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We’re in no hurry to tie the knot, say couples around the world these days. The modern lifestyle and industrialisation encourages people to make a rational decision to defer marriage to much later in life.

Simply put, the need to establish a career to attract a better mate requires a substantial investment in the form of longer work hours. And when they do get married, the decision to have children may be put off for a few more years, as couples increasingly prefer to build a financial nest egg first.

And when they finally decide it’s the right time to try for a child, couples around the world find it increasingly difficult to conceive. When the inability to conceive lasts more than one year of attempting pregnancy, this is medically recognised as infertility.

Why infertility?

In a nutshell: physical ageing. For different reasons, men and women lose their fecundity as they age, becoming less fertile in time.

Women in general experience a decline in fertility after the age of 35. Born with a fixed number of eggs in their ovaries, women have fewer and fewer eggs available for fertilisation as they age. Also the quality of these eggs decline with age, affecting the ability of these eggs to become a healthy baby.

While spermatozoa are produced in men’s bodies on a daily basis, both sperm production and quality does decline with age – as a secondary effect of disease and general wear and tear associated with lifestyle.1 More notably, men above 40 are more at risk of fathering babies with developmental disabilities such as autism.2

When you factor in the median age at marriage of Singaporeans – 29.7 for males and 36.9 for females in 2008 – and the median age of mothers at first birth (29.4)3, the picture becomes clearer: Singaporeans and their neighbours in other industrialised countries are cutting it to close to the fertility drop-off age.

Oh bring back my bonnie to me!

Statistics do not exist for infertility in Singapore, but Dr Julianah Abu-Wong, a gynaecologist at Pacific Healthcare and consultant at the Centre of Assisted Reproduction at SGH estimates that about 15 to 20% of couples seek medical advice for infertility.

The management of infertility involves a comprehensive history, examination and investigations of both the male and female partner at the same time. Depending on the diagnosis, an appropriate course of treatment will be recommended. A caveat: In 20% of couples, there may be a diagnosis of “unexplained subfertility”, where no obvious cause for their condition can be found.

Bringing back the stork

A common treatment is based on timing the coitus during the most fertile period of the female’s ovulation cycle, to maximise the chances of conception. The cycle can be monitored using urinary kits, ultrasound scans, or cervical mucus. These monitoring methods can be combined with intrauterine insemination if there is mild to moderate sperm abnormality in the male.

If the main diagnosis is anovulation (where the ovaries fail to ovulate), then medication in the form of oral drugs like clomiphene or injections like FSH may be prescribed to stimulate ovulation.

If the main problem lies with the male, a session with a urologist may be scheduled. There may be an obvious cause for the poor sperm quantity or quality such as a varicocele of the testes.

If there are no sperm seen in the semen, sperm can be extracted directly from the testes for in vitro fertilisation (IVF), where the egg is fertilised outside the body, and the resulting embryo is implanted into the uterus, hopefully leading to a pregnancy. Intra cytoplasmic sperm injection (ICSI) - often confused with IVF - can be performed with IVF if the sperm quality is in question.

Notes before usage...

Dr Abu-Wong advises all couples trying to conceive to have regular unprotected sex and enjoy themselves for a year before seeking medical advice. LW

(Footnotes)

  1. Eskenzi, B et al. 2003. “The association of age and semen quality in healthy men”, in Human Reproduction, 18(2): 447-454
  2. Saha S, et al. 2009. “Advanced Paternal Age Is Associated with Impaired Neurocognitive Outcomes during Infancy and Childhood”, in PLoS Med 6(3): e1000040.
  3. Statistics Singapore. 2008. “Population in Brief: 2008”, pp2.

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