Starting Families Asia Study

Endorsed by

Asia Pacific Initiative on Reproduction

Contents
About the Starting Families Asia study ................................................................................. 3

Foreword ........................................................................................................................................ 4

Section 1
Findings from the Starting Families Asia study .................................................................. 5
Introduction ............................................................................................................................................................ 6

1. What makes Asian women ready to conceive?..................................................................................... 7

2. What do women think about their ability to conceive? .................................................................... 9

3. How much do women really know about fertility? .......................................................................... 11

4. What do women know and think about treatment options? ........................................................ 13

Section 2
Fertility The Real Story: Facts and perspectives on fertility ..................................... 16
1. Facts & figures.............................................................................................................................................. 17

2. Fertility myths ............................................................................................................................................... 19

3. The real costs of infertility........................................................................................................................ 20

4. Fertility treatment success stories ......................................................................................................... 23

References .................................................................................................................................. 26
About the Starting Families Asia study
Endorsed by the Asia Pacific Initiative on
Reproduction (ASPIRE), Starting Families Asia is the
regions first and largest study commissioned to
better understand Asian womens knowledge levels,
decision-making considerations and barriers to
seeking help in instances where infertility exists.

Commissioned and sponsored by Merck Serono,

Starting Families Asia aims to provide useful
information to assist decision makers in addressing
the significant issue of declining birth rates within the changing socio-economic context of our
contemporary society.

Over the past few decades, economic and social modernization has been accompanied by a decline in
birth rates. Gains in mobility and standards of living coupled with changing social attitudes around
family planning have affected population trends and fertility rates globally. These trends, in addition to
an aging population and low work-force replacement, represent a significant challenge to countries
around the world, particularly in Asia, where these trends are more pronounced and where their
potential impact on socio-economic development and the progress of society will be felt more acutely.

According to United Nation figures, several countries in Asia, namely China, Japan, North Korea, South
Korea, Thailand, Singapore and Vietnam, have already dipped below replacement fertility levels. Today,
four of Asia's most prosperous economies Japan, Singapore, South Korea and Taiwan have among
the lowest birth rates in the world, according to a study done by East West Center1.

Asia has the lowest fertility rates in the world and the declining birth rates are a cause for concern.
Taiwan, despite its prosperity and growth, has the lowest average number of births per woman
registering just 0.91 births per woman in 2010, compared to 1.39 in Japan, 1.15 in South Korea, 1.16 in
Singapore and 1.11 in Hong Kong. In China, the birth rate is approximated to be between 1.2 and 1.4
births per woman2.

The Starting Families Asia study surveyed 1,000 women across 10 countries in Asia Pacific including
China, Hong Kong, India, Indonesia, Korea, Malaysia, Singapore, Taiwan, Thailand and Vietnam. This
report is a summary of the key findings based on the study and represents a starting point in gaining
insights into women and their role in declining fertility rates in Asia.

Starting Families Asia was designed and conducted in collaboration with one of Asias leading fertility
specialists Professor P C Wong, Head and Senior Consultant at the Division of Reproductive
Endocrinology and Infertility, National University Hospital Womens Centre in Singapore and reviewed by
Professor Chia Kee Seng, Dean of the Saw Swee Hock School of Public Health at the National University
of Singapore (NUS).

Starting Families Asia study 3

Foreword
Professor Yoshiharu Morimoto, MD, PhD
CEO & Chairman, IVF JAPAN group
President of ASPIRE, 2010 2012

Declining birth rates represent a significant challenge to countries around the world. Nowhere is this
seen more acutely than in the Asia-Pacific region, where we have the lowest birth rates and highest
rates of infertility. It was not too long ago that many experts feared an unsustainable population
explosion. The situation has changed quite dramatically and at least 60 countries now have a birth
rate substantially lower than the level needed to maintain themselves. In Asia, this trend is
accelerating as women are having fewer children, postponing parenthood until much later in life or
choosing not to have children at all.

Many Asian countries have begun to address this population growth challenge with innovative
government assistance programs to encourage multi-child families as well as subsidies for fertility
treatment options. But more needs to be done to both understand and tackle the problem. I am
therefore pleased to support the Starting Families Asia study, which sheds fresh light on some of the
factors that are impacting women and the choices they are making regarding having children.

I appreciate the commitment made by Merck Serono to this important initiative, which is a follow
up to the well-received and published Starting Families study of 2010. This new study gives us Asia-
specific data and will help us healthcare professionals better understand and address the challenges
and misconceptions faced by patients looking to start families in Asia.

4 Foreword
Section 1
Findings from the Starting Families Asia study

Starting Families Asia study 5

Findings from the Starting Families Asia study
Introduction
P C Wong
Professor, Department of Obstetrics & Gynaecology, National University of Singapore and
Senior Consultant & Head, Division of Reproductive Endocrinology & Infertility, NUH
Womens Centre, Singapore

Women in Asia consider child-bearing to be one of the most important goals in life. It is one of their greatest
sources of personal fulfilment. Yet Starting Families Asia reveals that misperceptions around fertility what
women think about their ability to conceive and what they know about treatment options are common.

This has significant repercussions for women and couples who want children, but also for national growth
and development. This is especially true at a time when the regions replacement fertility rate is declining and
challenges around supporting aging populations and sustaining growth arise.

Although the level of fertility awareness varies from country to country, Starting Families Asia identifies a
number of areas where change can be made for the better:

Fertility knowledge needs to be improved, especially around male and female fertility risk factors.
Especially the impact of age and obesity on fertility are underestimated.

The reasons behind fertility problems need to be addressed. These are primarily considered to be
lifestyle-related.

Misconceptions around fertility treatment need to be corrected and access improved. Although there
is widespread confidence in the safety and efficacy of treatment, potentially prohibitive factors such
as cost and lack of information about where to find treatment need to be addressed.

Tackling the above challenges will help to ensure that more women take timely steps towards improving their
chances of conceiving a child. Once women decide to have children, they should not leave it to too late. It is
harder for women to fall pregnant as they grow older, and fertility treatment cannot reverse the negative
impact of age on infertility.

My hope is that the findings of Starting Families Asia will equip healthcare providers and policymakers across
the region with insights to shape the actions needed to help more couples start families.

Methodology
The survey sample consisted of 1,000 women currently trying to conceive across 10 countries in Asia.

The respondents were married women aged between 20-45 years old

All women had been trying to conceive for the past 6 months or more and were not pregnant

17% of respondents declared that they have been diagnosed with a fertility problem

6 Introduction
1. What makes Asian women ready to conceive?

Most women in Asia agree that it is very

important for them to have a baby, but many
stop short of admitting that they cant
imagine life without children.

The desire for parenthood is highest

among women in India, Indonesia
and Vietnam. In contrast, having a
child seems less essential to women
in Hong Kong and Korea.
CHART 1: Womens desire for parenthood
(% of respondents with a high desire level)

Readiness to have a child both on the

part of the wife and the husband seems
to be the prerequisite before deciding to
have a baby. In China, India, Singapore,
Thailand and Vietnam the husbands
readiness to have a child is seen to be a
stronger influencer than the womans
readiness.

CHART 2: Womans feeling of readiness to

have a child vs. husbands feeling of
readiness as a key influencer on womens
decision to conceive
(% of respondents)

Other key factors that influence the decision by women in Asia to conceive include personal fulfilment
and the need to feel secure before having children secure in health, marriage and financial status.

Personal fulfilment is a much stronger reason to have children in India, Indonesia, Singapore
and China than in other countries.

A womans health is a more important factor in her decision to have a baby in Singapore,
Vietnam and Hong Kong than in other countries.

The importance of having a stable relationship is particularly important to women in Thailand

and Hong Kong

Starting Families Asia study 7

 Having secure employment is also a key concern in Korea.

The economic cost of having children is a key concern in Korea and Taiwan.

CHART 3: Influence of economic costs of having children (% of respondents)

Although the perceived higher social status of mothers and fathers in the community is not a significant
influencer across Asia, the importance of children in local culture, religion and community is a key
consideration for women deciding to have a baby in China and Malaysia.

CHART 4: Importance of children in local culture, religion or community (% of respondents)

Interestingly, the impact of having a child on a womans education or career is not a significant concern
for women across the region.

Across Asia, most women acknowledge that both their husband and their parents-in-law would want
them to have children. Moreover, they are keen to do what their husbands think is best. Notably,
however, in China and Korea, influence from in-laws appears to be stronger than from the husband. For
Taiwan, the expectation from the community is stronger and higher as compared to other countries.

8 What makes Asian women ready to conceive?

2. What do women think about their ability to conceive?

Most women believe their fertility level is moderate. In Indonesia and Vietnam, women believe their
fertility levels are higher, whilst more women from Singapore, Malaysia, Korea and Taiwan think their
fertility levels are lower.

Despite the perceived moderate fertility level by most, women generally believe their chances of getting
pregnant are still promising, especially in Indonesia, India, China and Vietnam. Women in Singapore
and Hong Kong are the least optimistic about their chances of falling pregnant.

Surprisingly, although the women who participated in Starting Families Asia have been trying to
conceive for more than six months, almost two-thirds (62%) of them do not suspect they may have a
fertility problem. Women are even less likely to believe that their husband may have fertility problem,
with 80% of women not suspecting their husband of having a fertility issue.

Among the 38% of women who suspect that they have a fertility problem, nearly half (45% of the 38%)
have already been diagnosed. Among the 22% of women who suspected their husband had a fertility
problem, 39% of husbands had already been diagnosed.

CHART 5: Self-perception of fertility: Wives fertility condition vs. husbands fertility condition

Wives fertility condition:

Husbands fertility condition:

Starting Families Asia study 9

A majority of women have identified lifestyle both theirs and their husbands as key reasons for why
they are yet to fall pregnant.

Fate whether its considered to be Gods will or bad luck is also believed to play a part in all Asian
countries except Thailand. Only in Singapore, Indonesia and Vietnam is the womans age seen as a
leading explanation behind fertility problems.

Emotional problems are also widely perceived to be a reason behind fertility problems. This is particularly
the case in China, Singapore, Indonesia and Thailand. About 1 in 3 respondents across the region feels
they are experiencing work and/or personal stress that they cannot cope with.

CHART 6: Perceived reasons for fertility problems

(% of respondents with high agreement)

Perspective from Professor PC Wong

Globally, it is estimated that one in ten couples face challenges with infertility. In general, a couple
would be classified as infertile if they fail to conceive after one year of trying. This period is shorter
for women who are older 35 years old and above.

Starting Families Asia, however, shows that most Asian women generally believe that their chances
of getting pregnant are quite high even though they have been trying to conceive for over six
months. Moreover, nearly two-thirds of women dont suspect that they may have a fertility problem.
An even higher percentage of women dont suspect potential problems with their husbands fertility
condition. These results show that many women are unaware of how prevalent the problem of
infertility is.

Many women seem to attribute their infertility challenges to fate or simply bad luck. This may mean
that many couples may go untreated. Greater awareness is necessary around the impact of age and
medical problems related to infertility, since many medical conditions can be treated if help is
sought.

10 What do women think about their ability to conceive?

3. How much do women really know about fertility?

Starting Families Asia reveals that knowledge of fertility is generally moderate to low. Knowledge is
weakest in relation to fertility risk factors and around facts about fertility that could possibly lead to a
delay in seeking medical attention. Women in China, Korea and Singapore demonstrate the greatest
overall knowledge of fertility, while Thailand, Indonesia and Hong Kong show the least.
Only 43% of women understand that a couple would be classified as infertile if they fail to
conceive after one year of trying. The level of knowledge ranges from 16% in Indonesia
(weakest), to 46% in Singapore and Vietnam, and 55% in Korea.

Only 36% realize that a woman in her forties has a lower chance of getting pregnant as a
woman in her thirties. Awareness ranges from 21% in Hong Kong (weakest), to about 26% in
Thailand, Indonesia and Taiwan, and 61% in China.

Only 32% know that a healthy lifestyle does not necessarily guarantee fertility, ranging from
7% in Korea (weakest), 10% in Thailand and 56% in Singapore.

Only 30% recognize that obesity can reduce fertility. The percentage of participants who know
this fact varies from 15% in Hong Kong (weakest), to about 30% in Thailand, Taiwan and
Malaysia, and 52% in Korea.

Half of respondents wrongly believe that a woman who never menstruates is still fertile. The
percentage of correct answers ranges from about 38% in Hong Kong (weakest), to about 55%
in India, Indonesia, Korea, Malaysia and Taiwan, and 62% in China.

There is also a widespread lack of knowledge about mens fertility issues:

43% of women do not know that a man may be infertile even if he can achieve an erection

49% of women did not realise that a man may still produce sperm even though he is infertile

73% of women are not aware that if a man has had mumps after puberty, he is more likely to
later have a fertility problem

CHART 7: Womens fertility knowledge (% of correct answers)

Starting Families Asia study 11

 Perspective from Professor PC Wong

Low awareness around fertility has many consequences. Most significantly, it severely decreases a
womans chances of success for having children.

Starting Families Asia highlights a number of key areas where action needs to be taken:

Understanding what infertility is. Not enough women realize when they
might have a fertility problem. Too few women know that couples who do
not achieve pregnancy after one year of regular, unprotected sexual
intercourse are considered to be infertile. In the case of women aged 35
or older, this period is may be shortened as a result of age.

Education around the causes of infertility. Most women in Asia believe

that so long as they lead a healthy lifestyle, they are fertile. Education is
needed to improve knowledge about the many causes of infertility
including physical disorders, genetic factors and environmental factors.
Risk factors particularly age and the impact of obesity are especially
widely misunderstood.

Increasing knowledge around mens fertility issues. Women across the

region have relatively low knowledge when it comes to male fertility.
Better education about male fertility issues and their prevalence must
necessarily be part of any comprehensive education programme.

12 How much do women really know about fertility?

4. What do women know and think about treatment options?

Generally, awareness of available fertility options is high across the region, particularly when it comes to
seeking advice from medical professionals.

Despite a common perception of Asians being conservative and reserved, women tend to disagree that
seeking fertility treatment is embarrassing. There is a good level of confidence in treatment safety,
efficacy and fitness of children born of fertility treatment.

Fertility treatments that women are most aware of include IVF, alternative/complementary therapies and
insemination of sperm. Strongest awareness of IVF is amongst women in Taiwan, Singapore and Hong
Kong. On the other hand, Vietnam has the weakest awareness of IVF, followed by Indonesia and
Thailand.

CHART 8: Awareness of fertility options (% of respondents)

While awareness of different treatment options is relatively high, half of all women in the region that
participated in the survey are unaware of where their nearest fertility centre is located. Approximately 9
in 10 women in Hong Kong and 7 in 10 women in Singapore do not know where the nearest fertility
centre is.

Overall, about a quarter of women claim to have ever received fertility treatment. A greater proportion
of fertility treatment experience is seen amongst women in China and Indonesia, while Korea and
Malaysia report lower levels of experience.

Starting Families Asia study 13

The single greatest barrier to seeking help is the perceived high cost associated with fertility treatment.
This perception stands out especially in Korea, Hong Kong, Singapore and Taiwan.

CHART 9: Perceptions of fertility medical treatment (% of respondents in agreement)

A womans decision to seek medical help for fertility is also determined by the level of support received
from her employer. India, Malaysia and Vietnam are amongst the countries noted for greater employer
support. Lower support is seen in Hong Kong and Taiwan.

CHART 10: Percentage of respondents indicating that their employer would give
them time off for fertility treatment

14 What do women know and think about treatment options?

Perspective from Professor PC Wong

It is encouraging to see that women appear to be aware of a wide range of fertility treatments,
from seeking fertility advice from a GP or specialist, to IVF and IUI. However, a number of barriers to
seeking and receiving treatment remain.

Cost of treatment. The fact that cost of treatment is perceived to be a

prohibitive factor in Korea, Hong Kong and Singapore suggests that women
in these countries may not be sufficiently aware of the government co-
funding programmes that are available to them. That said, cost can be a
factor in some countries, especially where access to treatment is still
comparatively limited and women may have to travel long distances to
receive specialist help.

Employer support. A supportive environment is a crucial factor for many

women who are considering fertility treatment. This can be seen in
countries such as India, Malaysia and Vietnam where women think that
their employer would provide support in the form of allowing them to take
time off for fertility treatment. Women in these countries are more likely to
start fertility treatment sooner than women in countries such as Hong Kong
and Taiwan, where employers are seen to be less supportive.

Finding specialist help. More work needs to go into informing women

where to go for treatment. It is concerning that in most countries, the
majority of women who have been trying to conceive for over six months
do not know where the nearest fertility centre is located.

Starting Families Asia study 15

Section 2
Fertility The Real Story: Facts and
perspectives on fertility

16 Fertility The Real Story: Facts and perspectives on fertility

Fertility The Real Story: Facts and
perspectives on fertility
1. Facts & figures
Infertility is a disease. The World Health Organization defines infertility as a disease of the
reproductive system measured by the failure to achieve a clinical pregnancy after 12 months or more of
regular, unprotected sexual intercourse4.

Infertility is common. It is estimated that 9.6% of couples face the challenges of infertility1. The
current trend of delaying parenthood may contribute to the increasing number of couples struggling to
conceive, by increasing the child-bearing age to increasingly higher ages of the female.

Fertility rates are declining globally. In the Asia-Pacific region, total fertility rates have fallen to the
population replacement rate of 2.1. In East and North-East Asia, this figure is even lower at 1.65. This
trend may bring new socio-economic challenges around supporting aging populations and sustaining
economic growth, with fewer births and younger replacement workers in the workforce.

Infertility is a two-sided issue. Male infertility is the primary diagnosis in approximately 25% of cases
and contributes to a further 15% to 25% of the remaining cases. 20% of cases remain unexplained6.

Modern fertility treatments are effective. In a recent Danish study 69.4% of treated couples had at
least one child within 5 years. Only 6.6% were able to conceive spontaneously outside treatment7.

The majority of couples with infertility issues remain untreated. Although effective treatments are
available, only 56% of infertile couples seek and 22% receive medical care against infertility3. In Asia,
with persisting social and personal barriers, low fertility awareness and limited access to treatment
access the figures are even lower.

About 8 out of 10 couples seeking medical care do not start, or persevere with the treatment
journey8-13. Emotional distress is one key reason given by couples who discontinue treatment14.

Access to advanced fertility treatments varies significantly across countries. It is estimated that in
vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI) treatments are available in 45 out of
191 World Health Organization (WHO) member states16. The number of treatment cycles performed per
million population ranges from 9 in Indonesia to 618 in Singapore15.

Advanced fertility treatments are not supported by government in the majority of countries. In
Asia, partial coverage of assisted reproductive technology (ART) treatments is available only in Korea,
Singapore and Japan. When available, access to ART support is often restricted by age of the women,
number of children they already have, and number of treatment attempts.

Starting Families Asia study 17

Global vs. Asian fertility rates 19
[reference: UN Populations Division, World Population Prospects: The 2010 Revision]

18 Facts & Figures

2. Fertility myths
IVF can fix anything. Success rates for IVF vary and
while they can be as high as 75%7, the higher rates of
success are usually achieved after multiple attempts.
And invariably, younger women fare better, although
egg donation can improve the chances of older women
conceiving through IVF.

The research assessing the degree to which IVF can help

older women increase their chances of conceiving
concludes that if a woman postpones an attempt to
become pregnant by 5 years (i.e. from age 30 to 35), her
chances of conceiving will be reduced by 9% and ART will only make up for 4% of the reduction. A
woman 35 to 40 years old will have a 25% lower chance of conceiving and ART can only improve her
chances by 7% overall18.

This sends a clear message to women 35 years or over who have not conceived after six months of
trying do not delay seeking help because even the most advanced treatments cannot make up the
births lost by the natural decline of fertility with age.

Fertility treatments mean multiple births. Using drugs to stimulate the ovaries to produce multiple
eggs can result in multiple embryos and multiple pregnancies. And transferring more than one embryo
per IVF treatment cycle may result in more than one baby being born as a result of successful IVF
treatment.

This may be an attractive and cost-effective strategy for couples desperate to have a baby but who
cannot afford multiple IVF attempts. It may also be appealing to couples who face time pressures on
becoming a parent because of their age. However, multiple pregnancies pose potentially serious health
consequences for both mothers and children19.

Policies that restrict the number of embryos transferred are already effectively reducing multiple birth
rates. Data from a number of countries indicate that there has been a gradual increase in single embryo
transfer rates in recent years, although a large degree of geographical differentiation persists20. It is
encouraging to note too, that although fewer embryos are being transferred each time, this has not
resulted in a drop in the number of babies born overall.

Starting Families Asia study 19

3. The real costs of infertility
Unfortunately, advanced fertility treatments are not
supported by government in the majority of Asian
countries. Support for fertility treatments is rarely a
priority on the agenda of policymakers and payers.
Often the discussion focuses on the cost-
effectiveness of investing limited public resources
into infertility treatments compared to other
healthcare priorities. While specific circumstances
may differ across different countries, it is important
that decision-makers and the public consider a
broader perspective.

Infertility is a barrier to a life goal 4. Infertility prevents people from realising an important life goal
the possibility to parent a genetically related child or a child created within the current relationship21.

Infertility can create inequality. The ability to have children should not depend on personal income.
For many couples the cost of advanced treatments is high. The cost of a standard IVF cycle ranges from
12% of an individuals annual income in Japan22 to an amount that is 50% higher than the gross
national income per capita in developing countries like China and India23.

At the same time, the cost of providing treatment is relatively low for a society. In Scandinavian
countries, where the levels of ART utilization and reimbursement are among the highest in the world, it
accounts for less than 0.2% of the total healthcare expenditure22.

ART can support total fertility rates. Many countries face significant long-term socio-economic
challenges due to declining fertility rates and aging populations. Government support to promote access
to ART will relieve the burden suffered by infertile couples and may contribute to addressing the issues
surrounding low total fertility rates24.

A study comparing the use of ART in Denmark and in the UK concluded that increasing IVF uptake in the
UK to Danish levels could result in the UK total fertility rate increasing from 1.64 to 1.68 children per
woman. Furthermore, it concluded that the direct costs associated with adopting ART as a national
policy are comparable to those of existing policies commonly used by governments to influence
fertility25.

20 The real costs of infertility

South Korea a case study

In 1970, South Korea had a total number of

births greater than 1 million, but as of 2005 this
dropped to under 500,000. If this alarming trend
continues, South Korea will see its population
starting to decrease in 2017, when the number
of deaths will exceed that of births.

In response to this national crisis, the

government introduced a number of new policies,
from generous maternity leave and child support
benefits, to baby bonuses and cash payments for
having more children, and expanded child care
facilities.

In addition, the government introduced an infertility initiative in 2006, providing qualifying couples with
co-funding of approximately 50% towards the cost of two IVF treatment cycles. As a result, South Korea
saw a jump of 14,000 births in the first year of the program that included 6,500 babies born from ART.

As a result of the success of these initiatives, the government expanded its support for fertility
treatment up to the third cycle in 2009 and to the fourth cycle in 2011. Today, Korean couples can
receive up to 50% support for the first three cycles and up to 35% for the fourth cycle.

Since introducing financial support for ART in 2006, South Korea has seen an increase in its fertility rate
from 1.08 in 2005 to 1.22 in 201024,26.

Chart: Annual number of IVF & ICSI cycles in Korea increased following the introduction of an IVF subsidy in
2006 26

Starting Families Asia study 21

 Policy overview of countries that support ART in Asia
Japan
Couples can apply for co-
funding of up to:
USD1,920 for each cycle up
to a maximum of three
cycles in the first year of
treatment;
Two cycles in each
subsequent year;
Maximum of 10 cycles in
the first five years of
treatment;
Couples can only receive
treatment at designated
facilities and cannot have an
income of more than USD
93,400 per year to qualify
Note: Figures provided in USD are conversions based on existing rates
22 The real costs of infertility
as of August 2012
Singapore Korea
Couples can use up to: Government co-funds up to:
USD4,800 of their Medisave USD1,600 for the first three
for the first fertility cycles;
treatment;
USD900 for the fourth cycle
USD4,000 for the second;
Co-funding is available at both
USD3,200 for the third public and private fertility
clinics
Government co-funds up to:
USD2,400 per cycle, up to a
maximum of three cycles at
public hospitals only
4. Fertility treatment success stories
The pathway to fertility

For June and her husband Steven, having a baby was of

paramount importance. But she never expected the challenges
they would encounter on the path to parenthood.

Shortly after Steven and I got married, we decided to begin trying

to have a baby. I was 35 at the time and had assumed that it
would be easy for me to fall pregnant. I led a healthy lifestyle,
exercised frequently and had a regular menstrual cycle.

We tried to conceive naturally for almost a year. There were many

ups and downs. As soon as my period was a couple of days
overdue, we thought that we had finally fallen lucky. It was an
emotional time for us. A lot of our desire to have children came
from watching all our friends getting married and having babies.
Our marriage felt empty without children.

After trying for nearly 12 months, I suggested that we see a fertility specialist to find out what might be
wrong. We found our fertility specialist through a referral from Stevens colleague. Steven called the
clinic immediately and we were lucky to get an appointment a few weeks later. I was not prepared for
the many tests that we would have to undergo. We soon discovered that we both had fertility issues. In
my case, I was in fact not ovulating every month despite a very regular menstrual cycle.

Right away, I started on a medicine to induce ovulation, but nothing happened after one cycle. We then
tried three cycles of intrauterine insemination. Again, we were unsuccessful. Our next and last
treatment option was to try in-vitro fertilization (IVF). I must admit that I wasnt prepared for IVF. It was
only during counselling sessions that I learned from the nurses what it would involve including the
duration and number of injections required. I did not feel comfortable injecting myself. Fortunately
Steven was more courageous at this and was very supportive.

Two embryos were transplanted in the first cycle. Sadly, however, they failed to implant. This was a huge
disappointment for us. At this stage I decided to take a few months rest to bring my body back into
balance. A few months later, I felt I was ready to try a second round. This time it worked and, thankfully,
the rest of my pregnancy was uncomplicated. Now I have a healthy four month old baby and four frozen
embryos which we contemplate using for a frozen embryo transfer in the near future.

Looking back, there are several things I wish I had known and done earlier. I wish I had gone to a doctor
to identify any fertility issues at the outset. Instead, I waited for nearly a year. I should also have done
more research into various methods of assisted reproductive technology. I was completely clueless about
IUI and IVF to begin with. Online motherhood forums, where women share their experiences, are a good
place to go.

I underestimated the impact of age on fertility. Once a woman hits 35 years, the chances of conceiving
are greatly reduced and fertility treatment cannot make up for this reduction. I hope more women
become aware of this!

Starting Families Asia study 23

The stork finally comes knocking

I never thought that I would be faced with the

issue of infertility until I was two years into my
marriage, and there had been still no sign of
pregnancy that was when I began to panic. I
decided to seek medical help, thus beginning my
five-year journey into becoming pregnant.

I first underwent artificial insemination. The third

attempt was finally successful but due to the side
effects of the ovulation medication I was on, I
experienced breathing difficulties and had to
undergo emergency stomach pumps to get rid of ascites in my stomach. Each time, 3000cc of ascites
were pumped from my body. At that moment, I wondered why my route to having a child was so painful.
Due to the seriousness of my ascites problem, I was hospitalized for almost a month and I felt really
depressed. Unfortunately, despite all the suffering I endured, I failed to get pregnant because the embryo
had not been implanted properly. I felt terrible when I heard this and started to avoid similar procedures
because of the unpleasant experiences I had just gone through. For the next two years, all I thought
about was when I will ever become pregnant.

Unexpectedly, a colleague told me about this doctor at a local hospital who was renowned for treating
infertility. However, my friends advised me against seeing him as they did not want me to go through
the same painful process again. However, my husband and I wanted a kid very badly and therefore I told
myself, if this is the route God wanted me to take, I will go forth courageously!

Hence, I made an appointment to see Dr. W who told me I needed to lose weight as I was chubby. A
series of medical examinations also found that I had high levels of sugar in my blood and an alarmingly
high level of testosterone in my body. This was the reason why I had difficulty ovulating. I was
diagnosed with Polycystic Ovary Syndrome. Even though I wanted to start treatment immediately, Dr. W
insisted that I got in shape and corrected my dietary habits before starting on the treatment. I was put
on a low-fat diet and began my exercise regime.

Controlling my diet was a torture as I have always been a glutton. However, the IVF process that I was
going through is more expensive and time-consuming than artificial insemination, which made me more
determined to make it work even though I knew the success rate was low. Throughout this process, Dr.
W emphasized the importance of exercise and despite not liking the idea, I still signed up at a gym near
my home and went there every day after work. To be honest, exercising after a long day of work was
tough but I kept encouraging myself that this will help me become pregnant. All this while, I had the
support of my husband which gave me the strength and energy to go on.

After having gone through artificial insemination thrice, the injections I had during this period were
nothing to me. The only problem I faced was that my tummy did not have enough spots for injection as
it was covered with scars from the injections I had from the previous treatments. Id be lying if I said the
injections did not hurt. Thinking back, I really wonder where my courage came from. Perhaps it stemmed
from my desire to be a mother. During the treatment process, I was fearful that I would experience the

24 Fertility treatment success stories

problem of ascites again. Dr. W understood my fears and was extremely mindful of the situation.

Two weeks later, I did a blood test. The 20-minute wait seemed like a century to me. Finally, I saw the
doctor walk towards me with a smile and said, Congratulations! The test results show that you may be
carrying more than one baby! The joy I experienced at that news is inexplicable.

From the bottom of my heart, I sincerely wish that all mothers-to-be who are reading this article will
one day also experience the same inexplicable sense of joy that I had. Under a strict diet, I finally
managed to obtain my ideal weight. Throughout my entire pregnancy, I did not experience any
uncomfortable symptom and successfully gave birth to two Tiger babies on the fourth day of my 37th
week. I am finally a blessed mummy!

My babies are now five months old and each time I hold them in my arms, I am reminded of the arduous
journey I had gone through to have them. To everyone who desires to be a mother, as long as you
believe, the stork will definitely arrive at your home with good news!

Starting Families Asia study 25

References
1
Sidney B. Westley, Minja Kim Choe, and Robert D. Retherford. Very Low Fertility in Asia: Is There a
Problem? Can It Be Solved? Honolulu: East-West Center Asia Pacific Issues, No. 94
http://www.eastwestcenter.org/publications/very-low-fertility-asia-there-problem-can-it-be-solved
2
Peter McDonald, ANU Population in the Asian Century East Asia Forum 2012
http://www.eastasiaforum.org/2012/03/14/population-in-the-asian-century/
3
Boivin J et al. International estimates of infertility prevalence and treatment seeking: potential need
and demand for infertility medical care. Human Reproduction. 2007; 22(6):1506-1512
4
Zegers-Hochschild F et al. The International Committee for Monitoring Assisted Reproductive
Technology (ICMART) and the World Health Organization (WHO) revised glossary on ART terminology.
Human Reproduction. 2009; 24(11):2683-2687
5
UNESCAP, Statistical Yearbook for Asia and the Pacific, 2011
http://www.unescap.org/stat/data/syb2011/I-People/I.3-Fertility.pdf
See also: http://www.unescap.org/stat/data/syb2011/I-People/Population.asp
6
Collins J A. Evidence-based infertility: evaluation of the female partner. International Congress Series.
2004; 1266:57-62
7
Pinbourg A et al. Prospective longitudinal cohort study on cumulative 5-year delivery and adoption
rates among 1338 couples initiating infertility treatment. Human Reproduction. 2009; 24(4):991-999
8
Stakeholder Insight: Infertility. Datamonitor. 2008
9
Collins J A, Van Steirteghem A. Overall prognosis with current treatment of infertility. Human
Reproduction. 2004; 10(4):309-316

Olivius K et al. Cumulative probability of live birth after three in vitro fertilization/intracytoplasmic
10

sperm injection cycles. Fertility & Sterility. 2002; 77(3):505-510

Land J A et al. Patient dropout in an assisted reproductive technology program: implications for
11

pregnancy rates. Fertility & Sterility.1997; 68(2):278-281

Schroder A K et al. Patient dropout in an assisted reproductive technology program: implications for
12

pregnancy rates. RBMOnline. 2004; 5(5):600-606

Rajkhowa M et al. Reasons for discontinuation of IVF treatment: a questionnaire study. Human
13

Reproduction. 2006; 21(2):358363

Brandes M et al. When and why do sub fertile couples discontinue their fertility care? A longitudinal
14

cohort study in a secondary care sub fertility population. Human Reproduction. 2009; 24(12):3127-
3135
15
Merck Serono data 2011, Indonesian Statistics Agency Data 2011 and Singapore Statistics, June 2011]

26 References
 Collins JA. An international survey of the health economics of IVF and ICSI. Human Reproduction.
16

2002; 8(3):265-277.

UN Populations Division, World Population Prospects: The 2010 Revision

17

http://esa.un.org/unpd/wpp/Excel-
Data/DB01_Period_Indicators/WPP2010_DB1_F01_TOTAL_FERTILITY.XLS

Leridon, H. Can assisted reproductive technology compensate for the natural decline in fertility with
18

age? Human Reproduction. 2004; 19(7):1548-1553

19
Gurga, T, Demirol, A. Why and how should multiple pregnancies be prevented in assisted reproduction
treatment programmes? Vol 9. No 2. 2004 237-244 Reproductive BioMedicine Online;
www.rbmonline.com/Article/1357 on web 23 June 2004

Maheshwari A et al. Global variations in the uptake of single embryo transfer. Human Reproduction.
20

2011; 17(1):107-120

ESHRE Task Force on Ethics and Law 14. Equity of access to assisted reproductive technology. Human
21

Reproduction. 2008; 23(4):772774

Chambers G M et al. The economic impact of assisted reproductive technology: a review of selected
22

developed countries. Fertility & Sterility. 2009; 91(6):2281-2294

Vayena E et al. Assisted reproductive technologies in developing countries: are we caring yet? Fertility
23

& Sterility. 2009; 92(2):413-416

24
Ledger W. Demographics of infertility. Reproductive BioMedicine Online. Vol 18 Suppl. 2 2009 11-14

Hoorens S et al. Can assisted reproductive technologies help to offset population ageing? An
25

assessment of the demographic and economic impact of ART in Denmark and UK. Human Reproduction.
2007; 22(9):24712475
26
Korea government data [2011]

Starting Families Asia study 27

Merck Serono S.A., Geneva, Chemin des Mines 9, CH-1202 Geneva, Switzerland

Merck Serono | You. Us. Were the parents of fertility

Reference