Worried about Infertility? A Fertility Specialist Offers 5 Important Advice

WORDS DR AGILAN ARJUNAN

FEATURED EXPERT
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?
An overview of the IVF process. Click for a larger, clearer image.

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.

CLOSING WORDS

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.

Planning to Have a ‘Dragon Baby’ in 2024? Here’s How to Start on a Right Note!

WORDS LIM TECK CHOON

FEATURED EXPERT
DR CHONG KUOH REN
Consultant Obstetrician & Gynaecologist and Fertility Specialist
TMC Fertility

To the Chinese, 2024 marks the auspicious Year of the Dragon. The dragon symbolizes courage, wisdom, and success—qualities that most couples would like to hope for their child. Hence, many would plan to have a ‘dragon baby’ come the next year!

“Planning for parenthood however, requires a lot more than just jumping into the process of baby-making,” says Dr Chong Kuoh Ren with a laugh.

As it is never too early to plan, he offers some tips for parents to have a healthy pregnancy and baby in 2024.

START WITH A PRE-PREGNANCY HEALTH CHECK

“A preconception checkup is a good idea, even if this isn’t your first pregnancy,” Dr Chong states.

Such a checkup typically involves a health review of the aspiring parents, with the doctor screening them for the presence of chronic conditions such as diabetes, hypertension, and more.

“According to the Malaysian Ministry of Health, these health screenings should be carried out at least 3 months before you’re planning to conceive,” he adds.

Dr Chong further adds that couples can further opt for genetic counselling if they are concerned about potentially passing on genetic disorders to their future offspring.

“Genes that cause genetic medical conditions such as thalassemia can be identified with a simple blood test. Having this knowledge can help you make better decisions about your pregnancy,” he elaborates.

GET YOUR BODY ‘BABY-READY’

Dr Chong mentions that there is no foolproof diet or exercise plan that will help one conceive.

“Nonetheless, a well-rounded diet and ideal body weight can have an impact on your pregnancy,” he says.

Such a diet should be balanced and filled with fruits, vegetables, lean proteins, and whole grains in order to provide essential nourishment for both mom and the future baby.

“Multivitamins are also a great way of providing this nourishment, especially folic acid,” he adds.

Folic acid aids in the formation of red blood cells and helps tissues grow. In pregnancy, folic acid is crucial in preventing neural tube defects, which refer to birth defects of the brain, spine, and spinal cord.

Dr Chong also highlights vitamin D, which is important for improving the quality of both egg and sperms. In pregnant women, vitamin D can prevent premature delivery.

Meanwhile, regular exercise will not only strengthen your body, but also help you manage your body weight sustainably. “You don’t have to do anything extreme, just focus on having some physical activity throughout the week. Simply doing 30 minutes of moderate exercise, such as brisk walking or gardening, can go a long way in helping you stay fit,” says Dr Chong.

DITCH UNHEALTHY HABITS

Don’t wait until one is pregnant to quit habits such as smoking and excessive drinking of alcohol.

“Smoking, especially, can adversely impact your chances of conceiving as it is linked to fertility issues in both men and women,” says Dr Chong. “Newer research has shown that secondhand smoke can increase foetal risk factors too.”

Excessive drinking is linked to lowered sperm counts and abnormal eggs.

TRACK THE MENSTRUAL CYCLE

This helps to identify the woman’s most fertile period — and in turn, help her to get pregnant faster.

Overview of the menstrual cycle. Click for a larger, clearer version.

“Start recording when your period starts and ends from month to month.” Dr Chong advises.

This will give one an idea of how long her cycles are.

While the average menstrual cycle is around 28 days, many doctors say the healthy range can be anywhere from 21 to 35 days.

“Cycle tracking can be trickier for women who have irregular periods in the first place,” Dr Chong concedes. “Broadly speaking, the general advice is to keep having sex every 2 to 3 days, so you don’t have to do all these calculations. I’d strongly advise consulting a specialist in these cases though, as irregular bleeding might be a symptom of more serious underlying issues.”

CAN’T CONCEIVE NATURALLY? DON’T DESPAIR, SEEK HELP

Dr Chong adds that couples should also not shy away from communicating with health professionals — and each other — if they continue to have problems conceiving.

Hoping for a Baby? These Multivitamins May Increase Your Odds of Success!

WORDS LIM TECK CHOON

Data from a recent study conducted by Singaporean researchers suggests that multivitamin supplements that contain folic acid and iodine may be beneficial to women that are planning and hoping to conceive a child.

WHAT THE STUDY DID

The investigators interviewed 908 women between 18 and 45 years old that were trying to conceive. These women were enrolled in the Singapore PREconception Study of long-Term maternal and child Outcomes (S-PRESTO).

As an aside, S-PRESTO is a large-scale study on the effects of nutrition, lifestyle, and maternal mood prior to and during pregnancy on the effects of the baby’s genetic materials and the presence clinically important outcomes of the pregnancy. This study is beyond the scope of this article, though!

Back to this study, the investigators were interested in 2 things:

  1. Fecundity, or the measure of the chances of successful pregnancy
  2. Time to pregnancy, or the time between the first moment when the woman tries to conceive and the time of successful conception
WHAT THE INVESTIGATORS FOUND
  1. Multivitamins containing folic acid and iodine improve the success rate of having a baby when compared to those that do not take these supplements.
  2. These multivitamins also are linked to shorter time to pregnancy.
  3. Vitamins D and E do not show any significant improvements to pregnancy success rate and time to pregnancy.
  4. On the other hand, consumption of evening primrose oil is linked to lower pregnancy success rate and slightly longer time to pregnancy, compared to those that do not take this supplement.
WHY FOLIC ACID?

Folic acid, or vitamin B9, plays a role in breaking down and reducing the levels of an amino acid called homocysteine in the body.

High levels of homocysteine can cause effects that can affect fertility, such as increasing the ageing rate of a woman’s eggs and triggering the death of trophoblasts, which are cells of the outer layer of the developing embryo that helps it to attach to the woman’s endometrium for further development, protect the embryo, and eventually form the placenta.

Hence, by reducing the effects of high levels of homocysteine, folic acid can help improve the chances of a successful pregnancy.

HOW ABOUT IODINE?

Past tests on animals suggested that iodine can help improve the regulation of ovulation, increase the odds of a successful fertilization of an egg by a sperm cell following sexual intercourse, and promote successful implantation of the fertilized egg into the endometrium of the woman for further development.

Iodine also plays an important role in the development of nerve and brain cells of the foetus.

HOWEVER, SOME POINTS TO NOTE BEFORE YOU RUSH TO THE PHARMACY!

The investigators noted that more research is needed before we can make any conclusive statements about the effects of folic acid and iodine on one’s hopes of a successful pregnancy.

For example, their study did not measure the exact amounts of these nutrients that will work best on a woman hoping to conceive, and more research would be needed to determine whether their results can be replicated.

However, they believed that women trying to conceive could potentially benefit from taking multivitamin supplements containing these two nutrients, when this is also done in conjunction with other beneficial lifestyle modifications such as being physically active and cutting down on smoking and alcohol intake.

Reference: Ku, C. W., Ku, C. O., Tay, L. P. C., Xing, H. K., Cheung, Y. B., Godfrey, K. M., Colega, M. T., Teo, C., Tan, K. M. L., Chong, Y. S., Shek, L. P., Tan, K. H., Chan, S. Y., Lim, S. X., Chong, M. F., Yap, F., Chan, J. K. Y., & Loy, S. L. (2022). Dietary supplement intake and fecundability in a Singapore preconception cohort study. Nutrients, 14(23), 5110. https://doi.org/10.3390/nu14235110

Diets & Exercise Tips to Regain Your Pre-Pregnancy Body Shape

WORDS DR VICKY KOH

FEATURED EXPERT
DR VICKY KOH
Medical Director
Clinic RX
WELL, READ THIS FIRST

Every woman’s body is unique. Therefore, the question of the ‘right option’ or ‘best option’ is something that each and every woman has to figure out on her own.

For example, mothers that breastfeed often experience rapid weight loss and may benefit from an increased intake of certain nutrients or supplements. Women that gave birth via caesarean section may need a longer time to recover. Existing health issues and lifestyle variables also need to be considered.

If you are interested to find out more about the topics discussed below, you should discuss the matter further with your doctor.

BREASTFEEDING CONSIDERATIONS

Postpartum weight loss averages about 4.5 to 5.5 kg in the first 6 weeks. Women often return to their pre-pregnancy weight within a year, though this time frame varies depending on how much weight was gained during their pregnancy.

Breastfeeding aids in weight loss since it consumes extra calories, resulting in a natural weight loss for many women.

Breastfeeding women should pay special attention to their diets at this time.

While experiencing weight loss after giving birth may seem like a good idea, doing so too quickly will actually hinder healing!

POST-PREGNANCY DIETARY RECOMMENDATIONS

Dietary recommendations should include a variety of fresh produce, whole grains, lean proteins, and healthy fats.

Breastfeeding mothers, in particular, should drink a lot of water (6-10 glasses daily). Try to stay away from sodas and other sugary drinks.

Meanwhile, for moms that had a C-section, they should focus on eating foods that are high in protein. Avoid junk foods and take vitamin supplements, especially if they are nursing.

Vitamin and mineral supplements are crucial for moms during and after pregnancy.

This is because nutrients such as calcium, iron, vitamin D, folic acid, zinc, and more are normally redirected from the mother’s bloodstream to the developing infant.

Furthermore, the delivery process as well as breastfeeding depletes the body of essential vitamins.

Hence, postnatal supplements such as calcium, vitamin D, B vitamins, docosahexaenoic acid (DHA), magnesium, selenium, iodine, and choline may be helpful in replenishing nutrients that were used up during pregnancy and after childbirth.

EXERCISE RECOMMENDATIONS

Regular exercise after childbirth will help strengthen and tone your muscles while increasing your energy levels and making you feel less weary.

It also aids in the loss of excess weight.

During the first 6 weeks, the uterus returns to its pre-pregnancy size, and some women may feel uterine cramping and discharge.

However, mothers are recommended to gradually resume their exercise habits, starting with less strenuous activities during the first few weeks after giving birth.

A few days after delivery, you can start doing gentle abdominal and pelvic floor exercises if they don’t cause you any pain.

Try to proceed at your own pace—you can gradually increase the duration and tempo of your workout of over time.

Swimming, cycling, yoga, pilates, mild weight training, and low-impact aerobics are all good alternatives after the first few weeks.

A Free App for Women, Especially Marginalized Women

WORDS LIM TECK CHOON

The University of Nottingham Malaysia (UNM) and Hanai Jiwa Ibu Sdn Bhd have developed an app, called Jiwa Ibu, to provide localised and tailored information on mental, women’s, maternal, and children’s health.

This app, developed in collaboration of the two entities with St George’s University of London, Universiti Malaya and Universiti Malaysia Sabah, serves to reduce the great disparity in access to healthcare between those residing in urban and rural communities. This is because rural communities have limited access to quality medical centres and professionals, and residents of those communities have to travel further in search of quality healthcare.

AN APP FOR MARGINALISED WOMEN

“For years, we’ve wanted to shift our focus to the rural and marginalised communities of Malaysia. Since the idea began, our team of eight dedicated women have run focus groups involving doctors, nurses, midwives, community nurses and everyday women, to better learn what the ideal women and maternal healthcare pathway should look like,” explains Hanai Jiwa Ibu Founder and CEO, Shamala Hinrichsen. “We don’t expect to solve the world’s problems, of course, but one tiny step forward is better than no steps at all.”

UNM and Hanai Jiwa Ibu recently inked a Memorandum of Understanding (MoU) to allow for the copyrighting and trademarking of the app, ahead of plans to work alongside Selangkah, Selangor’s healthcare app, to embed part of Jiwa Ibu into the system.

“The Jiwa Ibu app is expected to benefit 15 million women across Malaysia. During its initial alpha-test, the app was downloaded by 3,000 women, with 75% returning to the app within the span of one month from downloading,” shares Associate Professor Dr Joanne Lim Bee Yin of the UNM School of Media Languages and Cultures. “Based on the surveys and interviews that we carried out, 95% of respondents also shared that they wanted the app.

MANY FUNCTIONS FOR EMPOWERMENT & HEALTH SELF-MANAGEMENT

Jiwa Ibu will include a directory for doctors and healthcare centres within the vicinity of the user and other important resources, such as those for violence against women cases.

Users can also store and track their own health records and seek medical assistance through the app.

In an effort to be more accessible, the app will be made available in Bahasa Melayu, English, and other native languages.

Click here to download the app (link opens in a new tab) in the Google Playstore. The app is free.