Management of Infertility in Rural Areas: The Available Options – includes a free patient information PDF!

When do you consider a couple infertile?

The couple should start investigation after one year of marriage and staying together if the lady is less than 35 years old, and after 6 months if over 35 years of age. Women who can become pregnant but are unable to stay pregnant could also be included (1). This is just a guideline for starting evaluation. However, couples can have children after many years.

What is the process of becoming pregnant?

To become pregnant, the following must happen:

1. The woman’s ovary should release the egg
2. The egg should travel to the uterus through the fallopian tube
3. The egg should be fertilized by the sperm on the way
4. The fertilized egg should attach to the uterus and develop

How common is infertility and who contributes to it?

Infertility is a common problem, affecting about ten percent of the women between 15 years to 44 years of age. Problems in the men and women each contribute about one third of the causes of infertility, while the remaining third is due to combined problems (1).

What are the risk factors for infertility in women?

The following are the risk factors for infertility in women:

• Ovulation disorders and other hormonal disorders that affect the release of eggs
• Fibroids or swellings in the uterus
• Poor diet, alcohol intake, smoking, stress, etc.
• Older age
• Diseases like tuberculosis, cancers, chemotherapy for cancers, radiation therapy, etc.

What are the risk factors in men?

The following are the risk factors for men:

• Heavy alcohol use, drugs addictions
• Smoking
• History of mumps and pox, chemotherapy, radiation, etc.
• Use of tight undergarments and men who work in hot areas
• Some medicines like anti-hypertensives (high blood pressure medicine), medicine for stomach ulcers and antibiotics have also been implicated (2)

What about common factors?

The common factors include anti-sperm antibodies, inability to deposit the sperms at the correct place due to anatomical defects and so on. Many of the factors are unexplained and sub-fertility in both of them can combine to cause infertility.

What should be done for infertility in men?

These are described in detail in another article. The presence and quality of sperms are assessed. Varicocele (or increased blood vessels around the testis) is either confirmed or ruled out. Sometimes there might be a block along the way or retrograde (backward) ejaculation.

What should the women do for evaluation?

Patient Handout

You can print copies of this PDF handout for your patients, to reinforce what you have told them.

The simple way to check whether the woman is ovulating is to check the early morning temperature, when a small rise occurs with ovulation. Checking the cervical mucus every morning could again help in finding out about ovulation.

Ultrasound examination is one of the important investigations and can give a lot of information. Usually the infertility specialists are better trained for infertility evaluation.

Blood tests for blood sugars, thyroid functions, and in some patients, female hormones are carried out if problems are suspected. A simple test like ESR might help in screening for tuberculosis.

Diagnostic laparoscopy and hysteroscopy form one of the most important investigations. The added advantage is that the treatment is offered at the same time. This means having a look inside the uterus to find out if there are diseases like adhesions, tumours or swellings, and then take biopsies and also look for blocks in the tubes. Similarly, having a look inside the body can tell about tubal blocks, adhesions, cysts, endometriosis, polycystic ovaries and so on.

What is the possible medical treatment?

The medical treatment often aims at stimulating ovulation when ovulation is a problem. Hormones, medicines like Clomiphene and Bromocriptine or cabergoline (3). Treatments of the associated diseases are also important. Medicines like Metformin are used for polycystic ovarian disease. Anti-tuberculosis medicines and antibiotics for infection might be required. Thyroid replacements might be necessary.

What are the surgical treatments that are available?

The surgical treatments available are as follows:

1. Relieving or bypassing tubal blocks
2. Ovarian drilling
3. Removal of ovarian cysts, endometriosis, adhesions, pus pockets, etc.
4. Removing myomas or swellings in the uterus

What are the facilities available at the SEESHA surgical camps?

The SEESHA surgical camps, especially at the Bethesda Hospital in Aizawl in Mizoram, offer all the possible treatments mentioned so far. The surgical treatment is available at the other places like the Karunya community hospital, ICC hospital at Coimbatore, the Sielmat hospital at Churachandpur and Family health clinic at Dimpur and at the other places.

Laparoscopic surgery is carried out through the most modern and safe procedure of single incision gasless laparoscopic surgery. With only a small incision at the level of the umbilicus, there is hardly any scar tissue visible. It can be carried out in rural areas with spinal anesthesia.

The ureterorenoscope is used for looking at the fallopian tube opening, and if necessary, hydrostatic force or small guide wires could be used for relieving minor blocks. A urology resectoscope could be used for removing swellings inside the uterus.

Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.