What is infertility?
Infertility is the inability to conceive despite regular unprotected sexual intercourse after 12 months. Around 1 in 7 couples in the UK may have difficulty conceiving. It is expected that more than 80% of couples would have conceived within a year, and more than 90% within 2 years when the woman is forty years old or less.
Couples that have not conceived naturally after a year of regular unprotected sexual intercourse should see a fertility specialist to investigate why. The options then available will depend on test results, duration of infertility and the age of the couple.
What are the causes?
In order to conceive, a healthy egg needs to be released by the woman during ovulation. The egg should then be picked up by the fallopian tube and following sexual intercourse, healthy sperm should travel up into the fallopian tube to fertilise the egg, create a healthy embryo which should then travel along the fallopian tube, continuing to divide and develop into a viable embryo that will then get into the womb and implant. If these processes all work out in the specific cycle, a pregnancy will result.
Infertility will therefore arise if the female or male reproductive processes are not working optimally, or in many cases if the timing of sexual intercourse is wrong.
Male factors account for 30% of infertility.
- This includes sub optimal sperm quality or no sperm
- Sexual problems (erectile dysfunction, premature ejaculation etc)
Female factors account for 30% of infertility and include:
- Female age (egg quality and quantity diminish with age and may be a cause for infertility)
- Ovulation problems (premature menopause / menopause, Polycystic ovarian syndrome (PCOS) etc
- Tubal problems (blocked / absent tubes, damaged tubes, endometriosis etc)
- Uterine problems (fibroids, polyps, womb scarring etc)
- Sexual problems (vaginismus)
In 30% of cases, there are both male as well as female factors involved.
Fertility tests and diagnosis
Fertility investigations should be initiated early (if not pregnant after one year despite regular unprotected sexual intercourse, or earlier where older or have other problems, such as heavy periods, irregular cycles, PCOS, endometriosis etc).
Investigations should ideally be done in a one stop fertility service, involving male s well as female investigations.
Prompt diagnosis will help allay anxiety as well as commence treatment in good time, optimising the chances of successful conception.
Female investigations include:
- Blood tests:
– Anti-Mullerian hormone (AMH). This provides a good measure of egg quantity
– Blood thyroid function test and rubella immunity.
- 3D ultrasound scan to assess uterus and ovarian function. Results are available immediately
- HyCoSy procedure to assess uterus, ovaries and tubal patency
Male investigations include:
- Semen analysis: this will be the only test required for most men. However, if no sperm is found or where levels. are very low, other tests may be necessary.
- Blood tests for hormone levels (FSH and testosterone), genetic tests etc where appropriate.
- Testicular ultrasound scan where necessary
A third of couples will be investigated for infertility and all test results will be normal. This is known as unexplained infertility. Depending on age and duration of infertility, some could continue trying for a spontaneous conception. Over a 6-month period, 30-40% of these couples will conceive. However, if the woman is older than 37 years old, or they have been trying to conceive for more than 24 months, fertility treatment will be recommended. Most of these couples are treated successfully.
Primary and secondary infertility
Where a couple are having difficulty conceiving and have never been pregnant before, this is referred to as primary infertility. Secondary infertility refers to those who have conceived before and having difficulties conceiving again.
What treatments are available?
Treatments will be guided by the age of the couple, duration of infertility as well as investigation results.
Treatment options would include:
- Continuing to try for a spontaneous conception if the test results are all normal and the couple are young (unexplained infertility); alternatively,
- Medical (including ovulation induction with tablets or injections)
- Surgical (surgery for polyps, fibroids, womb scarring (Asherman’s syndrome), uterine septum, endometriosis, fallopian tubes etc
- Assisted conception treatments (IUI/IVF/ICSI)
Where can I see a specialist to discuss fertility investigations or treatment?
I also provide consultations, investigations and Fertility enhancing surgery, including surgery for fibroids, uterine septum, polyps, endometriosis etc at BMI Cavell and The One Hatfield Hospital.
As the Medical Director at Herts and Essex Fertility Centre *, I provide assisted conception consultations and treatments that include.
- In vitro fertilisation (IVF)
- Intracytoplasmic sperm injection (ICSI)
- Intrauterine insemination (IUI)
- Surgical sperm collection
- Egg freezing
- Donor egg IVF/ICSI
What affects my chances of getting pregnant?
Smoking: Smoking affects sperm as well as egg health. It also increases the risk of miscarriage. Smoking cessation not only improves the chances of delivering a live healthy baby, but also improves your general health and well being.
Weight loss: Being overweight (BMI >25) or obese (BMI >30) reduces the chances of conceiving spontaneously as well as with fertility treatment. Some women with PCOS may stop ovulating above a certain weight threshold and weight loss regulates their cycles.
Alcohol: This also affects sperm and egg health before conception and negatively affects the developing foetus in pregnancy. Consider not drinking when trying to conceive and in pregnancy. Caffeine: Minimise caffeine intake to a maximum two drinks a day. Where possible, take decaffeinated drinks. Some will find it easier to omit caffeinated drinks altogether.
How does fertility treatment work?
Fertility treatment will depend on investigation test results.
Ovulation induction and timed sexual intercourse.
Where ovulation is the problem, such as in PCOS, ovulation induction with tablets such as Clomiphene Citrate or Letrozole, or hormone injections will stimulate eggs to develop and ovulation to occur. Ultrasound and hormone level monitoring is required to confirm response and to time sexual intercourse.
In cases where regular sexual intercourse if not possible, either due to difficulties with erection, ejaculation or vaginismus, intrauterine insemination (IUI) is performed. Sperm is injected into the uterus during ovulation for conception to occur.
Women who require donor sperm (single, same sex female relationship, or whose partners have no sperm) can also have IUI with the donor sperm.
IVF / ICSI
With IVF, a hormone injection is administered daily over a 10-14-day period, with regular ultrasound scan monitoring every few days. The injected follicle stimulating hormone ( FSH) will stimulate the egg she would have ovulated from, as well as several other eggs that would have naturally done to waste that month (IVF does not therefore deplete a woman’s pol of eggs, but rather uses up what was destined to got to waste naturally anyway).
Once the developing egg containing follicles are large enough, a trigger injection (HCG) is administered to mature the microscopic eggs within the follicles. Eggs are then collected approximately 36 hours later using ultrasound guided needles, under anaesthesia.
Egg collection procedure takes approximately 20-30 minutes. The male partner will produce a sperm sample which will be prepared and used to fertilise the eggs. If the sperm is all normal, in vitro fertilisation (IVF) is utilised. The eggs and sperm are mixed in a petri-dish in the lab and sperm will swim and fertilise the eggs.
However, if sperm quality is suboptimal, there is a risk that the eggs may not fertilise. In that case intracytoplasmic sperm injection (ICSI) is utilised. A normal sperm is selected and under the microscope, injected it into each mature egg.
The fertilised eggs will be grown inside an incubator, a machine that mimics the fallopian tube environment in terms of temperature, oxygen levels, nutrients etc. The best quality fertilised eggs (embryos) will stand out over a 5-day culture period and this will be selected for transfer into the woman’s womb. In 30-40% of cases, some spare good quality embryos may be available to freeze for future use.
For more information about how we can help you, see at our Fertility Health Check Package.
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