WORDS DR AGILAN ARJUNAN
DR AGILAN ARJUNAN
Consultant Obstetrician & Gynaecologist and Fertility Specialist
evelyn Fertility & Women Specialist Clinic
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Infertility, a condition affecting millions of couples worldwide, remains a complex and emotionally challenging issue today.
The inability to conceive a child naturally has profound implications for individuals and couples, leading to feelings of frustration, sadness, and even societal stigmatization.
In Malaysia, the fertility rate is continuously declining. The fertility rate in 2023 is 1.924 birth per woman, a 0.88% decline from 2022.
Even though the topic of infertility has been written and spoken widely for many years, I noticed that many couples still face dilemmas in their fertility journey. In this article, I will highlight 5 things that you need to know about infertility.
DO YOU BELIEVE THAT YOU SUFFER FROM INFERTILITY?
Before you start worrying that you have infertility, you need to carefully assess your trying-to-conceive or TTC circumstances.
In general, a couple would suspect they might have infertility after consistently trying to conceive for about a year or at least about 6 months if the female partner is more than 35 years of age. The key factor in this time frame is that the couple has been able to perform unprotected intercourse during her fertile window.
When a couple is suffering from painful vaginal intercourse (vaginismus) or erectile dysfunction, they are not necessarily infertile.
For these couples, pregnancy has not happened yet simply because there is no chance for the sperm and egg to meet for fertilization to occur.
In my experience, couples in these circumstances have a very good chance to get pregnant, provided that there are no other major infertility factors.
When the female partner has an irregular period cycle, especially those with polycystic ovarian syndrome (PCOS).
A woman will have an irregular period cycle when the ovulation of her egg is erratic or irregular.
For example, if she ovulates later than 2 weeks after the start of her period cycle, say about 3 weeks, her next period likely will start 5 weeks after the current period cycle.
Usually, period starts about 2 weeks after ovulation. However, if her ovulation does not follow any pattern at all, it becomes nearly impossible to know her ovulation date or commonly known as fertile window.
Thus, these couple are not actually facing infertility but merely could not identify their fertile window.
Once the woman’s ovulation is induced with acceptable regularity, her chances to get pregnant are pretty good.
However, if you are suffering from PCOS, please discuss your condition with a fertility specialist.
ARE YOU DOING THINGS CORRECTLY?
Once a couple has recognized that they are facing infertility, they can be overwhelmed with many suggestions on what to do. The internet is flooded with many such posts, some from a reliable source and some are not.
Your first step should be to choose a fertility clinic and start your basic fertility tests.
Attend the session together, not the female partner first and the male partner later.
Basic tests should include a semen analysis for the male partner, an egg reserve test, a pelvic ultrasound scan, and probably a fallopian tube patency test (hysterosalpingography) for the female partner.
An egg reserve test can be done via an ultrasound scan to count the antral follicles count. It can be supplemented with a blood test called anti-Mullerian hormone (AMH). It is important for two reasons:
- It helps to determine the order of priority of treatment options. When the egg reserve is low, the couple might opt for an in-vitro fertilization (IVF) straight away or perhaps decide to do intra-uterine insemination (IUI) once or twice and continue with an IVF without much delay.
- The egg reserve helps you and your fertility specialist to manage your fertility journey timeline more effectively. If your egg reserve is low even when you are younger, it is probably wise to start your IUI or IVF treatment earlier than later. However, if your egg reserve is good and you are young, your fertility doctor might try simpler options such as ovulation induction and timed sexual intercourse.
WILL HORMONE TESTS HELP YOU?
The answer to this question lies in your own fertility history.
Many traditional hormone tests such as follicle stimulating hormone (FSH), luteinizing hormone (LH), and ‘day 21’ serum progesterone blood tests are not helpful to many young women. In a healthy, young woman with a regular period cycle and normal egg reserve, I do expect these tests to be normal. It does not necessarily add any valuable information.
However, some hormone tests are needed based on your clinical history, such as tests for thyroid function, serum prolactin, and serum insulin levels.
Rarely, a genetic test is needed for couples with recurrent miscarriages or for a male partner with zero sperm count (azoospermia).
WHAT ABOUT THE MALE PARTNER?
The male partner is equally as important as the female partner.
Although only a semen test is required for the male partner, it does not mean he contributes little to the success of the infertility journey. After all, 50% of the embryo is contributed by his DNA!
In my opinion, the first fertility test that needs to be done is a semen analysis. This test may provide valuable information about his fertility status and provide the fertility specialist with enough time to improve male infertility while at the same time focusing on the female partner.
I will do a semen analysis for all male partners regardless of their medical history. This is because there are no symptoms of male infertility. Seemingly healthy and well-built men may have azoospermia.
If a men’s semen analysis is normal, does that mean everything is okay with him? The answer is no.
A semen analysis does not necessarily indicate the actual quality of his fertility health.
For example, a cigarette smoker’s semen analysis results may be normal, but his sperm DNA fragmentation test—which look for the amount of damage to the DNA in his sperm—may indicate that there is higher damage to the genetic material carried by his sperm cells. The higher the DNA damage, the higher the likelihood of infertility and even miscarriage rate.
Thus, men should remember to take care of their general health and stop or reduce activities that may impair their fertility because there is no one test that can accurately assess their fertility health.
IS IVF THE ONLY SOLUTION?
Over 40 years of IVF treatment performed globally had led to over 8 million babies born worldwide. It is more common in countries like Denmark.
However, IVF is not the only option to get pregnant.
The first logical step is to try to identify the root cause of your infertility. Once this is done, take the necessary steps to make improvements which may help increase your chances of natural conception. However, in one-third of couples, there is no obvious cause of infertility found.
If there is no major or obvious infertility factor and the fertility tests are normal, the couple could start with an intra-uterine insemination (IUI) at least twice before considering an IVF treatment.
A word of caution: IUI could be the first treatment option for many couples, but the treatment choice should be tailored to your own fertility history, age factor, and financial capability.
IVF treatment could be the first option for couples suffering from bilateral blocked fallopian tubes or severe male factor infertility.
You should consider IVF as the first option if your egg reserve is low or if the female partner is older.
Ultimately, there is no clear and straightforward algorithm for determining the choice of fertility treatment.
In many instances, the choice is done based on financial burden rather than scientific factors.
I hope this article will help you at least do a preliminary assessment of your own fertility status and help you plan your fertility journey effectively to save time and money. The journey towards parenthood is not an easy path but definitely rewarding.