Having a baby is usually a joy. However, for some couples, the process of trying to conceive can be a challenging one. In Singapore, about 20 per cent of married couples have problems conceiving.

'How would you evaluate couples with infertility?' asked P, a medical student doing an elective posting in my clinic.

'First, let's define what infertility is," I said.

Infertility is a term commonly used with little attention to its precise definition. Simply put, it refers to an inability to conceive within one year despite having unprotected, well-timed intercourse. It also applies if a woman repeatedly conceives but cannot maintain a pregnancy.

Typical couples have 20 to 25 per cent chance of conceiving in any one month. This is known as the natural fecundity rate.

If couples keep on trying to conceive, 50 per cent of them will achieve pregnancy within three months, 70 per cent will do so within six months and 80 per cent will do so within one year. If a couple attempts for a year without success, it is appropriate for them to go for an evaluation.

In women aged 35 and above, fertility screening should be done earlier. Older couples are more likely to have problems and they have less time left to pursue treatment. It is recommended that couples in this age group seek help after six months of unsuccessful attempts.

The evaluation process involves a detailed medical, family, menstrual and sexual history. Past illnesses such as sexually transmitted diseases and past surgery on the reproductive organs may affect fertility.

Painful periods may be a sign of endometriosis, a common condition associated with infertility. Irregular and prolonged periods may be suggestive of polycystic ovarian syndrome (PCOS), a frequent cause of infertility. Sexual dysfunction is also a common cause.

Physical examination including pelvic examination in the female and testicular examination in the male should be conducted.

This would identify hormonal disorders and reproductive tract abnormalities. Fibroids (muscle growth of the womb) and ovarian cysts (liquid collections in the ovary) may be detected this way. Other fertility tests may also be needed to help identify the cause of infertility.

'What do these tests entail?" P asked. I explained that these tests usually include semen analysis, blood tests and special procedures. A man must produce enough healthy, motile sperm in order for a woman to conceive.

This could be easily checked with a semen analysis. If the first test is abnormal, it should be repeated as the quality and quantity of sperms fluctuate considerably from day to day.

Blood tests on sexually transmitted diseases such as syphilis and chlamydia may detect infections, which may hamper conception. Blood levels of female hormones, thyroid hormones and milk hormones (prolactin) may be useful if the menstrual cycle is irregular or absent.

To find out whether the ovaries are releasing eggs on schedule, ovulation tracking including charting of basal body temperature, urine testing of luteinizing hormone and ultrasound monitoring may be performed.

The anatomical assessment of female reproductive organs can be done by ultrasound examination and hysterosalpingogram, an X-ray test that outlines the insides of the uterus and the fallopian tubes to see if they are blocked.

Other tests include a hysteroscopy, which provides a telescopic view of the uterine cavity, and a laparoscopy to visualise the pelvic organs (uterus, fallopian tubes and ovaries).

'It must be quite tedious and distressing for couples to go through these evaluations," said P.

'Well, we should always be mindful of the emotional aspects of infertility. Many couples do not share their experiences openly with friends and family. They may feel isolated and depressed.

'We should give them emotional support and clarify how far they wish to go in the investigations and treatments," I concluded.

Dr Peter Chew
[email protected]

Dr Peter Chew is a senior consultant gynaecologist and obstetrician at Gleneagles Medical Centre. He is the founder chairman of aLife (www.alife.org.sg), a charitable organisation with a mission to nurture and promote healthy family life.

This article was first published in Mind Your Body, The Straits Times on Nov 27, 2008.