Q I am 33 and my husband is 40. We have been trying to conceive for the past two years.

I have irregular menstruation cycles, which last for 26 to 40 days but, otherwise, I am fairly healthy. My husband and I exercise regularly. We do not smoke or drink.

As the risk of fetal abnormalities increases when the mother is over the age of 35, I hope to conceive as soon as possible. What can we do to conceive naturally?

A Since you have tried unsuccessfully to conceive for two years, it is timely to consider an assessment and infertility treatment.

In general, after a year of trying to conceive, doctors will strongly advise the couple to seek some form of assessment.

We advocate individualised treatment, depending on the diagnosis and severity of the condition that is causing the infertility.

Not only does the risk of fetal abnormalities increase when the mother is more than 35 years old, but her ovarian reserves - the quantity and quality of her eggs - will also decrease significantly with age.

Causes of infertility include an- ovulation, which is the absence of ovulation; blockage of the fallopian tubes; endometriosis, a condition where the cells of the uterine lining are deposited outside the uterus; and abnormal quantity, form, structure or function of the man's sperm.

As you have irregular menses, you could have a problem with ovulation, which is the release of an egg from one of your ovaries.

Several conditions can cause problems with ovulation, such as sudden weight gain or loss, stress, over-dieting or excessive exercise and thyroid problems.

Other reasons include a small pituitary tumour (the pituitary is a small gland in the brain that secretes hormones) and polycystic ovarian disease.

Women with this condition have small follicles, or cysts, which are located at the periphery of their ovaries.

They have a slightly higher level of male hormones, which are associated with acne and excessive body hair. Some may also suffer from obesity and hormonal imbalance, which resemble the symptoms of diabetes.

Identifying the cause of your infertility will enable doctors to help you conceive. They can, for instance, induce ovulation with oral medication; use minimally- invasive reproductive surgery to treat endometriosis, blocked fallopian tubes and endometrial polyps; or prescribe medication to improve the man's sperm.

Sometimes, a low sperm count can be due to having distended veins near the testes. Simple surgery to remove the distended veins can help to improve the sperm count.

If these simple measures fail, you may have to resort to assisted conception.

There are two main methods:

• Intra-uterine or artificial insemination: Super- ovulation, where medication is used to stimulate the production of two or three eggs, is usually done. The doctor will monitor the follicles which contain the eggs. When the follicles are of the right size, ovulation is induced and the man's sperm is processed in the laboratory and placed in the wife's womb. This method is suitable only for milder forms of infertility, where the wife does not have blocked fallopian tubes or severe endometriosis and the husband's sperm is relatively good.

• In-vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI): Suitable for those with more severe forms of infertility. A common myth is that IVF is complicated, risky and difficult. With modern medications, doctors can simplify the IVF treatment, reduce its duration and the number of injections needed. IVF involves the stimulation of the ovaries to produce many follicles (egg-containing sacs) in the ovaries in a controlled manner. When the follicles are of the right size, the eggs within will be induced to mature. They are then extracted in a simple day-surgery procedure. Fertilisation will take place in the laboratory and the embryos will be transferred into the woman's womb. Hormones are used to stabilise the womb condition until the pregnancy is confirmed.

Dr Loh Seong Feei

Medical director at Thomson Fertility Centre

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