“I look and feel young. But why are my ovaries old?” bemoaned the 42-year-old youthful-looking woman who sat opposite me. Her disappointment stemmed from the fact that her last IVF (in vitro fertilisation) cycle had to be abandoned as we failed to obtain any eggs from her.

As a reproductive specialist with over 20 years’ experience, I’ve had this conversation countless times. This patient, married for 10 years, had spent her most fertile years prioritising career and financial stability. When she was finally ready, her biological clock had other plans.

So when is it too early to start the fertility conversation, and when would it be too late?

Most young people receive sex education in schools but very little fertility education, leaving them unprepared for family planning decisions in the future.

Women see their fertility peak in their early 20s, so we need to start educating them as early as their late teens, around age 18. This plants the seed of knowledge that will help them think about family planning in the long run. By their 20s, they can make educated decisions about having children.

As things stand, the knowledge gap is obvious.

In March 2025, KK Women’s and Children’s Hospital (KKH) launched Singapore’s first sexual health guidelines for women of reproductive age. Research among women aged 21 to 45 shows 57 per cent lack understanding of sexual health issues, and only 43 per cent seek medical help. Among healthcare providers, 81 per cent are unfamiliar with screening tools, and 63 per cent rarely/sometimes discuss sexual health with patients. The new guidelines provide a comprehensive framework for healthcare professionals, aiming to improve awareness and encourage open communication about fertility and sexual health.

But what’s lacking? Sex education in schools focuses on the human anatomy and preventing sexually transmitted infections and unwanted pregnancies. However, there’s little emphasis on the broader concept of fertility – what it is, how it works, and how it changes throughout our lives.

About one in six couples faces conception difficulties, ranging from ovulation problems and low sperm counts to blocked fallopian tubes and endometriosis. However, stigma around fertility issues often prevents couples from seeking timely help.

Both men and women need to understand their reproductive health and their partner’s potential issues. Teaching these concepts alongside health and social education helps young people make informed choices about when to have children and understand their options, including egg freezing.

As a woman enters her 30s, her fertility starts declining gradually. By her late 30s or early 40s, pregnancy chances drop significantly, mainly due to decreased egg quality. Low-quality eggs are less likely to join with sperm and create healthy pregnancies, often leading to failed implantation or miscarriage. Even assisted reproduction like IVF does not counteract this effect of female ageing. The impact of reduced egg quality, together with the age-related decline in egg numbers, means that older women can expect to have fewer eggs available for IVF and therefore a lower chance of having a good embryo.

Eligible Singaporean married couples can receive up to 75 per cent co-funding from the Government for IVF and other assisted reproductive technologies as long as the female partner is under age 40. But for many women, like my 42-year-old patient, her most realistic chance of motherhood would be through egg donation: this treatment involves IVF, but the egg is donated from a healthy woman under 38 years of age and fertilised with sperm from the recipient woman’s husband. The recipient woman then carries the pregnancy.

Men’s fertility also changes over time even though they don’t face the same strict “biological clock”. Sperm quality tends to decline after 40, and children of older fathers face higher risks of certain conditions like autism, schizophrenia and leukaemia. This often-overlooked aspect of male fertility deserves more attention in our conversations.

But fertility isn’t just about age.

Daily choices – from what we eat to how we handle stress – profoundly impact our reproductive health. Excessive exercise or a lack of physical activity can disrupt hormone balance crucial for reproduction, while smoking damages reproductive cells, and chronic stress interferes with conception. Adding to this, common conditions like polycystic ovary syndrome, endometriosis, or pelvic infections, can also impact fertility. Yet most people learn these facts only when struggling to conceive.

Even though we can’t control age, maintaining overall health optimises fertility potential.

It’s time to integrate fertility awareness into an ongoing conversation about overall wellness. Healthcare providers can offer opportunistic fertility guidance, especially when discussing contraception. Gyms and sports facilities, community centres, universities and other tertiary education institutions can be encouraged to keep fertility as part of the wellness conversation. And just as we have public health campaigns for issues like smoking or nutrition, we should launch more initiatives to focus on fertility health.

This is crucial as Singapore’s total fertility rate (TFR) has reached an all-time low of 0.97, far below the global average TFR of 2.2, and the ideal rate of 2.1, needed for population stability. There are multiple factors contributing to this decline, but one of the major ones is that couples are leaving it too late before they start trying for a family. Infertility is a cause of much distress, heartache and regret. Fertility education is not going to prevent infertility, but it will help reduce the impact.

By bringing these conversations into the open, we can help individuals understand their options and take control of their reproductive health before it’s too late.