The Lunar Year of the Tiger has just begun and if you are trying for a Tiger baby then the time is now! We got in touch with Dr Lim Min Yu, President of the Obstetrical & Gynaecological Society of Singapore, Consultant Obstetrician and Gynaecologist with Astra Women’s & Fertility Specialists, Gleneagles Hospital. Read on some valuable insights based on that conversation.
- What is Singapore’s fertility rate and why has it been plummeting over the years?
The pandemic seems to have led to a baby boom in Nordic countries (1), but not in Singapore. In fact, data released by the Singapore Department of Statistics (SDS) indicate fertility rates in 2020 fell to a historic low of 1.1 births per woman compared to 1.82 in 1980 (2), with the total number of births dropping dramatically from 41,217 to 38,590 over these two decades (3).
One of the main reasons for this, in addition to couples choosing to be child-free, is because couples are also having babies later. This is proven by SDS data which shows that fertility rates in 1980 were the highest among females aged 25 to 29, at 144.5 births per 1,000 women, compared to 2020 where the highest fertility rates were among women aged 30 to 34, at 90.8 births per 1,000 women (2). Couples who choose to focus on their education and career before planning for a family must be made aware that fertility decreases with age.
- What are the main causes of infertility in men and women?
In addition to increasing age, there are various causes of infertility in men and women. These include:
Tubal disease; Conditions such as infection can cause scarring of the Fallopian tubes, which will lead to difficulties in conceiving as the sperm meets the egg in the Fallopian tubes.
Endometriosis: This is a debilitating condition where cells from the uterine lining (endometrium) grow outside the womb, in the pelvis and around the ovaries and fallopian tubes. Affecting roughly 10% to 15% of women of reproductive age (4), patients with this disease have a significantly lower chance of getting pregnant, with the American Society of Reproductive Medicine noting that endometriosis is prevalent in 50% of infertile women, with as many of 30% to 50% of patients experiencing infertility (5) due to factors from a distorted pelvis to scarred/blocked fallopian tubes to impaired embryo implantation and altered egg quality.
Polyps: Uterine polyps are overgrowths of the endometrium that extend into the uterine cavity, also known as endometrial polyps (EP). Affecting between 8 and 35% of women (6), the prevalence of EP increases with age, and has been reported in 15% to 24% of infertile women (7). While the cause of polyp-associated infertility is unclear, researchers believe that they can impair implantation of the embryo.
Fibroids: These are growths from the muscle of the uterine walls. A common gynaecological condition that presents during childbearing years, it affects 20% to 30% of women (8) and is found in 5% to 10% of infertile patients (9). Fibroids can affect fertility, and like polyps, can affect the chance of successful embryo implantation.
Male infertility: A male factor contributes to 40% to 50% of cases and affects 7% of men (10). In most cases, male infertility is caused by deficiencies in the semen, including low sperm concentration, poor motility, or abnormally-shaped sperm.
Unexplained infertility: In Singapore, up to 15% of Singaporean couples fail to conceive within 12 months of trying (11). If a doctor finds no obvious problem, such as blocked fallopian tubes or a male factor, the couple is classified as being unable to conceive due to ‘unexplained infertility’, which affects up to 15% to 30% of infertile couples (12)
3. Why are couples choosing to have babies later? How does this affect fertility rates?
Couples in Singapore are getting married later, with the median age of marriage rising from 30 to 30.4 years old for men and 27.7 to 28.8 years old for women over the last decade (13). This directly affects when they will conceive, as indicated by SDS data which show that fertility rates in 2020 were among the highest in females aged 35 to 39, second only to women aged 30 to 34.
Although life’s circumstances may prevent couples from having children early, I must reiterate that fertility reduces with age because a woman’s eggs deplete over time. In fact, women are born with approximately 1 million eggs. By puberty, only about 30% remain. At 30, they would have lost 90% of their eggs, with only 3% remaining by 40 (14).
And thanks to this rapid decrease in healthy eggs, women only have a 30% to 45% chance of conception between ages 35 to 40. At 40, the chance of conception reduces to 20% or lower, with rates dipping to only 1% to 5% after 45, if you’re lucky (15).
In older men, we see decreases in semen volume due to impaired gland function, decreased sperm viability, and reduced sperm production. Other studies have found that changes in the shape of the sperm start as early as 40 years old (16).
- How can couples improve their chances of conception?
There are various options couples can practise to improve the chances of conception at home. These include:
Having frequent, regular sex – when trying to conceive, the Royal College of Obstetricians (RCOG) and other professional bodies recommend Nike’s world-famous slogan: Just Do It! According to the RCOG, couples should have unprotected sex at least twice or thrice a week because sperm can survive in the female genital tract for at least two or three days and the accumulated semen and sperm increase the chances of conceiving. However, while having more sex seems simple enough, many couples may think of themselves too preoccupied to have sex at least three times a week.
Taking your temperature – if you prefer to optimise the timing of intercourse rather than increase the frequency of sex, the woman can try taking her temperature daily as this increases by 0.3C when she ovulates. Unfortunately, this isn’t very exact as the temperature fluctuations are tiny and home thermometers aren’t very accurate. The method works best if you take your temperature at the same time each day.
Don’t stress – While temperature reading and ovulation tests can predict fertile windows, setting dates for sex can put unnecessary pressure on couples. This pressure may lead to performance anxiety in men or increased stress levels in women, which may alter ovulation cycles. So if these options don’t work for you, avoid using them, or speak to your doctor about suitable alternatives.
Using ovulation test strips –these work by detecting spikes in the Luteinizing Hormone and oestrogen levels to predict when you might be ovulating. Although easy to use, ovulation tests can be expensive in the long-term.
Avoid fertility apps – there are many fertility apps which predict a woman’s ovulation windows, but they’re usually incorrect. According to a study, only nine out of 33 fertility apps were accurate (17), so you may be better off without them.
- What are the different types of medical interventions available to aid conception? How do they work?
If a couple fails to conceive after 12 months of trying, or is found to have an underlying medical condition, they may be recommended fertility treatments, depending on the type of condition. The two most common fertility treatments are intrauterine insemination (IUI) and in vitro fertilisation.
IUI works by inserting prepared sperm directly into the uterus using a catheter, cutting down the time and distance sperm cells have to travel to the egg. While IUI is a simpler and cheaper procedure than IVF, it isn’t effective in women with blocked fallopian tubes. It offers a 5% to 15% chance of a live birth (18).
If women fail to get pregnant after IUI, they may proceed to IVF. Although originally intended for blocked fallopian tubes, its indications have greatly expanded over the years to include, endometriosis, male factors, unexplained infertility and more.
IVF treatment involves a combination of medicines and surgical procedures to help sperm fertilise an egg and implant the egg in your uterus. In the first 10 to 14 days of an IVF cycle, a woman undergoes daily hormone injections, visiting the clinic every two or three days for blood tests and ultrasound scans to see if she is responding well to the hormones.
After about two weeks, she should be ready for egg collection, which is done surgically, under sedation. The eggs are extracted and sent to the lab, while the husband’s sperm is collected on the same day and used to fertilise the extracted eggs. The eggs divide and become embryos, one or more of which are transferred into the uterus with a catheter, and pregnancy tests done two weeks after that. In short, an entire IVF cycle from start to finish takes about a month, or until you’ve used up all your frozen embryos.
In general, although IVF offers up to a 20 to 35% success rate, couples can’t rely on it to start a family as success rates decrease with age (19). In fact, while the chance of an IVF-assisted live birth is 32% in women under 35, this dips to 19% to 25% for women aged 35 to 39, with percentages further plummeting to only 4% to 5% after 45 (20).
- What are the side effects, complications or pitfalls associated with these procedures?
Common side effects of IUI can include discomfort when the catheter is passed through the cervix into the uterus. Some women may also experience some mild cramping after IUI as the catheter can irritate the uterus during insertion.
As for IVF, daily hormone injections can result in pain, swelling and/or bruising. The increased hormone levels can also affect a woman’s mood and emotions. In terms of potential complications, IVF is associated with a condition called ovarian hyperstimulation syndrome or OHSS where the abdomen can become bloated due to fluid build-up. If this occurs, patients may have to have the fluid drained. Severe OHSS is potentially life-threatening although modern IVF protocols have dramatically reduced the incidence of OHSS.
Finally, IVF is expensive, costing up to $15,000 to $20,000 per cycle, with no guarantee that it will be successful. While Singapore citizens can receive co-funding of up to $7,700 per fresh cycle and $2,200 per frozen cycle (for three fresh cycles and three frozen cycles) at public hospitals (21), it can be prohibitively expensive for many couples.
- Besides having more sex and giving birth earlier in life, how else can couples improve their chances of conception before resorting to third-party medical interventions?
If patients cannot have sex twice or thrice a week but want to optimise the timing of intercourse without relying on ovulation tests or temperature readings, they can come to the clinic for an ultrasound scan, which allows us to see how the follicles are developing in the ovary and predict when ovulation may happen.
Another option couples can try before resorting to third-party medical procedures are at-home aids such as the twoplus fertility Sperm Guide.
The twoplus fertility Sperm Guide is a simple-to-use product which has been designed to bring as much sperm to the cervix as possible. Soft, comfortable and drug-free, the device is as easy to insert as a tampon and can be used during coitus. After intercourse, the twoplus Sperm Guide captures the ejaculate, keeping it within the vaginal tract. This allows women to continue with their day to day activities, as the device is kept within the vagina for at least an hour. As it sits in the deeper region of the vaginal tract, semen is closer to the cervix, thus increasing chances for fertilisation as they have higher chances of entering the cervix to the fallopian tubes.
The at-home device directly mimics the CCI treatment, but without third-party medical intervention. It is also the only conception solution that allows couples to have intercourse while using the device.
- What lifestyle choices can couples practice to improve their fertility health?
A balanced lifestyle can improve your chances of conception. Quit smoking and take at least 150 minutes of moderate exercise every week. While working out certainly improves fertility health, women should avoid overexercising as bodies that have low fat do not menstruate. Men who enjoy hot baths and cycling should also do these in moderation as regularly soaking in hot water and long-term use of lycra shorts can raise the temperature of your testicles, killing sperm cells.
Last but not least, eat healthy, balanced meals. I recommend following the Health Promotion Board’s ‘Quarter Quarter Half’ rule, which advocates two portions of fruits and vegetables for every quarter portion of meat and carbohydrates per meal.
References:
- https://www.nationalgeographic.com/history/article/the-pandemic-delivered-a-surprise-to-nordic-countries-a-baby-boom
- https://www.singstat.gov.sg/modules/infographics/total-fertility-rate
- https://tablebuilder.singstat.gov.sg/table/TS/M810081
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5737931/#R1
- https://www.endofound.org/infertility
- https://specialty.mims.com/topic/endometrial-polyp
- (https://www.fertstert.org/article/S0015-0282(07)01249-6/pdf#:~:text=Endometrial%20polyps%20have%20been%20reported,an%20endometrial%20polyp%20(6)
- https://www.nuh.com.sg/Health-Information/Diseases-Conditions/Pages/Uterine-Fibroids.aspx
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3608270/
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4691969/.
- https://www.healthxchange.sg/women/pre-pregnancy/infertility-women-causes-treatment
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2505167/
- https://www.channelnewsasia.com/singapore/marriages-divorces-covid-19-2020-statistics-1988051
- https://news.st-andrews.ac.uk/archive/the-birth-of-the-biological-clock/.
- https://www.nejm.org/doi/pdf/10.1056/NEJMp048087
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6993171/#r11
- https://pubmed.ncbi.nlm.nih.gov/27275788
- https://www.cnyfertility.com/iui-success-rates
- https://www.nice.org.uk/news/blog/the-importance-of-3-full-cycles-of-ivf
- https://www.nhs.uk/conditions/ivf/
- https://www.moh.gov.sg/news-highlights/details/more-support-for-childhood-preventive-healthcare-and-fertility-treatments
- https://www.cochrane.org/CD000317/MENSTR_intrauterine-insemination-versus-intracervical-insemination-donor-sperm-treatment
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