Fertility is fundamental to human life and the impairment of fertility, like many diseases, is an epidemic plaguing much of the developed world. The latest Singapore Census 2020 has found a continued decline in Total Fertility Rate to 1.1 (note: a minimum of 2.0 is required to replace our own population). As a society, the failure to produce more babies is a result of many factors, including the personal choice not to have children. However, for those couples who actively attempt to conceive but to no avail, they face the medical disease — infertility. About 80-90% of (young) healthy fertile couples will conceive within one year if they have intercourse regularly without contraception; half of the remaining 10-20% will be able to conceive in the second year of trying, that leaves about 5-10% of couple in need of medical help for infertility.
What determines fertility for a couple?
So, what is infertility? By definition, it is the inability of a couple to conceive naturally through normal sexual activity, after 1-2 years of trying. For younger women under 35 years of age, up to 2 years of trying may be considered, whereas the older woman above 35 years old should not try for too long before seeking help (in general, they should see a specialist if there is no success after 1 year or less). This is because aging is an irreversible insult to fertility, hence women of different age groups should be attended to with different levels of urgency.
The above does not apply to couples who have known impediments to their fertility; they should see a suitable fertility specialist to start treatment (or at least monitoring) immediately.
The Big 5
Infertility as a disease, baffles even the medically-trained, let alone the lay person. In order to break down this complex condition for easier understanding, the factors that affect fertility may be grouped into 5 categories: Egg, Sperm, Womb, Tubes and Pelvis.
All the eggs that a woman will ever have are stored in her ovaries, in an immature form. After puberty, these eggs will be “recruited” in batches every month to be matured and ovulated (released for fertilisation). It is important to know if the amount of egg reserve is adequate to see the woman through her reproductive life and also whether the ovulation “mechanism” is working well to ensure an egg is released every month.
Being the only measurable contribution by the male partner, the sperm count is an essential tool to evaluate the reproductive health of the male. We are interested to know if the amount of sperm produced in each ejaculate is adequate, the ability of each sperm to swim (towards the egg) and their shape (quality).
This is the vessel that will carry the pregnancy. Any disruptions to the womb wall (fibroids, adenomyoma, etc) and the womb lining (denudation, polyps, scarring, etc) will affect the ability to carry a pregnancy.
The fallopian tubes are appendages of the womb that allows the sperm to swim towards the ovaries (eggs) and to transport the fertilised egg back to the womb for implantation. These delicate structures are crucial for natural pregnancy, but are easily damaged / blocked by medical conditions of the pelvis.
The pelvis is the environment where the female reproductive organs are located. This enigmatic factor is difficult to assess and often is overlooked when attention is not focused on it. The most common disease affecting this part of the female body is endometriosis. This results in chronic inflammation of the reproductive environment, leading to 2 main symptoms: pain and infertility.
At what age does infertility start?
When left to natural aging, a woman (who is born with all the eggs she will ever have in her lifetime) will start to experience a sharp drop in fertility potential after the age of about 35 years onwards, assuming she does not have any other medical conditions causing infertility. This accelerated decline in quantity and quality of eggs will taper off into a continued decline into menopause, which occurs around 50 years of age for most women. Hence even in the absence of diseases affecting the reproductive system, aging alone will lead to irreversible infertility.
How can you check your fertility?
Fertility is not something that a woman can assess for herself at home, at least not in a comprehensive manner. Here is a checklist that is useful to consider when deciding whether to see a fertility specialist (a gynaecologist who specialises in infertility):
- Have you been trying to conceive without success for at least 1 year?
- Are you 35 years old and above?
- Do you have irregular menstrual cycles?
- Do you have any painful symptoms such as pain / cramps / discomfort during menses, intercourse, passing urine / passing motion, or chronic pelvic pain that may not be related to any activity?
- Have you had any surgery or procedure done in the pelvis before?
- Do you have any difficulties having intercourse (inability to penetrate, erection problem, painful, lack of sex drive, etc)?
If your answer is “yes” to any of the above questions, then it is best that you consult a fertility specialist. In particular, any painful conditions are best evaluated by an endometriosis specialist. For women who are single, not trying to conceive yet or just want to have a snap shot of their fertility status, may also come forward to do a simple bedside evaluation to assess the Big 5.
For the healthy young couples, not affected by any obvious symptoms or diseases, we encourage them to try to conceive naturally for at least 1-2 years, before seeking fertility assessment. For those who screen positive with the above checklist, do consider coming forward for an early assessment. A healthy and active lifestyle with balanced diet and maintenance of optimum weight for both partners will be central to achieving a healthy pregnancy. While we focus our efforts on getting a pregnancy, let’s not forget about enjoying the journey and maintaining the strong foundations of the relationship, which will see us through the challenges that may arise along the way!