Are states in the South exhibiting higher rates of infertility compared to their northern counterparts? A recent study published in the PLOS ONE journal revealed that among the southern states, Kerala, Tamil Nadu, Karnataka, and Telangana are exhibiting high rates of infertility.
However, gynaecologists South First spoke to cautioned against relying solely on sampling, given the absence of structured infertility practices in public hospitals.
Nevertheless, they do acknowledge an overall increase in infertility across the country, and here are some of the possible reasons behind this trend.
What did the study find?
A recent survey on infertility patterns in Indian cities — titled ‘Surging trends of infertility and behaviourial determinants in India‘ — by the Centre of Social Medicine and Community Health at Jawaharlal Nehru University, New Delhi, and Department of Survey Research and Data Analytics at the International Institute for Population Sciences, Mumbai, found the rate of infertility higher in Goa, Kerala, Karnataka, Tamil Nadu, Telangana, Sikkim, Delhi, Himachal Pradesh, and the Union Territories of Lakshadweep, Daman and Diu, and Andaman and Nicobar.
These states have a high prevalence of infertility (above 20 percent) and low fertility rates.
In contrast, it found that states like Bihar, Uttar Pradesh, Jharkhand, and the northeastern states of Meghalaya, Nagaland, and Manipur had both high infertility and fertility levels.
“High infertility levels” indicate that these states have a significant portion of their population facing difficulties in conceiving or carrying pregnancies to term. “High fertility levels” suggest that despite the presence of infertility, these states also have a large number of women giving birth to multiple children.
This combination of high infertility and high fertility levels could be due to various factors, including differences in healthcare access, socioeconomic conditions, cultural practices, and healthcare infrastructure.
The study used secondary data from all four rounds of the National Family Health Survey (NFHS) — all the way from NFHS-1 conducted in 1992-93 to NFHS-4 in 2015-16. The four sets of data were mainly used to obtain an overall trend of infertility over the years.
The research emphasised the robust connections between infertility and risk factors such as the age of marriage, biological aspects, and lifestyle choices.
Key findings of the study
The study revealed several noteworthy findings that shed light on the surging trends of infertility in India. Notably, primary infertility showed a steady decline from 1992 to 2015. In contrast, secondary infertility exhibited an alarming increase, rising from 19.5 percent in 1992–93, to a staggering 28.6 percent in 2015–16.
This trend is closely related to declining fertility rates, particularly in the states of South India.
The age at marriage, biological factors, and lifestyle choices were all found to be strongly associated with infertility.
Goa emerged as the region with the highest infertility rate, followed closely by the four southern states. Interestingly, these areas also experienced lower fertility rates, with Goa’s Total Fertility Rate (TFR) standing at a mere 1.3 in 2019–20.
Factors affecting fertility
Lifestyle factors, such as smoking and alcohol consumption, were more prevalent in urban areas, significantly impacting both men and women’s reproductive health. Moreover, obesity, often linked to polycystic ovarian syndrome (PCOS), emerged as a significant factor affecting female infertility.
Unhealthy dietary habits, including the consumption of fatty foods, and a sedentary lifestyle further compounded this issue.
1. The role of age and marriage
Age at marriage was identified as a crucial factor contributing to infertility. The study revealed that women who married at a later age were more likely to experience primary infertility.
Additionally, the spousal age gap also played a role in infertility, with fertility rates declining as the age gap between the spouses increased.
Urban women, likely influenced by lifestyle changes and delayed marriages, exhibited higher rates of infertility. Working women, in particular, faced increased infertility rates, potentially due to a stressful work environment, which can disrupt menstrual cycles.
2. Impact of lifestyle choices
The study emphasised on the significant impact of lifestyle choices on women’s reproductive health. Smoking and alcohol consumption, which are more prevalent in urban areas, were found to negatively affect the ability to get pregnant.
Obesity, driven by unhealthy diets and sedentary lifestyles, was identified as a major factor in PCOS and infertility.
3. Contraceptives and other factors
Contraceptive use, including oral contraceptives and injectables, was also linked to infertility. Women who had experienced miscarriages and abortions were also more likely to face secondary infertility.
The study also noted a significant association between thyroid disorders and female infertility.
Doctors weigh in
Dr Hema Diwakar, former president of Federation of Obstetric and Gynaecological Societies of India (FOGSI) and the director of Diwakar’s IVF Centre in Bengaluru, shares her insights: “Relying on this sampling when we know that public hospitals don’t have structured infertility practice is not right”.
She adds that the study has used secondary data from all four rounds of the NFHS and can’t be relied upon to make this conclusion.
Explaining some of the possible reasons for these “perceived” high numbers, Dr Diwakar tells South First, “In the southern states, both in rural and urban areas, we have observed that higher levels of education tend to lead individuals to fertility centres, even if they have the potential for natural conception. Also, an education-focused approach, along with the emphasis on career-building, often results in delayed decisions to start a family, creating the impression of a higher incidence of infertility.”
Dr Diwakar also points out that economic factors can influence people in the South to seek fertility treatments, like IVF, earlier than in other regions, contributing to the perception of increased infertility cases.
Furthermore, the availability of healthcare providers plays a significant role. In contrast to rural North India, where access to medical professionals can be limited, the urban South has a greater concentration of couples of reproductive age due to their career commitments, which may contribute to the appearance of a higher incidence of infertility in the region, she adds.
Additionally, data collection is well documented in states in the South when compared to other parts of India. This, she says, could also be one of the factors the region shows a high incidence.
Dr Sowmya Sangamesh, Consultant Obstetrician and Fertility Specialist at BGS Gleneagles Global Hospital, Bengaluru, adds that it could also be due to the fact that states in the South are far more developed than the North. She says the higher incidence may be attributed to a “floating population, aspiring higher education, better jobs, competition, better access to contraceptive methods, postponing of pregnancy by women who aspire for financial independence, family planning services, better access to healthcare, literacy rate, etc”.
Infertility emerging as pressing concern
Recently, Shark Tank India judge Namita Thapar shared her experience of undergoing two failed in-vitro fertilisation (IVF) procedures.
Speaking on an episode of Shark Tank India season 2, she had revealed that she could not conceive a child even the second time through IVF, despite enduring 25 injections. She had explained how she faced fertility problems when she was trying to conceive a second child in her early 30s.
Infertility is emerging as a pressing concern in India, affecting countless couples and raising questions about the nation’s reproductive health.
Agreeing with this, Dr Sangamesh, explains, “The number has gone up and some of the reasons are marriage at late age, career choices leading to a busy schedule, wanting to pursue higher studies before marriage, and postponing pregnancy even though they were married early.”
Along with this, a sedentary and stressful lifestyle, mental pressure to keep up with financial commitments, constantly worried about achieving something can add on to the already-long list of reasons for infertility.
Dr Sangamesh attributes factors like obesity, alcoholism, smoking, unhealthy eating, and difficulty in managing relationships for the growing rate of infertility.
Also Read: Covid-19 impacts semen quality, says study
Male infertility on the rise too
Interestingly, infertility has increased among the male populations in the recent past as well. A study that was presented at the annual meeting of the European Society of Human Reproduction and Embryology (ESHRE) in Denmark, held in June 2023, showed that men recently infected with Covid-19 have decreased sperm counts for over three months, following even mild infections.
“The findings were considered to be intriguing as men produce new sperm every two or three months, and the findings were based on semen analysis taken after 100 days, suggesting that Covid-19 does damage the male reproductive tract,” the researchers stated.
Agreeing with this is Dr Swati Shree, obstetrician and gynaecologist at Apollo Clinic in Bengaluru. “Research has shown that Covid-19 may lead to alterations in semen parameters, such as decreased sperm concentration, reduced sperm motility, and changes in sperm morphology,” she says.
She explains that in the post-Covid era, more infertility cases are being contributed by male factor infertility.
“It has been observed that men coming to the IVF centre, who have a history of Covid-19 infection, are more likely to have abnormal semen parameters, in terms of decreased sperm morphology, motility, and count, with sperm morphology being affected the most.
“Most of these patients had Covid-19 approximately six months before, indicating that it is altering male reproduction. However, specific studies are needed to prove this,” she adds.
Covid a cause for male infertility or not?
Meanwhile, Dr Arunima Haldar, Consultant in IVF and Reproductive Medicine at Manipal Hospital in Bengaluru, says that it is a burning concern whether the Covid-19 has had an impact on sperm parameters and male fertility. Though there have not been many studies conclusively reporting this, Dr Haldar believes that the human male reproductive system is not completely immune to viral infections.
“Studies have established that several viruses, including mumps virus, HIV, Zika virus, have the potential to induce orchitis (inflammation of one or both testicles) and cause male infertility. However, this is not been proven for Covid-19. But some studies have shown decrease in sperm count,” she explains.
She adds that while a majority of viral infections temporarily reduce male infertility, 10 percent of Covid-19 cases may result in long-lasting spermatogenesis abnormalities and low sperm quality. However, in a majority of the cases, improvement can be shown after three to four months.
Dr Priya Selvaraj, director at GG Hospitals in Chennai, says, “There has been a general rise in male infertility among the urban population. However, we can also attribute this to lifestyle factors, in addition to a viral infection the man might have recovered from recently from.”
However, she says that they did not find any significant changes in semen analysis with specific reference to the post-Covid scenario.
Dr Devika Gunasheela, director at Gunasheela IVF Centre, weighs in that there has been an increase in male infertility cases and she says that the awareness among men to come voluntarily for tests has also gone up.
“The rise in these numbers, along with financial stress post-Covid, emotionally finding it difficult to balance relationships, job and money, awareness on infertility tests for men, coming voluntarily for semen analysis, might be some of the reasons for this sudden increase in infertility rate,” she adds.
Challenges and future directions
While further research is necessary to explore the dynamics of couple infertility, considering both male and female factors equally, doctors insisted that the surging trends of infertility in India demand immediate attention.
“There have been anecdotal and research evidence showing that there is an increase in infertility across the country and even globally. It needs to serve as a wake-up call, highlighting the multifaceted nature of this problem. To address these challenges, policymakers should consider enhancing current health and reproductive programmes, educating the population on lifestyle choices, and promoting healthier sexual behaviours,” says Dr Gunasheela.
She also stresses on the fact that there has been advancements in technology to help people pursue their dreams and ambitions and yet conceive successfully, like egg/sperm freezing and other reproductive medicine solutions, which people could consider.
“Delayed childbearing can increase the risk of infertility because fertility naturally declines with age, especially for women,” Dr Gunasheela adds.
Lifestyle factors should be taken extra care of, say doctors. Obesity can lead to hormonal imbalances and insulin resistance, which can interfere with fertility in both men and women. Exposure to environmental toxins, pesticides, and chemicals can have adverse effects on reproductive health.
Meanwhile, diagnosing certain medical conditions such as PCOS in women and low sperm count in men can help reduce the infertility rate.
Sexually transmitted infections, if left untreated, can also lead to reproductive tract infections that may, in turn, damage the fallopian tubes or testicles, causing infertility. Those with multiple sexual partners should also have this checked,” says Dr Gunasheela.
Consulting with a healthcare professional or fertility specialist is essential for those facing fertility challenges, in order to determine the underlying causes and explore available treatment options.