The Conception Crisis
THE WEEK|May 23, 2021
The sperm count is down, and egg quality low. Men and women in India are struggling to conceive. While lifestyle issues do contribute to infertility, researchers are more worried about hormone-altering chemicals that surround us. THE WEEK investigates how these are impacting our reproductive health
Pooja Biraia Jaiswal

Until about a decade ago, weekdays at the Agatsya Sperm Bank in Rajkot saw men, aged between 20 to 30 years, queue up outside the facility. A quick screening and the young, athletic, qualified, English-speaking men among them would be picked out. For, it would be certain that they would have sufficient volumes of “healthy swimmers”, enough to be transported to clinics across Gujarat for assisted reproduction. At the time, 70 per cent of the semen samples received were accepted and marked “ready for use”. But that was then, when the Indian sperm was healthy and in abundance.

Today, it is the opposite. “Now, 70 per cent of the samples we receive are rejected,” said Dr Yogesh Choksi, a microbiologist who started the facility in 1997. His is the oldest registered cryobank in Gujarat. “Even as the number of donors has, by and large, remained steady, the quality and volume of semen has fallen down sharply,” he said. When Choksi started the bank, he recalls that any given semen sample would range between 3.5ml and 4ml with a sperm count of 80-100 million per millilitre, which was considered normal at the time. That way, it was possible to fill five vials with a single semen sample. But now, “a single semen sample measures between 1ml and 1.5ml and the sperm count remains as low as 15-20mpm,” he said. “We barely get one full vial from a single sample.”

Shocking, right? But it is a reality that has been staring us in the face all along. And combined with a decline in testosterone levels in Indian men, it has consequently resulted in the rise in infertility cases.

SWIMMERS TAKE A DIP

In 2017, researchers in the US concluded that the sperm count of an average man in western countries had fallen by 59 per cent between 1973 and 2011. Next year, researchers at the CSIR-Central Drug Research Institute in Lucknow undertook a similar study, analysing just how steep and continuing the slump was among 6,000 fertile and 7,000 infertile Indian men from 1979 to 2016. The study found that semen parameters in Indian men—including the sperm count, volume and movement—had declined with time and the deterioration was quantitatively higher in the infertile group, with the mean semen volume as low as 0.77ml and the sperm count at 29mpm.

Said Rajender Singh, principal scientist (endocrinology) at CSIR-CDRI: “In the same period of study, if we do not distinguish between fertile and infertile men and take them as one cohort, we, in India, have witnessed a decline of 26 per cent in the overall sperm count, from 87mpm in 1979 to 64mpm in 2016.” Yet, what is concerning is not just that the count and quality are declining, but that they are declining below the World Health Organization’s normal reference range of 15mpm. Any value beyond this renders a man infertile. And, clinicians in India are witnessing a large number of men coming to them with complaints of infertility due to a sperm count that “at times falls down to extremely low (oligospermia) or even zero (azoospermia),” said Dr Aditi Dani, fertility consultant at Mumbai’s Masina Hospital.

‘EGGS’ISTENTIAL CRISIS

But it is not just men. The ability to conceive a child naturally has taken a hit in both men and women equally. “There is no doubt that an ever increasing number of girls in India are experiencing early puberty,” said Dani, “while women are losing good quality eggs at younger ages than their mothers or grandmothers did.”

India, the second most populous country after China, finds itself at the centre of a paradoxical situation: an ever-mushrooming population on one hand and a dramatic year-on-year decline in its fertility rate on the other. A fertility rate of about 2.2—a couple having two children—is generally considered the replacement level, the rate at which the population would hold steady. When the fertility rate dips below this number, the population is expected to decline. As per the National Health Profile 2018, the total fertility rate fell below two children per woman in 12 states, and just about reached replacement levels in nine others. While there is no doubt that family planning has been the chief guiding force behind this, experts believe that the rising incidence of infertility is also to blame. “Infertility is on an alarming rise in India, with the country estimated to be contributing to nearly 25-30 per cent of all couples diagnosed with it the world over,” said Dr Neeta Singh, senior consultant and professor, division of reproductive medicine at the All India Institute of Medical Sciences. According to the Indian Society of Assisted Reproduction, one in six couples suffers from infertility, amounting to 27.5 million infertile couples trying for conception. “You can gauge the magnitude of the problem from the patient load at the AIIMS ART Centre,” said Singh. “As per the medical records for 20182019, nearly 15 lakh patients consulted the outpatient department, of which 5,468 patients underwent ART (assisted reproductive technology) treatment.”

ABC OF EDCs

And while the reasons vary—age can be a contributing factor, as can lifestyle issues like stress and obesity—scientists and researchers are more worried about what are called endocrine-disrupting chemicals. EDCs represent a broad class of chemicals such as organochlorinated and organophosphate pesticides— used in agriculture and mosquito control—and industrial chemicals, plastics and plasticisers (used to soften plastics) and fuels. They are ubiquitous; EDCs can be found in food wraps and plastic water bottles, even in the perfume you wear, the tap water you drink and cook with, and the air you breathe. And, it is their unrestricted use that is harming our ability to have natural pregnancies.

“Their impact becomes even more magnified and frightening for India, as we are witnessing an ever-growing consumerist culture and have relatively easy regulations,” said Dr Kamlesh Sarkar, director, ICMR-National Institute of Occupational Health, Ahmedabad.

EDCs essentially interfere with and disrupt the body’s endocrine system that monitors the hormonal balance across different glands. Sex hormones—oestrogen and progesterone in women and androgens including testosterone in men—are essential for reproduction, as are hormones secreted by the pituitary gland and hypothalamus in both men and women. EDCs either block the connection between these hormones and their receptors or increase or decrease their levels in blood. They also mimic the body’s natural hormonal activity and trick the body into blocking the natural hormones from doing their job. Any alteration in the amount or timing of the release of sex hormones in the body can alter a couple’s chances to conceive. That is because if these hormones do not get to the right place at the right time, sperm production or ovulation— both necessary for reproduction— can get hampered.

And, infertility is not just an urban issue. In a 2018 paper, Dr Sonia Malik, director of Delhi’s Southend IVF, wrote that villages were reporting higher incidence of infertility owing to the “high use” of fertilisers and pesticides. In some ways, it is not surprising that EDCs cause unfortunate consequences. For instance, since human reproductive processes are similar to those of other species, many pest-control chemicals designed to harm pest reproductive systems also damage human reproductive systems.

According to experts, health defects associated with EDCs include a range of reproductive problems, from declining sperm counts and reduced fertility to male and female reproductive tract abnormalities, reduction in the number of healthy eggs in ovarian reserves, loss of foetus, early puberty and menstrual problems. In 2014, professor Kaustubha Mohanty, department of chemical engineering, Indian Institute of Technology, Guwahati, carried out a research on the lingering effects of endosulfan, which was indiscriminately sprayed on cashew plantations in Kerala’s Kasaragod district and caused abnormalities and androgenic defects among children. Ten years after India banned it, it is still found to exist, said Mohanty. “Its residues were detected from air, water and soil. It is becoming increasingly difficult to get it out of the system because of its toxic properties,” he said.

Such toxicity goes beyond state borders. In 2006, Rajvi Mehta from Hope Infertility Clinic and Research Foundation, Bengaluru, evaluated 16,714 semen samples from five different cities of India and found that 38.3 per cent men from Kurnool and 37.4 per cent men in Jodhpur showed complete absence of motile sperms. Fifty-one per cent of men in Kurnool suffered from an abnormally low sperm count—the highest reported prevalence in the world, said Mehta. As per the study, a possible link could be established between infertility and high use of pesticides in Kurnool, where cotton is grown as a cash crop. The study, published in the recent issue of the Asian Journal of Andrology, was initiated after the Hope clinic got an unusually high number of referrals for male infertility treatment from Kurnool. “In Jodhpur, there is a high level of fluoride in groundwater, and exposure to high fluoride levels has a detrimental effect on the male reproductive system in animals and can also cause disruption of reproductive hormones in men,” the paper said.

As per WHO, our exposure to EDCs has increased in the last two-and-a half decades owing to their increased presence in our environment, be it food, water, air or everyday products. “Most of the EDCs are lipophilic (they can dissolve in fats and oils) and accumulate in the adipose tissue (body fat); thus they have a very long half-life in the body,” said Alka Dubey, programme coordinator, chemical and health, Toxics Link, an NGO that specialises in research on toxic chemicals in India. “Many of these substances either do not decay or decay slowly, while others may be metabolised to compounds that are more toxic than the parent chemicals.”

POP GOES THE BUBBLE

Persistent organic pollutants (POPs) are an example of such chemicals; the name says it all. POPs, such as polychlorinated biphenyls (PCBs) and organochlorinated pesticides (OCPs), are highly persistent, toxic, and accumulate in the body fat of humans and animals. Endocrine disruption is one of the recently considered consequences of POPs because of their hormone-altering capabilities. Studies have long established how DDT and PCBs (used in electrical equipment and coatings) can impact the growth and function of testicles, leading to abnormal sperm development and male infertility later in life. While the United States has banned DDT, it continues to be used in the fight against malaria and other diseases in India. However, following continuous use, insects have become resistant to it.

It has left its footprints though; as early as 2001, Mumbai-based Bhabha Atomic Research Centre found residues of DDT and its metabolites in sediments and fish samples collected from the east and west coasts of India. Moreover, a 2018 report in the Archives of Environmental Contamination and Toxicology said that POPs were found in human breast milk samples collected from Bhatinda and Ludhiana in Punjab.

DROWNING IN PLASTIC

According to the Endocrine Society, the annual global production of plastics—which is found in almost everything we use and which contains EDCs—has grown from 50 million tonnes to 300 million tonnes since the 1970s.

Infertility is on an alarming rise in India, with the country estimated to be contributing to nearly 25-30 per cent of all couples diagnosed with it the world over. —Dr Neeta Singh, senior consultant and professor, AIIMS

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