‘We’ve been trying for two years’: Information gaps that trip up couples who want to conceive

Many young couples believe they are doing everything right, only to face unexpected health obstacles when they are ready for a baby.

Many young couples continue to assume that health equals fertility and there is always time, says the writer.
PHOTO: ST FILE

The couple sitting across from me had come prepared, in the way that most well-meaning couples do.

She was on folic acid. He had cut down on smoking. They had been tracking her menstrual cycle, which was around 40 days, but had assumed this was within the normal range. They had read the articles, downloaded the apps, and done what they understood to be the right things.

“We’ve been trying for two years. We thought we were doing everything right.”

What the investigations revealed, however, was a picture neither of them had expected. She had prediabetes and undiagnosed polyendocrine metabolic ovarian syndrome (PMOS), previously called polycystic ovarian syndrome. PMOS is a hormonal and metabolic condition that can disrupt ovulation, cause irregular menses and make it harder to conceive. His semen analysis showed reduced sperm motility.

None of this was catastrophic. All of it was actionable. But what struck me most was not the complexity of their situation. It was that they had never been given the information that might have helped them understand their own reproductive health earlier – not because they were careless, but because, like most people, they had assumed that being healthy meant that pregnancy would follow easily.

This is not always the case, and had they known sooner, they could have acted earlier, before time became the dominant constraint.

Singapore’s total fertility rate now stands at 0.87. A local study suggests that most young adults here overestimate their knowledge of fertility, and that even when awareness improves, it rarely translates into early action. Many continue to assume that health equals fertility, and that there is always time.

What preconception care actually means

To some extent, such situations arise because of how we perceive fertility, and when we feel it is worth thinking about at all.

We need to consider preconception care, which means providing medical and other forms of support to couples before conception occurs, with the aim of improving the health of mothers and children in both the short and long term.

It is not simply a checklist of supplements and lifestyle tips. It encompasses physical health, mental well-being, and the broader conditions that shape whether a pregnancy is likely to succeed and whether the child born from it will thrive.

The evidence for acting early is compelling. The two to three months before and after conception are a critical window for optimising the quality of eggs and sperm, and for supporting the early development of the placenta.

Targeted measures, such as managing chronic conditions, reviewing medicines, improving metabolic health, stopping smoking and taking folic acid, can improve health before pregnancy, increase the chances of natural conception, and reduce maternal and infant risks.

Some actions are most effective before conception, yet most couples do not even have such conversations until they have been trying to conceive for some time without success.

These conversations belong in the everyday spaces where people already seek care – a routine health screening, a visit to the general practitioner (GP), a pre-marital check. There does not have to be a fertility problem to initiate such discussions. Reproductive health is, after all, a normal part of our overall health, so all we need to do is to inquire about it, as well.

Three assumptions worth questioning

Several assumptions shape how we think about fertility, and each deserves examination.

The first is that fertility is primarily a woman’s concern. It is not. Male factors contribute substantially to difficulty conceiving.

Local research has also found that poor sleep, sedentary behaviour, chronic stress, and poor metabolic health are all independently linked to lower sperm quality. Since male reproductive health also changes with age, fertility is a shared concern and should be treated as such from the start.

The second assumption is that being generally healthy is a reasonable proxy for reproductive health. This is not always the case.

Many of the conditions that affect fertility are silent or go undetected. Metabolic syndrome and elevated blood sugar may be present without any obvious sign, discovered only through a blood test. And some conditions, like sperm abnormalities, remain hidden even then – invisible unless someone deliberately does a semen analysis.

In a Singapore preconception cohort, 48 per cent of participating women were overweight or obese at the point of preconception, and 18 per cent had metabolic syndrome – a cluster of conditions including high blood sugar, high blood pressure, and excess body fat – according to a study published in 2022. Women in this group with abnormal blood sugar levels are 44 per cent less likely to conceive in any given cycle. These are not rare findings, but they are often entirely unknown to the individuals concerned.

The third assumption is that fertility conversations should begin only when a couple decides to try for a child. This is perhaps the most consequential of the three, because it means that by the time the conversation starts, some of the most important windows for action may have already closed.

Reproductive health across a lifetime

Age is one of the strongest established factors affecting fertility that cannot be reversed. A woman’s reproductive potential declines gradually through her 30s and more steeply as she approaches 40. This is not a reason for alarm, but it is a reason for awareness – and awareness is most useful when it comes early enough to inform decisions, not after those decisions have already been made.

The case for thinking about reproductive health earlier is not simply about fertility. Improving physical and mental health from adolescence onwards yields benefits that extend well beyond conception.

Healthier young adults become healthier couples and healthier parents, regardless of whether or when they choose to have children. The opportunity to build that foundation is greatest early in life, when habits are still forming.

The motivation to act tends to be highest when couples are actively planning for pregnancy. Both windows matter, and a well-designed system of care would engage people at both.

This is not about pressuring people to have children earlier. It is about ensuring that when they are ready – whenever that is – they have accurate information, a clear picture of their own health, and enough time to act on what they find.

What good preconception care looks like

Good preconception care does not require a fertility problem to begin. At KK Women’s and Children’s Hospital, a Couple’s Preconception Clinic (CPC) sees both partners together, early in their fertility journey, to assess their health, identify risks, and provide targeted support while there is still time to act. The GP or polyclinic are alternatives, accessible settings for couples, where a simple conversation about family planning can open the door to timely advice.

The advanced practice nurse-led CPC launched in 2024 has seen over 100 couples, and around 15 per cent have conceived – some naturally, without any fertility treatment.

These are early numbers, but they point to something important: that identifying and addressing health issues before they become entrenched can open doors that might otherwise have remained closed.

The model is straightforward. When medical professionals speak to people of reproductive age, it offers an opportunity to discuss future pregnancy plans.

A simple question, “Are you thinking about having a child in the next year?”, can open a conversation that might otherwise never happen. For those who say yes, targeted advice on nutrition, supplementation and lifestyle can meaningfully improve their chances. This includes having a balanced diet, exercising regularly, getting enough sleep, and taking a multi-micronutrient supplement containing folic acid. If you smoke, try to quit, and cut down on alcohol where possible. Seek advice early if you have irregular menses (fewer than 21 or more than 35 days), an existing medical condition, or simply wish to learn more about your reproductive health.

For those who say not yet, the same conversation can plant the seeds of awareness that will matter when the time comes.

A different kind of preparation

The couple I described are now on a clear path forward. They came in thinking they had been doing everything right. In many ways, they had. They simply had not known that there was more to understand, and no one had offered to tell them.

Singapore’s falling birth rate is shaped by forces that medicine alone cannot resolve – economic pressures, shifting priorities, the texture of modern life. But within the space of what healthcare can offer, there is something worth doing that does not require new technology or significant resources. It requires only that reproductive health be treated as a normal part of health, and that the conversations which can make a difference happen early enough to matter.

Preparation for parenthood is something most couples think about carefully. The finances, the home, the timing. What is less often considered is the body itself, including both physical health and mental well-being. It is something worth understanding before it becomes the thing standing between a couple and the family they had always assumed they would have.

That conversation, had early enough, can make all the difference.

• The writer, Clin Asst Prof Ku Chee Wai, is an assistant professor and a consultant at the Department of Reproductive Medicine, KK Women’s and Children’s Hospital. As a clinician-scientist, his research includes preconception health, particularly metabolic and lifestyle factors affecting pregnancy

Source: The Straits Times© SPH Media Limited. Permission required for reproduction.