“Take the marriage in your stride and enjoy this companionship. Give yourself some time and don’t rush to the doctors so early for fertility treatments,” a psychologist at Institute of mental health and neurosciences (IMHANS), Kashmir, tells one of the females in her mid-20’s, who recently got married.
In an adjacent room, a 39-year-old female reveals in her first session, “It’s been five years of trying to conceive. We have gone through various fertility treatments but all in vain. With every passing year there is a disappointment and hopelessness that has set in. Nobody seems to understand what it does to a woman’s body and her self-esteem. I often get suicidal thoughts and sleep evades me.”
The inability to have children can crush the beautiful dream of parenthood and evoke a feeling of unending grief and loss. Experts believe that around 18 to 25 percent of married couples in Kashmir struggle with the problems related to infertility at present.
Within our community, this issue, however, unfolds at two ends of the spectrum. On one side, couples over the age of 35 deal with various problems of infertility and seek treatment. On the other side, recently married and younger couples face the intense pressure to conceive swiftly driven by societal expectations. This urgency leads them to pursue fertility treatment prematurely, resulting in disrupted hormones and a tumultuous cycle of shame and despair.
The National Family Health Survey for 2019-21 shows there has been a sharp fall in the total fertility rate (TFR) – the average number of children a woman bears in her lifetime. In Jammu & Kashmir, the fertility rate has dropped from 2.0 to 1.4, far below the national average of two since 2015.
What has caused a dip in fertility rate? Why are the married couples under immense stress? Has the age for marriage gone up? Has the lifestyle altered? To find the answers, Kashmir Observer spoke to several experts.
Infertility, causes and treatment
Infertility means not being able to get pregnant even after being with your partner or husband for almost a year without using any birth control.
There are various factors that can cause infertility. “Sometimes, there are issues with the woman’s ovulation, problems with the fallopian tubes (where eggs and sperm meet to start a pregnancy), or damage to these tubes due to tuberculosis, infection, or other diseases. Hormonal problems, such as issues with the thyroid, can also lead to infertility. One significant factor nowadays in our region is polycystic ovary syndrome (PCOS), a condition that can cause the absence of ovulation,” Dr Sabahat Rasool, IVF consultant and Reproductive Medicine Specialist told Kashmir Observer.
Both men and women who smoke, lead an unhealthy lifestyle, or are obese may also face infertility issues. Conditions like endometriosis, a disease in which tissue similar to the lining of the uterus grows outside the uterus. It can cause severe pain in the pelvis and make it harder to get pregnant. “In males, infertility can be genetic or result from surgeries, accidents, drug or steroid use like anabolic steroids used in the gym. Anabolic steroids are synthetically produced variants of the naturally occurring male hormone testosterone that are abused in an attempt to promote muscle growth, enhance athletic or other physical performance, and improve physical appearance,” Dr Sabahat said.
The doctor expert said that sometimes couples struggle to conceive even after one or two years of marriage due to physical reasons. “As people age, especially women, their ovaries also age, and the number and quality of eggs decrease. The age for marriage has gone up in our region primarily due to pursuit for stabilised careers. Late marriages and delayed pregnancy planning become major challenges because the chances of conception decrease and treatment success rates are lower for older women. Even if they do get pregnant, the risk of miscarriage is higher,” she said.
Dr Sabahat emphasized that many couples wait too long before seeking specialized treatment, losing precious time and the best chances for successful treatment. “After the age of 35, there’s a rapid decline in the number of eggs, and sometimes couples and their families hesitate to pursue further treatment.”
For treatment, the doctors begin with a comprehensive evaluation of both partners. Seeking fertility treatment together as a couple is crucial. “Bringing a child into the world is a joint effort, and it requires both partners to be in optimal physical and mental health. If there’s an issue with ovulation, we can use ovulatory drugs. Correcting hormonal problems, such as thyroid issues or adjusting prolactin levels involves weight management and targeted interventions. Laparoscopic surgery is advised for problems with the tubes. If all else fails, In vitro fertilization (IVF) or intrauterine insemination (IUI) may be recommended, especially in cases of unexplained infertility. While IVF can be expensive, costing in lakhs, IUI is a more affordable option.
Dr Sabahat emphasized that it’s after all a couple’s journey and blaming anyone, be it the man or the woman, doesn’t help.
“There’s no one to blame—it’s a shared challenge that requires joint effort. In the midst of fertility challenges, patience is key. Let nature take its course, maintain a healthy lifestyle and approach the journey with resilience and understanding,” she added.
Infertility and its association with mental health
Infertility is more than a medical problem. It affects all aspects of life, the most important being mental health. Infertility can cause psychological distress, emotional stress and financial difficulties for both partners.
Studies suggest that couples may feel “emotions like anger, guilt, sadness, depression, anxiety, and loss of self-confidence and self-esteem. Apart from this, the financial cost of infertility treatment also significantly contributes to the stress. The average cost for one cycle of IVF in India ranges from INR 1,00,000 to 3,50,000, with the additional cost of medications and tests. Because of such a high cost, some couples cannot get treatment leading to hopelessness.”
Dr Arshad Hussain, Professor of Psychiatry at IMHANS, Kashmir told Kashmir Observer that many married couples are referred to us by gynaecologists and endocrinologists when they don’t find any obvious cause, I see their anxieties and infertility stemming from mounting cultural and societal expectations.
“I have seen many such couples. They feel a lot of pressure, family friends and even neighbours seem to be contributing. The basic biology is that nature has linked procreation to pleasure, pleasure is primary and procreation is secondary natural and normal, pleasure creates absolute synchrony of hormones in the body for procreation to happen anxiety does the reverse. Pressures and anxiety produce an environment of disharmony not congenial for fertility. Hence, I advise all newly married couples to build the relationship, enjoy the moments, bring pleasures to each other, hold on, the happiness will come from the initial understanding that procreation is linked with pleasure. Dr Arshad said.
He stressed that now think of the opposite situation where having kids is the main focus. “This can mess up the pleasure part affecting hormone balance. The pressure builds up every month, leading many couples to consult gynaecologists. Some even face mental health issues. When talking to these patients, it’s clear that cultural pressure to have kids affects both men and women. This makes the situation even more complicated,” Dr Arshad added.
The psychiatrist said the implicit expectation that society has around the idea that every woman should be able to conceive quickly has led to a significant number of females seeking help and advice for resultant mental health distress.
From his clinical observations, he added that another important factor is that men and women both nowadays prefer to get married in their 30s and a focus on financial stability before having kids, which is a valid reason and cannot be sidelined. “The late marriages are, however, a contributing factor for infertility. Also, the primers of all non-communicable diseases (NCDs) share Etio-Pathological links with infertility; these are all linked to neuro endocrine disruptors often caused by genetic predisposition and environmental factors like diet, lack of exercise, sleep rhythm and stress. This creates conditions suitable for both NCDs and infertility,” he said.
Dr Arshad pointed out the couple should not only focus on producing an off-spring. “The companionship should be enjoyed without panicking and rushing to doctors. Give it time. Focus on a healthy lifestyle, including a balanced diet, regular exercise, and less stress about having kids. Conception will happen naturally without taking too much pressure,” he said.
Relationship between Exercise and Infertility
Aliya Farooq, a Fitness Trainer and Owner of Fitness Solution Gym at Khanyar in old city, Srinagar, said the around 70 percent of the young females enrolled in her gym suffer from Polycystic Ovary Syndrome (PCOS), a common hormonal disorder which is associated with infertility.
“We are approached by women with PCOS who often have irregular or no periods because they rarely ovulate. For overweight and obese women with PCOS regular exercise can increase the frequency of ovulation which leads to more regular menstrual cycles. As ovulation becomes more frequent, the chance of conceiving increases. We have several examples of married females suffering from PCOS who conceived after losing their weight and making proper diet changes,” Aliya said.
Aliya said exercise for females with PCOS includes regular workouts with cross trainer, cycling, treadmill, pelvic stretches etc. “This can help to improve insulin sensitivity and promote weight loss,” she said. The gym instructor added that before starting any exercise program, they inquire about any existing health concerns and accordingly make the diet and exercise chart.
The fitness expert said that for those who are still not ready for gym yet they can start with a brisk walk. “Walking is a low-impact exercise that can be done anywhere and doesn’t require any special equipment. Aim for at least 30 minutes of brisk walking, five times a week,” she said.
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