by Dr. Agilan Arjunan, Fertility Specialist & Gynaecologist, evelyn Fertility & Women Specialist Clinic, Petaling Jaya (Malaysia)
Article published on Health Today Magazine : https://malaysia.healthtoday.net/worried-about-infertility-a-fertility-specialist-offers-5-important-advice/
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 stigmatisation. 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 actually suffer from infertility?
Before you start worrying that you have infertility, you need to carefully assess your TTC (trying to conceive) 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.
In a scenario where a couple is suffering from 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 fertilisation 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.
The other more common condition would be 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 her PCOS is managed properly and 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 it right?
Once a couple has recognised 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 for the female partner. The fallopian tube patency test, Hysterosalpingography, is done based on your fertility test. For example, if the female partner is suffering from PCOS and irregular periods, I would first regulate her ovulation and do the test a bit later. However, this practice varies amongst fertility specialists.
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). The egg reserve test is important for two reasons. The first reason is to help determine the order of priority of treatment options. When the egg reserve is low, the couple might opt for an Invitro-Fertilisation(IVF) straight away or perhaps decide to do Intra-uterine insemination (IUI) once or twice and continue with an IVF without much delay.
The second reason is that 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.
Do hormonal tests help?
The answer to this question lies in your own fertility history. Of course, doing many traditional hormone tests for every couple is not helpful and is a waste of money. As mentioned previously, the AMH hormone test may help in determining the egg reserve.
A more traditional Follicle Stimulating Hormone (FSH), Luteinizing Hormone (LH), and ‘Day 21’ serum progesterone blood tests is not helpful in 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. A quick note about “day 21’ progesterone level. A Day 21 is supposed to be a ‘mid-luteal phase’ for a woman with a 28 days period cycle. If the progesterone level is elevated, it confirms ovulation. However, the ‘mid-luteal phase’ duration differs from woman to woman based on her period cycle length. For example, if a woman has a 35 day or longer but regular cycle, her serum progesterone level on Day 21 might not be elevated. This does not mean she is not ovulating. It just simply means she is ovulating later than usual.
Some hormonal tests are needed based on your clinical history such as Thyroid Function test, serum prolactin, and serum Insulin level. Rarely, a genetic test is needed for couples with recurrent miscarriages or for a male partner with ‘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. Fifty percent 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 is 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 ‘ok’ with him? The answer is no.
A semen analysis does not necessarily indicate the actual quality of his fertility health. For example, in a cigarette smoker, his semen analysis may be normal, but his sperm DNA fragmentation may be very high which indicates higher damage to the genetic material carried by the sperm cell. 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 my only solution
After over 40 years of IVF treatment performed globally, over 8 million babies have been 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 what is 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 burden. Social pressure is another major determinant in choosing the type of fertility treatment even though this is less discussed during a fertility consultation.
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. 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.
These are a summary of five important points that I feel every couple facing infertility should know about. I hope this 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.