How do I know if I'm infertile?

There are many assisted reproductive methods to assist a couple to get pregnant. — Pexels

Infertility, a condition affecting millions of couples worldwide, remains a complex and emotionally challenging issue today.

The inability to conceive a child naturally has profound implications for individuals and couples, leading to feelings of frustration, sadness, and even societal stigmatisation.

In Malaysia, the fertility rate is continuously declining: in 2023, it was 1.924 birth per woman, a 0.88% decline from 2022.

Even though the topic of infertility has been written about and spoken widely, many couples still face dilemmas in their fertility journey.

Here are five things you need to know about infertility.

Do you actually suffer from infertility?

Before you start worrying that you have infertility, you need to carefully assess your TTC (trying to conceive) circumstances.

Generally, a couple would suspect they might have infertility after consistently trying to conceive for about a year or at least six months if the female partner is above 35 years.

The key factor in this time frame is that the couple has been able to have unprotected intercourse during her fertile window.

In a scenario where a couple is suffering from vaginismus or erectile dysfunction, they are not necessarily infertile.

For these couples, pregnancy has not happened yet simply because there is no chance for the sperm and egg to meet for fertilisation to occur.

Couples in these circumstances have a very good chance to get pregnant, provided there are no other major infertility factors.

Another common condition would be when the female partner has an irregular period cycle, especially those with Polycystic Ovarian Syndrome (PCOS), where ovulation of the egg is erratic or irregular.

For example, if she ovulates later than two weeks after the start of her period cycle e.g. three weeks, her next period likely will start five weeks after the current period cycle.

Usually, period starts about two weeks after ovulation.

However, if her ovulation does not follow any pattern at all, it becomes nearly impossible to know her ovulation date or commonly known as fertile window.

Thus, these couple are not actually facing infertility; there are just not able to identify their fertile window.

Once her PCOS is managed properly and ovulation is induced with acceptable regularity, her chances to get pregnant are pretty good.

However, if you are suffering from PCOS, please consult a fertility specialist.

Are you doing it right?

Once a couple has recognised that they are facing infertility, they can be overwhelmed with many suggestions on what to do.

The Internet is flooded with many such posts, from reliable and unreliable sources.

Your first step should be to choose a fertility clinic and start your basic fertility tests.

Attend the session together – not the female partner first and the male partner later.

Basic tests should include a semen analysis for the male partner, an egg reserve test, a pelvic ultrasound scan, and probably a fallopian tube patency test for the female partner.

The inability to get pregnant has a profound impact on a couple, especially the woman. — Filepic

The fallopian tube patency test (hysterosalpingography), is done based on your fertility test.

For example, if the female partner is suffering from PCOS and irregular periods, I would first regulate her ovulation and do the test a bit later.

However, this practice varies amongst fertility specialists.

An egg reserve test can be done via an ultrasound scan to count the antral follicles count.

It can be supplemented with a blood test called Anti-Mullerian Hormone (AMH).

The egg reserve test is important for two reasons.

The first reason is to help determine the order of priority of treatment options.

When the egg reserve is low, the couple might opt for an in vitro fertilisation (IVF) or perhaps decide to do intra-uterine insemination (IUI) once or twice and continue with an IVF without much delay.

The second reason is that egg reserve helps you and your fertility specialist to manage your fertility journey timeline more effectively.

If your egg reserve is low even if you’re young, it is probably wise to start your IUI or IVF treatment earlier than later.

However, if your egg reserve is good and you are young, your fertility doctor might try simpler options such as ovulation induction and timed sexual intercourse.

Do hormonal tests help?

The answer to this question lies in your own fertility history.

Undergoing many traditional hormone tests for every couple is not helpful and is a waste of money.

As mentioned previously, the AMH test may help in determining the egg reserve.

The Follicle Stimulating Hormone, Luteinising Hormone, and Day 21 serum progesterone blood tests are not helpful for many young women.

In a healthy, young woman with a regular period cycle and normal egg reserve, these tests are expected to be normal; it does not necessarily add any valuable information.

The Day 21 is supposed to be a “mid-luteal phase” for a woman with a 28 days period cycle.

If the progesterone level is elevated, it confirms ovulation.

However, the duration of this phase differs for every woman based on her period cycle length.

For example, if a woman has a 35-day or longer but regular cycle, her serum progesterone level on Day 21 might not be elevated.

This does not mean she is not ovulating – she is just ovulating later than usual.

Some hormonal tests are needed based on your clinical history such as Thyroid Function test, serum prolactin and serum insulin level.

Rarely, a genetic test is needed for couples with recurrent miscarriages or for a male partner with azoospermia (no sperm in the ejaculate).

All about the male partner

Although only a semen test is required for the male partner, it does not mean he contributes little to the success of the infertility journey.

Fifty percent of the embryo is contributed by his DNA.

In my opinion, the first fertility test that needs to be done is a semen analysis.

This test may provide valuable information about his fertility status and provide the fertility specialist with enough time to improve male infertility while at the same time focusing on the female partner.

I do a semen analysis for all male partners regardless of their medical history because there are no symptoms for male infertility.

Seemingly healthy and well-built men may have azoospermia.

Even if a men’s semen analysis is normal, it doesn’t mean all is well.

The journey towards becoming parents may be challenging but equally fulfilling, — dpa

A semen analysis does not necessarily indicate the actual quality of his fertility health.

For example, a cigarette smoker’s semen analysis may be normal, but his sperm DNA fragmentation may be very high, which indicates higher damage to the genetic material carried by the sperm cell.

The higher the DNA damage, the higher the likelihood of infertility and miscarriage.

Thus, men should take care of themselves and stop or reduce activities that may impair their fertility.

Is IVF the only solution?

After 40 years of IVF treatment performed globally, over eight million babies have been born.

But, it is not the only option to get pregnant.

The first logical step is to identify the root cause of your infertility.

Once this is done, take the necessary steps to make improvements which may help increase your chances of natural conception.

However, in one-third of couples, there is no obvious cause of infertility found.

If there is no major or obvious infertility factor and the fertility tests are normal, the couple could start with an IUI at least twice before considering an IVF treatment.

A word of caution: IUI could be the first treatment option for many couples but the treatment choice should be tailored to your own fertility history, age and financial ability.

Social pressure is another major determinant in choosing the type of fertility treatment although this is less discussed during a fertility consultation.

IVF treatment could be the first option for couples suffering from bilateral blocked Fallopian tubes or severe male factor infertility, if your egg reserve is low or if the female partner is older.

There is no clear and straightforward algorithm for determining the choice of fertility treatment.

In many instances, the choice is done based on finances rather than scientific factors.

Use the points above to do a preliminary assessment of your fertility status.

The journey towards parenthood is not easy but definitely rewarding.

Dr Agilan Arjunan is an obstetrician and gynaecologist, and fertility specialist. For more information, email [e-mail]. The information provided is for educational purposes only and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.