India's falling fertility rate: A public health crisis
Infertility today spans urban, semi-urban, and rural areas, depending on geography, socioeconomic status, and environmental parameters. As per the recent figures of the National Family Health Survey (NFHS-5), there is a concerning trend. India's overall fertility rate has fallen to 2.0 below the replacement level of 2.1 for the first time. Presently, India is at a critical demographic junction. This is indicative of a broader problem: infertility is emerging as a public health problem, rather than merely a couple's issue relegated to the four walls of their homes.
The Urban Struggle
In cities, some of the major reasons for infertility are advanced maternal age, high stress levels, inactive lifestyle, unhealthy diet, and less intimacy. More couples are opting to conceive later, usually in their mid-to-late thirties, which can biologically diminish the fertility potential. In men, lifestyle-related declines in sperm quality and quantity are also being noted.
In Tier 2 cities, the reasons may vary from health conditions such as undiagnosed PCOS, obesity, to increased alcohol and tobacco use, and heightened stress levels.
Toxicity from the environment—such as industrial pollutants, water with heavy metal contamination can be among those contributing to declining fertility. Male infertility is also on the rise, with research demonstrating decreasing semen quality amongst both urban and semi-urban populations. Studies in Thoothukudi, an industrial city, showed that pollution of the environment by chemical industries may have been responsible for endocrine disruption.
This may have caused infertility and stillbirths as well as birth defects. Rural India also has its unique set of challenges. Here, infertility may be caused by malnutrition, ignorance, contact with agrochemicals and pesticides, and untreated conditions such as pelvic inflammatory disease that can harm reproductive organs.
Infertility in Bharat
In many areas of rural India, extensive application of industrial fertilizers and pesticides has provoked debate regarding their long-term effects on hormonal function and reproduction, particularly among farming communities.
A 2023 review in the Journal of Human Reproductive Sciences verifies that exposure to pesticides in rural populations in agricultural belts such as Punjab and Western UP has been linked to changed sperm parameters, reduced sperm count, and compromised ovarian function in females.
Moreover, sociocultural stigma and lack of access to reliable diagnostic care can make infertility a silent burden in rural areas. What we're witnessing is a complex mix of biological, environmental, and social factors that differ by region yet are united by one common thread, which is the growing need for accessible and high-quality fertility care.
This is where India's fertility industry is starting to come of age. Fertility treatment can no longer be a generic model. The heterogeneity of the country demands region-specific, bespoke treatment patterns considering local dietary patterns, stress levels, exposure to the environment, and even sociocultural practices.
By taking fertility care out of metros and into Tier 2 and Tier 3 areas, we are witnessing a change.
With more than 50% of the centres located in small towns now, there is greater access, earlier intervention, and most importantly, awareness. Awareness on subjects like irregular menstrual cycles, male factor-induced infertility problems are being relentlessly pushed in Tier 2 areas as well as rural areas.
There is also the benefit of more advanced technologies being available in the underserved regions. The aim is to provide international standard quality fertility treatment, along with bearing in mind the regional sensitivities.
With greater insight into regional specificity and a concerted effort to normalize fertility discussions across the board, India can tackle its own fertility crisis, geography by geography. Through an all-encompassing tackling of these issues, the right to parenthood is in reach and inclusive for all Indians.
(By Mr Shobhit Agarwal, CEO, Nova IVF Fertility)
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