What are fertility problems?
Infertility or subfertility is the condition in which a couple fail to achieve pregnancy after at least one year of regular unprotected sexual intercourse. Both partners in a relationship contribute to potential fertility. Both may be sub-fertile, and hyper-fertility in one may mask sub-fertility in the other.
For pregnancy to be achieved, several things need to happen at the right time.
• The woman has to produce an egg
• The man has to produce healthy sperm
• The egg has to travel from the woman’s ovary into the fallopian tube
• The couple have to have sex around the time the egg is released
• The sperm have to swim up the vagina and womb (uterus) into the fallopian tube towards the egg.
• The egg has to be fertilised by the man’s sperm
• The fertilised egg has to implant itself in the woman’s womb.
What causes them?
The causes of fertility problems are classified based on individual factors necessary for successful reproduction. They are as follows:
- Male factors (30-40%)
- Female factors (30-40%)
- Combined male and female factors (10-15%)
- Unexplained causes (5-10%) when the doctor cannot find any cause.
Male factor infertility could be due to any of the following:
- Hormonal problems.
- Disorders with the anatomy: The vas deferens which conducts sperm from the testes where they are produced to the outside may be absence from birth or blocked.
- Abnormal sperm production: Due to genetic abnormalities, undescended testes, previous mumps infection in childhood and exposure to radiations.
- Abnormal sperm motility.
- Sexual dysfunction: Retrograde (backward) ejaculation, erectile dysfunction, decreased libido.
- Problems with egg production.
- Infections like pelvic inflammatory disease, appendicitis, and infections following operations.
- Uterine problems such as formation of adhesions, uterine fibroids (especially the large ones), and structural abnormalities from birth.
- Problems with the cervix, such as chronic cervical infections and damage from surgical treatment.
It is now thought that unexplained infertility is probably caused by a small problem in each partner. On their own the problems wouldn’t matter. But if both partners have something slightly wrong it affects the chance of getting pregnant.
How is the cause found out?
When there is difficulty in making babies, it helps to see the doctor first, both partners preferably. The doctor will ask a number of questions and perform a physical examination on both partners. Relevant tests may also be requested to help them find out what is causing the sub-fertility.
Tests for fertility problems
For men, the semen will be analysed to see if the count is normal and if the sperm look healthy enough to fertilise an egg.
For women, there will be a blood test to find out if she’s ovulating normally and check her hormone levels.
If the tests are normal, some further tests can be run on the woman. These include:
- More detailed hormone tests
- An x-ray test that shows the inside of a woman’s womb and fallopian tubes to check for blockages or any abnormalities.
- An ultrasound test to show images of the womb and fallopian tubes for the same purpose as the x-ray test. It can also be used to watch the growth of eggs in the ovaries.
- In order to have a better view, the doctor may do a laparoscopy. This involves inserting a tube with a camera on the end through a small opening in the abdomen. He can also take tissue samples and remove growths.
What treatments work?
If the tests show a clear reason for the fertility problems, the doctor should be able to decide which fertility treatment may offer the best chance of getting pregnant. However, treatment may not work for every people and doesn’t reduce the chance of a miscarriage.
Medicines to stimulate the ovaries
Women whose infertility is caused by problems with ovulation are usually offered drugs like Clomifene to encourage ovulation as their first option. It is quite effective and about three times as many women get pregnant as would have done without treatment.
Side effects are not serious and don’t usually require treatment. There is a higher chance of having multiple pregnancies (twins or triplets) with this treatment. This happens because clomifene can make your ovaries release more than one egg at a time. There are some other types of drugs the doctor can suggest if this doesn’t work.
Doctors often suggest hormone injections for women with ovulation problems if drug treatment fails or when a hormonal insufficiency is responsible for the sub-fertility.
Hormone injections can cause side effects, most of which a mild. Less commonly serious ones such as kidney and liver problems may occur.
As with clomifene, taking hormone injections may make you more likely to have multiple pregnancies.
IVF and other assisted conception treatments
IVF is the most common form of assisted conception fertility treatment used for various types of fertility problems. It is quite effective but demanding, both physically and emotionally, with significant side effects.
In IVF the man’s sperm is mixed with the woman’s eggs in a laboratory. The sperm are allowed to fertilise the eggs. The product is put back into the woman’s womb so that they can grow.
Children born through IVF are more likely to be born premature and to have a low birth weight. But this is probably due to the greater number of multiple pregnancies and by the older age of women having IVF.
Other assisted conception treatments include:
ICSI (intracytoplasmic sperm injection) where a healthy sperm from the man is injected directly into the woman’s egg to fertilise it, and the embryo put back into the woman’s womb, as with IVF.
There is some evidence that children born through ICSI are more likely to have serious physical and mental problems.
GIFT (gamete intrafallopian transfer) where the egg-and-sperm mix is put into one of the woman’s fallopian tubes instead of waiting for them to fertilise in the laboratory.
The sperm fertilises the egg naturally in the woman’s fallopian tube.
Donated eggs or sperm can also be used to achieve assisted conception.
Surgery is only an option when other treatments have failed or if surgery will increase the chances that other treatments will work. They include:
- Surgery for ovulation problems
- Surgery for blocked or damaged fallopian tubes
- Surgery for problems linked to endometriosis. In endometriosis, cells from the lining of the womb (the endometrium) grow outside their natural confines. The damaged disuse that may be preventing pregnancy is removed.
As with all types of surgery, these procedures carry risks like excessive bleeding and infections.
In the absence of an obvious reason for the sub-fertility, a further trial of one year may be advised. After then, an in vitro fertilisation (IVF) may be offered depending on the doctor’s discretion. The older a woman gets, the less likely IVF is to be successful.
It might help to talk with an infertility counsellor. They can help you understand your options and your chances of success.
Things you can do yourselves
There are things you can do to improve your chances of getting pregnant,
whether or not you choose to have treatment:
- Maintain a healthy weight. Being overweight or underweight can reduce your chances of getting pregnant.
- No smoking. The chances of sub-fertility and miscarriages are higher when you smoke.
- Have sex regularly (about 2 to 3 times weekly) so you don’t miss the fertile period.
What will happen?
How couples decide to go about their fertility problems will depend on how important it is for them to have a child using their own eggs and sperm. Even without treatment, some couples go on to conceive.