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Infertility refers to an inability to conceive after having regular unprotected sex. Infertility can also refer to the biological inability of an individual to contribute to conception, or to a female who cannot carry a pregnancy to full term. In many countries infertility refers to a couple that has failed to conceive after 12 months of regular sexual intercourse without the use of contraception.

To become pregnant, the complex processes of ovulation and fertilization need to work just right. For some couples, infertility problems can be present from birth (congenital) or something can go wrong along the way that results in infertility.

The reasons for infertility can involve one or both partners. In general:

• In about one-third of cases, the cause of infertility involves only the male.

• In about one-third of cases, the cause of infertility involves only the female.

• In the remaining cases, the cause of infertility involves both the male and female, or no cause can be identified.

Studies indicate that slightly over half of all cases of infertility are a result of female conditions, while the rest are caused by either sperm disorders or unidentified factors. According to The Mayo Clinic, USA:

• About 20% of cases of infertility are due to a problem in the man.

• About 40% to 50% of cases of infertility are due to a problem in the woman.

• About 30% to 40% of cases of infertility are due to problems in both the man and the woman.

What are the risk factors of infertility?

In medicine, a risk factor is something that raises the risk of developing a condition, disease or symptom. For example, obese people are more likely to develop diabetes type 2 compared to people of normal weight; therefore, obesity is a risk factor for diabetes type 2.

• Age – a woman’s fertility starts to drop after she is about 32 years old, and continues doing so. A 50-year-old man is usually less fertile than a man in his 20s (male fertility progressively drops after the age of 40).

• Smoking – smoking significantly increases the risk of infertility in both men and women. Smoking may also undermine the effects of fertility treatment. Even when a woman gets pregnant, if she smokes she has a greater risk of miscarriage.

• Alcohol consumption – a woman’s pregnancy can be seriously affected by any amount of alcohol consumption. Alcohol abuse may lower male fertility. Moderate alcohol consumption has not been shown to lower fertility in most men, but is thought to lower fertility in men who already have a low sperm count.

• Being obese or overweight – in industrialized countries overweight/obesity and a sedentary lifestyle are often found to be the principal causes of female infertility. An overweight man has a higher risk of having abnormal sperm.

• Eating disorders – women who become seriously underweight as a result of an eating disorder may have fertility problems.

• Being vegan – if you are a strict vegan you must make sure your intake of iron, folic acid, zinc and vitamin B-12 are adequate, otherwise your fertility may become affected.

• Over-exercising – a woman who exercises for more than seven hours each week may have ovulation problems.

• Not exercising – leading a sedentary lifestyle is sometimes linked to lower fertility in both men and women.

• Sexually transmitted infections (STIs) – chlamydia can damage the fallopian tubes, as well as making the man’s scrotum become inflamed. Some other STIs may also cause infertility.

• Exposure to some chemicals – some pesticides, herbicides, metals (lead) and solvents have been linked to fertility problems in both men and women.

• Mental stress – studies indicate that female ovulation and sperm production may be affected by mental stress. If at least one partner is stressed it is possible that the frequency of sexual intercourse is less, resulting in a lower chance of conception.

According to the Department of Health and Human Services, USA, approximately 10% to 15% of couples in the USA are infertile – meaning they have not conceived after at least one year of regular, unprotected sex.

Many cases of apparent infertility are treatable. Infertility may have a single cause in one of the partners, or it could be the result of a combination of factors.

How Does Age Affect Fertility?

 Women are born with a finite number of eggs. Thus, as the reproductive years progress, the number and quality of the eggs diminish. The chances of having a baby decrease by 3% to 5% per year after the age of 30. This reduction in fertility is noted to a much greater extent after age 40.

What increases a man’s risk of infertility?

A man’s sperm can be changed by his overall health and lifestyle. Some things that may reduce the health or number of sperm include:

• Heavy alcohol use

• Drugs

• Environmental toxins, including pesticides and lead

• Smoking cigarettes

• Age

• Health problems such as mumps, serious conditions like kidney disease, or hormone problems

• Medicines

• Radiation treatment and chemotherapy for cancer

Female infertility can be also be caused by a number of factors, including the following:

• Damage to fallopian tubes. Damage to the fallopian tubes (which carry the eggs from the ovaries to the uterus) can prevent contact between the egg and sperm. Pelvic infections, endometriosis, and pelvic surgeries may lead to scar formation and fallopian tube damage.

• Hormonal causes. Some women have problems with ovulation. Synchronized hormonal changes leading to the release of an egg from the ovary and the thickening of the endometrium (lining of the uterus) in preparation for the fertilized egg do not occur. These problems may be detected using basal body temperature charts, ovulation predictor kits, and blood tests to detect hormone levels.

• Cervical causes. A small group of women may have a cervical condition in which the sperm cannot pass through the cervical canal. Whether due to abnormal mucus production or a prior cervical surgical procedure, this problem may be treated with intrauterine inseminations.

• Uterine causes.  Abnormal anatomy of the uterus; the presence of polyps and fibroids.

• Unexplained infertility. The cause of infertility in approximately 20% of couples will not be determined using the currently available methods of investigation.

Other factors that may play a part in infertility include:

• having had inflamed testes (orchitis)

• a past bacterial infection that caused scarring and blocked tubes within the epididymis as it joins the vas

• having received medical treatment such as drug treatment, radiotherapy or surgery – for example to correct a hernia, undescended testes or twisted testicles

• genetic problems

• diabetes

• lifestyle factors such as being overweight or having a job that involves contact with chemicals or radiation.

Male fertility is also thought to decline with age, although to what extent is unclear.

How  Cause of Infertility Determined?

If male infertility is suspected, a semen analysis is performed. This test will evaluate the number and health of his sperm. A blood test can also be performed to check his level of testosterone and other male hormones.

If female infertility is suspected, your doctor may order several tests, including:

• A blood test to check hormone levels

• An endometrial biopsy to check the lining of the uterus

Two diagnostic tests that may be helpful in detecting scar tissue and tubal obstruction are hysterosalpingography and laparoscopy.

• Hysterosalpingography (HSG). This procedure involves either ultrasound or X-rays taken of the reproductive organs. Either dye or saline and air are injected into the cervix and travel up through the fallopian tubes. This enables the ultrasound or X-ray to reveal if the fallopian tubes are open or blocked.

• Laparoscopy. In this procedure, a laparoscope (a slender tube fitted with a fiberoptic camera) is inserted into the abdomen through a small incision near the belly button. The laparoscope enables the doctor to view the outside of the uterus, ovaries, and fallopian tubes to detect abnormal growths, as in endometriosis. The doctor can also check to see if the fallopian tubes are open at the same time.

How Is Female Infertility Treated?

Female infertility can be treated in several ways, including:

• Laparoscopy. Women who have been diagnosed with tubal or pelvic disease can either undergo surgery to reconstruct the reproductive organs or try to conceive through in vitro fertilization (IVF). Using a laparoscope inserted through a cut near the belly button, scar tissue can be removed, endometriosis treated, ovarian cysts removed, and blocked tubes opened. 

• Hysteroscopy. A hysteroscope placed into the uterus through the cervix can be used to remove polyps and fibroid tumors, divide scar tissue, and open blocked tubes.

• Medical therapy. Women suffering from ovulation problems may be prescribed drugs such as clompiphene citrate (Clomid, Serophene) or gonadotropins (such as Gonal F, Follistim, Humegon and Pregnyl), which can lead to ovulation. Gonadotropins can induce ovulation when Clomid or Serophene do not work. These drugs also can enhance fertility by causing multiple eggs to ovulate during the cycle (normally, only one egg is released each month). Gonadotropin therapy may be offered for unexplained infertility or when other factors have been corrected without resulting in pregnancy. Metformin (glucophage) is another type of medication that may restore or normalize ovulation in women who have insulin resistance and/or PCOS (polycystic ovarian syndrome).

• Intrauterine insemination. Intrauterine insemination refers to an office procedure in which semen is collected, rinsed with a special solution, and then placed into the uterus at the time of ovulation. The sperm are deposited into the uterus through a slender plastic catheter that is inserted through the cervix. This procedure can be done in combination with the previously listed medications that stimulate ovulation.

• In vitro fertilization. IVF refers to a procedure in which eggs are fertilized in a culture dish and placed into the uterus. The woman takes gonadotropins to stimulate multiple egg development. When monitoring indicates that the eggs are mature, they are collected using a vaginal ultrasound probe with a needle guide. The sperm are collected, washed, and added to the eggs in a culture dish. Several days later, embryos — or fertilized eggs — are returned to the uterus using an intrauterine insemination catheter. Any extra embryos can be frozen for later use, upon the consent of the couple.

• ICSI. Intracytoplasmic sperm injection is used when there is sperm-related infertility. The sperm are injected directly into the egg in a culture dish and then placed into the woman’s uterus.

• Egg donation. Egg donation helps women who do not have normally functioning ovaries (but who have a normal uterus) to achieve pregnancy. Egg donation involves the removal of eggs — also called oocytes — from the ovary of a donor who has undergone ovarian stimulation with the use of fertility drugs. The donor’s eggs are then placed together with the sperm from the recipient’s partner for in vitro fertilization. The resulting fertilized eggs are transferred to the recipient’s uterus.

Infertility treatment must be treated if there is some known reason

For infertility, some basic questions to ask your doctor include:

• What are the possible reasons we haven’t yet conceived?

• What kinds of tests do we need?

• What treatment do you recommend trying first?

• What side effects are associated with the treatment you’re recommending?

• What is the likelihood of conceiving multiple babies with the treatment you’re recommending?

• For how many cycles will we try this treatment?

• If the first treatment doesn’t work, what will you recommend trying next?

• Are there any long-term complications associated with this or other infertility treatments?

Don’t hesitate to ask your doctor to repeat information or to ask follow-up questions.

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