The current population of Singapore, as of the end of the year 2019, stands at 5.7 million people from the 2018 population of 5.6 million people (both residents and non-residents).

This slight population increase has been a part of a gradual slowdown in the rate of population increase over the past ten years.

The gradual decline in the population growth of Singapore has been attributed to a number of factors.

In a study done by Lee Kuan Yew School of Public policy, delayed marriages among Singaporeans has dealt the population growth a significant blow. In this paper, most Singaporeans are now marrying at the age of 30 and 27 for males and females respectively as opposed to the ages of 26 and 23 seen in the ‘70s. 

Delayed marriages come with low fertility as the couple would have a shorter time for procreation. Furthermore, starting a family at an older age is another contributing factor to fertility issues since the number and quality of eggs decline with age.

Other factors that contributed to the fertility rate drop include the increase in proportion of single adults, desire for smaller family sizes and of course infertility.

So what are the most common causes of infertility that many couples find themselves struggling with here in Singapore?

In this article, we shall delve into the causes, diagnosis as well as the treatment. 

What are the most Common Causes of Infertility in Singapore?

The decrease in fertility rate in Singapore is definitely multi factorial, with the intrinsic fertility issues contributing significantly.

Some of the contributing factors include:

1. Endometriosis

This is a fairly common problem that affects women worldwide. The worldwide prevalence of Endometriosis is placed at around 10-15 % of the women.

In a local study done here in Singapore, 84% of the women affected are aged between 20-25 years.

This is a significant portion of women with a high birth rate.

What is endometriosis, and how does it cause infertility?

Endometriosis is a gynaecological condition affecting women mostly of reproductive age. The women affected have ectopic endometrial tissues in places other than the uterus.

Endometrial tissues are the tissues that line the uterus and are shed off during menstruation.

These tissues are found in other parts of the body such as the perineum, the abdomen, and sometimes even in the lungs. Since they are endometrial in origin, these tissues respond to hormones in the body.

Whenever a woman is having her period, these tissues will also be shed off, causing irritation to the surrounding structures and resulting in pain.

How does infertility come about?

Endometriosis causes infertility through secretion of inflammatory cytokines that causes inflammation and irritation of the genital tracts; the result is fibrosis and scarification, and adhesion that may end up causing tubal blockage which ultimately interferes with the fertilization process.

Infertile women are six to eight times more likely to have endometriosis than fertile women.

How do I know I have endometriosis?

Endometriosis will present with the following symptoms, such as deep pelvic pain, pain during sexual intercourse, infertility, spotting, among others. The most common sign is dysmenorrhea (painful periods).

Treatment of endometriosis

Endometriosis can be managed in two main ways:

Medical management: through the administration of contraceptives

Or

Surgical removal of the ectopic endometrial tissues.

The surgical removal of the endometrial tissues coupled with removal of adhesions (adhesiolysis), has shown positive effects in terms of more live births among patients who are already pregnant.

There is also a significant increase in pregnancies of up to 69% of spontaneous pregnancies among patients with endometriosis upon receiving treatment for endometriosis. 

2. Polycystic ovarian syndrome (PCOS)

Studies show that 6-10% of women in Singapore suffer from PCOS. The most affected age group is between 15 and 30 years with 59% being women between 14 and 22 years.

The frequency then gradually decreases with age with women above 30 years, making up less than 6% of the total number of women with PCOS.

What is PCOS?

PCOS is an endocrine disorder affecting women, and its presentation varies from woman to woman. Its signs include obesity, irregular menses, hirsutism (excessive hair growth), and infertility.

It comes about when the androgen hormone (male hormone) is in excess.

How does PCOS cause infertility?

Due to the hormonal imbalance caused by PCOS, women with this syndrome generally have a hard time getting pregnant.

As such, women ovulation may fail to occur due to the impairment of maturation process of the ova by the androgens.

The women also experience irregular menstrual cycles, making it hard for women to adequately predict the fertile days.

How is PCOS diagnosed?

From the presentation, one can be suspected of having PCOS, however, two or three of the following have to be present to come to a final diagnosis of PCOS; hirsutism, irregular menses, and cysts noted on the ovaries on an ultrasound scan.

How is PCOS treated?

Since the infertility in PCOS arises primarily from the hormonal imbalance, the mainstay treatment is hormonal therapy through the induction of ovulation.

This is done through the administration of Clomiphene which stimulates ovulation. Proper timing in terms of administration of Clomiphene and frequent coitus.

This combination has seen a 70% success rate when trying to conceive.

3. Fibroids

What are Fibroids?

Fibroids are the abnormal growth of muscle cells of the uterine wall. It is one of the most common benign tumours of the uterus.

Globally it is estimated that 4.5 -68.6% of the women have fibroids, with data varying from different geographical locations.

These growths present differently depending on where they are on the uterus and their sizes.

How does Fibroids cause Infertility?

These abnormal growths on the uterine walls can cause infertility through several ways. Fibroids located submucosally, below the endometrium, may interfere with the implantation of the fertilized ovum into the endometrium. 

Some fibroids may exert pressure on the fallopian tubes, thus impairing transportation and fertilization of the ovum.

Lastly, a small percentage of the population may have pedunculated fibroids that cause physical impedance to the transportation of the sperm.

How do I know that I have Fibroids?

Commonly, fibroids will cause symptoms like heavy menstrual bleeding. This may present with clots, and sometimes intermenstrual bleeds.

Increased cramping during menstruation, painful intercourse, and pressure symptoms such as feeling of pressure or fullness in your lower abdomen, frequent urination from bladder compression, abdominal swelling, low back pain, and pelvic pressure are some indications of the presences of fibroids.  

Treatment of Fibroids

Treatment depends mostly on their size and location.

The mainstay of treatment to boost fertility is surgery, myomectomy, which involves the removal of only the fibroids.

Some medications have shown some evidence of tumour shrinkage, but so far, they are being used just as a pre-operative approach. Getting fibroids out of the way improves fertility.

4. Tubal blockage

What is tubal blockage?

Tubal blockade for whatever reason, be it congenital or acquired, contributes significantly to both primary and secondary infertility not only in Singapore, but also globally.

Currently, bilateral blockage of the fallopian tubes contributes to a significant 19% of primary infertility cases and 29% of all the secondary infertility cases, which is a significant amount.

How does tubal blockage cause infertility?

The main cause of tubal blockage is chlamydia and gonorrhoea infections.

What these infections do, is they infect the genital tracts causing inflammation and fibrosis in the fallopian tubes on both sides, leading to blockage.

Blocked fallopian tubes, therefore, prevent the meeting of the ova and the sperm for fertilization.

How do I know I have a tubal blockage?

With a history of infertility and chronic pelvic pain, one might suspect having tubal blockage as a result of infection.

A test called the Hysterosalpingogram will be conducted by your doctor.

The test involves a dye being injected through your cervix with an image taken to check for any filling defects that connote a blockage.

Treatment for tubal blockage

The main treatment modalities for such patients are; first, surgery in the form of tuboplasty, and if that fails or cannot be done then In Vitro Fertilization (IVF) can be considered.

For minor blockages, surgery can be done to remove the scar, in an attempt to re-establish their patency.

This can be done by removing the blocked part and reconnecting the patent parts (tubal reanastomosis), creating a distal hole in the tube (Salpingostomy) or separating the clumped-up parts of the distal oviduct (fimbrioplasty).

These methods will ensure that the female egg produced passes through the tube and eventually gets fertilised.

5) Male factors Infertility

Ever heard of “it takes two to tango.”

Well, the same principle applies to fertility. It takes both a man and a woman to make a baby.

For a long time, infertility was viewed as a female problem. Male infertility was ignored and unheard of.

However, in truth, male impotence plays just as significant a role when it comes to the common causes of infertility in Singapore. 

What are male factors infertility?

Studies have shown that up to 40% of infertility problems in Singapore might be originating from the man. 

Infertility in men can be caused by factors such as Chromosome defects, injury to the testicle, diabetes, testicular infections such as mumps, gonorrhoea, or chlamydia, hyperprolactinemia, undescended testes, among others.

How do male factors cause infertility?

It depends on the specific cause of infertility. Infections such as mumps cause impaired formation of sperms, chlamydia will cause inflammation, scarring and eventually blockage of the vas deferens (a tiny muscular tube in the male reproductive system that carries sperm from the epididymis to the ejaculatory duct).

Congenital abnormalities such as an undescended testis will impair spermatogenesis due to the high intra-abdominal temperatures.

How are male infertility factors picked up?

Picking up male infertility will require proper screening of the male partner whenever a couple has difficulty conceiving.

Some causes might have physical manifestations such as chromosomal abnormalities, most common being Klinefelter’s syndrome, where the males affected are tall, have small penises, weak muscles and may have big breasts. 

Undescended testes can be noted through palpation of the scrotum, absence of one or both testes denotes the disorder.

People with chlamydia induced male infertility may have a history of urethral discharge. 

How are male infertility factors treated?

Again, this will depend on the cause, conditions such as Klinefelter’s syndrome are irreversible and the patient will rely on sperm donation while others such as an undescended testis, when picked early, can be salvaged through a surgical procedure aimed at attaching the testis to the scrotum.

Infections can be treated but if scarring has already occurred, then surgery will be needed to re-establish the patency of the tubes

Whenever you are struggling to conceive, always have the male partner accompany you to see a fertility specialist to determine the cause of infertility.

Struggling with Infertility? Help is Available

Infertility is currently a major issue affecting couples in Singapore, as evidenced by the steady decline in total fertility rate to 1.14.

If you are struggling with infertility, don’t be discouraged as there is hope.

Infertility is no longer a life sentence of barrenness and solitude. With the modern advancement in science, there is adequate medical and surgical technology, together with expertise to handle almost all the infertility issues.

Singapore prides itself on having numerous public and private facilities that can handle infertility issues and that means that you can still have your desired bundles of joy.

If you are struggling with infertility, visit a reputable medical facility and get both you and your partner checked.

This is the first step towards finding the best solution for you as you start your own family.