Infertility is the inability of a couple to achieve a pregnancy after repeated intercourse without contraception for 1 year.
It is increasingly common because couples are marrying later in life and waiting longer to have a child. Nevertheless, up to 60% of couples who haven’t conceived after a year of trying eventually will conceive.
The goal of treatment is to reduce the time needed to conceive. Major causes of infertility include: problems with sperm, ovulation, the fallopian tubes and the cervix. The diagnosis and treatment requires a thorough assessment of both partners.
facts & figures
In about 30% of infertile couples the problem lies within the man. A similar percentage is due to the women and the remainder to joint problems.
Fertility varies from person to person and at different stages of our lives. The following facts are true for most people:
- Fertility for men and women reaches its peak at about 24 years old
- An egg survives 12-24 hours after ovulation
Among couples having intercourse without contraception:
- 25% will conceive in the first month
- 60% will conceive within 6 months
- 75% will conceive within 9 months
- 80% will conceive within 12 months
- 90% will conceive within 18 months
What are the causes of male infertility?
Sperm take seven weeks to form and are very vulnerable to outside influences at all stages in their development. Problems with sperm can arise for the following reasons:
1. Testicular failure
Fortunately this is a very rare condition where the semen contains no sperm. It has various possible causes and is unfortunately not treatable. The known causes are:
- Klinefelter’s syndrome (a chromosomal abnormality).
- Injury to the testes
- Undescended testes
- Mumps during adulthood
- Low sperm counts
Many men with low sperm counts do father children although it usually takes longer than normal to achieve conception. Unfortunately, however, when there are few sperm the majority tend to be abnormal or have poor motility (ability to move). Low sperm counts or sperm abnormalities tend to be due to hormonal problems, anatomical problems, immunological problems or environmental factors. These are explained below:
2. Hormonal problems
Adequate production of testes-stimulating hormones by the pituitary gland, including luteinising hormone (LH), follicle-stimulating hormone (FSH) is essential for healthy sperm creation. A man’s ability to produce sperm will be affected if he is not secreting enough FSH and LH. Sperm production can also be affected by abnormal functioning of the thyroid and adrenal glands.
3. Anatomical problems
Some anatomical problems can be present at birth. Others can be caused by injury, infection or disease. Below is a guide to some of these problems:
Hydrocele: There is an excess of normal lubricating fluid around the testes. These conditions raise the temperature of the testes, inhibiting sperm production.
Varicocele: The veins of the scrotum and testes become enlarged.
Retrograde ejaculation: About 1% of men find that they do not ejaculate at the time of orgasm. This is because of retrograde ejaculation when the semen is ejaculated back into the bladder. The valve at the back of the bladder should close during ejaculation. Retrograde ejaculation occurs most commonly in diabetic men who have had surgery to the urethra or in men with spinal cord injury.
Blockage of the vas deferens: There is a blockage of either or both of the tubes that connect the testicles to the seminal vesicles. This condition may be present at birth or may arise due to an infection, e.g. gonorrhoea.
4. Immunological problems
Some men produce antibodies which attack their own sperm. These antibodies are produced by the immune system which for some reason sees the sperm as foreign bodies. This may be the result of injury or infection and is detectable by the presence of white blood cells in semen.
What tests can be done?
There are a number of tests that can be done to assess male infertility:
- Sperm assessment
- Post-coital test
- Sperm tests
See your G.P. for more information on these tests and how to arrange them.
As a woman gets older she is less likely to have a successful pregnancy. Particularly after the age of 35, a woman has a limited amount of time to resolve infertility problems before menopause.
What are the causes of female infertility?
Ovulation: Failure to ovulate is the most common cause of female infertility. It accounts for about 30% of all infertile women. It is usually due to hormonal problems and occasionally due to damaged ovaries or very rarely if the woman has run out of eggs.
Hormonal Imbalance: Fertility drugs are used to treat hormone imbalance; they include clomiphene, human chorionic gonadotrophin (hCG) and human menopausal gonadotrophin (hMG) . 90% of women will respond to these treatments i.e. achieve regular ovulation, however, for unknown reasons only around 65% will become pregnant.
Structural Problems: Natural conception is prevented if the fallopian tubes are blocked or damaged. This can happen for a variety of reasons, including: previous ectopic pregnancy, pelvic inflammation, surgical damage or infections. In addition to the fallopian tubes, the uterus may be scarred, contain polyps or fibroids, be subject to endometriosis or there may be a congenital abnormality.
Ovarian problems: Ovaries can be damaged by infection, scarring due to surgery on cysts or as a side-effect of radiation treatment. A woman’s supply of eggs may run out due to the menopause (or premature onset), surgical damage, or radiation therapy. In this case, IVF is the only treatment option.
All types of female infertility are treatable.
Tests for female fertility
Hormone and ovulation tests
The first priority is to find out whether you are ovulating. If simple tests show that you are you will be referred for the following investigations. These tests investigate for the functioning of your hormones, ovaries, uterus and fallopian tubes.
The hormone levels in your blood or urine are measured every day for an entire cycle. This test can indicate an imbalance in your hormones if there is a problem with ovulation.
This can check the development of your ovarian follicles and whether you are ovulating. Accurate assessment of follicular growth is essential for in-vitro fertilisation and is also useful in artificial insemination.
This involves taking a sample of your endometrium (lining of the uterus) and examining it under a microscope. The endometrium undergoes cyclical changes under the influence of oestrogen and progesterone. Endometrial thickening is due to an increase in progesterone. If progesterone levels are low, development of the endometrium may not be sufficiently advanced to allow implantation.
Tubal Patency Tests
These tests are performed to check the condition of the fallopian tubes.
This determines whether the tubes are blocked or damaged. It may also identify endometriosis, fibroids, malformations and adhesions.
This reveals any scar tissue in areas where the tubes join the uterus or in the lining of the tubes. It can also pinpoint polyps.
This is artificial insemination of a woman with either her partner’s sperm or that of a donor. This works best for couples where the problem is with depositing the sperm in the vagina, it is of limited value in cases where the male has a very low sperm count.
Donor insemination is usually considered when men are sterile or have subfertile or very low sperm counts that do not respond to treatment; where there is a major blood group incompatibility between the couple (e.g. Rh- female developing antibodies to Rh+ male) or where the male is a carrier of a serious hereditary disease.
There are complex emotional issues with this kind of treatment that should be considered carefully. Counselling is essential.
After all the other treatments have failed to result in a pregnancy, more and more infertile couples turn to in-vitro fertilisation. This procedure involves several steps:
- Stimulating the ovaries: A combination of clomiphene, human menopausal gonadotropins and a gonadotropin-releasing hormone agonist (a drug that stimulates the release of gonadotropins from the pituitary gland) is used to stimulate the ovaries so that many eggs will mature.
- Retrieving released eggs: Several eggs are removed from the follicles in the ovary by a needle guided by ultrasound.
- Fertilising the eggs: The eggs are placed in a culture dish and fertilised with washed sperm in the laboratory.
- Growing the embryos in a laboratory: The embryos are grown in the dish for about 40 hours.
- Implanting the embryos in the woman’s uterus: Three or four embryos are transferred from the culture dish into the mother’s uterus through the vagina.
Additional embryos can be frozen in liquid nitrogen to use later if pregnancy doesn’t occur. Despite the transfer of several embryos the chances of producing one full-term baby are only 18-25% each time eggs are placed in the uterus.
In cases where a woman is unable to produce an egg, donor eggs may be used for IVF. Drugs will probably be needed to stimulate thickening of the endometrium.
Occasionally, couples who have had successful IVF treatment may donate unused embryos.