Infertility is defined as the inability to conceive after 1 year of unprotected sexual intercourse.
Ideally, the frequency of intercourse should be 2-3 times a week. Up to 90% of couples should have conceived by the end of the 1st year of trying. At this point, if they still have not conceived, further investigations are warranted.
However, older couples, especially where women are over 35, should see a fertility specialist after six months of trying to get pregnant. In view of the impact of age, early diagnosis and treatment are crucial to the successful management of infertility.
Couples should also seek advice earlier if there is a high likelihood of a gynaecological disorder. E.g. If the woman has a history of irregular periods, this could indicate an ovulation problem where the egg is not released from the ovary regularly every month and will reduce her chances of conception.
If she has painful periods, this may indicate the presence of endometriosis, ovarian cysts or fibroids which may prevent the implantation of a healthy embryo in the uterus. A past history of infection resulting in pelvic inflammatory disease (PID), or previous surgery, may cause tubal disease which would prevent the egg and the sperm from meeting.
What are the causes of infertility?
Fertility problems may arise due to problems in the female or the male reproductive system.
Female infertility reasons can broadly be divided into
- Ovulation disorders e.g. caused by polycystic ovaries,
- Endometriosis where the lining of the uterus occurs outside its normal position e.g. at the back of the uterus and around the ovaries,
- Problems with the uterus e.g. fibroids and polyps
- Tubal disease.
Age is also an important contributing factor to infertility. In women, fertility steadily declines with age. Women are born with a fixed number of eggs. With increasing age, there is a fall in ovarian reserve – i.e. the number of functioning follicles or eggs left in the ovaries.
The likelihood of conceiving falls from 20% a month in a woman’s late 20s to 8% in the late 30s. Even the success rate of artificial reproductive treatment is not spared and pregnancy rates fall with increasing age from 40% in women < 35 years to just 10% in women over 40 years.
There is also an increased risk of miscarriage with increasing age. Although the evidence is less strong compared to women, men may also become less fertile as they get older. In men, the quantity and quality of sperm may deteriorate with time making it difficult for them to reach and fertilise an egg. This can occur as a result of poor diet or lifestyle habits as well as chronic illnesses such as diabetes and raised blood pressure. You can read more about fertility here.
How can infertility be treated?
The treatment of infertility depends on the underlying cause or causes.
- For problems related to abnormal ovulation: Fertility drugs or injections may help to enable ovulation to occur in a more predictable manner. Ultrasound scans may also be performed in the clinic to help determine more precisely when ovulation will occur. The doctor can then advise when is the best time for intercourse, to maximise the chances of successful conception.
- In the case of endometriosis, cysts, fibroids and blocked fallopian tubes: Laparoscopic or keyhole surgery may help to improve chances. Laparoscopic surgery involves the use of a fine telescopic camera and instruments which are passed through small incisions
- For poor sperm count and quality: Intra-uterine insemination or assisted reproductive techniques (ART) also known as in vitro fertilisation (IVF) may be needed.
It’s usually recommended that a couple start with intra-uterine insemination (IUI) first, then progress to IVF, if IUI is not successful. IUI is more ‘natural’. IUI typically involves the preparation of a semen sample and injection of the sperm directly into the uterus using a fine catheter. However, IUI is associated with lower success rates of around 15% per cycle.
IVF tends to have higher success rates. On the other hand, IVF is more costly and possibly more stressful involving daily injections of high doses of hormones. Depending on the fertility factors at play, couples may be advised to move directly to IVF if the sperm number and quality are very poor, or the woman’s fallopian tubes are blocked.
They may also be advised to try IVF if the woman is over 40 and/or has a limited ovarian reserve and wish to have a higher success rate than IUI. The success rate for IVF is very much dependent on age. For couples in their 30s, the success is 30 - 40%.
IVF treatment involves several different steps. Firstly, in order to increase the number of eggs produced by her ovaries, the woman has to undergo hormonal injections. For ovarian stimulation, different protocols are available which may be suitable for different women.
Secondly, ultrasound scans and blood tests are needed to assess the growth and maturity of the eggs. Once the eggs are ready, they are retrieved with the help of a vaginal ultrasound while the woman is under anaesthesia. The eggs are then fertilised with the sperm in the laboratory to form embryos before they are transferred back into the woman’s womb.
Complications of Fertility Treatment
Complications are uncommon but there may be side effects with the use of various hormone treatments. With fertility drugs, some side effects include abdominal bloating, nausea, headaches and tiredness. There is also a risk of multiple pregnancies including twins.
With IVF treatment involving fertility hormone injections, problems include psychological stress and physical discomfort. Egg retrieval, which is performed under anaesthesia, entails some small risks of anaesthesia, bleeding and infection.
With the rise in hormone levels in the body, there may be a risk of ‘ovarian hyperstimulation syndrome’ or OHSS. This condition can result in nausea, vomiting and dehydration, and may require hospitalisation. Hence, close monitoring, care and medical attention are important.
Also READ: 10 fertility myths revealed
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