This commentary was also published in Karyawan, A Magazine by the Association of Muslim Professionals (AMP), January 2019, Volume 14, Issue 1
Not everyone dreams of becoming a parent but, for those who do, failing to conceive is an agonising realisation. There are couples who spend a portion of their married lives attempting to avoid unplanned pregnancies and assume that, once they are ready to conceive, it will occur with little difficulty. They imagine that ‘shifting gears’ from preventing pregnancy to planning procreation is as easy as shelving birth control. A failure to conceive can then be devastating, often unsettling otherwise well-adjusted couples. In addition, the persisting stigma associated with the subject of infertility compounds these reactions.
According to the World Health Organisation, infertility is described as ‘the diminished or absent ability to conceive or produce an offspring’. It can also be defined as failure of couple to conceive after 12 months of regular intercourse without the use of contraception in women below 35 years of age; and after six months of regular intercourse without the use of contraception in women aged 35 years and above.
Infertility over the years
While there has been an increase in the number of patients dealing with infertility, according to doctors we interviewed, the good news is that there are treatment options available for it. In fact, over the years, treatment for infertility has become more effective with fewer side effects. It has become more affordable too. New methods of diagnosing and treating infertility have improved many couples’ odds of having a baby.
However, infertility treatment is sometimes seen as a luxury, involving significant financial costs that places it beyond the reach of the socioeconomically disadvantaged. In addition, although tremendous strides have been made in treating this relatively common condition, infertility is typically not openly discussed.
Deciding on fertility treatment
Generally, when a couple fails to conceive after a period of time has lapsed following marriage, concerns over their ability to conceive naturally will begin to set in. Based on interviews done by The Karyawan team, the decision to pursue medical options tend to happen between one and three years after marriage or sooner if a couple’s age has crossed the 30-year mark. Diana (not her real name), for example, did so after three years of marriage, at 28 years of age, fearing that it will be harder to conceive once she hits her thirties. Prior to this, she tried various means – from traditional medicine and massages to vacations to combat stress – in her bid to conceive naturally.
The decision to consider medical options was not an easy one. This is because, while awareness about infertility issues has increased over the decades, especially with the median age of marriage increasing, it remains a subject fraught with myths and misconceptions, which often leaves people struggling with infertility to suffer in silence.
Misconceptions about infertility
The reality, however, is that infertility is common and affects even healthy couples. There is a 15% to 20% probability that someone you know is struggling with it, even if you are not aware of it. According to HealthXchange.sg, one in six couples in Singapore are unable to conceive within 12 months of trying for a baby.
Our interviews suggest that husbands recognise that infertility affects both men and women but there is a lingering myth that women are more vulnerable. Consultant Obstetrician and Gynaecologist at Pacific Healthcare Centre, Dr Nurhidayati Mohamed Suphan, explained that theoretically, there is an equal chance that infertility could be due to the “male factor” as it is with the “female factor”. Each factor can be further broken down into different fertility issues. For example, for males, even if sperm count and volume are good, problems with sperm motility and morphology could still cause infertility. Similarly, women may face issues such as blocked fallopian tubes or polycystic cysts on ovaries. It is also possible for male and female factors to combine to contribute to infertility. She emphasised the complexities involved in assessing each case and cautioned against oversimplifying the causes of infertility along gender lines.
Which procedure should come first?
Given the responses of interviewees, there appears to be uncertainty about which fertility treatment should be attempted first. Nora (not her real name) was approaching her late twenties when she decided to see a doctor after “about a year of trying”. As she and her husband were both assessed to be “normal”, she was advised to try again for another six months. Six months later, she was back at the clinic and opted for Super Ovulatory and Intrauterine Insemination (SO-IUI). When it failed to produce results, she saw another doctor the following year who prescribed IUI as the couple were both “normal”. However, Nora said she was “impatient” and insisted on In-Vitro Fertilisation (IVF). She did get pregnant but, as blood tests indicated, she lost her pregnancy before an ultrasound scan could be done. Two years later, she gave IVF another shot but was again left disappointed.
Lisa (not her real name) also underwent IUI once. When she failed to conceive, she proceeded with IVF. After three attempts, she was successful and has since given birth to a pair of twin baby girls.
Looking back, Lisa wished she had skipped all the other procedures and went straight to IVF. She was advised that the success rate of IVF declines with age.
Dr Stephen Chew, Head and Senior Consultant at the Division of Reproductive Endocrinology and Infertility, National University Hospital Women’s Centre, however, explained that an aspiring parent should try IUI three to four times before considering IVF. It is only in some circumstances like bilateral blocked fallopian tubes or very low sperm count – for example, less than five million per millilitres – that IVF is needed from the start.
His views is concurred by Dr Nurhidayati, who advises against going straight to IVF before trying out IUI or Clomid (clomiphene), a non-steroidal fertility medicine. In the case of women, it is possible to have one fallopian tube which is normal and another which is blocked. This reduces the likelihood of pregnancy but IUI could still be considered. IVF is most useful if the fallopian tubes are completely blocked.
Chances of successful outcome
Dr Chew also debunked the misconception that the success rate of IVF is 100% as many think or hope for. It is in fact in the region of 30% to 40%. He has seen couples rushing to do IVF and ending up failing, then getting pregnant on their own or after IUI. This is true in the case of Nora. After her second IVF attempt failed, she took a two-year break and then saw another doctor who strongly advised her against considering IVF again before trying IUI at least three times. She settled for IUI and finally became pregnant – a journey spanning more than six years.
Dr Nurhidayati has a patient who went for numerous IVF cycles, only to conceive naturally at the age of 43. There may be many chemical factors to it but if, for instance, a person relaxes, the possibility of pregnancy rises.
Dr Chew also shared that there are other steps to take to increase chances of successful pregnancy: lose weight if one is overweight, take folic acid and have regular intercourse – two times per week if one has no time to determine ovulation timing.
How long will it take?
Is it normal for an attempt to conceive a child to take many years?
According to Dr Chew, for a couple with good sperm, normal fallopian tubes and who is ovulating every month, in most cases, pregnancy will occur within a year. This is on the condition that the couple has regular intercourse, not once a month but about two times a week. If the couple does not manage to conceive after trying for a year, it is time to seek help.
For women older than 37, he recommends seeking help earlier, after six to eight months of trying, so that they can be quickly assessed and fertility treatment, IUI or IVF, started earlier if needed. Couples who start too late risk going through multiple IVF cycles and still failing to get pregnant despite the best efforts from everyone, including the doctors’. His advice: do not wait till it is too late.
Dr Nurhidayati added that, generally, the younger the couple, the better their prospects of getting pregnant. If a person is in his or her forties, he or she could go for medical consultation right away. There are many reasons why a person should seek one. While age 35 is a good guide, it remains an arbitrary cut-off. Thus, in the case of a woman, the younger she is, the brighter the hopes of fertilisation.
Emotional and financial support
Undergoing fertility treatment requires time commitment and emotional support. Diana shared her experience of juggling work and fertility treatments. Going to the hospital frequently, injecting herself every day, taking medical leave and enduring the emotionally-taxing wait. She worries about taking too many days of medical leave. Fortunately, her manager and colleagues were supportive. Moreover, she kept her spirits up by participating in online support groups. Her husband’s support has been instrumental in seeing her through the difficult times. She is now pregnant with her first child.
Procedures like IUI and IVF are costly and may pose a challenge for those in the lower-income brackets. The cost of IVF in Singapore for private hospitals ranges from $12,000 to $20,000 while that for public hospitals from $10,000 to $15,000. This includes doctor’s consultation, ultrasound, egg collection, egg transfer, lab charges, nursing fees, use of the operating theatre and recovery room. The price excludes medication, additional lab fees and optional procedures. For IUI in private hospitals or fertility centres, a patient may pay between $850 and $1000.
However, there are schemes available that mitigate the prohibitive costs of such procedures. The Enhanced Co-Funding for Assisted Reproduction Technology (ART) Treatment initiative aims to make ART treatments more affordable. This refers to treatments such as IVF and its variations.
Eligible couples seeking ART treatment in public hospitals can receive up to 75% in co-funding from the government for a maximum of three fresh and three frozen IVF cycles.
Pressure from social circle
All of The Karyawan’s interviewees experienced pressure that is brought to bear by their family and/or social circle.
Nora feels that people should refrain from thinking that a couple who is childless are not trying hard enough or are deliberately delaying having a child. This is the last thing, she said, a couple wants to hear and that it is best for them to keep their speculations to themselves.
Lisa wished that people would stop asking casually about when a couple plans to have a baby. She said, “These are private matters between husband and wife. We have friends who have not yet conceived but we never tell them what we did (the fertility treatments) because we understand their plight, having been through it ourselves. Society is not ready to accept couples’ decision to try IVF because of the prevailing stigma: relatives and friends will think that the husband or wife has a problem. This is village thinking in a modern country.”
Diana thinks people still tend to put the “blame” on women although the inability to conceive could as likely be contributed by male infertility. She has even heard remarks such as her not knowing how to have intercourse. Occasionally, she will be upfront about her condition to curtail further probing about her plans.
In her quest for a baby, there were times when she tried “whatever people suggested that might work”.
The experiences of those who struggled with infertility suggest that there are still substantial gaps in knowledge of infertility among the masses and that casual questions about when a couple plans to have a baby should be made a socially taboo topic.
Abdul Shariff Aboo Kassim is a Researcher / Projects Coordinator with the Centre for Research on Islamic and Malay Affairs (RIMA), the research subsidiary of the Association of Muslim Professionals (AMP).
Nabilah Mohammad is a Research Analyst at RIMA and holds a Bachelor of Science in Psychology and a Specialist Diploma in Statistics and Data Mining.
Photo Source: Alex Pasarelu on Unsplash