Infertility is the inability to get pregnant or failure to conceive after one year of regular unprotected sexual intercourse. It can affect 10-15% of couples trying to conceive. Over 80% of couples having regular sexual intercourse should conceive within one year if the woman is below 40 years old.
To get pregnant, there are several processes that must happen. The woman’s body must release an egg from one of her ovaries (ovulation). This egg must go through a fallopian tube toward the womb. The man’s sperm must travel through the vagina, womb and go through the fallopian tube to join with (fertilise) the egg. Then the fertilised egg (embryo) must attach to the inside of the uterus (implantation). Anything that may hinder or interfere with any of these steps may cause infertility. In about about 25-30% of couples, no obvious causes of infertility can be found.
Infertility is classified into two main types:
Primary infertility
Primary infertility refers to couples that have never been able to conceive naturally after one year of engaging in unprotected sexual intercourse. This is often diagnosed when there is no successful history of pregnancy and the couple has been trying to conceive for a long time.
Secondary infertility
Secondary infertility refers to couples who have previously conceived naturally and are unable to conceive again after one year of regular unprotected intercourse. This type of infertility can occur after either a live birth, stillbirth, miscarriage or ectopic pregnancy. Secondary infertility may arise due to new health conditions or complications that have developed since the previous conception.
Both types of infertility can be caused by factors affecting either the male, female or both. It is essential to seek medical advice if pregnancy has not occurred after a year of trying, particularly if the woman is over the age of 35.
Both men and women may not have obvious symptoms as listed below, and the list is non exhaustive. Hence, a comprehensive medical evaluation is recommended for those facing difficulties in conceiving.
It is essential to see a doctor if you have been trying to conceive for a year without success if you are under 35, or after six months if you are over 35. It is natural for fertility to decrease with age. As such, it is recommended to seek advice sooner for women over 35.
Women who have undergone previous operations particularly to the ovaries, fallopian tubes or uterus should have an early appointment with the fertility specialist. Women who have experienced miscarriages and wish to conceive again should also consider seeing a fertility specialist.
For men, seeing a doctor is recommended if there are concerns about ejaculation, erectile ejaculation, low libido or if there is pain and swelling in the testicles. If either partner has a history of sexually transmitted diseases, cancer treatments, surgeries or other health conditions that may hold back chances of conception, consulting with a doctor early in the process is crucial.
Early intervention increases the chances of diagnosing and addressing any underlying issues.
Age: The number and quality of eggs diminish with age.
Problems with ovulation such as polycystic ovary syndrome (PCOS) where no eggs are released (anovulatory).
Damaged or blocked tubes hence preventing the sperm and egg from meeting.
Endometriosis: A condition which can cause pelvic pain or painful periods, and may cause distortion to the female anatomy in severe cases. This can affect the fallopian tube function or may cause a hostile environment that may interfere with fertilisation. It can also affect ovarian reserves (egg count) in severe cases.
Fibroids and polyps that can distort the cavity of the womb and impair implantation.
Premature ovarian failure such that eggs are no longer released. This can occur naturally or as a result of chemotherapy, radiotherapy or even previous ovarian surgeries.
Low sperm count or poor sperm motility which may have a genetic cause. This will mean fewer sperm getting to the fallopian tubes to meet the egg.
Absent or no sperm: This may result from obstruction in the sperm ducts (vas deferens), the tube that delivers the sperm from the testis to the penis, or due to impaired sperm production in the testis.
Erectile dysfunction, retrograde ejaculation resulting in failure of delivery of sperm in the vagina.
Note: Up to 25% of couples have no identifiable cause for subfertility. This is known as unexplained subfertility.
There are many factors that can increase the risk of infertility in both men and women.
Recognising and addressing these risk factors early can help improve the chances of conception.
If you have not conceived after one year of regular intercourse without the use of any contraception, it is recommended that you see a doctor. The age of a woman is an important consideration as both the number and quality of eggs decline with age. Hence, it is important to seek medical help early especially if the woman is over 35 years old.
Relevant tests for both the male and female will be done to check for the different causes of infertility.
For the female, blood tests are performed to look for ovarian reserve and to assess for ovulation. Women who have irregular cycles may also have their thyroid and prolactin levels checked.
A pelvic ultrasound scan is usually done to evaluate the uterus and ovaries for fibroids, polyps or cysts. A hysterosalpingogram or ultrasound saline infusion may be offered to assess tubal patency and to check the uterine (womb) cavity.
For men, the semen test is performed after abstinence of three to five days.
Treatment is highly individualised based on underlying problem(s), and the fertility specialist will discuss with the couple regarding the best option.
For disorders of ovulation, ovulation induction medications (Clomifene or Letrozole) may sometimes be prescribed. Assisted reproductive techniques (ART) include intrauterine insemination (IUI) and in-vitro fertilisation (IVF).
Damaged or blocked tubes
Under certain circumstances, surgery or cannulation of the tube may 'open' up the tubes. If despite treatment, there is no conception or the tubes cannot be unblocked, then in-vitro fertilisation (IVF) will be the treatment of choice.
Problems with ovulation
Problems with ovulation such as polycystic ovary syndrome (PCOS). Patients with PCOS who are overweight should lose weight as this may lead to resumption of ovulation. Screening for medical conditions like diabetes and high cholesterol should also be strongly considered. Ovulation induction with Clomifene or Letrozole may be used.
Endometriosis
Treatment of endometriosis is highly individualised. Patients with large endometriotic cysts (>5 cm) or with severe pain may consider surgery. IVF may be the next step if there is no conception postoperatively. Not all endometriotic cysts require surgery, as repeated surgeries can further reduce ovarian reserves. As endometriosis tends to recur, it is advisable to consider medical treatment to prevent recurrence if fertility is not desired.
Fibroids and polyps
Fibroids and polyps that distort the womb cavity can be removed through the hysteroscope, a telescope that allows visualisation of the womb cavity. The camera is introduced through the vagina.
Premature ovarian failure
Premature ovarian failure (early menopause) is a condition where the woman's ovaries stop releasing eggs. Under these circumstances, an egg donor is necessary as there is no proven treatment to reverse this condition. It can be genetic or caused by medical treatments (e.g., cancer treatment). Hence, prior to any cancer therapy, both women and men are counselled about how they can preserve their fertility. Men can bank their sperm and women can bank their eggs, ovarian tissue or embryo (if they are married) for future use.
Age
The number and quality of eggs diminish with age. There is no proven treatment that can reverse the effects of age and hence for women older than 35, infertility investigations may commence after six months of trying.
Low or no sperm
Hormonal tests, chromosomal tests and an ultrasound of the scrotum may be performed to find the underlying cause. In a small percentage of men, the cause is hormonal and replacement of hormones may allow the resumption of sperm production.
For men with low sperm count, intracytoplasmic sperm injection where sperms are injected directly into the egg at IVF will give the sperm the opportunity to fertilise the egg.
For men with no sperm, sperm may be obtained directly from the testis or epididymis via a surgical procedure. As the number of sperm retrieved are low, IVF/ICSI is necessary. For those where no sperm is retrieved, sperm donation can be considered.
For men with erectile dysfunction, psychosocial counselling and medication like Viagra may be helpful.
Other treatments
Intrauterine insemination (IUI)
This is a treatment where washed sperm is introduced into the womb with a cannula through the cervix at the time of ovulation. This is indicated for women with unexplained subfertility, at least one patent tube, with mild sperm problem or couples with sexual dysfunction (problem of nonconsummation, vaginismus or erectile dysfunction). IUI may be performed together with ovulation induction medications or with hormonal injection.
In-vitro fertilisation (IVF)
IVF is a procedure which involves daily hormone injections to grow multiple eggs. Eggs are then retrieved from the woman and are inseminated with the husband's sperm in the laboratory. The resultant embryo is then placed back into the womb a few days later.
IVF is indicated for the following problems:
Despite advances in IVF, the chances of conception vary from 20-35% depending on a woman's age.
If you are under 35, it is recommended to try conceiving for a year before consulting a doctor. For women over 35, it is recommended to seek help from a doctor if you have tried for six months without success, as fertility declines with age. If there are any risk factors for infertility or previous fertility tests that are abnormal, do consult a fertility specialist early.
Yes, lifestyle factors such as smoking, excessive alcohol use, overweight and stress can all affect the chances of conception in both men and women.
Some of the early indicators of infertility commonly reported may include irregular periods and painful menstruation in women. For men, they are erectile dysfunction or low sperm count. Regular medical check-ups may help identify potential concerns early in these cases.
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