Infertility is on the rise. As the numbers continue to raise concerns, Dr Haris Njoo, a fertility specialist, talks to New Sarawak Tribune about what infertility is and how to go around it.
Declining fertility rates in Malaysia
Procreation is the very essence of life. Without which, human life and civilisation would cease to exist.
However, not everyone is blessed with fertility, and infertility is on the rise in Malaysia.
The National Population and Family Board (LPPKN) reported that 6 to 9 per cent of Malaysian couples experienced infertility in 2014, and that number doubled to between 10 and 15 per cent in 2020.
According to Dr Haris Njoo, a fertility specialist at Sunfert Kuching, one of the major causes of the rise in infertility among Malaysian couples is the increasing age at which women plan to start a family.
This could be due to a variety of factors, such as couples who lead busy lives and may prioritise their careers first, or to achieve financial stability before starting a family.
He added that one in every six Malaysian couples will experience infertility at some point during their reproductive lives.
Dr Haris, who is also former state consultant and head of the department of Obstetrics and Gynaecology at Sarawak General Hospital (SGH), also mentioned how Malaysia’s birth rate is declining, from a total of 528,612 births in 2014 to only 470,095 births in 2020, and how Sarawak has not been spared, with birth rates in the state falling to nearly half from a decade ago.
If left unchecked, this could have a negative impact on the country’s socioeconomic development in the long run.
Dr Haris said that a woman’s fertility peaks between the ages of 20 and 30 years old, and that between the ages of 31 and 35 years old, fertility begins to decline gradually.
By the age of 36 to 40, their fertility or ability to conceive has declined rapidly.
He added that this could be due to both a decline in egg quality and the ability to release an egg every month.
Furthermore, there may be a higher prevalence of gynaecological problems among women of this age group, which can have a negative impact on their ability to conceive.
Without assisted conception, it would be even more difficult for couples over the age of 41 to have a healthy baby.
To put it another way, at birth, a woman would have between 1 and 2 million eggs in her ovaries, and by puberty, only 300,000 to 400,000 eggs are left. The total number of eggs is rapidly decreasing over time.
After puberty, only one of a group of eggs that can grow per cycle will develop, while the rest will degenerate or die.
By the age of 40, the number of eggs remaining in the ovaries would be less than 10 per cent of pre-birth numbers, and the chance of normal conception would be less than 5 per cent per menstrual cycle.
“Age is the most important factor in determining egg quality,” said Dr Haris.
The quantity and quality of your eggs decrease as you age. As the egg’s quality deteriorates, the genetic material may become more damaged and less reparable.
As a result, when the egg and sperm combine to form an embryo, the risk of chromosomal abnormalities or genetic defects increases.
Other causes
In a large multinational study conducted by the World Health Organization (WHO) to determine infertility aetiologies, 37 per cent was attributed to female factor infertility, 35 per cent to both male and female causes, and 8 per cent to solely male factor infertility.
According to the same study, the most common identifiable factors of female infertility are ovulatory disorders or failure to release eggs on a regular basis (25 per cent), endometriosis (15 per cent), pelvic adhesions (12 per cent), tubal blockage (11 per cent), and womb abnormalities (11 per cent).
Women suffering from ovulatory disorders are more likely to have irregular periods and may only have one or two cycles per year.
Polycystic ovarian syndrome (PCOS) affects approximately 40 per cent of women who have ovulatory disorders.
According to Dr Haris, women who have had surgeries on their ovaries to remove cysts or who have had cancer treatment may have low ovarian reserve or a declining ability to produce eggs.
Endometriosis is a condition in which tissue cells similar to the inner lining of the womb can be found in the ovaries, uterine wall, pelvic wall, and fallopian tubes.
They would often present with very painful periods and even dyspareunia or pain during sexual intercourse.
This condition has the potential to cause significant inflammatory as well as anatomical or functional damage to these structures over time.
In the ovaries, for example, it may cause endometriotic cysts or chocolate cysts, which damage the ovaries and affect their ability to produce quality eggs.
Endometriosis and pelvic infection can also cause pelvic adhesions and fallopian tube blockage.
Infertility can be caused by womb abnormalities acquired during their reproductive years, such as fibroids, adenomyosis, or structural abnormalities acquired at birth.
While much of this article has focused on female factors, it is important to remember that male factor infertility accounts for a significant portion of the identifiable causes of infertility.
It accounted for nearly half of the total and is still increasing. According to Dr Haris, approximately 60 per cent of sperm analyses would reveal abnormalities, with some showing no sperm in the ejaculate (azoospermia).
External factors such as alcohol, cigarette smoking, and diabetes may cause increased oxidative stress and DNA damage during sperm production, resulting in lower sperm count or quality.
He also said that the prevalence of erectile dysfunction is increasing, even among younger men.
Symptoms and various treatment options
Infertility is defined as the inability to conceive after 12 months or more of regular unprotected sexual intercourse.
Couples experiencing infertility may not exhibit all of the signs and symptoms described in this article.
In fact, based on routine examination and investigations, approximately 10 per cent of infertile couples may have no identifiable aetiology.
Women who have irregular or painful periods, as well as those who have had surgery on their ovaries or cancer treatment, may be at a higher risk of infertility.
While men with chronic medical illnesses such as diabetes, who live an unhealthy lifestyle, or who frequent hot baths and saunas are more likely to have poor sperm quality as well.
Dr Haris advised couples who have failed to conceive after a year of trying to see a fertility specialist to help them achieve their dream.
At the Sunfert clinic, a comprehensive medical history would be obtained from the couple.
The husband would have his semen analysis performed and the results would be available in about an hour, while the wife would have a pelvic examination and an ultrasound scan of her pelvis.
A scan of the uterus and ovaries in relation to their cycles may reveal information about the possible causes of female infertility as well as assess the ovarian reserve by counting the number of antral follicles in each ovary.
In many cases, according to Dr Haris, preliminary assessments can identify potential causes of infertility.
In some cases, hormonal blood tests such as anti-mullerian hormone (AMH) and tubal patency tests may be required.
Additional checks may be required if the couple has other issues, such as recurrent miscarriages, previous unsuccessful advanced fertility treatment, or hereditary diseases.
Finding the root causes, on the other hand, may not be the most effective approach, especially for couples eager to begin fertility treatment as soon as possible.
In these cases, Dr Haris takes a problem-solving approach, recommending the best method of treating infertility based on the couple’s specific circumstances.
Younger couples may decide to continue trying naturally for a while, but older couples may prefer to move forward with cutting-edge fertility treatments that give the best chance in the shortest amount of time, like in-vitro fertilisation (IVF) or intra cytoplasmic insemination (ICSI).
According to Dr Haris, trying naturally may include advice on fertile periods, advice on living a healthy lifestyle, and taking supplements that are beneficial to the couple.
It may also include taking fertility medications and using a timed pelvic scan to assess follicular (egg) development.
Once the eggs have reached maturity, a single injection is given to induce ovulation or release the eggs. After that, the couple will be asked to time their intercourse accordingly.
Intrauterine insemination (IUI): This is a type of artificial insemination in which washed and concentrated sperm is inserted directly into the womb’s cavity via a thin catheter at the same time that one or more eggs are released by the ovaries.
The sperm would then travel through the fallopian tubes to fertilise the eggs, which would hopefully result in a pregnancy.
According to Dr Haris, this method could be beneficial in cases of mild to moderate male factor infertility. However, tubal patency must be determined first.
Test-tube babies: IVF and ICSI are two types of assisted reproductive treatment (ART) in which eggs are fertilised with sperm outside of the body.
The first step in this treatment is Hormone stimulation, in which the woman’s ovaries are stimulated with a course of injectable fertility drugs.
This is followed by Egg retrieval, in which the eggs are retrieved while the woman is under light anaesthesia.
Embryo development is the third step, in which the eggs are fertilised by the sperm.
When using IVF, the male partner’s sperm is added to the eggs to facilitate fertilisation.
During ICSI, the Embryologist selects a single sperm and injects it into each egg with a microscopic needle.
The fourth step is Embryo transfer, which is the placement of the embryo in the womb. This could be a planned fresh or frozen embryo transfer.
The fifth step is to test for clinical pregnancy and continuous care.
