than those who had no children born. Women belonging to other castes were 21 percent more likely to receive any treatment than that of scheduled castes. Women who attained more than 10 years of schooling were 60 percent more likely to receive any treatment than that of women having no schooling. Women who were not engaged in employment sector were 12 percent more likely to receive treatment than those who were employed. Women belonged to middle and rich wealth quintiles were 14 percent and 62 percent respectively more likely to receive treatment for infertility compared to women belonging to poor wealth quintiles. The likelihood of receiving treatment for infertility increased with an increase in age at marriage. For example, women with more than 30 years of age at marriage were 44 percent less likely to receive treatment compared to women marrying below 18 years of age.
Discussion
Infertility issues have largely been ignored in the government policy in India. The National Population Policy (2000) also very briefly mentions about the infertility issues in the context of providing information, counselling and regular supply of medication only for deprived communities like tribal, displaced and migrant populations who "may not need fertility regulation" (MoHFW, 2000). There is also limited focus on services for infertile couples in the Reproductive and Child Health Programme (RCH). Though the Tenth Five-year Plan (2002-07) has discussed on the access to essential clinical examination, investigation, management and counselling services for infertility, such services are in practice rarely available in the public sector. Recently, government of India came out with the "ART regulation bill 2010" to provide for a national framework for the accreditations, regulation and supervision of assisted reproductive technology clinics, for prevention of misuse of assisted reproductive technology, for safe and ethical practice of assisted reproductive technology services.
The findings of the study showed that approximately 8 percent of currently married women in India suffered from infertility both primary and secondary. Primary infertility rate was found higher among young women i.e. women of age less than 25 years and decreases as age of women increases. On the other hand, secondary infertility was found lower among young women and higher among older women i.e. women of age more than 35 years. The study found that the incidence of infertility increases with the women’s age because for a pregnancy to occur, several things have to happen, such that, an egg must develop in the women’s ovary. The egg has to be released each month into the fallopian tube. A men’s sperm must fertilize the eggs in the fallopian tube. The fertilized eggs must be able to travel through the fallopian tube and attach in the lining of the uterus. If any of these events do not happen or are disrupted, it will result in infertility (28). Again, quantity and quality of eggs decrease with the women’s age. So women marrying above 30 years show the highest rate of infertility problems and most of them were primary infertility.
Infertility problems may be because of either male or female problems or combined. However, the most common problem of female infertility is ovulation problem; tubal blockage, age related factors, uterine problems, sexual disorder and other unknown causes. With the advancement of medical sciences, today, about 85 percent of causes of infertility can be taken care of using appropriate surgical and medical interventions such as assistant reproductive technology (ART). The rapid increase in the number of infertility clinics providing "ART" services is a good indication for the people looking for solution. Although ART offers a hope to infertile couples to bear a biological child, several issues remain to be addressed. The findings of the study also stated that though about 80 percent of infertile women sought for any treatment in India, only half of them received allopathic treatment. The remaining 50 percent of women seek non-allopathic treatment such as traditional methods, Ayush or different religious treatments. The treatment seeking behavior towards allopathic or modern treatment makes them more vulnerable to infertility. Furthermore, access to modern treatment remains beyond the reach for most of the poor and middle class women due to high expense of the services. Evidence here also showed that among poor women, 36 percent received non-allopathic treatment and 34 percent received allopathic treatment whereas among rich women, allopathic treatment was opted by 63 percent of women and only 22 percent of rich women had-non allopathic treatment. Another concern of infertility treatment in India is quality of care. Services are not regulated and quality of treatment varies with the clinics run by both qualified and unqualified practitioners. Public health care system in India largely ignored these issues. There is an urgent need to consider this emerging health issue and also the need to regulate all infertility clinics run by both qualified and unqualified practitioners to ensure the quality and affordability of the services.
Conclusion
Infertility is one of the emerging medical problems among individuals. It also has enormous social implications. Each couple has the right to have a child. In the Indian social context, children are considered as a kind of old age insurance. In the context of policy response, it can be said that there is a need to improve the exiting service and quality of care for infertile couples. Services for infertile treatment should be integrated into the larger reproductive and child health package of services. Investigations for infertility could be conducted at various levels of the health care system. Effective mechanisms need to be implemented to regulate and manage high technology treatments for infertility, which are offered mostly in the private sector, have low success rates and are expensive. Guidelines should be implemented in a manner that doctors are compelled to look critically into the issues of informed consent, screening donors, legal and ethical issues and quality of care. Policies should ensure that the rights of women as users of these technologies are not in any way compromised. The issue of exploitation of patients in low-resource settings should be addressed as well.
Conflict of Interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. No specific funding was received for this study.