Usually, women who have regular cycles, tend to ovulate consistently. Women who have irregular cycles may have delayed ovulation or even skipped ovulation. A few clues of ovulation are

– watery cervical fluids during the fertile period
– feeling warm or feverish during the 2nd half of the cycle
– one-sided pelvic around the ovulation time
– a ‘positive’ reading with a ‘Ovulation Prediction Kit’

Not all women ovulate on Day 14 of her cycle every month (only 10% do). It depends on individual cycle length. Ovulation usually occurs two weeks before the next period starts. So we have to count backwards from the predicted start of the next period in order to find the most fertile time this month

Take the number of days in the usual cycle (from the beginning of one period to the beginning of the next) and subtract 14. For example:

• a woman with a 35-day cycle would likely ovulate around day 21 (35-14=21)
• a woman with a 28-day cycle would ovulate around day 14 (28-14=14)
• a woman with a 25-day cycle would ovulate around day 11 (25-14=11)

* If your menses have a range of between 28 to 32 day cycles, then ovulation may be as early as day 14, up till day 18 (32-14=18) of the cycle. So, to cover ALL possibilities, we recommend starting intercourse 1 or 2 days before the earliest predicted ovulation day, continue having intimacy alternate days, up till 1 or 2 days after the last predicted ovulation day. So, for women with 28 to 32 days cycles, have intimacy on day 12, 14,16,18, 20.

Getting pregnant is hard work!

85% of normal, healthy couples usually conceive naturally by the end of 1 year. So, if you have been seriously trying to conceive (TTC) for more than a year, then it’s best to see a gynaecologist or a fertility doctor.

However, if known causes infertility exists, eg:

• Irregular menses
• Previous surgery to fallopian tubes (ectopic)
• Any ‘cyst’ treated or not
• Endometriosis – ‘chocolate cyst’
• Age >35 year old
• Repeated miscarriage
• Sperm production problems
• Erectile dysfunction

then it’s best to see a doctor sooner, rather than later.

Generally, fertility ability drops after 35 years (some even before 30 years!) of age. This ‘biological clock’ phenomenon is tied to the fact that women have limited amount of eggs available when they came into the world at birth.

The quantity of eggs left falls every year, and more marked after 35. Apart from egg quantity, there’s the issue of egg QUALITY, which are also tied to a woman’s age. After 40, outlook for conceiving is drops considerably

It depends.

Too much stress causing lack of sleep, poor food intake, zero exercise, etc will take a toll on the body’s health. This may signal the ovaries (egg factories) to temporarily stop egg production as the body is not in good condition to get pregnant.

On the other hand, focusing too much on reducing stress, quiting job, moving house, yoga everyday of the week, and not making sure the other components of fertility are in working order, eg, healthy tubes, good quality womb lining, and normal sperm function, just solves one part of the fertility jigsaw puzzle.

Using lubrication, eg, KY jelly, may help reduce friction and discomfort during intimacy. However most commercial lubricants contain preservatives and other chemicals that may affect and slow down the sperms. Saliva contains enzymes that kill bacteria and digest food. So both are NOT recommended if trying for baby.

Natural lubricants that are safe are raw egg whites (make sure don’t swallow to avoid getting salmonella infection) or vegetable oil, like olive oil. There are ‘fertility safe’ lubricants which are marketed as being safe for conception, eg PreSeed.

Many well-meaning folks may have suggested that certain conditions are best for conception, some say depending on how your womb ‘lean backwards, or lean forwards’ or even whether the moon is full or not.

Some also advise certain positions after sex, eg, legs in the sky, pillow under buttocks, etc, to prevent sperm from leaking out.

The fact is as long as the tubes are clear, the egg has/is about to ovulate, sperms are good swimmers and present in adequate amount, position really does not matter. Good swimming sperms will enter the womb in a few minutes after being deposited in the vagina, and should reach the ovaries within 20 to 30 minutes. All we need is only 1 sperm to meet 1 egg.

Initial check would be to get information on the menstrual cycle, eg, cycle length, bleeding days, painful periods, medical problems, pregnancies, and any previous surgeries. Next would be physical examination which includes heart, abdomen and pelvic examination and pap smear (if needed).

Ultrasound:

Ultrasound examination is an important part of detecting any structural problems of the womb, tubes and ovaries, and can be done in under 5 minutes. Both scanning from the tummy as well as internal scan is carried out to get a full picture of internal structures.

Blood tests:

There are a wide range of ‘blood tests’ that can be done, from the basic ones, which look at the general wellbeing, hormone tests which have to be done at different times of the menstrual cycle, to more advanced tests looking at auto-immune antibodies (immune system cells that which mistakenly attack the own body) and specific genetic tests, eg, thalasemia or chromosomes.

Fallopian tubes:

Ultrasound examination can pick up obvious blockages that cause swellings of the tubes, but some blockages may not be seen. A HSG (hysterosalpingogram) is a procedure done at a hospital by an x-ray doctor (radiologist), who will spray a small amount of special liquid up the cervix, into the womb and subsequently flow through the fallopian tubes into the abdomen. This can be seen via x-rays taken at a few minutes intervals to track the flow of the special fluid that can seen with x-rays. Blockages of the tubes can then be identified if the flow of fluid through the tube does not happen. Sometimes problems with the womb cavity can be seen too, eg, polyps, scar tissue.

If there are large cysts present at the ovaries, and laparoscopy ‘keyhole’ surgery is required, the fallopian tube can be checked by spraying a blue coloured dye into the womb from the cervix. The added advantage of checking the tube during laparoscopy surgery is that treatment of underlying cause of the tube blockage can be done at the same time.

Endometrial sample:

The endometrium or womb lining is where the baby will stick and grow into a pregnancy. In women above 30 years of age, a condition known as endometrial hyperplasia may occur, especially if the menses are irregular, ie, comes only every 2-3 months. Small strips of the tissue can be remove in the clinic and sent to the lab to confirm it’s presence.

A lot of folks assume that infertility only affects women. In fact, male fertility problems can be found in 40% of couples trying to conceive, TTC. Therefore it’s good to just check the male side early, and not after extensively putting the female side through a battery of tests over half a year, only to find out that the male partner is the cause of infertility.

For guys, initial check up is quite straight forward. Questions will be asked regarding any medical illness or surgery done before, particularly relating to his reproductive organs, ie, any mumps infection, fall and trauma to the scotum, etc.

Next step would be a Seminal Fluid Analysis – ‘sperm test’, whereby a fresh sample of the sperm (note: no sex for 3-5 days for a good sample) is examined for 3 important criteria:

• Concentration – numbers
• Motility – how fast they swim
• Morphology – shapes of the sperms

If the sperm test is normal, usually that’s all that is need.

If the sperm test is abnormal, then further tests, eg, blood test for hormone levels and genetic testing, ultrasound scanning of testes, and physical examination by a urologist may be required.

Yes, definitely! Even though this is something you may not want your current partner/husband to know, being pregnant before means that at least one of your tubes have been normal, and the environment inside your womb was suitable for pregnancy. And I’m sure your fertility doctor would benefit with this information.

You may inform your doctor later, during another visit, when your current partner/husband is not around.

Having kids previously is a good sign, meaning your womb, and fallopian tubes and partner’s sperm were in working order previously. However, this is not a guaranteed situation as aging affects both men and women. Aging decrease the quality of eggs, and this decrease fertility, and increases the risk of miscarriage.

Other problems could be infections or immune system disorders that develop after the previous successful pregnancy.

Some ladies, even if they have just delivered and are still in the hospital, can’t wait to get pregnant again and start production for baby no. 2, no. 3, and so on. This understandable as people can’t get enough of this tiny bundle of joy.

For these excitable ladies, I would like to curb their enthusiasm slightly by advising them to give themselves at least a year of rest before trying for the next baby (natural or caesarean delivery, the time frame is the same). Their body just underwent tremendous changes over a period of 9 months, including surgery, bone loss (in form of calcium to your baby), and their kidneys and heart have barely finished recovering from the physical toll of pregnancy.

Another consideration is if they are breast feeding exclusively (full time), the menses will not come for at least 6 months (this is because the hormone prolactin which promotes milk growth will stop the ovaries from producing eggs for at least 6 months). This is also nature’s way of making sure the mother is well rested before the next pregnancy.

The 3rd issue is that they now have a small baby to take of during the next pregnancy, which means physically moving about, carrying the baby (which you didn’t need to do the first round) with a pregnant tummy.

For women who are <35 years of age, and couple does not have any major issues (e.g, fallopian tube blockage, polyps, or sperm quality problem), each IUI cycle carries a pregnancy rate of 20%. If one of the tubes are blocked, or if the husband’s sperms are slow swimmers, then the chances drops.

If both tubes are blocked, or if the husband’s sperms counts are extremely low (less than 1 million/ml after washing), then IUI success drops to less than 5%

By comparison, average success rates of:

• Fertility pills – 10% per month
• IVF – 40 to 60% per treatment cycle (depending on individual circumstances)

Medications to get the eggs growing are:

1. Fertility tablets only, usually 5 days in total
2. Hormone injections only, between 4 to 8 days
3. Mixture of fertility tablets, and hormone injections (usually 3 to 5 times)

The purpose of tablets and injections are to encourage the eggs to grow, aiming for 2-3 mature eggs (as compared to only one in a natural cycle). Depending on individual response, sometimes injections may not be needed at all.

Not really, most women find it tolerable, and not ‘traumatic’ at all.

The first part of the treatment is the 2 weeks after the menses, whereby fertility medications are given, either in tablet form, or injections are given (between 3 to 5 in total on average). These injections use very, very small needles, and can be self-administered.

The actual IUI procedure, is almost like a pap smear examination, whereby a speculum (shaped like the beak of a duck) is used to help see the womb opening. Some pressure is felt when the speculum is inserted and opened. Next, a small straw tube, 1.5mm diameter is passed through the womb (some cramping sensation will be felt) and the partner’s sperms are released within the womb.

After resting for 20 minutes, the women can go home, or even back to work.

In our centre, IUI costs between RM 1500 to RM 2000 (USD 330 to 450).

This includes consultations, scans, medications (tablets and injections), sperm preparation, IUI procedure, and hormone tablets after the IUI. Payment is made step by step, and not as a ‘lump sum’.

Not all women/couples need IVF straight away.

There are other simpler treatments of getting pregnant. However, there are certain conditions whereby IVF is recommended:

• Blocked fallopian tubes
• Endometriosis – ‘chocolate cyst’
• Moderate to severe male factor infertility
• Older age (>35 years of age)
• Unexplained (everything looks ‘normal’ but can’t seem to get pregnant)

Please see this article here for case studies of the above examples

IVF treatment has been around since the 70s, and the potential side effects are well understood.

Hormonal injections that stimulate the eggs to grow commonly cause tiredness, and some bloating, especially nearer to ovulation period. Bruising around the injection site on the tummy is also common, and disappears after a few weeks. The egg collection procedure will be done under anaesthesia (which lasts for about 10 to 15 minutes). The effects of drowsiness may last half a day due to residual anaesthesia in the body. There may be some light bleeding and cramps for 1 day after the procedure.

Bad reaction to anaesthesia is very rare, about 1 in 5000 cases.

Serious injury during egg collection happens about 1 in 2000 cases.

OHSS, ovarian hyperstimulation syndrome is a condition that happens after egg collection, whereby the egg shells of both ovaries continue to leak body fluids into the tummy, due to over sensitive ovaries. The tummy may swell due to the body fluids, and in rare cases collect in the lungs too. Younger women, or women with many eggs, are at higher risk of developing OHSS. The risk of severe OHSS is uncommon nowadays as fertility doctors have some strategies to reduce their risk, eg, freezing the embryos, and post-pone the embryo transfer to a month or 2 later.

The issue is to balance the chance of getting pregnant (the more embryos we transfer, the higher the chance of embryos implanting in the womb) vs risk of multiple pregnancy (danger to mother and babies).

In the early days of IVF (80s and 90s), transferring 3 to 5 embryos was the normal practice. This lead to many problems, notably multiple pregnancies, eg triplets, quadruplets, etc, which in turn led to severe premature births (eg, babies born at 5 or 6 months, less than 0.5kg).

As IVF technology matured, and pregnancy rates improved, lower numbers of embryos are transferred back to the womb. On average, 1 or 2 embryos are transferred in our centre. Some of the factors that influence how many embryos to transfer:

1. Age of the mother
2. Quality of embryos on Day 3 or Day 5
3. Others (previous successful IVF cycle or not, overall quality of embryos, etc)
   • Less than 35 years of age – 1 or 2 embryos
   • 35 to 39 – 2 or 3 embryos
   • 40 or above – 2 or more embryos   (simplified from ASRM guidelines)

Your fertility doctor will discuss with you the optimum number of embryos to transfer based on your individual circumstances

The miscarriage rate for IVF pregnancies (and also pregnancies via IUI, or fertility pill) babies are the same as the general population.

Commonly, women who undergo IVF or fertility treatments tend to be in the older age group, ie, more than 30, and this increases their risk of having miscarriage in the first place.

Abnormal babies (about 1 in 100 pregnancies) can happen to any pregnancy, at any age, with natural pregnancy, as well as with IVF pregnancy. Even with latest IVF technology, doctors are unable to check for all possible abnormal babies before putting the embryos back into the womb. (see PGD/PGS)

Once pregnant, tests (scans, blood tests, etc) can be done to examine whether the baby is abnormal or not (however, not 100% accurate).

Of course!

IVF babies, IUI babies, naturally-conceived babies are similar in every aspect. The care during pregnancy, and therefore during delivery is the same for these babies. As long as there are no high risk conditions to the baby, eg, low lying placenta, stunted growth, macrosomia (baby weight >4kg)  buttocks-down position, etc, that will be determined during the final months of pregnancy.

It is important to note that natural delivery carries some risk to the baby as the baby undergoes strong pressures during labour (10 hours on average for 1st time mothers) and may develop complications like fetal distress or passing feces in the womb. Birth complications to the baby, are more common during normal delivery vs C-section.

C-section on the other, lowers the risk to the baby, but places more risk on the mother, eg, blood loss, operation on the tummy, pain, etc.

IVF babies tend to end up with C-section due to the ‘precious’ nature of being an IVF baby. These parents say that since they have tried so long, and spent so much time and emotion trying to get pregnant, they don’t want any hiccups to happen during the delivery.

Yes, the technology exists, and is used for the following medical reason.

There are certain inheritable illnesses that runs in families, and are linked to gender. For example, Duchenne Myodystrophy, a progressive muscle-losing disease, Haemophilia, faulty bleeding factors of blood cause severe bleeding condition, and Fragile-x syndrome, which is associated with mental retardation. In these conditions, if either one of the parents carry these faulty genes, then selection of particular sex of the baby will prevent having a child with the illness.

PGD testing can determine the gender of the embryo to prevent these conditions from being passed on to the future child.