Infertility is the inability to
get pregnant after one year of
trying. It is a common problem
that can affect 1 in 7 couples.
80% of couples having regular
sex should conceive within one
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 30 percent of
couples, no obvious causes of infertility
can be found.
For women, try to conceive when
you are still young. Fertility starts to
fall at age 34 and diminishes further at
age 37, falling quite drastically after 40.
Fibroids and endometriosis can occur at
any age but tend to be more common
in older women.
Damaged tubes in the female and
blocked vas in the males may occur
as a result of sexually transmitted
infections (STI). Condom use can protect
against STI. If you have an infection,
seek treatment early.
Certain infections such as mumps can
cause inflammation of the testis and
impair sperm production. That is why
most children are vaccinated against
Problems with ovulation may be
due to hormonal disturbance. If you
have irregular infrequent periods, see
your doctor to see if these hormonal
imbalances, for example thyroid
dysfunction, can be corrected.
If you have period
pains and painful sex,
see your doctor so that,
if necessary, treatment
can be instituted for
Certain lifestyle issues
like smoking and being
under or overweight
can also affect fertility.
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
Your doctor will be able to run some
tests to identify where the problem
For the female partner, hormonal
tests are performed to look for ovarian
reserve and to assess for ovulation.
For women who have irregular cycles,
hormone tests for thyroid and prolactin
levels are also checked.
An ultrasound scan can easily
identify any fibroids or cysts. A
hysterosalpingogram or ultrasound
saline infusion may be offered to assess
Infertility is a common problem.
There are many types of
treatment tailored to every couple
depending on what the cause may
be. Seek treatment early as success
depends on the age of the female
For men, the semen test is performed
after abstinence of three to five days.
Treatment is directed at the underlying
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. Ovulation
induction with clomiphene, letrozole or
FSH injection may also be used.
Patient with large endometriotic
cysts (>5 cm) or with severe pain
may consider surgery. If there is still
no conception 6-12 months postsurgery,
then IVF may be the next
step. As endometriosis tends to recur,
it is advisable to consider medical
treatment to prevent recurrence if
fertility is not desired.
If the cyst is not large or there is a
recurrent cyst after surgery, then IVF
should be considered. This is because
repeated operations can reduce the
ovarian reserve as ovarian tissue may
be removed during surgery.
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
Premature ovarian failure
Premature ovarian failure such that
eggs are no longer released. Under
these circumstances, an egg donor or
embryo donor is necessary as there is
no treatment of this condition. Prior to
any cancer therapy, 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 for
The number and quality of eggs
diminish with age. There is no
medication that can reverse the effects
of age and that is why for women older
than 35, infertility investigations may
commence after six months of trying.
Low or no sperm
Hormonal or chromosomal tests 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
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 eididymis. 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.
Intrauterine insemination (IUI)
This is a treatment where washed
sperm is introduced into the womb
with a cannula at the time of ovulation.
This is indicated for women with
patent tubes, with mild sperm problem
or couples with problem of nonconsummation
or erectile dysfunction.
IUI may also be performed together
with ovulation induction with hormonal
injection. This is ideal for couples where
the women are younger (<35) with
patent tubes and no or mild male factor
problem. This may also be for couples
with ovulation problems or where no
known cause is found.
In-vitro fertilisation (IVF)
IVF is a procedure where eggs are
retrieved from a woman and are
inseminated with the husband’s semen
in the laboratory. The resultant embryo
is then placed back into the womb.
To make IVF more efficient, hormonal
injections are given to the woman to
induce more eggs so that it allows for
more opportunities for the eggs to
be fertilised. IVF is indicated for the
Despite advances in IVF, the chances
of conception vary from 20-35 percent
depending on a woman’s age. In
Singapore, IVF is not allowed once a
woman is over 45 because the chance
of success is very poor.
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