Subfertility and Infertility: Understanding Fertility Problems

In 2016, the Department of Statistics Malaysia reported that the country’s birth rate was plummeting, reaching a new historic low. The country’s total fertility rate has also been declining for the past 38 years, going from 4.9 babies per woman aged 15–49 years in 1970 to just 1.9 babies in 2017. What’s more worrying here is that first-time mothers are getting older, with a national average of 27.7 years old. Evidently, the issue of fertility is a pressing one and should be properly addressed.

Couples and fertility problems

The prerequisite to a successful pregnancy is a fertile set of couple. Couples with fertility problems struggle for years to conceive their first bundle of joy. Up to 85% of couples with normal fertility are believed to conceive following unprotected sexual intercourse within a (1) year. If not, the chances of conceiving will continue to drop as the couple gets older. Multiple factors contribute to this problem which include age, hormones, body weight, health status, diet, occupation as well as lifestyle

Nowadays, infertility problems may be overcome successfully through medical intervention such as ovulation induction, Intra-Uterine Insemination (IUI), Intracytoplasmic Sperm Injection (ICSI) or In-Vitro Fertilisation (IVF). However, none of these methods guarantee success but they greatly increase the chances of conceiving. 

This begs the question – what’s making couples less fertile in today’s society? Who, if any, is at fault here? 

Asking the expert

To understand the issue better, the Hello Doktor team spoke with Dr Helena Lim, a Fertility Specialist and Consultant Obstetric & Gynaecologist at KL Fertility Centre in a casual interview session.

Dr Helena graduated from the National University of Malaysia (UKM) in 1999 and went on to complete her Housemanship training at Hospital Kuala Lumpur. She then became a trainee lecturer at the Obstetrics & Gynaecology department of UKM Medical Centre. In 2006, she pursued her master in Obstetrics & Gynaecology in the United Kingdom before coming back to UKM as a full-fledge lecturer.

Because of her deep interest in the field of fertility, she conducted multiple studies and underwent rigorous training on the subject matter. In 2012, she decided to join the KL Fertility & Gynaecology Centre team as one of its esteemed consultants. Since then, she has helped countless couples to overcome their fertility problems and achieve successful pregnancy. According to Dr Helena, every time a couple successfully conceives, she too shares the same excitement and happiness. She believes that it is a beautiful and noble cause that she should never turn her back on. 

Male vs female: Who’s to blame?

It is almost a knee-jerk reflex to ponder on who is at fault when a couple struggles to have kids. More often than not, society tends to pin the blame on the lady when it comes to this matter. 

Yes, it’s true that certain female health conditions and other factors can greatly contribute to the increase or decrease in chances of conceiving. After all, women are special as they bear and nourish the fetus in their womb for 9 months. However, what is also true is that making babies involves teamwork, so when they fail to achieve that objective, they fail as a team. 

In fact, in the past 5 to 10 years, problems with male fertility has been on the rise. It is estimated that between 40 to 50% of all infertility problems are caused by men. According to Dr Helena, it is pointless to argue and blame one another. When faced with such a situation, couples should seek help and counselling from fertility specialists.

infertility-in-men

Subfertility vs Infertility

According to Dr Helena, beyond infertility, there’s also the problem of subfertility. The two terms are often used interchangeably yet they do not bring the same meaning. Subfertility simply refers to delay in attaining conception. Because of this, couples facing subfertility still have a chance of getting pregnant without the aid of fertility treatment, albeit longer. 

Infertility, on the other hand, refers to the inability of a sexually active couple to conceive through unprotected sexual intercourse after a period of a (1) year. It is unlikely for infertile couples to achieve pregnancy without medical intervention.

Subfertility risk factors

In general, both men and women share the same risk factors for subfertility which include:

  • Age (Men beyond the age of 40 and women beyond the age of 35)
  • Being overweight or underweight
  • Smoking cigarettes
  • Illicit drug use
  • Excessive alcohol intake
  • Physical and/or mental stress
  • Frequent exposure to radiation
  • Frequent exposure to toxin
  • Chronic use of certain medications

Causes of subfertility and infertility often overlap. Below are some factors which can contribute to fertility problems:

#1. Ovulation problems

Before fertilisation can occur, mature and healthy eggs need to be released from the ovary. If there are any anomalies to the ovulation mechanism, fertilisation may not take place at all. Some ovulation problems affecting fertility include:

  1. Polycystic ovarian syndrome (PCOS): Hormonal imbalance due to PCOS interferes with the growth and release of eggs from the ovaries (ovulation).
  2. Diminished ovarian reserve (DOR): DOR occurs when a woman’s ovaries lose their reproductive potential. A woman’s ovarian reserve refers to the quality and quantity of her eggs, and diminished ovarian reserve indicates that those factors are deteriorating. It can be due to aging, medications or previous ovarian surgery. 
  3. Premature ovarian insufficiency (POI): Also known as premature ovarian failure, POI occurs when a woman’s ovaries stop working normally before the age of 40. This condition leads to premature menopause and could largely be caused by certain medications or cancer treatment. 
  4. Conditions affecting the hypothalamus and pituitary gland: The hypothalamus-pituitary axis regulates the secretion of various hormones in the body. If there are anomalies concerning these glands, important ovarian hormones will ultimately be affected as well, leading menstrual problems and eventually infertility. 

#2. Uterus problems

The uterus is where a baby is nourished and grows before it is delivered. Therefore, any anatomical defects of the uterus will affect its ability to sustain a viable pregnancy. The structural defects or anomalies can either be congenital or acquired over time. This includes:

  1. Septate uterus: As the name suggests, this condition refers to a uterine deformity where the uterus is divided in the middle, separating it into two pockets.
  2. Bicornuate uterus: This uterine anomaly refers to the development of a deep indentation at the fundus (top) of the uterus, reducing the uterus cavity, giving it a heart-shaped appearance.
  3. Uterus didelphys: This rare uterine anomaly refers to the existence of two different uterus in a woman’s reproductive tract. They can either share the same vaginal canal (unicollis) or have a dedicated one for each uterus (bicollis). 
  4. Fibroid: Fibroids are non-cancerous growths that develop in or around the womb (uterus). The growths are made up of muscle and fibrous tissue that vary in size. It affects the possibility of pregnancy by reducing the amount of available normal uterine wall for implantation.

#3. Fallopian tube problems

Fallopian tubes are the conduit between the ovary and the uterus. It is the channel in which an ovum uses to travel to the uterus. Any obstruction in this vital tube will prevent fertilisation or implantation from taking place. Some diseases that can lead to problems of the fallopian tube include:

  • Endometriosis
  • Pelvic inflammatory disease (PID)
  • Scar tissues from previous surgery (i.e. from ectopic pregnancy removal)
  • History of gonnorrhea or chlamydia

#4. Sperm production problems

Conditions that affect the testes’ ability to produce normal and healthy sperms can lead to infertility. These anomalies can be due to several reasons such as:

 

#5. Sperm motility problems

Sperms swim through the uterus to reach the ovum. However, if there are problems with the sperm’s ability to move, fertilisation is hard to come by. Causes of sperm motility problems include: 

#6. Problems with the body’s immune system

In rare instances, certain immune-related conditions can cause the mother’s immune system to attack the developing embryo – preventing a viable pregnancy from taking place. 

What can you do?

Dr Helena advises couples not to delay seeking treatment as one of the main factors involved in this problem is age. As couples begin to age, their fertility rate declines, making it more difficult to conceive. Fertility screening should begin as soon as possible, especially when either half of the couple reaches the age of 35 and above. This allows doctors to detect the causes of infertility early and treat it while the damage is still minimal. This will also provide doctors with insights on the extent of the problem, and whether it is limited to just one partner or both. 

Despite the marvel of modern medicine and technologies, Dr Helena conceded that in 25% of all cases, the causes of infertility or subfertility may not be found at all. It is heart-breaking and disappointing for both couples and specialists as they struggle to understand the root cause of the problem. The thought of seeking answers after several years of trying, and only to be told that everything seems normal, can leave couples devastated.

In conclusion, fertility problems involve complex and multifactorial issues which should not be seen as a one-sided problem. Should you be diagnosed with infertility or subfertility, giving up should not be an option. There are several treatment options available to help struggling couples welcome a new addition to their family. 

Hello Health Group does not give medical advice, diagnosis or treatment. 

msBahasa Malaysia

Sources
Dr. Helena Lim Yun Hsuen Fertility - Obstetrician & Gynaecologist
Dr Helena Lim Yun Hsuen qualified as a doctor from Universiti Kebangsaan Malaysia in 1999. She obtained her specialist ...
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Dr. Helena Lim Yun Hsuen Fertility - Obstetrician & Gynaecologist

Dr Helena Lim Yun Hsuen qualified as a doctor from Universiti Kebangsaan Malaysia in 1999. She obtained her specialist degree in the UK in 2006 and completed her master degree in Obstetrics & Gynaecology in the same year. She has been a Consultant in Obstetrics & Gynaecology with special interest in Fertility since then. In 2018, Dr Helena Lim received her Fellowship award from the Royal College of Obstetricians & Gynaecologists, UK (FRCOG). Dr Helena is especially interested in the impact of nutrition, stress and psychology on fertility. 

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