Infertility myths

By Dr. Christopher Ng Chee Mun
Obstetrician and Gynaecologist
MBBS (London, UK), FRANZCOG (Aust-NZ), MMed (S'pore), FAMS (S'pore)

1. Can you debunk some common infertility myths?

Myth: Taking oral contraceptive pills (OCPs) causes infertility

Fact: OCPs do not lead to infertility in the long term. The effects of OCPs are short-acting, so fertility returns almost immediately once a woman comes off the pill, provided there are no underlying background causes of infertility.

Myth: Infertility is a woman’s problem.

Fact: One-third of the causes are entirely due to women, one-third are entirely due to men, and one-third are due to a combination of male and female factors.

2. Does stress cause infertility? Or is it plain psychological? What is the difference?

Yes, stress does decrease fertility. Stress hormones like cortisol or epinephrine, which rise and often remain high during times of chronic stress, play a key role. Stress can affect the functioning of the hypothalamus. This is the part of the brain that controls hunger, feelings, and the hormones that women need to make eggs and men need to make testosterone. This makes it harder for a woman to have an egg and makes a man's sperm less healthy and less of it. In a research published in the journal Human Reproduction, doctors compared pregnancy rates in couples that reported being stressed and those who were not. They found that pregnancy was much more likely to occur during months when couples reported feeling good, happy, and relaxed. It was less likely to happen when they said they were stressed or worried. In my own practice, I similarly find this happening too.

3. In your opinion, how does our modern way of living affect fertility for most couples?

With the hectic lifestyle, career goals, and stresses of modern society, more couples are starting their family only in their mid 30s to early 40s, and this has contributed to the increase in infertility. This is because the risk of genetic abnormalities, miscarriage, and infertility increases after 35 years of age. A woman is in her best physical condition in her 20s. If women are concerned about having enough energy and endurance to chase a toddler, or want to avoid many of the potential health complications that can occur in 30 and 40-something women, they may want to have their children in their 20's. In fact, a woman's fertility peaks before she turns 25 and starts to go down in her early 30s. 10 percent of women under 30 have a miscarriage, but a third of women in their early 40s do, and the risk goes up the most after 35.

The effect of age on men's fertility is less clear. There is a small decline in sperm counts and motility in men over 45. For most men, sperm quality usually remains within normal limits until about age 70.

Although it can sometimes be difficult for busy couples in today’s society, one should try to reduce stress, exercise more regularly, and have a healthy diet. Couples should avoid cigarettes and alcohol, which can contribute to lower sperm production or motility (ability to swim). Studies have traced chromosomal damage in sperm to cigarette smoke and heavy alcohol intake. Low levels of vitamin C and zinc can cause sperm to clump together. Vitamin E can counteract excess free-oxygen radicals, which can also affect sperm quality.  So men should also take their multivitamins.

4. Many specialists have said lifestyle changes are crucial for infertile couples. What are some of the key changes they should adopt and how can they ensure they are on the right track?

Besides sorting out any medical issues, couples who wish to conceive should also have a healthy diet, exercise regularly, stop smoking and drinking alcohol, and reduce their levels of stress. This advice is good for a couple's overall well being, especially if fertility is sought.

1. Watch your weight - aside from the other risks it poses to your health, excess body fat can lead to an overproduction of certain hormones that disrupt ovulation. Your cycles may be less regular, you may ovulate less often, and you lower your chances of getting pregnant. Too little body fat means your body may not produce enough hormones to ovulate each month or to sustain a pregnancy if you do conceive.
   
2. Eat healthy foods - staying well nourished increases your odds of conceiving. Make sure to include enough protein, iron, zinc, and vitamin C, because deficiencies in these nutrients have been linked to decrease fertility and a higher risk of early miscarriage.
   
3. Quit smoking - aside from health concerns, cigarette toxins not only damage a woman's eggs, interfering with the fertilization and implantation process, but also cause the ovaries to age.
   
4. Know your fertile period - when you're ready to conceive, find your "fertile window," during which you should have intercourse regularly. You can try an ovulation test kit, which checks for certain hormones in your urine, or note daily changes in your basal body temperature and cervical mucus.
   
5. Reduce Stress - learning to manage stress through relaxation techniques (such as mindfulness meditation or yoga) or support from counselling.
   
6. Avoid alcohol and reduce caffeine intake - alcohol consumption decreases the ability to get pregnant (not to mention the harm it can cause to a developing fetus). Alcohol alters oestrogen levels, which may interfere with egg implantation. Cutting back on caffeine while you try to conceive and during your pregnancy is encouraged. Women who drink the equivalent of two cups of coffee per day are twice as likely to miscarry as those who didn't consume any.
   
7. Frequent intercourse - during your fertile period, you should try to have intercourse on alternate days. Outside of this, intercourse at least twice a week is advisable. Because mandatory sex on certain days can become a chore, you might also try making love every few days all month long.
   
8. Don’t douche – try not to douche after immediately after intercourse as this may wash away some of the sperm that may be still in the vagina. Give yourself at least 20-30 minute before cleaning yourself to give the healthy sperm time to swim into the uterine cavity. Douching can wipe out normal, protective bacteria in the vagina, shifting the balance and putting you at risk for bacterial vaginosis, a common but often overlooked vaginal infection. A fishy odour and greyish discharge are often the only signs. Untreated vaginal infections have been linked to preterm labour and may be associated with higher risk of miscarriage and infertility.
   
9. Looking after your partner’s health - cigarettes, alcohol and a poor diet can contribute to lower sperm production or motility (ability to swim). Studies have traced chromosomal damage in sperm to cigarette smoke and heavy alcohol intake. Vitamins E and C and the mineral selenium help healthy sperm production so taking a daily multivitamin is advisable. After all, conceiving is a joint effort so both parties should play their part.

5. What are the red flags that couples should look out for before seeking a professional diagnosis?

Infertility according to medical definition is when a couple has been having unprotected regular intercourse for 1 year without achieving pregnancy. So, strictly speaking, after a year of unsuccessfully trying, couples should seek investigations into the cause of their infertility. However, as the risk of genetic disorders, miscarriage, and infertility increases with increasing age, women who are over 35 years old and have been unsuccessful may wish to seek medical help after 6 months of contraceptive-free intercourse for these very reasons.

6. What treatments/medication are available for infertility? Which methods are popular or more effective?

Ovulation induction

If the woman does not ovulate, there are medications she can take to stimulate ovulation. Even if a woman is ovulating, she may need to release more eggs in order to get pregnant. The medication used most often to stimulate ovulation is clomiphene citrate. It may be used for several cycles. The dosage may be increased over time if ovulation does not occur. Ovulation or pregnancy may not occur after treatment with clomiphene citrate. Most women who take drugs to cause ovulation start to ovulate regularly. If there are no other problems, more than half of such women get pregnant within 6 treatment cycles.

Multiple pregnancies may occur with the use of these drugs. That is when more than one fetus grows in the uterus. Rarely, a condition called ovarian hyperstimulation syndrome may occur.

Surgery

If the fallopian tubes are blocked, surgery may be performed to open them. Surgery also may be done to:

• Remove growths such as polyps or fibroids
• Remove scarring from a previous surgery, infection, or endometriosis
• Treat endometriosis (if found)

If the problem is because of a blocked sperm duct, surgery can sometimes fix it. The success of surgery depends on the type and extent of the problem.

Assisted reproductive technologies

1. Superovulation intrauterine insemination (SOIUI) is offered for

• mild male factory infertility
• mild endometriosis
• cervical factor infertility
• unexplained infertility
• after several failed clomiphene citrate cycles

Both tubes must be patent in order for SOIUI to be performed. If women do not ovulate with oral clomiphene citrate, then gonadotropin (GnRH) injections (Puregon, Gonal-F) are given to stimulate several follicles (eggs) to grow and mature. Ultrasound scans are done regularly to determine the number and size of eggs within the ovary.

On the day of insemination, a fresh sample of the husband's sperm is brought to the lab, where it is treated in a certain way. This specially prepared healthy sperm is placed directly into the womb with a fine tube.  Medications are given to improve the chances of implantation and pregnancy. A pregnancy test is performed 14–17 days after insemination.

Live birth rates are around 12-15% per cycle, or 26-36% after 3 cycles. The overall success rate varies with the cause of infertility and the age of the female partner. There is a 15% chance of twin pregnancies and a small risk of hyperstimulation.

2. In vitro fertilization (IVF) uses sperm to fertilize eggs from the woman in a lab. This is offered to women with

• irreparably damaged fallopian tubes
• blocked fallopian tubes
• severe endometriosis
• ovulatory dysfunction
• unexplained infertility
• severe sperm disorders

High-dose gonadotropin (GnRH) injections (Puregon, Gonal-F) are given to stimulate several follicles (eggs) to grow, and their maturation progress is monitored with serial ultrasound scans. This medication stimulates more than one egg to mature. These eggs are removed from the ovaries just before a woman ovulates with a needle that is inserted through the vagina and into the ovary by direct ultrasound guidance. This procedure is called "oocyte pick up". Pain relief or a sedative may be given. The eggs are combined with healthy sperm and monitored in the lab to see if they become fertilized. A few days later, one or more fertilized eggs (embryos) are placed in the woman's uterus through her vagina. This is called embryo transfer. Transferring fewer embryos reduces the risk of a multiple pregnancy. Any extra embryos that are not used may be frozen and stored for later use (embryo freezing).

Overall live birth rates varies with the cause of infertility and the age of female partner (<35 years old better).

Approximate IVF success rates (per cycle)	Age (yrs)
30-35%	<35
25%	35-37
15-20%	38-40
8%	>40

There is a 20% chance of twin and a 3% chance of triplet pregnancies, as well as a higher risk of hyperstimulation.

3. Intracytoplasmic sperm injection (ICSI) is similar to IVF except that a single sperm is injected directly into each individual egg to increase the chances of successful fertilization. This may be a good option if there is a problem with the man's sperm (i.e. very low quality or quantity) because only a few healthy sperm are needed. This can be used alone or in combination with IVF. The disadvantage is that there is no natural selection involved in the fertilization process between the sperm and egg.

7. Do the treatments or medications cause side effects or involve risks (e.g., multiple pregnancies)?

With all these assisted reproductive technologies (ART), there is a risk of multiple pregnancies. This risk is higher with gonadotrophins than with clomiphene citrate. Multiple pregnancies are considered high-risk pregnancies compared to singletons. Women undergoing SOIUI have a 10% chance of having twins when taking clomiphene citrate and less than 1% of triplets or multiples. For IVF, there is a 20% chance of twins and a 3% chance of triplet pregnancies.

Ovarian hyperstimulation syndrome (OHSS) can happen when the fertility drugs make the ovaries work too hard. The ovaries become suddenly very swollen and fluid leaks into the abdomen and chest, resulting in abdominal distention and shortness of breath. OHSS occurs only after the eggs are released from the ovary (ovulation). Again, the risk of OHSS is higher with gonadotrophins than with clomiphene citrate.

OHSS affects up to 10% of women who go through in vitro fertilization. In most cases, the condition is mild, but in some women it can be severe and even dangerous. In this case, they will need close monitoring, hospital admission, and the cycle may need to be cancelled.

8. How long must the average couple seek treatment before successfully conceiving?

This is an impossible question to answer as there are so many variables that can affect a successful outcome. The older the woman, along with the more causes for infertility, the longer it would theoretically take. At the end of the day, keep trying until you are successful if pregnancy is really what a couple truly desires.