'There are people who don't know how to have sex'

India's foremost fertility expert Dr Firuza Parikh recently launched her book -- The Complete Guide to Becoming Pregnant. In this interview, she speaks about the various reasons why couples fail to conceive and why her job is relevant despite the country's billion plus population.

Benu Devi* is blessed. This farmer's wife who lives in Naugachiya, a sleepy tiny village far, far away north of Patna, in Bihar, has twin little girls named Bansri and Baiju*.

What sets these three year olds apart from the other naughty tots that scamper around Naugachiya is that they were conceived in a petri dish in Mumbai, an unbelievable 90 hours away from their remote village in the shiny, high-tech labs of Jaslok Hospital and Research Centre in 2007.

The doctor responsible for their birth, the gentle, maternal Dr Firuza R Parikh, director at the department of assisted reproduction and genetics, distinctly remembers Benu for the exhausting and brave journey of hope she undertook to reach her Jaslok clinic in the faint but sturdy belief that the trip would result in the child that the young Bihari woman deeply yearned for.

Says Dr Parikh, "She had to travel almost 90 hours I think (to reach here). She took a small (shared) taxi to come out (of her rural neighborhood), then she took a bus, then she took a train. And she just plopped in here. They just showed up!"

Benu Devi, accompanied by her husband, arrived clutching a battered newspaper clipping. "When she came in she just gave me one small cutting which was in Hindi. I have read this (cutting) and I want you to do this for me, she said. She was young; about 28 or 29. She had married very early and not had any children. Benu Devi had probably been married for eight or nine years. We tried to decipher what it was she wanted."

The Cumulus Aided Transfer technique, which uses the cumulus cells that surround an ova to nourish the laboratory-produced embryos, that Dr Parikh had recently perfected as a significantly better and more successful method of in-vitro fertilization had catapulted Parikh into the media limelight. News of this new procedure, surprisingly, had even reached Benu's distant village and was the impetus for her long, optimistic passage to Mumbai.

Remembers Parikh, "I was very impressed that somebody so far away would know what is done only here in the whole of India and would come here and specifically ask for this saying that I know this will make me pregnant. She had a tubal block (of the Fallopian tubes) so she needed IVF. And they came with very limited resources. They were not to know what IVF is and how it costs a lakh of rupees or whatever. She said in her (local) dialect that we have come as two and now you send us back as three! That is all she knew and all she cared about.

"Luckily I had a friend (willing to give) me some money to help needy people. So I described the whole thing to them: 'This is a couple who have no clue where to stay and what to do. They have no relatives here. They were clueless.'" Aided by  prominent Mumbai business family, the Pallonji Mistrys, Benu and her husband were able to stay on in Bombay for 45 days and conceive twins, going by not as two or three but as four, bringing their mom delirious happiness! Parikh hears from Benu every Navratri.

Life stories as touching, and finally upbeat, as Benu Devi's color Parikh's professional life. The Jaslok doctor has helped women and also men -- from all over India, and beyond India's shores, rich or poor, famous or unknown, film star or farmer, conceive the child they dreamed would perfect the meaning of their life.

Parikh's laboratory-nursery has given life to 5,000 and counting.

The fertility specialist very recently published a book, The Complete Guide to Becoming Pregnant (Random House India), to reach out to more women weighed down by fertility issues. In an interview with rediff.com Parikh discusses India's changing attitudes to infertility, IVF treatment and more: 

What do you feel a young person in their twenties must know about getting pregnant, (either married or expecting to be married)?

A young person must be aware or made aware of the normal physiology of reproduction. A healthy lifestyle, minimisation of life style issues like smoking, frequent late nights, irregular eating habits, unprotected sex which can cause sexually transmitted diseases resulting in tubal blockage should be emphasised.

Ms X: I cannot get pregnant. What is your first piece of advice to young people who come to you with this statement?

Although young women do have time on their side, it may be worthwhile to complete the simple tests such as endocrine profile and tubal patency testing along with a semen analysis. Most importantly couples who are young and trying may need to know that having regular sex is important for having a baby.

Image: After a round of IVF hormonal injections a woman will have more than the average number of eggs to harvest. Dr Firuza Parikh harvests eggs from the graafian follicles which are fluid-filled sacs in the ovaries. Corora lutea are formed after ovulation. These are formed after the egg has been harvested.

What kind of pressures do young couples face today when it comes to having babies. On the one hand you have this huge and growing section of double-income, no-kids (DINK) couples who don't want to have children at all. On the other hand in the same city

They don't want children for a while. Many of these people who are double income and don't want children by the time they are 37 and 38 they come back saying that look we thought we won't have children but I think it is time for us to have children.

And then the inability to have children can also lead to tension and sometimes divorce...?
 
Absolutely. There is a lot of blame on one side or on (one) partner (or the other). And many times the couple may not be keen to have a baby right away but it is the pressure from the family from society. Any time you walk into any place the first question is how many children do you have, what does your husband do, what are your children doing. So there is a lot of pressure both from within and from without. From within the couple as well as from the society.

So how do you counsel them? And what kind of counselling do you offer?

Most of the time it is the husband and the wife who come.

Occasionally it may be somebody else from the family, like a sister-in-law or a mother-in-law who come, but most of the time they come as a couple, as a unit. I don't. But my husband does. Dr Rajesh Parikh. He is a neuro-psychiatrist. He does the counselling.

Just the simple personal counselling that happens day-to-day where we have to guide them through the process we do. But if we find that there is a lot of comorbidity (an additional illness) because of the situation of infertility they are facing depression or they are facing ostracisation, then it is time for someone who is experienced in this is to take over and put things properly.

Stress plays a major role in unexplained infertility. We have been researching this issue in our centre over 20 years and there is compelling evidence to show the correlation between stress and infertility.

We identify patients who are experiencing signs of stress and advise them either counselling or medication or sometimes both. We believe that counselling is one of the factors for our high success rates.

Also the thing is with IVF there are a lot of expectations. Everyone feels that oh IVF is a panacea for having a baby. But one has to be realistic about IVF.

IVF is not something that is going to happen in 100 percent of the time in 100 couples.

People need to know ok you are going for IVF or taking some form of infertility treatment these are your chances, these are your chances of failure, this how you should approach, so counselling at the medical level as well as psychological counselling. Both are very important.

And also when not to do IVF. Today I had a girl from Ulhas Nagar. She came without her husband. She says there is a lot of family pressure (to have a child). They were just married for six-seven month. They were staying in a surrounding where there is not too much privacy so obviously they are not able to plan their baby well. And everybody is pressurising her to have a baby we had to tell them look six months is not enough time to give yourself. There's lots of time for you. Don't panic.

Infertility resulting from lack of privacy must be quite common in Indian urban areas?

Yes, because of lack of space. Of being clustered up. We have seen situations where in a joint family (home) there is just one bedroom. Couples actually take turns using the bedroom. We have seen that.

Infertility in India, if one is to believe the sexual advice columns in the newspapers, must also often result from ignorance?

Yes, for some people (infertility results because they) don't have regular sex. They think: 'Okay we will have sex only on the fertile days which they think is the ninth day the tenth day.'

We have to educate them.

Unless you have success you can't make a baby. There are people who don't know how to have sex. There are some people who have vaginismus where the vaginal muscles tighten at the time of intercourse either because of some injury or the scare of having sex. These are real life situations

What percentage of couples suffer from these kinds of issues?

Not very high. About five per cent of couples will not time their sex properly. A good ten percent have lost all interest in sex; they are barely having sex. There thing is it is like a performance. The doctor will say ok these are the days when you plan.

These are not the fertile days. Everything is programmed and that also causes so much performance anxiety to the couple. They sometimes cannot perform.

We see that all the time.

The other trend which is something we must think about is that people are only meeting in the boardroom not in the bedroom.

Couples are just not meeting in the bedroom. The woman works hard, cooks a meal is tired. The husband comes late. They just sleep. They are just not meeting and making time for ourselves. And this is an urban phenomenon.

Is it spreading to the tier-two towns

Not really. I do not see that much in the smaller towns.

What percentage of success does IVF have?

It depends on the age of the woman. If somebody is between the age of 25 and 35 she will have a good 45 to 50 percent chance of getting pregnant. The moment she hits 37 those figures start falling. Then it becomes 30 percent. At 39 It becomes 20 percent. At 40 and above it drops to 10 percent. Above 42 it is less than five percent. As an average it varies anywhere be 30 to 45 percent

You mentioned earlier that positive thinking really helps when a couple attempts IVF. Could you elaborate on that?

Yes I gave an example. Sometimes when I have a waiting hall (full of patients), I  look at whose waiting. And I think (in my mind that) this lady will get pregnant. Its their whole demeanor. The way they carry themselves. The way they sit with that determination. We now got that knack of saying, 'Look she is focused. She knows what she want. This one knows what she wants.' There are woman who come in for the IVF and say, supposing the period comes then when should I come back for the next (course). And I ask but why are you thinking of failure. Why are you not concentrating (on success)?

They just feel very defeated. They have suffered for infertility for so long for them they feel okay it is going to be a failure. I don't know if they lack the strength. They have the inherent ability. But I think it is because they have had negatives, negatives, negatives it is more of a negative (outlook). It is very important to be realistic about IVF but at the same time to be in charge of your body -- to be in control. Those are the woman who conceive. We see that time and again

How cooperative are the husbands who come in with their wives for IVF?

We see a very healthy trend of husbands accompanying their wives for treatment. They want to be a part of the treatment process and the decision making.

Tell us about the Indian attitude to twins (a common consequence of IVF treatment).

Twins are usually welcomed by couples even if it means more bed rest during the pregnancy and extra work for the parents after the birth of twins.  Most couples feel that they have got a bonus when getting twins through IVF/ICSI. Of course one must be cautious with twins as there is a higher chance of premature deliveries and birth defects with twins.

Why is it of late, it seems, more difficult for young people to conceive?

It may be that younger people are proactive and want to fix a problem no sooner than it is detected. It may also be related to one's lifestyle. To give you an example we see more women with polycystic ovaries. The disease is tied up to obesity, insulin resistance, deranged blood sugar levels. These may be triggered by one's lifestyle. Fast food, food with high glycemic index, lack of exercise can all set up a vicious cycle promoting anovulation and PCOs.

What is the cost of IVF?

IVF in our country is much cheaper than what it would be say in USA  or any country. In USA it will cost a couple almost $15,000 to $20,000 dollars to do a cycle. Here putting the medicine, putting the cost of the hospital comes to between Rs 1 lakh and Rs 1.5 lakhs which although is a lot is quite affordable for some people.

Many of them what they do is they make savings, they collect money, they do it after they collect money over a couple of years. What we advise people who are.

I don't there are any facilities for a bank loan and even insurance doesn't cover it unfortunately unlike some states in the US where it gets covered.

We try to help them wherever we can. Subsidise costs. I have a lot of patients who help. We have an infertility foundation. Lot of our patients help another couple in need.

Tell us a little more about how a woman with cancer, specifically breast cancer, can save her eggs?

It depends on the kind of chemotherapy that a woman receives. Breast cancer is for very hormone dependent. It is dependent on estrogen and progesterone. (It feeds off them). Certain types of breast cancer are hormone dependent and can be flared with a pregnancy and can be flared with taking hormones.

And some breast cancers are not hormone dependent. Most of the chemotherapy agents which are used for breast cancer will halt the cancer because it attacks dividing cells. And the cells in the ovary are dividing cells so that is how it kills off all the eggs in the ovary.

That is why young women, recently married and who discover they have cancer very quickly must at least have one cycle of IVF to either store their eggs if they are not married. If we don't do IVF how will we take out (enough of) the eggs.

We need eggs which we are going to store. We need extra eggs. We need to pick up as many as 10, 15 or 20 eggs so those can be either frozen in the egg state if they don't have a male partner or if they are married in an embryo state. Usually the doctor will give what is a five year survival (window). Normally for five years one should no try having a baby after the chemotherapy.

So the moment you try to make the uterus receptive to accept the baby you have to give estrogen and progesterone. So that is why you have to wait usually for five years ideally.

It must be quite tough for a woman to organise this in a short space of time?

It is very, very, very traumatic because you know on one side the oncologist is getting them ready for chemotherapy/radiotherapy and here is the need to freeze the embryos or the eggs. It is always a struggle

Are oncologists in India alert to the fact that for instance that this X person is 24 years old and she needs to freeze some eggs

Not all. There needs to be and education and awareness. In fact in America now there is a whole specialized special interest group for fertility preservation. These are specialists who have gone into this fertility preservation of woman who have cancer. So it needs a lot of study, a lot of research.

How cases like this have you dealt with?

Not so many. Say in two months or so we will see somebody who is coming forward for egg freezing or embryo freezing. There are cases (of young cancer ridden women who must consider freezing their eggs or embryos). But it must translate into knowledge and awareness that such facilities are available (in order to come forward to do it). That is why in America and other places there are special interest groups. There will be a centre that deals with women who have this issue.

What about gay and lesbian couples. Do you get a lot of them too?

We do. In about a year we would have 20 or so coming forward for surrogacy

Is this only from the metros or also from smaller towns?

Mostly it is big metros. And a lot of people from out of India. The Indian government is very conducive to having surrogacy for single parents, single sex couples and gay couples. One of the easiest countries for surrogacy I think is India.

What is the oldest couple that has come to you?

Usually I accept couples till the age of 45. Sometimes we stretch it to 46 or 47. Usually I never go beyond 50 because there are at 50 you know other issues that come up. Women's health. Whether she is going to develop osteoporosis, heart disease, blood pressure, other issues. So for me the cut off is usually 45 to 47

But you must have a lot of pressure from women who are 48 or so but yet entreating you to help them have a baby?

(They are told that) we usually do not do it. It is not fair to the child. (By the time the child is 15) the parents are 60 or 65. It is not fair to the child. You must be very judicious also I feel. There was some part of India where they got a 72 year old pregnant. I mean you can even get a 90 year old pregnant if you want. (But you must have) a cut off for yourself.

Yesterday or day before somebody came. They had lost their 26-year-old son in a car accident. She had two girls in fact; aged 27 and 21. She was 51. She had gone through menopause. She came to ask me if we could reverse menopause for her. She wanted a boy. But in any case we don't do boy or girl (selective IVF). And I could not help her she was 51. These are the people who need a lot of counselling. It is not as if you can offer IVF to everyone.

She had come here from Madhya Pradesh. Her husband was doing some business. (She was) not so uneducated. But still she had a misconception that if she comes here we will do something and her periods will start again. We had to counsel her a lot. I sent her to (my husband) Rajesh. She was going through clinical depression.

Requests from people in such situations must be common?

Usually when they come to us it is in grief, as a kind of rebound to quickly have a baby. Many of them, when they get over the grief realise they can't do it. It is not easy.

What are your thoughts on surrogacy?

I think surrogacy is a very well established medical form of treatment and it is an integral part of IVF. Because there are woman sometimes who are born without a uterus, woman who because of tuberculosis their lining gets affected, woman who have high diabetes or high blood pressure or who have miscarried several times or who have a problem in the shape of the uterus. Those are definite candidates for surrogacy.

How popular is the womb-renting phenomenon? Do you have lots of such cases?

Womb renting is not popular in the sense that everybody does it but it is a viable option and it is something that should be considered part of IVF treatment

We don't do too many cases. But yes wherever it is needed we can do it. We do two or three in a month.

You must be bombarded with requests for IVF treatment that results in a boy child?

We get constant requests for a male child. In fact there are many couples who come to me for having a baby and they say they want only one child and "can it be a boy?" Of course such requests cannot be entertained.

In our country the girl child occupies a very precarious position and therefore the practice of sex selection in favor of a male child would further weaken the social fabric of our country.

If a man has diabetes does that lead to infertility?

Oh yes. Men who have diabetes, their wives are more prone to miscarriages because diabetic men have more genetic changes in the DNA of the sperm head. In fact we are doing a very large study right now where we are looking at men with long standing diabetes and seeing their sperm apoptosis that is programme cell. And we find that diabetic men with long standing diabetes have more problems with the DNA in the sperm head

Many of them lose their libido (desire to be sexually active). They have premature ejaculation and they lose their erection. Very common. Sometimes the wife herself diagnoses it. Like she will say: 'Last three month no sex. He just cannot have an erection.' So we ask them to do their blood sugar and it comes out that he is diabetic. One in six Indians are diabetic or getting into diabetes.

You are probably quite familiar with Indian attitudes to adoption. How has it evolved?

Adoption is still not accepted by couples as a realistic choice. Most couples look at adoption as the last resort. Some do not even want to contemplate on the idea of adoption.

How do the issues of getting pregnant differ between urban and rural areas in parallel income groups and how has it changed over the years?

The urban population comes straight to the infertility specialist by and large. Whereas in the rural areas the couple would first consult their family doctor who would then refer them to the gynecologist. The gynecologist would then decide the need for consulting an infertility specialist.

Single largest myth that still exists about getting pregnant?

Infertility is a curse from God and IVF is unnatural

Have you met Louisa Brown or her doctor?

I have Professor Bob Edwards at an IVF conference and he is a role model for many of us. Unfortunately I have not met Louise Brown. 

How relevant do you think your job is considering that we are a country of billion people?

It is a question of balancing nature. Just because on one hand you have people who have lots of babies. What about the other arm? We can't always skip the balance. You have to cater to needs of everybody in society

So many years on, what do you feel about this career you have chosen?

I feel energised and happy. The happy smile on my patients' faces and their fulfilment is what drives me for the next challenge.

How many babies do you have?!

More than 5000 and ticking

*Names changed to protect privacy