19.AUG.2016 6 MIN READ | 6 MIN READ

If you and your spouse have been trying to conceive for months without a sign of a baby, you may begin to wonder if you have a fertility problem.

Dr Kelly Loi, obstetrician and gynaecologist at Mount Elizabeth Hospital, gives us the facts regarding infertility and the options available to you if or when you have problems conceiving.

What causes infertility?

Fertility problems may arise due to problems in the female or the male reproductive system.

Female infertility reasons can broadly be divided into ovulation disorders, endometriosis (where the lining of the uterus occurs outside its normal position) and tubal disease.

If a woman managed to conceive previously but has problems conceiving again, she is said to have ‘secondary infertility’. In such cases, it is possible that a patient had an underlying health problem when she conceived before, but was fortunately not affected then.

Age is also an important contributing factor to infertility.

Although it happens more commonly in women, men may also become less fertile as they get older. In men, the quantity and quality of sperm may deteriorate with time making it difficult to fertilise an egg. This can also occur as a result of poor diet or lifestyle habits, as well as chronic illnesses such as diabetes and high blood pressure.

In women, fertility steadily declines with age. Women are born with a fixed number of eggs. With increasing age, there is a fall in ovarian reserve ie. the number of functioning follicles or eggs left in the ovaries. In cases of early menopause, the eggs run out much sooner than usual.

In general, the likelihood of conceiving falls from 20% a month when a woman is in her late 20s, to 8% in her late 30s.

Even the success rate of artificial reproductive treatment is not spared and pregnancy rates fall with increasing age from 40% in women under 35 years old to just 10% in women over 40 years old.

With increasing age, our general health also tends to decline. Existing conditions may worsen or new illnesses may develop, which can have an impact on fertility too. In addition, there is a decline in quality of eggs with an increased risk of genetic abnormalities. This in turn results in an increased risk of miscarriage. Women under the age of 35 have about a 15% chance of miscarriage while women aged 35 – 45 have a 20 – 35% chance of miscarriage.

What advice should be given to couples trying to conceive?

For couples:

  • Try to start planning for a family as early as possible
  • Maintain a normal weight, exercise and eat a diet rich in fruits, vegetables and antioxidants
  • Stop smoking – smoking impairs sperm quality and female smokers are 1.6 times more likely to be infertile
  • Limit alcohol intake to 2 drinks per day

For the women:

  • Limit coffee intake to one cup a day. High levels of caffeine are associated with decreased fertility and an increased risk of miscarriage
  • Take folic acid to prevent certain birth defects

For the men:

  • Wear loose-fitting undergarments
  • Avoid extremely hot temperatures, such as hot tubs or saunas
  • Use lubricants which are suitable for conceiving

When should a patient see a fertility specialist?

Early diagnosis and treatment of infertility is crucial in the successful management of a couple seeking infertility treatment.

Infertility is defined as the inability to conceive after 1 year of unprotected sexual intercourse. Ideally, the frequency of intercourse should be 2 – 3 times a week. Up to 90% of couples should have conceived by the end of the 1st year of trying. At this point, if they have still not conceived, further investigations are warranted.

Older couples should be referred to a specialist even earlier, particularly in the case of women over the age of 35.

Such couples should be referred to a fertility specialist after 6 months of trying to get pregnant.

In other cases where the likelihood of a gynaecological disorder may be high, the woman should also seek specialist advice sooner rather than later.

For example, an early referral is indicated if she has a history of amenorrhoea (no periods), oligomenorrhoea (infrequent periods), dysmenorrhoea (painful periods), pelvic inflammatory disease (PID), or previous surgery.

A history of menstrual irregularity could indicate an ovulation problem which would benefit from ovulation induction medication. Painful periods may indicate the presence of endometriosis, ovarian cysts or fibroids which may benefit from surgery to improve her fertility status. A history of pelvic inflammatory disease or previous pelvic surgery may cause tubal disease which would then require tubal surgery to unblock the tubes, or in-vitro fertilisation to bypass the tubal blockage.

How can infertility be treated?

Infertility can be treated depending on the cause.

  • In the case of cysts, fibroids and blocked fallopian tubes: laparoscopic or keyhole surgery may help to improve chances.
  • For problems related to abnormal ovulation: fertility drugs or injections may help to enable ovulation to occur in a more predictable manner.
  • For poor sperm count and quality: intra-uterine insemination, or assisted reproductive techniques (ART) may be needed.

ART and in vitro fertilisation (IVF)

Artificial reproductive technology (ART) refers to the use of laboratory techniques to bring the egg and sperm together outside of the woman's body. ART may also be referred to as in vitro fertilisation (IVF). ART generally involves several treatment stages.

Firstly, in order to increase the number of eggs produced by her ovaries, the woman has to undergo hormonal injections.

Secondly, ultrasound scans and blood tests are needed to assess the growth and maturity of the eggs. Once the eggs are ready, they are retrieved with the help of a vaginal ultrasound while the woman is under anaesthesia.

The eggs are then fertilised with the sperm in the laboratory to form embryos before they are transferred back into the woman’s womb several days later.


Article contributed by Dr Kelly Loi, obstetrician and gynaecologist at Mount Elizabeth Hospital


Age and Fertility. (n.d.) Retrieved from https://www.reproductivefacts.org/news-and-publications/patient-fact-sheets-and-booklets/documents/fact-sheets-and-info-booklets/age-and-fertility/

Centers for Disease Control and Prevention, American Society for Reproductive Medicine, Society for Assisted Reproductive Technology. (2017, October) Assisted Reproductive Technology National Summary Report. Retrieved from https://www.cdc.gov/art/pdf/2015-report/ART-2015-National-Summary-Report.pdf

Smoking and infertility. (2008, November) Practice Committee of American Society for Reproductive Medicine.Fertility and Sterility,90(5 Suppl):S254-9. doi: 10.1016/j.fertnstert.2008.08.035

Villines, N. What are the miscarriage rates by week? (n.d.) Retrieved from https://www.medicalnewstoday.com/articles/322634.php#pregnancy-loss-rates-by-age

Loi Shen-Yi Kelly
Obstetrician & Gynaecologist
Mount Elizabeth Hospital

Dr Kelly Loi is an obstetrics and gynaecology specialist practising at Mount Elizabeth Hospital, Singapore.