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Fertility is on the decline globally. In Singapore, there has been a relentless downward trend since the ’80s. The government, in response, has set in place some pronatalist incentives that have evolved over the years. However, the government’s efforts to change the status quo will be effective based on the effort couples put into starting a family. It’s also important for couples to be proactive about infertility.

The first step in the right direction is educating yourself. In that way, you can appreciate the importance of health promotion and timely treatment as a way to address fertility issues. To help you get started, we answered ten questions you may have asked yourself.

What is infertility?

According to the World Health Organization (WHO) infertility is clinically defined as, “a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse”.

Infertility is also classified into two – primary and secondary infertility. Primary infertility refers to couples who have not become pregnant after at least 1 year of having sex without using birth control methods. Secondary infertility refers to couples who have been able to get pregnant at least once, but now are unable to conceive. Those who repeatedly experience spontaneous miscarriage or whose pregnancy results in a stillbirth, after their first baby would classify to have secondary infertility.

What are the causes of infertility?

There are several reasons behind infertility. In women, the usual cause is a problem with ovulation. Meanwhile, the usual root cause of infertility in men is a problem with sperm cells and how they function. Other factors that may affect fertility include age, health conditions, structural issues of the reproductive system, and even your lifestyle. In some cases, no cause of infertility can be found, which is called unexplained infertility.

Causes of Female Infertility

  1. Failure to Ovulatee
  2. Endometriosis
  3. Primary Ovarian Insufficiency (POI)
  4. Polycystic Ovarian Syndrome (PCOS)
  5. Malfunction of the usual hormonal (hypothalamo-pituitary-gonadal) axis
  6. Reproductive Tract Infection
  7. Structural Abnormalities of the Reproductive System
  8. Uterine Fibroids
  9. Impaired implantation
  10. Autoimmune Disorders

Read: 10 Common Causes of Infertility in Women

Causes of Male Infertility

  1. Varicocele
  2. Infection
  3. Ejaculation issues
  4. Antibodies that attack sperm
  5. Tumors
  6. Undescended testicles
  7. Hormone imbalances
  8. Defects of tubules that transport sperm
  9. Chromosome defects
  10. Problems with sexual intercourse
  11. Celiac disease
  12. Certain medications
  13. Prior surgeries
  14. Environmental causes (e.g. heavy metal, radiation, heat)
  15. Lifestyle issues (e.g. drug, alcohol, tobacco)

What are the different ways to diagnose infertility?

Infertility diagnosis involves a battery of tests to find out what’s holding you or your partner back from conceiving. Since the problem that causes infertility is usually not visible to the eye, there are specific tests that can help doctors arrive at a diagnosis. There are tests specific to men and women. Here’s a look at the list of options below.

Diagnostic Tests for Female Infertility

Generally, doctors use blood tests, physical examination, and diagnostic tools to assess a woman’s reproductive capacity. The process will usually involve different methods to get a full picture of the problem because infertility in women can stem from multiple causes all at once.

Urine Ovulation Test: A urine test can tell when and if you ovulate.

Blood test: There are different hormones in the body that can affect female fertility. Doctors can assess these hormone levels through a blood test. You can expect them to check follicle stimulating hormone (FSH), luteinising hormone (LH), prolactin (PRL), thyrotrophin (TSH) and anti mullerian hormone (AMH). 

Pelvic exam: This type of exam can be part of a regular check-up or fertility check. Your doctor will assess your vulva, vagina, cervix, ovaries, uterus, rectum and pelvis for any abnormalities. A Papsmear and hpv test, which screens for cervical cancer is commonly performed at the same time during a pelvic exam.

Transvaginal ultrasound: This procedure is among the initial investigations done for infertility. It is done by inserting an ultrasound wand into the vagina to look for problems with the reproductive system. It allows your OB to get a closer look at your reproductive organs, including your uterus and ovaries.

Hysteroscopy: This is a procedure done for infertility investigations where a thin, lighted tube (hysteroscope) is inserted into the vagina to examine the uterus.

Saline Infusion sonohysterogram (SIS): Also known as a saline ultrasound, this procedure scans the uterus by filling it with a small amount of saline (salt solution) that allows the lining of the uterus (endometrium) to be clearly seen on an ultrasound scan.

Hysterosalpingogram (HSG): This is a common first-line diagnostic test that evaluates the uterine cavity and the patency of your tubes. An X-ray captures an injectable dye as it travels through the fallopian tubes to check for blockages.

Laparoscopy: Female pelvic laparoscopy allows an OB to look inside the abdominal cavity using a laparoscope (thin tube with a camera) to help identify problems like endometriosis, uterine fibroids tubal blockage and scar tissue.

Diagnostic Tests for Male Infertility

Doctors can look at different angles to check for infertility problems. They can either check the semen directly, run blood tests, or they can check for existing structural problems.

Semen analysis: Also referred to as a sperm count, this is an essential part of testing male infertility. This test checks three main factors: the number of sperm, the shape of sperm, and the movement of the sperm (sperm motility). 

Blood test: A blood test can check testosterone, thyroid and other hormone levels. Doctors will also suggest a genetic blood test to look for chromosomal abnormalities if there are severe sperm abnormalities. 

Scrotal ultrasound: An ultrasound of the scrotum identifies varicoceles or other testicular problems.

Read: Infertility Diagnosis: 6 Tests to Check Why You’re Unable to Conceive

How is Male and Female Infertility treated?

What are fertility treatment options for all genders?

Some couples need some help conceiving. To boost the odds of getting pregnant, a woman may be advised to take certain medications to stimulate ovulation while a couple can try one of the following options: 

  • Intrauterine insemination (IUI): A procedure that involves a long, thin tube to introduce sperm directly into the uterus. 
  • In vitro fertilization (IVF): It’s a type of assisted reproductive technology (ART) where eggs are harvested at the end of the stimulation and placed together with sperm in a lab dish. Once the sperm fertilizes the eggs, a provider transfers one of the fertilized eggs (embryo) into the uterus. 
  • Intracytoplasmic sperm injection (ICSI): It’s a technique that involves the direct injection of a single sperm into an egg using a fine needle. 

These options all have their pros and cons which you should thoroughly discuss with your OBGYN. Doctors can advise based on your specific case, with all outstanding factors considered.

Read: How to Start a Family Through Intrauterine Insemination

When should you seek help for infertility?

Women under 35 who aren’t pregnant after one year of trying are advised to seek professional help. However, those who are older than 35, must get checked sooner, or after six months of trying. It’s important to remember that a woman’s chances of getting pregnant decreases with age. Fertility can drop by half between 20 and 30. 

It is also true that regardless of gender, one should seek help as soon as possible if there are risk factors that affect fertility.

What can I expect during my fertility check-up? 

During fertility check-ups, your first visit will usually involve a detailed medical history taking and physical exam. Expect to be asked questions about your menstrual period, discharges, pelvic pain, abnormal vaginal bleeding, or any disorders that can potentially mess with your ability to conceive.

Remember that visits like these are advised for couples. So, you and your partner should expect questions concerning your health, such as: 

  • Birth defects in your family
  • Past pregnancies and their outcomes
  • Illnesses (e.g. sexually transmitted diseases)
  • Past surgery
  • Use of tobacco, alcohol, or illegal drugs

You will also be asked about your sexual history. Therefore it’s important that you are open and honest about it. You will have to share information about birth control, how long you’ve been trying for a baby, how often you have sex and past sexual relationships.

After basic information has been collected, doctors may order blood tests and other relevant diagnostic exams. Fertility check-ups can involve several visits, and it may be emotionally taxing. That is why it helps to have a doctor that you will be comfortable with, on top of their credentials. 

How can I prevent infertility?

Infertility covers a spectrum of causes where some are preventable, while others are inevitable. Since there’s a good chance that there’s something you can do about it, it helps to know how you can prevent the problem.

Men and women can take these steps to protect their fertility, especially while trying to conceive:

  • Eat a well-balanced diet 
  • Maintain a healthy weight.
  • Don’t smoke, misuse drugs or drink alcohol in excess.
  • Get treated for STDs.
  • Limit exposure to toxins.
  • Stay physically active, but don’t go overboard with exercise.

Read: How Can You Fuel Fertility Through Your Diet?

Are there any measures to help a couple afford the cost of treatment for infertility?

The Singapore government offers MediSave for Assisted Conception Procedures (ACP). 

To afford the cost of treatment for ACPs, a couple are allowed to withdraw $6,000, $5,000 and $4,000 from Medisave for the first, second and third treatment cycles respectively. There is a lifetime Medisave withdrawal limit of $15,000 per patient for ACP.

The government also provides a co-funding scheme for Assisted Conception Procedures at Public Hospitals. In this arrangement, eligible couples undergoing ACPs in public Assisted Reproduction (AR) centres can receive up to 75% in co-funding from the Government, which took effect 1 Jan 2020. 

The co-funding will cover up to $1,000 per cycle for three cycles of Intra-Uterine Insemination (IUI). You are eligible for ACP co-funding at public AR centres if you meet all the following criteria set by the Ministry of Health. First of all, you must be a Singaporean citizen to qualify. IUI co-funding applies to those below 40 years of age at the start of the IUI cycle and for those who have undergone assessment by a doctor at a public Assisted Reproduction centre and is found to be suitable to try IUI before proceeding to ART. 

If you have other questions or clarifications about infertility,  Dr Pamela Tan would be happy to help you with your concerns. Some may leave conception to chance, or others may take their time, but it’s also important to be mindful of the changes your body is going through and your role in it. Call us today at +65 6254 2878 (Thomson) for your appointment

Dr Pamela Tan
About Dr Pamela Tan

Dr Pamela Tan is a board certified obstetrician and gynecologist in Singapore. She finished her undergraduate studies at the National University of Singapore and earned her post-graduate degree at the Royal College of Obstetricians and Gynaecologists in the UK. She is an accredited specialist by the Specialist Accreditation Board (Ministry of Health), and a fellow of the Academy of Medicine, Singapore. She subspecialises in colposcopy and is certified to perform Level 3 minimally invasive keyhole surgeries such as laparoscopic hysterectomy, myomectomy and cystectomy. Dr Pam also supports the natural birthing method and she strives to provide a personalised care and treatment for each patient.