Infertility - a Basic Understanding

What is infertility?

Infertility means difficulty in conceiving (becoming pregnant) despite having regular sex without using contraception. There is no definite cut off point to say when a couple is 'infertile'. Many couples take several months to conceive. About 17 in 20 couples conceive within a year of trying. About 19 in 20 couples conceive within two years.

Looking at this another way, about 1 in 7 couples do not conceive within a year of trying. However, more than half of these couples will conceive over the next year without any treatment.

As a rule, it is worth seeing a GP if you have not conceived after one year of trying. A GP can check for some common causes, talk things over, and discuss possible options.

A quick review of how pregnancy occurs

To conceive, an ovum (egg) from the woman has to combine with a sperm from the man. An ovum is released from an ovary when a woman ovulates. This usually occurs once a month between 12 and 16 days from the start of your last period if you have a regular monthly cycle of 28-30 days. The ovum travels down a fallopian tube to the middle of the uterus (womb) over 12-24 hours.

If there are sperm in the fallopian tube then one may combine with (fertilise) the ovum to make an embryo. The tiny embryo travels down into the uterus and attaches to the lining of the uterus. The embryo then grows and matures into a baby.

Sperm lie next to the cervix (neck of the uterus) when a man ejaculates ('comes') during sex. The sperm travel up past the cervix to get into the main part of the uterus, and into the fallopian tubes.

What can cause fertility problems?

Ovulation problems
Failure to ovulate is the cause in about 3 in 10 cases. In some women this is a permanent problem. In some women it is intermittent when some months ovulation occurs, and some months it doesn't.

There are various causes of ovulation problems which include:

• Early menopause.
• Polycystic ovary syndrome - which can also cause excess hair growth, acne, menstrual problems and is associated with obesity. See separate leaflet for more details.
• Hormone problems. For example, too much prolactin, or too little thyroxine.
• Being very underweight or overweight can affect your hormone balance which can affect ovulation. In particular, women with anorexia nervosa do not ovulate.
• Excessive exercise such as regular marathon running can affect your hormone balance which can affect ovulation.
• A side-effect from some medicines is a rare cause. Medicines that sometimes cause this are anti-inflammatory painkillers, some chemotherapy medicines, and cannabis.
• Insecticides, herbicides, and fungicides may be a factor in some cases.
• Various other problems with the ovary such as ovarian cysts and certain genetic problems.

Fallopian tube or uterine problems
These are the cause in about 2 in 10 cases, and include the following.

• Endometriosis causes about 1 in 20 cases of infertility. Another leaflet explains this condition in more detail. Very briefly, tissue that lines the uterus (endometrium) is found outside of the uterus. It is 'trapped' in the pelvic area and can affect the ovaries, uterus, and nearby structures. It often causes lower abdominal pain and/or painful periods.
• Previous infection of the uterus and fallopian tube (pelvic inflammatory disease) is another common cause. This can cause scarring and damage which can affect fertility. For example, scar tissue may block the egg (ovum) from travelling down the fallopian tubes. Another leaflet deals with this condition in more detail.
• Previous surgery to the fallopian tubes or uterus can cause scarring and damage.
• Large fibroids or cysts may cause problems.

Male problems
These occur in about 2 in 10 cases. Some men are born with testes that do not make any sperm, or very few sperm. Some are born without a vas deferens.

Some men make less sperm than normal (a 'low sperm count') for a variety of reasons which can reduce fertility. These include:

• Certain hormone problems.
• Current or past infection of the testes.
• Tumours of the testes.
• Side-effects of some medicines and drugs. These include: sulphasalazine, nitrofurantoin, tetracyclines, cimetidine, colchicine, allopurinol, some chemotherapy drugs, cannabis, cocaine and anabolic steroids.
• Regular excess heat (regular saunas, hot baths, etc) is possibly a cause.
• Environmental factors may be a factor in some men. For example, a lot of exposure to chemicals, x-rays, or heavy metals.
• Varicocele may affect fertility. A varicocele is common and is like a 'varicose vein' in the scrotum (the skin that covers the testes).

Unknown
No cause can be found in about 3 in 10 cases of infertility.

Age is a factor
Older women tend to be less fertile than younger women. The 'fall off' of fertility seems to be greatest once you are past your middle 30's. For women aged 35-39 the chance of conceiving is about half that of women aged 19-26.

Looking into the problem

Most GPs are happy to talk through any difficulties with fertility. It is best for both partners to see the GP. It is quite usual for GPs to do the following.

• Go over your general health, discuss any past illnesses, and examine both partners.
• Talk about sex and be sure there are no sexual problems. Sometimes people ask their doctor about difficulties with fertility when the real problem is difficulty with sex.
• The GP may suggest a few tests. For example:
  • a semen analysis (sperm test) in 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. The blood sample is taken on the 21st day of a regular 28 day cycle counting day one as the first day of bleeding.

Your GP may advise referral to a specialist for further advice and tests. As a rule, this is done if you have been trying to conceive for about 18 months without success. That is, provided no problem is found by the examination and initial tests done by a GP. You may be referred sooner than this if a medical problem is found that can be treated, or the female partner is aged over 35.

Some general advice

The chance of conceiving gradually goes down over time. However, for couples where no cause is found for the problem, there is still a good chance of conceiving without treatment. In such couples, without treatment:

• About half who do not conceive within one year conceive within the next year.
• Those who do not conceive within three years still have about a 1 in 4 chance of conceiving over the next year.

Therefore, the usual 'pre-conception' advice still applies. For example, women are advised to:

• take folic acid each day to reduce the chance of a spinal cord problem in a baby.
• have a blood test to check that you are immune to rubella (german measles). You will be offered immunisation to rubella if you are not immune.
• eat a healthy diet.

See separate leaflet called 'Planning to Become Pregnant?' for further details on pre-conception advice. In addition, the following may be relevant to some people.

• Smoking can affect fertility in men and women. It has been estimated that in each menstrual cycle, smokers have about two thirds the chance of conceiving than non-smokers. Smoking is also harmful to a developing baby if the mother smokes. Therefore, it is a good time for both partners to stop if you are smokers.
• Alcohol in excess may affect male fertility. Also, for women expecting to become pregnant, it is advised that you drink no more than 1 or 2 units of alcohol once or twice a week. (The equivalent to one or two glasses of wine, once or twice a week.) This is because alcohol may harm a developing baby. The safe level of alcohol for an expectant mother is not clear, so a low amount, if any, is advised.
• Weight control. You have a reduced chance of conceiving if you are very overweight or underweight. For the best chance of conceiving you should aim to have your body mass index (BMI) between 20 and 30. If appropriate, see you practice nurse to measure your BMI and for advice over diet and weight control.
• Some street drugs can affect fertility and are best avoided.
• Heat and sperm production. It is often advised for men who have a low sperm count to wear loose fitting underpants and trousers and to avoid very hot baths, saunas, etc. This allows your testes to be slightly cooler than the rest of your body, which is thought to be good for sperm production. It is not clear whether these measures improve a sperm count, but they seem to be sensible.

Sex and fertility

It is best not to try and time when you have sex to coincide with expected ovulation. This may cause anxiety, which can sometimes lead to sexual or relationship problems.

Sperm survive at least 48 hours, and possibly up to seven days after having sex. Therefore, even though an ovum only survives 12-24 hours, having sex two or three times a week is sufficient if you are trying to conceive. You may want to have sex more often, which is fine, but it probably will not increase your chance of conceiving. It is thought that the more relaxed and spontaneous your sex life is, the more likely you will conceive.

Doctors are used to talking about sexual problems. Any worries or concerns in this area are best talked over with a GP.

What are the treatments for infertility?

Sometimes a cause can be found for a couple's infertility. Some causes are treatable and normal fertility can be restored. For example, some cases of ovarian failure can be treated with medicines. Hormone problems can often be treated.

If no cause is found, or the cause is not treatable, then 'assisted conception' is often possible. The number of techniques and success of treatments has increased in recent years. There is a separate leaflet called 'Treatments for Infertility' which gives a brief overview of these treatments. However, you need to see a specialist for a full discussion about the various treatment options. Also, the organisation detailed below is an excellent source of information, advice, and help.

Further help and advice

Infertility Network UK (I N UK)
Charter House, 43 St Leonards Road, Bexhill on Sea, East Sussex, TN40 1JA
Tel: 08701 188088    Web: www.infertilitynetworkuk.com
Provides advice and information for the public and for professionals on all aspects of infertility.

Human Fertilisation & Embryology Authority - HFEA
21 Bloomsbury Street London WC1B 3HF
Tel: 020 7291 8200    Web: www.hfea.gov.uk
The HFEA produces a wide range of information on a range of different infertility treatments, as well as on legal issues, consent procedures, success rates of treatments, what you should expect from fertility treatment centres, how to make a complaint, etc. Their "Guide to Infertility and Directory of Clinics" is a comprehensive guide to infertility treatments and clinics in the UK and can be downloaded from their website.

Patient UK
The infertility section - www.patient.co.uk/showdoc/380/ - provides a large set of links to organisations and patient groups concerned with infertility and it's treatment.

© EMIS and PIP 2005   Updated: November 2005   PRODIGY Validated