Migrants returning from the Gulf with infertility

Migrant workers returning from the Gulf and Malaysia make up 40% of infertility cases at Paropakar Maternity and Women's Hospital in Kathmandu.

Studies have highlighted the problem of sterility among men who have returned from working abroad in extreme temperatures and are prone to unhealthy lifestyles including smoking and alcohol consumption.

Sarlahi resident Sanjeev Sah had gone to Saudi Arabia for work just a year into his marriage. Concerned about his wife having to raise a child alone during his absence, 32-year-old Sah and his wife postponed their plans for a baby. Three years later after his return, the couple has not been able to conceive.

They sought treatment at Paropakar Hospital in Thapathali. Sah was diagnosed with azoospermia, with no measurable sperm count. “Doctors told me that working in high temperatures abroad reduced the quality of my sperm,” says Sah.

Suraj Adhikari from Dhading worked in Malaysia for three years, He married at 28 but was unable to conceive with his wife and was also diagnosed with azoospermia at an infertility clinic.

Adhikari worked at a construction site in Malaysia which left him little time for basics such as food and water. Despite extremely high temperatures, he often went without water for prolonged periods because it was not always available. Doctors blame his time and lifestyle for the decline in his sperm quality.

“Neglecting essentials while working abroad has led to a costly and time-consuming treatment for me,” Adhikari laments.

Infertility is on the rise, globally and in Nepal. This is especially true for workers returning from the Gulf and Malaysia, having worked in hotter temperatures. Half of the patients with childlessness visiting the outpatient department at Paropakar Maternity and Women's Hospital every day are migrant returnees.

“Working conditions with high temperatures reduces the quality and quantity of sperm in young men,” confirms Vinita Thapa, sperm specialist at the hospital.

Shree Prasad Adhikari, the director of Paropakar Maternity and an infertility pathologist, notes that 25 out of every 100 couples face infertility presently, and the problem has now grown particularly among those returning from foreign employment.

Two years ago, Tribhuvan University Teaching Hospital conducted tests on 186 men seeking infertility treatment at the institute. Of these, 46.2% had previously worked in the Gulf. The research report, published in the journal PubMed, revealed low sperm quantity and quality in some cases as well as a very low number of sperm capable of fertilising eggs in others.

According to the WHO, one in every six adults, or 17.5% of the world’s population suffers from infertility.

In Nepal, where children are seen as a form of security and add to the social prestige, infertility can have far-reaching implications. An increase in infertility could also be a contributing factor to an ultimate decline in population together with delayed marriages.

And yet, assisted reproductive technologies such as in vitro fertilisation (IVF) remain financially inaccessible and carry social stigma for many individuals.

A study by the Hebrew University of Israel and Mount Sinai School of Medicine in the US found that the average sperm count globally has decreased by half over the past 50 years.

The study also revealed a decline in sperm quality, including a decrease in the number of sperm capable of fertilising eggs. Between the 1970s and 1990s, the rate of sperm count decline increased from 1.16% per year to 2.64% by the early 2000s.

Paropakar Maternity and Women's Hospital introduced a semen storage service in June, allowing Nepalis to preserve semen and eggs if they require delayed childbirth.

For instance, young individuals going abroad for a long time can store semen for reproduction upon their return. Additionally, if the husband is absent, the wife can undergo artificial insemination using the stored semen, a technique called intrauterine insemination (IUI).

In the IUI process, women are given medication and injections to stimulate egg production. Once mature eggs are produced, they are released through an injection. About 36-40 hours after releasing the eggs, a viable sperm is selected and placed into the uterus using a catheter, explains sperm specialist Thapa.

The hospital is performing IUI on four to five women on a daily basis, at Rs5,000-10,000 per procedure. If pregnancy doesn’t occur after six IUI attempts, IVF is recommended. Adds Thapa: “Many are not aware but 90% of couples facing childlessness can be treated.”

Since the introduction of the storage service in June, 15 couples have inquired but only two couples have agreed to store semen.

The maternity home is also launching semen and egg donation programs wherein women having difficulty producing eggs can use donor eggs and the husband’s sperm. Similarly, when their husband’s sperm isn’t viable, the wife’s egg can be combined with donor semen for insemination.

“The stored semen remains effective for almost six years, retaining 60% of its initial quality,” assures Thapa.

But more often than not, most childless couples fail to seek medical attention on time, resorting instead to shamans, witch doctors, and other ineffective measures.

Paropakar is the sole government facility providing effective treatment for childlessness at present. Hospitals often lack counselling services.

Infertility treatment depends on the underlying cause ranging from pharmaceuticals to embryo implantation through assisted reproductive technologies (ART).

Some 80-90% of childless couples can find solutions through regular treatment, says Paropakar director Adhikari. He adds that weight loss could be a solution for obese women struggling with infertility. In the case of blocked fallopian tubes, there are medications. For those with uterine tissue growth causing pregnancy complications, surgery can help their chances.

But while normal medication can stimulate egg production, up to 50% of women facing infertility lack viable eggs. “Some older women might have reduced fertility despite having eggs. In such cases, medications and hormones can increase their capacity,” says Adhikari, adding that the government doesn’t need as much resources to fight infertility as much as it needs commitment.

Treatment needs to be scaled up to reach all the district hospitals so that couples can easily access artificial insemination and other services while also promoting awareness and reducing the stigma associated with childlessness in Nepal.

The fact that migrant workers who are in every sense the backbone of Nepal’s economy don't have access to treatment means it is even more crucial that infertility, the stigma and the treatment are prioritised and effectively addressed.