The empty cradle

It is mostly the women who bear the stigma of infertility.

It’s a typical afternoon at the Australian Concept Infertility Medical Centre (ACIMC) in Clifton, Karachi, crowded with women draped in abayas and men with blank expressions. Going by the looks of the patients in the centre’s waiting lounge, it’s hard to tell that behind their respective veils, many of them are concealing signs of turmoil.

But in the privacy of the doctor’s office, their repressed anguish often gives way to emotional outbursts.

“Many infertility patients are under serious mental strain. Women often start weeping during consultation,” says Dr Syed Sajjad Hussain, the CEO of ACIMC in Karachi, in a matter-of-fact tone. “We try to comfort them, but as doctors we also need to be realistic and professional with them.”

Infertility — medically defined as the inability of a couple to conceive within 12 months of unprotected sex — affects nearly 1 out of 5 couples of childbearing age. However, this biological condition has grave ramifications for couples in our society, where producing children is arguably considered the most important function of marriage.  The failure to produce children is considered a social taboo, and it is generally the woman who gets a disproportionate share of the blame.

Mahnum*, who has been married for four years and lives in the UK with her husband, has been diagnosed with polycystic ovarian syndrome, a hormonal disorder which affects one out of five women and is the leading cause of sub-fertility in women.

“I dread coming to Pakistan because of questions about the ‘missing’ baby,” she says wryly. “Distant relatives and even strangers come to me at get-togethers and wistfully declare that children are the light of one’s life, just to taunt me.”

The social pressure to have a child has entangled Mahnum in a vicious cycle: her inability to conceive means that she is bombarded with prying questions from relatives, which stresses her out, and that in turn interferes with her ability to conceive.

“Doctors have often told me that stress disturbs my hormones and hence prevents my pregnancy,” she explains. “But how can I curb my anxiety when there’s so much pressure?”

Many infertile couples then pin their hopes on fertility treatments — a popular one being in vitro fertilisation (IVF) — but their success rate varies between 35 and 50 per cent at best.

“I went through IVF twice and it was highly stressful,” says Lahore-based Mehrunissa*. “Since, my in-laws had great expectations from the treatment, I thought that I would let everyone down if it did not work out.”

IVF failed to bear fruit for her, but she refused to go through it a third time because she was wary of having more hormones injected in her body. Instead, she and her husband adopted a child from within the family.

Many years after she had the ineffectual IVF procedures, she was diagnosed with leukemia. However, she miraculously beat the life-threatening disease after a bone marrow transplant and heavy chemotherapy.

“Even though doctors could not pinpoint a cause for my cancer, I blame all the hormones injected into my body since I don’t have a family history of cancer at all,” she asserts adamantly.

“There is a mild risk of cancer if hormones are used repeatedly over a long period of time, but one or two IVF cycles will not increase the risk,” says embryologist Sara Tanwir Ahmed.

The link between IVF treatments and an increased risk of cancer is a subject of heated debate in the field of medicine, but despite extensive research, there are still no clear answers.

Many couples who don’t opt for fertility treatments, or for whom such treatments are ineffective, ultimately adopt children like Mehrunnisa eventually did. However, women who can’t have children are often still plagued by the insecurity that their husbands will remarry to have children who are ‘of their own blood’.

For those on the verge of losing their husbands this way, desperate times call for desperate measures.

More than a decade ago, Yasmeen*, a woman in her late 30s, brought a strikingly beautiful teenage girl to see Dr Neelofer Leghari, a leading gynecologist based in Lahore, for a medical examination.

Yasmeen was very upset that the 17-year-old girl had not conceived even after two months of regular, unprotected sex.

“I really want her to get pregnant, somehow,” she blurted anxiously.

When Dr Leghari asked her how Yasmeen was related to the girl, out tumbled an infertile housewife’s scheme gone awry.

“Yasmeen had ‘bought’ the girl from an Afghan camp after an agreement with her parents that her husband would temporarily marry and impregnate her,” recounts the doctor. “Her plan — fully endorsed by her husband and the girl’s family — was to keep the baby and then send the girl back to the camp after getting her divorced.”

She had told her in-laws that the Afghan girl was a maid at their house, but every night Yasmeen secretly coaxed her to have sex with her own husband.  But two months into her own plan, the barren woman had grown jealous and lost patience.

This is clearly an atypical case. However, it is a good indicator of how infertility takes an emotional toll on women in a society where marital security is often tied to a woman’s ability to have children.

Dr Leghari has also witnessed other cases of women organising ‘temporary marriages’ for their husbands with girls from lower  income groups.

For barren women, she says, the imperative of saving their marriage in the long-term is often the most important motive for producing children.

But a second marriage, or even these ‘temporary’ marriages, is hardly a guarantee for producing children. In approximately 50 per cent of infertility cases, the male is the sole or the contributing factor.

However, ignorance about this fact is quite widespread, confirms Dr Hussain.

“I have witnessed the same man bring his four wives for fertility treatment, even though the problem is actually in him,” he says.

A man’s inability to produce children implies a lack of virility and to be labelled a namard in surely damning for men. But, in our patriarchal society, it is easy to shift the blame on to the woman.

“Many men refuse to get tested,” says Dr Hussain, “while others reject their semen analysis reports because they just aren’t ready to believe that something is wrong with them.”

And ironically, women themselves are complicit in spreading the notion that the burden of infertility should be borne solely by them.

Jamal Mahar, a student of Aga Khan University (AKU), witnessed this while at the department of gynecology and obstetrics at AKU hospital.

“When doctors would tell women to bring their husbands for testing, their mothers-in-law, who were accompanying them, would openly refuse and say that they believed their sons had no problem,” he says.

Junior consultant Lubna Durrani at Atia General Hospital is no stranger to men’s reluctance in dealing with their failure to produce children.

On a busy Saturday afternoon, the spry doctor counsels a couple on IVF in a modest room at the Sindh Institute of Reproductive Medicine in Atia General Hospital. Adjacent to the consultation room is the waiting area which is chock-full of patients.

“Many men request us not to tell their wives of their condition while they undergo treatment,” she explains, as she sits to catch a moment’s breath after the couple exits.

Sitting right across the doctor is Azeen*, who is engrossed in an intense discussion with another medical consultant. She clutches a file containing a record of medical tests in her hands — but that record is neither hers nor her husband’s. It is in fact her brother’s, who is suffering from azoospermia — the lack or absence of sperm in a man’s semen.

“My brother’s in Bahrain. He doesn’t want his wife to know about his condition, so I am here to consult the doctor regarding his medical tests,” says Azeen. “He will come to Karachi for his treatment soon.”

The woman’s sister-in-law remains in the dark about her husband’s biological shortcoming. She’s been vaguely told by hospital authorities that due to ‘certain problems’, she and her husband can only have a child through IVF treatment.

Azeen adds quietly, “Actually my brother is married to our first cousin. He’s afraid that if his wife finds out about his condition, she will make a big issue and let everyone in the family know.”

According to Islamic law, a woman has the right to divorce her husband if his infertility is the sole obstruction in childbearing. But, unlike men, who are ready to remarry if their wife is infertile, women are less likely to abandon their sterile husbands. In fact, many women sympathise with their husbands and emotionally support them after finding out about their physical shortcoming, if testimonies of medical experts are to be believed.

“My experience shows that women become very caring and sympathetic towards their husbands when they find out about their biological predicament,” explains Dr Sajjad.

And in the jam-packed waiting rooms of fertility clinics, one will find many women who are keen to support their husbands through this ordeal. Twenty-four-year-old Kiran is one such woman, with a soft corner for her barren spouse. She waits patiently in ACIMC ‘s waiting lounge, as her partner sees the clinic’s urologist.

“I have had numerous tests but all of them were clear; the real problem is actually with my husband,” she explains compassionately. “I often accompany him to the centre, so that nobody finds out that he’s actually the one with the issue.”

But the tone of her voice suddenly changes, as she sarcastically blurts out, “And it’s really no use telling his family the truth. It’s not like his mother is ever going to believe that there’s anything wrong with her son!”

There’s a clear gender imbalance in the implications that infertility has for men and women. But there are people who say that education and class make a marked difference in this regard.

Nabat*, who has been married for the past seven years, found out that her husband had azoospermia six months into her marriage.

“He has absolutely no hang-ups in acknowledging his condition and discussing it with family members. My husband comes from an educated family of doctors and thus has full knowledge of what he is going through,” she says.

She continues with a sympathetic smile, “He is very loving and has often told me that I am free to divorce him and remarry if I want kids.”

Nabat’s spouse Fareed* has no qualms in acknowledging his condition.

“I have openly discussed my condition with my sister, who’s a doctor in the US, and my mother. What’s the problem in doing that?” he says in a matter-of-fact manner.

There are also others, like Lahore-based urologist Dr Ramzan Chaudhry, who claim that educated men from urban areas willingly go through testing, and actively seek treatments for infertility.

“Times are changing now. I have worked for 30 years in the field and young men of today do not typically resist fertility tests,” he says.

They may have recourse to the latest fertility treatments, but the uncertainty that accompanies such procedures is excruciating for the couples waiting in queues at crowded infertility clinics, caught between hope and despair.

As Kiran says with a sad smile, “It’s God’s will, after all — He is the one who decides when to gift a couple with a child.”

*Names have been changed to protect privacy.

 

Published in The Express Tribune, Sunday Magazine, January 8^th, 2012.