There are many reasons why it might be difficult for a couple or individual to conceive and this can be a very stressful experience. There are, however, a variety of different treatment options available to you, which will often depend on your stage of life, medical history, lifestyle, and personal preferences. It is important to discuss with your doctor which options are right for you. In many cases, the doctor may recommend a physical examination and order some tests to diagnose any issues which are causing fertility problems and ensure the most appropriate treatment for you.
- Causes of infertility in women
- Causes of infertility in men
- Improving Your Prospects of Becoming Pregnant
- Diagnosing Infertility Issues
- Infertility Treatment
- Possible Complications of Infertility Treatments
Some people have difficulty in becoming pregnant naturally even though they have regular unprotected sex and do not use contraception. For many people it can take months to conceive and the vast majority will become pregnant within a year or two of trying. It is usually suggested that if a couple has not conceived after one year then it is worth visiting your GP to be examined and tested to determine if there are underlying medical causes preventing the couple from conceiving. Your GP can provide support and discuss possible options. If you are over the age of 36 or if either partner has a history of fertility problems, then it is advisable to see your GP earlier.
There are a range of different reasons why people may have difficulty becoming pregnant and this can be due to either female of male fertility issues. In fact, infertility issues affect men and women equally and it is important to note that in around one quarter of couples experiencing infertility, no cause can be found.
Causes of infertility in women
After the age of 30 you tend to become less fertile, especially once you are past your mid-30s. At any age, however, there are a number of reasons why you max experience difficulties in becoming pregnant. These include:
- Ovulation Problems. In around a quarter of couples that cannot conceive, the issue is that the woman is not producing eggs (ovulating). Sometimes this is a permanent problem, whereas in other women it may be temporary or may fluctuate over time. The causes of ovulation problems include:
- Premature ovarian insufficiency.
- Polycystic ovary syndrome (PCOS).
- Hormone problems (such as hormone imbalance), which in some cases can be caused by excessive exercise.
- Being very underweight or overweight.
- Chronic conditions such as uncontrolled diabetes, cancers and chronic kidney disease.
- A side-effect from some medication such as chemotherapy medication.
- Certain recreational drugs.
- Other ovarian problems and certain genetic problems.
- Fallopian tube, cervix or uterine problems. Such issues account for around another quarter of cases and problems include:
- Pelvic inflammatory disease (PID).
- Surgery to the Fallopian tubes, the neck of the womb (cervix) or the uterus.
- Large fibroids.
Causes of infertility in men
In many cases, the underlying cause of infertility is found in the male partner, usually relating to a problem with sperm, such as when the sperm may be reduced in number, less mobile, or be abnormal in their form. There are risk factors that may affect sperm production and male infertility, including:
- Infection of the testicles such as mumps.
- Sexually transmitted infections.
- Tumours of the testicles.
- Testicles that haven't dropped properly.
- Side-effects of certain medications and recreational drugs.
- Scarring from previous operations such as an inguinal hernia repair.
- Enlarged blood vessels in the scrotum (a varicocele).
- Certain hormone problems.
- Some inherited genetic conditions.
- Being overweight.
Improving Your Prospects of Becoming Pregnant
It is not recommended to try to time when you have sex to coincide with expected ovulation as this can cause stress, anxiety, and sexual or relationship problems. Similarly, using temperature charts and ovulation kits to help predict when you are most fertile has not been shown to improve your chance of becoming pregnant. There are now many apps on the market to help you predict when you ovulate, though having spontaneous, unprotected sex every two to three days is likely to maximise your chance of getting pregnant, but of course you can have sex more frequently.
To improve your prospects of conceiving, there are a number of other actions that you can take. These primarily include behavioural changes to reduce lifestyle risk factors, which impact both male and female fertility and which can have a negative effect on developing babies:
- Quitting Smoking. It has been estimated that smokers have about two thirds the chance of conceiving compared to non-smokers.
- Reducing Alcohol Consumption. It is recommended that women trying to become pregnant do not drink any alcohol.
- Weight control. Your chance of conceiving may be reduced if you are very overweight or underweight. Your GP clinic can measure your BMI and provide advice about diet, exercise and weight control.
- Stopping recreational drug use. Recreational drugs can affect fertility and should be avoided.
A healthy diet will increase your chance of getting pregnant. Avoid foods high in trans fats including hydrogenated oils, packaged snacks, baked goods, fried foods, shortening, and some margarines. Choose unsaturated fats such as avocados, olive oil, almonds, walnuts, seeds, eggs, and omega-3-rich fish such as salmon. Replacing meat sources of protein with vegetable sources of protein, such as beans, lentils, soy, nuts, seeds, and quinoa, may decrease the risk of infertility. Wholegrains also help to stabilise blood sugar to prevent hormonal fluctuations that can disrupt fertility. Avoid refined carbohydrates such as white bread, pasta, and sugary cereals. Also, make sure that you get sufficient vitamin D every day as vitamin D deficiency may be correlated with a lower chance of pregnancy.
Diagnosing Infertility Issues
You can seek advice from your GP who will ask you a range of questions relating to your efforts to become pregnant, your medical history, and many other aspects of your life. The GP will also conduct a physical exam of you and your partner and order tests in order to identify any underlying medical conditions that may be preventing you from becoming pregnant. These could include:
- Semen analysis of the male partner.
- A blood test to check that ovulation occurs in the female partner. This measures the hormone progesterone which is high just after ovulation.
- Ovarian assessment including an AMH blood test.
- Sexual Health Screening.
- Other blood tests.
- Referral for an ultrasound scan to check your womb, your fallopian tubes and your ovaries (useful for diagnosing conditions like polycystic ovary syndrome (PCOS)).
- Referrals for imaging tests, laparoscopy, genetic testing, or to other medical specialists.
Depend on the underlying cause of the infertility issue, different treatments are available. Such treatments broadly fall into three categories:/
- Assisted conception, including techniques such as:
- Intrauterine insemination (IUI).
- In vitro fertilisation (IVF).
- Intracytoplasmic sperm injection (ICSI).
Sometimes, these different options are used in combination.
Medications are usually used to help with ovulation. You may be prescribed Clomifene (taken in tablet form), medicines that contain gonadotrophins (these need to be injected) or medicines that contain gonadotrophin-releasing hormone. Metformin may sometimes be prescribed to women with polycystic ovary syndrome (PCOS) who have trouble conceiving, usually in addition to Clomifene. Your doctor will be able to advise you on taking medication for infertility so that you understand success rates, potential side-effects or risks (see below) and the latest research and evidence.
Surgical fertility treatments
The circumstances where surgery may be an option include:
- Fallopian tube problems. Most surgery to the Fallopian tubes is done by keyhole surgery.
- Mild Endometriosis. Endometriosis is a condition where tissue similar to the lining of the womb grows in other places, such as the ovaries and fallopian tubes. Keyhole surgery can be used to remove areas of endometriosis tissue in order to improve symptoms and fertility.
- Polycystic ovary syndrome (PCOS). Keyhole surgery may be used and a heat source (diathermy) is usually used to destroy some of the tiny cysts that develop in the ovaries.
- Fibroids. Surgery to remove fibroids that grow into the womb cavity may be an option for some women.
- Male infertility. When there is a blockage in the tube inside the scrotum that is used to store sperm surgery may be helpful.
Once again, your doctor will be able to advise you and recommend surgical options if they are appropriate for you.
There are several options to assist conception and your specialist will advise you which options are best suited to treat your particular cause of infertility and will explain the chance of success.
- Intrauterine insemination (IUI). This is the process by which sperm are placed into the woman's womb (uterus). IUI is also suitable for single women or lesbian couples who want to get pregnant using donor sperm. It is done by using a fine plastic tube which is passed through the neck of the womb into the womb. Sperm are passed through the tube. It is a relatively straightforward procedure. It can be timed to coincide with ovulation in women who are still ovulating. Fertility medicines may also be given beforehand to maximise the chance of ovulation occurring. Women who have this procedure need to have healthy Fallopian tubes to allow the egg to travel from the ovary into the womb. If successful, fertilisation takes place within the womb. The sperm used can be either from a male partner, or from a donor.
If IUI does not work, other methods described below are often used.
- In vitro fertilisation (IVF). IVF means fertilisation outside of the body in a laboratory dish or test tube. IVF is used in couples whose infertility is caused by blocked Fallopian tubes or where their infertility is unexplained. It may also be used where there are certain problems with ovulation or a combination of factors causing infertility. It involves taking fertility medicines to stimulate the ovaries to make more eggs than usual. When the eggs have formed, a small operation is needed to harvest them (egg retrieval). Each egg is mixed with sperm. This is obtained from either the male partner or from a donor. The egg/sperm mixture is left for a few days in a laboratory dish with the aim is for sperm to fertilise the eggs to form embryos. One or two embryos which have formed are then placed into the woman's womb using a fine plastic tube passed through the cervix. Any other embryos which have formed in the dish are either discarded or, if you wish, frozen for further attempts at IVF at a later date.
When IVF is used, three cycles are usually offered to women aged under 40 years, and one cycle is usually offered to women aged 40-42 years if they have not had IVF in the past. The likelihood of IVF succeeding decreases after each unsuccessful cycle. Around one in four IVF procedures result in a successful pregnancy. Your chance of success with IVF may be higher if the female partner is under the age of 37, has been pregnant before, and has a healthy weight and body mass index (BMI).
- Intracytoplasmic sperm injection (ICSI). This involves an individual sperm being injected directly into an egg, bypassing any natural barriers that may have been preventing fertilisation. ICSI can also be used when a male partner has a low sperm count, as only one sperm is needed. The egg containing the sperm is then placed in the womb in the same way as with IVF. ICSI is usually used where IVF has been unsuccessful or where the quality or number of sperm is too low for normal IVF to be likely to succeed.
- Egg donation. This involves stimulating the ovaries of a female donor with fertility medicines, and collecting the eggs which form. The eggs are mixed with and fertilised by sperm of the recipient's partner (similar to IVF). After 2-3 days, embryos are placed in the womb of the recipient via the cervix. This method is an option in several circumstances, including where a woman has ovarian failure and cannot produce eggs, or for a woman who has had her ovaries removed, or for a woman who has a condition where her ovaries do not work. It is also used where there is a high risk of transmitting a genetic disorder to the baby and for same-sex male couples and single men wanting to become fathers (with a surrogate).
Possible Complications of Infertility Treatments
No treatment is without potential complications. These may potentially include:
- Multiple pregnancy. Twins and multiple pregnancy are more common in some forms of infertility treatment including medication treatment (e.g. with Clomifene) and in some assisted conception treatments. Having twins or triplets can carry an increased risk of problems during a woman's pregnancy, such as high blood pressure and diabetes. There is also a higher risk of other complications such as a having a small baby or going into premature labour.
- Pregnancy in the Fallopian tube. A pregnancy which develops in the Fallopian tube (an ectopic pregnancy) may be slightly more likely in women who are undergoing treatment for infertility, especially if the infertility is due to a problem with the Fallopian tubes.
- Stress. Going through investigations and treatment for infertility can be a very stressful thing and can put a strain on many relationships.
- Over-stimulation of the ovaries. There is a small risk that some of the medicines used to treat infertility, such as the gonadotrophin medicines, can over-stimulate the ovaries. This may lead to a condition known as ovarian hyperstimulation syndrome. In this condition, the ovaries can swell due to a number of cysts that develop on the ovaries. The condition can usually be treated easily and normally does not lead to any major problems. In some cases, however, it can be more serious and can lead to liver, kidney and breathing problems or a blood clot in an artery or vein. Close monitoring using ultrasound scans is often used when women are given medicines to stimulate the production of eggs by the ovaries.
- Other side-effects. Some of the medicines used to treat infertility - for example, the gonadotrophins - may cause hot flushes and menopause-type symptoms.
Before deciding to go ahead with any treatment, you should have a discussion with your doctor on the benefits and risks of the treatment proposed and the risk of problems and side-effects.