MD Singapore May 2011

Fertile Future

Fertility Preservation Techniques

Dr Kelly Loi

Fertility problems may arise due to problems in the female or the male reproductive system. Female infertility reasons can broadly be divided into 1) ovulation disorders, eg, caused by polycystic ovaries, 2) endometriosis and 3) tubal disease. In secondary infertility, it is possible that a patient had an underlying health problem when she conceived before, but was fortunately not affected then.

Age is an important contributing factor to infertility. Although the evidence is less strong compared to women, men may also become less fertile as they get older. In men, the quantity and quality of sperm may deteriorate with time, making it difficult for them to reach and fertilise an egg. This can occur as a result of poor diet or lifestyle habits as well as chronic illnesses such as diabetes and raised blood pressure.

The likelihood of conceiving ranges from 20% a month in a woman in her late 20s to 8% in the late 30s. Even the success rate of artificial reproductive treatment is affected by age and pregnancy rates fall with increasing age, from 40% in women < 35 years to just 10% in women over 40 years.

Women are born with a fixed number of eggs. With increasing age, there is a fall in ovarian reserve, ie, the number of functioning follicles or eggs left in the ovaries. In cases of early menopause, the eggs run out much sooner than usual. In addition, there is also a decline in the quality of eggs, with an increased risk of genetic abnormalities. This, in turn, results in an increased risk of miscarriage. Women under the age of 35 years have about a 15% chance of miscarriage while those 35-45

years old have a 20-35% chance of miscarriage.

With increasing age, our general health also tends to decline. Existing conditions may worsen or new illnesses may develop, which can have an impact on fertility too.

Referring to a Fertility Specialist

Early diagnosis and treatment of infertility is crucial in the successful management of a couple seeking infertility treatments. Infertility is defined as the inability to conceive after one year of unprotected sexual intercourse. Ideally, the frequency of intercourse should be two to three times a week.

Up to 90% of couples should have conceived by the end of the 1st year of trying. At this point,

if they still have not conceived, further investigations are warranted. However, older couples should be referred to a specialist earlier, particularly in the case of women over the age of 35. It would be prudent to refer them to a specialist after six months of trying to get pregnant.

An early referral is also indicated if a female patient has a history of amenorrhoea (no periods), oligomenorrhoea (infrequent periods), dysmenorrhoea (painful periods), pelvic inflammatory disease (PID) or previous surgery. In such scenarios, the likelihood of gynaecological disorders is high and she should seek specialist advice sooner rather than later. A history of menstrual irregularity could indicate an ovulation problem

Medical Advice for Patients Trying to Conceive

For couples

Try to start planning for a family as early as possible

Maintain a normal weight, exercise and eat a diet rich in fruits, vegetables and antioxidants

Stop smoking as smoking impairs sperm quality and female smokers are 1.6 times more likely to be infertile

Limit alcohol intake to two drinks per day

For women

Limit coffee intake to one cup a day as high levels of caffeine are associated with decreased fertility and an increased risk of miscarriage

Take folic acid to prevent certain birth defects

For men

Wear loose-fitting undergarments

Avoid extremely hot temperatures, such as hot tubs or saunas

Use lubricants which are suitable for conceiving

MD Singapore May 2011

which would benefit from ovulation induction medications. Painful periods may indicate the presence of endometriosis, ovarian cysts or fibroids, which may benefit from surgery to improve her fertility status. A history of PID or previous pelvic surgery may cause tubal disease which would then require tubal surgery to unblock the tubes, or in vitro fertilisation to bypass the tubal blockage.

Fertility Preservation for Cancer Patients

Treatments for cancer – such as chemotherapy and radiotherapy – may damage fertility. In such cases, sperm and eggs can be frozen before treatment starts in order to prolong fertility.

Recent advances in cancer therapy have resulted in an increased number of long-term cancer survivors. It has been estimated that by 2010, one in 250 young adults will be childhood cancer survivors (Blatt, 1999). Quality of life is an important issue for cancer survivors and fertility after cancer treatment is often a concern. With the recent success and advances made in fertility preservation for cancer patients, international guidelines now recommend that these options should be discussed with the patient. If a young patient is diagnosed with cancer, it is important to let them know early about such possibilities.

The strategies to preserve fertility in women with cancer include frozen storage of embryos, storage of oocytes for future in vitro fertililisation and storage of ovarian tissues.

Cryopreservation of embryos

Cryopreservation of embryos is the most established technique but requires ovarian stimulation, oocyte retrieval and in vitro ferti