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Fertility problems are rising across Syria as couples try to delay having children due to the devastating living conditions in the country.

Environmental pollution, industrial contamination and modern agricultural practices around food production have all added to the problem. On top of this, fertility treatments, where available, are gruelling and costly, putting them out of reach to most civilians in the light of widespread poverty, displacement and lack of work across Syria. ÌýÌýÌý

The limited options for those suffering from fertility problems are arduous. First, they need to meet the requirements for accessing treatment. Then, they may need to undergo repeated assisted fertilisation operations, as these are often unsuccessful the first or second time. Sadly, the story often ends with the couples' surrender to a bitter reality, and often with a divorce, and the husband marrying a second time.

Infertility: A global problem

According to the World Health Organization (WHO) infertility is a disease of the male or female reproductive system defined by the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse. It is estimated that 48 million couples and 186 million individuals across the world suffer from infertility problems.

"Fertility problems are rising across Syria, in part due to an increase in later marriages, as couples try to delay having children due to devastated living conditions in the country"

Assisted conception technologies are one method for treating infertility and achieving pregnancy artificially. Technologies include artificial insemination, in vitro fertilisation (IVF), and intracytoplasmic sperm injection (ICSI). However, these treatments seem an unrealistic fantasy to many couples in northwest Syria because of their eyewatering costs.

Fadwa Ali (40), who lives in Al-Bab town, northeast of Aleppo, is still awaiting "divine intervention" to achieve her dream of motherhood after she took the "agonising" decision to halt her treatment with a specialist doctor.

Her doctor telling her she had just a five percent chance of conceiving led to her decision, she says, adding that the low percentage didn’t inspire hope that she would ever have a baby "after ten years of marriage", despite having tried "every way available to increase the odds, but with no results," she says.

Fadwa married relatively late and suffers a number of health issues, and over time it became obvious that there was a problem – she wasn't getting pregnant. However, the full cost of the proposed assisted conception treatment – with its meagre chance of success – was $5,000. This led her to drop the plan, in light of her husband's poorly paid job as a builder, for which he earns no more than $200 monthly.

Cost-of-living a barrier to fertility treatment

Zaynab Al Nazih (43), an IDP from MaaratÌýAl-Numan now living in Sarmada, gave up on fertility treatment because she and her husband’s combined income hardly covered the bare necessities of food, clothes and other essentials.

She says that when the first assisted fertilisation operation she tried didn't succeed, the cost was increased for further attempts, so she gave up on the hope of a baby after fifteen years of marriage, as the debilitating cost-of-living crisis in Syria would not allow them another attempt.

"A society shattered by war, and a near-total absence of security are major factors in the rise of second marriages"

"I don't know how long my husband's patience can last without children, I feel he is considering marrying again which makes me anxious and unhappy… but in the end… I mustn’t selfishly prevent him as he has the right to fatherhood," says Zaynab.

Social breakdown sees rise in second marriages

Second marriages have become a defacto solution in many cases where a wife suffers fertility issues. While polygamy used to be linked, where it occurred, to a husband's rising prosperity and his ability to support two wives (and families), this is no longer the case in Syria.

The war has decimated everything, leaving behind extremely complex and fragile social and societal conditions. However, this hasn't stopped some from pursuing other marriages using a wife's infertility as an excuse. In these cases, renouncing the first wife is now usually the sole option.

A society shattered by war, and a near-total absence of security are major factors in the rise of second marriages. Many young girls are forced to become second wives to much older (and not necessarily wealthy) men, desperate to escape violence and abuse within their own families. This inevitably threatens the first wife's marriage.

Salwa Abdul-Rahim (29) fell in love with a colleague at university. While the road to marriage wasn't easy, she says, eventually they overcame the barriers and were able to tie the knot. However, the couple's joy was short-lived – with time it became clear that Salwa suffered from fertility problems.

Remarriage in a patriarchy: For men only

For nine years, the couple sought treatment in vain – nothing helped. In the end, her husband agreed to his parents' proposal that he marry a second wife to become a father. His marriage to another woman was the hardest experience of Salwa's life. She recalls how her husband stopped showing an interest in her, focussing instead on his new wife. She asked for a divorce, and her husband agreed, leaving Salwa bereft of both the hope of motherhood, and of the man she had believed was her life's partner.

Salwa bitterly slams the patriarchal system: "He rejected me because I couldn't have children, and no one blames him, everyone supports him. However, if he was the infertile one and I had left to marry someone else, society would have shown no mercy – I would have been blamed and condemned."

"He rejected me because I couldn't have children, and no one blames him – everyone supports him. However, if he was the infertile one and I had left to marry someone else, society would have shown no mercy – I would have been blamed and condemned"

Until recently, there were no specialist fertility clinics in northwest Syria, so couples trying for a baby would have to travel to Damascus or outside the country to access fertility treatments.Ìý However, recently a specialist centre for fertility treatments has opened in Dana city, northern Idlib, which offers a range of assisted conception techniques: intrauterine insemination (IUI), ICSI, sperm freezing and other services, according to Dr Zakaria Ibrahim, one of the senior doctors at the centre.

Dana fertility centre

Dr Ibrahim says the various treatments have given hope to many, and are completely safe, without future complications or side effects. The centre first evaluates the fertility level of the couple, carrying out necessary tests for both of them, and then offers an appropriate treatment plan. Checks are also carried out on embryos before implantation in the mother's womb. For example, tests for genetic markers that could cause inherited diseases like sickle-cell anaemia and chromosomal conditions such as Down's syndrome.

Despite the possibilities the Dana centre has opened up for some, the costs prevent many from accessing its treatments. The cost for an IUI treatment plan, for example, with accompanying medicines, is around $2,000 for the first attempt. If unsuccessful, the treatment can be repeated for smaller feesÌý– $750 for the second attempt and $500 for the third.

Dr Ibrahim explains that the accompanying medicines required are very expensive alongside the cost of treatment, laboratory tests and medical consultations.

Ayah Al Omar (33) finally got to become a mum after she and her husband visited the Dana centre after they had given up on having children naturally because her husband suffered from a hereditary issue causing erectile dysfunction. SheÌýconsiders herself one of the lucky ones in northwest SyriaÌý– her husband has a decent income which gave her the chance to fulfil her dream of motherhood after 11 years of marriage and many failed IVF attempts.

Gazing at her daughter’s tiny face, Ayah is radiant with joy: "Thanks be to God, who blessed us after many years with a daughter who has filled our world with happiness, the feeling is wonderful and I wish everyone deprived of children could have this."

"Until recently, there were no specialist fertility clinics in northwest Syria, so couples trying for a baby would have to travel to Damascus or outside the country to access fertility treatments.Ìý However, recently a specialist centre for fertility treatments has opened in Dana city, northern Idlib, which offers a range of assisted conception techniques"

She says the idea to seek fertility treatment began when she and her husband decided to put all their effort into having a child before more time passed, and began undergoing the necessary tests at the Dana centre. They were overjoyed when the doctors said they had a 50 percent chance of successful fertilisation, and proceeded with the treatment. Ayah became pregnant and gave birth with a caesarean section.

According to Idlib's Health Directorate, the number of pregnant women who visited health facilities for the first time reached 253,000 in the last six months, and the number of pregnant women to complete four visits was 443,000 in the same period.

Batoul Al Khidr, an official in the reproductive health department at the directorate says the directorate's role in the region is administrative and concerns the organisation and distribution of health services depending on need, as well as supervising the quality of the services provided.

She said services offered to pregnant women at health facilities were monitoring, post-birth follow-ups, and prescribing necessary vitamins and vaccinations for women and babies. They also provided free natural and caesarean deliveries at the health clinics, family planning services, and appropriate contraceptives.

According to the WHO, necessary interventions for treating infertility still form a challenge in most countries, and diagnosing infertility and treating it are usually not priorities in national policies – it is rare that diagnosis and treatment will be included in funding from the public health budget. Added to this, a lack of trained employees and supplies as well as rising medicine costs are major obstacles even in countries seriously working on responding to problems around infertility.

While assisted conception technologies have existed for three decades and have resulted in the birth of more than 5 million children across the world, these technologies are still not available to many, and it is impossible to access or afford them in many parts of the world, especially low-income countries like Syria.ÌýÌý Ìý

Hadia Al Mansour is aÌýfreelance journalist from SyriaÌýwho has writtenÌýforÌýAsharq Al-Awsat,ÌýAl-Monitor,ÌýSyriaUntoldÌýandÌýRising for Freedom Magazine.

Article translated from Arabic by Rose Chacko