After trying to conceive a baby for more than 12 months it is generally suggested that a couple consult their medical professional to perform a few tests to determine the cause of the couple not achieving a successful pregnancy. However, if the woman is over the age of 35, testing can be requested after six months, as fertility has begun it’s natural decline by this age.

The first step for you to take is for both partners to have some testing done to determine where the problem lies.

Generally the male partner is tested first as infertility testing for a man is less invasive than for a woman. Both a blood test and a semen analysis are performed. The semen analysis will tell you about the quantity and health of the male partner’s sperm while the blood test will show if there are any concerns with his hormone levels.

If there are any concerns with the male partner’s tests, it is likely that the female partner is not tested and the couple will work with the information they have already gained. There are times when sperm count and quality can be improved by diet and / or surgery and hormonal issues can be treated as well. However there are times when either the man’s body is not producing the quantity or quality of sperm required for no apparent reason. In these cases it is recommended that the couple look into assisted reproduction therapy (ART).

In the even of the male partner’s tests coming back all clear, the female partner will begin her testing, usually this will involve determining if she is ovulating. The doctor may request that the woman charts her cycle for a few months so she can see if she is ovulating that way. Alternatively, the doctor may request blood tests and ultrasounds at various times of the woman’s cycle to see if her hormones are working correctly and to see if her ovaries are working correctly.

If these tests come back showing that the female partner is ovulating, there are further investigations started. These will check on the health of the woman’s reproductive system and are quite invasive. A hysterosalpingography involves dye being injected into the woman’s uterus through her vagina, she is then given x-rays to determine whether there are any blockages in her fallopian tubes that are stopping the eggs from moving where they need to be. A laparoscopy looks at the health of the ovaries, fallopian tubes, and uterus and can determine if there are any issues such as endometriosis, polycystic ovarian syndrome (PCOS) or if there are any physical abnormalities in the organs investigated.

After testing is completed and an issue is found with either partner, the doctor will help to couple decide which direction to take next, usually this depends on the problem that has presented. Unfortunately though, up to 10% of couples that are tested for infertility in Australia will be diagnosed with “unexplained infertility” which means that they have not conceived a child within 12 months of having unprotected sex, but all of the tests rule out any of the usual problems.

There a variety of options available these days to overcome infertility, such as inter-uterine insemination, IVF, egg or sperm donations or even adoption. Once a diagnosis has been made these options are assessed until the most suitable one is found for your particular case.

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In the not too distant future young women could be able to drop into a bank during their lunchbreak and deposit their eggs for safe keep until they are needed in maybe 10, 20 or even 40 years later. It may sound bizarre but medics are predicting this is only a couple of years away…..

Since many women are now choosing to leave motherhood until a later stage, this revolutionary development leaves women to get on with their lives without worrying about their biological clock.

In 2002, the median age of all women giving birth in Australia was 30.2 years and the Australian Bureau of Statistics predicts this is on the rise.
Unlike previous generations, getting married and starting a family has taken a back-seat as women are now focussing on building a successful career, travelling and generally just having fun.

At 20 years old a woman’s eggs are at their best and have a one in 1000 chance of conceiving a Downs Syndrome baby. At 30 the risk of Down Syndrome is increased to one in 600 and at 40 it is one in 62.

Specialists have recently discovered a way to successfully freeze and thaw eggs without inflicting any damage. A dozen or so eggs are frozen in canisters of liquid nitrogen at minus 196 degrees celcius.

When the owner is ready to have a baby the eggs are thawed and fertilised by intracytoplasmic sperm injection , ICSI, in other words the injection of a single sperm into the egg. This has as much chance of successful fertilisation as an egg fresh from the ovaries and doctor’s are confident there is no apparent impact on the embryo’s development.

Many specialists believe the opening of “egg banks” is no more than a couple of years away.

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Consultant pediatrician Dr Elizabeth Bryan is a leading specialist in the field of multiple pregnancies. She established the first clinic for twins in London in 1987 and works closely with families with multiple births. As founder and medical director of the Multiple Births Foundation UK and a co-founder of the Twins and Multiple Births Association, Dr Bryan is the author of more than 50 medical papers and her widely acclaimed book, Twins and Higher Multiple Births.

In medical terms the world of assisted conception and fertility treatment is still relatively new. Research is constantly being conducted to further develop assisted reproductive technology (ART) and to investigate long-term repercussions for both the children and parents concerned.

Figures indicate that as the use of ART increases, so too does the incidence of multiple births, due to the practice of multiple embryo transferral (involving the transferral of 3-10 embryos in one cycle) being routinely carried out in many countries. In the Czech Republic and Greece, more than 70% of IVF cycles still involve three or more embryos being transferred.

The result, an escalating number of higher order multiple births (triplets or more), is a key issue concerning health professionals throughout the world.

There were 3,900 multiple births registered in Australia in 2000, compared to 2,200 in 1980. Of these, 3,800 produced twins while the remaining 100 resulted in triplets or higher births. According to the Australian Bureau of Statistics, the number of twin births has increased by 71% since 1980, and the number of triplet births has increased by 257%.

"The whole IVF scene has escalated," said Dr Bryan, during an address at Melbourne's Royal Women's Hospital.

Dr Bryan was in Australia speaking about the "emerging epidemic of multiple births" and its costs to all involved. Of greatest concern is the increase in triplet births directly related to multiple embryo transferral, she said.

In her presentation titled, "The Cost of Multiple Births - too high a price?" Dr Bryan addressed several key issues. These included the following:

Perinatal Factors

The term "perinatal" refers to the period from the 28th week of gestation to one week following delivery. Medical professionals are deeply interested in the effect that perinatal factors may have on multiple birth babies.

It has been found that many multiple birth babies suffer from intra-uterine growth retardation. In particular, the prevalence of cerebral palsy dramatically rises with triplets, said Dr Bryan. Research shows that those babies exposed to a "stormy" perinatal period are more likely to have cerebral palsy, she said.

In some cases, if one of the multiple birth babies has died during the pregnancy, there exists an increased risk of cerebral palsy in the surviving baby or babies.

It is common for women giving birth to multiples to experience delivery complications, added Dr Bryan. In many hospitals throughout the world, delivery of multiple babies culminates in a Caesarean Section.

Premature Babies

It is known that multiple birth babies are much more likely to be born pre-term, before 40 weeks. Statistics show that many twins are born around 37 weeks, although some are born much more prematurely.

In one study, 62% of twins were born at 36 weeks and beyond, but only 12% of triplets and 7% of quadruplets, were born beyond 36 weeks gestation. Incidentally, multiple pregnancies extending beyond 41 weeks are known to increase the risk of perinatal problems occurring.

Birth Weight

Another concern is the incidence of low birth weight, prevalent in multiple births, said Dr Bryan. Many multiple birth babies are generally born 1000 grams lighter than single born babies. Figures show that 6% of singleton babies weigh less than 2500 grams. This compares with 50% of twins, 90% of triplets, and almost all of higher multiple birth babies (that is quadruplets or more) being born recording birth weights less than 2500 grams.

Furthermore, figures indicate that 0.7% of single born babies fall below 1500 grams in weight, compared to 9% for twins, 28.4% for triplets and 52.3% for quadruplets. Birth weight discordance, where the babies are growing at different rates, is a great concern and often raises an ethical dilemma.

"What do you do for a foetus that is failing to grow? Do you try and save that one, at the same time risking the pre-term complication in the otherwise healthy baby?"

Perinatal Mortality

Of grave concern is the increase in the incidence of perinatal mortality among births resulting from assisted conception, compared to those of non-ART births.
"If you lose one of your babies, you are a deeply grieving family," said Dr Bryan.
"There are the added complications of caring for surviving children. Celebrating the birth or births of surviving children while mourning the death of another can be a very complex position to be in - and one that some parents cannot cope with. They may even reject the survivors as they grieve the baby that has died," she said.

Environmental Factors

Families of multiple births inevitably face environmental factors. It has been found that many multiple birth babies suffer learning difficulties and this is particularly prevalent among monozygotic multiple births, said Dr Bryan. Monozygotic multiples occur when one egg is fertilised by one sperm and then splits into two or more. The embryos produced are always the same sex and are identical.

In assessing the causes, Dr Bryan said we must take into account the following:

The Shared Mother-Infant Relationship

"Some mothers, and indeed some fathers, find it very difficult to fall in love with more than one baby at a time," said Dr Bryan.
Likewise, children of multiple births may have difficulty in relating to their mother and father and find that the shared relationship inhibits them the access to the attention and the stimulation that a normal single child would receive.

At times the competition can be intense and even aggressive, said Dr Bryan.

This may retard development and as a result, many of these children are more likely to have difficulty in communication and language development. This problem is further compounded if one child has a medical condition requiring more attention.
A study involving 200 pairs of twins found that at the age of four years, the average age of development of twins was 3 1/2 years, six months behind that of single children. Language development is an area particularly affected.

Aspects of communicating as a threesome include:

• Reduced eye contact
• Reduced dialogue with the mother - studies have shown that mothers of twins talk less to their children than mothers of single children, partly because they are busier, partly because they tend to think that the children can entertain each other
• Reduced opportunity to learn - often time is short and many expeditions are near impossible with two children
• Furthermore, it has been noted that single children tend to have an adult as a language role model, whereas multiple infants tend to have a constant exposure to each other's inferior communicative skills, reinforcing errors, she said.

Concentration

Solitude is important for a child to learn to be comfortable in its own company and is important in developing concentration, she said. Twins often lack solitude.

Research has shown that twins are more likely to suffer from attention hyperactivity distraction syndrome, often partly due to perinatal factors, but reinforced by the fact that they rarely have time on their own, she said.
"Some may never have time alone," said Dr Bryan.

Premature Babies & Mothers

A study in the United States compared premature twins and premature single babies and how their respective mothers behaved towards them. The babies involved in the study were aged 18 months.
The study found that, in general, mothers of twins showed fewer initiative responses, were less responsive to the positive signals of their babies, and were less responsive to their babies crying. These mothers lifted, held, touched, patted and talked less to their twin babies. "This behaviour was predictive of the cognitive development of these children," said Dr Bryan.

Behavioural Factors

Domination

The problem of domination is common in multiples, particularly boy-girl twins, especially in the pre-school period when the girl tends to be more socially confident and mature, appointing herself spokesperson.

"She will often look after her brother and he may be happy for her to do so. This is not the way to get the esteem of his peers and should not be allowed to continue, she said. Such domination can have far-reaching effects.

Twin girls, Sophie and Lucy, came to the clinic in London and drew pictures of their family. Lucy drew a picture in which she was vastly smaller in proportion that her sister. Lucy clearly did not feel the same size as her sister although she was the same size and they were monozygotic. It was Lucy's self esteem that was the problem.

Self Esteem

A study carried out involving pre-school twins linked both birth order and birth weight to self-esteem. The first-born child, and the child recording the greater birth weight, displayed more confidence.

The most important factor of all, however, was the order in which the newborn babies were taken home from the hospital. While this may seem surprising, several cases have highlighted this aspect, said Dr Bryan.

"It should be strongly encouraged, where possible, that twin children are taken home together," says Dr Bryan.

Collusion

Disciplinary problems, in general, are greater for twins than for single children. And for parents, collusion can be one of the biggest concerns.

As Psychologist Dorothy Birlingham said:

"Twins use each other to accomplish what one cannot do alone. They have the strength of two and are invincible".

They have each other to encourage unruly behaviour and with their combined skill they do not get bored of being naughty, said Dr Bryan. Disciplinary problems are further compounded with triplets and quadruplets.

The Problem of Exclusivity

Children of multiple births get used to being thought of as special due to the "twinship" and later in life they can find it very difficult when they are separated from their twin. "Often part of their own self-image and confidence was due to their 'specialness' as twins and they excluded the world because they themselves were exclusive," said Dr Bryan.

Practical Problems for Families

Adjustment is always tough for any parents welcoming newborns into the family. With multiples, the pressures are often compounded yet help is not always readily at hand. The Australia Multiple Birth Association asked 74 mothers of six-month-old triplets to calculate how many hours it took to look after the babies and do the housework each week. The mothers calculated that it took 197.5 hours - there are only 168 hours in a week.

Furthermore, many mothers of multiples who have undergone fertility treatment are older women and often have less energy. In 1980, there were 730 multiple births to women aged 30 years and over, constituting 1% of all births to women in that age group. By 2000, this number has increased to 2,300, constituting 2% of births in this age group.

Depression

Not surprisingly it's been found that depression is more common amongst mothers of twins and higher multiple births, said Dr Bryan. A study in the United Kingdom in 1991 concluded that mothers of twins are more likely to experience depression, indicating the additional and exceptional pressures placed upon the mothers' emotional wellbeing. The children involved in this study were five years old, disclaiming the possibility of postnatal depression, she said.

Sibling Behaviour

Behavioural problems among siblings in families with twins are considerably higher than siblings of single children. Studies have shown a three-fold increase in the behaviour of siblings in the 2-5-year age group. In the older age group, 8-11 years, the effect of the arrival of twins was even more profound with a six-fold increase in behavioural problems.

Child Abuse

Research in Japan showed a higher prevalence of child abuse among multiple births. There was a ten-throw increase amongst multiples, and it tended to be the disadvantaged child, either the smaller or less responsive or disabled child, that was affected. In the rare cases where both twins were affected, serious psychiatric illnesses were usually present, she said.

Positive Factors

While parenting multiples is clearly more demanding, such a life-changing event can have its up side for all involved.

"Clearly there are positive factors," said Dr Bryan.

Being a child of a multiple birth is certainly a unique existence. Among the many benefits, Dr Bryan cited the bonds of companionship, affection, co-operation, stimulation, encouragement, security, sympathy and empathy.

"I know many adult twins who regard their twin-ship as their greatest bonus in life," she said.

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Conception is the fertilisation of the egg by the sperm and its implantation in the uterine wall.

Not all couples conceive as soon as they stop oral contraception and decide to become parents as some couples are more fertile than others. It may take many cycles for conception to occur, even if both partners are normally fertile, healthy, fit and sexually active.

Many couples today are confronted with “unexplained” fertility problems or have experienced a previous pregnancy that resulted in miscarriage, stillbirth, malformation or impaired development.

It's been estimated that 60 per cent of couples will conceive after three menstrual cycles and that 85 per cent will conceive within a year.

Timing, health, hormonal state and age of both the male and female can all affect conception. A woman under 25 may conceive within two or three months, whereas a woman over 35 may take six months or longer. The reason for this is that as a woman gets older, the vitality and number of her eggs being released which are capable of being fertilised, is in gradual decline.

The quality of sperm is also an important factor, but deterioration only becomes significant beyond the age of 60.

Fertility Times

Women remain fertile for only 24 hours a month. During ovulation the ovum or egg is released by the ovary into the fallopian tube. Whereas ovum remain ripe for 24 hours, male sperm have a longer life span, surviving for four to five days in a woman’s body. This means that there are about five or six days during which time conception could possibly occur each month. To maximise the chances of conception, sexual intercourse ideally should occur in the six days leading up to and on the day of ovulation as the quality of sperm deteriorates the longer it is inside the woman’s body.

Most women ovulate in the middle of their menstrual cycle. In a 28-day cycle, ovulation will occur around day 14.
Your partner may recognise the most reliable signs of ovulation as follows:

• a distinct rise in temperature
• the cervix becomes softer and slightly more open
• the mucus plug, or discharge, comes away from the cervix to allow the entry of sperm
• the discharge has a similar consistency to egg white and is elastic in texture
• an increased libido
• a tugging sensation in her lower abdomen

The nature of this fertile mucus helps your sperm to swim up through the vagina and cervix, through the uterus and into the fallopian tubes.

Genetic and Medical History

It is important for both of you to assess your family medical and genetic history. Is there a history of diabetes, high blood pressure, heart disease (especially valve replacement), epilepsy, kidney disease, tuberculosis, syphilis, active herpes, cerebral palsy or AIDS/HIV? It may be wise to seek genetic counselling and discuss prescribed medication with your doctor to see if there are implications for a healthy pregnancy. You may need to adjust your medication.

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Eating well during pregnancy is essential but your baby’s health begins before conception. Only healthy sperm and a healthy egg can create a new human life. Health professionals advise couples planning a pregnancy to allow at least three to six months preparation before conceiving so the red blood cells in your body can fully regenerate. During this time, particular attention should be given to diet, stress and conserving your energy levels as all these factors affect your chances of conceiving, the health of your pregnancy and ultimately the wellbeing of your baby.

The health of both the male and female is as equally important. Poor health, exhaustion and a low immune system at the time of conception can influence your baby’s development, both within the womb and throughout its entire life.

Fertility problems often arise through long-term dietary and hormonal deficiencies that can be corrected. If you are eating good quality food, your natural ability to maintain high energy levels and manage stress will be greater.

Foresight, a highly-reputed organisation based in England committed to preconception care and reproductive health, cites nutrition as one of the leading factors in determining successful conception, pregnancy and birth.

Chemically free, organic food not only tastes better but also provides higher levels of nutrients that are often leached during commercial farming practices. What you eat now become the building blocks of your child’s lifelong health and prepares you for parenthood. In the first days following childbirth, your body is at risk of nutritional deficiencies. Click through to out our Health and Fitness section for ideas on how you can physically prepare your body for becoming a parent.

Steps to follow

These simple steps will go a long way:

• plan balanced meals
• drink lots of fresh water
• cut down on ready prepared foods and junk food
• stock up on vegetables
• introduce fresh fruits instead of sweets
• make the transition gradually so it becomes a way of life rather than just a fad
• take zinc and folic acid
• cut out coffee
• try dry skin brushing
• drink freshly squeezed juices
• sessions of reflexology will help balance the endocrine system in preparation for conception
• women should drink raspberry leaf tea, known to balance reproductive hormones

Be sensible and intuitive. Once you are pregnant, nature provides its own screening mechanism to protect the growing foetus. It is common for women to give up coffee, smoking and alcohol, among other things, during pregnancy. Statistics show that pregnant women eating nutritious foods have better pregnancy outcomes than those with poor diets.

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The following are circumstances that may contribute to difficult conception and may require early investigation. These include:

• the woman is over 35
• absent periods or irregular cycle
• history of endometriosis
• history of sexually transmitted infection
• history of pelvic inflammatory disease
• overweight or underweight
• the man has a history of groin or testicle injury
• history of drug or alcohol abuse
• history serious infection such as Hepatitis or HIV
• heart disease
• liver problems
• thyroid disease
• diabetes
• epilepsy
• multiple sclerosis
• mental illness
• asthma

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• IVF (In Vitro fertilisation)
• GIFT (Gamete Intra-Fallopian Transfer)
• ICSI (Intra Cytoplasmic Sperm Injection)

In Vitro (in glass) Fertilisation

IVF involves eggs being removed and fertilised by sperm. As many as ten, or as few as three fertilised eggs are then placed back into the womb. IVF has assisted some couples to conceive with the success rate per cycle consistently quoted at around 16 percent. This figure, considered low, is mainly due to the fact that women over 35 are more commonly using this method. It is far more successful in women in who are in their twenties and early thirties.

Gamete Intra-Fallopian Transfer

GIFT is a method whereby sperm and eggs are taken and mixed externally then injected back into the fallopian tube.

Intra Cytoplasmic Sperm Injection

Is a relatively new technique injecting sperm directly into the egg. It has revolutionised the treatment of male fertility.

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There are many elements to consider when trying to conceive and statistics indicate that many couples try for up to six months before conception occurs. Infertility is thought to be present when a couple has been unable to conceive after a year to 18 months of trying. There are many causes of infertility.

Female infertility may arise due to problems associated with ovulation. The hormonal system may not be releasing the necessary hormones. This system is extremely sensitive and may be affected by factors such as:

• allergies or sensitivities
• significant weight loss
• strenuous physical activity
• stress
• exposure to chemicals
• nutritional disturbances
• an inability for the body to absorb essential nutrients disease

Structural Faults

In rare cases, there may be congenital structural faults. There could be a lack of reproductive organs or faulty organs such as blocked or twisted fallopian tubes. The health of the vagina, womb and fallopian tubes may not be favourable for fertilisation to occur. Sometimes the womb lining is unable to support implantation.

Medical Conditions

A history of endometriosis, polyps, fibroids, pelvic inflammatory disease or genitourinary infection such as chlamydia trachomatis may also affect the environment.

Age

Age decreases fertility. The reason for this is that as a woman gets older, the eggs being released that are capable of being fertilised are in gradual decline.

In Australia 53 per cent of fertility can be attributed to mothers under 30 years of age. Figures for percentage of total births born to particular age groups are as follows (per cent):

19 and under 5.2,
20-24 16.8
25-29 31.0
30-34 31.1
35-39 13.5
40 and over 2.5

The Egg

A particular egg may not be healthy and may be incapable of developing after fertilisation. Or it may implant but produce abnormalities. An egg may implant incorrectly outside the womb to produce an ectopic pregnancy. This is more likely in cases where the tubes are blocked due to infection.

Nature has an amazing ability to detect deformities and encourage miscarriage in early pregnancy, which is when many miscarriages occur, often undetected.

Poor Nutrition

A woman’s body may not be healthy enough to maintain the pregnancy, perhaps due to poor nutrition, an over-high level of copper, zinc or magnesium deficiency, infection, allergic illness or toxicity.

Stopping Contraception

Often a woman decides to stop the contraceptive pill after a long period of time in the hope of becoming pregnant. The hormonal cycle has been controlled artificially for so long that it may take some time for the body to resume its own natural hormonal rhythm. It has also been found that long periods of taking the contraceptive pill can lower the levels of folic acid, the B vitamin necessary for healthy foetal development.

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Absence of live sperm

This can arise due to structural problems such as blocked or twisted seminal tubes or no tubes at all. The endocrine system may not be working properly to stimulate the production of sperm. An injury or birth defect may also be the cause.

Low sperm count

It is generally considered that a man has a low sperm count if he has less than 20 million sperm in a millilitre of semen. There have been a number of reports that male sperm counts have declined over the past few decades.It is generally considered that a man has a low sperm count if he has less than 20 million sperm in a millilitre of semen. There have been a number of reports that male sperm counts have declined over the past few decades.

• Reasons for low sperm count include:
• nutritional imbalances including deficiencies in Vitamin E, zinc, Vitamin B12
• chemicals in the home and workplace
• high stress occupations
• exposure to chemicals and vibrations in the workplace
• high levels of toxic metals such as cadmium or lead
• overheating of testicles caused by wearing tight and frictional clothing
• overheating caused by frequent hot baths. Males are advised to avoid hot baths, as sperm require cool temperatures to survive. This is why sperm are stored in testes that hang outside the body.
• medical conditions including circulatory problems around the testicles
• Drugs, both medical and recreational. Long-term use of tobacco and alcohol can also affect fertility.
• infections
• excessive exercise
• hormonal imbalances

Unhealthy sperm

The health of sperm will influence performance.

• The sperm may have poor mobility and fail to reach the egg
• If there is a zinc deficiency, the sperm may fail to penetrate the egg
• Smoking, alcohol, chlamydia infection, social drugs and some medicinal drugs may also affect sperm function.

Healthy Sperm

Antibodies

Sometimes the man has antibodies in his own sperm that may prevent the sperm from being released at all.

Physical problems

These could include injury to the male sex organs, damage to the testes, or in more rare cases an absence of vas deferens or testes.

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