Unable to conceive after her first baby, Abida blames it on the evil spirits that only manifest in women. According to Fozia, she is unable to conceive after trying for five years because it is a divine punishment. These examples represent two types of infertility, which can be of primary type, when pregnancy is never achieved, or secondary type, when at least one pregnancy is achieved. It is important to understand that unless we fight the myths and misconceptions around infertility, women will continue to face violence, stigma, stress, and they will not be able to enjoy their basic right to the highest attainable standard of physical and mental health.
Infertility is defined by the failure to achieve a pregnancy after twelve months or more of trying regularly. World Health Organization has estimated that 1 in 6 people globally are affected by infertility. A study estimates that 48 million couples and 186 million individuals worldwide live with infertility. In Pakistan, infertility prevalence is reported as 22 per cent. Infertility may be caused by issues in either male or female reproductive systems and sometimes, it is due to unidentifiable reasons. The problem is exacerbated because we live in a culture where the family name is carried forward through the birth of a child and involves inheritance rights, and children are seen as a future source of household income and a source of strength in old age. Unfortunately, in our society, mostly women are blamed when couples are unable to have babies. Women should empower themselves with crucial information related to infertility so that they can take appropriate steps for their happiness and wellbeing.
“We have been trying for six years to have children. My husband says there is no need for him to get checked because it is a female-only problem,” elucidates Sajida, a 29-year-old woman. This is a common myth in our country that needs to be addressed. Infertility may be caused because of issues in the male reproductive system, and this is commonly caused by problems in ejection, low levels of sperm, or abnormal shape and movement of the sperm. While women may have issues such as lack of irregular ovulation, blocked or damaged fallopian tubes, and endometriosis (tissue growing outside the womb), affecting fertility, their male partners may also be the contributing factor. For this reason, it is important to get a clinical diagnosis. Once the problem is identified, a doctor can advise treatment accordingly.
Many couples remain unaware of the preventable causes of infertility that threatens to snatch away their dream of becoming parents.
• Sexually transmitted infections (STIs): Several STIs can affect fertility. For example, chlamydia may cause fallopian tube infection without any symptoms and may cause permanent damage to the fallopian tubes, uterus, and surrounding tissues, which can lead to infertility.
• Smoking: Tobacco-use can negatively affect fertility in both males and females. Smoking (including passive smoking) can reduce your chances of conceiving and can affect semen quality. Studies show that counselling by the doctor in fertility clinics can help in successful quitting.
• Weight: Less than optimal weight meaning being obese (having a BMI of 30 or over) may reduce fertility in women. Being severely underweight can also affect ovulation.
In addition to the above mentioned preventable factors, there are some other issues that can lead to infertility such as complications from unsafe abortion, postpartum sepsis (due to infection after childbirth) or complications from abdominal/pelvic surgery, and stress, that in extreme cases, may impact both male and female fertility by affecting ovulation and sperm production.
While many in our population remain unaware of the scientific reasons behind infertility, misconceptions prevail where the issue is incorrectly ascribed to oral contraceptive pills or intra-uterine contraception device (IUCD). To counter lack of awareness, WHO advises incorporating fertility awareness in national comprehensive sexuality education programmes, promoting healthy lifestyles to reduce behavioural risks, including prevention, diagnosis and early treatment of STIs, preventing complications of unsafe abortion, postpartum sepsis and abdominal/pelvic surgery, and addressing environmental toxins associated with infertility.
The role of diet
Researchers from Harvard found that having a healthy diet with folic acid, vitamin B12, and omega-3 fatty acids has a positive effect on becoming pregnant whereas Trans-fat and diets rich in processed or red meat and sweetened beverages have a negative effect. Therefore, if you are trying to get pregnant, having a healthy diet with pre-natal vitamins may positively impact your chances of conceiving.
The treatment offered to you will depend on the underlying cause of infertility identified in your case. Testing may include semen analysis, hormone testing, ovulation testing, imaging tests and others. Treatment can be in the form of medicines, e.g., for stimulating ovulation, surgery to correct fallopian tube blockage, or it can be assisted reproductive technology (ART). There are different types of ART; the most common is the IVF (in vitro fertilisation). IVF is a multi-step process that involves egg stimulation, retrieval, lab fertilization and transfer of embryos in the uterus. If IVF is not successful or if semen quality/quantity is poor then there are other techniques such as ICSI (Intracytoplasmic sperm injection) where a single healthy sperm is injected directly into a mature egg.
Sajida’s husband also does not like her to go to a doctor because doctors ask the male partners for tests and more importantly, because he finds traditional healers as affordable who prescribe a few herbs and pills to his wife at low costs. Treatment for fertility is available in Pakistan but the accessibility due to prohibitive cost of treatment remains a challenge. A research found that the direct medical costs paid by patients for a single round of in vitro fertilisation (IVF) are often higher than the average annual income of people from low- and middle-income countries. There has been a lack of national and international policy interest in fertility care mainly because of competing concerns around overpopulation and limited resources. Despite the challenges, we must acknowledge access to fertility health as a basic right and we should support women in finding hope beyond infertility.
Give yourself a break
Treatment can be physically and emotionally exhausting. Sometimes, multiple tries can fail, it may feel too aggressive, and you may feel that your body cannot take it anymore. It is alright to acknowledge that it is hard and that you need a break. You can always explore other options.
Parents who adopt children say that love transcends biological connection. Perhaps the bond of love is indeed strong but in Pakistan, the process of adoption is certainly tougher than having biological children. Famously, Nadia Jamil, a Pakistani actress, shared her experience of adopting a baby girl and wrote, “Nerve wracking assessments waiting. Imagine if biological parents were interviewed, checked for maturity, parenting skills, financial security and dedication the same way!” Hadiqa Kiani, another Pakistani celebrity has also shared her difficult experience of adopting a baby boy after the 2005 earthquake.
Despite challenges, whether procedural or related to the society’s reactions, these women have demonstrated that adoption is a beautiful way to have children. When we choose to love someone, we have the capacity and the capability to love unconditionally.
If adoption does not work for you either, remember, not having children is also a choice. There is a growing number of women now who are choosing not to have children. They find fulfilment in other pursuits, such as careers and travel. They would rather keep the freedom that enables them to follow their passions. Being a mother is only one part of who you are and your motherhood status does not need to define your intrinsic value as a woman. Find your source of happiness and know that you can be childless and be happy at the same time.
Fariha was 21 years old, just six months after her wedding; she was sitting in a doctor’s clinic with her mother-in-law and her husband, when the doctor revealed that she would never have kids.
Fariha was diagnosed with a rare type of cancer for which she was treated in 2006 at Shaukat Khanum Hospital. Perhaps the most shocking news for her, after learning about her diagnosis, was the news about the future of her motherhood. Her immediate family members were very supportive in helping her process the life-altering news. Seventeen years later, she is a strong cancer survivor and a cancer thriver. Looking back, she says that her husband has been her biggest support throughout this journey. “When I discussed the situation with him, he said, ‘If this is your test then it is my test and I will always stand by you’,” expresses Fariha. “He has never ever mentioned our situation related to children; not even during any fight,” she adds. She feels blessed to be surrounded by supportive and loving family. There are some people in the society, she mentions, who make her feel excluded with their behaviour, for example, by hiding their pregnancy from her for whatever reasons but she feels that it is because of the concept of nazar (evil eye) or because they are afraid she would be envious, which is unfair. She has witnessed both types of behaviours, where women are hesitant to let her near their children and where friends ask her to hold and feed their kids. She is very close to her nieces and nephews and she remains their favourite aunt. In moving forward, she is grateful to her husband and then her mentors who helped her a lot by giving her self-confidence to explore the purpose of her life. Fariha now provides counselling to cancer patients, survivors, and caregivers, conducts cancer awareness activities, and participates in many charitable works. To other women who are unable to have children, Fariha urges them to find purpose in life. “Motherhood is wanting the best for others and not expecting anything in return. There is motherhood in each and every one of us,” she says with conviction.
If you are facing difficulties in having children, find your source of strength, discuss, and reach the solution which is best for you, and never forget that there is hope beyond infertility.
The writer is a LUMS alumna and a community social worker with special interest in public health, philosophy, and human rights.